Why Healthcare Policy Needs To Focus On Prevention with Dr. Anand Parekh
Coming up on this week's episode of the Doctors Pharmacy policy-makers need to help Americans The healthy choice the easy choice Hey everybody it's Dr Mark Hyman so whenever I talk to my patients about going gluten free the first complaint is giving up pasta now. I Love Pasta Ula Pasta. We all have pasta Austat but going gluten free and even eating grain free and low carb doesn't have to mean missing pasta thanks to something called wonder under noodles from thrive market now wonder noodles are also known as Shiva Taki noodles and had been used for centuries in Asian cooking. They're made from a route called Cognac route. Cognac Yam and they contain glucose mannion which is actually a very powerful soluble fiber. It's been proven to lower blood sugar her to lower cholesterol to actually help with weight loss. And also feed all the good bugs in your gut that helps keep your mic rebound healthy and you healthy and because wonder noodles. Noodles are made from this fiber. 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The health of our country and trying to find solutions to our chronic disease epidemic. That's crippling everyone in this society and one way or another whether it's someone you love or yourself or economy or just all the crazy crises of healthy we have in this world today. That we really find are are mostly unnecessary because we can prevent them. And that's why I've invited doctor a non Perak. WHO's an extraordinary physician? He's the chief medical adviser for the bipartisan policy. Does he center. which is a group of policy makers physician scientists come together to solve difficult problems around health in the country? It's pretty extraordinary and many other issues. He's provided added credible support to our nation through his work in the government he's Basically been focused on work that he did to his decade gate of service at the US Department of Health Human Services He was the Deputy Assistant Secretary for health. From two thousand to two thousand fifteen. He developed and implemented national initiatives on prevention prevention wellness and care management at the BBC now. He's focused in areas of aging prevention of Global Health He's really an important figure in our country and trying to think differently about about how we solve our big chronic health issues. He's a board certified internal medicine doctor. He's a fellow of the American College of Physicians. He's an adjunct professor of Health Management and policy at the University of Michigan School of Public Health off and Adjunct Professor Assistant Professor of medicine at Johns Hopkins. He's spoken widely extensively and written a lot about topics on health including his new book. Prevention mentioned first policymaking for a healthy America published by Johns Hopkins Press which is an amazing book. I read it. It's a little dense but is full of the solutions that we need to solve our chronic disease crisis. All right. Welcome Dr. Thank you for having great to be on the podcast with you. So we met a number of years ago. When I came to Washington I was human health and Human Services advocating for lifestyle interventions for chronic disease as treatment and I went around and met with many leaders in healthcare at at the time the head of the Senate committee? Congress Secretary Sibelius Nancy into Pearl and the White House trying to advocate for a simple idea which inches we could take these patients crock disease and use aggressive lifestyle interventions in groups to help them transform their health and get better and everybody was one hundred percent on board and nobody wanted to vote against it but ended up on the cutting room floor in the affordable. Care Act because There was the backroom horse trading. I think that happened but everybody. He was on board the idea because they re realized that we really have this global crisis and in America were leading in that global crisis. We have the best trained doctors in the world. We have the best hospitals we have the best technology we have the most cutting edge treatments and drugs for a whole multitude problems patients from all over the world to get healthcare here but on the other hand our own citizens are pretty unhealthy. In fact we have pretty crappy life expectancy. I think we're forty third of the world yet. We spend more than twice ever any other nation on healthcare. We have services aren't guaranteed everybody we have uneven quality of care we have health disparities And we're lagging behind almost every other country in health metrics including life expectancy. How come it's a great question A lot of I think important reasons for that. I think you're absolutely right. There are significant disparities in the United States. And I think that's one of the reasons why why we're different. Just take income if you compare life expectancy of the of the top one percent wealthiest Americans and you compare it to the one percent poorest Americans. There's a fourteen year. Life expectancy difference for men in a ten year. Life expectancy different for women even so income matters take race though. Infant mortality has has gone down in this country. We are behind many of our peer nations and one reason for for that is is disparities. Based on race and ethnicity African American populations American Indian populations have significantly higher infant mortality rates than other subgroups. So race is also important. Our system also Dr High Minute Health system is different in the sense that you know we only have about ninety percent of Americans Americans with health insurance. Most of our pure countries have ninety nine to one hundred percent so a lot of differences. That way I think the final difference I would know. It is Lately there's been a lot of research on how much we spend in this country. I'm healthcare versus social services. Compare we're paying for the wrong end of that equation. That's right that's right. They you know we spend nearly eighteen percent of our GDP as you know in in the United States on healthcare Compared to many other almost one and five dollars of our entire economy I mean three point six trillion dollars and we are headed to four five six trillion dollars in in the near term. And if you compare air that to our pure countries many well developed countries. That's almost twice as much on the social services side so that what does that mean that. Means investments in housing and nutrition and transportation education and income supports We spend probably a little bit less than our peer countries or or about that much. But if you look the ratio so social social services to health care where at about one to one whereas most of the countries That we compare with their close to two to one on racial matters because there's been research even domestically that looks at the fifty states in our country and those states that have a higher social service to help your services ratio. They have better outcomes. They have less Crohn's disease risk factors. They do better with chronic diseases. Lower mortality rates. So it's really that ratio of social services to help your services as a country we were to take care of people before they get sick and you wait till they get an absolute so whether it's Children's and child care whether it's it's it's seniors and in home supports and home delivered meals whether it's paid family leave for working Americans The Social Service report art supports in those countries we have them here But the ratio of social services to healthcare service report a service spending. That is really. What's what's different friendliness? And I imagine what's not captured in that is an. We're spending twice as much on healthcare because we're not taking care of those people early is also another invisible costs which is productivity. Absolutely because if you have a population that's healthy. They're more productive more engaged with communities and families when you have our population which is super sick you lose all this productivity value in the economy so the costs are