The People's Pharmacy

Humans have five senses, but for most of us, sight dominates. That’s why vision problems are so distressing. Have you been dealing with difficulties with your eyes? During this broadcast episode, our guest expert is ready to answer your questions about vision problems. At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, June 20, 2026, through your computer or smart phone (wunc.org). Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on June 22, 2026. On this episode, we will be taking calls from listeners. You can ask your question ahead of time by emailing radio@PeoplesPharmacy.com. Or call 888-472-3366 directly between 7 and 8 am EDT on Saturday, June 20, 2026. Are More People Nearsighted? Myopia, the technical term for nearsightedness, is increasing at a rapid rate. Globally, 23 percent of the world’s population had myopia in 2000. By 2020, that rate had risen to 34 percent. Some experts estimate that it could reach 50 percent by 2050. Rates among children and adolescents are even higher in some places, reaching 70 percent among East Asians and an alarming 86 percent among Singaporean Chinese youth 15 and under (British Journal of Ophthalmology, July 2016). Why are so many people, including young people, myopic? Are there implications beyond a need for corrective lenses (glasses or contacts)? Can we reverse this trend by limiting screen time or encouraging more time outdoors? Are there treatments that can help children and adolescents improve their vision? Which Vision Specialist Should You See? Eyes are complicated, and caring for vision problems has become increasingly specialized and technically sophisticated. As a result, ophthalmologists (eye doctors) now often treat just one part of the eye, such as the retina or the cornea. Some surgeons specialize in removing cataracts. Others, like Dr. Sharon Fekrat, are expert in retinal surgery. There are also pediatric ophthalmologists who treat children. In addition, some people need to consult a neuro-ophthalmologist or someone who specializes in inherited retinal degenerations, uveitis or ocular oncology. How can you determine which type of eye doctor you should see to address your particular problem most effectively? What Is in a Complete Eye Examination? Dr. Fekrat will describe the elements of a complete eye examination. Why is each one included? What further steps are needed if trouble is detected? This will give you an idea of how vision problems are assessed and where to turn for treatment. Managing Dry Eyes One of the most common complaints is dry eyes. This condition is uncomfortable as well as common, affecting up to half of adults in the US. What are the causes? Are there treatments? People often use eye drops to alleviate the discomfort. Which ones work best? What can a person do if they have severe dry eye problems and are referred to a dry eye specialist with an appointment months in advance? Is it dangerous to postpone dry eye care? What to Do About Blepharitis When the problem is more the eyelid than the eye itself, doctors call it blepharitis. One typical symptom is crust on the lids, which may feel itchy or scratchy. Some people find that applying warm compresses morning and evening is helpful. Others need medication. You may have seen ads for Xdemvy, which is aimed at reducing the population of Demodex mites living in the follicles of the eyelashes. Mites are not the only problem, however. Sometimes bacterial infections are the underlying cause of blepharitis. Rosacea and seborrheic dermatitis that affect skin elsewhere on the face may also show up with the same symptoms. Topical ivermectin cream has been used off-label on the eyelid margins and may help reduce Demodex mites, but it is not an FDA-approved eye treatment and should only be used under an eye clinician’s direction because it is not intended for instillation into the eye. How Will the Doctor Diagnose Glaucoma? Glaucoma is generally understood as a condition in which pressure inside the eye rises and damages the optic nerve. This disease can lead to vision loss. That’s why intraocular pressure measurement should always be part of the eye exam. But this simple diagnostic technique alone may be incomplete. We’ll ask Dr. Fekrat about additional approaches that might pick up normal-pressure glaucoma. How is it treated? Age-Related Macular Degeneration Deserves Treatment Another of the vision problems that can cause serious impairment is age-related macular degeneration. In this disorder, the central part of the retina, the macula, loses its ability to focus. Patients may notice that the central part of the vision is blurry, and it may be harder to see under low light conditions. Ophthalmologists now have a range of medications to inject to slow the progression of macular degeneration. Dr. Fekrat can describe the difference between “dry” and “wet” macular degeneration and the drugs used to treat them. What Other Vision Problems Are Troubling You? This is a chance to ask questions and get answers about vision problems from an expert. You can send email to radio@PeoplesPharmacy.com or call in your questions to 888-472-3366 between 7 and 8 am EDT on Saturday, June 20, 2026. This Week’s Guest Sharon Fekrat, MD, is a retina surgeon at the Duke Eye Center of the Duke Health Integrated Practice and vice chair of faculty affairs and the Robert Machemer MD Distinguished Professor of Ophthalmology at the Duke University School of Medicine. She is associate chief of staff at the Durham VA Healthcare System and past interim chief of surgery there. She is Director of Duke iMIND Research Group and Chief Editor of the book All About Your Eyes as well as the Digital Journal of Case Reports of Ophthalmology. Dr. Fekrat is past President of the NC Society of Eye Physicians and Surgeons. The People’s Pharmacy is reader supported. When you buy through links in this post, we may earn a small affiliate commission (at no cost to you). Sharon Fekrat, MD, FASRS, Duke Eye Center Listen to the Podcast The podcast of this program will be available Monday, June 22, 2026, after broadcast on June 20. You can stream the show from this site and download the podcast for free. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.

Are you concerned about your bone health? Do you worry about osteoporosis? According to the CDC, more than 10 million Americans have low bone density that makes them more vulnerable to fractures. For many older people, a fracture can be devastating, reducing mobility and possibly even leading to death. What does the latest medical science tell us about how you can maintain strong bones? At The People’s Pharmacy, we strive to bring you up‑to‑date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen: You may have heard this interview when it was first broadcast on Saturday, Sept. 27, 2025. If you did not, you can download the mp3 using the link at the bottom of the page, or listen to the stream on this post by clicking on the little triangle in the green circle. We have added extra information to these notes, but not to the interview itself. Strong Bones You may have seen Halloween skeletons or even chewed the meat off a bone that you then dropped on a plate with a clatter. No wonder we usually think of bones as hard, unchanging objects. Dead bones are. But living bones are quite different. Strong bones are constantly undergoing change. Scientists call it remodeling. One set of specialized cells, osteoclasts, breaks bone tissue down and recycles it. Another set, the osteoblasts, builds bone back. Ideally, their activities are in balance. But if the osteoclasts start to get ahead, as they tend to do while we age, that can weaken bone. The result is low bone mass, known as osteopenia, or even serious bone loss called osteoporosis. This puts a person at risk for fractures. Who Gets Osteoporosis? Osteoporosis may have been less common a hundred years ago or more, when many people had to do manual labor that put stress on their bones. That helps for strong bones, so today’s sedentary lifestyles can undermine bone health. Although we think of osteoporosis as typically affecting postmenopausal women, men can lose bone mass too. Medications may contribute to the risk for bone loss. Steroids such as prednisone or methylprednisolone are especially risky if taken for a long period of time. Androgen deprivation therapy for prostate cancer is a risk factor specifically for men. Wait–MEN Can Get Osteoporosis? Q. My husband and I have two friends with significant disability largely due to spinal fractures as a result of osteoporosis. One man was always an avid exerciser, including running marathons. Both men are over six feet tall and have always appeared to be muscular. My husband is shorter and is physically active, playing tennis and going to the gym regularly. Because of our friends’ bone issues, I advised him to request a DXA scan to assess his bone health. The nurse practitioner told him that it was not recommended for men. I am still concerned that he may be at risk for osteoporosis. Are there medical studies that determine the risk factors for men? A. The nurse practitioner was mistaken. Men can develop osteoporosis, as your friends discovered. Many medical guidelines recommend that men over 70 be tested with a DXA scan to assess bone health. If your husband has low testosterone levels or has taken medications such as prednisone, he could be at increased risk for a fracture. He would be prudent to have the assessment. Diagnosing Osteoporosis Doctors assess bone mineral density with imaging called dual-energy X-ray absorptiometry, or DEXA for short. Then they compare the results on the scan to the results they would expect from a 30-year-old person. Results more than 2.5 standard deviations from that could result in a diagnosis of osteoporosis. A person who experiences a fracture without trauma, such as falling from standing height, is also suspected and often diagnosed with osteoporosis. Non-Drug Approaches to Strong Bones: People who want to keep strong bones need to focus on exercise. High intensity exercise can be helpful, but brisk walking may be enough. Tai chi and yoga are also popular. If you have been diagnosed with osteoporosis, be sure to check in with your doctor before you start a new exercise program. Building balance and core strength without increasing your risk of a fall (and thus a fracture) would be ideal. Our guest expert, Dr. Kendall Moseley, says the jury is still out on technology such as vibrating platforms, weighted vests or vibrating belts. More studies should show how valuable these could be. Following a diet that supplies adequate protein, vitamin D and calcium is also crucial. If you must take a calcium supplement, calcium citrate may be well tolerated and absorbed. How Do Doctors Treat Osteoporosis? Physicians prescribe several different types of medications to help curb bone less and perhaps even build it back. Some of the oldest and least expensive are the bisphosphonates such as alendronate (Fosamax). These slow bone break down and give the osteoblasts a chance to catch up. They can be hard on the digestive tract, though, and they have been associated with a few rare but alarming side effects: jawbone deterioration and atypical thigh bone fracture. Most people seem to do well on them. Doctors generally prescribe them for up to five years. Did You Forget Evista? Another type of osteoporosis medicine is called raloxifene (Evista). It is appropriate only for women, because it is an estrogen modulator. It acts like estrogen in the bones and reduces bone loss. In the breast and uterus, it opposes estrogen activity. Raloxifene does double duty in reducing the risk of breast cancer as well as osteoporosis. Like all drugs, though, it has some worrisome side effects. It can increase the risk of blood clots that cause deep vein thromboses and strokes. What About Prolia? Denosumab (Prolia) is a monoclonal antibody that also interferes with osteoclasts. That is how it improves bone density. One thing to keep in mind about Prolia is that stopping it requires careful planning and backup medication. Otherwise, a patient can lose all the bone that was built rather quickly and may suffer debilitating fracture. This Week’s Guest: Kendall Moseley, MD, is Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. She is also Clinical Director of the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. In addition, Dr. Moseley is Medical Director of the Johns Hopkins Metabolic Bone & Osteoporosis Center. Kendall Moseley, MD, is Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. Listen to the Podcast: The podcast of this program will be available Monday, Sept. 29, 2025, after broadcast on Sept. 27. You can stream the show from this site and download the podcast for free, or you can find it on your favorite platform. In the podcast for this episode, we discuss the pros and cons of estrogen for strong bones. You’ll also learn about a drug that builds bone, teriparatide (Forteo). And you’ll hear about the importance of preventing falls and how to do that. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript for Show 1446: A transcript of this show was created using automated speech-to-text software (AI-powered transcription), then carefully reviewed and edited for clarity. While we’ve done our best to ensure both readability and accuracy, please keep in mind that some mistakes may remain. If you have any questions regarding the content of this show, we encourage you to review the original audio recording. This transcript is copyrighted material. All rights reserved. No part of this transcript may be reproduced, distributed, or transmitted in any form without prior written permission. Joe 00:00-00:01 I’m Joe Graedon. Terry 00:01-00:05 And I’m Terry Graedon. Welcome to this podcast of The People’s Pharmacy. Joe 00:06-00:13 You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. Joe 00:14-00:27 Hypertension is often called the silent killer, but osteoporosis might be considered a silent and deadly disorder. This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:41 If an older person breaks a hip, the consequences can be disastrous. They often lose mobility and they may even die. Joe 00:42-00:50 The focus for osteoporosis is usually on older women, but we should remember that men can also lose bone and become vulnerable. Terry 00:51-00:57 There are drugs that hurt bone health as well as help build it back. What about supplements or exercise? Joe 00:57-01:06 Coming up on The People’s Pharmacy, the science of strong bones, lifestyle, medication, and movement. Terry 01:14-02:32 In The People’s Pharmacy health headlines, semaglutide has gotten a lot of attention over the past few years. If you don’t recognize this generic drug name, you probably do recognize the brand names. Ozempic for type 2 diabetes and Wegovy for weight loss. Both these medications are self-administered injections, but not everyone is enthusiastic about needles. There’s also an oral form of semaglutide called Rybelsus. The FDA has approved it for treating type 2 diabetes six years ago, and so far it has mostly gone under the radar. A new study published in the New England Journal of Medicine demonstrated that oral semaglutide at 25 mg a day helped people without diabetes lose significantly more weight than placebo. The randomized trial included more than 300 volunteers and lasted approximately a year and a half. This could be good news for people who have trouble accessing injectable semaglutide or keeping it cold. People taking semaglutide reported improved quality of life. They were also more likely to report side effects, especially digestive distress. Joe 02:34-04:17 Aspirin has been available for well over 100 years, but the active ingredient has been used by native healers for thousands of years. In 1991, a research article in the New England Journal of Medicine reported that regular aspirin users were 40 to 50 percent less likely to die of colon cancer. Now, 34 years later, another research paper in the New England Journal of Medicine reports that people taking aspirin had a significantly lower chance of colorectal cancer recurrence. Swedish scientists recruited patients after they’d had their tumors removed. The particular hotspot mutation called PIK3CA. The aspirin dose was 160 milligrams, or roughly half a standard strength tablet daily, for three years. 626 patients were randomly assigned to receive either aspirin or placebo. 7.7% of people taking aspirin experienced a recurrence of their colorectal cancer, whereas 14.1% of those on placebo had a recurrence. That was about a 50% relative risk reduction. 43% of the participants taking aspirin experienced a non-severe side effect compared to 35% of those on placebo. Serious adverse events occurred in 17% of aspirin takers compared to 12% of placebo recipients. The authors conclude that low-dose aspirin represents an effective, low-cost treatment approach to prevent colorectal cancer recurrence in high-risk, genetically selected patients. Terry 04:17-04:58 Nutrition experts have praised the Mediterranean diet as a way to reduce cardiovascular risk. It’s also been considered as a way to lower the likelihood of developing dementia and a natural approach to calming inflammation. Now, dermatologists have announced the results of a study showing that four months on a Mediterranean diet can reduce the severity of psoriasis symptoms. Almost half of the participants following a Mediterranean diet reduced their psoriasis score by 75 percent, and none of those on the control diet did so. The researchers conclude that this dietary strategy could be helpful along with medical treatment. Joe 04:59-05:41 A new study of acupuncture for chronic low back pain called Back in Action produced positive results. 800 patients were randomized to receive either standard acupuncture of 8 to 15 treatment sessions, enhanced acupuncture, which included 4 to 6 maintenance sessions beyond the standard, or usual medical care alone. Those in the acupuncture groups had significantly greater reductions in their pain-related disability than those in the usual care group. The authors conclude that, quote, these findings support acupuncture needling as an effective and safe treatment option for older adults with chronic low back pain. Terry 05:42-06:05 Do cocoa flavanols normalize blood pressure? In the COSMOS study, people with systolic blood pressure under 120 were significantly less likely to develop hypertension if they were taking cocoa flavanols than if they took placebo pills. People whose blood pressure started higher did not get the same benefit. And that’s the health news from the People’s Pharmacy this week. Terry 06:14-06:17 Welcome to the People’s Pharmacy. I’m Terry Graedon. Joe 06:17-06:29 And I’m Joe Graedon. According to the CDC, over 10 million Americans over 50 have osteoporosis. That means their bones have become fragile and more vulnerable to fracture. Terry 06:30-06:40 More than 40 million Americans have low bone mass or osteopenia. What can be done to prevent fractures, disability, and death from weakened bones? Joe 06:41-07:00 To find out, we’re talking with Dr. Kendall Moseley. She is Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. She also serves as medical director of the Johns Hopkins Metabolic Bone and Osteoporosis Center. Terry 07:01-07:04 Welcome to the People’s Pharmacy, Dr. Kendall Moseley. Dr. Kendall Moseley 07:05-07:10 Thank you so much for having me today. I’m very excited to chat with you both about a topic that’s near and dear to my heart. Joe 07:11-07:48 Well, it’s near and dear to our hearts as well, Dr. Moseley, but I suspect that there’s a tremendous amount of confusion when it comes to bones because we’ve all seen skeletons. We’ve all had interactions with bones, perhaps in food. And it just always seems as if bones are so solid. And yet, in reality, bones are constantly breaking down and building up. It’s a very dynamic process. Could you just give us a quick overview on bone physiology? Dr. Kendall Moseley 07:49-09:21 Absolutely. And I think you’ve highlighted something I always try to stress when I talk to groups of people is that bones are not these inanimate objects. I mean, we’re not these walking, kind of lumbering rocks moving down the street. In fact, we have this very important scaffold underneath our skin that enables us to walk and roll and twist and bend. And without a very strong scaffold, we’re kind of in trouble. So you’re right. Bones are dynamic. Our bones are always building up and they’re always breaking down. And it’s that process of kind of building up and breaking down that allows us to be flexible, right? If we didn’t have remodeling of our bones, we’d be very stiff and brittle. But it’s that balance, that key balance of how our bones build up and how they break down that really dictates how strong our bones can be. Clearly, you would prefer a lot more building up than breaking down. And at different parts in our life cycle or different times in our life cycle, we have different balances in that building up and breaking down. If you really want to get into the nitty gritty of the pathophysiology, which I think is important to understand because there are two very different types of cells that treatments for bone disease sometimes impact, we really boils down to these cells, one of which is called the osteoclast. It’s kind of like a little Pac-Man cell that’s responsible for breaking down our bone if it’s an area of injury or a little micro fracture. So that osteoclast will come in and kind of carve out a pit of bone so that the osteoblast, B as in build, can come in and fill in new bone. Again, to rejuvenate that area and to keep your bones flexible. Terry 09:22-09:34 And I’m assuming that as we get older, there are more osteoclasts or they’re moving faster than the osteoblasts building our bones back. Am I wrong? Dr. Kendall Moseley 09:35-10:58 No, I think that that’s a wonderful way to think about it. You know, the life cycle is complicated. You know, when I meet patients for the first time, and again, I’m in a metabolic bone clinic, so I see patients who generally come already with a diagnosis of osteoporosis or low bone density. And when we’re sitting there talking to one another, we say, gosh, why aren’t your bones perfect? And believe it or not, what we do is we go all the way back to childhood because changes happen throughout the life cycle to bones. We build or gain bone. We’re building more bone than we’re breaking down until about the third decade of life. So those osteoblasts are overtaking the osteoclast to give us nice, strong skeletons. So you might imagine how early childhood insults could impact the bones. In midlife, we have kind of a steady state where the blasts in the clasps are kind of remodeling at a usual rate, generally in balance with one another. At around the time of menopause that women go through, there is a steep decline in bone density, which is driven primarily by those osteoclasts, those Pac-Man cells that break down bone at a much more rapid rate than the osteoblasts are able to keep up with. And men have an inflection point later on in life. They don’t go through a menopause per se, but about the time, about 70 years of age or so, again, that imbalance starts to shift, which favors the osteoclast or bone breakdown, where again, it’s kind of like a tortoise and the hare story that the tortoise is no longer keeping up with the hare and the bones will break down. Joe 10:59-11:46 Dr. Moseley, I’m curious as to how things have changed, because I suspect that our ancestors, and when I say our ancestors, I’m not talking about Neanderthals. I’m talking more about our grandparents and our great-grandparents. they were probably spending a lot more time outdoors. You know, farmers and just workers and, you know, both men and women were just physically more active than we are today. Today, I think we spend a lot of time sitting. And I’m curious as to how our lifestyles have affected bone health over the last, let us say, 50 to 100 years. Dr. Kendall Moseley 11:47-13:01 Now, I think that that is a fair assessment. We know that activity movement is critical for bone health. You know, in fact, when we talk about the tenets of therapy for osteoporosis and low bone density, one of the things we always have to discuss in clinic is how can we get you more active? What kinds of exercises should you be doing? Because movement really stimulates those bones to kind of rebuild, grow, remodel. And so absolutely, you know, back in the days when we were out and about, you know, in the farms or, you know, pushing things, you know, down the street. I think we did have a lot more activity related to our bones. I will also counter, though, you know, we didn’t live as long back in the day. And so that graph that I just kind of talked about with this aging process kind of inevitably causing slow and steady bone loss as we get older, a lot of the implications for weakened bone really don’t occur until that later stage in life where women are postmenopausal or men are older. And