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Episode 88
The Doctor's Farmacy

Why Healthcare Policy Needs To Focus On Prevention

Open the Podcasts app and search for The Doctor’s Farmacy. If you’re viewing this site on your phone, you can just tap on the

Tap the subscribe button and new shows will be added to your library.

If you’re using a different device, our show is available on the following platforms.

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We have the best hospitals, most highly trained doctors, and people come from all over the world to get medical treatments in the US. Yet, we’re lagging behind almost every other country in health metrics, including life expectancy and infant mortality. 

That’s because we’re not being set up for success: The policies and systems we rely on for healthcare aren’t supporting prevention, education, and accessibility for all our communities. We are spending a massive amount of money on healthcare (1 of every 5 federal dollars) but we’re not spending on the social services to invest in lifestyle wellness that prevents disease in the first place. 

This week on The Doctor’s Farmacy, I sit down with Dr. Anand Parekh to talk about solutions to our country’s healthcare crisis and examine what’s already working.

Dr. Parekh and I dive into the major healthcare problems that we’re facing, like health disparities related to income and race, reactive versus proactive policies, and lobbying power in Washington that is not in the best interest of the public. From his time in the trenches with BPC, Dr. Parekh has gained some really valuable insights for how we can solve these problems and he shares those with us in this episode. 

There are many powerful treatment models that are working in different communities all over the country. In Pennsylvania a real Food Farmacy tailored to families’ needs had dramatic effects; Virta Health has had a 60% reversal for poorly controlled diabetics using their digital platform; I also see patients thriving every day in the Functioning for Life group program at Cleveland Clinic. There are solutions out there, we just have to keep pushing policymakers to support them and take action in our own communities. 

Healthcare doesn’t have to be stagnant. I hope you’ll tune in to hear how we can change the future of wellness.

This episode is brought to you by Thrive Market. Thrive Market has made it so easy for me to stay healthy, even with my intense travel schedule. Not only does Thrive offer 25 to 50% off all of my favorite brands, but they also give back. For every membership purchased, they give a membership to a family in need, and they make it easy to find the right membership for you and your family. You can choose from 1-month, 3-month, or 12-month plans. And right now, Thrive is offering all Doctor’s Farmacy listeners a great deal, you’ll get up to $20 in shopping credit when you sign up, to spend on all your own favorite natural food, body, and household items. And any time you spend more than $49 you’ll get free carbon-neutral shipping. All you have to do is head over to thrivemarket.com/Hyman.

I hope you enjoyed this conversation as much as I did. Wishing you health and happiness,
Mark Hyman, MD
Mark Hyman, MD

In this episode, you will learn (video / audio):

  1. Why life expectancy and other health metrics are so poor in the United States
    (2:45 / 5:09)
  2. Why policymakers do not focus on prevention and proactive policies to improve health
    (10:57 / 13:21)
  3. Personal responsibility in a toxic health environment
    (16:57 / 19:24)
  4. Challenges with the Supplemental Nutrition Assistance Program (SNAP) or our food stamp system
    (18:40 / 21:06)
  5. Social needs vs social determinants of health
    (25:46 / 28:12)
  6. Obesity: the public health crisis of our century
    (29:20 / 31:46)
  7. Dr. Parekh’s 5 key takeaways for policymakers
    (36:22 / 38:48)
  8. Targeting and creating pathways for existing healthcare programs and interventions that have been shown effective
    (44:36 / 47:02)
  9. Why the government is so important in scaling healthcare solutions
    (49:38 / 52:04)
  10. The need for clinical-community linkages
    (50:05 / 52:31)

Guest

 
Mark Hyman, MD

Mark Hyman, MD is the Founder and Director of The UltraWellness Center, the Head of Strategy and Innovation of Cleveland Clinic's Center for Functional Medicine, and a 12-time New York Times Bestselling author.

If you are looking for personalized medical support, we highly recommend contacting Dr. Hyman’s UltraWellness Center in Lenox, Massachusetts today.

 
Dr. Anand Parekh

Dr. Parekh is the Bipartisan Policy Center’s (BPC) chief medical advisor, providing clinical and public health expertise across the organization, particularly in the areas of aging, prevention, and global health. Prior to joining BPC, he completed a decade of service at the U.S. Department of Health and Human Services (HHS). As a HHS deputy assistant secretary for health from 2008 to 2015, he developed and implemented national initiatives focused on prevention, wellness, and care management. He has spoken widely and written extensively on a variety of health topics and is the author of a new book entitled Prevention First – Policymaking for a Healthier America.

Show Notes

  1. Bipartisan Policy Center

Transcript

Dr. Anand Parekh: policymakers need to help Americans make the healthy choice the easy choice.

Dr. Mark Hyman: Welcome to the Doctor’s Farmacy. I’m Dr. Mark Hyman. That’s Farmacy with an F, F-A-R-M-A-C-Y, a place for conversations that matter. And today’s conversation, I think, will matter if you care about your health, the health of our country, and trying to find solutions to our chronic disease epidemic, that’s crippling everyone in this society in one way or another, whether it’s someone you love or yourself, our economy, or just all the crazy crises of health that we have in this world today that we really find are mostly unnecessary, because we can prevent them.

Dr. Mark Hyman: And that’s why I’ve invited Dr. Anand Parekh, who’s an extraordinary physician. He’s the Chief Medical Advisor for the Bipartisan Policy Center, which is a group of policymakers, physicians, scientists come together to solve difficult problems around health in the country. It’s pretty extraordinary, and many other issues. He’s provided incredible support to our nation through his work in the government. He’s basically been focused on work that he did through his decade of service at the US Department of Health and Human Services. He was the Deputy Assistant Secretary for Health from 2008-2015.

Dr. Mark Hyman: He developed and implemented national initiatives on prevention, wellness, and care management. At the BPC now, he’s focused on areas of aging, prevention, and global health. He’s really an important figure in our country in trying to think differently about how we solve our big chronic health issues. He’s a board certified internal medicine doctor. He’s a fellow of the American College of Physicians. He’s an adjunct professor of health management and policy at the University of Michigan School of Public Health, and assistant professor of medicine at Johns Hopkins.

Dr. Mark Hyman: He’s spoken widely and extensively, and written a lot about topics on health, including his new book, Prevention First: Policymaking For a Healthier America, published by Johns Hopkins Press, which is an amazing book. I read it. It’s a little dense, but it is full of the solutions that we need to solve our chronic disease crisis. Welcome, Doctor.

Dr. Anand Parekh: Thank you, Dr. Hyman. Great to be on the podcast with you.

Dr. Mark Hyman: We met a number of years ago. When I came to Washington, I was at Health and Human Services advocating for lifestyle interventions for chronic disease as treatment. I went around and met with many leaders in health care at the time, the head of the Senate committee, Congress, Secretary Sebelius, [inaudible 00:02:19] and the White House, trying to advocate for a simple idea, which is we could take these patients with chronic disease, and use aggressive lifestyle interventions in groups to help them transform their health and get better.

Dr. Mark Hyman: And everybody was 100 percent on board. Nobody wanted to vote against it, but it ended up on the cutting room floor in the Affordable Care Act, because it was all the backroom horse trading, I think, that happened. But everybody was on board with the idea, because they realized that we really have this global crisis. In America, we’re leading in that global crisis. We have the best trained doctors in the world. We have the best hospitals. We have the best technology. We have the most cutting edge treatments and drugs for a whole multitude of problems.