probably even more absolutely and and that's not to take into account even from a national security perspective. Uh Our our military these the number one reason for for new recruits to enter the military. The number one reason that they're not allowed to join his is because of obesity obesity and and and high high body weight so all of these issues whether it's economic military national security are standing there. were all connect back back to the need to focus more upstream. Yeah I mean even you know in General Jackie and I I knew him. He was been commander in Iraq war and he said seventy percent of the recruits from the military rejected because they're unfit to fight Kids in school. Academic performance is terrible in America. We should have very academic performance. Where thirty first in math and reading in the world and be at Phnom is better than us? You know. It's like a very poor developing country does better than us. What's going on and it's really speaking to the food? We're feeding our kids to school lunches to the amount of toxic food environment that we have. We're all exposed to this driving these choices. And it's pretty much unregulated in this country absolutely and I would say that this is the right time to be talking about this very subject because this is the first time we're experiencing in one hundred years in our nation's history since World War One where in this country we are now experiencing three consecutive years of life expectancy declines and that's because of the OPIOID epidemic the obesity crisis as well as what's what's considered the plateauing and the decline of debts from cardiovascular disease as well as cancer the CDC estimates that every year there two hundred and fifty thousand potentially preventable deaths. That's in the United States. So that's just taking the five leading causes of death heart disease stroke cancer chronic lower respiratory disease and unintentional injury if if the states that had the highest mortality rates did as well as estates in this country that that that that had the lowest mortality rates we would save two hundred. I'm fifty thousand Americans every single year. And so I think the time a timing of this conversation is really true is really important. And you know it's interesting if you take a map you can go on the CDC and these maps of obesity diabetes and life expectancy they completely superimpose in terms of the states with the highest rates. It's of these problems and the worst or the South East. Yeah yeah southern cooking. I guess where there's more obesity there's more disease and you know when I graduate medical school probably you did too. That was not a single state that had an obesity rate over twenty percents and now there's not a single state that has an obesity rate under twenty percent in many have forty and many more encroaching on forty so when you think about forty percent. Obesity rates seventy percent overweight. I mean the tar countries and unfortunately enforcing many of the states That that that you cited you know have that ratio of a pretty low spending on social services who's been and and they also have high uninsured rates as well so they're finding themselves spending a lot of money on the healthcare side of the equation for things that are that are preventable if if we tried to tackle them up and you know you you were in key positions in government trying to think about these problems and create policies to help overcome some of these challenges challenges and and that's not an easy job because there's so many competing forces that are at odds trying to solve the problem. We don't want to have a nanny any state you write about in your book. Danny stay idea that you know I'm like well what's wrong with Nannies. What do they do? Their job is to protect our children. Should we protect our children. I mean think about it. There was a foreign nation that it was doing to our children. We're doing to them. We would go to war to protect our kids right absolutely and yet we just kind of let it go. How how you break through that? Ah Challenge Changing those policy. I thought a lot about this while writing the book you know we all agree. That prevention is important. But but why has it not been the policymakers elevated. Why haven't they elevated this issue at the top and came up with a couple a couple of reasons That'd be happy to share. I you know I think the first is an you touched on this lot of policy makers are reactive in. General and prevention requires a proactive approach. And the reason they're reactive is is whether you're an executive branch or your member of Congress. They're oftentimes so many emergencies. Either real or or or imagined or crises or political controversies diversities that. oftentimes you spend a lot of time reacting to the fire. Absolutely as opposed to thinking about proactive policies to improve health and then Prevention oftentimes takes time as well. So you have to have that. Patients and oftentimes results are at least from a public. Health perspective are often invisible when when things are working and and and health is being protected and so I think the first reason is that The mindset of policymakers needs to shift from being reactive to proactive. Think the second reason is it could very well be. The policymakers are just not as eh tuned to the evidence base whether it's lifestyle medicine weather. It's prevention whether it's a social determined to help understanding the evidence now that has been generated unrated about the effects of all of these other modalities I think is critical. And when you don't know the evidence Then then you tend to think well that might be a slush fund. You know those those dollars in prevention might be a slush fund. You know why should we support it there others as you said who who who may think of prevention Shen as you're right part of the nanny state prevention is is about individual responsibility and the government shouldn't be involved so I think those are a couple of reasons but then I think it goes beyond that prevention and public health that require resources and right now in this country. If you look at our national health expenditure accounts only about three percent of our our dollars go to public health. Only five percent go to primary and secondary prevention and so even though we're on a tight fiscal the climate. We're always going to be in a tight fiscal. Climate finding opportunities through our discretionary budgets are mandatory budgets. CBO doesn't always help with their tenure Budget aged window in terms of scoring so just to clarify for people congressional budget. Office's the watchdog that's right it looks over the cost of things for the government policies and laws and and they score policies based on their impact over ten year period but the benefits of prevention might be over twenty year periods. So Cost Center instead of Uh Cross savings absolutely absolutely and and I think that's a very important point And I think so there needs to be more focus on on Finding the will really the political will to expand resources using discretionary about two swells are mandatory budgets in through Medicare and Medicaid. Because that's really how we scale things so I think that that's that's also critical point. I think after hyman another reason. Why policymakers haven't gravitated towards is prevention? Is We have a three point. Six trillion dollar healthcare system and frankly D- can't make make as much money on prevention as as you can on on treatment so the incentives they are in the system are not as much there now value based on the government yet from people running healthcare absolutely now value-based healthier transformation with the focus on payment based on outcomes as both a volume should change that over time. But that's that's that's going to be a long haul so we're just to clarify for people people the way. Typically doctors get paid and hospitals get paid is like widgets the mortgage stuff you do. The more you get paid more angioplasties you do the more surgeries you do. Marcona squeeze you the more visits. You do the more money you