so did we really see the full effects of osteoporosis and bone loss, you know, in prior generations when perhaps they didn’t live to be the older ages where the fracture started to manifest or people passed earlier from other conditions that we didn’t have treatments for? Terry 13:01-13:19 Dr. Moseley, I want to just revisit something you said a few minutes ago and really bring it back up because a lot of people think of osteoporosis as a women’s problem. And you mentioned men get osteoporosis too. Tell us a bit more about that. Dr. Kendall Moseley 13:20-14:28 Terry, thank you for bringing that up. It is a very important point. And oftentimes, you know, my practice is a lot of women in my practice, and oftentimes women will bring their significant others or their spouses and they listen to my spiel and they kind of turn to their spouse or significant other and they say, well, gosh, Maybe that means we need to screen you as well. And it’s true. So men do get osteoporosis. It is a misconception that this is a woman’s disease. Statistically speaking, about 10 million Americans in the United States have osteoporosis greater than the age of 50. About 8 million of those individuals being women, 2 million being men, although even that statistic I counter. One big point is that we really under-diagnose osteoporosis. We don’t name it when we see it, and secondly it relies upon screening for osteoporosis and as we’ve just said men really we don’t see this as a man’s disease so are we screening men to even be able to make the diagnosis in that portion of the population so absolutely bones thin at different times in our lives but there are still other factors other disease states other medications that can threaten a man’s Joe 14:28-14:56 skeleton just as easily as it can a woman’s well you mentioned medications and of course a lot of men who are diagnosed with prostate cancer are given hormone suppressing drugs, what we call antiandrogens. And I suspect that has a profound impact on bone strength and not just in men, in women too, because testosterone people think, oh, that’s a man’s hormone, but it’s responsible for bone strength in both men and women. Dr. Kendall Moseley 14:57-16:11 Right, right. No, absolutely. So one of the biggest offenders and we, you know, the term is iatrogenic, meaning sadly, we as doctors do this to patients, I mean, deliberately, because oftentimes we’re treating another disease state and we have no choice, but we do give patients oftentimes medications that have side effects that directly hurt the bone. One of those medications, in fact, is androgen deprivation therapy. So on prostate cancer with a goal to get testosterone levels to zero, we give them these hormone blockers. And it’s kind of like a menopause for men that they go through when we have that low testosterone. We know testosterone is converted into estrogen. So that causes low estrogen in men, which can hurt the bones. Women, there’s a corollary with breast cancer. So our breast cancer survivors, we treat with drugs such as aromatase inhibitors, where again, we render estrogen levels to zero. And we see oftentimes a significant amount of bone loss associated with those medications as well. Probably the worst drug that we use, but oftentimes very, very necessary for patients with chronic inflammation or autoimmune disease would be things like steroids. So steroids, I always refer to as somewhat dirty drugs. You know, if you need them, you need them, just like anti-cancer therapies. But those medications as well can really thin bones through a number of different mechanisms. Joe 16:12-16:36 So the anti-estrogens for breast cancer, the anti-androgens for prostate cancer, and the corticosteroids that are used for so many different conditions, including autoimmune disease and asthma and COPD, all of those medications can have a profound effect. Should everybody who’s taking one of those medications get a bone scan? Dr. Kendall Moseley 16:37-18:07 In my humble opinion, absolutely. And I think most guidelines would agree. I, you know, it depends on timing. So the low hanging fruit, the easy answer would be with your anti-estrogen medications and your anti-testosterone medications. And certainly if you know an individual is going to be treated with those drugs, it’s usually for a longer period of time. So anti-estrogen medications upwards of five to 10 years in many breast cancer survivors. Anti-androgen medications oftentimes not as long, but sometimes two years or more. And in those patients, you absolutely do want to get a screening bone density test and anticipate that in fact those medications are going to thin the bones and ideally jump ahead of that problem. And again, we have interventions we can use pharmacologically and lifestyle-wise to anticipate the bone loss and obviously treat it before it becomes a problem. Steroids are a little bit trickier. Steroids in general, we say that if a patient is going to be on a dose of prednisone or an equivalent of 5 milligrams or more for 3 months or more continuously, that would be a dose at which you certainly would want to get a screening bone mineral density test, potentially treat to prevent bone loss, depending on what that screening bone mineral density test shows, and then follow the patient more closely. We’re not as worried about the inhaled steroids. We’re not as worried about steroid injections that patients oftentimes will get for joint pains and arthritis. It really is the systemic steroids that cause the most problems. Terry 18:08-18:15 You’re listening to Dr. Kendall Moseley, Medical Director of the Johns Hopkins Metabolic Bone and Osteoporosis Center. Joe 18:16-18:21 After the break, we’ll learn the difference between osteopenia and osteoporosis. Terry 18:21-18:24 If you break a bone, does that mean you have osteoporosis? Joe 18:25-18:27 What are the options for treating osteoporosis? Terry 18:28-18:30 Exercise might be helpful. Which ones are best? Joe 18:31-18:33 Should you be wearing a weighted vest? Terry 18:39-18:42 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 18:51-18:54 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 18:55-19:13 And I’m Terry Graedon. Joe 19:13-19:21 Today, we are talking about bones. How would you know if your bones are strong or vulnerable to breakage? Terry 19:21-19:27 What options are available to maintain bone health? Are some exercises better than others? Joe 19:27-19:52 We’re talking with Dr. Kendall Moseley, Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. Dr. Moseley is Clinical Director of the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins. She’s also Medical Director of the Johns Hopkins Metabolic Bone and Osteoporosis Center. Terry 19:53-20:17 Dr. Moseley, I think there are a lot of kind of long, complicated words that we need to deal with in this interview that people may have heard or maybe not have heard, but are not completely certain what does it mean. So let’s start with the difference between osteopenia and osteoporosis. Dr. Kendall Moseley 20:18-24:09 Right. I think that’s a great question. There’s a lot of big words in the bone field, and those would be the big ones that patients bring to the office. So we have to think about bone density and bone health and bone strength along a spectrum. So, you know, spectrums are uncomfortable for a lot of people. We like to have our bins, our diagnoses. And so in the bone world, we divide things into normal. We say osteopenia, although we are getting away from that term. We more so use low bone density and then frank osteoporosis. And the World Health Organization would define those three terms based on a T-score. And what is a T-score? So To make a diagnosis, to screen for osteoporosis, we use a very specialized scan called a DEXA scan. It’s a dual energy X-ray absorptiometry scan. You can see why we call it DEXA. And it’s basically a fancy X-ray. And it’s a 2D interpretation of bone quantity, usually looking at the spine, looking at the hip. And it’s two different locations in the hip. It’s the total hip and the femoral neck. And sometimes we even look at a forearm in certain circumstances and disease states. And it’s that fancy x-ray, again, that we use to follow osteoporosis, but more importantly, to diagnose it in those in whom we’re worried that they have thinner bones. That T-score is really just a standard deviation. And the standard deviation is that individual’s bone compared to that of a 30-year-old, which seems very unfair. But as I said earlier in the segment, we really gain bone until about the age of 30. So we’re kind of comparing that patient to what their ideal should have been back in the day. A T-score, anything between 0 and negative 1 is considered normal, so normal bone density. Anything between negative 1 and negative 2.5 or 2.4, excuse me, is considered low bone density or osteopenia. And anything less than or equal to a negative 2.5, again, negative 2.5 standard deviations from normal is considered osteoporosis. And that’s what spits out on the reports, and that’s oftentimes what patients bring to the clinic. Although it’s very, very important to insert a big caveat here. People with low bone density or osteopenia can still fracture. In fact, the majority of fractures, which is the take-home message, we’re trying to prevent broken bones, the majority of people who fracture actually are in the osteopenia or low bone density range as compared to the osteoporosis range bone density. So if someone comes to clinic and maybe that DEXA scan says the T-score is a negative 1.5 or it’s a negative 1.8, which technically, again, is osteopenia or low bone density. If that same patient has also had a fracture, a fragility fracture, that patient has osteoporosis. So it doesn’t matter to me what this screening scan shows. If that bone has broken in a fragility manner, and gosh, I get that question all the time, too, so I’m going to beat you to it. What is a fragility fracture? This is a fracture of the spine, hip, pelvis, wrist, upper arm from standing height or less. So slipping outside on an icy street and bracing your fall with your wrist, if you break that wrist, that is a fragility fracture. Stepping out of the bathtub and maybe the floor is a little bit slippery and you come down hard on your hip and you have a hip fracture, that is osteoporosis. Falling out of a two-story building or a motor vehicle accident and you break your pelvis, that’s just lucky, you know, walked away with just one broken bone. So, again, fragility fractures, no matter what that bone density test is showing, whatever that score says, if you have a fragility fracture, you have a diagnosis of osteoporosis, that should be treated. It’s akin to having a heart attack, right? I don’t need a cath if you’ve had a heart attack to tell me you have cardiovascular disease and we have to take that seriously. Joe 24:09-24:51 I’ve got a question for you because our grandson, who’s seven, was running the other day at camp and he tripped and he fell and he broke his arm. That happens a lot to kids. You know, they fall off the jungle gym or they fall off their bicycle and they land and out goes their arm and boom, they’ve broken it. Now, they don’t have osteoporosis. Why would a woman who falls in a similar situation, maybe while riding a bicycle, why would she be automatically defined as osteoporotic? Dr. Kendall Moseley 24:53-26:07 Well, a woman who falls off a bicycle, that’s considered traumatic, right? So maybe it’s less than standing height because she’s sitting down on a bicycle, but she’s fallen off of a moving object going presumably at a fairly rapid speed and you get entangled in the wheels, etc. So I would probably talk through the logistics of that particular fall, and I would probably walk away saying that was more traumatic than atraumatic. Getting back to kiddos, they’re a different bird. So again, falling off of a jungle gym, that’s from a height higher than standing height. Kiddos also have just very different bones. So their bones are kind of built to be a little bit more flexible. They’re a little bit more rubbery. They remodel at a faster rate. And so they do oftentimes get these fractures, you know, tripping, falling, bonking their heads. We had that a couple of weeks ago in our household. We know those fractures heal very rapidly. Where we start to worry in kiddos, and this is probably beyond even the scope of our discussion today, is when there are multiple fractures, low trauma fractures, you know, situations in which it doesn’t make sense that that arm or that leg breaks. And then there’s a whole host of genetic conditions that oftentimes we will screen for to make sure that, in fact, that child doesn’t have a metabolic disease. Terry 26:07-26:42 Well, I think it’s important for parents to realize that a situation like that requires extra attention. But we’re not going to follow through on that any further. What I’d like to do is go back to your idea that a fracture might institute treatment. And what I mostly hear from people my age, women my age, is that they have been told by their doctor that they have to take a drug because of the osteoporosis. Joe 26:42-26:47 And a lot of them don’t want to take a drug. Or the osteopenia in some cases. Terry 26:47-27:08 Or the osteopenia. And the most popular drugs are the bisphosphonates like alendronate, which used to be called Fosamax. So what options are there for treating osteoporosis? Is bisphosphonates where you start? Or are there other things people can do? Dr. Kendall Moseley 27:10-29:57 Now, when I talk to patients, I always break it down into, gosh, what are things that you can leave here with? What is your to-do list going to look like? And that can be things like calcium, vitamin D, exercise, protein, other healthy lifestyle interventions, and we can get into that absolutely. And then there’s things that maybe I need to do, you know, when the prescription pad may need to come out. When we think about osteoporosis and how we treat osteoporosis, again, we love our bins in medicine. It helps to organize our thoughts and kind of talk to people about how we’re thinking about their disease state. And osteoporosis is no different. We think about it on a spectrum. So is the osteoporosis mild? You know, in a mild case of osteoporosis, maybe just low bone density, no prior fractures. We sometimes use a tool called a FRAX calculator that comes up in the guidelines. If we’re seeing signals that things are generally fairly positive, we might just recommend lifestyle interventions, calcium, vitamin D, some good exercise, protein, et cetera. As we move further down into the different bins, we get into different categories. So moderate osteoporosis or low bone density, where again, the DEXA scan is giving us data, we don’t like to see the numbers are decreasing. There’s maybe an increased falls happening at home. The FRAX calculations are more elevated. That might be a category in which, in addition to lifestyle interventions, we might recommend medical therapy, usually something more mild. You know, if we think about it as a swimming pool, we start in the shallow end and get a little bit deeper. That might be an oral bisphosphonate. For women, we use things called selective estrogen receptor modulators, which act on the estrogen receptors within the bone. As we wade deeper into the pool, we get into the more, you know, severe osteoporosis or, excuse me, high-risk osteoporosis or severe osteoporosis. In those categories, that’s when we start using, again, in addition to lifestyle interventions, the calcium, the vitamin D, and the exercise, that might be a place at which we do start to recommend more intense pharmacotherapy. That might still just be an oral but it may be an infusion, it may be an injection, depending on the case. What I think, though, doesn’t always matter. I think everything comes down to forming a relationship with a patient and talking through what the patient’s concerns are about their bones, what their concerns are about the logistics of a medication. Because if I think you need a daily injection, but you don’t want to do anything, there’s no point in us kind of not reaching any sort of conclusion in terms of treatment. If you’re in a very high-risk fracture category, we might want to start with a bone-building drug. But if you tell me all you’re willing to do is an oral pill once a week, I’d rather not let perfect be the enemy of good. And we might start with something milder, despite what I think. Joe 29:57-30:24 Dr. Moseley, you’ve mentioned exercise a couple of times, and we’ve gotten all kinds of recommendations with regard to exercise. You know, it has to be bouncy exercise. You have to jump up and down. You have to stress your bones. And then we’ve heard from other experts who say, you know, if you do Tai Chi, it’ll actually be good for your bones. Terry 30:24-30:24 Or yoga. Joe 30:25-30:37 Or yoga will be helpful. And so there’s just a lot of confusion around the best kind of exercise or it’s just exercise in general. Walking, will that be helpful? Dr. Kendall Moseley 30:39-32:45 Yes, yes, and yes. So my take home with patients is always just keep moving. Just keep moving. We all have physical limitations, right? There are patients who can’t, you know, run. They can barely walk. Oftentimes they’ll come in in a wheelchair and a walker, but it’s important that they move their bodies. Walking counts in terms of exercise. There are two, you know, big picture issues when we think about exercise and bone or movement and bone. And the first is, yes, is there a way that we can kind of physically tax or stress bone in a way that promotes healthy bone remodeling and bone building. And there are data in individuals who use high-intensity exercise. There was a trial called the LIFTMORE trial looking at women and men, older women and men, with supervised high-intensity exercise about three times per week and showing, in fact, there was benefit to the bone. And this is heavy weights. This isn’t just your little two or three pounders that you’re using, but in fact, supervise, you know, high weight, high intensity exercise, and they gained bone. Is that possible for all patients, to all patients have access to that sort of exercise and gyms and equipment, et cetera? Not necessarily. So the second thing we need to think about with exercise and the importance of exercise is, gosh, how do we keep you upright and fracture free by virtue of the fact you’re not falling? So if we can strengthen individuals, lower body strength, core strength, and you can get that just through walking or through yoga or through Pilates, you know, really making sure that you have a sense of self in space, keeping you from falling, that’s a victory in and of itself as well when it comes to bone strength. So, yes, I mean, would we love everybody out there lifting, you know, 30-pound weights and a supervised setting and potentially gaining some bone? That would be lovely. But I think realistically speaking, we all bring different limitations to a clinical setting. And just moving, again, just getting those legs working, just getting a sense of balance, sending people to physical therapy for balance training and core and posture, that can be just as important as getting them into a gym. Terry 32:45-33:30 Dr. Moseley, there’s something else I’d like to ask you about while we’re on this topic of physically stimulating our bones. Something that’s gotten some buzz is vibration. And there are people who have purchased pads that they stand on that vibrate to try to help their osteoporosis. there is also a device that I saw, I think it has been cleared or approved, I’m not sure which, by the FDA. You wear it like a fanny pack. It’s a belt called an Osteoboost and it vibrates for half an hour a day, provided you wear it that long. Are these devices of any use? Dr. Kendall Moseley 33:32-35:28 I think the jury’s still out. I get those questions all the time in clinic because, Again, I’m very encouraged that patients want to feel empowered with their health and they want to do things other than just take a pill or do an injection. I think it’s important. It’s a partnership that way. What can you do? What do I need to do to strengthen your bones? So vibration plates and these vibratory belts that are out there now, I think they’re trying to get at the pathophysiology of bone remodeling, which is, again, stressing bone, targeting mechanoreceptors that live in the bone that cause release or non-release of hormones that could be detrimental to bone remodeling and bone strength. And I think there’s promise there in the idea that it’s targeting, again, these mechanoreceptors in the bone. What we don’t have with either the vibratory plates or the belt are fracture data. So there are some data potentially showing stability of bone density with the use of these different devices. There are some data potentially showing some improvement in bone density. With the belt, it was only tested in individuals with low bone density or osteopenia. We don’t know in an osteoporosis population. The vibratory plate data is kind of all over the place. But what we don’t have with those devices is fracture prevention data. And that’s always hard to get. Even in the drug trials, you need thousands and thousands of study subjects to determine if that intervention is going to reduce fracture risk. So we may never have that information. So what I tell patients when they bring those, you know, pamphlets to the office or that printout or that clipping from a newspaper article is they say, I don’t think that these devices are going to hurt you at all. I think, in fact, they potentially could be beneficial to you. And how can we work those devices into our treatment plan so that, Again, you are doing things at home that may be beneficial to your bone, but I’m also keeping tabs on your bone density. And we, again, can decide together if we need to ratchet up your treatment plan to the point where we need pharmacotherapy. Joe 35:28-35:38 Dr. Moseley, I’ve been seeing a lot lately about weighted vests or sort of backpacks that are supposed to be good for you. Any thoughts about that? Dr. Kendall Moseley 35:39-36:37 Weighted vests are going to fall into the vibratory plate category and even these belts. And it’s the idea that you want to put deliberate strain on your bones to encourage them to remodel more actively. And again, this is a space where we maybe have some data showing stability of bone density, maybe a little bit of improvement in bone density. We do not have fracture data showing that weighted vests are beneficial to bone health. My challenge I have with them is depending on the vest, and there’s so many different types out there, they sometimes can cause low back pain. They can cause posture problems. We certainly don’t want anyone falling over from their weighted vest. So if there’s any hint that the vest might cause instability in the patient, I tend to be against them. But gosh, if it’s one more tool hanging by the front door that encourages someone to go outside and take a walk with their weighted vest on, by all means, I’m very optimistic that this could be something, again, to motivate people to take their bones into their own hands. Terry 36:38-37:03 You’re listening to Dr. Kendall Moseley, Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. Dr. Moseley is also Clinical Director of the Division of Diabetes, Endocrinology, and Metabolism and Medical Director of the Johns Hopkins Metabolic Bone and Osteoporosis Center. Joe 37:04-37:08 After the break, we’ll learn about raloxifene as a treatment for osteoporosis. Terry 37:09-37:12 It might reduce the risk of breast cancer as well as of bone fractures. Joe 37:13-37:20 What other drugs do doctors prescribe for osteoporosis? And what are their pros and cons? Terry 37:20-37:24 Are there problems in stopping certain bone-building drugs? Joe 37:24-37:27 Dr. Moseley will share her pillars of treatment. Terry 37:40-37:43 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 37:53-37:56 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 37:56-38:13 And I’m Terry Graedon. Joe 38:13-38:23 There are now numerous medications to improve bone health, but they all have some side effects. Which are the safest and most effective? Terry 38:23-38:41 The FDA first approved a drug called raloxifene in 1997 to prevent postmenopausal osteoporosis. The brand name was Evista. Although other osteoporosis medications approved around the same time are still in wide use, raloxifene has almost disappeared. Joe 38:42-38:52 Why don’t doctors consider raloxifene for osteoporosis? This medication has another important benefit that has seemingly been forgotten. Terry 38:52-39:18 Today’s guest is Dr. Kendall Moseley, Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. Dr. Moseley is Clinical Director of the Division of Diabetes, Endocrinology, and Metabolism and Medical Director of the Johns Hopkins Metabolic Bone and Osteoporosis Center. Joe 39:20-40:00 Dr. Moseley, we’d like to talk about treatment first and some of the medications