Dr. Mark Hyman: Patients come from all over the world to get health care here, but on the other hand, our own citizens are pretty unhealthy. We have pretty crappy life expectancy. I think we’re 43rd in the world, yet we spend more than twice any other nation on health care. Services aren’t guaranteed to everybody. We have uneven quality of care. We have health disparities, and we’re lagging behind almost every other country in health metrics, including infant mortality, life expectancy. How come?

Dr. Anand Parekh: That’s a great question. A lot of important reasons for that. I think you’re absolutely right. There are significant disparities in the United States, and I think that’s one of the reasons why we’re different. Just take income. If you compare life expectancy of the top one percent, wealthiest Americans, you compare it to the one percent poorest Americans, there’s a 14 year life expectancy difference for men, and a 10 year life expectancy difference for women. Income matters.

Dr. Anand Parekh: Take race. Though infant mortality has gone down in this country, we are behind many of our peer nations. One reason for that is disparities based on race and ethnicity. African American populations, American Indian populations have significantly higher infant mortality rates than other subgroups, so race is also important.

Dr. Anand Parekh: Our system also, Dr. Hyman. Our health system is different in the sense that we only have about 90 percent of Americans with health insurance. Most of our peer countries have 99-100 percent. A lot of differences that way. I think the final difference that I would note is lately, there’s been a lot of research on how much we spend in this country on health care versus social services. If you compare-

Dr. Mark Hyman: We’re paying for the wrong end of the equation maybe.

Dr. Anand Parekh: That’s right. That’s right. We spend nearly 18 percent of our GDP, as you know, in the United States on health care, compared to many other countries.

Dr. Mark Hyman: That’s almost one in five dollars of our entire economy.

Dr. Anand Parekh: That’s exactly right. $3.6 trillion, and we are headed to $4, $5, $6 trillion in the near term. If you compare that to our peer countries, many well-developed countries, that’s almost twice as much on the social services side. What does that mean? That means investments in housing and nutrition and transportation and education and income supports. We spend probably a little bit less than our peer countries or about that much, but if you look the ratio, so social services to health care, we’re at about one to one, whereas most of the countries that we compare with are close to two to one.

Dr. Anand Parekh: And that ratio matters, because there’s been research even domestically that looks at the 50 states in our country. Those states that have a higher social service to health care services ratio, they have better outcomes. They have less chronic disease risk factors. They do better with chronic diseases. There’s a lower mortality rate, so it’s really that ratio of social services to health care services. As a country, we’re out of whack. That may have something to do with it.

Dr. Mark Hyman: They take care of people before they get sick, and we wait until they get sick.

Dr. Anand Parekh: Absolutely. Whether it’s children and child care, whether it’s seniors and in-home supports and home delivered meals, whether it’s paid family leave for working Americans. The social service supports in those countries, we have them here, but the ratio of social services to health care service spending, that is really what’s different in this country.

Dr. Mark Hyman: And I imagine what’s not capture in that is … and we’re spending twice as much on health care, because we’re not taking care of those people early, is also another invisible cost, which is productivity.

Dr. Anand Parekh: Absolutely.

Dr. Mark Hyman: Because if you have a population that’s healthy, they’re more productive, more engaged with their communities and families. When you have our population, which is super sick, you lose all this productivity value in the economy. The costs are probably even more, right?

Dr. Anand Parekh: Absolutely, and that’s not to take into account even from a national security perspective, our military. This is the number one reason for new recruits who want to enter into the military, the number one reason that they’re not allowed to join is because of obesity and high body weight. All of these issues, whether it’s economic, military, national security, our standing in the world, all connect back to the need to focus more upstream.

Dr. Mark Hyman: Yeah. Even General Jack Keane, I knew him. He was a big commander in the Iraq War, and he said 70 percent of the recruits for the military are rejected, because they’re unfit to fight. Kids in school, their academic performance is terrible. In America, we should have very high academic performance. We’re, I think, 31st in math and reading in the world.

Dr. Mark Hyman: I think Vietnam is better than us. If a very poor, developing country does better than us, what’s going on? It’s really speaking to the food we’re feeding our kids, to school lunches, to the amount of toxic food environment that we have that we’re all exposed to that’s driving these choices. It’s pretty much unregulated in this country.

Dr. Anand Parekh: Absolutely, and I would say that this is the right time to be talking about this very subject, because this is the first time we’re experiencing, in 100 years in our nation’s history, since WWI, where in this country, we are now experiencing three consecutive years of life expectancy declines. And that’s because of the opioid epidemic, the obesity crisis, as well as what’s considered the plateauing and the decline of deaths from cardiovascular disease, as well as cancer.

Dr. Anand Parekh: The CDC estimates that, every year, there are 250,000 potentially preventable deaths in the United States. That’s just taking the five leading causes of death: heart disease, stroke, cancer, chronic lower respiratory disease, and unintentional injury. If the states that had the highest mortality rates did as well as the states in this country that had the lowest mortality rates, we would save 250,000 Americans every single year. I think the timing of this conversation is really important.

Dr. Mark Hyman: And it’s interesting. If you take a map, and you can go on the CDC and see these maps of obesity, diabetes, and life expectancy, they completely superimpose in terms of the states with the highest rates of these problems. And the worst are the Southeast, Southern cooking, I guess, where there’s more obesity. There’s more disease.

Dr. Mark Hyman: When I graduated medical school, and probably you did too, there was not a single state that had an obesity rate over 20 percent. And now, there’s not a single state that has an obesity rate under 20 percent, and many have 40 percent. And many more are encroaching on 40 percent, so when you think about 40 percent obesity rates, 75 percent overweight, the entire country’s affected.

Dr. Anand Parekh: Absolutely, and of course, many of the states that you cited have that ratio of pretty low spending on social services and health care spending. And they also have high uninsured rates as well. They’re finding themselves spending a lot of money on the health care side of the equation for things that are preventable if we try to tackle them up front.

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

Dr. Anand Parekh: Absolutely.

Dr. Mark Hyman: And yet, we just let it go. How do you break through that challenge of changing those policies?

Dr. Anand Parekh: I thought a lot about this while writing the book. We all agree that prevention’s important, but why has it not been that policymakers have elevated, why haven’t they elevated this issue to the top? And I came up with a couple of reasons that I’d be happy to share. I think the first is, and you touched on this, a lot of policymakers are just reactive in general, and prevention requires a proactive approach.

Dr. Anand Parekh: And the reason they’re reactive is, whether you’re in the executive branch or you’re a member of Congress, there are oftentimes so many emergencies, either real or imagined, or crises or political controversies that oftentimes you spend a lot of time reacting.

Dr. Mark Hyman: Putting out the fire.

Dr. Anand Parekh: Absolutely, as opposed to thinking about proactive policies to improve health. And then prevention oftentimes takes time as well. You have to have that patience, and oftentimes, the results are, at least from a public health perspective, are often invisible when things are working and health is being protected. I think the first reason is that the mindset of policymakers needs to shift from being reactive to proactive.

Dr. Anand Parekh: I think the second reason is, it could very well be that policymakers are just not as attuned to the evidence base, whether it’s lifestyle medicine, whether it’s prevention, whether it’s a social determinant to health. Understanding the evidence now that has been generated about the effects of all of these other modalities, I think it’s critical. When you don’t know the evidence, then you tend to think, “Well, that might be a slush fund. Those dollars in prevention might be a slush fund, and why should we support it?”

