Why Being Sick and Overweight Is Not a Personal Choice

Welcome to the Doctor's Pharmacy.

I'm Dr. Mark Hyman. This is a place for conversations that matter. And I think this conversation today will really matter with Dr. Sonya Angel, who's the Deputy Commissioner of the New York City Health Department in Mental Hygiene and has done extraordinary work in her life. We're going to talk about it all. I'm really thrilled to be here with her. She oversees the Division of Prevention and Primary Care at the New York City Department of Health and Mental Hygiene. She's overseen nutrition and policy initiatives across the government. She's been involved in restricting trans fats in the New York City restaurants, which has then spread across the country. She's led a national initiative around national salt reduction and established food procurement standards for the New York City government agencies, meaning the government buys a lot of food and are they gonna buy junk? Are they gonna buy stuff that promotes health? And they have the ability to do that. She's also helped move forward in changing labeling around sodium in chain restaurants and expanding calorie label regulations. She's a practicing doctor. She's board certified internal medicine. She's on the faculty of Columbia. and she went to UCSF Medical School. I did my residency there as well. She did her residency at Brigham and Women's. She's got a diploma in tropical medicine hygiene from the London School of Hygiene and Tropical Medicine, a master's in public health. You must have been in school for a long time. I spent a fair amount of time in there. She was a senior advisor for the Global Non-Communicable Disease at the CDC and non-communicable disease is basically heart disease, diabetes. I don't think they're non-communicable. I think they're very contagious and driven by the social environments in which we live. She's also Robert Wood Johnson Clinical Scholar and a fellow of the Aspen Institute Health Innovators Program. Quite a resume. And we met at this conference called Food for Thought, which was put on by the British Medical Journal and an insurance company, which was curious on how do we actually deal with this food-related health problem. And it was scientists and food influencers from all around the world. And I was very impressed with your talk. You produced a paper out of that talk, which was the role of government policy in nutrition, barriers and opportunities for healthy eating. And you wrote that with one of my friends and colleagues, Dariush Mozaffarian, who's the dean of the Tuffs School of Public Health and Nutrition and Policy. And in that paper, you really put out some really often controversial and forward thinking and disruptive ideas about how the food system has to get changed and how it affects chronic disease and so much that matters. But before we get into that, I wanna go back to how this all started for you. You started as a Peace Corps volunteer in Nepal and as a community organizer, which are not exactly the pre-med adventures of most doctors. So how did you get into that and what did you do over there and how did that influence your thinking about how to address chronic disease and health disparities, which is now the focus of your work?

Yeah, I think I've always had a focus on thinking about social justice issues and equity and how important that is really as a basic tenet of a society that functions well. And so I was a journalism poli-sci major undergrad. and decided to join the Peace Corps was the right thing to do to really understand what's going on globally. By the time I came back, I realized I didn't really want to write about things selectively anymore. I really wanted to do more about things. Now, I will say that the writing skills become even more important, as you know, to change anything. So it was good that I had that foundation. But ultimately, when I came back, I really started thinking about how can I work within communities in the United States. I became a community organizer and it was actually down on the US-Mexican border where I was, at that time, the North American Free Trade Agreements were being negotiated and we were working to try to really understand what would it mean to have agreements that could lift up communities on both sides of the border. And it was then that I met a physician who was working on the US side who delivered a number of anencephalic Babies, these are babies born without brains that's associated with benzene exposure, also folic acid deficiency. So we have an environmental as well as a nutritional potential influencer. But it was really seeing that physician raise up the needs of the community and have conversations, tough conversations about the environment that made me realize that the physical health of the community is absolutely central to the economic and broader health of the community. And so I decided to become a doctor.

Wow. And it was related to environmental toxins and our food, which are two things that we as doctors don't get taught about at medical school. That's right. That's right.

That's absolutely right. So why I became a doctor out of that, I don't know. It really probably didn't make much sense, but that's where I went. The funny thing is that when I finished my training as a physician, I actually realized that rather than necessarily broadening the impact I could have, I was suddenly just working one-on-one with patients. Now, I find that the most remarkable honor. I love being a physician. I love working with individual patients and really understanding what's going on with them and helping them find solutions. And providing treatment when it makes a lot of sense, whether it's medication or recommendations on how they can change their lives. But what I also realized is that the thing that was causing most of the illness that I was seeing in my clinic was not just about an individual making a choice that may not have been a good choice for their health. It was actually where they were living and what was around them that was pushing them into having choices that weren't healthy for them, which is very different. So if you really want to improve the health of that individual, you need to change the environment of the community that they're in, which is why I then went into public health and have married the two since that time.

It's so true. I mean, you know, Paul Farmer talks about this idea of structural violence. You know, what are the social, economic, and political conditions that drive disease and you see people at the end of the spectrum of disease, the question is what caused it? And it's not necessarily their own personal choices, it's really the environment in which they're the context in which they live and grow up and the food around them and all the social economic pressures, the health disparities, those are the real things and we don't really address those. And as an afterthought, we may go, oh, maybe you should see the social worker. Right? But we don't, it's not a, it's not real medicine. But we were saying the real medicine is not actually in the clinic, the.

Real medicine is in the community. That's right, that's right. I mean, there's no question that we can save a lot of medicine or lives with the times of treatments that we have, but it's really oftentimes a little bit too late. And if we had worked more upstream, they never would have gotten to that point where we needed to treat them with medications.

So you're almost like a doctor of the community, right?

Yeah, I guess so.

In fact, you are.

I guess it's mixed together as a deputy commissioner.

