How Food Marketing is Making Us Sick and Fat with Dr. Sean Lucan

Welcome to the Doctor's Pharmacy. I'm Dr. Mark Hyman and that's Pharmacy F-A-R-M-A-C-Y, a place for conversations that matter. And today we have a great conversation that really matters about food, the food environment, the politics of food, the science about food is medicine, and lots more with our guest, Dr. Shawn Lukas. Now he's a practicing family physician in the Bronx. He treats kids and adults. He's an award-winning National Institute of Health funded investigator who's published numerous articles on food related issues. He's co-authored one textbook on nutrition and another on stuff that I don't really like, which is biostatistics, and epidemiology is okay, preventive medicine and public health. Now he earned his MD and MPH, his master's in public health at Yale before completing residency in family and community medicine at the University of Pennsylvania. After residency, he completed a fellowship in the Robert Wood Johnson Foundation Clinical Scholars Program, which is a big deal. where he earns master's in health policy research. He's currently a fellow at the National Academy of Medicine, formerly the Institute of Medicine. And that is a big deal, guys. National Academy of Medicine is the epicenter and the epitome of the best in science and medicine. And you only get in if you know what you're doing. Dr. Lukin's research focuses on how different aspects of urban food environments can influence what people eat and what the implications are for obesity and chronic diseases, particularly in low-income and minority communities, which unfortunately are really targeted by the food industry. And some of your work was fascinating. We want to get into that about how deliberate targeting is made to low and income minority groups, even when they're not the highest volume, they're targeting them. Another focus of his work is the critical examination of the clinical guidance and public health initiatives that are related to nutrition. In other words, how do we make science into policy? All right, welcome, Dr. Luken. Thanks for being here.

Thanks for having me.

Thanks for the intro. Okay, so you're a family doc, you're interested in community medicine, I'm a family doc. How did you get interested in this issue around food? Because clearly we don't learn about food in medical school and residency, and we certainly don't learn about health policy, we don't learn about the politics of food, and yet you've made this your life's work to really show the connections between the food environments that we live in and the behaviors that lead to obesity, diabetes, and chronic disease, and particularly in communities that are affected far more than others, communities of color, minorities, the underserved, the poor. This is just striking to me how this actually is so deliberate.

Yeah, so I'm a family doctor. I treat children and adults and the patients that I see predominantly are obese and suffer from diet-related chronic diseases and it's Frustrating as a physician, as a provider, treating patients one-on-one, talking yourself blue in the face, giving the same advice over and over, and then seeing patients.

Really struggle and not being able to succeed. Which is what doctors get told to do. Eat less, exercise more, come back in.

Three months, and if you're not better, I'll give you medication. That just doesn't work. Well, that doesn't work. And part of the reason it doesn't work, especially in the communities where I work, is that there are such environmental obstacles or contextual barriers to people doing the things that they would otherwise want to do, you know, be motivated to do and just are challenged in getting done. So, you know, I, you know, routinely counsel patients on diet and nutrition and making good, healthy choices and optimizing their eating, and then they go out into a world where that you know, becomes a real difficulty for them. So during residency, I remember we did this community survey where we went out and just kind of looked at the neighborhoods and saw where our patients were living and tried to understand, you know, try to see life through their eyes.

And one of you actually went out into the community, homes and their environments and actually got out of the clinic.

Homes and environments, but also, you know, into the stores and into the retail environment and, you know, having an interest in nutrition, you know, one of the things that I wanted to focus was on was food sources. And so we went into community grocery stores and it was there that I took a picture that I still use in presentations to this day. It's this improvised wooden bin of moldy onions and old potatoes. And that was the produce section of a supermarket. It was called Supermarket.

Old, ugly, rotten produce, right?

Terrible, right? And that was right next to shelf after shelf of highly processed, refined, sugar added, salty, unhealthful snacks that-- and addictive and colorful. Addictive and colorful and enticing. And all those things, right?

Heavily marketed, yeah.

Just kind of an overwhelming incentive or an overwhelming impetus to eat poorly or to not have the best diet.

It was hard to make the right choice, easy to make the wrong choice.

It's exactly right. I mean, the default was to not do the healthy thing.

So, embedded a little bit in what you're talking about is the idea, I think that's pretty strongly held by most nutritionists, doctors, certainly policy makers, and certainly the food industry, which is that it's all about personal responsibility. That your choices are your own, and that if you make bad choices, it's because It's a moral failing or you're weak or there's some issue with you that guides your choices. And if you just were serious about your health, you would just eat less and exercise more and everything would be fine. What's wrong with that idea?

I think that's absolutely preposterous. I mean, in my patients, I'm struck by how motivated people are, how much they want to get better, how much effort they put into doing the thing that will help them be healthier and yet being stifled in every, you know, at every turn by an environment that's just not supportive of those efforts. And so it's really, you know, it's it's it's it's really not a matter of will or willpower or determination. I mean, my patients have, you know, buckets of all.

Yeah.

And yet are still, you know, find themselves in situations where it's just hard for them to succeed and they're in an environment that's set up to help them fail really. Yeah. So.

The reason is because the environment that people are in is sort of a toxic nutritional landscape. It's a wasteland where you could say get moldy onions and limp, rotten broccoli as opposed to some other stuff which is cheaper and easier to get and more heavily promoted. You write about something that's quite interesting in your research that I think people aren't aware of, which is not only the obvious stuff, which is heavy food marketing by food industry, not only having all the junk food in all the convenience stores and even grocery stores, and not only just the fast food stores, but something you call O.S.B. Now, that is an interesting concept, which is something that actually drives a lot of behavior that people don't know about, and I really wasn't even aware of as a driver of a lot of the bad choices. what is OSB and why does it matter and how can we affect it?

So OSB is actually just an acronym that the journal came up with. So our first paper about this, so it stands for other storefront businesses. But it just gets to the point that there is a lot of unexpected food sources out there. So when people think about the food environment or food deserts or food swamps or these toxic, you know, landscapes of food, you know, everyone's talking about either the paucity of grocery stores or, you know, full service supermarkets or the overabundance of fast food outlets. But there are so many more sources of food out there than just food stores and restaurants. And to that point, like what?

Like you mentioned barber shops, gyms, hardware stores, laundry mats.

I was in Staples the other day, right? Yeah, you get food at Staples. Chalk Depot.

Candy and Staples.

Everywhere. Candy, cookies, snacks. you know, potato chips, sugar sweetened beverages of, you know, every color and variety.

So it's like flashing neon lights, buy this, buy this, and it's impulse buying and people don't actually think about it. It's all in places where they naturally are, but not normally a place where you would get food.