Dr. Anand Parekh: There are others then, as you said, who may think of prevention as, you’re right, part of the nanny state. Prevention is about individual responsibility, and the government shouldn’t be involved. I think those are a couple of reasons, but then I think it goes beyond that. Prevention and public health, they require resources, and right now in this country, if you look at our national health expenditure accounts, only about three percent of our dollars go to public health. Only about five percent go to primary and secondary prevention.

Dr. Anand Parekh: Even though we’re in a tight fiscal climate, we’re always going to be in a tight fiscal climate. Finding opportunities through our discretionary budgets or mandatory budgets, CBO doesn’t always help with their 10 year budget window in terms of scoring, but-

Dr. Mark Hyman: Just to clarify for people, the Congressional Budget Office is the watchdog that looks over the costs of things for the government in the policies and laws, and they score policies based on their impact over a 10 year period, but the benefits of prevention might be over a 20 year period, so it seems like a cost center rather than a cost savings.

Dr. Anand Parekh: Absolutely, and I think that’s a very important point. There needs to be more of a focus on finding the will really, the political will, to expand resources using our discretionary budgets as well as our mandatory budgets, and through Medicare and Medicaid, because that’s really how we scale things. I think that’s also a critical point.

Dr. Anand Parekh: I think, Dr. Hyman, another reason why policymakers haven’t gravitated towards prevention is we have a $3.6 trillion health care system and, frankly, you can’t make as much money on prevention as you can on treatment, so the incentives there in the system are not as much there. Now, value-based health care-

Dr. Mark Hyman: Not from the government, but from the people running health care.

Dr. Anand Parekh: Absolutely. Now, value-based health care transformation, with the focus on payment based on outcomes as opposed to volume, should change that over time, but that’s going to be a long haul, so we’re still-

Dr. Mark Hyman: And just to clarify for people, the way typically doctors get paid and hospitals get paid is like widgets. The more stuff you do, the more you get paid. The more angioplasties you do, the more surgeries you do, the more colonoscopies you do, the more visits you do, the more money you make. And it doesn’t care if the product is good or not. Imagine paying for a car, but it didn’t work. You’re not paying for the outcome.

Dr. Mark Hyman: And so value-based care is a new way of thinking that’s incentivizing health care systems and doctors to be accountable for the outcomes of their patients’ health. Keeping them healthy, so now, if somebody bounces back to the hospital, the hospital makes money. In the future, the hospital won’t make money. It’ll be making money by keeping people out of the hospital. And that’s a very different paradigm shift, but we’re not quite there yet.

Dr. Anand Parekh: Absolutely, absolutely. We’re about a decade into this, but still, the vast majority of health care payments are still currently paid based on the services provided and a fee per service. We’re not quite there. And I think the last reason why this hasn’t really gotten the attention of policymakers is really, I think if you look at the general public as well, we haven’t galvanized the American public.

Dr. Anand Parekh: And whether they don’t realize the power of prevention, or we haven’t communicated to them the importance of sound policies to support the healthy choice, policymakers need to help Americans make the healthy choice the easy choice. I think galvanizing the public … There are not a lot of lobbying firms or interest groups going to members every single day in the halls of Congress, preaching the power of prevention, but you do need a grassroots movement.

Dr. Anand Parekh: You do need the American public to say, “Hey, I’m doing everything I can every day for my family to eat well, to exercise, to avoid substances, to stop smoking, to drink alcohol in moderation. I’m doing everything I can, but if there are not community supports, if there are not policy supports, if there aren’t policy systems and environmental change helping me and my family, it’s going to be very, very difficult to do.” And I think that’s a critical message in this book.

Dr. Mark Hyman: I think that’s pretty important, because if you don’t actually provide an environment that allows people to make easy, healthy choices, it’s hard to do the right thing. I think one of the biggest challenges in this conversation is the dichotomy between the idea of personal responsibility and the nanny state, the environment we live in. How do we change the toxic environment?

Dr. Mark Hyman: And I think most of the messaging from most professional associations, much of our government policy, and certainly the food industry is that it’s your fault you’re overweight. It’s your fault you’re sick. It’s a personal choice, just like smoking’s a personal choice. They talk about moderation. There’s no good amount of calories. 1,000 calories of broccoli is the same as 1,000 calories of soda.

Dr. Mark Hyman: There’s focus on exercise as the solution. There’s focus about moderation, and it’s really interesting. It’s a culture that’s really focused on personal responsibility, but it ignores the fact that you actually can’t be personally responsible in a toxic environment. If you can’t go in your neighborhood and buy a vegetable, and you have to take two hours of buses to buy a carrot, that’s a problem. And if we don’t address the environment we live in, we’re not going to be able to get people to make healthy choices.

Dr. Mark Hyman: I remember reading a study where they looked at people who are overweight and diabetic, who lived in very low socioeconomic neighborhoods. They moved to a slightly better neighborhood, and their blood sugar went down, and their weight went down. Without any other intervention, just giving them a better zip code. Basically, the zip code we have was a bigger determinant than our genetic code when it comes to our health.

Dr. Mark Hyman: And we don’t really seem to acknowledge that in our policies. We say that it’s all about choice, and I think one of the areas I wanted to talk about is the whole SNAP debate. Now, the Bipartisan Policy Center, you write about it in your book, Prevention First, did a very important report called Leading with Nutrition, that outlined some of the challenges with our food stamp or SNAP program, Supplemental Nutritional Assistance, which is … I don’t know if it should be called that, because it’s supplemental food assistance.

Dr. Mark Hyman: It’s not nutrition, I wouldn’t call most of it, because 75 percent of it is junk food. 10 percent of it is soda. It’s very clear that people who, compared to an income eligible person who’s not on SNAP, is less healthy. They drink more soda, and they have more health consequences. People go, “Well, we can’t really limit people’s choice when it comes to soda. They have to be able to buy that. It’s going to stigmatize them.”

Dr. Mark Hyman: And you’re right, the policymakers are influenced by Big Food. Soda companies, Coca Cola, I think 20 percent of their US income is from food stamps. Walmart, of the $750 in a farm bill for food stamps, about $138 billion goes to Walmart. They don’t want this to change, and it’s a real challenge. You’re right. I remember walking into Senator Harkin’s office. He was a really great senator. He’s no longer a senator, but he said, “Well, what organization are you from?” And I’m like, “Well, none. I’m just representing the science and the policy and my patients, and I want to get science into policy.”

Dr. Mark Hyman: He goes, “Well, that would make too much sense.” When you’ve got all this evidence that this is true, we know as doctors and scientists that this is really the problem, but the policies really are being heavily influenced by lobby money. How do you deal with that, and break this cycle of blaming the victim and not changing the environment and not helping people make better choices? Sorry, that was a little winded speech, but-

Dr. Anand Parekh: No, terrific, and thank you for raising this topic to the SNAP program, previously the Food Stamp program. The purpose of the Bipartisan Policy Center’s Task Force was to really put the N back in SNAP, which is exactly your point, that nutrition and diet quality ought to be a key factor of that program.

Dr. Anand Parekh: The program has been around for several decades now. 40 million Americans rely on the SNAP program every year. It has substantially reduced food insecurity in this country. Food insecurity does have indirect health benefits for children, for new mothers, for seniors as well. With our obesogenic environment in the last several decades, the program has not evolved to ensure that diet quality and nutrition is paramount as well.