that you do prescribe. And I’m just curious about a drug that seems to have been forgotten. I mean, it never really gained much popularity, but it’s, I think, kind of an interesting medication called raloxifene because it has both, I’ll call it pro-estrogen and anti-estrogen activity, which seems like an oxymoron. Like, how could that possibly be? But could you just give us a quick overview of a drug that seems to have gotten kind of dusty in the dustbin of history? Dr. Kendall Moseley 40:02-43:08 Sure. I don’t think of it that way as a dusty drug. We actually use a fair amount of it in our clinics because it has a role in osteoporosis care. So raloxifene is what we call a SERM. It’s a selective estrogen receptor modulator. And as you indicated, it has stimulatory properties at the level of the bone and actually inhibitory properties to tissue such as the breast and the uterus. So raloxifene is actually similar to a drug called tamoxifen that many women and men have heard of it that’s used as an anti-breast cancer medication in that patient population. So raloxifene, for starters, because it’s a selective estrogen receptor modulator, is not to be used in men. It is solely to be used in women. And we generally, as I was talking about those bins of risk, the low, the moderate, the high risk, and very high risk, we generally reserve that medication for individuals in a low to moderate risk category. And that’s because we have data showing that raloxifene, in fact, does reduce the risk of vertebral compression fractures. And again, we look at different types of bones and different fractures. We don’t have as much data demonstrating that raloxifene actually reduces the risk of hip fracture. And so when we have patients who maybe have low risk or moderate risk osteoporosis, it’s spine predominant, we see that that’s the lowest site. Oftentimes we will use raloxifene. It’s a daily pill. It’s easy to take. It’s easy to stop. It has a relatively low side effect profile. So probably the first thing I warn women is beware, your hot flashes may come back once you start this medication. Some run for the hills when I bring that up. Others say no problem. It doesn’t typically last forever, but certainly for the first few weeks or so, those hot flashes can come back. The other side effect that’s certainly more serious than the hot flashes would be that it can increase the risk of blood clots and stroke as a result. So if there’s a patient who has a history of blood clots or a clotting disorder or pulmonary embolus, again, that would not be a medication of choice. The reason it is appealing to a lot of women and certainly even our use in clinic is it doesn’t necessarily come with the more scary side effect profile that some of the other drugs have. So, again, you can start it and stop it at any time without any ramifications, no rebound bone loss. You can take it indefinitely as long as the patient is tolerating it without concern for jaw necrosis or atypical femur fractures that, again, come up with some of our other drugs. So it’s fairly easy to use. It’s inexpensive. We don’t typically have to fight the insurance companies too terribly hard to get it prescribed. So that’s helpful. And we actually wind up using raloxifene a fair amount for, again, those patients who come in and they acknowledge that their bones are less than perfect. They’re concerned about their bone health, but perhaps they’re similarly concerned about medication side effects. And again, in the interest of not letting perfect be the enemy of good, if what we decide upon is raloxifene, this daily pill that may not have that hip fracture prevention data, it’s certainly better than nothing. So again, in our bone clinics, we do use it. Joe 43:08-43:51 And the thing that I think a lot of women find very attractive about raloxifene is that it It has a breast cancer prevention piece as well as, as you pointed out, a vertebral fracture prevention piece. So it’s sort of a double benefit. But let’s move on, Terry, to some of the other medications because, as you’ve already mentioned, there are some pretty serious side effects. And you mentioned atypical femur fracture. We want to talk about the tooth problem. And we want to talk about some of the newer drugs that are injectable that once you get them, it may be in your body for six months or longer. Terry 43:51-44:04 But let’s take that one at a time. So let’s start with those bisphosphonates that Joe was alluding to. What drugs are we talking about? When do you use them? What do people need to know about them? Dr. Kendall Moseley 44:06-47:19 Right. So we can start, I guess, with the bisphosphonate category. And bisphosphonates are probably the old guard of the osteoporosis regimen. I mean, they started, you know, greater than two decades ago with use of these. And probably the one most people have heard about is alendronate. Alendronate is a once-a-week pill that’s a little bit challenging to take. You take it first thing in the morning, full glass of water, nothing else to eat or drink for an hour, no going back to bed. And these medications, the way that they work in the bisphosphonate category is they are drugs that effectively get incorporated into the bone, into the hydroxyapatite matrix of the skeleton. And once these drugs are incorporated into the bone and they come in proximity of those Pac-Man cells, see here those cells come back again. When those Pac-Man cells come along and encounter these bisphosphonates, they effectively render the Pac-Man cells, the osteoclast, useless. So they can’t break down bone anymore. they’re incorporated into the skeleton, so they do have a lasting effect. And when I talk to patients about these, we kind of think about it like coats of paint, right? So with each year that you’re on these drugs, you kind of paint the wall once again and once again and once again, and the paint can accumulate, which is why there can be concern about long-term use of these medications. And I’m going to throw five years out there, but there’s no rule that five years is a maximum amount of use you can do these. But after about five years of use, we do start to consider a pause in therapy in the appropriate patient because of these layers of pain and this, you know, potential paralysis of the Pac-Man cell and paralysis of a bone remodeling process can cause adynamic and potentially more brittle bone. You know, if your bones are frozen and they can’t rebuild and remodel themselves, we worry that that’s not healthy either for the skeleton because we do start to encounter very rarely atypical femur fractures where kind of there’s a hip fracture that happens below the, you know, kind of along the thigh, which is not anticipated, or we can see jaw complications with jaw erosion, that things can get infected, all stemming from this idea that brittle old bone can’t rebuild, remodel, and heal itself as easier as, you know, refreshed bone. There’s an IV formulation of that pill now called zoledronic acid. It’s administered once a year. So in patients who really aren’t good at swallowing pills, patients who have esophageal disorders, history of ulcers, which can be a side effect of the alendronate therapy or the oral bisphosphonates, this once a year drug can be quite helpful. It’s given through the vein over about 30 minutes. That one, typically three to five, although again, with an asterisk in the appropriate patient, sometimes we go shorter versus longer. But that drug two, similar side effect profile with rare risk, again, of these atypical femur fractures and jaw necrosis. But I always like to pause there and say, you know, these are rare side effects and we have to always consider the alternative, which are what are our real concerns about you breaking your hip or breaking your spine or losing bone in the context of that new steroid that you’ve been prescribed. So it’s always a balance talking about side effects of medicine, which they all have, and the benefit of the drug at the end of the day and reducing fracture risk. Oftentimes we have to 50 to 60 percent. Terry 47:19-47:32 And I’m supposing that there’s no really good way to predict ahead of time who might be at higher risk for one of those really awful side effects like an atypical femur fracture. Dr. Kendall Moseley 47:33-49:37 Yes, I mean, I wish I had a crystal ball. I mean, we do know that there are certain individuals at higher risk for the more rare but real side effects. So jaw necrosis, in general, the risk will be higher in, let’s say, cancer patients. So they get bisphosphonates at much higher doses, much more frequent doses. But even in osteoporosis patients, and it would typically be in the setting of what we consider to be invasive dental work. So this is if you are having an extraction, you’re having an implant, you’re having a bone graft where there’s kind of deliberate invasion of the jaw bone itself that can become subsequently infected. and the concern is that bone once infected can’t heal itself well and can, you know, erode over time. We get questions a lot about things like root canals or what about, you know, braces. Sometimes our orthodontists are worried about braces or bridges, caps. Those are not invasive. We’re not getting into the jaw in those contexts. So again, we’re less worried about that and the jaw necrosis complication. Atypical femur fracture is something that typically we have observed, and it’s been really since the onset of alendronate. Women used to get a prescription for alendronate in one hand and hormones in the other hand, and it was see “see you again never.” So we’ve learned now that with longstanding bisphosphonate use, we can see these atypical femur fractures. And that’s why I gave that five-year number a little bit ago, which is where after about five years of use, We don’t see a precipitous increase in atypical femur fractures, but we certainly start to consider, is this medication actually necessary? Because that long-term use can be a problem. We see increased risk in individuals on bisphosphonates who’ve also been treated with long-term steroids. Both conditions can cause this adynamic or frozen bone. And we know that Asian women are at higher risk for atypical femur fractures. So that’s something that we always want to consider when meeting with the patient, again, on that yearly basis to decide whether or not it’s appropriate to continue therapy versus discontinue the therapy. Terry 49:38-50:12 Now, Dr. Moseley, let’s assume that your patient has been on a bisphosphonate for five years, has stopped, comes back to you in a year or two, and you say, that osteoporosis, it’s still a problem. We’re going to move on to the next category of drugs. You have those bone-building drugs, but there’s a problem with them as well. You mentioned before that raloxifene, the SERM, is easy to stop, but some of these bone-building drugs, they could be hard to stop. Dr. Kendall Moseley 50:13-50:25 Well, I want to kind of push back a little bit on the bone-building. I think the drug you may be referring to is denosumab, which actually is a drug, which is an anti-breakdown drug, first and foremost. Joe 50:26-50:42 And Dr. Moseley, a lot of people are not familiar with generic names like Alendronate or Denosumab. So we’re talking about Fosamax in the case of the bisphosphonates, and Prolia is the brand name for Denosumab. Terry 50:42-50:46 Or is it pronounced Prolia [pro-LEE-ya]? I’m never sure exactly how, and I’ve heard it both ways. Dr. Kendall Moseley 50:47-52:44 I’ve heard it in both scenarios as well. You could probably use them interchangeably. And I’m glad you said that too. The academician in me has been taught never to use the trade names. But no, the denosumab, the prolia, or prolia, however you’d like to inflect that, that’s the one that’s an anti-breakdown drug that has more anabolic properties. So if you want to gain bone, oftentimes we do see more improvements statistically at the spine and the hip with that every six-month injection. But indeed, and I’m glad you brought this up, Terry, because it’s important, that drug, once you start it, it can be challenging to stop. That drug works very differently from the bisphosphonates. It is what’s called a RANK ligand inhibitor, which basically interferes with how the osteoclast and the osteoblast communicate with one another. But it’s a monoclonal antibody, meaning it doesn’t get permanently incorporated into the skeleton. Rather, it’s given every six months because it’s almost as though the clock strikes midnight when you stop it. And all of these cells, all of these osteoclasts that have been kind of paused for the duration of the use of the medication, if you stop it abruptly, they wake up and have a party and can actually break down your bone at a very rapid rate to the point at which we’ve even seen spontaneous vertebral compression fractures in patients who stop their medication without talking with their doctor first. So that drug gets every six months. It is not impossible to stop. In fact, we’re looking as a society at different transition mechanisms, usually, and almost, actually, I’ll say almost always with the use of a bisphosphonate to try to prevent this rebound effect of the drugs to see if patients can stop the medication. but it can be very challenging. So that drug is not for those who come to see me and don’t want to take anything or those who oftentimes have a difficult time making it to their clinic appointments. That is a drug for individuals highly committed to their bone health and very dedicated to a treatment course of 5, 10 or even beyond that years. Joe 52:45-53:28 Dr. Moseley, what about estrogen? I mean, estrogen, it seems like a roller coaster ride. Back in the, oh, I’d say 1970s, 1980s, Premarin was the number one most prescribed drug in America. Just about every woman who was going through menopause was put on Premarin. It’ll take away your hot flashes. It’ll build your bones. It’ll make you feel sexy. I mean, it’s the greatest. And then of course along came the women’s health initiative and then oh my goodness no estrogen it’s too dangerous and now it seems like estrogen is coming back again tell us a little bit about estrogen and bones. Dr. Kendall Moseley 53:29-55:08 Yes, well I mean, that’s uh, you’re right it’s a very very hot topic now and I think we’re all kind of re-evaluating how we think about estrogen not just for bone health but also women as they’re going through the perimenopause, you know, did we kind of throw the baby out with the bathwater, so to speak? We love estrogen for bones. You know, as I described earlier, women lose a tremendous amount of bone density through their perimenopause due almost entirely to this decline in estrogen. It’s like we take the brake off of the osteoclasts and they wake up and they break down a lot of bones. So we absolutely like estrogen for bones. What’s happened though, is that estrogen is really not first-line treatment for osteoporosis or low bone density, in part due to the fact that we do have these data potentially in older women showing increased cardiovascular risk, increased cancer risk. So we don’t typically use it as a first-line drug to treat osteoporosis or prevent bone loss. But if we do see women who are on estrogen for other purposes, maybe they’re on it for vasomotor symptomatology or mood or difficulty with sleeping, We certainly will keep those women off on their hormones, excuse me, and potentially add additional therapy down the road for bone health if we feel that it’s warranted. So we’re probably going to see that pendulum continue to swing back. There is a committee being formed as we speak to reevaluate this exact question about the role of menopause hormone therapy and osteoporosis treatment to see, again, if maybe we got a little bit ahead of ourselves and underestimated the importance of estrogen and bone health, particularly in younger women. as they go through the early stages of their menopause. Terry 55:09-55:21 Dr. Moseley, unfortunately, I don’t have these generic names on the tip of my tongue, but drugs like Forteo, for example, now, is that a drug that is meant to build back bone? Dr. Kendall Moseley 55:22-57:04 Absolutely. I’m glad we’re spending some time on this because it’s a very important category of medications, these anabolic or bone-building drugs that we use in these high-risk fracture individuals. So very low bone density, multiple fractures, oftentimes failing other drugs, where we have to turn to this category of bone building drugs. And there’s a few, luckily, in that category now. So starting with your self-injection medications for up until about two years, we’ve got abaloparatide and teriparatide, also known as Tymlos and Forteo. And these are subcutaneous injections that patients, in fact, give themselves. And sometimes we see those eyebrows shoot straight up when that seems to be a tall ask for the patient. But it’s a self-injection for up to two years. It’s actually parathyroid hormone, interestingly enough. So we’re harnessing the body’s own hormone, giving it back to patients in a pulsatile fashion, which can increase bone density. And then the other drug that’s slightly newer approved in 2019 called romosozumab or Evenity, which are subcutaneous injections administered monthly in a healthcare setting for up to one year, so 12 sets of injections. It should be noted that all of the bone-building drugs, the abalaparatide, the teriparatide, and the romosozumab, after that one- to two-year treatment duration have to be followed by an anti-breakdown drug. If they’re not followed by an anti-breakdown drug, either an oral bisphosphonate, an IV bisphosphonate, or denosumab, in fact, those patients very sadly can lose whatever bone they’ve gained while on treatment back down to baseline, which is always a very, very sad day when we see those patients in clinic because it’s a wasted opportunity to build good bone. Joe 57:05-57:40 Dr. Moseley, there’s one important area that we have not talked about, and that is fall prevention. You know, we talk a lot about exercise. We talk about other lifestyle changes, but avoiding a fall may be the most important thing of all in preventing a fracture of the hip or even a fracture of arms or legs or goodness knows what else. So how can not just women, but older men avoid a fall that could lead to a fracture? Dr. Kendall Moseley 57:41-59:36 Right. No, I think that’s a tremendous question. In fact, every clinic visit, when I see patients, we go through, have you had any falls this year? The first step is assessing the home. And I think the majority of falls happen in the home and it might be a throw rug. It may be furniture that’s too close together. It may be, you know, plastic toys from the grandchildren underfoot, pets. I’m not saying get rid of the grandchildren or the pets, but we do have to be conscientious about our home environment to make sure there’s grab bars on the shower. Make sure that the impediments to just walking aren’t challenging. Some people choose to move to single-story homes, you know, if stairs become too difficult. I think that’s also something to consider. But then there’s also the strengthening itself, the balance and the posture. So oftentimes we fall when we become unstable. Sometimes we don’t have a choice. There’s neuropathy, excuse me, that sets in due to nerve conditions, diabetes, et cetera. Sometimes there’s low vision that we have very little control over. But those things that we can modify, lower body strengthening, posture, core strength, which certainly over time become weaker, people become more stooped. all of those things lead to increased risk of falls. And then finally, we have to really, as clinicians especially, reevaluate those medication lists. I think geriatricians or, you know, boneheads, people across the board agree that a lot of times falls happen because of the medicines we put people on. And this can be anything from anti-diabetes medications, which can cause dips in blood sugar and cause some dizziness, to different types of nerve medications that may cause dizziness over treatment of blood pressure, where blood pressure is quite low. I see many, many falls in the context of maybe overly aggressive medication regimens, or maybe patients just aren’t talking about how they feel dizzy every single time they stand up after that new blood pressure medicine was added. But we really owe it to our patients to make sure that every drug on that medication list needs to be there, particularly as it pertains to fall safety. Terry 59:37-59:51 Dr. Moseley, we have only two minutes left of time. So I am going to ask you to summarize, please, your pillars of treatment, the things that we all need to take away from our conversation today? Dr. Kendall Moseley 59:52-01:00:03 Oh, so many pillars and so little time. So we started with lifestyle. It absolutely is important that patients really follow as healthy a lifestyle as possible. Calcium is important for bone… Terry 01:00:03-01:00:04 How much? Dr. Kendall Moseley 01:00:03-01:00:09 I know there’s a lot of debate. So calcium, the recommendation… Joe 01:00:07-01:00:09 How much and what kind? Dr. Kendall Moseley 01:00:09-01:01:27 So exactly. So the boneheads and even the cardiologists agree that calcium for those with established bone disease, again, this is not a healthy community dwelling population, but those who make it into a bone clinic who are at risk for fracture, 1200 milligrams a day, ideally through diet, ideally, but there are dietary restrictions. So if you have to take a supplement, calcium citrate is the supplement of choice. It’s better absorbed. You don’t have to take it with a meal. And in fact, it does not require an acidic environment for absorption. Vitamin D, very important. Ideally, we’re shooting for a blood level anywhere between 20 to 30 nanograms per milliliter, depending on what guidelines you look at. And for some patients, that might mean 1,000 units a day. For others, 5,000 units a day. For others, prescription strength. So that’s something to work on with their physician. Exercise so resistance training and walking counts about 150 minutes per week as high intensity is tolerated and then finally protein we really protein is having its moment so we want to aim for 0.5 grams of protein at least per pound of body weight because we know we lose muscle as we get older and that’s critical for bone health so lifestyle factors and then obviously the pharmacologic strategies as we discussed earlier if absolutely necessary. Terry 01:01:28-01:01:33 Dr. Kendall Moseley, thank you so much for talking with us on The People’s Pharmacy today. Dr. Kendall Moseley 01:01:34-01:01:42 Thank you so much for having me. And it’s always a joy to talk to people who are interested in bones. And hopefully people walk away with a few little lessons themselves today. Terry 01:01:43-01:02:08 You’ve been listening to Dr. Kendall Moseley, Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. Dr. Moseley is clinical director of the Division of Diabetes Endocrinology and Metabolism. She’s also medical director of the Johns Hopkins Metabolic Bone and Osteoporosis Center. Joe 01:02:09-01:02:18 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Terry 01:02:18-01:02:25 This show is a co-production of North Carolina Public Radio, WUNC with the People’s Pharmacy. Joe 01:02:26-01:02:55 Today’s show is number 1446. You can find it online at peoplespharmacy.com. The show notes now include a written transcript of this conversation. At peoplespharmacy.com, you can also share your comments about today’s interview and let us know what you do to keep your bones strong. You can also reach us through email. We’re radio at peoplespharmacy.com. Terry 01:02:56-01:03:19 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. In the podcast this week, you can hear how estrogen might be used to make bones stronger. What about other drugs that build bone? What practical steps could you take to prevent falls and avoid breaks? Joe 01:03:19-01:03:43 At peoplespharmacy.com, you can sign up for our free online newsletter to get the latest news about important health stories. When you subscribe, you also have regular access to information about our weekly podcast. We’d be grateful if you would consider writing a review of The People’s Pharmacy and posting it to the podcast platform you prefer. In Durham, North Carolina, I’m Joe Graedon. Terry 01:03:43-01:04:21 And I’m Terry Graedon. Thank you for listening. Please join us again next week. Thank you for listening to The People’s Pharmacy Podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money. Joe 01:04:22-01:04:31 If you like what we do and you’d like to help us continue to produce high-quality, independent healthcare journalism, please consider chipping in. Terry 01:04:32-01:04:36 All you have to do is go to peoplespharmacy.com/donate. Joe 01:04:37-01:04:50 Whether it’s just one time or a monthly donation, you can be part of the team that makes this show possible. Thank you for your continued loyalty and support. We couldn’t make our show without you.