I'm a doctor in your community. That's your job. To understand and think about how to change the health of the population. Right. Which is often divorced from clinical medicine and we were chatting a little before about how there's this weird dichotomy between the ideas of public health, which is education and vaccines and all the important things we need to do and actually treating disease. But there's actually an intersection where we can treat disease by treating the community and dealing with the public health issues, which is our food environment, our social environments, the access issues, Right.

And in some ways, it's kind of a relief in the sense that there are structural issues that are causing this. That means that you can shift those structures and improve the health of millions of people. The challenge is that shifting those structures can be quite difficult. And I think that's where the art of policy and government comes into place and where it becomes so important for communities to be a part of those conversations and a part of helping us define the solutions.

Yeah, I mean, with trans fats, you know, there was an unintended consequence of inventing Crisco 100 and plus years ago, which seemed like a good idea and turned out to be deadly and really didn't have a shift in policy until pretty recently, just in the last few years, it's become labeled a non-safe substance to eat or non-grass substance by the FDA. Even before that happened, you were part of the initiative in New York that said no more trans fats in the deep fryers. Then the question is, that moves that, but what do they put in instead? So there's all these intended and unintended consequences of what we do. It's tricky.

It's tricky, and you need to be very thoughtful about not only the interventions that you make, but also the evaluations that you do to understand where things are going afterwards to make sure you might need to course correct in some situations, or perhaps what you're doing really isn't resulting in the expectation that you had.

Yeah, and you were saying before that chronic disease seems like a difficult problem that it's chronic, it's not something that's urgent to deal with. But in fact, it really is. And it turns out that we talk about the opioid epidemic, there's 70,000 people that die every year, which is horrific and we have to do something about it. But there's almost 10 times that, almost 700,000 people die every year from diet-related lifestyle diseases like diabetes, heart disease, cancer, dementia, and other things that are related to what we're eating. So your focus has really been on food. How did you connect so strongly to nutrition and food as the solution here? Because most doctors really don't pay much attention to what people are eating other than eat well and exercise more, which doesn't really work.

Yeah, but I think to your point, if you start with what's killing people and what's really making them sick is chronic diseases, right? So they heart disease and stroke and cancer are the leading causes of death in the United States. They're the leading causes of premature death also. So premature death, death before 65, premature deaths. we often think of with respect to chronic disease as being preventable. Because most people who are dying from heart disease or from cancer before 65, it's because they've had certain influences on their lifestyle. And ultimately, if those things would have been changed, they would not have got the disease. For example, we know that alcohol, smoking, poor diet, physical inactivity, all of those things are risk factors for heart disease and stroke. and all of those things can be changed. Now the question is how do you change them? Right, right.

Exactly. So the things you just mentioned, food, exercise, smoking, inactivity, they all seem like personal choices. And in fact, that's how we approach them for the most part through public health. It's what most of our policies are driven towards. It's what the food industry certainly says about how we get healthy is just eat less and exercise more. It's all about calories in, calories out. energy balance. But as part of this paper that you wrote for this Food for Thought conference, you outlined a very different model. And there's a beautiful graphic and we'll try to share it, which shows the individual as this tiny small bit of the bigger picture, which includes the social cultural aspects, it includes the community environment, it includes agricultural policies in the food marketplace, government policies and global trends and trade agreements, things that we don't think of as affecting the individual. How does a global trade agreement affect the individual? You mentioned NAFTA. Well, NAFTA was a good idea in many ways, but it led to the opening of the market of Mexico to American fast food and soda, and that led to this massive increase in obesity and diabetes, where one in 10 children in Mexico have type 2 diabetes, which is the same as adults have in this country. So, there are all these issues that happen that are far beyond the individual. And I love really how you came to that. How did you begin to sort of map that out? Because it's a very different picture than is being promoted through most other government policies and agencies and even public health organizations.

Yeah, I think when you start to look at the epidemiology, specifically where the disease is, at higher levels, you really start to realize quite easily, just from observation, that it's being driven by what's around the individual and not necessarily the individual. So for example, in New York City, Brownsville in Brooklyn has a much higher rate of premature death than Tribeca, one of our wealthiest neighborhoods in the city. And if you go from one neighborhood to the next neighborhood, you'll see that those neighborhoods look very different. And when we talk about healthy choices, I always say you can't make healthy choices if you don't have healthy choices.

Yes.

And if you go to one of those neighborhoods where the diseases are much higher and you look around some of the neighborhoods and what's for sale, what's being marketed, you can see that it can be quite different, very different. You can try to buy, you know, fresh fruits and vegetables, they're simply not available in some areas of our city.

Or if they are, they're pretty gross looking and wilted.

Yeah, they might not be fresh or they're potatoes and yucca and things that we don't necessarily have as sort of primary vegetables that we would recommend in a well-balanced diet. Right. So it's pretty easy to see that where the disease is higher is also where the neighborhoods have less resources. Not only with respect to food, we have higher rates of crime. When you have higher rates of crime, it's much more difficult to walk in the streets, to use the parks, kids are kept indoors. All of that, it snowballs. And in the end, you can see very much that this is about the structure. So the question is, how did that happen. And we in the United States have a long history of racism, of discrimination, of limitations, of opportunities and access. In New York City, when we have a place-based issue, we often have a race-based issue because we have one of the most segregated cities in the country. So you'll also note that these also tend to be neighborhoods of color, and these are populations that historically have been discriminated against and haven't had the same opportunities. and that is- It's like the third.

World in Bronx and Brooklyn, right?

Well, it certainly carries over into what the communities have and the options that they have. And so that's when you can really start to see manifest this diagram that we have that it isn't really just an individual in a neighborhood, it's an individual in a neighborhood that has a history and has very different resources than in other places.