Well, normally a place where you wouldn't think you would get food, but increasingly it's everywhere. And so another study that we did, so not only just demonstrating the prevalence and how kind of ubiquitous it was, but the fact that it's becoming even.

More prevalent, even more ubiquitous. so what percent of overall food consumption are these OSBs for people who live in these urban or so we can't comment on consumption.

We don't even know purchasing at this point, but we can tell you, you know, the proportion of food sources that they represent. So they're as numerous as restaurants at this point.

So the volume of food available in those is as much as restaurants.

So more numerous than supermarkets. more numerous than grocery stores, more numerous than food stores, and as numerous as restaurants currently. And that's been increasing. So we looked over a five-year period, and there was food available in 30% more businesses five years after an initial look than there was when we looked at the baseline.

It's accelerating. And they're not selling hummus and nuts at the checkout counter, right?

Generally not. Although I have to say, so a third of all these kind of non-intuitive other storefront businesses offer food currently. That represents about a quarter of all the healthful options out there and about two-thirds of all the unhealthful options.

Meaning what's available in those is mostly unhealthy.

Disproportionately unhealthy, although occasionally you will find, so people will sell nuts, they'll sell dried fruit, they'll sell whole grain crackers, they'll sell things that are less detrimental to good eating and the kind of things that we want patients to choose, people to choose to be healthier. But those are overwhelmed generally by the sodas and the candy and the chips and the cookies and the other things that we really don't want them eating. And so it's a big issue and it's one that hasn't gotten a lot of attention and that people have kind of glossed over and that it gets lost in the whole discussion about food deserts and food swamps and if a neighborhood has access to food or if they don't, no one's really considering these things.

How does that stuff get there?

Well, how does it get there? I think it gets there because it sells.

So the food industry is deliberately creating another channel distribution sort of under the radar that is hugely impactful. and provides the volume far greater than we have estimated.

We have every reason to believe that it is. And what my research has demonstrated, and some of this is published already and some of it is in press or under production, but it's showing that the greatest, the food is more prominent, more prevalent, available in more places, in more challenged neighborhoods, in neighborhoods that are more disadvantaged, suffer from diet and diet-related diseases. And so it's interesting that it's not, you know, uniformly available across the board. It tends to be more available in the communities that need it the least.

So it's pretty amazing. You're just sort of living in your ivory tower, you know, writing about this stuff. You're literally working in the Bronx in underserved neighborhoods with the poor and minorities seeing this stuff every single day living and working in that environment. So you've written a lot about how do we start to change these toxic food environments? What are the levers that we can pull? What are the strategies that we can use to help shift that? Because at the end of the day, it's the food system and the food environment that is the bigger determinant by far of health, obesity, diabetes, chronic disease, than personal choice and responsibility. That's really clear. I think it's not certainly the consensus, but I think if you look at the data, there's no question about it. So what are the kinds of things that you've talked about? It's not just, you're not just sort of criticizing this. You're talking about how do we change the food environment? What can we do creatively to actually make a difference? And how do we build on those things and scale them?

So I think there are a lot of levers at a lot of different levels. you know, certainly for physicians, for health systems, I think there's a lot we can do, or I think there's a lot more we can do. And there's been some glimmers of hope and things that people have done already. So, for instance, in our clinic, we've experimented with a bunch of initiatives to help address the issue of food access and communities and try to improve that. One thing is a fruit and vegetable prescription program. So not initiated by us, but something that we tried and glommed on to. and, you know, so this is a strategy whereby, you know, patients come into the office, they are suffering from obesity or diet related diseases, have a need for better food in their environment, and we write them a prescription just as we would for a medication or a device or any other, like six nuts.

Three times a day.

Well, we write them a prescription that says you should be eating more fruits and vegetables or generally, you know, you know, some amount of fruits and vegetables. And then that serves not only as written advice from a physician, from a doctor, from a trusted source to do the good thing, but it also served as a coupon to then take to a local store to subsidize the purchase of those healthy foods. So how is the mechanism of payment there?

So the doctor writes a prescription. Doctor writes a prescription.

Does insurance pay for the groceries? The insurance does not pay for the groceries. So this was grant money. Right? And so it's basically philanthropy. You need money. Well, it is. And then, but so the idea is to get it started. And then it's working with the local stores, the corner stores, so that they, and grocery stores, and, you know, in some cases we also used farmers markets [Mm-] to make the supply of healthful food more available, right? So it works on kind of two levels. So it's not only increasing demand, by giving direct advice for patients to eat more. But it's also working on the supply side by working with owners, saying you should stock this, we're gonna be sending patients to you, this is gonna create demand and opportunity. And ultimately what it does is it gets both consumer and the businesses into the habit of exchange of healthy food. and it becomes more the norm, right? And it becomes something where, well, this corner store is offering fruits and vegetables. We're sending patients there. Patients are shopping at that corner store now. The corner store that's not participating sees that they're losing business or that there's a competitive advantage to offering fruits and vegetables and they come onto the scene, right? And so there could be this extension or this ripple effect out in the.

Community that makes the food environment healthier overall. So it pushes people to buy healthier food and businesses to stock healthier food.

It does both of those things. Yeah. So it works on both. And I think any strategy is going to have to work on both the supply and the demand.

Well, there's one other piece of that, which is I work in Cleveland and again with poor communities and you say somebody eat an avocado, they don't know what it is. Right. They never bought one or have some kale. They don't know what it is, how to make it. How do you deal with the problem of the lack of awareness of even.

What to do with these foods?

Excellent point. Excellent point.

Because one thing is they eat this and then they go, well, I didn't hear. So I did some work early during fellowship with the Food Trust in Philadelphia, which is a nonprofit organization dedicated to the idea that everyone should have access to helpful food. And there they did some corner store work that worked both on the supply and demand side. So on the supply side, they worked with corner store owners to stock fruits and vegetables and in forms that were appealing to kids. So like cut up fruit salads, maybe with you know, some shelf talkers or some advertising that made it look appealing. And then, you know, Tony the Tiger for Froot Loops. Yeah, or something. Well, exactly. Right.

You need some branding or some icon or a logo called Super Sprouts, which.

Had, you know, Colby Carrot and yeah, Brian Broccoli. Well, exactly. Superhero. And I think one of the aspects of their marketing or advertising was actually coming up with a comic book to.

Go along with it.