Dr. Anand Parekh: And you’re absolutely right. The number one consumption of SNAP enrollees are soda products. Now, that’s not too different than the rest of the population, where soda is number two, but it does beg the question of, “Are we doing the best job that we can to incentivize the consumption of healthy food and disincentivize the consumption of unhealthy food?”

Dr. Anand Parekh: And what our task force did is, there were Republicans on there, Democrats on there, and we asked ourselves some pretty tough questions. SNAP is an important program. It reduces food insecurity, but how do you improve nutrition? When we looked at sugar sweetened beverages, Dr. Hyman, as you know, there is no nutritional impact in soda and sugar sweetened beverages. And yet-

Dr. Mark Hyman: Well, there is. It’s harmful.

Dr. Anand Parekh: It’s absolutely, in terms of good health.

Dr. Mark Hyman: Not only is there not a benefit, but there’s a tremendous harm. It’s the leading cause of obesity and diabetes.

Dr. Anand Parekh: And what we saw in the retail community, during the period when SNAP enrollees were purchasing their food, sugar sweetened beverages and soda were really the ones that are being marketed to them. I think we all found it-

Dr. Mark Hyman: I want you to hit on that for a little bit, because people don’t realize that. When the first of the month comes, people get their benefit cards. That’s when these stores that are in these poor neighborhoods highly advertise for-

Dr. Anand Parekh: Disproportionate marketing, particularly.

Dr. Mark Hyman: And not even in, yeah. In better neighborhoods that are more affluent, they don’t advertise. Literally, it’s race targeting. It’s poverty targeting.

Dr. Anand Parekh: It’s terrible, yeah. And that adds to issues about health equity and it adds to health disparities as well. The task force recommended, it was a difficult recommendation, but that sugar sweetened beverages ought to be excluded. And that doesn’t mean that individuals can’t purchase these things out of their own pocket, but from a health perspective, in a taxpayer funded program, we ought to be, again, incentivizing healthy food and disincentivizing unhealthy food.

Dr. Anand Parekh: In fact, there was a follow-up study from Tufts University and Harvard School of Public Health that actually looked at the mix of both incentives and disincentives over time in an excellent simulation, and found that you could prevent a substantial amount of heart disease and diabetes and save health care costs-

Dr. Mark Hyman: Billions of dollars.

Dr. Anand Parekh: Billions of dollars. And the Venn diagram between SNAP and, for example, Medicaid overlap in such a way that this could have significant impacts on state Medicaid programs. I think there’s a lot there. We really wanted to elevate this issue that, yeah, the SNAP program is important, but if it can evolve to elevate nutrition, then we can really do something for the public’s health.

Dr. Mark Hyman: You’ve got the hunger groups completely opposed to this, that are focused on food insecurity and hunger, and they’re like, “You can’t restrict that. It’s going to stigmatize these people. They should have the same opportunity to purchase as everybody else.” But you can purchase a two liter bottle of soda, but you can’t purchase a rotisserie chicken on food stamps, so there are restrictions.

Dr. Mark Hyman: You can’t buy cigarettes. You can’t buy alcohol. You can’t buy cooked food. There’s a lot of restrictions, and the other programs that we have in the government, like WIC, it’s Women, Infants, Children, and school lunches, they have nutrition guidelines that ensure quality nutrition. But we don’t have that, and there’s so many groups opposing any change. How do you see that happening? It just seems like a hopeless cause.

Dr. Anand Parekh: Yeah, we talk about that a little bit in the book, that we released the recommendations, and there weren’t a lot of people cheering. On both sides, there were folks who said, “Leave it alone. Don’t touch it. We want to focus just on food insecurity.” On the other side, there were folks saying, “Hey, we question the fiscal integrity of the program.” We, again, had both sides involved. That’s what we do at the Bipartisan Policy Center.

Dr. Anand Parekh: Looking at it from a health perspective, improving on the current program is the way to go. And that’s been our message to lawmakers and policymakers as well. The farm bill passed recently, but every several years, these issues get resurfaced. I think we have to keep on ensuring that there’s a drum beat to ensure that the N in SNAP, the nutrition part, becomes a paramount principle.

Dr. Mark Hyman: And that’s part of what you talk about in terms of social determinants of health. We’ve talked about it on this show before, but people don’t understand that the environment in which you live is a bigger determinant of your health outcomes than anything else, even than your diet, your exercise, your smoking. And those things are not addressed in health care. We ignore them, and so you talk about health care without walls. What does that look like, and what do we have to think about differently in how to address these things?

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

Dr. Anand Parekh: For nutrition, social determinants of health are ensuring with healthy food financing initiatives, you can increase the availability of healthier food, farmer’s market. Social needs is ensuring there’s a home delivered meal. For transportation, social determinants of health is improving community infrastructure through land use or zoning policy. For social needs, it’s ensuring that there’s ride sharing available, so people can make their appointments.

Dr. Anand Parekh: Health care is getting into the business of social needs, because they see it connected to the value proposition of improving outcomes and potentially reducing preventable health costs. And I think that’s all fine, but health care is not going to take care of the broader social determinants of health. We still need focus and resources on education and income and housing and nutrition and transportation, because you’re exactly right. Those have profound implications on the health of the population, and are also connected to a lot of the behavioral risk factors that are driving chronic diseases.

Dr. Mark Hyman: It seems to me, and I’m obviously biased, because I’m focused on food a lot, but it seems to me that the food and the food system, if we had to pick one thing to target, would be the biggest thing, because that’s affecting the chronic disease burden. The majority of, I think, chronic diseases are caused, in part, by diet. 11 million people die every year around the world from diet-related diseases.

Dr. Mark Hyman: I think it’s an underestimate, because you add in the additional causes, such as diabetes and heart disease, it’s in the 40-50 million range. And so, when you have that level of impact, it seems like we can’t address all of these issues unless we fix the food system, and that the forces that are opposing that are quite big. Just in the farm bill alone is a half a million dollars in lobbying on it, just for that. The majority of that is food stamps.

Dr. Mark Hyman: How do we … You’ve been in government. You’ve been in these conversations. You’re not just talking about it from a think tank. You’ve actually been there. What’s your perspective on how you move the needle? Do we have to wait for a new administration? Do we have to wait until the community of activists rises up like in abolition and changes our government? What do we have to do to see change? Because it’s discouraging for people to feel like they can’t do anything about this.

Dr. Anand Parekh: Yeah, yeah. Given the political winds in this country change pretty regularly, I think it’s important, Dr. Hyman, that we take incremental progress whenever we can. But you’re absolutely right. Your premise that I-

Dr. Mark Hyman: So take a base hit?

Dr. Anand Parekh: I think you have to educate policymakers. That’s what part of this book is. We should go for the … It shouldn’t be that we’re just going for base hits. We should go for the home run, but it’s also important, when there are incremental opportunities presented, to take them. I agree 100 percent with your premise. I call obesity the public health challenge of our century. That is the critical challenge. Cancer will soon, in this country, be the leading cause of death for Americans, and it will surpass heart disease. The reason for that is really obesity and poor diet.

Dr. Mark Hyman: People don’t understand this, but obesity is linked to cancer. It’s not just heart disease and diabetes.

Dr. Anand Parekh: Absolutely. At least a dozen cancers are now very well, the establishment, the link between obesity and cancer is now pretty well-developed.