And we would often approach these problems by just having better education, telling people to eat more fruits and vegetables and exercise more, but that doesn't really work, does it?

Right, well so you can infuse individuals with all the assets possible. You can educate them, you can give them money, you can provide them with extra time to cook, all of those things. But again, if they walk outside and those foods aren't available, it doesn't matter if you have money. It doesn't matter if you know what you should be eating. These things that you can't separate one from the other. So the environment absolutely influences individuals' ability to exercise all of those assets that we want people to have. Now that doesn't mean we still shouldn't educate. We need to do that, right? We need to provide people with information about what's in their foods. Food labels are incredibly important, for example. But all of that is irrelevant if it's not available to the person to be able to use those in a positive way in their life.

And not many people realize the degree of health disparities in this country. I mean, it's really like two countries. It's a developing country and a developed country. And you've got African Americans having far greater rates of diabetes, heart disease, early death, cancers, You've got same thing in the Hispanic population. I mean, and it's not surprising because the environments that they live in are heavily targeted by processed food, fast food outlets, and even advertising and marketing, which is pretty striking. I mean, the average African-American kid drinks twice as much soda as the white kid does because they're heavily targeted and it's directed at them. You know, we were talking about how in Mexico they're saying that their Coca-Cola is their traditional indigenous food. It's not really.

Yeah, no, it's remarkable how a lot of things that have been in our community for a long time, we start to assume it's because there's some sort of cultural tendency towards that, when in fact some of it may be imposed from the outside for all of the reasons that we've just been discussing.

Yeah, I mean, in this article, I just want to read a little bit about what you wrote about, because the complexity of how our environment affects our health. I don't think it's appreciated by most people. It's really focused on personal responsibility and individual choice. And that's convenient for the food industry because then they're off the hook, right? So I'm just creating these products. People are eating them. I'm just giving people what they want. I've talked to top executives at Pepsi and they were just giving the consumers what they want. I'm like, well, if you gave them $2 bags of cocaine, they'd probably want that too. But it's not necessarily the right solution. So you wrote that growing evidence makes clear that multiple complex factors beyond personal decisions strongly influence dietary choices and patterns. Even at the individual level, dietary habits are determined by personal preference, age, gender, culture, education, income, health status, cooking skills, nutritional knowledge, and psychological influences about food and health incentives, motivations, values. Food preferences may be influenced by early life exposures and mother's diet, infant feeding practices. We know, for example, the mother eats a lot of sugar, the baby's gonna like sugar more, right? We know this is sort of these epigenetic effects. And you talk about these broader social cultural determinants of personal choices that are how much television you watch, how much sleep you get, what the family and community norms are, what the social pressures are, what your social classes, your social networks, your race, ethnicity, all these play a role in the local environment, how these commercial pressures also affect choice, right? Like you said, where we can access, but it's food marketing, it's food packaging, it's advertising, the social determinants that are really driving what we actually eat. And each of these is shaped by broader drivers of food choice, like food industry formulations, what they make, the globalization of food systems, farming policies, production practices, trade agreements like we talked about with NAFTA and other ecosystem influences. This is a very different view of why we're all fat and sick in this country. It's not just about what Joe or Sally choose to eat that affects their health. It's like I said, influenced by everything from trade agreements to advertising and marketing.

That's right. That's right. And that's where I think government plays a very important role. It's sort of really understanding being able to describe that, collecting the data as we do to really understand where the challenges are, talking to communities to help them become part of the solution and help us understand how we can best serve the neighborhoods. Yeah.

One of the things you talk about in this article as well and you advocate for is a coherent government set of policies that are thoughtful, evidence-based, integrated, and not at odds with each other.

Right.

Right. Which is often what we have because things that pop up in these sort of discrete ways and we apply this policy or that policy and we don't necessarily do a 360 on the effects of it. aren't able to see the unintended consequences. We're not coordinating between agencies. There's, I think, eight agencies influence different aspects of food policy, everything from the FTC for marketing to the FDA for labeling to the USDA for dietary guidelines and on and on and on. And they're not talking to each other and they often have contradictory policies. That's right. And in fact, I don't know if you know this, but Dari and I met with Tim Ryan, who's a congressman from Ohio, and we asked him if he would help the government accountability office to review our government policies around food from all these disparate agencies and their effect on health and the economy and other things. So that has never been done before. You know, it's like you think about it, it's kind of crazy, but you're advocating for this new way of actually approaching this. Can you talk more about how that could happen and what you think that being in government for so long, how do you fix those big problems where nobody's talking to each other and they're all working in different ways?

Yeah, well I think, you know, nutrition and health isn't the only sort of victim of siloaded government. That's in general a challenge that we have at the local, state, and national level. But we're in a unique position at the local level because we're smaller, we can be more nimble, that we can really coordinate across our different agencies to come up with solutions that are more coherent and that really reflect a common vision. So Mayor de Blasio example has for New York City, one NYC, as the sort of plan and direction for the city to become a fair and just place for all New Yorkers to live. And sustainability is an important piece of that. I would, I would, I bring that up because sustainability is a hot issue right now. It should have been and has been incredibly important for a long time, but I feel like right now It's where both the conversation around nutrition and the environment and the climate is coming together in a way that has never, in my mind, been as obvious in drawing the dots and connecting the dots.

Can you explain what those connections are?

Yeah, well, so look, if you're going to, you know, food is big business. It's a very important part of our economy. That's right. That's right.

It's the biggest industry, I think. I guess, globally, because everybody eats three times a day.