make. That's right and it doesn't care if the product is good or not it's like imagine you know paying for a car but it didn't work like you're not paying for the outcome value. Base care is a new way of thinking that's incentivizing healthcare systems and doctors to be accountable for the outcomes of their patients health. So keeping them healthy if now somebody bounces back to the hospital the Dr Dos but makes money in the future of the hospital won't make be making money by keeping people out of the hospital hospital and that's a very different paradigm shift or not quite there. You absolutely absolutely. We're about a decade in into this but still of the vast majority of healthcare payments are still currently paid based on The services provided and a fee per service. So so we're not. We're not quite there and I think the last reason why You know this hasn't really You know in gotten the attention of policymakers is really think if you look at the general public but we haven't galvanized the American public And whether that's They don't realize the power of prevention or or We haven't realized or or where we haven't communicated needed to them the importance of sound policies to support the healthy choice rate policy-makers need to help Americans Make the healthy choice is the easy choice. And so I think galvanizing the public Lobbying firms or interest groups going to members every single day in the halls Alza Congress preaching prevention but you do need a grassroots movement. You do need the American public the hey I'm doing everything. I can every day for my family to eat well to exercise to avoid Substances to stop smoking to drink alcohol in moderation. I'm doing everything I can. But but if they're not community supports if they're not policy supports if there aren't policy systems environmental change helping me and my family. Yeah it's going to be very very difficult tickled to do and I think that's a critical message in this book. I think it's pretty important because if you don't actually provide an environment that allows people make healthy choices. You know no it. It's hard to do the right thing and I think one of the biggest challenges in this conversation is the sort of dichotomy between the idea of personal responsibility and so the nanny state you know the environment we live. And how do we change the toxic environment and I think you know most of the messaging I'm from most professional associations much of our government policy and certainly the food industry is that it's your fault. You're overweight is it's your fault you're sick. It's a personal choice. Just like smoking's a personal choice and and they talk about moderation. There's no good mad calories that thousand calories of Broccoli thousand calories hours of soda there's focus on exercise as the solution there's folks about moderation. It's really interesting and it and it's a a culture that's really focused focused on personal responsibility but ignores the fact that you actually can't be responsible in a toxic environment if you can't go in your neighborhood in by a vegetable and you have to take two hours of buses for you know by a care at that's a problem and if and if we don't address the environment we live in. We're going to get people to make his. I remember eating study where they looked at people who are overweight and diabetic. Who lived in very low socioeconomic neighborhoods? They moved to his slightly better neighborhood and their blood. Sugar went down and their weight went down without any other interventions. Just giving them a better zip code amazing so basically the ZIP code we have is determined. Terminate our genetic code when it comes to our health and we don't really seem to acknowledge that in our policies we said it's all about choice and I think one of the areas I wanted to talk about. This is the whole snap APP debate. Now the bipartisan policy. Center right about it in your book prevention. I did a very important report card leading nutrition that outlined some of the challenges is with our food stamp or snap program supplemental nutritional assistance. which is I don't know what should be call that because it's simple mental food assistance? It's not nutrition I would call most of it go. Seventy eighty five percent of it is junk food ten percent of it is soda and And it's very clear that people who you know compared to an income eligible person who's not on snap is less healthy And they drink more soda and they have more health consequences so you know people will go well. We can't really limit people's choice when it comes to sort of they have to buy that. It's going to stigmatize them You know and and and you're right. The policy makers are are influenced by big food. I mean Soda Companies Coca Cola. I think twenty percent of their US income from food stamps Walmart of the seven hundred fifty billion dollars the farm bill for food stamps about one hundred and thirty eight billion goes to so they don't want this to change and and it's it's a real challenge and you're you're right. I mean I remember walking into Senator Harkin's office is a really great center longer senator but I said you know he said well what what organization are you from. And I'm like well none just representing the science and the policy and my patients and I wanNA get science into policy goes well that would make too much sense you know and I think I think so when you've got all this evidence that this is true you know as doctors and scientists at this is really the problem but the policies really are are being heavily influenced is by lobby money yet. How do you how do you deal with that? And sort of break this cycle of blaming the victim and not changing the environment and not helping people make better choices. Yeah so now that terrific and thank you for raising this topic to the snap program. Previously the Food Stamp Program. The purpose of the bipartisan Policy Center was is really put the end back and snap exactly your point that nutrition and diet quality ought to be a key factor that program. The program has been around for for several decades now. Forty million Americans rely on the snap program Every year It has substantially reduced food insecurity in this country important and food. Insecurity does have indirect health benefits for children for new mothers for seniors as well But with our obesity genyk environment airman and in the last several decades The program has not evolved to ensure that diet quality nutrition is paramount as well. And you're absolutely right. The the number one Consumption of of of snap benefits of snap enroll ease Soda Products Now. That's not too different than than the rest of the population. We're so does is number two. It does beg the question that are we doing the best job that we can to incentivize the consumption of healthy food would and disincentivize the consumption of unhealthy food. And what our task force you know. There were Republicans and Democrats on there and we ask yourself some pretty tough tough questions. It's Snap is an important program food insecurity for sure. But how do you improve nutrition when we looked at sugar sweetened beverages decker Hammond his. You know there is no nutritional attritional quality nutritional impact in in so it on sugar sweetened beverages And yet it's harmful i. It's absolutely yeah. I know it was a tremendous harm as a leading cause of obesity diabetes. And what we saw in the retail community in fact during the period when when and snap enroll es were purchasing Their food sugar sweetened beverage and soda. Were really the ones that are very bring marketed to them You know and I think we all found we hit on that for a little bit because people don't realize that when the first of the month cons people get their benefit cards. That's when these stores that are in these poor neighborhoods highly. Advertise this war marketing. Yeah yeah in in in better neighborhoods. That are more affluent. They don't advertise absolutely they're they're literally targeting already targeting. It's terrible. Yeah Yeah and that adds to see issues about health equity