So to kind of get kids, get your superpowers. Yeah, make it cool. Make it, make it something appealing to kids. so that's on the demand, on the supply side. On the demand side, they went into the schools and did tastings with kids, demonstrations with kids. So a lot of these are, kids are growing up in families that generationally have lost cooking skills, that have, you know, moved to, you know, processed and convenience items that are, you know, opening dinner from a box as opposed to, you know, making it from scratch. And so a lot of these kids had never tasted a pepper. They'd never tasted a strawberry. They've never tasted different kinds of fruits and vegetables. And when they're given to them in fun shapes and novel ways and different mechanisms, kids actually like them.

They like them, yeah.

And so you can introduce the kids, get their taste buds excited, and then send them to the store where they see the item that they just had. And again, it kind of sets up a loop. And so this takes grant money or seed money or some type of initiative to get things running. But once if you can find that magic point where you get it started, it creates a positive cycle that reinforces. And it's good for communities. The store owners have some reticence, right? I mean, they don't necessarily all jump onto the opportunity, but some realize a real business opportunity, a real opportunity to improve their communities. Many of the corner store owners or small store owners are from the communities that they're working in, and so they have a vested interest in making their communities healthier. And so, those are- Finding the little.

Tweaks that can help people stimulate different behaviors, right?

Absolutely little tweaks. And I think the more the better, right? So, the food industry spends impossible amounts of money promoting, marketing, making available- Billions of dollars. Yeah, the stuff that we just do not want patients eating or the things that are making patients sick, quite frankly. I mean, they're selling sickness. And to counter that, we need as many strategies as possible.

I mean, think about it. I think the data change by the end of 10 and 13 billion dollars spent on just advertising and marketing poor quality food. And the worse the food is, the more marketing and advertising they devote to it. And the drives behavior. And the average kid sees 6, 000 to 10, 000 ads. for processed junk food on TV and media. And probably now it's hard to measure, but through social media and stealth advertising, it's probably even more. It's more surreptitious. Even before they used to say, Here's a picture of a baby in the 50s drinking 7-Up and Coca-Cola and how good it is to get them to drink their formula. That's obvious and terrible. Nobody would go for that. Now it's all subliminal. It's celebrities. It's kind of friend marketing and it seems like it's authentic and natural, but it's not and it's deliberate and it's one of the drivers of so much of the behavior. It's a problem.

Yeah, and to your point about surreptitious advertising and I should come back later to some other strategies that we're using in the clinic to counter that. But we did a study in the Bronx actually looking at subway advertising. So this is something that no one had really looked at before. I mean people have done this is.

Shocking, everybody listen in because this is shocking.

Well, people have done studies looking at TV advertising and advertising on computer games and advert games and video, and all kinds of screen media. But there hadn't been a lot looking at the environment where patients, or particularly children, are living, are playing, are going to school, are commuting back and forth. So we decided, wouldn't it be interesting to go and see what was being promoted in the subways? system in the subway stations. And so we rode every subway line in the Bronx, got off at every station and looked at every ad.

Wow.

And characterized it. And so, you know, it's like 68 stations on like seven lines and there were like 1500 ads. And we, you know, did a content analysis and measured their sizes. And particularly we're looking for promotion of unhealthy foods and beverages. Yeah. What we found was that there was.

Ad for broccoli all over. So there was cereal ads, not a.

Single ad for a healthful food product. Not a single one.

Eat almonds, nothing.

Nothing. However, as for unhealthful food products, so alcohol, sugar-sweetened beverages, sugary cereals, processed foods, fast foods, were disproportionately found in stations that were in neighborhoods home to communities that were challenged by you know, various demographic and diet related issues.

More diabetes, more obesity, more diabetes, more.

Hypertension, more hypercholesterolemia, high cholesterol.

These are poor minorities.

And then also more poverty, lower education, more children in the neighborhoods, more foreign born, more immigrants, right? So, adds disproportionately to that. So we looked and we said, well, maybe it's just a function of the fact that these are just the biggest stations, right? So, like Yankee Stadium big outlier. You know, it's a huge number of ads in Yankee Stadium. So maybe it's just a function of foot traffic, right? So, you know, advertisers are just, you know, selling to the biggest, biggest possible eyeballs, right? Yeah, as many eyeballs as possible, right? So they're just, you know, putting their money where, you know, the most, where they can reach the most eyeballs. And it just so happens that those are in these neighborhoods. Well, it turns out exactly the opposite. So it turns out that those unhealthful ads were not related proportionately to the amount of foot traffic or the number of eyeballs, the inverse was true. So it wasn't that they were trying to reach the biggest audiences, they were trying to reach select audiences. And the select audiences that they seem to be trying to reach were those who were most challenged, right? So poor, minority, foreign-born children living in poverty.

So this is important for people to just pause and understand what this is about. So basically, these are areas where the worst affected by obesity, disease, poverty, where the minorities live, people who have lack of education and are the most burdened. Yet by volume of people, the number of eyeballs, it wasn't the greatest, it was just the ones that were at most risk. Now, why is that happening? Because it's much easier for the food industry to sell people who are already eating poorly more bad food than have you or I start to eating Coca-Cola, drinking Coca-Cola or eating processed food or having junk. So they target existing communities to create what they call heavy users. Michael Moss talked about in his book, Salt, Sugar, Fat. This is a deliberate strategy by the food industry. Now, when you say, well, they're not bad actors or just have legacy products, they have unintended consequences, they're trying to shift their product formulation, okay, they are, maybe they are. But they're also employing these nefarious tactics which are targeting the most at risk and the ones who have the least amount of ability to stand up and have a voice for what's going on, the least ability to understand it and also the most affected. I mean, this is in my view criminal.

I agree 100% and I think it's awful and I think, you know, the silver lining that came out of that research was that It happened to be published at a time when there was a huge campaign and a lot of effort and interest in getting alcohol ads out of the subway system, out of mass transit. And what we were able to document was that among the unhealthy food products or food and beverage products that we looked at, we were able to subtract out alcohol and saw that the same relationships held, right? So the same disproportionate advertising, the same targeted marketing. And so that was compelling evidence to then bring to the MTA, you know, who runs the subway to say, you know, this is just unspeakable, right? And it moved people. I mean, it was one rare case where evidence can influence policy, and that's unusual and rare in this day and age. But it wound up, you know, a unanimous vote to take alcohol ads out of mass transit vehicles and properties, so across the whole system. So that was a win. However, as with any public health win or initiative, you have to worry about unintended consequences. Well, I was really happy about that, that children are no longer going to be children minorities, the poor, uneducated, or lesser educated, rather, are not going to be exposed to alcohol ads on their daily commutes or as they go around the city. go to and from their homes, what you have to worry about is what fills that space.

Do you think we should be banning unhealthful advertising and marketing?