Yeah. And so when we look locally at the city level, for city government, we spend about $300 million on food every year. We serve 240 meals and snacks through city agencies to New Yorkers. That's a lot of food. That's also a lot of purchasing power. And so about seven or eight years ago, New York City came together and thought across all of our agencies, What are we buying and how does nutrition fit into that decision making? And we created the first nutrition criteria for procurement for a large city for all government dollars. Now these are- maybe we shouldn't be.

Buying tater tots, right?

But I think this is the point, is that you might have in one environment a need to buy a lot of food to fill somebody's stomach because you're trying to deal with food insecurity. but at the same time, you need to providing the healthiest food that you can for the people who are at the greatest levels of vulnerability, right? That would be the nutrition side of it. And coming together and having those conversations about what are we serving in daycare centers? What are the requirements there? What are we serving in senior centers? Is this the best way we could be using our money, not only to provide good food, but nutritious food at the same time. And so we created these food procurement standards and it brought together all of our agency, 12 different agencies, with over 3,000 feeding programs. We had to look at a way to create criteria that would be feasible, right? Because we all want everybody to have the most nutritious food possible, but if those products aren't available, it doesn't make any difference if you put them into a standard if people can't purchase them, right? If they're not available through a contract. Or if people, right? It's this sort of give and take along the way. You know where you're going, you know as the city where we're going and how we want to reinvest our dollars. And really it's investing in the way that models what is not only good for the city economically, but also good for the city from a nutrition standpoint. And in fact, they're the same thing in the end, right? A healthy population is the population that can be more successful, more productive, live longer and happier lives. And that really is the essence of.

What government's supposed to do. Yeah, so that's an interesting thing. So the government should be the food, I mean, think about the amount of food that federal government buys, the military, with school lunch programs, with just their employees, the amount of money that's spent and the ability to drive decisions through the food service programs are huge, right?

Right, and so when we create these requirements and contracts then are being made by bidders to New York City contracts, they're reformulating their foods to be able to meet those contract needs. those same producers are producing across the country and other places. So there could be a downstream effect also for other cities and states that are buying from these same producers.

So you also worked at the federal level in the CDC in chronic disease. How did you sort of tackle these big issues around food there? Because the federal level is a whole different animal, right?

Yeah. My work at the Centers for Disease Control, which is the federal agency, was working in global non-communicable disease. so in 2011, the UN had its first assembly that focused on non-communicable diseases. It's interesting, right? 2011 and chronic diseases are the leading cause of death globally, not just in the United States. And yet countries around the world, particularly low and middle income countries, were really not in a place to be prepared for the sort of new, this new epidemic of disease. So particularly low and middle income countries that are dealing with infectious diseases suddenly are now dealing with chronic diseases at the same time. They're dealing with malnutrition and undernutrition and overnutrition at the same time. And how to reconcile all of that can be incredibly difficult for countries with very low budgets. It's incredibly difficult for us. We're not winning this. And so I think one of the other opportunities in working in the global community is to look for lessons to find other places where they're being successful and see how some of those same approaches might be valuable and useful in the United States. yeah.

So what, what, what can we learn and what, what's worked and what are the things where you see the most leverage? Because it's, you know, may not be having commercials like Yul Brenner was saying cigarettes are bad for me. People saying soda is bad for me. Maybe it's things which make things automatic. How do you make the right choice, the easy choice? Right. Talk a lot about that. Yeah, it's default.

So if there's no trans fats in your french fries, well, you're not eating trans fats. And nobody made that decision. It was made for you. Right. Right. And I think, you know, because nobody goes into a fast food restaurant and says, I want my french fries with trans fats in them. That's a false choice. We didn't ever have that choice. It was put in there and we just received it that way. And I think that's the way we really need to work with the food industry, is to really understand what is it that we are losing in terms of choice because of the way things are being produced and can we produce it so we create more choice for individuals? Specifically, for example, when we talk about added sugar, or sodium, right? The vast majority of sodium in our diet is already in the food when you purchase it. It's coming from processed and packaged foods. It's not what you're putting on at the table. It's not the salt that you're putting on your food when you're cooking. Because of that, because it's already in the food when you purchase it, you don't have the choice of having a lower sodium diet because the vast majority of foods already has it in there. If industry, however, lowers the amount of sodium in processed and packaged foods, then you do have the choice. The choice is back in the hands of the consumer. Now they can add it at the table they want, they can add it to taste, or they can choose not to add it at all. But at least it's a choice that the consumer has. So when we start thinking about how to change the environment at large, you just want to think about what's out there in the foods already and how can we change those. So what people grab for is going to be a healthier choice to begin with.

And one of the things that we don't have control over is the way we're inundated with marketing. you know, I think there, there were a report came out from the Rudd Center a few weeks ago showing that the food industry targets poor minorities with advertising, television advertising specifically. And there was, I think, like 11 billion dollars spent. And the average kid sees 10 or more ads a day. That, and that doesn't count all the stealth marketing, social media, you know, American Idol, where everybody's drinking Coca-Cola on stage and all Right. All the celebrities, all the invisible marketing. That is a lot of effort to sort of shift behavior when you're getting inundated with that much marketing. And there are countries like Chile that literally have killed Tony the Tiger. There's no more cartoon characters on kids' cereals. There's warning labels on the front of packages. And I know you've sort of looked into this whole strategy. I think I was shocked when I talked to Barry Popkin who was involved in this Chile effort to change the policies around nutrition. He said the biggest effect on reducing consumption wasn't the soda tax, it was the food marketing changes. So what can you tell us about how we need to think about that and what the obstacles are because it seems so self-evident. I mean, we're one of the few countries in the world that allows unregulated food marketing to kids, right?