as to help disparities as well And so the task force recommended. It was a difficult recommendation but that sugar sweetened beverages ought to be excluded and that doesn't mean that individuals can't purchase these things out of their own pocket but from a health perspective In Taxpayer refunded program. We ought to be again incentivizing healthy Food and disincentivising unopened. In fact there was a follow up. Study from. Tufts University versity Harvard School of Public Health. That actually looked at the mix of both incentives and disincentives over time an excellent simulation and found that you could you could prevent a a substantial amount of heart disease and diabetes and save healthcare costs billions of dollars billions of dollars and there is a the vendee grams between snapping for example Medicaid. Overlap in such a way that that this could have significant impacts on State Medicaid Medicaid program. So I think there's a lot there we wanted to. You know we really wanted to to to elevate this issue that yes. The snap program is important but if it can involve to elevate nutrition Than than we can really do something for the public. You know you've got the hunger groups completely opposed to this. You know yet are focused on food insecurity and hunger like you. Can't you can't restrict that it's going to stigmatize these people people you know. They should have the same opportunity. Purchase everybody else but you know you can purchase a two liter bottle soda. But you can't purchase a rotisserie chicken on stamps so there are restrictions. You can't buy cigarettes. You can buy alcohol you. I can't cook food. There's a lot of the restrictions absolutely other programs. We have in the government like Wick and women infants and children in school lunches. They have nutrition guidelines ensure quality nutrition. But we don't have that and there's so many groups of posing any gains. Yeah so how do you see happening. It just seems like a hopeless. Yeah yeah well. We'll talk about that a little bit in the book at that you know we released recommendations and and there there there were a lot of people are cheering because on both sides there were folks said. Leave it alone. Don't touch it. We want to focus on food insecurity on the other side or folk saying hey well you know we questioned the fiscal integrity of the program and and so we again had had both sides involved. That's that's what we do at the bipartisan Policy Center and said you know for looking at from a health perspective improving on the current program is the is is the way to go and that's been our message to lawmakers and policymakers as well You know the farm bill passed Recently about every several years these issues shoes get get resurfaced. So I think we have to keep on You know Ensuring that there was a drumbeat to ensure that the N. in snap the nutrition in part becomes a paramount principle in this part of what you talk about the social determinants of health. You know we've talked on the show before but you know people understand that the environment I mean you you live is a bigger determine of your health outcomes than anything else absolutely even in your diet or exercise or and those things are not addressed in healthcare. We sort of ignore them you know. Yeah and so you talk about you know healthcare without walls. What does that look like? What do we have to think about differently? In in how to address these things. Yeah healthcare slowly moving in this direction but they are And and probably there are better place address social needs and there's an important distinction I think between social needs and social help social determinants of Health for housing. Let's say a building affordable housing addressing. A social need is modifying the home to re- to reduce falls for example for nutrition social determines the health ensuring during the healthy food financing initiatives. You can increase the availability of healthier food. Farmers Market you know social needs is entering a home delivered meal for Transportation Social Terminus Chairman's health is improving community infrastructure through land users owning policy for social needs. It's ensuring that there's ridesharing available so people can make their point. Women so healthcare is getting into the business of social needs because they see it connected to the value proposition of improving outcomes and potentially reducing preventable health. And I think that's that's all fine but but their healthcare is not going to take care of the broader social himself. We still need focus and resources on education an and income and housing nutrition and transportation. Because you're exactly right. Those have profound implications on the health of the population and are also connected to a lot of the behavioral risk factors driving so it seems to me. I'm biased because I'm focused on food but it seems to me that you know the food food food system. If we had to pick one thing to target would be the biggest thing and because that's affecting the chronic disease burden the majority of I think chronic disease are causing part by diets. Million people die every year around the world from Diet related. I think that's an underestimate because when you add in the the additional causes such as diabetes and in heart disease and yeah it's it's like in the forty fifty million range and so when you when you when you have that level of impact. It seems like we can't address all these issues unless we fix the food system. Yeah and and that the forces that are opposing that are quite big. You know just the farm bill known as a half a billion dollars of lobbying on it yes for that and the majority of food stamp so how do we how do we. You've been in government you've been in these these conversations you've you you're not just talking about it from a think tank. You've actually been there. What's your perspective on? How you move the needle I mean? Do you have to wait for newness. Ration- do we have to wait till the community of Activists rises up like abolition changes. Our government I mean what what are we to do to see change because it's discouraging for people to sort sort of feel like they can do anything about this. Yeah given the political winds in this country change Pretty regularly. I think it's important Dr Hyman that we take incremental progress whenever we can. But you're absolutely right. You're premise that I took a base hit. I think I think I think you have to educate policymakers. That's what part of this book is You know we should go for the whole you know. It shouldn't be that that we're just going for basis we go for the home run But it's also important when there are are incremental opportunities to take them. I agree one hundred percent with your premise I I call sort of obesity the public L. Challenge of of our century. I mean that it is the critical challenge. Cancer will soon in this country. The leading cause of death for Americans and and it will surpass heart disease and the reason for that is really Poor poor diet so people don't understand this but obesity is linked to cancer not just learning at least a dozen cancers are now very well the establishment management the link between obesity and cancer is now a pretty well developed in some most common cancers breast colon all the big ones. Yeah Yeah so I. I think that that that we need to you know so when I talk about sort of incremental progress so for example right now you know try to look at things sort of glass glass half full from a policy perspective. Look at the Food and Drug Administration. There's an important in the next several months A new change to the nutrition. Facts label able I in that all foods will need to have information about added sugars And that's that's pretty important fact. There was a recent study done that if in fact this has done over the next You know two decades There would be substantial reductions in both diabetes diabetes and cardiovascular that's and significant healthcare cost savings now if if the industry actually then reformulated their foods given that now this is transparent on the label There