Dr. Mark Hyman: For the most common cancers: Breast, colon, prostate. All the big ones.

Dr. Anand Parekh: Yeah, so I think that we need to … When I talk about incremental progress, so for example, right now, I try to look at things as glass half full from a policy perspective. You look at the Food and Drug Administration. I think there is an important, in the next several months, a new change to the Nutrition Facts Label, in that all foods will need to have information about added sugars.

Dr. Anand Parekh: And that’s pretty important. In fact, there was a recent study done that, if in fact this is done, over the next two decades, there will be substantial reductions in both diabetes and cardiovascular deaths, and in significant health care cost savings. Now, if the industry actually reformulated their foods, given that now this is transparent on the label, there would be even more, a doubling of an impact over 20 years. I think it would go from $30 billion in health care cost savings to $60 billion, and from one million cases of heart disease and diabetes averted to two million.

Dr. Anand Parekh: These are substantial pieces. Salt, voluntary sodium reduction, it’s voluntary. This was started in-

Dr. Mark Hyman: Good luck with that.

Dr. Anand Parekh: This was started in the Obama Administration, 2016, but this current administration is moving forward with voluntary sodium targets in 150 different food groups. And if indeed, manufacturers are able to meet these targets, within two years, we can reduce the average consumption of sodium in this country, which is about 3,400 milligrams to 3,000. Within 10 years, we can get to 2,300 milligrams, and that could save substantial lives down the road, in terms of heart disease and reduced health care costs.

Dr. Anand Parekh: I think there are some things that don’t get a lot of attention that are important. There are then more challenging things: Sugar sweetened beverages and the taxation of that and the politics of that. Portion size, which I think is a really important issues also over the last several decades. The portions of food that we get are so large.

Dr. Mark Hyman: Scary.

Dr. Anand Parekh: Deborah Cohen, who’s a researcher at RAND, has done some important work on portion sizes, and has shown that, as portions have increased, our consumption has increased, of course, as well. And she’s actually advocated for standardizing portion size, just like we do with alcohol. If you have a certain amount of alcohol, there’s a standard size. With a standard size of portions, you could reduce consumption there, particularly for unhealthy food.

Dr. Mark Hyman: This takes away the whole idea of personal choice. It’s mandating different portion sizes. I remember Dan Buettner, who wrote the book Blue Zones, created an initiative in, I think it was in some Midwest state, and essentially got community interventions that were invisible. Everybody switched out their plates to 10 inch plates. What was it? The checkout counters at the grocery stores changed to healthy options instead of candy.

Dr. Mark Hyman: They built walking paths. They basically created initiatives that were just frictionless, that allowed people to make better choices, and that made a huge difference in health care costs, in health outcomes. It’s stuff that we think of as the nanny state, but it’s actually stuff that’s proven to be effective.

Dr. Anand Parekh: And I would say that it doesn’t actually take away individual choice. People are certainly-

Dr. Mark Hyman: Can go back for seconds?

Dr. Anand Parekh: Absolutely, but I think it’s shown that, when the healthy choice is the easy choice, that people change their practices. I think that information … Take menu labeling now, which is common, and that policy change, so giving people the information, I think, the behavioral economics piece that you’re talking about. Those things, the incremental ways forward in those areas, I think are important as well.

Dr. Mark Hyman: My favorite study is where they took people and gave them a bowl of cereal. One bowl would constantly refill from the bottom, and the other one just was a fixed amount of cereal. And the ones that had the constantly refilling cereal just kept eating it, like it was a trick bowl.

Dr. Anand Parekh: That might be me, because I actually love cereal [inaudible 00:33:57]. I got to admit that on your podcast that cereal is one of my-

Dr. Mark Hyman: That’s okay. We all have our weaknesses.

Dr. Anand Parekh: … my favorite foods.

Dr. Mark Hyman: I think I’m a cereal killer. I hate cereal. I think it’s one of the worst inventions out of our society. It’s 75 percent sugar.

Dr. Anand Parekh: Talk about added sugar right there.

Dr. Mark Hyman: Oh my God, that’s huge.

Dr. Anand Parekh: It is, absolutely.

Dr. Mark Hyman: Okay. As a policymaker, now as policy think tank advocate, you had mentioned a lot of these initiatives, you think, can make a difference. But I just keep pushing back against the idea of how does the individual citizen get their congressman to go? Because they don’t have millions of dollars to go lobby. When I went to Washington, I paid my own ticket. I paid my own hotel, and Washington’s not cheap. I paid my own food.

Dr. Mark Hyman: And they’re like, “Who are you? Where are you from, and what are you doing?” Because they’d never seen an individual be an advocate, but there are ways, right? There are ways to get involved, and I think the Food Policy Action Network is a group that scores your congressmen and senators on their voting on food and ag policy. There are ways to affect it, but it’s tough.

Dr. Mark Hyman: You’ve got, for example, on the SNAP subject, you’re probably aware of this, but when there’s a hearing about SNAP to try and improve the nutrition quality in SNAP and talk about soda reduction, maybe you were at the hearing?

Dr. Anand Parekh: Yeah.

Dr. Mark Hyman: There were many of the committee members on the ag committee who basically said, “It’s all about personal responsibility. It’s about more exercise. That’s the real problem. It’s not about the food.” And when you look at who was funding their campaigns, it was soda companies, to the tune of literally and collectively millions of dollars. How do you fight that?

Dr. Anand Parekh: Yeah, I think it’s, first and foremost, helping Americans understand that there are things that government and policymakers can do to support them in these areas, that it’s not just about personal responsibility. Some of it is education and empowerment there. Some of it is also the doctor/patient relationship, as you know it, Dr. Hyman, is a trusted one. I think ensuring that health care professionals can be that voice as well, to support patients.

Dr. Anand Parekh: Some of this is educating policymakers as well, and policymakers, on their own, understanding the importance of prevention. In my book, for example, there are five key takeaways for policymakers at the end, in terms of what they can do to support Americans. The first, for example, to make prevention the number one priority for this or any administration coming in. The Health and Human Services Secretary saying, “There’s a lot of mission essential functions, but prevention will be the number one priority.” All of our agencies, whether it’s the Centers For Disease Control or the FDA or the National Institutes of Health, figure out how prevention elevates to the top.

Dr. Anand Parekh: Number two, health care professionals, in value-based health care transformation, we’re now going to measure you and hold you accountable, not just for how well you manage diabetes or heart disease, but how well you prevent them in the first place. We’re going to hold you accountable, not just for how much you screen for obesity and tobacco, but-

Dr. Mark Hyman: Yeah, just do the blood sugar, but actually get them better.

Dr. Anand Parekh: … actually reduce it. And what that’ll do is force the health care community to build the community linkages to help support individuals. That’s a second takeaway. A third takeaway is-

Dr. Mark Hyman: These are all in the book?

Dr. Anand Parekh: These are all in the book, right.

Dr. Mark Hyman: Prevention First.