Well, my concern is that now that the alcohol advertising is gone, what's going to come in are ads for Coca-Cola and M&Ms and other unhealthful products that appeal to children more directly and that they're direct consumers of. Do I think we should ban it? So I'm always cautious about bans. So I think bans are well intended, but as I said, as with any public health campaign, but particularly with bans, there are unintended consequences. So you have to really think like what, if you ban the unhealthy food products, for instance, what comes in to fill that space?

Yeah, it's interesting. There's an initiative in Chile, which you probably heard around, which is a sweeping set of reforms we've chatted about on the podcast before. And I talked to Barry Popkin, who was one of the architects of the reforms in Mexico and Chile are on food policy because they're so disproportionately affected by the obesity and diabetes epidemic. And what he said was they got a fair bit of funding to look at the impact of the change of these policies. And one of the policies was eliminating any character cartoons from kids marketing or any products, right? So cereal boxes can't have superheroes or anybody else on there. They eliminated any advertising in movies, rent, radio, TV, I think even online for kids between 6:00 a.m. and 10:00 p.m. And that they even put in an 18% soda tax, but what was more impactful than all the other policies was eliminating the marketing. Like four-fold bigger impact, which was shocking to me. and spoke to the fact that we have to find a way to deal with this. We are one of the only westernized or civilized countries or developed countries that allow unrestricted food marketing to kids. Now, because it was the First Amendment, right? We have right to free speech, corporations are people according to the Citizens United, they should be able to sort of say whatever they want to say. And yet we do regulate things around children differently. And I think when it comes to children and particularly given that 40% of kids are overweight now, that if a kid's a teenager who's obese or overweight, their life expectancy is 13 years less than someone who's not at that age. These are really serious issues. And so I think we have to figure out how do we get the political will to do this? How do we get the data to show this impact? Some of these other countries are innovating around this. So if you were in charge.

Well, I was just gonna say, I think that's absolutely true and it's exciting work that's come out of those other countries. In this country, I think we've focused on tobacco and alcohol, which I think everyone can agree are unambiguously not good for kids to be exposed to or early introduction to or initiation with. It gets a little tricky in the food landscape because it becomes the question of, well, what is healthy, what is unhealthy, and how do you define that? And I actually think marketing for healthy foods could be a beneficial thing. I mean, as you mentioned earlier, put a cartoon character on it.

They don't eliminate marketing for food, just the unhealthy the stuff.

But then, yeah, how do you define unhealthy?

I don't know. I think you and I could probably.

Agree on how to define it. Well, we probably could come up with some definitions, but, you know, and this is what, you know, the pushback from the sugar, sweet, and beverage industry. And one of the tricky, you know, nuances and caveats is it's been tried in different municipalities.

Right.

So, you know, certainly sugared sodas. Right. But did diet sodas fall under that, you know, umbrella? Philadelphia thinks so.

The juices, the juice drinks, do, you know, do flavored waters. Yes. That, you know. Right. So, right. So, you know, it becomes a sticky issue. I just got back from Abu Dhabi. and it's an interesting, it's a benevolent leadership there, which is fairly autocratic. They can make very easy, quick decisions and they're not beholding the food industry because there's no taxation in the country. They get no revenue from the food industry. They really don't have investments in the food industry. There's no way for them to influence policy. And they have this massive obesity and diabetes epidemic, and they put in a 100% tax on energy drinks and a 50% tax on soda. and one of the products was Red Bull that was impacted. I think of the finance minister from Austria, he said, where I think Red Bull is from or something, called the guy who was in the government and said, hey, what's going on? We're seeing a 70% reduction in consumption of this. We're going to have to lay off all these people. He's like, well, we made the policy. We're sorry. That's how it's going. The pushback from the food industry is quite strong.

Well, and no doubt it would be. I mean, it cuts directly into their profits.

And this is, by the way, this is a government official calling another government official saying, your policies are hurting our companies, which is not in the public health's interest.

Right. Well, so even with the success that's been seen with some of these measures, a lot of that success has been narrowly conceptualized or focused just on food. And I think, particularly with advertising, as I mentioned before, if advertising for food is eliminated, something else comes in to fill that space. And if that something else is not good for health either, let's just say, in this country we don't have tobacco advertising. Well, let's just say you eliminate food advertising and not tobacco advertising comes in. Or e-cigarette advertising comes in. Or advertising for misogynistic movies or things that impact people's health in other realms other than food or what they consume, that's not necessarily a net benefit for public health. And so I think that all has to be considered. And likewise with the sugar, Red Bull sales go down or sugar sweetened beverage sales go down, maybe that's a good thing, but does that trend, so maybe people aren't spending their money on their sugar sweetened beverages anymore. Now they're buying cookies and cakes and sweets instead and drink, is that necessarily the win?

Is that a better Well, I think they're looking at overall health or looking at obesity.

I think you have to look at overall health. And, I think that's one of the problems with past research and one of the things where I think research and policy and awareness needs to move into the future is that you can't narrowly look at single ingredients or single foods or even diet in isolation from broader lifestyle and broader health. I think you have to look at the whole picture and see what the ultimate impact is on people, on communities, on quality of life.

Totally. So you talk a lot about food is medicine and when food isn't medicine. And you really highlight the lack of nutrition education in medical school that's been talked about. And you're a doctor in a healthcare system. and yet it's clear that the solutions aren't necessarily in the doctor's office. And you've really done a lot of work on looking at what are the approaches that a health system can take to own the health of their populations and communities through better health and nutrition practices. So what are the kinds of initiatives that you've explored that could be fixes to the food disaster that's in the communities that you see?

Yeah, so I mean, as you said, and as I mentioned, it's frustrating in clinic to engage with patients one-on-one and face all these obstacles. And so I think, you know, the real solutions come from getting outside of the literal boxes of doctors' offices and clinics and hospitals and out into the community and making it so that the environment better supports people's motivations to be healthy, right? And their intent to do the right thing and to help them. And so, as I said, you know, we've done some work in our clinic, you know, I mentioned the fruit and vegetable prescription program. I mentioned some of the work that the Food Trust has done. We've also done things like, you know, directly try to impact food access. So we've partnered with a farmer's market that comes to our clinic during the farmer's market season. So you go to the doctor's office.

You can go to the farmer's market.

You can go to the same time. And you can get a, you know, again, you get a voucher, right? You get a, you know, written advice from the doctor, a little financial subsidy, and the, you know, fresh fruits and vegetables in appealing form. are freshly picked and right available to you. And we've also done things like cooking demonstrations and tastings to help patients understand what to do with these products. A lot of them are foreign. A lot of the products are foreign to patients. They haven't seen them before. They haven't tasted them before. They don't know what to do with them, how to prepare them if they'll even like them. And to shell out money for that is a big gamble and risk. not necessarily someone's going to take unless you can demonstrate to them, oh, this is what you do and this is.