Yeah, marketing's tough. I mean, just gonna absolutely acknowledge what you're saying. Marketing is done because it does change the way people purchase products. That's what they understand to be. And in public health, we're at a distinct disadvantage because our budgets are nothing like the- and- you- don't have $11 billion to spend on- well, not in my back pocket, no. Unfortunately. In the public. Unfortunately. No. But what we can do is work with communities to really help them understand what the best choices can be, what the best opportunities are, and then to create incentives and opportunities for them to be able to exercise those choices. choices, which is something that we do throughout the city overall, but in particular in some of those communities where they have the greatest challenges with us.

Well, that's a beautiful thing you could share with us because you're working in Harlem in terms of advocacy program around diabetes and other things. You're on the ground, you've got your fingers dirty, there's dirt under your fingernails, and you see what's happening. What are the challenges in those communities? Do these communities want to solve this problem? Do they understand that they're the victims of this food injustice, which seems like invisible, sort of like, you know, fish swimming around in polluted water. They don't necessarily know they're swimming in polluted water until they get sick and die. How do you address that with them?

Yeah, so, you know, I always, I strongly believe that the communities that are affected know what the solutions are and they also know what the problems are and they can describe them well. We can come to them and provide the data to help sort of put the architecture around the narrative and the discussion But really, people know what the challenges are. The reality is that there are victims. There isn't awareness that they're victims. Well, you know, I don't want to put words in a community's mouth about being victims or not victims, but I think that communities know the challenges that are making them unhealthy. And I also want to acknowledge that it's not just food, right? Food is a very important part of staying alive. You've got to eat. But also when you don't have a roof over your head, when you don't have a job, you know, when you're trying to support your child and you're working two jobs a day, you're spending less time trying to think about what exactly you're taking home to feed your child. And so the conversations in communities, when you ask them what their priorities are, health issues do come up. But so do things like pollution and noise and violence and all of these other areas that create what is wellness. And wellness is much more than absence of health. Wellness is all that's around us.

The absence of disease.

Or absence of disease, thank you. It's much more than the absence of disease, right? And it's much more than what we define as health. Wellness is that whole sort of external sense of of safety, of happiness, of fulfillment. And you know when that's missing in your life. And the flip side of that is that these communities often have built up remarkable resilience and have assets. So part of getting to the point of finding solutions is working with communities to recognize what the assets are that are already there to build from. and then using that as a springboard to build further solutions and really to advocate and give people the opportunity to be leaders in their own right.

So how do you be a community organizer, put that hat on, and activate those communities to take the empowerment that they actually do have to start to make those changes?

That's right. Well, so we do that through, for example, we have our neighborhood health action centers. We have, in Harlem you mentioned, And we have a program there where we have community health workers that are going into five of our public housing units, NYCHA housing, of their buildings. And they work with members in the community one-on-one to help address their health needs, talk with them about where they think the solutions might be, help those individuals get access to the resources they need to start to create the change around them. So it's a slow process. Change can be slow, but when it's directed by the people that are affected by it, it is really meaningful and the solutions are very relevant.

And that sounds, you know, like what we have to do. I think I said to the chief financial officer of Cleveland Clinic, we need to hire 10,000 community health workers to solve our problem because we're seeing this influx of chronic disease. We're going to be shifting to a payment system that's going to create payments for getting better outcomes at lower costs, not just running people through the mill. And you're going to need that community-based solution, otherwise you're going to lose money. In fact, that's exactly what happened at Cleveland Clinic. We initially were able to improve some efficiencies around diabetes care. We were giving value-based payments. We actually made money the first year, and now we've lost money because we're not really dealing with the social drivers. We're not dealing with the food issues, and we're trying to build a program around food pharmacy, which is where we provide free food and California you mentioned is doing this as well, to food insecure diabetics along with coaching support, education, cooking classes, shopping classes to actually change the social environment as well as the food environment and save huge amounts of money.

Right.

And you mentioned a great program that's happening in New York called Pharma-- Farm to Farm, which is P-H-A-R-M to F-A-R-M. Tell us about that.

Yeah, so it's a neat program. We've got it right now operating in six pharmacies, which are chosen because they are near year-round farmers markets. And the idea is that we realize that people with chronic diseases, the etiology is often either influenced by, created by, or can be improved by improved nutrition. So how do we identify people who need improved nutrition with chronic diseases. So we're working with pharmacies, patients in those pharmacies who are on SNAP, which is our food stamps program, with hypertension. We're modeling it with hypertension as a disease. When they come in to pick up their medications, they get $30 worth of health bucks, and health bucks can be redeemed at our farmers markets. So this creates an incentive for people to come in and pick up their medication every month, so that increases the likelihood of adherence and control, but also it creates the opportunity for them to have healthier foods and to take those foods home to their family members.

So it's like Monopoly money just for farmers market, basically.

That's right. That's right.

Yeah, you know, there is a flaw with that. Okay, what is it? The flaw is if people do that, they're gonna eat the good food, they're not gonna need their medications, they won't.

Need to go to the pharmacy. Well, we can figure out how to fix that.

That's a problem I would be happy to find a solution for. yeah, I had a diabetic the other day. He was in my office and, you know, I changed his diet, got him healthy. He said, you know, he normalized his blood sugar, got off his medications in three months, lost 30 pounds. And he said, I've saved now ten thousand dollars a year in co-pays for my medication. I don't need to get them anymore.

There you go.

That's a good problem to have. That's a great problem to have.

Yeah.