Dr. Anand Parekh: These are the five overarching takeaways for policymakers, which I think then can be helpful to Americans out there. In this country, if you’re a drug, a pill, or a device, there’s a pathway in this country for that intervention to be scaled. There’s a Food and Drug Administration that assesses safety and efficacy, and once FDA approves that intervention, CMS, Medicare, and Medicaid decides whether it’s reasonable and necessary for payment or for coverage. And then a lot of private payers follow what Medicare does, but if you’re-

Dr. Mark Hyman: Just to interrupt you there for a minute, the recent study that was published showing that stents in bypass and angioplasties down work for the majority of patients that get them is not a new story. I read this article in different iterations in the past, and it keeps getting repeated. The research gets more robust, and yet Medicare and Medicaid pay for these services, because they’re a device and they’re in, but they won’t pay for stuff that works, like the lifestyle program that can reverse diabetes.

Dr. Anand Parekh: Right, right, right. On the treatment side, but if you’re an evidence-based program, in either prevention or treatment, lifestyle focused, to your point, there is no pathway in this country like there is if you’re a drug or a device. And yet, there are so many evidence-based programs, like the one you just mentioned, the lifestyle treatment or prevention programs, whether it’s falls prevention or chronic disease self-management programs. There are so many programs out there where thousands are benefiting, but millions need to be benefiting.

Dr. Anand Parekh: In my book, I actually call for a parallel pathway. Just like you have FDA looking at the safety and efficacy of drugs or devices, whether it’s CDC or the Administration on Aging, Congress ought to give them a regulatory authority to review a lot of these evidence-based community treatment or prevention programs. If they meet the bar, then CMS would have to consider them as being reasonable and necessary for payment, just like they do for a drug or device.

Dr. Mark Hyman: In other words, at Cleveland Clinic, we’ve got a program called Functioning For Life, where we take people in with chronic disease, we change their lifestyle, we change their diet. We actually, through social support, help them change their behavior. We’re seeing extraordinary results, reversing diabetes, heart failure, all kinds of stuff, weight loss obviously. And yet, it’s not really reimbursed. We’re saving-

Dr. Anand Parekh: That’s right. There’s a double standard there.

Dr. Mark Hyman: We’re saving so much money, and we’re not getting paid for what we do. We get paid 30 cents on the dollar, and we’re lucky if we make $100 on a patient when we see them, or less. It doesn’t even cover our cost of running our center, but we’re providing so much value in the system, which is benefiting Medicare, Medicaid, and also private insurers. And so the whole system is rigged to not incentivize to do the right thing. And there’s no money to study it. I’d love to get … There’s literally billions of dollars spent on research in this country, and almost nothing spent on nutrition or lifestyle research.

Dr. Anand Parekh: That’s right, and therefore, a parallel pathway could help infuse resources in to research as well as ensure that there’s not a double standard for a lot of these interventions that are focused on lifestyle or occur outside the clinical arena.

Dr. Mark Hyman: Amen to that. Now there’s two other points.

Dr. Anand Parekh: Two others. The fourth is, look, we have about a four trillion dollar budget in the federal government. This is, prevention, public health, it’s too important to underfund this. There needs to be bipartisan support to finance evidence-based prevention and public health interventions. It could be community-based prevention programs. I talk about several things that we did at Health and Human Services from the Recovery Act back in 2009.

Dr. Anand Parekh: There are opportunities to finance the public health infrastructure, which is significantly underfunded in this country. A public health emergency fund, so the next Ebola or the Zika we face, we’re not waiting on Congress to fight for months at a time before there are resources. But targeted investments to lift up prevention and public health, that has to be a national priority.

Dr. Anand Parekh: And I think in terms of bipartisanship, how do you crack that nut? There was an important commission on evidence-based policymaking that Senator Patty Murray and former Speaker Paul Ryan actually led a few years ago, and it talked about the importance of evidence-based policymaking. In that same vein, there ought to be bipartisanship around, “What are those priorities in the prevention and public health space that we actually need to invest more in?”

Dr. Mark Hyman: Right, because the truth is, food industry and pharma are not investing in research around this.

Dr. Anand Parekh: That’s right, and that leads me to the fifth point, which is we need, Dr. Hyman, more research. We have an evidence base right now, but we need more research into prevention. Now, the National Institutes on Health estimates that 19 percent of their budget every year goes to prevention. Now, one could ask, “Is that the right number or not?” I don’t know. Another-

Dr. Mark Hyman: Is that really true? 19 percent of the NIH budget goes to prevention?

Dr. Anand Parekh: 19 percent, 19 percent. Now there’s been-

Dr. Mark Hyman: That seems high.

Dr. Anand Parekh: … another study that I recently saw that, if you look at the National Cancer Institute, only five percent of their budget goes to prevention. Whatever the number is, I think that these are all low.

Dr. Mark Hyman: Well, let’s just define prevention, because is a mammogram prevention? Is a colonoscopy prevention? No. It’s early detection, right?

Dr. Anand Parekh: Yeah.

Dr. Mark Hyman: True prevention is really dealing with the causes, the upstream causes that you talk about in your book.

Dr. Anand Parekh: Right, right. I would argue, and I argue in the book, that there ought to be a much more focused research emphasis on prevention, that looks at not just the biology of illnesses, but also the importance of behavioral change as well as policy as well as other areas. And that will also actually help the Congressional Budget Office, irrespective of what happens with the 10 year budget window. The more research, the more evidence there, will help policymakers.

Dr. Anand Parekh: I think, in all five of these areas, number one, leadership prioritizing prevention, number two, health care professionals focusing on prevention, not just management, number three, a parallel pathway for lifestyle interventions and evidence-based community prevention interventions, number four, public health resources, and number five, prevention research. All of these, they’re all heavy lifts, Dr. Hyman, but I think that … I wouldn’t be writing a book if these weren’t heavy lifts, but these are absolutely important for policymakers on both sides of the aisle to understand the importance of these.

Dr. Anand Parekh: I think, if there’s movement on the policy side, the American public will see this also as a way to support themselves as they try to make the healthy choice. But the American public is clamoring for assistance. The behavioral change is difficult given the environment, which you have so beautifully described, and I think the best way to counter that environment is through policy change and empowered Americans speaking out.

Dr. Mark Hyman: Yeah. One of the things you mention in your book, in addition to these points, is targeting things that work, but aren’t paid for. Digital health, for example. You’ve mentioned Omada Health, which I helped advise when they starting out, and I said to them, “Look, the diabetes prevention was a good start, but it’s based on a little bit antiquated nutritional data about low fat diets, high carb diets for diabetics.” But it worked, because … And I met people who were in the program. They said, “It worked, because we came to groups, because we had to write down everything we ate, because we exercised together.”

Dr. Anand Parekh: Yeah, the group dynamics.

Dr. Mark Hyman: Yeah, and it wasn’t so much the food, although it was healthier. It wasn’t the healthiest. And there’s been more advanced versions of that that have developed that are digital. For example, Virta Health, you’ve probably heard about, where they literally take in poorly controlled, pretty overweight, poorly controlled diabetics. 60 percent, 60 percent reversal. Now, in traditional medicine, it’s zero.

Dr. Anand Parekh: That’s amazing.

Dr. Mark Hyman: It’s zero, right?

Dr. Anand Parekh: Yeah.

Dr. Mark Hyman: Unless you get a gastric bypass, and they had 60 percent reversal. They had 90 percent or more off of insulin or very low insulin doses. They had 12 percent weight loss, which is a massive amount. In weight loss studies, if you get five, everybody’s dancing around and happy and excited for a five percent weight loss. And they did it through a digital platform, where there were coaches and support. There was remote monitoring for ketones, for weight, for blood sugar.