How easy it is and this is.

What it tastes like. And they want to know.

And they want to know. They absolutely want to know. I was in a cooking class at Cleveland Clinic, one of the hospitals, 300 people showed up and we demonstrated how to make smoothies and different healthy foods and they were just so engaged. And these were not sophisticated people who were shopping at Whole Foods. They were people who just wanted to get better health who were often disadvantaged.

Yeah, and I think that's crucially important. I mean, other things that we've done are things like bodega, helping bodegas redesign. So like, you know, going out into the community, into the stores around our clinic, and you know, speaking with owners, you know, trying to incentivize them to stock healthy foods. I mean, the fruit and vegetable prescription program.

So you walk into the bodega with your white coat and you say, Hey.

You might even go in as a group of white coats and say, yeah, hey, I'm a doctor in the community. I care about the community. working in the community, you come from the community, you know, is there something we can do to help incentivize you to store healthier products or where can we make some money?

Nobody's gonna buy it.

They're not gonna. Sometimes they do. And so, but so, so you see what you can negotiate and see what you can experiment with. And sometimes it happens just by patient demand. Like, you know, if I tell patients that, you know, if you're going to be choosing bread, you want to choose like a whole grain bread or a sprouted bread. And they did go to their store and they tell me all they have is white bread.

Well, then that starts a conversation with the owner. And the patient says, you know, my doctor tells me I should have whole wheat bread. Would you carry whole wheat bread?

Yeah.

It just tells me that, you know, White bread, white bread, is just as bad as sugar, if not worse. And they still put high fructose corn syrup in the bread. I don't understand. And like five other kinds of sweeteners.

Well, I mean, so talking about solutions.

Outside of- Cake bread.

Yeah, no, it is dessert bread. And I think that gets to a bigger issue. So before I mentioned there are many levers on many levels, and that gets to a bigger level of our food production system and our subsidies and how we do crop management in this country and what we focus our interests on. I mean, the amount of interest, effort, and resources that go into producing corn and soybeans and other commodity crops that get then highly processed and injected into virtually everything is astronomical. And if we better aligned our our systems with healthy food production, I think it'd be better overall. Farm bill revisions.

Well, farm bill revisions.

But, you know, so it'd be better for us as consumers. And then, you know, there's also arguments better for us as a planet, right? So, you know, we are, our health is also related to the health of the planet. And when we don't, you know, respect the earth, I mean, you know, this is, this just happens to be where we live and we don't have a lot of options to go elsewhere.

So, yeah, I mean, people don't realize that, you know, so eating processed food made from corn, wheat and soy is actually a huge contributor to climate change. People think, oh, if you eat meat, it's going to be the problem. But no, the way we grow these commodity crops destroys the soil, clears the water supplies, the carbon can't be held.

In the soil, reduces the forests.

Yeah, clear cutting to raise more of these crops. And so we're destroying the rainforest of of the prairies, which is the soil, which actually probably has a bigger capacity to hold carbon. And when people don't realize that, so you're, you're thinking, oh, I'm eating, you know, you know, soy corn and wheat. I'm having, I'm a plant-based diet, and yet you might be just as big.

A contributor to climate change if you're not aware of how the food is grown. Yeah. Although I will say that, you know, those, those corn and soy products, I mean, a lot of those are used to feed our animals.

Yeah. Right. That's the other problem.

I mean, so the animal, it's like double. Animal agriculture doesn't get a pass here. No, it's double whammy. Yeah, it's a total double whammy. But I mean, that's part of the animal production system and part of our, you know, factory farming, you know, highly commercial industrial processing, right? So, you know, we've kind of gotten away from, you know, everything has become big ag, you know, big production.

So what about small ag? You talk about some of the initiatives.

You'Re doing with community gardens. Community gardens, yeah.

So we had a community garden at our house. The system intersect with how did that happen?

I mean, these are all little small projects that I think can grow and blossom, right? But I think there's real interest in that. And I did a study in Philadelphia during fellowship where I talked to.

Patients.

Well, community residents really, about their incentives, about the things that promote healthy food production and the things that get them to eat otherwise. And one of the things I heard, we did a whole wide swath of patients. In the older patients, predominantly they were from the South, they were from farming traditions, they had grown crops as kids, they still engaged in gardening, and they were you know, involved in food production. Whereas as you go through the generations, there's a loss of that food production knowledge, there's a loss of that food preparation knowledge, there's increased reliance on convenience and processed and packaged items. And so bringing that back, you know, there is a there is a knowledge base there, right? I mean, so the old heads in these communities, we're very much in favor of producing food and growing food and community gardening and I think get really excited when there are initiatives like that where they don't have to rely on the food industry to supply these almost unrecognizable things that they would never have eaten as kids but now have become part of their regular dietary pattern in old age because our food system has changed. so dramatically. So I think, you know, there is opportunity there. It's huge. And you get kids involved, and they love it.

They love gardening.

They're astounded that they can't believe that food grows on a plant.

Yeah. My daughter thought we grew eggplants. She was like, where's the egg? She was like, yeah, yeah, I'm gonna pick this.

Maybe saying, no, but when you see. When you see a piece of fruit on a plant and, like, you know, like the Earth, the soil, the plant produce that, that you eat. you know, because. Right. Otherwise, their, their whole conception is divorced. It comes in a shrink-wrapped package that they open up in the store, and they think, you know, fruit comes from a can or fruit comes from a jar. No, fruit comes from the plant. It comes from the earth, and you can grow it and you can be self-sufficient and you don't have to rely on Industry to provide you with inferior product. You can, you know, be a part of that, you know? And so in urban landscapes, that's more of a challenge.

I mean, you know, there's space issues and stuff, but, but there's definitely, there are definitely Lots that have been converted. Sure. You know, you gotta bring in salt from the It's amazing making this point sort of stimulates me to think about the victory gardens in World War II. So many people aren't aware that 40% of our food during World War II was produced from people's own home gardens. And we were at war. And in a sense, we're at war now. I mean, if there was another country that was causing 70% of our population to be obese, one in two people that have chronic disease that was costing literally 84% of our 20% GDP that's used for chronic disease. We'd be at war. If another country was doing to our kids what we're doing and the food industry is doing, we'd be at war. So maybe we need to think about the victory gardens a little bit differently here and say, well, let's re-engage people in the growing and production of food. You know, we used to have 50% of people on farms. Now we have less than two. Yeah. And I think it's not that hard to grow stuff. You obviously can't grow oil.