would be even more a doubling of an impact over twenty years. I think it would go from thirty billion dollars in healthcare cost savings to sixty billion and from one million cases this is of heart disease and diabetes two million. So these are these are substantial pieces assault of voluntary sodium production. So it's voluntary. This started Arctic. Look without a society Obama Administration. You're only sixteen but this current administration is moving forward with voluntary sodium targets in one hundred fifty different food groups and if indeed Manufacturers are able to meet these targets within two years we can Reduce the average consumption sodium in this country. Which is about thirty four hundred milligrams to three thousand within ten years we can get the twenty three hundred milligrams and that could save substantial? Daniel lives down the road in terms of heart disease and reduced healthcare cost so I think there are some things that don't get a lot of attention. I think that are important. There are then more challenging things things Sugar sweetened beverages and taxation of that and the politics of that portion size which I think is is a really important issue also over the last several decades. The portions of scared at that we get are so large. Deborah Cohen researcher at rand has done some important worked on portion sizes and has shown that that that as portions have increased our consumption increased Of course as well. And she's actually advocated for standardizing portion size. Just like we did with alcohol so I if you have a certain amount of alcohol. There's a standard size standard size of portions CNN's you could reduce consumption there. Particularly for unhealthy foodstuffs takes away the whole idea personal choices sort of like mandating different portions. Dan Buettner who wrote the Book Blue Zones Create Initiative and I think it was in some Midwest state and and essentially got community interventions. That were invisible so everybody's sweatshops shot the place to ten inch plates. What was it the checkout counters? The gross changed a healthy options candy. Yes they build walking past. They basically created initiatives that were just to friction lists about people make better choices that mainly huge difference in healthcare costs and health outcomes stuff that we think of as the the nanny state. But it's actually south it's proven to be effective and I would say that it it doesn't it. I would probably say that. It doesn't actually take away individual choice so people are certainly you can go back for seconds. Yeah absolutely but I think it's shown that that that when when the healthy choice easy choice or that people Change their practices. And I think that information take menu labeling now which which is common and that policy change giving people the information. I think the behavioral economics peanut. You're talking about those things. I think incremental ways forward in those areas I think are important my favorite studies where they up to people and give them both cereal. One bowl constantly refilled from the bottom and the other one was a fixed amount of cereal and the ones that had the constantly feeling so I just kept eating it like it was like a trick bowl I actually love I gotta think thank you know. I'M A serial killer hate zero. I think it's one of the worst invention Saudi seventy five percent. Sugar top about added sugar. Oh my God. That's huge absolutely okay. So let's so as a policymaker man that was a policy think tank advocate. You mentioned a lot of these initiative everything can make a difference but I just keep pushing back against the idea of you know how. How's it going to be a citizen sort of get their congressmen to go? Because they don't we'll have millions of dollars to lobby right. I when I went to Washington I pay my own ticket at hotel. Washington's not cheap food on their like who are you where are you from. And what are you doing unlike because they never seen a individual being advocate and so but there are ways right there are ways to get involved and I think there's a food policy action network. Is I think a group that scores your congressmen and senators on their voting on food and AG policies so there ways to affect it. But it's tough because you know you've got for example on the snap Subject you probably wear this when there's a hearing about snap to try to improve the nutrition quality and snap and talk talk about the Soda Reduction. Maybe you were hearing. There were many of the committee members committee who basically said it's all about personal responsibility responsibility more exercise. That's the real problem is not about the food and when you look at who is funding their campaigns it was soda companies tunes tunes to the tune of collectively millions of dollars. Yep How do you fight that. Yeah Yeah Well I. I think it's first and foremost helping Americans understand That there are things that the guy that government and policymakers can do to support them in these areas is that that it's not just about personal responsibility and so some of it is sort of education and empowerment there Some of it is also the doctor patient relationship as you know Dr Khomeinism trusted one I think You know ensuring that healthcare professionals can be that voice as well to support Support Patients On some of this is educating policy makers as well and policy makers You know on their own understand the importance of preventing so in my in my book for example example there five sort of key. Takeaways for policymakers at the end in terms of what they can do to support Americans you know the first for example Apple To make prevention the number one priority for this or any administration Coming in the health and Human Services Secretary saying thank you know there's a lot of mission essential functions but prevention will be the number one priority all of our agencies whether it's senators disease control and prevention or the FDA or the National Institutes of health. You know figure out. How prevention elevates at the top number two healthcare professionals in value based healthcare transformation commissioning? We're now going to measure you and hold you accountable. Not just for how. Well you manage diabetes heart disease but how will you prevent them in the first place. We're I can hold you accountable. Not for how. How much you screen? Just screen for tobacco's to the test for blood sugar but actually reduce it and and what that will do is force the healthcare community to build the clinical community linkages to help support individuals so that sort of second takeaway a third takeaway is. These are all in the book. These are correct the overarching takeaways. For policymakers which I think that can be helpful to to Americans out there. The third is in this country. If you're a drug a pill or or device there's a pathway in this country for that that intervention To be scaled. There's a food and Drug Administration that that assesses safety and efficacy and once. FDA approved that intervention cms Medicare Medicaid decides whether it's reasonable and necessary for payment for coverage and then a lot of private payers follow. What Medicare ties to interrupt you there? The recent study that was published published showing that stents and bypass angioplasties. Don't work for the majority of patients to get them is not a new story. I read this. This article in different iterations in the past and keeps getting repeated in the research gets more robust and yet Medicare and Medicaid pay for these services because there are device and they're it's sort of the end but they won't pay for stuff that works absolutely lifestyle program that can reverse diabetes right right on on the treatment side so but if you're an evidence based program and either prevention or treatment lifestyle focus to your point. There is no pathway in this country. Like there is if you're a drug or a device vice and yet there are so many evidence based programs like the one you just mentioned the lifestyle treatment or prevention programs whether it's falls prevention across the sea self