Dr. Mark Hyman: And they published the data. It was a ketogenic intervention, which is the opposite of the DPP, which is basically high fat, and yet, this is not reimbursed. It’s the amount of savings in these patients is astronomical, so how do we get … This goes back to the conversation we were having earlier about prevention and treatment. Prevention is important. It’s a population-based intervention. Not all the people you’re going to do the intervention on are going to get the problem. It’s not everybody who gets a colonoscopy was going to get colon cancer.

Dr. Mark Hyman: But everybody who’s already sick needs the intervention of lifestyle interventions, because it’s lifestyle as treatment, not only as prevention. But that’s not reimbursed, and yet, it’s probably the biggest bang for the buck in terms of our health care system. How do we get our government to start to understand that? And maybe it’s just what you talked about, it’s finding more research that proves the model.

Dr. Anand Parekh: Right, right. I think it’s all of the above. Also, having pathways. Again, as you said, there’s no real pathway. Medicare, Medicaid don’t really know what to do with a lot of these interventions that are not the traditional medical model. As you know, in 1965, when Medicare was first created, it essentially paid for the treatment of disease using routine medical services. It hasn’t really caught up with today’s day and age, and what we know about the importance of lifestyle medicine, either with prevention or treatment.

Dr. Anand Parekh: I think some of this is research. Some of this are new pathways in the government, regulatory pathways. Some of this is educating the public. It’s really going to take, I think, all of the above to change the status quo, because there are a lot of opportunities out there that are not being realized right now.

Dr. Mark Hyman: You were in the middle of it all.

Dr. Anand Parekh: Yeah.

Dr. Mark Hyman: Did you feel like there was movement when you were there? That people were trying to actually shift the policies in ways that actually were effective? Or was it spinning the wheels?

Dr. Anand Parekh: Yeah, yeah. No, I think certainly-

Dr. Mark Hyman: Because people go, “Government’s broken. It’s not going to do anything. What’s the point?” But you have a different view.

Dr. Anand Parekh: Yeah. There are lots of things that I saw with the Affordable Care Act. Just take clinical preventive services. One part of that was now high value clinical preventive services. There ought to be no cost sharing for them, and that makes sense, from a value-based insurance design perspective. That should increase the likelihood that Americans receive high value evidence-based clinical preventive services.

Dr. Mark Hyman: Meaning if people need to get screened for disease or a PAP test or mammogram, they shouldn’t have to pay for it. The private insurance shouldn’t give them a copay, and the Medicare shouldn’t give them a copay.

Dr. Anand Parekh: That’s absolutely right. Cancer screenings or counseling interventions for tobacco, alcohol, immunizations. These things can improve health.

Dr. Mark Hyman: We can’t get a nutrition appointment reimbursed for fuck’s …

Dr. Anand Parekh: Right. I think we still have a ways to go-

Dr. Mark Hyman: That’s terrible.

Dr. Anand Parekh: … in some areas, but that’s just one example where we’re trying to make it easier for people to access important clinical preventive services. In terms of community preventive services, I know that Diabetes Prevention Program may as antiquated, a nutrition aspect of the intensive lifestyle piece there, but there, the team at Medicare and Medicaid, just getting the Diabetes Prevention Program through took a lot of work. It required the authorities of a newly created center at Medicare and Medicaid called CMMI, which is the Center for Medicare and Medicaid Innovation.

Dr. Anand Parekh: There was a test, essentially, of the Diabetes Prevention Program. It was found to save money and reduce costs. That’s the only way it got expanded. But that’s why I call for a parallel pathway. Otherwise, you’re reliant on [crosstalk 00:49:29].

Dr. Mark Hyman: But the government has to fund this. This is not coming from industry, right?

Dr. Anand Parekh: Yeah, exactly. Exactly, so I think the government … And the reason why the government is so important is, the private sector is critical, but there’s only so much from a scale perspective that philanthropy or non-profit organizations can do. The needs here are for millions, and we’re only reaching thousands. The only way to scale from thousands to millions, there could be other ways, but there is a role for government. I think that’s part of the premise of the book as well.

Dr. Mark Hyman: And the community based stuff is important, because when you think about where disease happens or where health happens, it doesn’t happen in the hospital or at the clinic. 80 percent of our health is determined by where we live, and by our diet and lifestyle, and our genes. Things that have nothing to do with what you get when you go to the hospital or see the doctor, and yet, 80 percent of our funding is for what happens with the doctor and hospital, so it’s completely backwards.

Dr. Anand Parekh: Yeah, it is, absolutely. We talk about the importance of, for example, nutrition counseling, but if you got the best nutrition counseling, but somebody walks out of that clinical setting, they see fast food establishments, they see no farmer’s markets, there are no Meals On Wheels programs, how do you expect them to … The whole idea of clinical/community linkages is they reinforce what happens. All the important efforts on the clinical side, to reinforce them on the community side. Otherwise, they’re not going to stick.

Dr. Anand Parekh: One example, a couple years ago, I was out in the South Side of Chicago, and I visited a program called CommunityRx. And essentially, in this program-

Dr. Mark Hyman: Love that.

Dr. Anand Parekh: … CommunityRx-

Dr. Mark Hyman: Community as medicine.

Dr. Anand Parekh: Exactly. At CommunityRx, the program mapped out social service providers and community based organizations around the city, and then they took that information, linked it to the electronic health record, and linked it to particular conditions and diagnoses. At the same time, whenever a patient came to a community health center, they always got a HealthyRx script, based on their diagnosis, matching them up with appropriate community services in the community. What they learn in the clinical setting, then they received essential referrals to get supports in the community, reinforce what they learned in the clinic. And that’s just one example of how we need to build these clinical community linkages.

Dr. Mark Hyman: Yeah, at Cleveland Clinic, we started a program with … Because I’m a very strong advocate of getting out of the hospital. It’s there when you need it. I had a heart rhythm problem this year, and I had to have an ablation. I’m like, “Thank God,” but most of the problems in these communities are not what’s going on in the hospital and can’t be solved there.

Dr. Mark Hyman: We went into a very underserved African American community in Cleveland near Cleveland Clinic, and we started a community program in a community center. It wasn’t in the hospital. It was in their community health center. No, it wasn’t even a hospital, just a community center, and we developed a group program. I arranged for them to get meals, fresh whole food meals, got them the right nutrients just as a temporary solution, to see what would happen if people had the support.

Dr. Mark Hyman: In their neighborhood, there was nowhere to get good food, and within six weeks … It’s a 10 week program, we’re going to have them following for a year. There were dramatic changes, people who lost 20 pounds in five weeks. They had dramatic drops in their blood sugar, their blood pressure. This one woman had a stroke, couldn’t really talk or lift anything, now was talking and was actually able to carry things with her arm. I was shocked.

Dr. Mark Hyman: And it was so simple. We taught them to cook. We did cooking classes together. They went shopping. They learned about food. We had talks with a nutritionist and the health coaches. It’s really powerful, because they wanted to change. They just didn’t know what or how, and nobody showed them or nobody told them. And I think those kinds of things are what we need to be thinking about, because this is not going to be solved in the hospital. We still need acute care medicine, for sure, what the problems we have aren’t solved in the hospitals.