Well, yeah. I mean, I don't think we have to initially transition back to an agrarian Society. However, there are opportunity. I mean, so even when there aren't, you know, Lots or soil available on land, I mean, there are all kinds of rooftop gardening. Yeah. Which, which have, you know, benefits not only for food production, but also like community beautification and socialization and heat retention.

Have you been to the Green in Brooklyn and the big rooftop garden?

I haven't, but I've seen it and I know, yeah, I've been to a similar setup in Chicago and it's unbelievable. There are also indoor growing options, growing walls and things. There's a Bronx teacher, Steve Ritz, who's become very famous and he does a lot of work with food production and getting kids engaged in, you know, taking ownership of their food and he does a lot with green walls and indoor growing options, which are perfectly viable and something you can do even in the city and require a lot less resources than people think and can be beneficial on multiple fronts.

So you're not just sort of conceiving of these things, you're actually implementing these things in the Bronx and poor communities. what changes have you seen as a result of that?

Well, you know, locally, so, you know, in the, so with our, you know, programs around our clinic with, like, the bodega or small store redesign with the fruit and vegetable prescription program, with the farmers market, with community gardens. We've also done things like bodega walks or grocery walks where, you know, you go out with a nutritionist or a doctor. into the store, you do kind of a guided tour of the shelves, how to read a label, how to... Hopefully.

It'S a doctor who knows something about nutrition.

Yeah, exactly.

You and one other guy in Brooklyn.

Right, right, right. People motivated and educated and informed to do this kind of work. But, you know, through that, you know, patients become more engaged, more involved, more aware, more motivated and better prepared, better able to navigate these challenging environments. So, you know, in many cases, you.

See the change in your clinic and patient outcomes and their health.

So, I mean, I can point to select examples, right? I can't say that that's across the board, but there's no question that a better prepared patient is better able to make changes, implement them. And I've had many patients who have been able to get off medication. improve their health, improve their numbers, so to speak, the ways that we kind of track their progress from a chronic disease standpoint just by virtue of making these lifestyle changes, just by virtue of changing what they're eating or making tweaks to their food shopping and preparation and consumption patterns.

That's interesting. The issue is, how do we shift help practice and help policy to motivate these changes. And right now, I would say we really don't have evidence-based medicine in America. We have reimbursement-based medicine. So there's an interesting pilot you've probably heard about for a food pharmacy by Geisinger Health Systems in Pennsylvania where they took food insecure diabetics. These were people who would just worry about where they're gonna get food, they don't have a lot of money, they're poorly controlled, they're just struggling. They identified these patients, they gave them $2,400 a year for food, for food pantries and groceries. Then they provided the support for them to actually know what to do with it. They provided health coaches, nutritionists, education, support groups. And they filed these patients for a year. And the average patient, because they were having amputations and hospitalizations and complications, their costs were astronomical. $40,000 per patient. And in one year, just by giving $2,400 of food and a little social support, they were able to save $192,000 per patient. That's 80% savings while dramatically improving their health and lowering the hemoglobin A1C, their average blood sugar, and getting them off medications. And yet, this is not something that's paid for.

Well, I think that's the critical point. I mean, I think you you know, alluded to that before, like how, you know, it's about political will and who bears the cost. So there can be tremendous cost savings, but who reaps those benefits and, you know, who, you know, pays to get these initiatives started. And I think that misalignment is one of the big barriers or issues right now. But, I mean, there are a lot of strategies that you can experiment with. Yeah. You know, we, there've also been, you know, Health systems that has experimented with food pantries actually in the health system themselves or in the hospitals that have done CSAs, Community Supported Agriculture, where local farms will come and deliver a box of, you know, goods that patients can pick up at a clinic site or at a hospital site or things like that. So there are ways to engage, you know, and, and actually, one of the things that I've been interested in and that my research has, you know, kind of got me thinking about is how do we change the landscape that is changing? So this landscape is becoming more unhealthful. So there's more food available and more of it is less healthful. Some of that work's published already. Some of it is under production and should be coming out soon. But we've documented that over time, there's more food available in more places and more of it is just not good for good health. And so much of that is driven by the storefront landscape, right? So the food stores, the restaurants, but then these other OSB or other storefront businesses. And so what do you do to combat that? Or what do you do to, you know, work against those forces? So I think mobile options hold a lot of promise because they aren't restricted or constrained by, you know, the storefront model. So you don't need the capital. Like a food truck or a food truck or a green cart or, you know, in New York City, we have these green carts, which are fresh fruit and vegetable vendors, which can, you know, move from place to place even within a given day. And they can, you know, come into a neighborhood and, you know, make available, you know, healthful products to patients, communities, residents in need, and, you know, be in multiple places, you know, throughout a day. And so what do these look like?

Are these refrigerated bus.

No, they're not really push carts.

Like my grandmother used to use in the Lower East Side.

So generally they're push carts. So we did a couple studies of the mobile vendors across the Bronx. And what we found was that a small percentage of them are these Department of Health condone endorsed green carts. So this is a city program which is unprocessed fresh fruits and vegetables. which are available on a pushcart and can go into neighborhoods that are, you know, the city has designated as challenged, which is most of the Bronx. It's almost the entire surface area of the Bronx. That said though, we found that the vast majority, so over two-thirds or about, sorry, about two-thirds of all the vendors out there were unlicensed, unpermitted, and people just selling, you know, impromptu from, you know, improvised setups. out of the back of a car, out of the side of a van, out of a blanket on the street. I think that's great when they're selling healthful foods. Majority of the time they're not. So majority of the time they're selling junk. Chips and candy and cookies and homemade pastries and other stuff.

However-- this is sort of a natural sort of industry that's in those communities.

It's a natural industry in the communities. However, there are vendors that are selling fresh fruits and vegetables and healthier products. And I think if we can incentivize those, if we can make it so that there are policies that support and promote the placement of those types of vendors and communities in need and getting them to the people that would really benefit from having access to them, then I think that could be a real positive thing and could reap...

So how do you support these mobile vendors?

Well, there are a number of ways. So, I mean, one thing... So they are selling perishable products. And so, you know, and, and fruits and vegetables aren't necessarily cheap, right? So if you can come up with, like, some bulk purchasing Arrangements so that they can negotiate for, like, lower prices and, you know, have them kind of buy en masse to help keep prices down, that's one thing. Another thing might be, you know, supporting the purchase of the vehicle themselves. Right. So, I mean, that's out of pocket money for the vendor, but if they could, could be some subsidy. just in terms of loans for the cart, or for the van, or for the truck, or whatever vehicle they're vending from, or some prioritized, or some special treatment in terms of the permitting or licensing, or where they can sell, or things like that.