So in terms of the the policies that are going to make the most difference. You talked about some of the issues around the food industry and product formulation. That seems to be the most difficult thing for me to tackle with because how do we start to push the food industry to do the right thing? Part of what they've done that created this epidemic was actually in response to a government set of guidelines, which was to cut the fat and exonerate sugar. And that happened in the 80s and product reformulation happened and you got Snackwell cookies and low-fat this and low-fat that and your low-fat morning yogurt with fruit sweetened yogurt has more sugar per ounce than a can of soda, right? So that was an unintended consequence. Nobody said, oh, we're gonna do this and make people fat. But if you look at the spike in obesity and diabetes, 1980 was the hockey stick and that's when we started making these recommendations. How do we push the industry to do the right thing and reformulate and work together? Because they're also resisting the change. They don't want soda taxes. They don't want changes that are going to limit what they can do because it's going to affect their business, right? How do you navigate that as a government official, someone who's trying to change the public health, who understands these dynamics?

Yeah, I mean, the first thing that we need to acknowledge is that the healthiest diet is is one that's based on whole foods, not a processed food diet and not an ultra processed food diet. So while we can work with industry around packaged foods and beverages, and we have to because we rely heavily on them, we don't want to lose sight of the fact that the best foods that we really should have as a central part of our diet are not in that realm, right? These are the fruits and vegetables. They're not ultra processed. They're going to be the fruits and vegetables.

Packaged fruit and I have packaged nuts.

And I, there's things I can get that are real food. So let's sort of shift. Okay, after acknowledging that, and those are foods that are unlabeled, so we don't have to worry about labels for them, right?

We don't, no banana has trans fat.

In it, for example, right? Those are all, There's no nutrition facts label on a banana. Right, right, right. So all good there. We do need to create incentives for people to eat more of those foods, right? And that's what the Health Bucks program, for example, that I told you about. creating a means for the fruits and vegetables to be less expensive in farmers markets for people in particular who have limited resources. So let's now look at the processed and manufactured foods.

So there are some-- Before you get into it, I just want to share that there was an article that came out in the Journal of the American Medical Association recently that found that for every 10% of your diet that was ultra-processed food, there was a 14% increased risk of death. Now our diet is 60% ultra processed food on average, which can give you an idea. I don't know if the math works out, but that's like 140% increase of dying if you eat that food.

Yeah, so we need to pay attention to this. So this is where we need to really think, and I think this is where government has a really important role as well, because there are some foods that have no nutritional benefit. And I would put sugar-sweetened beverages into those. And I think that it's important that we have conversations about them, but let's remember that the food industry is quite diverse. And outside of sugar-sweetened beverages, with the exception of a few other products certainly, the vast majority, some of them are good for us, some of them are better for us, some of them are great, and some of them are not good. But there's no easy way to bucket all of them. What we can do though... Cigarettes are bad, Cigarettes are just bad, bad. Food is more complex. But they're not food. I mean, I haven't seen people eating cigarettes. It's more complex. It's more complex. Right. So I'll give you an example of what we did here in New York City working with over 100 other organizations across the United States. So in 2008, we were looking at the problem of excess sodium in the diet, recognizing, as I mentioned earlier, that the majority of sodium in our diet is not from what people are adding at the table. already in the foods. So we started to have some conversations with the food industry and we asked them if they would please reduce the amount of sodium in foods that they were selling in New York City. They told us, no, we don't produce foods for New York City, we produce foods for the nation, or variably different regions. But to create a whole different formulation for New York City doesn't make sense, and they were correct. So the most important thing to start with when you're a local government is to recognize you really need to understand to the industry at large and respond in a way that makes sense to them.

Because, you know, like for example, in Europe, they don't, they have this reach legislation, they have other legislation about food. They don't allow most GMOs. They don't actually add certain food additives. So Kraft macaroni and cheese in England doesn't have the dyes and colors and chemicals that we do in this country. It's the same brand, same company, same product.

And there have been people pushing back on that. That's true. So, but different country. But like London itself, it would be very hard for the food industry to make a special product just for London. It can happen and there are certain, there are other examples of it. Let me say that, you know, we have, local government has a lot of authority in different ways. But in our effort to really think more broadly about the food supply and sodium, what we realized is that at this time the federal government was going to act is that what we needed was a national initiative. So we started reaching out to cities and states across the country and this was a model based on what was going on in the UK that had demonstrated that they could reduce sodium in foods by setting targets and having industry make commitments to those targets. So we created the National Salt Reduction Initiative and we set targets for sodium reduction. And when we measured, because we created a huge database that had all of the information about 80% of the packaged foods that were being sold in specific categories, we had information on the amount of sodium in them and we linked that with sales information. We found at the end of the initiative that sodium was reduced by about 7% sales-weighted volume. So it made a difference to work with industry to set targets for reduction by category and to measure and hold industry accountable to meeting those targets. So the federal government now has adopted very much the same policy. and is moving forward with that. We are now redoing our work, focusing on sugar and added sugar.

How's that going?

So we're early in the process. So we've set our targets. We are in an iterative process right now with industry where they've responded to it, we're reviewing their comments, and we'll have the final targets out in this next year. But I guess the key point here is that these things can be done. They can be done in a very thoughtful way, but one of the key elements is that you do it in a way that's measurable, specific, that's gradual, and that does recognize that it's not just about government saying, do this at this level. It's a conversation that needs to happen between industry and government to understand what's feasible too. That doesn't mean that you just let anybody off the hook, but it does mean that you really need to understand where the, where they are.

I mean, there are voluntary recommendations that happen in the street, but they often don't follow them.

Well, you know, so then the next opportunity is, and this is a federal government conversation at this time around sodium, would be to understand what they do if industry doesn't meet those targets.

And we, you know, we have a lot of conversations, particularly in this article in other places, of incentives to do the right thing and disincentives to do the wrong thing, both on the consumer level and also on the business level.

Yeah.