management programs uh-huh there there's so many programs out there where thousands are benefiting benefits in my book. I actually call for a parallel path just like you have. FDA looking at the safety and efficacy of drugs or devices whether it's CDC or the administrator admission aging Congress ought to give them a regulatory authority story to review a lot of these evidence based community treatment or prevention programs and if they meet the bar then cms would would have to consider them as being reasonable and essays for payment. Just like they do for Cleveland Clinic. We've got our program called functioning for life for people with chronic disease. Change their lifestyle. We changed our diet. We actually to social support. Help them change their behavior. We're seeing extraordinary results. I mean we're worsening diabetes heart failure all kinds of stuff weight loss. Obviously and and yet. It's not really reimbursed. That's right and we're saving saving so much money and we're not getting paid for what we do. We get paid thirty cents on the dollar and reluctant who make one hundred bucks on a patient. And we see them or less you know and it doesn't even cover our costs of running our center. But we're providing so much value in the system. Yeah yeah which is benefiting Medicare Medicaid and also private insurers so the whole system is sort of rig right not incentivized to do the right thing. Yeah right yeah absolutely. And so. And there's there's no money to study it. I was like oh I'd love to get you know I mean there's literally billions of dollars spent on research and right country and almost nothing's been nutrition or lifestyle reset and that's right and therefore a parallel well. Pathway Cook could help infuse resources in you know to to research as well as ensure that there's not a double standard for a lot of these interventions That that are focused on lifestyle or occur outside the clinical clinical arena. Remember that and others to other to others. The fourth is look we have about about a four trillion dollar budget fed government. This is prevention public health. It's too important to underfund this and there needs to be bipartisan. Support to finance Evidence based prevention and public health interventions. So it could be community based prevention programs. Rams I talk about several things that we did health and Human Services from from the Recovery Act of your house and nine there are opportunities finance the public health infrastructure which is significantly underfunded underfunded in this country a public emergency funds so the next baller or the Zeka we face. We're not waiting on Congress to fight for for months at a time before their their resources but targeted targeted investments to lift up prevention and Public Health That that seems to be that has to be a national priority and I think in terms of bipartisanship Hoti crack that not. There was an important commission on evidence. Based policymaking that Senator Patty Murray Murray and former Speaker Paul Ryan actually let a couple years ago and talked talked about sort of evidence the importance of evidence based policymaking in that same vein. There ought to be bipartisanship around those priorities in the prevention and public health. Space that we actually need to invest more visit because the truth is you know. Food Industry in Pharma are not investing in research around this. That's right that's right and that leads me. The sort of the fifth breath point. Which is we need Dr More Research? I mean we. We had the We have Evidence based right now but we need more research into prevention of the nationals Soussan News on health estimates at nineteen percent of their budget every year goes to prevention. Now one could ask. Is that the right number or not. I don't know another really true. Nineteen percent prevention nineteen percent. Now there was another study that I recently saw that. If you look at the National Cancer Institute only five percent of their budget it goes to prevention so whatever. The number is I would think I think that these are all sort of low well that well let's just to find prevention because he's a mammogram. Prevention is a colonoscopy prevention Russian. No it's early detection. Yeah yeah true. Provision really dealing with the causes the upstream causes right. You talk about your right right right and so I would argue and I argue in the book that that there ought to be a much more focused research Emphasis on prevention. That looks at and not just sort of the biology of illnesses but also the importance of behavioral change as well as policy as well as other areas and so and that will also so actually helped Congressional Budget Office irrespective. What happens with the ten year budget window? The more research the more evidence there will policy makers so I think in all five of these Zacharias Number one leadership prioritizing prevention number two healthcare professionals focusing on prevention not just management number three a parallel pathway for lifestyle interventions in evidence based community prevention interventions number for public health resources in number five prevention research. All of these. They're all heavy lifts Dr Hammond but but I think that I wouldn't be writing a book if if these weren't absolutely important for policymakers on both sides of the aisle to understand the importance of these and I think if there's movement on the policy side the American public will we'll see this Also as away to support themselves as they try to make Sort of the healthy choice. But but the American public is is clamoring for assistance. The behavioral change is is difficult given the environment which you have so beautifully described and and I think the best way to counter that that that environment is through policy policy change and empowered American. Speaking out yeah one of the things you mentioned your book in addition to these points is so targeting things at work but aren't paid for so digital regional health for example. You mentioned Mata help. I helped advise when they were starting out right right and I and I said to them. Look the diabetes. Prevention was a good start but is based on a little bit antiquated equated. Nutritional data about low fat diets carbonized for diabetics. But it worked because and I met people who are in the program and well the work because we came to groups because we had had to write everything we eat because we exercise together. And you know it wasn't so much the food although healthier wasn't the healthiest and and there's been and more sort of advanced versions of that that have developed. Yeah that our digital for example a health you probably heard about where they literally taken poorly control. Pretty overweight poor diabetics sixty percent sixty percent reversal now in traditional medicine. It's like zero zero right. Yeah unless you get a gastric ashby bypass and they had sixty percent. Reversal had ninety percent or more off of insulin or very low insulin doses. They had twelve percent weight. weight-loss which is an amount studies at five everybody's dancing around happiness excited for five percent loss and they did it through a digital platform arm where they were coaches and support those remote monitoring for key tones for Wade from blood sugar and publish the data using a Ketogenic Ganic intervention. which is the opposite of the EPA which is basically high fat and yet this is not reimbursed? And it's the amount of savings in these patients just astronomical call. So how do we sort of get because this sort of goes back to the conversation earlier about prevention and treatment so prevention is important. It's a population based intervention. Yeah you know not all the people you're GONNA do. The intervention are going to get the problem and there was not everybody gets a colonoscopy colon. Cancer right yeah but everybody who's already sick yet. Needs the intervention of lifestyle intervention because its lifestyle is treatment not only prevents right right right but that's not reimbursed and yet it's probably the biggest bang for the buck in terms of our