So these are organically developed businesses. These are not something that some company designs that we're going to pay mobile food carts. They're just like there already?

Well, the green carts are a city program, the official green carts. But other vendors are largely, you know, a gumption of some entrepreneur.

And you're thinking of how do we partner with them to-- How do we.

Partner with them to like, you know, to incentivize the sale of healthy product and then the placement of vendors selling helpful products in the communities most in need and then also restricting you know, those selling less helpful products or selling, you know, the people selling the cotton candy and the hot dogs and the, you know, the donut trucks and, you know, those kind of things. Like we don't necessarily need more of.

The ice cream van coming around. Yeah, it was interesting. There was an article in the New York Times in this whole series called Planet Fat about Brazil and how in these poor communities way up in the mountains, they had these little push carts, but they were not filled with healthy food. They were filled with processed food and sugar. It was thought to be healthy and promoted as better than in poor communities that didn't know better. And so they're thinking, well, we're just gonna have this powdered shake or we're gonna have this process, this or that, and it's healthy. And it's, you know, shifting to a model where you actually, I mean, I, you know, my, my family moved here from Russia and Poland at the turn of the century, 19th century. And my great grandparents all had push carts, you know, selling pickles or, you know, thumb, thumb, thumb, like sewing stuff and thimbles.

Yeah.

You know, it's like, that's a whole different way of actually. creating a more distributive, egalitarian, and better quality access to food than is in these communities. Right.

Yeah. But it's challenging, you know, and it's not, I shouldn't represent it as a single solution or even the solution, but I think it's one strategy that could be helpful. I mean, one of the challenges and one of the things that our research made clear was that, you know, not being protected in these enclosed boxes, these are vendors who are vulnerable to the weather. And so when the weather's not nice, they're not out.

I mean, Adam's hot out, your lettuce is going to be gross and wilted.

Well, that's another issue. So like the perishability and how quickly you have to move product is another issue. But so yeah, weather plays a key role. And then also the distribution of unhealthful to healthful currently is not ideal.

So, do you find yourself like a unicorn in the health system in the Bronx? I mean, is there interest in this? I mean, are you just out there in the wilderness crying and nobody's paying attention?

Or like what?

Because it seems like oh, no, people are definitely interested.

It seems like such a different model of like how you're going to do this. Yeah, but no, we so and I think our health system is interested and I think increasingly, you know, as accountable care organizations and as there's, you know, as reimbursement is linked to or payment is linked to how communities do and how much you engage in health promotion and disease prevention as opposed to just treating disease when it comes to your door. I think those things all lead to having interest in these types of initiatives. So, just to be clear for people.

Who are listening, value-based care means that you're going to get paid for doing the right thing and getting people healthy and better outcomes at lower cost. rather than just doing more stuff. Right now, everybody wins. The more surgeries you do, the more procedures you do, the more visits you have, the more medications, that's how the system is rigged now. And there's a movement afoot to change the reimbursement to pay for actually people getting better and doing better at lower costs, which then motivates initiatives. But the problem with healthcare systems is they don't know how to do this. This isn't their baleiwick. This isn't their bodega, so to speak. actually understand how to actually be in the community, drive these changes where the problem is. No, absolutely. And I think, you know, the bigger.

Health care systems recognize that and are experimenting with it. And, you know, I mentioned some of the initiatives. Yeah. You know, in our health system and around the country. What's the health system you work in? It's a Montefiore. Montefiore, which is in the Bronx. And it's the predominant provider of care in the Bronx. I mean, it's huge. It's a behemoth. And, and it engages in a lot of good work. I mean, I think our, you know, office of community health and the community health folks in the health system are doing a lot of this work, including some mapping stuff to see where kind of the hotspots are for obesity and diet-related diseases and then linking that up to retail outlets and what the food sources are and are these areas that we want to target and where do we want to focus our attention and that kind of thing. So, I mean, there's a lot of interesting work. Yes, I don't think anybody knows how to do this, but we're all experimenting and we're all trying things.

And I think, like I said, and the leadership in the mature health system is engaged and interested in doing this kind of stuff.

Fully supportive. Yeah. Yeah, I think so. From the top down. Because there's benefit to it. I mean, it's a financial win too, right? It's not, you know, as long as you're getting paid. It's altruistic, but I mean, like there's, you know, like if you keep patients healthy, you're rewarded for that. if you keep them from getting readmitted, you're rewarded for that. We're kind of though in that no.

Man'S land where all the payments aren't value based and still like we're experiencing that at Cleveland Clinic where we're trying to create a whole new initiative called Cleveland Clinic Community Care. And that is a wonderful population of initiative to try to do these things, but we're all at the same time feeling the pressure of how do we pay the overhead when we have you know, all these pressures around volume and it's a tough no man's land. Yeah.

Well, and I think to your point earlier, I mean, maybe it's not doctors who should be doing this. I mean, doctors can be engaged in this work and probably should be and should pay attention to it, but we're not experts in this realm.

And you use community health workers, you use health coaches.

Community health workers, you use, you know, you use diabetic educators, you use nutritionists, to use social workers, you know, it's a whole team. And, you know, through that collaboration and through that kind of team-based model where everyone has a role, you know, something good comes.

And are you guys measuring how these initiatives and things are working?

So, you know, the research aspect has been or the assessment evaluation has been less rigorous. And that's one place where we need to grow. But it's beautiful.

I think Bloomberg gave $30 million to assess the impact of some of these policy changes in places like Mexico and Chile and the impact they have on the health of the population, consumption patterns.

Yeah, sure. Well, I think the Department of Health in New York, DOHMH, Department of Health and Mental Hygiene, has a lot of initiatives in this space and has done some evaluation. One of the exciting things. so, you know, I mentioned the green carts or the, you know, fruit and vegetable vendors. So one piece that I saw them publish, and I never saw the follow-up this was just kind of a one, a one pager or a brief. But what it suggested was that in the communities where these vendors are placed or locate or where they find themselves, that there is a broader fruit and vegetable provision across the board. So not just from the mobile vendors themselves, but from the surrounding storefront businesses because they see, well, these vendors come in and now they're, you know, getting a market share and maybe taking customers away or whatever. And so they compete on that. And now they start providing fruits and vegetables themselves. And so the overall provision for the community improves and there's those ripple effects like I talked about before.

And you're saying your patients want this stuff. It's not like you're providing these access, but then they know, how do we.