I mean, one of the things that seems like an obvious thing is we're subsidizing all this marketing to kids why not remove the tax subsidy for the marketing as a tax deduction, which is billions of dollars a year in revenue, right?

Right. I mean, there's all kinds of ways in which government can think about where its levers are at different levels. And I think part of the opportunity here is to be creative and to really understand where the incentives are, as you're saying, and what you can do.

What do you see in your career in government as having made the most difference and that you feel most proud of and that actually is a model for what we can continue to think about and do.

Yeah, I think what I'm most proud of is having been a part of a pretty remarkable team of creative, thoughtful, smart, and really committed people at the Health Department who were willing to say, let's take a step back and look at this problem from a different angle. And I'll tell you, you know, when I first started at the Health Department, When we think about, for example, approaches that were being used for infectious disease in the food environment in restaurants, right? So restaurant inspectors go into restaurants every single day and you think of restaurant inspectors as being those people who make sure your food doesn't have any bacteria in it or anything. No bacteria, right? No contaminants in it. Well, we started looking at this now from a chronic disease angle saying this has worked. This has worked very well for and infectious diseases, how can we use that same model for chronic diseases? And from that was our work around trans fat. Because in order to understand trans fat use in restaurants, we actually trained inspectors to read labels, go into restaurants, and to understand how much trans fat was being used in restaurants. That then became our understanding of how to react and respond and develop a policy that ultimately resulted in restricting trans fat in restaurants. So now inspectors go into restaurants and they also look to see whether or not trans fat is being used in our foods. So that causes disease too. We used a model that historically had been used for infectious disease to say, this is what's killing us now, chronic diseases. Let's not back off from infectious diseases and contaminants, but let's add on to that other very relevant policies that now will keep New York City residents healthier. And that has proven out.

It's fascinating. It's hard to control that because you don't know what the sources of the products are using, you know the quality of them. I went to a very well-known, pretty expensive restaurant a few days ago and I asked about the, it was sort of a high-end Asian place and I went to this, had this duck and they had hoisin sauce, which is kind of a sauce that they use in Chinese food and I asked them, did you guys make that from scratch or did you get it? He says, no, we get it from these big containers. And afterwards, I knew I got a headache because it had MSG in it. I'm sure it had MSG in it. And I was like, wow, you know, even at the best places where you think you're getting the cleanest food, you may not be, right?

Well, I mean, I think in general, it's a very complex system at large. That's definitely true.

So do you see the food industry being a willing partner or are they resisting? Or is it different across different companies.

Yeah, I think again the food industry is not just one monolith, it's a group of very different actors and players and some of them are very interested to collaborate, talk, try to figure out what the best thing, you know, within any company there are great people that are willing to work with you, there are some companies that can be a little more difficult to work with certainly. Again, this is where it becomes so important that government steps in to help level the playing field because you don't want any company to be at at a disadvantage just because they're willing to do the right thing.

So there's regulation, there's legislation. What about litigation? Is this something we did with tobacco? Is this something that should happen in the food industry?

I mean, the options are there. I think we, for example, in restaurants, warning labels, I mean, that's something that we ended up in quarter rounds. So warning labels on products that contain very high levels of sodium. New York City was the first and I think Philadelphia recently also has introduced on any products that have greater than 2300 milligrams of sodium, a warning label that's required to go on there. And we ended up in court for some time on that.

Did you win or lose?

We did. And they're up in the city.

Well, in California, they had those big billboards with soda saying, warning, this is bad for your health. And the food industry, soda industry, came out and sued them in court. initially they won, they came back and appealed and they ended up losing. So now they don't have those labels on the front of the billboards which say this is not good for you, right?

Yeah, well, so I'm not a lawyer and I won't be able to go into the details of that, right? Sometimes you win and sometimes you lose. But the intent of these policies really is to give consumers more information about how to make the best choices when they're going into restaurants, which as you know often doesn't have food label information available. at the moment when you need it, until more recently with calorie labeling in chain restaurants. Yeah.

And you think that's a good idea because if people focus on calories, not quality, is that a good distinction for people to make?

Well, so you know, the menu boards are pretty busy already. So there's a limited amount of information that you can put on there in a way that can be absorbed very quickly when you go in to make a decision. But know that with the chain restaurant regulations Restaurants are also responsible to give you information that provides broader nutrition information on the products that they sell. You just can't put it all on the menu board.

Right. Yeah, that's good.

So.

You'Ve been around for a while. If you were in charge, you were queen and you had an autocratic power to change everything in terms of food, food policy, what are the biggest things you would focus on? You know, I was recently in Abu Dhabi and I met with the head of the Sovereign Wealth Fund there who shared with me an interesting story. They put 100% tax on energy drinks and a 50% tax on soda. Now, they don't have any taxation in that country, so they get no tax revenue from any industry. They're an autocracy, so they don't need funding for elections, so there's no lobbying. And they have a very obese population and they wanted to do something about it. They were called by the, I think, head of Red Bull and said, what are you doing? Our sales are down 70%. 20% and we're gonna have to fire 800 people and Abu Dhabi says, okay. They're impervious to that kind of influence. So if you had that level of autonomy and you could actually look at the landscape of chronic disease and food and you've done so much work on this, thought so much about, what would be the levers that you would pull that make the biggest impact?

Yeah, I mean- what are the laws or regulations or- Right, no, I mean- Decreases. No, I think our conversation has really illustrated how complicated this is.

Yes, very complicated.