Over the years, we have spoken with scores of healthcare experts about chronic illness. Many of them attribute the problems to inflammation, which is after all a natural response to infection or injury. But not everyone has a system for locating and addressing the source of the inflammation. If you want to treat the cause, not just the symptoms of your disease, you might want to consider functional medicine. At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen: You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, May 30, 2026, through your computer or smart phone (wunc.org). Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on June 1, 2026. What Is Functional Medicine? Many people have heard of integrative medicine. We asked our guest, Dr. Susan Payrovi, how this differs from functional medicine. (She practices both.) According to Dr. Payrovi, while both approaches embrace lifestyle therapies, integrative medicine may focus on individual organ systems, just as conventional medicine does. Functional medicine, on the other hand, is more likely to focus on how the body works. What functional systems are involved when a person experiences fatigue, for example? If there is a problem with the way the body produces energy, how could that be resolved? If you are dealing with a problem caused by underlying inflammation, you could prescribe a potent anti-inflammatory or even a medicine that counteracts the immune system’s response to danger by blocking interleukins, for example. Or you could search upstream for the disturbance that is causing the immune system to overreact. Going upstream to find the cause is the functional medicine approach. Sending the Body Safety Signals If inflammation is a response to a danger signal, how can we let the immune system know that the body is safe? Lifestyle therapies offer some powerful interventions, even though they may sound very ordinary. Getting adequate sleep can make a huge difference for the immune system and lower inflammation dramatically. Stress management is another potent non-pharmaceutical approach. Consuming a diet rich in anti-inflammatory foods or even medicinal herbs could also contribute to a sense of safety and reduced inflammation. The Silo Problem of Modern Medicine We have spoken with many people who have struggled with a disease that manifests in multiple symptoms. They end up seeing a variety of specialists who don’t seem to communicate with each other. NO tool manages every condition. Too often, specialists pay attention only to the specific organ that they are assigned, and as a result, nobody puts the big picture together for a long time. The hope is that functional medicine would do a much better job for such patients, including those whose suffering has an emotional, psychological or spiritual aspect. Functional Medicine and Chronic Fatigue Syndrome One example where patients are demanding more of their medical care is chronic fatigue syndrome. Conventional medicine has a notoriously difficult time treating such patients. Coaching patients on small but important lifestyle changes is one approach that functional medicine can offer. Pacing and learning to prioritize are vital skills for such patients. Dr. Payrovi learned a lot about the value of such approaches in dealing with her own illness, multiple sclerosis. Finding a Functional Medicine Practitioner People looking for a functional medicine practitioner can consult the Institute for Functional Medicine. The organization lists practitioners on its website, ifm.org. So does the Academy of Integrative Health and Medicine, aihm.org. This Week’s Guest Susan Payrovi, MD, is a physician practicing Integrative and Functional Medicine at Stanford’s Center for Integrative Medicine. Dr. Payrovi is board certified in Anesthesiology, Hospice and Palliative Medicine, as well as Integrative Medicine. She has additional training in Functional Medicine and acupuncture. https://med.stanford.edu/profiles/susan-payrovi. Her website is drsusanpayrovi.com. Susan Payrovi, MD Listen to the Podcast The podcast of this program will be available Monday, June 1, 2026, after broadcast on May 30. You can stream the show from this site and download the podcast for free. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.

In this episode, a renowned neurosurgeon shares what he has learned in decades of working to restore ailing brains. His new book covers a vast range of neuroscience. Our dilemma was what to pay attention to in all those options. In a sense, that is always the human situation. We are capable of conscious processing of approximately 200 bits per second (bps) of information. Our unconscious brain deals with as much as 11 million bps. At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen You could listen through your local public radio station or get the live stream Saturday, May 16, 2026, at 7 am EDT on your computer or smart phone (wunc.org). Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on May 18, 2026. (This show originally aired April 25, 2025.) The Power of the Unconscious Brain Our senses feed us a tremendous amount of information all the time, but we don’t have the bandwidth to pay attention to more than a small fraction of it. That’s where the unconscious brain is so valuable, juggling millions of bits of information while we focus our conscious attention on what seems important. One surprising outcome of the research on how our brains function is a re-assessment of what is going on when people are unconscious. For centuries, doctors thought there was really no brain activity while a person was comatose. Then, a few decades ago, a scientist was recording the brain waves of a patient in a coma. The activity was very peculiar, as if the person were watching a ball being lobbed back and forth across a tennis court. In actuality, a television set in the room was broadcasting a world championship match between Roger Federer and Rafael Nadal. The neuroscientist recognized that this individual was following the match and was not nearly as deeply unconscious as had been thought. Further research showed that this kind of unconscious brain activity is not uncommon. It may hold keys to determining who has the best potential for recovering from their coma. Freud and the Unconscious Brain If you hear the term the unconscious mind, you may think of Sigmund Freud. He really popularized the concept that some very important brain activity takes place outside of our conscious awareness. It still has a powerful influence on our behavior. By the way, if we recognize that our conscious attention is indeed a limited resource (200 bps, remember), we won’t try to multitask. Humans actually aren’t very good at multitasking; instead, we switch our attention from one thing to another. Some people can do that fairly easily, but for most of us, it is less effective than staying focused. Three Stages of Brain Development Evolution likes to build on what it’s already got in place, so it shouldn’t surprise us that we can track three different evolutionary stages to our human brains. The reptilian brain came first, of course, and is there as a base, operating mostly on reflex. It’s definitely an important part of the unconscious brain. The mammalian brain brings in emotions. The hormone oxytocin is relevant for this discussion. It is critical for birthing and nursing young. As it turns out, oxytocin can also be put to other uses, such as bonding mates together and creating friends. Finally, we have the primate part of our brain. We humans, like other primates, can exercise empathy because our mirror neurons allow us to relate to another creature’s experience. In fact, mirror neurons were discovered by scientists studying macaques and eating gelato. Listen for a great story! Speaking of empathy, we wondered about empathy fatigue. We started hearing about empathy fatigue during the COVID pandemic, when healthcare providers were overwhelmed by extreme demands with inadequate support. Research shows that “constant, repetitive exposure to the pain of others leads to empathy fatigue.” Lack of empathy can lead people to do terrible things. Wonders of the Unconscious Brain Our brains are full of clocks. To some extent, these are shaped by how we use them. Musicians who play percussion instruments can perceive time differences of just a few hundredths of a second. All of us are entrained to a 24-hour a day cycle, whether we observe sunrise and sunset or not. But if we are deprived of connection with that cycle, our internal clocks can’t keep good time, and our brains may get far off track. What About Premonitions? Some people think premonitions are a fantasy. Yet this is another area where our unconscious brain may be more capable than we imagine. Dr. Hamilton describes an experience in the Swiss Alps where he and his wife had a choice of which path to take down from the summit. One appeared to be a shortcut, and they did have some time constraints. But as soon as they had taken a few steps that direction, he had a premonition of something terrible. They took the other path and learned later that there had been a landslide on the shortcut that would have swept them helplessly down the mountain. According to Dr. Hamilton, some people have the ability to influence the output of random number generators. Those of us who can’t may wish to reject that idea, but it has been documented. The Princeton Engineering Anomalies Research lab has run many studies demonstrating an impact on random number generations, not to mention remote viewing. In this way, some of the hidden power of the unconscious brain appear as cerebral entanglements, analogous to quantum entanglements at the sub-atomic level of matter. This Week’s Guest Dr. Allan Hamilton, MD, FACS, is a neurosurgeon who has specialized in treating brain tumors. His extraordinary journey from janitor to Harvard-trained neurosurgeon is just the beginning of his remarkable story. A decorated Army veteran, he now holds four professorships at the University of Arizona and has been recognized as “One of the Leading Intellects of the Twenty-First Century.” As the only American honored with the Lars Leksell Award for pioneering scientific discovery in stereotactic neurosurgery, Dr. Hamilton’s groundbreaking work has revolutionized the field. He has had a life-long interest in the application of computer technologies to enhance surgical care and reduce avoidable medical adverse events. In addition, he has served on two White House Advisory Committees under two presidential administrations. Allan Hamilton, MD, FACS His expertise extends beyond medicine, having studied creative writing under Rod Serling and serving as a senior medical consultant for Grey’s Anatomy for nearly two decades. Dr. Hamilton’s seven non-fiction books have garnered numerous awards and international translations, offering insights that have inspired leaders across various fields. Dr. Hamilton’s 7th non-fiction book is Cerebral Entanglements: How the Brain Shapes Our Public and Private Lives. The People’s Pharmacy is reader supported. When you buy through links in this post, we may earn a small affiliate commission (at no cost to you). Listen to the Podcast: The podcast of this program will be available Monday, April 28, 2025, after broadcast on April 26. You can stream the show from this site and download the podcast for free. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.

Medicine has changed enormously over the last several decades. As with other parts of society, digital technology has disrupted previous practices. Clinicians can now care for patients at home, monitoring them with sophisticated sensors for oxygen saturation, heart rhythm, blood pressure and much more. Even more significant, patients now have greater access to medical knowledge as well as to the state of their own bodies, measured through wearable tools such as smart watches or continuous glucose monitors. With the internet, they can connect with patient groups that offer valuable information as well as emotional support. Find out how patients are using technology to heal healthcare. At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen: You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, Feb. 14, 2026, through your computer or smart phone (wunc.org). Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on Feb. 16, 2026. How Technology Is Transforming Healthcare: When we spoke with Dr. Marschall Runge, we reminisced about the changes in medical care that have taken place since the time of his grandfather, a general practitioner. There is quite a contrast. While his grandfather made house calls, few doctors today would do so. However, some very modern medical centers now offer patients the option to recover at home from a major procedure. Dr. Runge describes his personal experience with at-home recovery following hip replacement surgery. The clinical staff was able to keep close tabs on his progress with the help of a variety of monitors, and a nurse was available to answer questions or provide advice until he was back on his feet. There are distinct advantages to the patient to be able to recover at home; among other things, he could sleep much better in his own bed. What other digital technology will healthcare employ? One possibility is using AI conversational agents to assist with differential diagnosis. Some devices can detect depression based on a patient’s speech. Others can pick up heart rate variability, an important parameter of heart health. Dr. Runge does not expect that robots will replace doctors. They could be very helpful in certain situations, though. How Patients Are Using Technology: We turn next to Susannah Fox, author of Rebel Health. She has been studying how patients are using technology to improve their health for decades. We first met Susannah through our mutual friend, Dr. Tom Ferguson. He was a staunch advocate for self-care and excited about the prospects for the internet. (His white paper, “e-Patients: How they can help us heal health care” is a classic. Look for it at the website of the Society for Participatory Medicine.) Not only do patients everywhere now have access to PubMed (the National Library of Congress), they can also connect with each other. Peer-to-peer advice and care is a topic Susannah knows well. In some cases, patients have conducted research that is focused on the questions crucial to their lives; these are not always the same things that researchers want to study. One shining example of patient-initiated research is a paper in Nature on long COVID by the Patient-Led Research Collaborative (Nature Reviews Microbiology, April 17, 2023; initial publication Jan. 13, 2023). This paper has been downloaded 2 million times, illustrating the value of patient-led research. In addition to this outstanding example, some journals have adopted a policy of disclosing patient input into the research. Although very few studies report patient input, setting the expectation that they might make valuable contributions could help shape the perception of who ought to be involved in developing research protocols. Patients Using Technology to Access Medical Knowledge: PubMed is an impressive collection of published medical information because it is an online index of important research publications. Some of the journal articles could be difficult for patients to understand, however, as researchers are writing for other scientists and may often use specialized or complicated language. Now people are using LLMs like ChatGPT or Claude to summarize the articles in language they can understand. Indeed, these AI agents can translate articles into a different language if necessary for comprehension. With this technology, patients are better able to determine if their diagnosis makes sense and to search for potential interventions that might be useful in their specific case. Imbalances of Power and Attention: Despite these changes, there are still many medical systems that resist potential input from patients. Power is not evenly distributed, and Susannah Fox has found that many people are furious about it. We asked her to describe the schematic from Rebel Health that epitomizes where most attention is needed. It has two axes, one running from visible to invisible and the other from needs not met to needs met. A lot of medical care is devoted to the upper right quadrant–visible needs that are being met. The lower left quadrant, where the needs seem invisible and are not being met, is where patient frustration comes to a head. Rare diseases often fall into this category. Researchers and physicians need to know about patients’ lived experiences so that invisible needs not being met can be addressed. Using Technology to Repurpose Old Drugs: One of the ways in which AI is contributing to important changes in medical care is the search for medicines that can treat inadequately treated diseases. Susannah Fox praised the efforts of Dr. David Fajgenbaum, whose EveryCure organization is using AI to uncover how old drugs can be used to treat cancers, rare diseases, immunologic disorders and other problems that don’t yet have effective standards of care. Other patients who are showing the way to using AI for improving patient experience and patient health are Dave deBronkart (epatient Dave) and Hugo Campos. They have found that using an agent like ChatGPT in a dialog can help them move forward a lot more quickly in solving patient problems. Online Prescribing and Dispensing: Around the turn of the 21st century, Joe and Dr. Tom Ferguson had a heated ongoing disagreement about the concept of online prescribing. Tom was enthusiastic and Joe was skeptical, to say the least. Susannah Fox weighs in on this argument supporting Tom’s side at this point. With wearables like smart watches or continuous glucose monitors to track important markers of health, we see some patients using technology to follow up on how well their prescriptions are working, regardless of whether they were prescribed in the office or online. We also asked Susannah to provide advice for how we can successfully advocate for our own health. Her most important nugget: ask good questions! Clinicians appreciate good questions that help them re-think the patient’s situation or explain it more clearly. This Week’s Guests: Marschall S. Runge, M.D., Ph.D., is the former executive vice president for Medical Affairs at the University of Michigan, dean of the Medical School, and CEO of Michigan Medicine. During his tenure in these leadership roles, Dr. Runge implemented transformative change and positioned Michigan Medicine and the Medical School internationally for continued success. He earned his doctorate in molecular biology at Vanderbilt University and his medical degree from Johns Hopkins School of Medicine, where he also completed a residency in internal medicine. He was a cardiology fellow at the Massachusetts General Hospital. Dr. Runge is the author of The Great Healthcare Disruption: Big Tech, Bold Policy, and the Future of American Medicine Marschall Runge, MD, PhD Susannah Fox helps people navigate health and technology. She served as Chief Technology Officer for the US Department of Health and Human Services, where she led an open data and innovation lab. Prior to that, she was the entrepreneur-in-residence at the Robert Wood Johnson Foundation and directed the health portfolio at the Pew Research Center’s Internet Project. She is the author of Rebel Health: A Field Guide to the Patient-Led Revolution in Medical Care. Her website is https://susannahfox.com/ Susannah Fox, author of Rebel Health: A Field Guide to the Patient-Led Revolution in Medical Care The People’s Pharmacy is reader supported. When you buy through links in this post, we may earn a small affiliate commission (at no cost to you). Listen to the Podcast: The podcast of this program will be available Monday, Feb. 16, 2026, after broadcast on Feb. 14. You can stream the show from this site and download the podcast for free. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1461: A transcript of this show was created using automated speech-to-text software (AI-powered transcription), then carefully reviewed and edited for clarity. While we’ve done our best to ensure both readability and accuracy, please keep in mind that some mistakes may remain. If you have any questions regarding the content of this show, we encourage you to review the original audio recording. This transcript is copyrighted material, all rights reserved. No part of this transcript may be reproduced, distributed, or transmitted in any form without prior written permission. Joe 00:00-00:01 I’m Joe Graedon. Terry 00:01-00:05 And I’m Terry Graedon. Welcome to this podcast of The People’s Pharmacy. Joe 00:06-00:26 You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. Medicine has changed tremendously over the last several decades. How has technology transformed health care? This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:42 Clinicians can now care for patients at home and monitor them with sophisticated technology almost as well as if they were in the hospital. Joe 00:42-00:51 Patients themselves now have access to far more information than ever before. They can look at the results of lab work on their patient portal. Terry 00:52-01:01 Patients can also communicate online through thousands of support groups that are specific to health conditions. They’re also beginning to conduct research. Joe 01:01-01:08 Coming up on The People’s Pharmacy, how patients are using technology to heal health care. Terry 01:14-02:10 In The People’s Pharmacy Health Headlines: We’re still in the middle of a serious flu season, and scientists have just published another reason to try to avoid coming down with influenza. Beyond the fever, congestion, aches, coughs, and general misery of flu, influenza A infections can harm the heart. When the virus invades the heart, it can kill specialized heart muscle cells that control rhythmic pumping. People with pre-existing heart disease appear to be especially vulnerable. In some cases, white blood cells of a type called prodendritic cell 3 pick up the infection in the lungs and transfer it to the heart. The interferon that these white cells produce damage the heart muscle cells. The scientists suggest that this new information could help doctors mitigate heart risk in people with influenza A. Joe 02:11-03:16 A study published in Nature Communications demonstrates that the bacterium Chlamydia pneumoniae can lie dormant in the eye and brain for years. This respiratory pathogen can lead to sinus infections or pneumonia. It can also trigger infection-driven inflammation. C. pneumoniae has been linked to hard-to-treat asthma and COPD. The latest research, however, suggests that this microbe might also be linked to Alzheimer disease. People with dementia had substantially greater amounts of C. pneumoniae in their retinas and brain tissues than people with normal cognitive ability. The investigators report that infection-driven aggravation of neuroinflammation appears to lead to amyloid beta buildup in the brain and cognitive decline. This research opens up new opportunities. For one thing, it raises the possibility that patients with detectable C. pneumoniae bacteria might benefit from antibiotic-based treatment. Terry 03:16-04:46 If you’re a coffee drinker, you may be helping your brain. That’s the conclusion of a new study published in JAMA. The title of the article is Coffee and Tea Intake, Dementia Risk and Cognitive Function. The investigators tracked 131,821 volunteers for up to four decades. These were participants in the Nurses’ Health Study and the Health Professionals’ Follow-Up Study. The researchers were asking this question, is long-term intake of caffeinated and decaffeinated coffee associated with risk of dementia and cognitive outcomes? The authors answered that question this way. In two large prospective cohorts, including U.S. female and male participants with repeated dietary assessments and extended follow-up, higher intake levels for caffeinated coffee, tea, and caffeine were associated with a reduced risk of dementia. The researchers also reported modestly better cognitive function in the caffeinated tea and coffee consumers. Two or three cups of coffee, or one or two cups of tea, were enough to demonstrate cognitive benefits. People who drank decaffeinated coffee or tea did not seem to experience any advantage. The authors point out that their findings are consistent with other research reporting protective associations of caffeine and coffee intake with cognitive decline. Joe 04:47-05:57 Lifelong learning is also associated with a reduced risk for Alzheimer’s disease. That’s the conclusion of research published in the journal Neurology. There were nearly 2,000 octogenarians without dementia who began the study. Follow-up lasted for about eight years. The researchers questioned people about childhood learning experiences as well as current behavior. People who participated in intellectually stimulating activities such as learning a language, reading, or writing seemed to develop Alzheimer’s disease five years later than other people in the sample who had not embraced lifelong learning. Those who developed mild cognitive impairment did so seven years later than those without lifelong learning. Those with higher lifetime enrichment showed less cognitive decline before death compared with those with less opportunity to learn. The lead author noted, quote, Our findings are encouraging, suggesting that consistently engaging in a variety of mentally stimulating activities throughout life may make a difference in cognition. And that’s the health news from the People’s Pharmacy this week. Terry 06:14-06:17 Welcome to the People’s Pharmacy. I’m Terry Graedon. Joe 06:17-06:32 And I’m Joe Graedon. Medicine has changed radically over our lifetimes. It’s hard to imagine that doctors once made house calls, but medical technology is revolutionizing how doctors diagnose and treat their patients. Terry 06:32-06:40 Patients are also adopting technological advances to improve their knowledge and access to the most appropriate treatments. Joe 06:40-07:08 To learn more about how doctors envision this revolution, we turn to Dr. Marschall Runge. He was the former executive vice president for Medical Affairs at the University of Michigan, Dean of the Medical School, and CEO of Michigan Medicine. Dr. Runge is the author of “The Great Healthcare Disruption: Big Tech, Bold Policy, and the Future of American Medicine.” Terry 07:08-07:12 Welcome to the People’s Pharmacy, Dr. Marschall Runge. Dr. Marschall Runge 07:13-07:16 It’s great to be with you today. Thank you very much, and I look forward to our conversation. Joe 07:17-07:51 Dr. Runge, you come from a long line of health professionals. It’s my understanding that your grandfather was a doctor and your father was a doctor and you’re a cardiologist and you’re the head of Michigan Medicine at the very pinnacle of modern medicine in America. So how has healthcare changed since when your dad was practicing cardiology, when your grandfather was a doctor? Would they even recognize what is going on today? Dr. Marschall Runge 07:52-08:48 I don’t think they would. They’d say, ‘What is this?’ My grandfather was in an era where really everything about being a physician was talking to patients. The physical examination was critical. There were very few tests, the electrocardiogram, he was one of the early people working on electrocardiograms. And that was about the only tool we had in x-rays. Fast forward to my father. My father was a cardiologist. I grew up in Austin, Texas. And he did cardiology and internal medicine. Cardiology was just an emerging field at that time. And one of the things that was most fascinating, I would go around with him sometimes on hospital rounds. And he had a great way with people. He also did house calls, and he had gotten his car rigged up with a mobile headlight kind of thing that he could shine to see if he was at the right address. And I thought as a kid, that was so cool. Terry 08:50-09:04 Well, the very idea of making house calls is, I think, probably completely foreign to most doctors today. The whole setup of medicine must have changed so much. Dr. Marschall Runge 09:05-09:45 It has. And while there still are a few people, generally senior people, let’s call them, like myself, who would be willing to make house calls, very few people make house calls. Now, on the other hand, I think we’ll be seeing much more care in the home now and in coming years due to technology, where a person can get a very high level of care at home with what are essentially wearable devices and contact with health care providers. In fact, I had one experience like that. And it is… so I think it’s the pendulum swings one way, it swings back the other way. But the overall practice of medicine is so different than it used to be. Joe 09:45-10:09 Well, you know, we love the idea of home care, which brings up a very personal experience for you. You had a hip replacement surgery, and things did not go as anticipated, and you ended up being at home but receiving very high-quality care. Can you tell us about that whole experience shortly, please? Dr. Marschall Runge 10:10-12:31 I’m glad to. I needed a hip replacement. It’s usually a pretty routine procedure, you go home the same day. I did. But I had an unusual complication, which made me short of breath. It wasn’t a pulmonary embolism. It was little shards of fat from where they put in the implant. And so I went to the hospital, went back to the hospital, went to the emergency room. My oxygen saturation was very low. They whipped me upstairs. And after a little while, I was in the ICU. And I’d been there about 24 hours, and I was feeling much better, but I was feeling much crazier. I just couldn’t stand it. I was getting checked on every 30 minutes; I couldn’t get any sleep. And I knew we had a great home care program. So I said, how about if I go home? And they said, no, no, no, you don’t want to do that. And I said, why not? And they said, well, what if something happens? And I said, well, what do you tell other people who are you going to send to home care? And they said, yeah, but you’re different. I think they were worried that I would have a bad experience. But they let me go, and I went home. And waiting for me, by the time I got home, were several sort of wearables. I had a pulse oximeter, I had a mobile blood pressure cuff, I had several other things. I had an incentive spirometer. And I had a nurse who went through all this with me, was available over the next several days, 24-7 if needed. And I had a physical therapist who came later that same day and had physical therapy every day. And the fantastic part is I slept for about 12 hours the first night I was at home because I was just so exhausted. So I think, and my experience is very similar to others, that one of the ways that people can get better faster, have less expense, and a better outcome is to have home care. We now know in our system, some people that would ordinarily go from either a phone call to their doctor or a visit in the clinic directly to the emergency room, there’s a group of those people who can get care at home. So we’re trying to figure out how can we best expand that kind of care. Because for those of you who have been in hospitals, it’s no walk in the roses. And I think that this is one of the many ways in which technology can actually improve the care of all of us. Joe 12:32-13:13 Well, the thing that’s so fascinating to me is that there are so many devices now. I mean, you can monitor not just blood pressure, but blood glucose. You can measure respirations. You can measure temperature. And it’s even conceivable that you could have a video hookup so that a nurse back in Ann Arbor at the hospital could be monitoring you. And if there was an emergency, you could have two-way communication with a healthcare professional almost immediately. So, you know, the idea of being able to sleep at home, wow, what an improvement over trying to sleep in the hospital. Dr. Marschall Runge 13:15-14:11 You’re right. And, in fact, there is very high-level potential for monitoring, which is used in some more rural settings. And it’s, I won’t call it an ICU, but it’s not too far from an ICU with all the components you just mentioned. And the care, it’s called a virtual CCU or a virtual emergency room. And the care can be excellent. Now, you have to have health care providers, doctors, nurses, and others who are enthusiastic about this and who understand how to use the technology. But I think we’ll see much, much more of it. And for example, a day in the hospital is about $1,500 on a regular floor, more like over $2,000 in an ICU. And a day at home is about $200. And so we worry about the cost of health care. That’s one way we can make it better. But as you said, it’s much better for the person, for the patient. Terry 14:13-14:56 Well, I know there are plenty of patients who are using, as you put it, wearables to improve their own health. And they’re going online to find other people with similar problems, similar health problems, so that they can all learn from each other. I’m wondering now, how can patients and doctors work together to use, for example, artificial intelligence for diagnosis? When you’ve got something wrong with you and you don’t know what it is, how does that diagnostic process play out differently now or in the future with the access to artificial intelligence? Dr. Marschall Runge 14:58-17:35 Well, on the one hand, I am a huge fan of artificial intelligence. And I think that one of the benefits it brings is the ability to analyze huge amounts of data, very large amounts of data that would be hard to do in any other way. And I think that in the near future, we’ll see much more use of wearables. And today, it’s hard to connect the wearables to the electronic medical record, but that’s getting better. So that when you come in for a visit, or it can be done trans-telephonically, an awful lot of information can go to your doctor about what’s been going on in your life. And it can be cataloged in a way that allows it to suggest different potential early diseases or different potential approaches that might be used. To give you a couple of examples, there are devices, both devices and telephones, which can, at a very early stage, pick up depression and allow it to be detected and dealt with far before it gets to impacting one’s life. In other examples, there are wearables that can show that how much variation you have in your heart rate is one of the markers for how heart healthy you are. And that can be measured. And that’s currently being able to be measured on wearables. But once those download into your electronic medical record, I think that’ll be even much more powerful. To give you one little example of why I think AI has such promise, if you ask for your medical records these days, they’re so extensive, you get it on a CD or maybe on a USB drive, and you try to read it, and you could spend hours and hours and hours reading it. If you take that and put it on, make a PDF out of it and put it into your favorite AI engine, in about two minutes, you can get, if you say, I’d like a three-page summary of what my major medical problems are, what medications I’m currently taking, and what medications have not worked. You get it. You get it in about two minutes or less. It’s that kind of technology and that kind of reach that AI has that I think will really change healthcare. I want to put in one negative about AI. I don’t think AI bots can replace human beings and human interaction. And I think that will come to be proven over and over again. It already has in some circumstances. So this idea that you’d have an AI bot instead of a doctor or a nurse or a therapist, I don’t see that happening. Terry 17:36-17:41 Dr. Marschall Runge, thank you so much for talking with us on The People’s Pharmacy today. Dr. Marschall Runge 17:42-17:44 Well, thank you both. It’s great to talk to you. Terry 17:45-18:06 You’ve been listening to Dr. Marschall Runge. He’s a cardiologist and the former executive vice president for medical affairs at the University of Michigan, dean of the medical school and CEO of Michigan Medicine. Dr. Runge is the author of The Great Healthcare Disruption, Big Tech, Bold Policy, and the Future of American Medicine. Joe 18:07-18:13 After the break, we’ll talk with Susannah Fox, a patient advocate who helps people navigate health and technology. Terry 18:14-18:21 Dr. Tom Ferguson was a great proponent of how e-patients would help to heal healthcare itself. How is that vision holding up? Joe 18:21-18:24 We’ll discuss patient-led research in a variety of forms. Terry 18:25-18:28 The Internet and PubMed changed people’s access to medical knowledge. Joe 18:29-18:35 Now people are using AI to help them understand medical articles and check on a differential diagnosis. Terry 18:39-18:42 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 18:51-18:54 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 18:54-19:08 And I’m Terry Graedon. Terry 19:24-19:39 Today, we’re excited to be talking with someone we have known and admired for decades. Susannah Fox was with the Pew Research Center Internet Project when the three of us were participating in Dr. Tom Ferguson’s e-patient scholars group. Joe 19:39-20:20 Our goal was to turn medicine upside down and empower patients through access to information and tools. Our organization was a precursor to the Society for Participatory Medicine. We turn now to Susannah Fox, who helps people navigate health and technology. She served as Chief Technology Officer for the U.S. Department of Health and Human Services, where she led an open data and innovation lab. Prior to that, she was the Entrepreneur-in-Residence at the Robert Wood Johnson Foundation. She’s the author of “Rebel Health: A Field Guide to the Patient-Led Revolution in Medical Care.” Terry 20:20-20:24 Welcome back to The People’s Pharmacy, Susannah Fox. Susannah Fox 20:24-20:25 Great to be here. Joe 20:27-20:55 Susannah, our mutual friend, Dr. Tom Ferguson, died 20 years ago. He was a leading advocate in the world for medical self-care. He really spearheaded this vision. I wonder how that vision has changed, how it helped lead the patient revolution in health care that you have written about. How’s it fared over the last two decades? Susannah Fox 20:56-22:13 I think Tom would be amazed at the progress that’s been made by patient survivors and caregivers who are demanding access to information, demanding access to data and tools to take care of themselves. He was a visionary. He foresaw how the internet was going to change healthcare. And yet I think he would be surprised by how quickly it’s moved forward. For example, one of the great milestones to me in research is that a paper written for Nature, one of the preeminent scientific journals that was written primarily by patients, by people who live with the disease that they’re writing about, has now been downloaded almost 2 million times. And that is a milestone that I think would make Tom so happy because he was an early advocate for people having access to information to help them make better decisions and to help clinicians and do their work better. Terry 22:14-22:22 Absolutely. I think he would be thrilled at that. Can you tell us a little bit more about that paper? What were the patients writing about? Susannah Fox 22:22-24:02 They were writing about long COVID. And as you might recall, during the early part of the pandemic, clinicians and scientists told everyone that if you got better in two or three weeks, you were through the woods. And COVID-19 was primarily a respiratory virus that if it didn’t kill you, that you would feel better. And it was patients themselves who identified that it’s not only a respiratory virus. They started tracking the symptoms that they were experiencing. They were able to not only track those symptoms, but do a worldwide survey, publish that data, get the attention of the British government, of the government in the U.S., and eventually the scientific community adopted the name that patients themselves were using, which is long COVID. And these patients, along with Eric Topol, decided to publish a paper that looked at the mechanisms and recommendations that they had for further study of long COVID. And it was led by the citizen scientists behind the patient-led research collaborative for long COVID. And it’s a milestone to see that they were, number one, able to publish it in Nature Microbiology, but now it is in the 99th percentile of most influential papers. Terry 24:02-24:40 It really is a milestone. And the fact that it was, in fact, patient-led is still pretty unusual and pretty remarkable. Another hopeful sign that I have seen is that there are a couple of journals, I think they’re mostly British journals, that will, in their little summary of the research, will say, what input did patients have into the plan or the protocol of this study? And unfortunately, most of them still say patients didn’t have any input, but at least they’re thinking that patients might have some input. Susannah Fox 24:41-25:00 I love that. Yes, British Medical Journal [BMJ] and The Lancet Psychiatry are requiring that authors share how patients, how people with lived expertise contributed to the research. And by asking that question, they’re changing the default. I love that. Joe 25:01-25:50 Susannah, you know, Dr. Tom Ferguson loved the idea that people would have access to information. And these days, people do have an extraordinary amount of access. For example, the National Medical Library in the U.S., PubMed, is available to people all over the world. And yes, most of the journals only provide abstracts, but there are more and more full-text articles available on PubMed, which means that it’s not just doctors, it’s not just scientists and researchers who access this information, it’s everybody, and people are so much more literate, most of the time they can kind of figure out what those docs are talking about. Susannah Fox 25:52-26:55 Yes, and what I also see spinning it forward is people using large language models like ChatGPT to feed those abstracts or full-text articles into essentially a translation app to say, can you put this into words for me? Or can you do a differential diagnosis based on my child’s symptoms and what we know from these latest articles? And people are leveraging these tools. Another thing that I love is you can use ChatGPT to translate it into a different language to say, my mom only speaks Spanish. Can you please translate the science into Spanish? Or can you make this into a cartoon that makes it easy for everyone in my community to understand the basics of what’s going on? That is the promise that I think Tom would be most excited about. Terry 26:57-27:10 What sorts of precautions should patients be exercising if they’re using ChatGPT, for example, to try to see whether the diagnosis they’ve been given makes sense? Susannah Fox 27:12-28:48 Well, here I look to the people who are shining a light on the path forward in terms of how patients are using AI effectively. I’m thinking of e-patient Dave DeBronckart, and I’m thinking of Hugo Campos. What they have written about is that ChatGPT and tools like it should be used to help us reason through a problem. You can be in conversation with these tools, but it’s best not to ask for a diagnosis. It’s better to say, if you were teaching a medical school class on this topic, what are the most important things for you to teach medical students? And in that way, you’re asking the tool to teach you, maybe a lay reader, about these issues that you don’t yet understand. What I really appreciate about this era that we’re in is that we are able to skip ahead from square one, where we may not even understand the diagnosis, and we have to make sure we’re spelling it correctly. And we can skip ahead three or four spaces on the game board so that we can understand the mechanisms of disease, what the latest research is, and then we can still go in and get the expert opinion based on our medical history with a clinician. Joe 28:50-30:17 Susannah, what you’re talking about in terms of medical education is quite fascinating and using artificial intelligence like ChatGPT or Claude or whichever particular program you are comfortable with. But I’m wondering how medical education has adapted to patients all over the world communicating with one another in support groups or accessing medical information. Because it seems to me, and I could be mistaken, that medical education hasn’t changed that radically in the last 20 years. It still seems like the old medical model that Tom was ranting about, that pyramid with the super specialists at the top and then the internists and then the family practice docs at the bottom and the geriatricians even below that, that it’s still the old medical model that patients, although they’ve got a lot of autonomy and a lot of access to information, that the medical system hasn’t changed that dramatically. And we still have to wait for hours in the emergency departments, and there’s still an imbalance between doctors and patients. Help me understand better how the system has adapted to this revolution that you have talked about. Susannah Fox 30:19-32:17 Well, first, I should say there are many systems, especially in the United States. And what we are observing in the research that I do and in talking with clinicians and patients is that you’re absolutely right. In areas of healthcare where people seem, whether it’s clinicians or patients, where something’s pretty well known, then they don’t seem to feel the need to look to people with lived expertise to contribute. But if there is a problem that is particularly vexing, if there is an issue that has historically been invisible or ignored, or it’s rapidly emerging, as we saw in the case of long COVID, then specialists are more likely to listen to patients. The most extreme examples that I’ve studied are in communities of people living with rare diseases and life-changing diagnoses, where they’re really medical mysteries. It’s a genetic disease. It’s something where there’s very few people who live with the condition. And so it is the communities who are pooling data, who are pooling resources, who deeply understand the mechanisms of disease. That’s when clinicians and scientists are very interested in learning from patients. And again, this could be something that is a genetic disease with a very small number of people or something more widespread like long COVID, that if there is a mystery that needs to be solved and patients, survivors, and caregivers can help solve it, that’s when companies and scientists are building those intake valves for that lived expertise. Terry 32:18-32:33 Susannah, something you just said triggered my memory of a schematic you put in Rebel Health in terms of how well-known something is. It’s a four-part schematic. Can you describe it to us, explain it to us? Susannah Fox 32:33-34:22 Sure. I came up with this as a way to try to explain why some issues are more ripe for the patient-led revolution and some are not. So if you can imagine a line right down the middle, and at the top is the word visible, and at the bottom is the word invisible, and then a line through the middle from left to right, and at the far left are the words needs not met, and at the right are the words needs met. And what I mean by that is whether things are visible or invisible to mainstream healthcare and whether people’s needs are being met or not by mainstream healthcare. So the bottom left quadrant is where I spend a lot of my time as an anthropologist, spending time in communities of people whose needs are not being met and they are or feel invisible to mainstream healthcare. At the opposite end of the spectrum are issues where people’s needs are being met and they are visible to mainstream healthcare. And here we might think of a typical pregnancy and childbirth or a cancer diagnosis. We, as an American healthcare system, we have invested a lot of money in cancer. And so people kind of know what they’re doing. It’s still really tough, but people really know what they’re doing in some areas. Whereas down in the quadrants where people’s needs are not being met, we might see a more rare genetic disease or an emerging diagnosis. Terry 34:23-34:26 Thank you, that was helpful. Joe 34:26-34:54 One of the challenges on those rare diseases, Susannah, is the cost. Because patients and specialists and researchers have teamed up to create some unbelievable treatments and in some cases cures. But the cost, it can run half a million, a million, and in some cases over two million dollars. Terry 34:54-35:08 Well, you can get that even in that