Don'T want to buy that. We want to buy. Well, they do and they don't. So again, to my point earlier about, you know, the generational differences, and the increased reliance on processed food. And to your point about the marketing, the food industry knows that if you get kids early and you set up their taste habits, patterns, behaviors in childhood, you've got a customer for life. And so you get kids hooked on like sugary, salty, fatty, unhealthful processed stuff, they're less amenable to trying the healthier things.

Yeah.

That said, parents, patients, those who are suffering, know that they need to change, want to change, and want these options. And when they come, I think, are appreciative, right? They're appreciative of any assistance you can give to help navigate. I think you used the word toxic, and I don't think that's misplaced. The toxic environment, right? This environment that's just overwhelming, this overwhelming, ubiquitous abundance of unhealthful, less healthy stuff that's right there for impulse purchases in the communities that need them the least with just these small pockets of good things to find in the way. And so helping them find those small pockets of good things and how to maximize them and optimize them and make them more available and more available to them.

Okay, final question. You are given complete authority to make sweeping changes in healthcare and our food system and health policies, food policies, what are the top things that you would focus on to have the biggest impact to transform our disease creating economy and our bad health, chronic disease epidemic, and our toxic food system? Given what you know, because you've been studying this your whole life and you know more than everybody how to do this.

I know more than everybody. You're pretty, you're pretty, but I have done a lot of work in this area and I've thought about it a bit. I mean, I think as a guiding principle, we want to encourage less food from factories and more food from farms. So less food from industrial processing plants and more food from living botanical plants.

Yeah, that's like a pawn.

Yeah.

So, if you grow it in a plant, eat it. If it was made in a plant, don't eat it.

Yeah, that's a rough paraphrasing, but yeah, that sounds Polynesian. So, I think, so marketing is key. I mean, I think, you know, we've talked about that, you know, a few times during this segment, and I think that's a huge lever and one that I think could produce a lot of benefit if we could restrict the marketing of less healthful things and promote the marketing of more healthful things. I think that would be hugely impactful on the demand side. On the supply side, I think we have to subsidize the production of healthful foods and not reward these commodity crops that are overproduced and toxic not only to us, but to our planet and to broader health more generally. So I think working on the food production, the supply side, working on advertising, marketing, education, and desire to eat healthy on the demand side. Those are kind of the two things that I would try to address simultaneously, and there may be multiple mechanisms to do that. I don't know that anyone's found the one right solution. I don't know there is one right solution. I think this is a complex multifactorial process problem that requires a multifaceted approach.

Yeah, it was interesting in Europe, use high fructose corn syrup because it's more expensive. And I talked to the vice chair.

Of Pepsi once and he's like, Mark.

The reason we use it.

It's more expensive than sugar? Yeah.

I said, the reason because of tariffs are more expensive than sugar, not here. That's what I mean. Oh, yeah, yeah, yeah. Okay. And so, but he said, Mark, in.

This country, like it's so cheap, the government makes it so cheap that I can't afford not to use it as a businessman. You can't afford not to use it. That's exactly right. You can't afford not to.

And so that's the problem. So when you live in a world where that's the reality, where you can't afford not to do the unhealthy thing, Yeah.

Then you've got a problem.

It's true. So dealing with the marketing and the education, all the pieces around what drives behavior, which we know very well from advertising marketing, and two, providing supports and incentives for growing the right kind of food and removing the supports and incentives for doing the wrong kind of food production.

But I think so this has been a generational decline, right? So this process has not happened overnight. I mean, it's been insidious in lots of respects and it's been it's been a process that has taken time to get to where it is. And I think climbing out of that hole is likewise going to take generations, right? You don't just flip a switch and change things overnight. I mean, as I mentioned earlier, tastes, habits, behaviors, preferences developed in infancy or maybe even before birth. Yeah. You know, with exposures during prenatal, during the prenatal period.

Yeah, I would love to see one more thing. I would love to see our government and our states and cities incentivize pay for our train and deploy a million or more community health workers and health coaches because you and I as doctors, we're not going to be able to solve this problem. We need people in the communities, in people's homes, like you said, taking them to grocery shopping, showing them how to make something with an avocado, how to actually find the right kinds of foods, what to do with it. People want to know. And that was the most striking thing that you said today for me was you are dealing with some of the most sick and disadvantaged people in this country and they want to get better. They want to do the right thing. They want to make healthy choices. They don't know how they can't get access and they aren't aware of what to do. And it's just too difficult environment. So changing that is huge. And I think that's really the message here is that we have to stop blaming the individual and start changing the environment that they live in in a real way with real incentives that I think are happening. There are pockets of innovation and creativity happening. You mentioned a lot of them during this show. And I think that's really what people need to focus on. It's not necessarily waiting for the government to fix it, but, you know, oh, no, I can actually start doing things like the community gardens, like the communities where agriculture, like the things that cities are doing, like these green cards. I mean, these are like little solutions that aren't going to solve the whole problem, but if enough of this starts happening, it starts to shift the culture.

And shift the trajectory. Yeah, absolutely. And I don't think you're going to legislate your way out of this problem. And I do think, in terms of cultural shift, and one of the other things I didn't mention that we do in our clinic is group visits. And the nice thing about a group visit is you don't need community health workers. you create a community of patients and patients learn from each other and everyone knows something and everyone contributes to the group.

It's so true.

And so you get that group think, that group knowledge. Very powerful. And then you can have group successes and you build those groups and then they translate to broader changes, broader cultural, community, cultural societal changes.

Families, yeah.

Yeah, so and that's another part of the solution, I think.

Yeah, we do that at Cleveland Clinic and what we're finding is that people who are in the groups have far better outcomes and medical outcomes than the ones doing one-on-one visits with the doctor.

Absolutely. Because there's value in social support. There's value in recognizing you're not the only one. There's value in learning from your peers. There's value in having that support network.

I always say community is the cure and group is the medicine. I did a Ted talk called if we can't cure the patient, can the community? And I believe strongly that that's really where the focus of healthcare has to be. Well, thank you for joining us.

Thanks for having me.

I'm an amazing physician, researcher, thinker in this space, very brave to take on these issues. And if you've enjoyed this conversation, be sure to subscribe to the Doctor's Pharmacy, anywhere you get your podcasts. If you like this show, please leave a review. We'd love to hear from you and we hope to see you next time on the Doctor's Pharmacy.

Thanks a lot.

Hey everybody, I just wanted to remind you all that the information in this episode is not intended to be used as medical advice. Always work with your doctor and if you can, find a functional medicine doctor. My staff, including physicians and nutritionists at the Ultra Wellness Center in Massachusetts, is trained in functional medicine to find the root cause of disease and create health for you every step of the way. For more information about the Ultra Wellness Center, visit www.UltraWellnessCenter.com.