This conversation is around food. And the food that we eat today is not just a product of decisions being made around production and around consumption. They are the product of a history of experiences that we have as populations, as communities, and as individuals. So I don't think there's a quick fix. I don't have one policy that I'm going to tell you. But I do really, I really think one of the most vital things that could happen at this moment, at this this time is for us to break down these silos around decision making related to things that influence food, our environment, and our economy, and have really difficult conversations, but meaningful conversations in a way that helps us really get aligned so that our policies do help lift us up in all of those different areas, and that we're not sort of undermining one side for the other side ultimately. And that really needs to happen at local, state, and national level as well.

So bringing together all the stakeholders together to make coordinated decisions that are in the best interest of all of us.

That's right. That's right.

Yeah, I mean, and you talk about that on that paper, which is, you know, creating a cabinet level or minister level position to coordinate all the interagency national, local, state level decisions that have to get made to create a better food system. And it's really across the spectrum from how we grow food, how we process it, how we distribute it, how we consume it. I mean, all those, how we market it.

That's right.

All those issues.

That's right.

And the beautiful thing is there are a lot of people thinking about this now, and when it wasn't really an issue. And there are so many solutions that are available, everything from the Farm to Farm to the Harvard Health Advocacy Program to food pharmacies. There's innovations popping up everywhere. And I think they're at the margins, but they're going to come to the center. And I think people in governments are going to have to deal with this because the burden of this, both economically, the loss of human capital, the loss of natural capital in terms of climate change, the loss of economic capital, I mean, I don't know if it's true, but I heard that I think over the next 20 years, there's going to be $37 trillion spent by Medicare just on chronic disease.

We can't afford not to react, right? We can't afford because the burden of disease is too too great. We can't afford not to act because the burden on our environment and our climate is too great. And we can't afford to act because our economy needs it. Our economy needs all of this to be in line because an economy that's killing people is not economy that's viable.

So Dr. Andrew, are you a unicorn? Are you a unicorn in the sense that you're kind of one of a kind in the government thinking about these things, advocating for this, seeing the connections and the patterns? or do you find colleagues who are of similar mind? Because I haven't met too many.

I think there's a lot of unicorns out there. We might be hiding a little bit. But I really do think that there's an increasing appreciation and an increasing sense of the need to really, really break out from where we are and connect a little better. So hopefully you'll see a few more of these unicorns.

Good, well, you know, we're at that pain point where it's gotten too costly and there's too much human suffering to ignore this problem anymore. And the central role of food in it, the central role of the social determinants are becoming much more evident. And whether it's in health care, whether it's in, you know, local government policies, it's really time. It's time for a food fix.

And, you know, we haven't talked about health care that much over this point, but I really think also that's where a lot of right now, some of the most interesting innovation of really connecting what's happening in the community with what's happening in the clinics is happening in a way that's also aligning the way that we're reimbursing. And when you have your financial incentives recognizing the need for our clinical interventions to connect with community, that's when actually it happens more effectively.

Right, I mean right now the way the incentives are is that you get paid for doing an amputation, a diabetic, $10,000, but you won't get reimbursed for seeing nutritionist, even though that may, or a health coach or community health worker, which is actually what maybe needs to happen.

And all of that's changing very quickly.

That's right. Where do you see those changes? Where's the intersection between public health and clinical medicine?

How are those barriers breaking down? What does the future look like? Yeah, so what's happening right now, I think at a really remarkable speed, is this acknowledgement that what we're doing in the clinic needs to be connected to the community, but the way that it's being most commonly connected is through referrals. So we'll say we acknowledge, so we being, say, the medical community is saying we acknowledge that the social determinants of health are incredibly important. Social determinants of health are things like housing, food, employment. And so we say, well, look, our patients in order to be healthy need to have jobs, they need to have a place to sleep, and they need to have food. And so we refer them effectively actively oftentimes into the community for them to get those resources. That's happening even more so. And some of the things you're talking about, coaching in the community, the National Diabetes Prevention Program, all of these things we're starting to do more effectively in the community. What's not happening though is a true integration of systems. So I think the magic will happen when the clinical care delivery system truly merges with the public health system, not just referring them into different services, but really appreciating how these two very powerful entities together can really mixed to make better health for all of our populations and communities. Now that's critical because most of the money, as you know, is in the care delivery system. It's not in public health. And yet prevention happens in the community where public health is. So to get that prevention, to get the benefit of of decreased number of six people and an increased number of people that are healing with conditions, you need to invest in public health. And I think that's what's really next when that dollars and that connection really starts to happen.

I think you're exactly right. And I think the obstacle to it has been the idea that public health is about prevention. So it's a long game.

Yeah.

It's hard to measure the payoff, the economic value, the outcomes.

Right.

What you're talking about is public health as an intervention for treating disease. not just as a preventive strategy. And that is a big paradigm shift.

It's a huge paradigm shift. But it's the most logical one. It's absolutely logical. And we have so many assets in public health that are so meaningful to the health care delivery system, from our ability to do surveillance, to be able to really describe where the disease is and the opportunities for health, right? Our ability to use policy to change entire communities these resources so that they can become healthier. We have lots of resources along that are incredibly complementary on both prevention and healing. And so when those systems come together.

I think that's more democratizing healthcare, decentralizing healthcare, empowering people, communities, putting with the center of the healthcare, not just the clinic and the doctors and the hospitals. That's exactly right. That's right. Amazing. Wow, this has been an awesome conversation. Thank you, Sonja Angel. You have been really a light in shining on these problems in the way that I don't think many people think about the connections here. So I really appreciate you being on the Doctor's Pharmacy. It's a place for conversations that matter. If you like this podcast, please feel free to share it with your friends and family on social media. Leave a comment. We'd love to hear from you and sign up wherever you get your podcasts. And we'll see you next time on the Doctor's Pharmacy.

Thank you. Pleasure to be here. Thank you.