health care system. In how how do we. How do we get our government to start a understand that and maybe you talked about your funding more research? That proves the model right right. Well I think it's all they bob also having pathways again as you said there's no real pathway Medicare Medicaid. Don't really know what to do with a lot of these interventions that are not sort of the traditional medical model You know nine hundred. Sixty five Medicare was I Created it was essentially paid for the treatment of disease. He's using You know routine medical services. So it hasn't really caught up with today's Day and age and what we know about the importance of life installment medicine either with prevention or treatment So I think some of this is is research some of our new pathways in the government regulatory pathways ways Some of this is educating the public. it's really gonNA take all of the above to change the status quo because there are a lot of opportunities out there that are not being realized right so so you are. You're in the middle of it all and you feel like there was movement when you were there that people were were trying to actually shift the policies in ways that actually were effective or was it sort of spinning wheels. Yeah no I think governments broken. It's not going to do anything. What's the point? But yet you have a different view. There are lots of lots of things that I saw with the affordable care actors State Clinical Preventive Services. One part of that was now high value clinical preventive services There ought to be no cautioning for them that makes sense from a value based Insurance Zayn perspective and that should increase the likelihood that Americans receive high value based clinical preventive services. So meaning if people I need to get screened for disease or a PAP test mammogram right. They shouldn't have to pay for it and the private insurance shouldn't get co-pay and Medicare shooting at McDonalds after cancer screenings or or or counseling interventions inventions for tobacco alcohol immunizations. These things Can improve health reconnected. Nutrition in proportion reimbursed for a while. Right right right well. I think we saw a waste. Go in in some areas but but that's one example where we're trying to make it easier for people To access important clinical preventive services serves in terms of community preventive services. I know that that'd be is prevention program. Maybe as antiquated sort of Nutrition aspect of the intensive lifestyle piece there. But they're You know the team at Medicare Medicare just getting the Diabetes Prevention Program through took a lot of work required the authorities of a newly created center at Medicare Medicaid called CMO which is a center for Medicare Medicaid innovation there. There was a test essentially of the Diabetes Prevention Program and it was found to save money and reduce costs. That's the only way got expanded. Sure but that's why I call for a parallel pathway. Otherwise you're reliant. On on on the government has the fund is not coming from industry right. Yeah exactly exactly exactly. So so. I think the government You know and the reason why the government so important is the private sector is critical. But there's only so much from scale scale perspective that philanthropy or nonprofit organizations can do the needs are for millions and we're only reaching thousands and the only way to scale from thousands to millions There there could be other ways but but government there's a role for government and I think that's part of the premise of the book as well In in the community base stuff is important. Because when you think about word disease happens or health happens it doesn't happen in the hospital or the clinic you know. Eighty percent of our health is determined by where we live by our diet and lifestyle and our genes things that have nothing to do with what you get when you go to the hospital she. The doctrine yet eighty percent of our funding for what happens with its veteran hospital so clearly backwards. Yeah absolutely we talked about the importance for example nutrition counseling but you get the best nutrition counseling but then somebody walks clinical setting they see fast food establishments and they see no farmers markets. They're no meals on wheels programs. Now would you expect them. To so the whole idea of clinical community linkages is to reinforce what happens all the important efforts on the clinical side to reinforce him the community site. Otherwise they're not gonNA stick so one example. A couple years ago I was out in the south side of Chicago and and I visited a a program called Community Rx and essentially in this community are axes community is medicine. Exactly the the the the community are they the program Graham mapped out social service providers and community based organizations around the city and then they took that information linked to the electronic health record and and and linked at two particular conditions and diagnoses so at the same time whenever a patient came to community health center. They always got a healthy healthy Rx script based on their diagnosis matching them up with appropriate community services in the community. So what they learned in the clinical setting was was was then than they received Essentially referrals to get supports in the community. Reinforce learned the Clinton and that just sort of one example of how we need to build old. These clinical community couldn't clinic. We started program because I'm very strong advocate of getting out of the hospital. And it's there when you need it. I mean I had had heart rhythm problem this year and I had to have an ablation. I'm like thank God but most the problems in these communities are not going on in the hospital. It can't be solved there So he went in very underserved African-amer community in Cleveland. You're Cleveland Clinic and we start. Community Program in a community center wasn't in hospitals and their the help center and no it wasn't even hospital just a community center and we developed a group program. I arranged for them to get meals. Yeah sort of fresh rush. Whole food meals got the right nutrients just as a temporary solution? See what would happen. If people had the support in their neighborhood there was nowhere to get get food and within like six weeks. It's a ten week program we're GONNA have a follow on for a year. They're dramatic changes. I mean Apple's lost twenty pounds owns in five weeks. They had dramatic blood sugar. Their blood pressure as stroke couldn't really talk or lift. Anything now is talking and actually was able to carry things with her arm. I mean it was. I was shocked and and it was so simple and we taught them to cook get cooking classes together. We went shopping. They learn about food. You know we had Cox with the nutritionist and the health coaches and it was really powerful because they wanted to change. They just didn't know what or how and nobody showed him and nobody told him. And it's an I and I think those kinds of things are where we need to be thinking of. This is not going to be solved in the hospital. We still need acute care medicine for sure. Yeah but the problems we have aren't solved in the hospital. Yeah absolutely absolutely agree. I give you another example gazing health system in central Pennsylvania. Your podcast skull. The Doctors Pharmacy. They opened up their first food pharmacy. A couple of years ago and they did a a really good job matching the acuity of the individual with the intensity of the intervention so they took poorly controlled diabetic patients who screened positive for Food Insecurity Security and the intervention there was not just diabetes self management training in counseling. They actually provided for food. Who Two meals a day for ten meals a week for the whole family family? All right and what they found in their pilot was average hemoglobin agency which indicator of of of severity diabetes thought from nine point six percent seven point five percent and why why that matters is is every one percent drop reduces mortality from diabetes and