upper right quadrant where your needs are theoretically being met and they’re visible. But if it’s going to cost a million dollars, I don’t think anybody would claim that it’s accessible. Joe 35:08-35:25 So in the minute that we have left, the cost of some of these breakthroughs–and even in general, the cost of medicine and medical care–it seems like it’s breaking the bank for an awful lot of Americans. Susannah Fox 35:26-35:49 It absolutely is breaking the bank. And we need to have a public conversation about where our research dollars go and where our health care delivery dollars go. What rare disease patients would say is that the breakthrough that they find for their rare disease may actually light a path forward for many diseases. Joe 35:50-36:07 And do you see affordability as being a key factor going forward? Because the medical system as it exists now, it’s going to crack and crumble over the next couple of years. Susannah Fox 36:10-36:43 That is particularly true in the U.S. When I was on my book tour with a book where the title is Rebel Health, people would come to my events and be angry that my book is not about the overthrow of the American healthcare system. People are extremely angry about the cost and lack of access to healthcare. My book is about access to the tools of innovation and invention, but we need to talk about cost and access to care. Terry 36:45-36:53 You’re listening to Susannah Fox, author of Rebel Health, a field guide to the patient-led revolution in medical care. Joe 36:54-36:59 After the break, find out why patients’ lived experience is more important now than ever. Terry 37:00-37:10 We’ll learn more about Dr. David Fajgenbaum and his Every Cure organization with patients and doctors finding novel ways to treat diseases with old drugs. Joe 37:10-37:16 What do you think about online prescribing and dispensing? I used to think it’s a terrible idea. Terry 37:16-37:19 If there were follow-up, though, it could be really helpful. Joe 37:19-37:24 How will patients take more control of their care in the future? Terry 37:39-37:42 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 37:52-37:55 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 37:55-38:06 And I’m Terry Graedon. We’re talking about how new technologies have changed both the practice of medicine and the ways in which people approach being patients. Joe 38:07-38:20 There was a time when physicians controlled all of the medical knowledge. That changed with the Internet. People can now interact with other patients all over the world with the same kinds of health conditions. Terry 38:21-38:28 In some cases, patient support groups are even initiating research that addresses their most challenging concerns. Joe 38:28-38:54 Our guest today is Susannah Fox. She helps people navigate health and technology. In the past, she was the entrepreneur in residence at the Robert Wood Johnson Foundation. She also directed the health portfolio at the Pew Research Center’s Internet Project. Susannah is the author of “Rebel Health: A Field Guide to the Patient-Led Revolution in Medical Care.” Terry 38:56-39:02 Susannah, why are patients’ lived experiences more important now than ever before? Susannah Fox 39:04-40:37 We are dealing with increasingly complex problems, increasingly complex treatments and decisions to be made, and we deserve to have everybody off the bench and on the field helping to solve those problems. If we do not include people with lived expertise, then we are not going to be able to recruit clinical trials that nobody wants to participate in because nobody thought to ask patients and caregivers about what are the endpoints that they care about or how to design a study that people really want to participate in and are able to participate in. We also need to have public conversations about how in the past patients have revolutionized parts of our healthcare system. In some ways, this is not new. This is very ancient that we turn to each other for help. And in the modern system, we have access to all kinds of technology. But let’s remember, peer support was revolutionized by Alcoholics Anonymous in the 1930s. When two people who are shut out of mainstream healthcare, they were dealing with alcohol use disorder, they turned to each other. That is one example of so many radical health movements of the past that we can draw inspiration from. Joe 40:39-40:49 You know, one of the things that comes to mind when we talk about patient involvement was a medical student by the name of Fajgenbaum. Terry 40:50-40:51 David Fajgenbaum. Joe 40:51-41:42 David Fajgenbaum. He was at University of Pennsylvania, and he had some very mysterious medical crises in which he got very close to death. In fact, a priest had administered last rites, he was so close. His body was shutting down. But during a slight recovery, he was able to eventually kind of figure out what was going on with the help of one of his medical mentors. And he eventually was able to, if not cure his condition, he was able to control it by using a medication that had been developed to prevent organ rejection when people got a transplanted kidney, for example. And that drug not only saved his life, but now many other people who have a condition called…? Terry 41:42-41:43 Castleman’s. Joe 41:43-42:21 Castleman’s disease. Bottom line, these off-label drugs have been coming to the rescue for a number of conditions, and Dr. Fajgenbaum is leading the charge now that he has become a physician. He has an organization called Every Cure, and we really love his approach because it brings, again, patients into the process. I’m wondering what your thought is about the idea of patients and physicians teaming up to come up with novel approaches, especially using old drugs. Susannah Fox 42:22-44:20 I’m so glad that you bring up his work because Dr. Fajgenbaum is the perfect example of someone who embodies all four of the archetypes that I talk about in my book. When he was sick, he became a seeker. And not only was he a seeker of new information, he asked his friends and family. When he was too weak to sit up at the computer and do searches, his friends and family did so. He was a networker. He found other patients and other clinician scientists who were focused on Castleman disease. He was a solver. He realized that by repurposing drugs that are already on the shelf, he could solve problems that were in that invisible needs not met quadrant that frankly, nobody was paying attention to. One of the big wake up calls that he writes about in his book, “Chasing My Cure,” is that he really thought that people were working on every disease. And it’s not true. Sometimes you have to be the one to say, wait, people need to be focused on this disease because my kid has it or it’s affecting my community. And then he became a champion. He became someone who uses his power as a clinician. He also went to business school, so he has an MBA. He was able to create the organization Every Cure and use these amazing large language models and artificial intelligence to try to match, again, the mechanisms of a rare disease with what a certain drug that’s already on the shelf can do. And he represents the full stack of the patient-led revolution. Joe 44:22-45:40 Susannah, I’d like to change gears for a moment and talk about something that Dr. Tom Ferguson and I fought about bitterly. It was one of the few things that we just could not ever agree on. Tom imagined a day when there would be online prescribing and online dispensing of medications. And I said, “Tom, these drugs are too complicated for somebody to have an online conversation with a health professional and then get their prescription filled and nobody follow up.” And he said, “No, no, no, no, no, follow up, that’s the secret. And that’s the magic sauce. You can follow up online daily, weekly, monthly. And doctors aren’t doing that right now.” And I was like, “Oh, well, that’s kind of interesting. I wonder if that’ll happen.” Well, it has happened in the sense that now there’s online prescribing like crazy. And there are a lot of private companies that are selling drugs for sexual functioning and drugs to lose weight and drugs for anxiety, and drugs for depression, and you can talk, in quotes, to an “online prescriber.” Terry 45:40-45:42 But we don’t know how good the follow-up is. Joe 45:42-46:02 That’s the question. And so I’m wondering what you think about online prescribing and dispensing. Eli Lilly, for example, is doing it, I believe, with its online very successful weight loss drug called Zepbound. So give us a little feedback on Tom’s vision and how it’s actually been implemented. Susannah Fox 46:02-48:35 Joe, I would have been in your camp up until about two years ago. I would have said, oh no, this is not a good idea. What has changed my mind is the sophistication of wearables so that we can instrument ourselves. We can wear a ring. We could wear something on our wrist. We could even have something very lightweight, a continuous glucose monitor, or any kind of lead that you could put on your chest. And that could create a real-time feed of how your body is reacting to the treatments that are prescribed by a clinician who you might not see in person. And they would have more sophisticated data to look at than they would have if you saw them twice a year in the clinic. And so that to me is one area where I’m going to come down on the side of Tom and say, it’s the follow-up that you can do not only through a screen where you can talk to someone and they can see the context of your life, but also the wearables that they can have access to the data. And this is something that the patient-led revolution has to create because it was in diabetes care that people demanded access to the data being generated by their own bodies by way of the continuous glucose monitor. And now it’s the default that we have access to that data. I think we need to go further. I think it should not only be consumer devices, these Apple Watch or Google Pixel or the Oura Ring. I think we need to demand access to every type of medical device that’s collecting data about us so that it can be in a dashboard that we have access to as well as our clinicians. Because guess what? Who’s going to look at it more often, the patient themselves, the people who love them. The clinician can check in and make sure that, yeah, okay, the dosing is correct on that. But self-management is going to be on steroids, to coin a phrase. And I’m excited about the future in that way. Terry 48:36-48:47 Susannah, you’ve talked about wearables. And just for people who may not have encountered that idea before. You’ve given us a couple of examples. Can you give us a few more? Susannah Fox 48:47-50:19 Sure. And I should disclose that I’m actually an advisor to Google and they gave me a Pixel Watch for free to try out their new AI coach that’s integrated with Fitbit. And it’s pretty amazing to, for example, wear something on your wrist that can not only track your heart rate, it can tell so much from the data that’s collected on your wrist. It can tell you the quality of your sleep. It can tell you the quality of the workouts that you’re doing. And the real promise is in being able to engage in a conversation with the AI coach where that coach can look at your personal data, not generalized data, but your personal data and give you advice that is based on all of the academic research that is available about sleep or fitness. And that to me is pretty incredible because a lot of us have access to fitness information, but very few of us have access to someone who’s actually a sleep specialist. So the democratization of access to that information, and as you know, sleep is incredibly important for brain health. Terry 50:20-50:34 And that’s what I’m really excited about. Well, that actually feeds right into the next question that I wanted to ask you, which is what has you most excited about patients taking more control of their health care in the future? Susannah Fox 50:37-51:24 I am not only excited about all the technology that we’ve talked about, whether it’s the AI or the wearable devices or the medical devices. I am very excited that people are starting to understand that they can take control of their health. And also, no matter what they face, they are not alone. There are people who would love to help you if only they knew how to find you. And you can go online and find a community of people who are facing the same mysterious symptoms, and you can navigate it together. That is the real promise of the Internet. Joe 51:26-52:03 Susannah, the idea that medicine has changed so dramatically and patients have so much more control and now they’re able to link up with other patients, other caregivers and other health professionals truly is the vision that Tom was offering us over 20, 30, 40 years ago. Where does your crystal ball lead us in the future? What can you imagine with the technology and with the interactivity, the self-help groups from all over the world? Susannah Fox 52:05-53:19 I foresee more citizen science. I see people who are frustrated by lack of access, formulating their own treatments, by the way, for good or for ill. And people using the tools that they have, ever more sophisticated tools to contribute to science. As, unfortunately, we watch people losing trust in institutions, people losing trust in government, in our healthcare system, people are turning to each other. Now, that is a mega trend that we need to be cautious about. I think we need to include patients and survivors and caregivers in the design of any tool, of any intervention, so that we can rebuild trust, so that we can show people that they are included. And it is not a faceless institution making decisions. That is what I hope will happen as we become ever more sophisticated in our own pursuit of health and well-being. Terry 53:20-53:32 Susannah, in the last minute we’ve got, can you give us some ideas about how we all can successfully advocate for health for ourselves and our families? Susannah Fox 53:35-54:16 I think it’s important to know what questions you’re asking. And you can use, for example, the data that you get from your own self-tracking, whether it’s on paper or wearables, or whether you hone your questions using Claude or ChatGPT. Ask good questions. Every clinician that I’ve ever talked to appreciates a good question. And that’s something that Tom often talked about. Don’t come in with the answer, come in with a great question. Terry 54:17-54:23 Susannah Fox, thank you so much for talking with us on The People’s Pharmacy today. Susannah Fox 54:24-54:24 Thanks for having me. Terry 54:26-55:13 You’ve been listening to Susannah Fox, a health and technology strategist. She’s a former chief technology officer for the U.S. Department of Health and Human Services, where she led an open data and innovation lab and launched InventHealth, an initiative focused on user-driven innovation for medical and assistive devices. As an entrepreneur in residence at the Robert Wood Johnson Foundation, she built project teams to bring patient and caregiver insights into its work. For 14 years, she directed the health portfolio at the Pew Research Center’s Internet Project, where she coined the phrase peer-to-peer health care. Her book is “Rebel Health: A Field Guide to the Patient-Led Revolution in Medical Care.” Joe 55:13-55:22 Lyn Siegel produced today’s show, Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Terry 55:22-55:30 This show is a co-production of North Carolina Public Radio, WUNC, with the People’s Pharmacy. Joe 55:30-55:45 Today’s show is number 1,461. You can find it online at peoplespharmacy.com. That’s where you can share your comments about this episode. You can also reach us through email, radio at peoplespharmacy.com. Terry 55:45-56:28 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. Here at the People’s Pharmacy, we encourage our listeners to take an active role in their own health care. There is a lot of information available on the web. Some of it’s excellent, and some is just okay, and some is misleading. To help you find the latest medical research, we suggest going to PubMed. This is the National Medical Library, available online to anyone. It may be a little hard to interpret the “medicalese,” but now AI agents can help you translate. Joe 56:28-56:49 At peoplespharmacy.com, you could sign up for our free online newsletter to get the latest news about important health stories. When you subscribe, you also have regular access to information about our weekly podcast. We’d be grateful if you’d write a review of The People’s Pharmacy and post it to the podcast platform you prefer. In Durham, North Carolina, I’m Joe Graedon. Terry 56:49-57:28 And I’m Terry Graedon. Thanks for listening. Please join us next week. Thank you for listening to the People’s Pharmacy podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money. Joe 57:29-57:38 If you like what we do and you’d like to help us continue to produce high-quality, independent healthcare journalism, please consider chipping in. Terry 57:39-57:43 All you have to do is go to peoplespharmacy.com/donate. Joe 57:43-57:57 Whether it’s just one time or a monthly donation, you can be part of the team that makes this show possible. Thank you for your continued loyalty and support. We couldn’t make our show without you.

Inflammation is a double-edged sword. When you have a sudden injury or infection, your body responds by calling immune cells to the site of the problem. It may become red, swollen and painful, but all that is supposed to be part of the healing process. What happens with chronic inflammation is more insidious. Many serious diseases, such as diabetes, depression or heart disease, feed off chronic inflammation. Anti-inflammatory drugs can control the problem temporarily, but they have drawbacks if they must be used continuously. How can we go about calming chronic inflammation without medication? At The People’s Pharmacy, we strive to bring you up‑to‑date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen: You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, Jan. 31, 2026, through your computer or smart phone (wunc.org). Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on Feb. 2, 2026. How Inflammation Works: One of the hallmarks of modern life is the impact of stress on the digestive tract. Excess weight, unrelenting stress and environmental toxins can all contribute to an immune system that goes into overdrive. Sometimes the consequence will be an imbalance in the microbiota, with the result that the tight junctions of the gut are disrupted. That can lead to “leaky gut,” more respectably termed “intestinal permeability.” When pathogens or toxins that should be confined to the gastrointestinal tract start circulating elsewhere, the immune system reacts. If the process continues, the consequence is chronic inflammation. Are there natural approaches to calming chronic inflammation? Calming Chronic Inflammation: When we want to help our immune system so that it doesn’t have to be hypervigilant all the time, we should start with our diet. If dysbiosis contributes to leaky gut and inflammation, the best approach might be to feed our gut microbes what they need. In most cases, that means increasing our fiber. Gut microbes thrive on fiber, and most Americans don’t get close to eating enough. Another important aspect, of course, is to avoid foods that might cause trouble. According to Dr. Low Dog, fructose degrades tight junctions in the intestines and could contribute to intestinal permeability and inflammation. To reduce fructose, we just need to cut back on sweets Finding Fiber in our Food: Where can we find fiber in our diet? Starting with breakfast, a lot of folks enjoy cold cereal, pancakes or pastries. There’s not much fiber in any of those, unless you’ve chosen bran cereal. But even a choice as simple as eating an apple with the skin on can provide a good amount of fiber. Do you like salmon for breakfast? That’s a very anti-inflammatory choice. One worrisome development is the spread of microplastics throughout our diet. As a result, most of us have microplastics in our bodies. Some of the compounds in these little particles of plastic are endocrine disruptors that contribute to inflammation. Maintaining Healthy Barriers: The colon is not the only part of the digestive tract that provides an important barrier. The mouth is also susceptible. Brushing, flossing, dental care and a low-sugar diet are important steps to protecting our bodies against chronic inflammation. Periodontal disease contributes in a major way. To maintain good tight junctions, we need to eat about 20 grams of insoluble fiber and 8 grams of soluble fiber daily. Beans and vegetables are great sources of both. Nuts and seeds like sunflower seeds or walnuts are also good sources. So are whole grains. And if we have any trouble reaching our fiber goals with diet, there is nothing wrong with adding a daily dose of psyllium, which is mostly soluble fiber. It lowers cholesterol and can reduce the risk of diabetes as well as promote regularity. Herbs to Ease Inflammation: In addition to paying attention to a high-fiber anti-inflammatory diet, we can benefit by using certain herbs or spices to calm chronic inflammation. Green tea, garlic, onions, hot peppers and other flavorings all have anti-inflammatory power. Turmeric, the yellow spice in curry, is a potent anti-inflammatory. To get the best benefit from adding turmeric to food, it should be used to spice a meal with some fat in it. Black pepper as part of the spice profile also helps with the absorption of compounds from turmeric. Dr. Low Dog cautions us all to vet our turmeric carefully, though. Some brands are high in lead. She suggests that Simply Organic and McCormick are both brands that were relatively free of lead when tested by ConsumerLab.com or Consumer Reports. One supplement that may be unfamiliar to most listeners is nattokinase. It is derived from natto, a fermented soybean dish that is very popular in Japan. People who are taking anticoagulants should probably avoid nattokinase, even though it has anti-inflammatory activity. It could interact with anticoagulants and increase the danger of bleeding. We would add that precaution should also hold for curcumin supplements derived from turmeric. They should not be taken by anyone on an anticoagulant. Other Natural Approaches to Calming Chronic Inflammation: When we asked Dr. Low Dog about her favorite way to calm chronic inflammation, she mentioned walking in nature. High cortisol levels drive chronic inflammation, but green spaces reduce stress and help bring cortisol down. Other marvelous approaches include seeking out ways to embrace contentment and joy and humor. For some people, that will mean meditation. For others, it will mean hanging out with good friends or going for a run. Nourishing our mental and spiritual health with art and poetry help connect us with meaning and purpose in our lives. This Week’s Guest: Tieraona Low Dog, MD, is a founding member of the American Board of Physician Specialties, American Board of Integrative Medicine and the Academy of Women’s Health. She was elected Chair of the US Pharmacopeia Dietary Supplements/Botanicals Expert Committee and was appointed to the Scientific Advisory Council for the National Center for Complementary and Alternative Medicine. Tieraona Low Dog, MD, author of Fortify Your Life Her books include: Women’s Health in Complementary and Integrative Medicine; Life Is Your Best Medicine and Fortify Your Life: Your Guide to Vitamins, Minerals and More. Dr. Low Dog’s latest is eBook is Healing Heartburn Naturally. Physical copies are available for purchase via Amazon: Click here. Her websites are drlowdog.com and https://www.medicinelodgeranch.com/ The People’s Pharmacy is reader supported. When you buy through links in this post, we may earn a small affiliate commission (at no cost to you). Listen to the Podcast: The podcast of this program will be available Monday, Feb. 2, 2026, after broadcast on Jan. 31 You can stream the show from this site and download the podcast for free. The podcast is supported in part by Superpower.com. For a limited time, our listeners get an additional $20 off with code PPOD. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1460: A transcript of this show was created using automated speech-to-text software (AI-powered transcription), then carefully reviewed and edited for clarity. While we’ve done our best to ensure both readability and accuracy, please keep in mind that some mistakes may remain. If you have any questions regarding the content of this show, we encourage you to review the original audio recording. This transcript is copyrighted material, all rights reserved. No part of this transcript may be reproduced, distributed, or transmitted in any form without prior written permission. Joe 00:00-00:01 I’m Joe Graedon. Terry 00:01-00:05 And I’m Terry Graedon. Welcome to this podcast of The People’s Pharmacy. Joe 00:06-00:26 You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. Immune reactions are both helpful and harmful. Immune cells fight infection, but they can also trigger inflammation. This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:47 Dr. Tieraona Low Dog is a medical doctor and an expert in botanical medicine. She explains the complexity of the immune system, how it can heal in the short term, and what happens when inflammation persists. Joe 00:48-00:57 Tens of millions of people take non-steroidal, anti-inflammatory drugs every day. Is there a downside to quelling inflammation? Terry 00:58-01:05 Ongoing inflammation is behind many serious diseases, including cancer, diabetes, and heart trouble. Can we address it naturally? Joe 01:05-01:10 Coming up on The People’s Pharmacy, calming inflammation without drugs. Terry 01:14-02:44 In The People’s Pharmacy Health Headlines: Appendicitis, an acute inflammation of the appendix, is a surprisingly common problem, affecting an estimated 7 to 8 percent of people over their lifetimes. Until about 10 years ago, appendicitis was nearly always treated as a surgical emergency. In 2015, scientists published a randomized clinical trial comparing surgery to antibiotic treatment. A large majority of patients who got antibiotics did not require surgery for a recurrence of appendicitis within one to two years after treatment. That study included 273 people undergoing surgery and 257 taking antibiotics. Over the years, some of those who were initially treated with antibiotics did require surgery. Five-year follow-up showed that 39% who got antibiotics later required surgery. Now the same scientists are reporting the results of 10 years of follow-up. They were able to check in with 253 of the original 257 patients. More than half of them did not require surgery. The researchers conclude, among patients initially treated with antibiotics for uncomplicated acute appendicitis, the rate of recurrence in appendectomy at 10-year follow-up supports the use of antibiotics as an option for uncomplicated acute appendicitis in adult patients. Joe 02:44-03:37 High blood pressure contributes to heart attacks, strokes, congestive heart failure, and kidney damage. Accurate measurement is important for diagnosis and treatment. Researchers at Harvard and Brigham and Women’s Hospital in Boston recruited over 3,000 patients with uncontrolled hypertension. All participants were given a free home blood pressure monitor that could send data electronically to the research database. They also received personalized coaching and reminders to monitor blood pressure. One-third failed to take their blood pressure even once, and only about a third managed the 24 to 28 weekly measurements the researchers were hoping for. The authors conclude that the, quote, low engagement rates observed highlight the need for alternative approaches that are more convenient for patients. Terry 03:37-05:02 There are several medications used to treat type 2 diabetes. A new study compares the effects of two different classes with respect to their effects on kidney function. People with diabetes are vulnerable to developing acute kidney disease. Now, Danish researchers have analyzed health records to compare how two classes of diabetes drugs affect the kidneys. The SGLT inhibitors include drugs like empagliflozin, better known by its brand name Jardiance. GLP-1 receptor agonists are medicines like semaglutide, known as Ozempic. The population included people with type 2 diabetes who were taking metformin. When an additional drug was needed, 36,000 plus took one of the gliflozin drugs, while more than 18,000 took a GLP-1. Over five years, 6.7% of those on SGLT-2 drugs developed chronic kidney disease. In comparison, 8.2% of those on GLP-1 drugs had that outcome. The investigators conclude collectively these findings support a lower risk of acute and chronic kidney outcomes with SGLT2I versus GLP-1RA, especially among individuals with a low a priori risk of kidney disease. Joe 05:02-05:58 There was a time, not so long ago, that if you wanted to know if you had the flu, you had to make an appointment with your physician to be tested. That could cost precious time. But now, pharmacies sell over-the-counter flu and COVID tests for rapid detection at home. The FDA has approved another test. The new four-in-one home test called FlowFlex Plus can detect RSV as well as influenza A and B and COVID-19. RSV, an abbreviation for respiratory syncytial virus, is dangerous in babies and young children and accounts for many hospitalizations. This test may be used in infants as young as six months old and could help parents manage this serious infection at the earliest possible stage. And that’s the health news from the People’s Pharmacy this week. Terry 06:14-06:17 Welcome to The People’s Pharmacy. I’m Terry Graedon. Joe 06:17-06:33 And I’m Joe Graedon. When you hear the word inflammation, what comes to mind? We have frequently been told that inflammation is our enemy. Tens of millions of people take anti-inflammatory drugs every day to overcome pain. Terry 06:33-06:45 But inflammation is an essential process for healing injuries, infections, and other acute problems. It’s part of the immune system’s initial response to a wide range of threats. Joe 06:46-07:29 To find out how inflammation can be both our friend and our enemy, we are talking today to Dr. Tieraona Low Dog. She is a founding member of the American Board of Physicians Specialties, American Board of Integrative Medicine, and the Academy of Women’s Health. She was elected chair of the U.S. Pharmacopeia Dietary Supplements Botanicals Expert Committee and was appointed to the Scientific Advisory Council for the National Center for Complementary and Alternative Medicine. Her books include: “Women’s Health in Complementary and Integrative Medicine,” “Life is Your Best Medicine,” and “Fortify Your Life: Your Guide to Vitamins, Minerals, and More.” Terry 07:30-07:34 Welcome back to The People’s Pharmacy, Dr. Tieraona Low Dog. Dr. Tieraona Low Dog 07:34-07:37 Oh, thank you for having me back. It’s so good to be with you. Joe 07:38-07:48 Well, Dr. Low Dog, you are perhaps the most frequent guest on The People’s Pharmacy and one of the longest. We have been talking to you for so many years. Terry 07:49-07:49 And our favorite. Joe 07:50-07:50 And our favorite. Terry 07:51-07:52 Don’t tell anybody else. Joe 07:52-07:54 But don’t share that information. Dr. Tieraona Low Dog 07:55-07:56 Thank you. Joe 07:56-08:29 So, Dr. Low Dog, we’re going to talk about a couple of things today on The People’s Pharmacy. But we’d like to take advantage of your expertise as both a medical doctor and a natural healer. And we’re going to start with inflammation because it seems to be at the center of so many health problems. First of all, can you tell us when we say inflammation, what are we talking about? And why does it play such an important role both in healing and harming our bodies? Dr. Tieraona Low Dog 08:31-10:39 Oh, you know, the inflammatory response is absolutely crucial for our survival, right? So we’ve recognized sort of the five hallmarks of inflammation for a long time, right? You know, 2000 years ago, they were writing about heat, redness, swelling, pain, and loss of function, right? So those are kind of the five cardinal pieces. And that really was speaking a lot to like an acute inflammatory reaction. So you are out running and you fall down and you skin your knee and you break the skin and it’s kind of bloody and messy and you go home and clean it. Well, if you feel it, it will be warm because you’re bringing more blood flow to the area. It will be red because of the heat and the increased blood flow. Swelling as you’re trying to bring in all your good white blood cells and all of your, you know, warriors to come and clean out any debris, pain and loss of function because we’d like you, you know, to kind of favor that knee for a little bit so that we give the body opportunity to heal it. This inflammatory response is absolutely necessary for cleaning out debris, dead cells, making sure there’s no infection taking place, and also then stimulating, in that case, collagen and wound repair. So a lot of times it’s easiest for people to think about inflammation because everybody’s had a wound and they’ve all experienced that pain and swelling, redness and recovery. I think what a lot of people don’t realize is that you can have similar inflammatory responses that are acute, like when you get a fever, that’s your body’s opportunity, right, to generate heat and activate your white blood cells and fight off infection, and then you get better. But you can also have inflammation that becomes more chronic, and I think that’s something that’s much newer on the scene, this understanding that there can be a low-grade chronic burn going on in the body that is driving a lot of chronic disease. Terry 10:40-11:09 Let’s talk a little bit about some of those chronic diseases, because when we talk to various experts over the years about diabetes or Alzheimer’s disease or arthritis, all kinds of problems that people have, various types of digestive problems, we say, well, what’s behind it? And they say inflammation. So tell us a little bit about chronic inflammation and how it affects the body. Dr. Tieraona Low Dog 11:10-13:15 So, you know, the whole thing with chronic inflammation and the fact that it is the uniting, underpinning root cause of all the conditions you just talked about, the progression of cancers, metabolic diseases, type 2 diabetes, depression, you know, mental health challenges, heart disease. You know, when I went to medical school, heart disease was just cholesterol, right? It’s all cholesterol. And now we know that cardiovascular disease is really a disease of inflammation. So, you know, when we look at these diverse things like depression, pain, periodontal disease, how do those all connect? They connect through this thing we call systemic inflammation. And, you know, today we do so many things that drive that inflammation. We put on weight around the midsection, right? So visceral fat or tummy fat, and I don’t mean the kind you can pinch. I’m talking about the deep fat that develops around our organs, high fructose, high saturated fat diets, that combination pattern, Western diets, not exercising, not moving, prolonged stress, you know, just chronic physiologic or psychosocial stress. And then, of course, environmental exposures, endocrine disrupting chemicals and toxins in the environment. And an area that I have been mostly focused on lately is alterations in the oral and gut microbiota, the bugs that live there, and then leaky gums and leaky gut and how that drives this systemic inflammation. Hippocrates said more than 2,000 years ago that all disease begins in the gut. And if we’re going to think about chronic inflammation, we really have to focus on what’s happening in the mouth and what’s happening in the gut. Joe 13:16-13:26 Well, Dr. Low Dog, I want to talk just a moment about that leaky gut. The gastroenterologists have a very nice terminology for it. Terry 13:26-13:42 Oh, yes. They call it intestinal permeability, which sounds a lot more respectable than leaky gut. Actually, some gastroenterologists laugh at leaky gut, but they don’t laugh at intestinal permeability, which is actually the same thing. Joe 13:42-14:24 And, you know, tens of millions of Americans swallow a non-steroidal anti-inflammatory drug every single day. Maybe it’s for their arthritis or their headache, whatever. And that’s whether it’s Advil or Aleve, that’s to say ibuprofen or naproxen. And these drugs that we just take as if they were, you know, a vitamin can have a profound impact on our digestive tract and can contribute a bit to leaky gut. But I suspect our diet and other things can as well. Can you just describe quickly what this intestinal permeability is all about and why it might lead to chronic inflammation? Dr. Tieraona Low Dog 14:24-17:21 Sure… and I think intestinal permeability is the medical term that we do use. But when I speak to many audiences, what they’ve heard of is leaky gut. And I think that, you know, in many ways, it allows people to visualize what’s happening. The intestine, I mean, think about all the food that we’re digesting and everything that goes along with that coming into the stomach, into the small bowel and the large intestine. And we all know what comes out the other end, right? So there is a critical need for the intestinal, the cells inside of the intestine, to be able to have the selective ability, you know, to decide when water or nutrients or electrolytes are being, you know, absorbed from food out into the systemic circulation, right? And keeping harmful substances inside the intestine, right? So it has to be able to act like a gatekeeper. Well, inside of those cells, the things between the cells are something called tight junctions. And think of these as just like tightly fitting bricks, right? And when we need to absorb things, these proteins open up and they allow the body from the inside of the intestine, things to move out into the lymphatics and the bloodstream, keeping things that need to stay in the intestine inside. The problem is there are a lot of things, including what you just mentioned, like the continuous use of nonsteroidal anti-inflammatories that disrupt those tight junctions. And they allow larger molecules, endotoxins, and even some viable bacteria to pass through that lining out into the bloodstream. And that is a problem. These endotoxins, mostly they’re coming from gram-negative bacterial membranes and walls. When those get out into the bloodstream, they’re highly immunogenic. They trigger an immune response. And that then just drives this systemic inflammation. Now, if it happens once in a while, that’s not really a big problem. When this is occurring on a regular basis, it’s driving this ongoing inflammation that affects insulin regulation. It affects the blood brain barrier, you know, causing neuroinflammation. It affects metabolism. I mean, it is the great unifier, if we think about it, of what is driving this slow burn inside of us. This dysbiosis, anything that disrupts those bacteria and other microbes inside of the intestine also will disrupt those tight junctions and they lead to inflammation. So there’s a lot on this. This is not a mystery. It’s pretty well defined. It’s just biology. Terry 17:23-17:49 You’re listening to Dr. Tieraona Low Dog, a founding member of the American Board of Integrative Medicine and the Academy of Women’s Health. She has served on the Scientific Advisory Council for the National Center for Complementary and Alternative Medicine. Her books include: “Life is Your Best Medicine” and “Fortify Your Life: Your Guide to Vitamins, Minerals, and More.” Her latest book is “Healing Heartburn Naturally.” Joe 17:49-17:57 After the break, we’ll learn what to do to help the immune system so it doesn’t feel like it has to be vigilant every second. Terry 17:57-18:03 If fiber is a great way to support the immune system by supporting the gut, what should we eat? Joe 18:03-18:14 I love talking about breakfast because too many of us rely on high-carb, low-fiber options like pancakes or pastries. What would be better? Terry 18:14-18:20 We do worry about microplastics. We all have them in our bodies. Could they be triggering inflammation? Joe 18:21-18:29 Might brain inflammation be a reaction to infection? Could it lead to Alzheimer’s disease? Terry 18:39-19:09 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 20:54-20:57 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 20:57-21:46 And I’m Terry Graedon. Today, we’re learning how to calm chronic inflammation. It’s been estimated that one in three adults has inflammatory markers in their bloodstream. Inflammation contributes to conditions such as rheumatoid arthritis, lupus, psoriasis, cardiovascular disease, and metabolic conditions. Joe 21:47-22:05 We’ve been talking about the gastrointestinal tract. How does inflammation in our GI tract affect organs in the rest of our body? What’s your favorite breakfast? Do you find a bagel and cream cheese keeps you going? What about oatmeal or bacon and eggs? Terry 22:06-22:12 We should be paying attention to what’s on our plates for sure, but we should also know what to avoid. Joe 22:12-22:45 To learn more, we turn back to Dr. Tieraona Low Dog. She is a founding member of the American Board of Physician Specialties and was elected chair of the U.S. Pharmacopeia Dietary Supplements Botanical Experts Committee. Her books include “Women’s Health in Complementary and Integrative Medicine,” “Life is Your Best Medicine,” and “Fortify Your Life: Your Guide to Vitamins, Minerals, and More.” Her latest is an e-book, “Healing Heartburn Naturally.” Terry 22:46-23:21 Dr. Low Dog, it sounds as though the inflammation that we’re talking about, chronic inflammation, is really a consequence of sort of chronically putting the immune system on alert. So not letting it relax and then jump to attention and then relax again. What can we do to help the immune system not have to feel like it’s always on patrol? Dr. Tieraona Low Dog 23:21-25:00 Well, it starts by making sure that you ensure barriers are not being disrupted. Barriers are important. In the mouth, it’s important to reduce the amount of sugar intake and to regularly get your oral cleanings. While we focus a lot on intestinal permeability, the number of diseases that are associated with high oral permeability, meaning through the gums, is also enormous. And it’s something we seldom talk about. So I do want to just note that that’s the beginning of the GI tract. So making sure you’re, you know, keeping down the sugar, you’re brushing, flossing, and you’re seeing your dentist every six months. And then when it goes to the gut, how do we maintain tight junctions? One, probably the biggest thing you can do other than cutting back on sugar, because fructose just definitely degrades that barrier, high consumption of sugars, is to increase your consumption of fiber. Fiber’s huge. And, you know, forever we’ve been telling people to increase their fiber and high fiber diets. We know they increase the health of the bugs, the microbes that are inside of our intestines, especially those that produce the food or the short chain fatty acids that are necessary for the intestinal cells to remain healthy. High fiber diets decrease intestinal permeability. That’s why, you know, we say that eating high fiber diets can help reduce the risk of colorectal cancer, can help lower cholesterol, you know, all of these amazing things. Terry 25:01-25:21 It does all those amazing things. But I think that a lot of people hear high fiber diet and they don’t really know what to eat. So Dr. Low Dog, if I were to go out to lunch today, what should I choose to make sure I’m getting a high fiber meal? Dr. Tieraona Low Dog 25:21-25:55 Absolutely. So, you know, we want both soluble and insoluble fibers, right? So, you know, how much do you need? You know, somewhere around 20 grams a day of the insoluble fibers and about eight per day of soluble. Those are the prebiotics. Those are the ones that lower cholesterol, regulate blood sugar, and help maintain those good tight junctions. So maybe this morning you got up and you had an apple with the skin on. That just gave you almost six grams of fiber and half of the soluble fiber you need for the day. One medium-sized apple, right? Terry 25:55-25:56 Okay. Dr. Tieraona Low Dog 25:56-28:24 I mean, so that’s great. If you’re going out for lunch, have your nice salad, but make sure you also put some beans on it, right? If you’re at a place where you can put, you know, garbanzo beans, black beans, a half a cup of cooked black beans is essentially seven grams of fiber, a half a cup. And almost four grams of that is soluble fiber, right? Pinto beans. I live in New Mexico. Pinto beans is another great place. A half a cup gives you five and a half grams of soluble fiber. So add some sunflower seeds. Put some walnuts on your salad, right? Make sure you’re adding more vegetables to the diet. The whole point is that all of the recommendations that we have for a plant forward diet, where we’re wanting people to increase their intake of fruits, vegetables, nuts, seeds, whole grains is because they’re rich in dietary fiber. And dietary fiber feeds the good bugs that we have inside of our gut, and it decreases intestinal permeability, which decreases inflammation. They have beneficial effects for lowering cholesterol, regulating blood sugar, you know, helping to reduce the risk of colorectal cancer. I mean, you name it. Even there’s data showing that higher fiber diets decrease the risk of respiratory infections and also increase our lives, our lifespan, our health span. So, you know, if you’re going to invest in one thing, that would be it. And for some people who are like, you know, I just, I just can’t eat that much fiber. I would say that psyllium, our old friends, psyllium seed and psyllium seed husks, which have been used forever, is a very good, you know, supplement that you can just take. It’s predominantly soluble fiber and it’s, you know, seven to three soluble to insoluble fiber roughly. And it’s the only fiber that is recommended by the American College of Gastroenterology for treating irritable bowel syndrome and chronic constipation (American Journal of Gastroenterology, Jan. 1, 2021). And the reason for that is it doesn’t tend to cause as much gas and bloating as some of the other fibers do. The FDA has actually allowed two health claims also for psyllium. It can reduce the risk of type 2 diabetes and it can lower cholesterol and reduce the risk of heart disease. So just think about that. Terry 28:24-28:34 Yeah, that’s what I was just going to jump in to say is there’s actually quite good research showing that it lowers cholesterol. And so that’s why I take it every day. Joe 28:33-29:15 Well, you know something about our favorite breakfast, as Terry will attest, my favorite breakfast is refried beans with lots of onions and peppers and, of course, olive oil. And then we put an egg on top, and it’s just fabulous. And then today we had Terry’s whole wheat bread, which, by the way, is absolutely fabulous. Terry has become the best bread baker you can imagine. And on top of that, we had avocado. So it was avocado toast and salmon. And it was just delicious. And it felt like, well, we were getting our fiber, and it tasted good, too. Terry 29:15-29:21 And I think actually salmon probably qualifies as an anti-inflammatory food too, doesn’t it, Dr. Low Dog? Dr. Tieraona Low Dog 29:21-29:33 It’s one of the most of the anti-inflammatory foods when we rank them, you know, by actually what they do in the body. So all I’m saying is me and all the other listeners are wanting to know when we’re coming over for breakfast. Joe 29:35-30:01 Come on down. But here’s the problem, Dr. Low Dog. I’ve been paying attention, as Terry will attest, to plastic for the last 50, 60 years. And, you know, when we saw the movie “The Graduate” and Dustin Hoffman is told plastic is the wave of the future, I had shivers up and down my spine. Terry 30:01-30:40 Well, Joe actually was paying attention when a grad school classmate of mine, we all got together and his girlfriend had been working for the plastic industry as a newsletter editor. And this is so long ago, back when I was in graduate school. We’re talking, you know, 1970. And she said, the industry is concerned because these compounds leach out of the plastic and into the stuff that the containers are holding. Joe 30:41-31:04 But now we even see microplastic or nanoparticles of plastic in our brains, and not just in our brains, like a lot of them, these little tiny plastic particles. But they’re in our