Dr. Anand Parekh: I absolutely agree. I’ll give you another example: Geisinger Health System in Central Pennsylvania. Your podcast is called the Doctor’s Farmacy. They opened up their first food pharmacy a couple years ago, and they did a really good job matching the acuity of the individual with the intensity of the intervention. They took poorly controlled diabetic patients, who screened positive for food insecurity, and the intervention there was not just diabetes self management training and counseling. They actually provided-

Dr. Mark Hyman: The food.

Dr. Anand Parekh: … two meals a day, 10 meals a week.

Dr. Mark Hyman: For the whole family.

Dr. Anand Parekh: For the whole family, and what they found, just in their pilot, was that the average hemoglobin A1C, which is an indicator of the severity of diabetes, fell from 9.6 percent to 7.5 percent, and why that matters is, every one percent drop reduces mortality from diabetes and complications by 20 percent, and saves $8,000 in health care costs.

Dr. Mark Hyman: And what’s also important to realize is that two point drop may not seem like a lot, but if a drug gets a half a point drop, it’s a raging success.

Dr. Anand Parekh: There you go.

Dr. Mark Hyman: It’s four times as good as drug effects.

Dr. Anand Parekh: That’s right. That’s right, absolutely.

Dr. Mark Hyman: There’s evidence-based, so why doesn’t Medicare now pay for food pharmacies and pay for food for everybody?

Dr. Anand Parekh: Well, I think we need to move in that direction. Again, it’s that medical model that has been the focus of policymakers for so long. And as we build this evidence base, and in some areas, it’s substantial now, that different “types of interventions” can actually do more than the traditional interventions, that’s the-

Dr. Mark Hyman: More than medical interventions.

Dr. Anand Parekh: More than medical interventions, that’s where we need to focus, because that’s where we’ll deliver, not just the best improvements in health, but also the most significant health care cost savings.

Dr. Mark Hyman: If you were an autocrat, and you were in charge of America and policy, and you were the Putin of health care, and you could do … I realize that’s not a good analogy, but you could actually just take a wand and make the changes that you see are going to make the most difference, what would they be?

Dr. Mark Hyman: You mentioned the five things already. Because those things are realistic, but if you really had things that were going to have the biggest impact, what would you do? Not just in terms of health care, but across our whole society, in terms of making the changes that need to happen.

Dr. Anand Parekh: I’d be laser focused on the risk factors driving chronic diseases in this country as well as the social determinants of health. And there are organizations out there, like Trust for America’s Health, who issues recommendations in this area. But I think it’s really a package, Dr. Hyman, of policy changes.

Dr. Anand Parekh: On the chronic disease risk factor side of the equation, whether it’s tobacco or poor diet, lack of physical activity, alcohol, there are a series of policy interventions there. Smoke free laws, raising pricing on tobacco, reducing alcohol outlet density, increasing nutrition/physical activity access in schools, reducing the availability of unhealthy foods in different ways. There are a package of policy changes there.

Dr. Anand Parekh: And then, on the social determinants of health side, whether it’s housing and affordable housing, Housing First, whether it’s education, universal pre-kindergarten, whether it’s income, paid family leave, earned income tax credit. There are a series of interventions that go beyond the four walls of the clinical setting, but tackle both the social determinants of health, as well as the lifestyles, the risk factors driving chronic disease. And in this country, as you know, half of adults have chronic diseases.

Dr. Mark Hyman: 60 percent now.

Dr. Anand Parekh: Yeah, 60 percent now. Half of that half have multiple chronic conditions, which was really my focus at Health and Human Services. And virtually all the $3.6 trillion that we spend in this country go there, so I would be laser focused on the risk factors driving chronic disease and the interplay that the social determinants have and policies there. A lot of this, again, is outside the four walls of the clinical setting.

Dr. Mark Hyman: I agree. I would add in there, and I think as going in the upstream conversation, is what is driving the social determinants? What is driving a disease? For the most part, I would say it’s our food system, and you have to change the way we grow food, what food we grow, how it’s supported. All those upstream things, it’s like we’re just still down in the weeds if we don’t actually change the food environment.

Dr. Anand Parekh: Yeah. If you look at the subsidies going to our agriculture sector, the marketing by the food industry, there are a lot of forces that, whether they admit it or not, make it harder, make it harder for Americans out there to make the healthy choice the easy choice. And I don’t think we want to demonize parts of our society, but we want to work with all sectors of our society to see how we can all push health forward. I think that’s in the best interest of health care.

Dr. Mark Hyman: Well, look. We came down hard on tobacco, because we were clear about its danger, but now obesity and food has overtaken tobacco as the leading cause of death, so I think we have to start to really think about that honestly.

Dr. Anand Parekh: And I think the industry does as well. For the sake of their own future and their bottom line, they need to understand which products of theirs are leading to ill health, and change their practice and culture as well. And I think there are some in the industry who have taken positive steps, and I think when that happens, we need to applaud them. But I think you’re absolutely right. As a whole, I think it’s important. Where it’s not possible to see that voluntary steps, I think government’s got a role.

Dr. Anand Parekh: It’s got a really important role, because ultimately, that’s why we have governments. I always say, health and education, those are the two most important things. Health provides the foundation. Education provides the acceleration as we pursue our goals in life. And if anywhere where government needs to lean forward, it’s got to be in those areas.

Dr. Mark Hyman: I agree. I think this is great. Well, thank you for your work.

Dr. Anand Parekh: Thank you.

Dr. Mark Hyman: Thank you for working for us in the government for so long, trying to do the right thing, and now with the Bipartisan Policy Commission, which is, I think, one of the most important organizations out there, bringing parties from all sides together to solve difficult problems across government. What I think is you need a big lobby arm. You need a hundred million dollar lobbying fund so you can be out there telling these stories in ways that get lawmakers to pay attention.

Dr. Mark Hyman: Thank you so much for your work and for your book, Prevention First: Policymaking For a Healthier America. It’s a real contribution to how do we do the right thing, because if we keep going the way we’re going, we’re screwed. Thank you, and check out the book on Amazon, wherever you get books, in your bookstore, Barnes and Nobles. And check out the work of the Bipartisan Policy Center. I love their stuff. It’s a little nerdy. I’m a little geeky, but I love that stuff. You might too.

Dr. Mark Hyman: And if you love this podcast, please share it with your friends and family on social media. Leave a comment. We’d love to hear from you. Subscribe wherever you get your podcasts, and we’ll see you next time on the Doctor’s Farmacy.

Dr. Anand Parekh: Thank you. Thank you for your leadership, Dr. Hyman. Thank you for having me on.

Dr. Mark Hyman: Thank you.

Dr. Mark Hyman: Hi everyone. It’s Dr. Mark Hyman. Two quick things: Number one, thanks so much for listening to this week’s podcast. It really means a lot to me. If you love the podcast, I’d really appreciate you sharing it with your friends and family. Second, I want to tell you about a brand new newsletter I started called Mark’s Picks. Every week, I’m going to send out a list of a few things that I’ve been using to take my own health to the next level.

Dr. Mark Hyman: This could be books, podcasts, research that I’ve found, supplement recommendations, recipes, or even gadgets. I use a few of those. And if you’d like to get access to this free weekly list, all you have to do is visit drhyman.com/picks. That’s drhyman.com/picks. I’ll only email you once a week, I promise, and I’ll never send you anything else besides my own recommendations. Just go to drhyman.com/picks. That’s P-I-C-K-S, to sign up free today.

If you are looking for personalized medical support, we highly recommend contacting Dr. Hyman’s UltraWellness Center in Lenox, Massachusetts today.

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