complications by twenty percent and saves eight thousand dollars in healthcare costs. And what what's it's also important to realize. Is that two point. Drop out seem like a lot but if a drug gets a half a point drop. It's a raging success right there. You got four times as good as drug. That's right that's right. It's a Louis. So there's evidence based so why doesn't Medicare now pay for food firm. Susan pay for food for everybody. Yeah well I think we need to move in that direction again. It's the medical model model that has been the focus of policy makers for so long and as we build this evidence base and in some areas it's substantial now that that different quote unquote types types of interventions can actually do more than the traditional interventions that medical intervention more than medical interventions. That's where we need to focus because that's where we'll deliver Ah Not just the best improvements in health but also the most significant healthcare cost savings. So if you were an autocrat and you were in charge of American policy and you were the Putin of healthcare. You're not a bad good analogy but you could actually take a wand and make the changes that you see are going to make the most difference Prince. What would they be mentioned the five things already it because those things are are realistic? But if you really had things are gonna GonNa have the biggest impact. What would you do well not just in terms of healthcare across our whole society in terms of making the changes that need to have laser focused on the risk factors driving chronic diseases in this country as well social determines health and their organizations out there like trust for America's health who issued recommendations In in in this area but but I I think it's really a package. Dr Hyman of policy changes so on the chronic disease risk factor side of the equation whether it's tobacco oh poor diet physical activity alcohol their series of policy interventions their smoke free laws are raising Pricing on tobacco reducing alcohol outlet density increasing nutrition physical activity access in schools reducing the availability of unhealthy foods in different ways. They're a package of policy. Changes There and then on the social terminal the health side whether it's housing affordable housing housing first Whether it's education universal pre kindergarten whether it's income paid family leave You know earned income tax credit their series of interventions that go beyond the four walls of the clinical CEO but tackle both the social determinants the health as well as the lifestyles the risk factors driving Crohn's disease and in this country as you know half of adults have chronic diseases Shaft Awesome. Yeah sixty percent now. Half of that half have multiple chronic conditions which was really my focus at health and human services and virtually all the three point six trillion dollars that we spend in this country. Go there so as you're like focused on on on the risk factors driving Crohn's disease and the interplay that the social determines have an policies. They're so a lot of this again is outside the four walls of clinical setting agree. I I would I would add in there and I think you know going upstream conversation. Is You know what is driving this social terms. What is driving the disease for the most part I would say it's our food system and you have to change change the way we grow food? What food we grow? How is supported all those upstream things? It's like we're just still yeah down in the weeds if you don't actually change the food environment. Yeah Yeah if you look at the subsidies going to their agricultural sector the marketing by the food industry There are a lot of forces That Whether they admit it or not make it harder. Make it harder to four Americans out there To make the healthy choice easy choice and I don't think we want to demonize parts of but we want to work with all sectors of our society to see how we can all push health for and I think that's the best best interest. Well what you know we. We came down hard on tobacco because we were clear about. It's dangerous but now. Ob City and food is overtaken tobacco as leading cause of death. So you you know. I think we have to start to really think about that honestly. I think the industry does as well for the sake of their own future and their bottom line. They need need to understand which products of theirs are leading to ill health and and and And change their practice and culture as well So you know I think there are there are some You know in the industry who taken positive steps but but I and I think when that happens we need to applaud laud them but I think you're absolutely right as a whole I think it's important where it's not possible to see that voluntary steps? I think governments German scholar role. It's got a really important role because ultimately that's why we have government still You know I always say health and education. Those are the two most important porn things you know. Health provides the foundation education provides the accelerator You know as we pursue our goals in life and and if anywhere where where government needs lean lean forward. It's gotta be in those types of I agree. I think that's great. Well thank you for your work. A thank you for working for us in the government for so long trying to do the right thing and now with the bipartisan policy commission. which is I think? One of the most important organizations out there bring parties from all sides together to solve difficult problems across government. And I think you know what I think. Is You need a big lobby arm. Yeah you need like one hundred million dollars. Lobbying fun to be out there telling stories in ways that get lawmakers maker to pay attention so thank you so much for your work and for your book. Prevention I policy making for a healthier America. It's a real contribution to our thinking about. How do we do the right thing? Because if we keep going the way we're going we're screwed so thank you and check out the book on Amazon where we get books Bookstore Barnes and nobles and Check out the work of the bipartisan Policy Center. I love their stuff. It's a little nerdy. I'm a little geeky. I love that stuff you might to and If you love this podcast please share your friends and family and social media. Believe a common. We'd love to hear from you. Subscribe every area podcasts. And we'll see you next time on the doctors pharmacy. Thank you thank you very leadership dot com thank. You wanted Dr Mark Hyman so two quick things number one. Thanks so much for listening to this. This week's podcast. It really means a lot to me if you love the podcast. I really appreciate you sharing with your friends and family second. I WanNa tell you about a brand brand new newsletter. I started called marks picks every week. I'M GONNA send out a list of a few things I've been using. Take my own health. The next level is can be books. PODCAST research that I found supplement recommendations recipes or even gadgets. I use those and if you'd like to get access to this free weekly list all you have to do is visit Dr Hyman dot com for slash picks. That's Dr Hyman Dot Com for slash picks. I'll only the email you once a week. I promise I'll never send you anything else besides my own recommendations so just go to Dr High Dot COM for sized picks. That's P I C K S Saina a free today. Hi Everyone. I hope you enjoyed this week's episode. Just a reminder that this podcast is for educational purposes only this podcast. This is not a substitute for professional care by Dr or other Qualified Medical Professional. This podcast is provided on the understanding that it does not constitute medical or other professional advice services looking for helping journey seek out a qualified medical practitioner. If you're looking for a functional medicine practitioner you can visit IFM dot. Org and search. They're fine a practitioner database. It's important that you have someone in your corner who's trained. WHO's a licensed healthcare practitioner and can help you make changes especially when it comes to your health?