blood vessels, they’re in our sexual organs, they’re just all throughout our body. And I can’t help but think that’s not good for us. Terry 31:04-31:06 It might even be inflammatory. Dr. Tieraona Low Dog 31:06-33:14 Oh, they’re very inflammatory. They definitely disrupt, you know, the microbiome. They alter signaling pathways. They alter immune responses. Yeah, it’s interesting because my mother never liked plastic. She would never, or cans actually, she didn’t like aluminum. She didn’t like the way cans things tasted. She didn’t like, um, she didn’t like anything in plastic. She never stored things in plastic, uh, cause she said that she could taste it. Now, I don’t know, you know, if she could taste it or not, but she certainly thought she could. And so I grew up just never having things, you know, in plastic. And, and I could never get the kids to not want to microwave in plastic when they were younger. And so I just got rid of everything that was plastic and bought glass containers for food storage. And, you know, and I learned from my grandmothers to save every pickle jar and everything else and recycle the glass, you know, and use them over and over again. But this is concerning even down to tea bags, right? Just even your brands of teas that have microplastics that you’re leaching out every morning and from your tea bags. So this is a huge issue and it’s going to be a challenge because it’s so woven into food delivery, you know, fast food packaging, food storage. But I would agree with you. And Joe, you were just way ahead of the crowd. Maybe my mom was too, just not wanting plastics. But it is very inflammatory, highly inflammatory, and they’re accumulating everywhere. And we do know that they cause neuroinflammation. So think about this with young children and a lifetime of having these microplastics in their liver driving inflammation and in their brains. And what happens when you’ve exposed a central nervous system as well as other areas of the body to 60 years of neuroinflammation? Joe 33:14-34:17 Well, speaking of neuroinflammation, you know, there is a growing theory that Alzheimer’s disease and other forms of dementia may be in part neuroinflammation. And some people are suggesting maybe a reaction to an infection, you know, like herpes simplex is reactivated, perhaps because of COVID or perhaps because of some other problem that stimulates, as we know, herpes is lingering in the brain for long periods of time. And now people are starting to look at anti-inflammatory approaches and maybe even antiviral approaches to dealing with the neuroinflammation. And what we’re hearing is that some of the medications that have been used and are so super expensive to deal with amyloid may not really be solving the problem. Dr. Tieraona Low Dog 34:17-38:01 Yeah. Well, you know, it is interesting. There was there was a review that was done, a meta-analysis looking at Alzheimer’s and then mild cognitive impairment, right? So looking at both. And they were looking at a variety of things. But in this case, they really found a very strong connection with oral inflammation, with periodontal disease. And those who had severe periodontal disease, you know, the risk for Alzheimer’s was almost five-fold more likely, an odds ratio of almost five. It was kind of shocking. So if we step back again and go, okay, so in the gut and in the oral cavity, when there’s this permeability, when there’s inflammation in the mouth and there’s leakage or there’s dysbiosis and there’s increased intestinal permeability, these endotoxins from these gram-negative bacteria are getting out. These are what we call lipopolysaccharides, right? So you’re going to see that word everywhere. But we know that when those are in the circulation, they degrade the blood-brain barrier and they turn on these cells, these little cells inside the brain called microglia that are normally just resting and happy and they’re there to clean up things or take care of an infection if it happens. But this turns it on. LPS, there’s little receptors for them and they turn on these microglia and we know that they drive neuroinflammation. And when you measure lipopolysaccharides in people with depression or animals with depression versus healthy animals or people that are healthy without depression, lipopolysaccharides are quite high. And so, you know, it’s, I agree, active infection, lingering infection, latent infection, but I would also have to say, step back, root cause, you know, root cause drives the inflammation down by making sure barriers, including the blood brain barrier is nice and strong. The gut barrier is nice and strong. Um, I think that for so long, so long, we keep just, you know, like that saying is we keep pulling people out of the river and keep finding new ways to, you know, dry them off and to get them on their way. But nobody’s really going upstream to figure out why they keep falling in the first place. That’s why I’m excited with the new data looking at what’s driving, what connects a bad diet, obesity, chronic stress, poor sleep, bad digestion, poor digestion. What connects all of these things to heart disease and metabolic problems and Alzheimer’s and depression and anxiety, even osteoporosis, cancer, aggravation of autoimmunity? It’s inflammation. And how do we tamp that down? And it starts with how we’re born. It starts with how we’re fed at birth. It starts with how many antibiotics we take when we’re young, the diets that we eat, the way we manage our stress, and the health of our gut. So, you know, it’s a big topic. And you all have covered so many of these subjects over the years. And I would just say, you know, all roads are sort of leading back. They’re leading back to this root cause, which is this persistent inflammation and, you know, now microplastics, endocrine disruptors in the environment. I mean, there’s just a lot of things. So we’re going to have to figure out how are we going to protect those barriers? How are we going to protect the gut and ultimately then the mind? Terry 38:02-38:37 You’re listening to Dr. Tieraona Low Dog. She’s a founding member of the American Board of Physician Specialties, the American Board of Integrative Medicine, and the Academy of Women’s Health. Dr. Low Dog has served on the Scientific Advisory Council for the National Center for Complementary and Alternative Medicine. Her books include “Women’s Health in Complementary and Integrative Medicine,” “Life is Your Best Medicine,” and “Fortify Your Life: Your Guide to Vitamins, Minerals, and More.” Her latest book is “Healing Heartburn Naturally.” Joe 38:38-38:45 After the break, we’ll learn about herbs that can help fight inflammation. There are a surprising number of them. Terry 38:46-38:51 What’s the best way to get the benefits of turmeric? You know, that yellow spice in curry. Joe 38:52-39:07 It’s become one of the most popular herbs in the health food store and pharmacy. And we’ll get a golden milk recipe. That’s really terrific. Most people have never heard about golden milk in the U.S. It’s very popular in India. Terry 39:08-39:16 You do have to be a bit careful with turmeric or curcumin supplements. If you’re taking anticoagulants, there could be an interaction. Joe 39:16-39:26 Yes, it could increase your risk for bleeding. We’ll also discuss something you’ve probably never heard of, nattokinase. Why is it beneficial? Terry 39:27-39:45 We’ll also find out about other ways to calm inflammation, like meditation, massage, or magnesium supplements. You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 39:54-39:57 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 39:57-40:17 And I’m Terry Graedon. Today we’re considering calming chronic inflammation and we may need to learn about some supplements that might not be entirely familiar. You’ve probably heard of turmeric, which is a potent natural anti-inflammatory, but perhaps you’ve never heard of nattokinase derived from fermented soybeans. Joe 40:18-40:46 Our guest today is Dr. Tieraona Low Dog. She is a founding member of the American Board of Physician Specialties and was elected chair of the U.S. Pharmacopeia Dietary Supplements Botanicals Expert Committee. Her books include “Women’s Health in Complementary and Integrative Medicine,” “Life is Your Best Medicine,” and “Fortify Your Life: Your Guide to Vitamins, Minerals, and more.” Terry 40:46-41:30 Dr. Low Dog, you’ve given us all very good advice about how to keep our intestines in shape and keep those tight junctions tight and how to take care of our oral health. And what we want to do is make sure we cut back or eliminate the sugar and we increase the fiber and more fresh fruits and vegetables are going to be better along with beans and maybe some whole grains. But what about herbs? We’ve talked to you before about herbs, but I don’t remember which herbs might be most helpful for fighting chronic inflammation. Dr. Tieraona Low Dog 41:30-43:16 Oh, my gosh. There’s so many. There’s so many. So I’ll go into detail into a few. But, you know, just having that, you know, tea in the morning is good, especially green tea. Adding more spices to your diet. I think I heard you say about onions this morning. So onions are highly anti-inflammatory and so is garlic, you know, cilantro, basil, you know, cinnamons, all of these beautiful spices are so anti-inflammatory. And if Americans could just learn to cook a bit more with more culinary herbs and spices, we would begin to really start to see a shift in our inflammation. Speaking of spices, I know you know what I’m going to say. Turmeric, turmeric obviously is one of my favorite herbs and second really only to salmon when it comes to anti-inflammatory power. And when we look at turmeric, adding that to the diet, you know, putting it in your rice, adding it to your tomato soup, or for some people taking a supplement, but the data, you know, why does turmeric seem to, you know, when people eat turmeric over a lifetime, why does it seem to reduce Alzheimer’s? You know, why are studies showing that turmeric seems to help with depressed mood, you know, and memory? How can it reduce inflammation in the gut? Well, we think it’s because it’s a pretty powerful anti-inflammatory and it feeds good microbes in the gut and it reduces intestinal permeability. So turmeric does all kinds of amazing things. So I would say definitely increase turmeric. Joe 43:17-43:54 Well, hang on just a sec, because I know you’ve been to India recently, which seems like the origins of turmeric and, of course, the active ingredient curcumin. And in India, I’m guessing that a lot of people are cooking with turmeric and they’re using some ghee, some fat with that turmeric to get it to absorb better and maybe a little black pepper. You know, Americans love pills. And I keep seeing all these commercials about the best turmeric on TV. Terry 43:55-44:00 But curry tastes so much better than a pill. And probably you’re absorbing it better. Joe 44:00-44:05 Exactly. So tell us a little bit about cooking with turmeric. Dr. Tieraona Low Dog 44:05-46:10 Oh, yeah. Well, you know, we cook with turmeric probably three, four times a week. You mentioned a couple of the most important pieces, some sort of fat, right? So rather that’s your, you know, olive or coconut or ghee or butter, putting that turmeric in and letting it be absorbed with some fat. I love it. I love it in tomato soup. I love cooking with turmeric and a little black pepper saffron in my tomato soup. And of course, for many people, just making a golden milk, it’s so simple, right? You just take a little bit of ghee, [clarified butter], you know, or a little butter, and you just cook the turmeric in there for a minute or two and then add your milk or your non-dairy milk. Let that kind of simmer. If you’d like, put a pinch of cardamom, some dates, chop a date up. Cook that all up, put a sprinkle of black pepper in at the end and drink. I serve it here all the time for our classes and guests and people that visit our ranch. And they’re like, this is so delicious. So cooking, adding it to curries. One thing I would say for your listeners is that we do know that there’s been problems with lead and turmeric in the spices, right? So you do want to, Consumer Labs and Consumer Reports, there’s been a number of groups that have tested them. So just making sure that you’re buying really good turmeric to use in the kitchen. A couple that came out really good, you know, obviously McCormick is very good, which is available, but Simply Organic. Their range of spices also came in exceedingly clean. But I was concerned out of 31 different turmeric spices that were taken off the shelves around Boston, many of them exceeded all safe lead levels. So making sure you’re buying a good curry powder or a good turmeric powder to use at home with your cooking. Joe 46:10-46:36 One word of caution. We have heard from a lot of people who are taking pills, supplements, that they end up with nosebleeds or sometimes other bleeding problems, especially if they’re also taking an anticoagulant like warfarin at the same time. So apparently turmeric does have the ability to quote unquote thin the blood. Terry 46:37-46:53 Or perhaps interact with warfarin. So somebody on warfarin needs to be cautious, I would say, especially with supplements, but possibly also make sure that you don’t overdo on the curry. Dr. Tieraona Low Dog 46:53-47:13 Yeah. You know, but I would say this about warfarin just as a physician. Changing your diet in a dramatic way will affect warfarin, you know, just the way the kinetics work. And, you know, I used to tell the med students, if you have four answers and one of them’s warfarin for an interaction, always choose it because it’s so finicky. Terry 47:13-47:15 It interacts with a lot of things. Dr. Tieraona Low Dog 47:15-47:45 It interacts with a lot of things. So I would tell any listener who’s on something like a Coumadin or something like, you know, for platelet aggregation and blood clots, you just have to be very careful with even any really dramatic changes in diet or adding supplements. Make sure you’re working with your practitioner because we can always adjust your dose of your warfarin to accommodate your diet. It’s just changing your diet around a lot can be problematic. Joe 47:46-48:00 I do have a quick question that’s completely off the subject, but it has been reminded in my brain because of the conversation about turmeric as an anticoagulant in part. And that’s something called nanokinase. Terry 48:01-48:02 Nattokinase. Joe 48:02-48:20 Nattokinase. So what is nattokinase and why would it be beneficial? We heard from an internist, you know, mainstream medical doc, highly placed at one point at Duke, and he said he and his wife are now using nattokinase to prevent clots. Dr. Tieraona Low Dog 48:20-49:39 Yeah. So when you boil… natto’s made from boiled soybeans, right? You ferment them with bacteria and it creates, nattokinase is the enzyme that comes from NATTO, N-A-T-T-O, right? We looked at this when I was at the USP, at the United States Pharmacopeia, looking at it from a safety perspective, because it definitely does seem to have the ability to help with blood pressure, help prevent blood clots, etc. The problem with it is, you know, when we’re putting you on something to reduce blood clots and somebody who really has a high risk for them. We can control the dose so that we make sure you’re not under or over coagulated. That’s more challenging. It’s just, it’s more challenging. If you’re looking at something, you know, that can just kind of help with blood pressure and, you know, maybe even brain health or things like this, you know, having some of it in the diet isn’t really a problem because, I mean, there’s a food. Natto is a food. So I’d say that was fine. Where I would be cautious is if you were told you need to be on an anticoagulant because you have a high risk of throwing clots, I would say that this is not reliable because you can’t keep a steady state. Terry 49:40-50:03 Right. So for that, you need a medication. It might be warfarin or it might be one of the others. Dr. Low Dog, other approaches to calming inflammation. Is there any room for things like mindfulness meditation, massage therapy, acupuncture? What are your favorite modalities? Dr. Tieraona Low Dog 50:05-50:08 Walks in nature. You knew that would be my favorite. Terry 50:08-50:12 That is great. Tell us a little bit more about that. Dr. Tieraona Low Dog 50:14-52:28 You know, just being out wherever is like a place for you. So if it’s around a lake or near the beach or walking in a park if you live in a city, green spaces we know have a very beneficial effect on blood pressure, on mood, on our overall sense of well-being. And of course, you know, we know that when we let little kids, there were some beautiful studies done looking at little children in daycares where they’re out playing in the dirt or like planting plants. When we looked at their risk of infections, like respiratory infections, and also looked at their stool, their microbes, they are just much healthier than kids that don’t get to play outside in the dirt. So I love being out in nature. I think it’s one of the best things we can do for our health and our well-being. I do, I meditate. I meditate also when I’m walking, but mindfulness can be very powerful for reducing stress and cortisol. Remember that this high cortisol that many people have from persistent stress, cortisol, you know, also causes disruption of our gut bacteria, drives systemic inflammation. So, you know, helps us put on more weight in our tummies. So doing things that reverse that are important. Exercise can do that too, right? Physical activity, relationships, the power of connections and friends, finding ways, you know, whether that’s art or music, poetry or affirmations, things that can help connect us to meaning and purpose in our lives. All of these things not only drive down inflammation in our bodies and help our brains and help us from a physical health, but they also nurture and nourish our emotional and our spiritual selves. And when those three are in balance with each other, when we’re addressing all three of those is when we experience contentment and joy. And that’s really what’s so wonderful about being human. Joe 52:30-53:14 Many of your colleagues, Dr. Low Dog, prescribe what we would call anti-inflammatory drugs. And we’ve already talked a little bit about the non-steroidal anti-inflammatories. But as you said, the body has its own cortisol. And doctors like to prescribe drugs like prednisone or methylprednisolone. And there are certainly times for those medications. When I lost my hearing temporarily, they brought my hearing back. I loved the drugs. But Terry will attest to the fact that I wasn’t much fun to be around on big doses of prednisone. Terry 53:15-53:15 Joe gets weird. Dr. Tieraona Low Dog 53:16-53:17 So do I. Joe 53:18-53:36 And rather irritable. Yes, it wasn’t fun. How do we create our own, shall we say, more natural approaches to calming inflammation rather than relying on prednisone for weeks, months, and for some people, years, especially when it’s a condition like osteoarthritis? Dr. Tieraona Low Dog 53:37-56:40 Well, I mean, I think there’s so much that can be done. There’s so much with herbal medicines that can help with, you know, with like arthritis. And like turmeric, we just mentioned a little while ago, but there was a review done by Tufts researchers (Seminars in Arthritis and Rheumatism, Dec. 2018). They did a systematic review looking at all the studies, and they found that both turmeric and curcumin, more specifically, and Boswellia, which is also known as Indian frankincense, that both of those were very effective at relieving arthritis pain and recommended it as another way of thinking about treating osteoarthritis without having all of the side effects, right? So, you know, I think fish oil, also omega-3s, increasing your omega-3s, which, you know, trying to drive towards a higher omega-3 index, that’s something that can just be measured. A lot of my chronic pain patients. I try to increase their, you know, their omega-3 index to seven to eight percent over time so that we’re, you know, that we’re driving down inflammation and also helping with pain. But there’s a number of things that, you know, that you can do for chronic pain. I’m saddened by how many people live with persistent pain. And if you have, you know, vitamin D, can I just even throw out vitamin D? We know that when vitamin D gets too low, when those levels get too low, you know, that that actually causes pain, causes, it worsens arthritis pain and muscle pain and widespread chronic pain, like people with fibromyalgia. So making sure that people are getting adequate amounts of vitamin D is really important. Some people may, you know, may need things like, you know, CoQ10 or magnesium. Can I just share a quick story? When I had my hip replaced in 2022, I went up to the floor after my surgery and they kept coming in asking how my pain was and rating my pain. And my pain was great. And family came to visit and it was eight, 10 hours later and I saw them coming in and they were hanging magnesium with my IV. And I said, oh, was my magnesium low? And they said, no, it’s just your orthopedic surgeon likes to use magnesium during and after your surgery because he finds it reduces pain and how much opiate you need. Right now, I just had a huge surgery. I didn’t have a single opiate for more than 30 hours after having a hip surgery. Just for magnesium. So I’m fascinated by this. And so magnesium, we know, helps with migraines. It can help with a variety of things. But, you know, magnesium is another one that can relax muscles, can relax muscles in the jaw, in the neck, just so many things we can do for chronic pain. And also magnesium drives down inflammation, reduces C-reactive protein. Terry 56:40-57:59 Well, I think we’ll need to leave it there. And it sounds like there are quite a few modalities that people could use to address inflammation, to address pain. Dr. Tieraona Low Dog, thank you so much for sharing that with us today on The People’s Pharmacy. Tieraona Low Dog 56:59-57:01 Thank you. It was a pleasure. Terry 57:01-57:38 You’ve been listening to Dr. Tieraona Low Dog. She is a founding member of the American Board of Physician Specialties, American Board of Integrative Medicine, and the Academy of Women’s Health. Dr. Low Dog has served on the Scientific Advisory Council for the National Center for Complementary and Alternative Medicine. Her books include “Women’s Health in Complementary and Integrative Medicine,” “Life is Your Best Medicine,” and “Fortify Your Life: Your Guide to Vitamins, Minerals, and More.” Her latest work is an e-book, “Healing Heartburn Naturally.” Joe 57:39-57:48 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Terry 57:49-57:57 This show is a co-production of North Carolina Public Radio, WUNC, with the People’s Pharmacy. Joe 57:58-58:13 Today’s show is number 1,460. You can find it online at peoplespharmacy.com. That’s where you can share your comments about this episode. You can also reach us through email, radio at peoplespharmacy.com. Terry 58:14-58:22 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. Joe 58:23-58:52 At peoplespharmacy.com, you could sign up for our free online newsletter to get the latest news about important health stories. When you subscribe, you also have regular access to information about our weekly podcast. We’d be so grateful if you would write a review of The People’s Pharmacy and post it to the podcast platform you prefer. If you find our topics interesting, please share them with friends and family. In Durham, North Carolina, I’m Joe Graedon. Terry 58:52-59:31 And I’m Terry Graedon. Thank you for listening. Please join us again next week. Thank you for listening to the People’s Pharmacy Podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money. Joe 59:31-59:41 If you like what we do and you’d like to help us continue to produce high-quality, independent healthcare journalism, please consider chipping in. Terry 59:41-59:46 All you have to do is go to peoplespharmacy.com/donate. Joe 59:46-59:59 Whether it’s just one time or a monthly donation, you can be part of the team that makes this show possible. Thank you for your continued loyalty and support. We couldn’t make our show without you.

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