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  Show 1446: The Science of Strong Bones: Lifestyle, Medication and Movement (Archive) 23.07.2026 1ชม. 6นาที

  Are you concerned about your bone health? Do you worry about osteoporosis? According to the CDC, more than 10 million Americans have low bone density that makes them more vulnerable to fractures. For many older people, a fracture can be devastating, reducing mobility and possibly even leading to death. What does the latest medical science tell us about how you can maintain strong bones? At The People’s Pharmacy, we strive to bring you up‑to‑date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen You may have heard this interview when it was first broadcast on Saturday, Sept. 27, 2025. If you did not, you can download the mp3 using the link at the bottom of the page, or listen to the stream on this post by clicking on the little triangle in the green circle. We have added extra information to these notes, but not to the interview itself. Strong Bones You may have seen Halloween skeletons or even chewed the meat off a bone that you then dropped on a plate with a clatter. No wonder we usually think of bones as hard, unchanging objects. Dead bones are. But living bones are quite different. Strong bones are constantly undergoing change. Scientists call it remodeling. One set of specialized cells, osteoclasts, breaks bone tissue down and recycles it. Another set, the osteoblasts, builds bone back. Ideally, their activities are in balance. But if the osteoclasts start to get ahead, as they tend to do while we age, that can weaken bone. The result is low bone mass, known as osteopenia, or even serious bone loss called osteoporosis. This puts a person at risk for fractures. Who Gets Osteoporosis? Osteoporosis may have been less common a hundred years ago or more, when many people had to do manual labor that put stress on their bones. That helps for strong bones, so today’s sedentary lifestyles can undermine bone health. Although we think of osteoporosis as typically affecting postmenopausal women, men can lose bone mass too. Medications may contribute to the risk for bone loss. Steroids such as prednisone or methylprednisolone are especially risky if taken for a long period of time. Androgen deprivation therapy for prostate cancer is a risk factor specifically for men. Wait–MEN Can Get Osteoporosis? Q. My husband and I have two friends with significant disability largely due to spinal fractures as a result of osteoporosis. One man was always an avid exerciser, including running marathons. Both men are over six feet tall and have always appeared to be muscular. My husband is shorter and is physically active, playing tennis and going to the gym regularly. Because of our friends’ bone issues, I advised him to request a DXA scan to assess his bone health. The nurse practitioner told him that it was not recommended for men. I am still concerned that he may be at risk for osteoporosis. Are there medical studies that determine the risk factors for men? A. The nurse practitioner was mistaken. Men can develop osteoporosis, as your friends discovered. Many medical guidelines recommend that men over 70 be tested with a DXA scan to assess bone health. If your husband has low testosterone levels or has taken medications such as prednisone, he could be at increased risk for a fracture. He would be prudent to have the assessment. Diagnosing Osteoporosis Doctors assess bone mineral density with imaging called dual-energy X-ray absorptiometry, or DEXA for short. Then they compare the results on the scan to the results they would expect from a 30-year-old person. Results more than 2.5 standard deviations from that could result in a diagnosis of osteoporosis. A person who experiences a fracture without trauma, such as falling from standing height, is also suspected and often diagnosed with osteoporosis. Non-Drug Approaches to Strong Bones: People who want to keep strong bones need to focus on exercise. High intensity exercise can be helpful, but brisk walking may be enough. Tai chi and yoga are also popular. If you have been diagnosed with osteoporosis, be sure to check in with your doctor before you start a new exercise program. Building balance and core strength without increasing your risk of a fall (and thus a fracture) would be ideal. Our guest expert, Dr. Kendall Moseley, says the jury is still out on technology such as vibrating platforms, weighted vests or vibrating belts. More studies should show how valuable these could be. Following a diet that supplies adequate protein, vitamin D and calcium is also crucial. If you must take a calcium supplement, calcium citrate may be well tolerated and absorbed. How Do Doctors Treat Osteoporosis? Physicians prescribe several different types of medications to help curb bone less and perhaps even build it back. Some of the oldest and least expensive are the bisphosphonates such as alendronate (Fosamax). These slow bone break down and give the osteoblasts a chance to catch up. They can be hard on the digestive tract, though, and they have been associated with a few rare but alarming side effects: jawbone deterioration and atypical thigh bone fracture. Most people seem to do well on them. Doctors generally prescribe them for up to five years. Did You Forget Evista? Another type of osteoporosis medicine is called raloxifene (Evista). It is appropriate only for women, because it is an estrogen modulator. It acts like estrogen in the bones and reduces bone loss. In the breast and uterus, it opposes estrogen activity. Raloxifene does double duty in reducing the risk of breast cancer as well as osteoporosis. Like all drugs, though, it has some worrisome side effects. It can increase the risk of blood clots that cause deep vein thromboses and strokes. What About Prolia? Denosumab (Prolia) is a monoclonal antibody that also interferes with osteoclasts. That is how it improves bone density. One thing to keep in mind about Prolia is that stopping it requires careful planning and backup medication. Otherwise, a patient can lose all the bone that was built rather quickly and may suffer debilitating fracture. This Week’s Guest Kendall F. Moseley, MD, is Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. She is also Clinical Director of the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. In addition, Dr. Moseley is Medical Director of the Johns Hopkins Metabolic Bone & Osteoporosis Center. Kendall F. Moseley, MD, Johns Hopkins University School of Medicine Listen to the Podcast: The podcast of this program will be available Monday, Sept. 29, 2025, after broadcast on Sept. 27. You can stream the show from this site and download the podcast for free, or you can find it on your favorite platform. In the podcast for this episode, we discuss the pros and cons of estrogen for strong bones. You’ll also learn about a drug that builds bone, teriparatide (Forteo). And you’ll hear about the importance of preventing falls and how to do that. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript for Show 1446: A transcript of this show was created using automated speech-to-text software (AI-powered transcription), then carefully reviewed and edited for clarity. While we’ve done our best to ensure both readability and accuracy, please keep in mind that some mistakes may remain. If you have any questions regarding the content of this show, we encourage you to review the original audio recording. This transcript is copyrighted material. All rights reserved. No part of this transcript may be reproduced, distributed, or transmitted in any form without prior written permission. Joe 00:00-00:01 I’m Joe Graedon. Terry 00:01-00:05 And I’m Terry Graedon. Welcome to this podcast of The People’s Pharmacy. Joe 00:06-00:13 You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. Joe 00:14-00:27 Hypertension is often called the silent killer, but osteoporosis might be considered a silent and deadly disorder. This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:41 If an older person breaks a hip, the consequences can be disastrous. They often lose mobility and they may even die. Joe 00:42-00:50 The focus for osteoporosis is usually on older women, but we should remember that men can also lose bone and become vulnerable. Terry 00:51-00:57 There are drugs that hurt bone health as well as help build it back. What about supplements or exercise? Joe 00:57-01:06 Coming up on The People’s Pharmacy, the science of strong bones, lifestyle, medication, and movement. Terry 01:14-02:32 In The People’s Pharmacy health headlines, semaglutide has gotten a lot of attention over the past few years. If you don’t recognize this generic drug name, you probably do recognize the brand names. Ozempic for type 2 diabetes and Wegovy for weight loss. Both these medications are self-administered injections, but not everyone is enthusiastic about needles. There’s also an oral form of semaglutide called Rybelsus. The FDA has approved it for treating type 2 diabetes six years ago, and so far it has mostly gone under the radar. A new study published in the New England Journal of Medicine demonstrated that oral semaglutide at 25 mg a day helped people without diabetes lose significantly more weight than placebo. The randomized trial included more than 300 volunteers and lasted approximately a year and a half. This could be good news for people who have trouble accessing injectable semaglutide or keeping it cold. People taking semaglutide reported improved quality of life. They were also more likely to report side effects, especially digestive distress. Joe 02:34-04:17 Aspirin has been available for well over 100 years, but the active ingredient has been used by native healers for thousands of years. In 1991, a research article in the New England Journal of Medicine reported that regular aspirin users were 40 to 50 percent less likely to die of colon cancer. Now, 34 years later, another research paper in the New England Journal of Medicine reports that people taking aspirin had a significantly lower chance of colorectal cancer recurrence. Swedish scientists recruited patients after they’d had their tumors removed. The particular hotspot mutation called PIK3CA. The aspirin dose was 160 milligrams, or roughly half a standard strength tablet daily, for three years. 626 patients were randomly assigned to receive either aspirin or placebo. 7.7% of people taking aspirin experienced a recurrence of their colorectal cancer, whereas 14.1% of those on placebo had a recurrence. That was about a 50% relative risk reduction. 43% of the participants taking aspirin experienced a non-severe side effect compared to 35% of those on placebo. Serious adverse events occurred in 17% of aspirin takers compared to 12% of placebo recipients. The authors conclude that low-dose aspirin represents an effective, low-cost treatment approach to prevent colorectal cancer recurrence in high-risk, genetically selected patients. Terry 04:17-04:58 Nutrition experts have praised the Mediterranean diet as a way to reduce cardiovascular risk. It’s also been considered as a way to lower the likelihood of developing dementia and a natural approach to calming inflammation. Now, dermatologists have announced the results of a study showing that four months on a Mediterranean diet can reduce the severity of psoriasis symptoms. Almost half of the participants following a Mediterranean diet reduced their psoriasis score by 75 percent, and none of those on the control diet did so. The researchers conclude that this dietary strategy could be helpful along with medical treatment. Joe 04:59-05:41 A new study of acupuncture for chronic low back pain called Back in Action produced positive results. 800 patients were randomized to receive either standard acupuncture of 8 to 15 treatment sessions, enhanced acupuncture, which included 4 to 6 maintenance sessions beyond the standard, or usual medical care alone. Those in the acupuncture groups had significantly greater reductions in their pain-related disability than those in the usual care group. The authors conclude that, quote, these findings support acupuncture needling as an effective and safe treatment option for older adults with chronic low back pain. Terry 05:42-06:05 Do cocoa flavanols normalize blood pressure? In the COSMOS study, people with systolic blood pressure under 120 were significantly less likely to develop hypertension if they were taking cocoa flavanols than if they took placebo pills. People whose blood pressure started higher did not get the same benefit. And that’s the health news from the People’s Pharmacy this week. Terry 06:14-06:17 Welcome to the People’s Pharmacy. I’m Terry Graedon. Joe 06:17-06:29 And I’m Joe Graedon. According to the CDC, over 10 million Americans over 50 have osteoporosis. That means their bones have become fragile and more vulnerable to fracture. Terry 06:30-06:40 More than 40 million Americans have low bone mass or osteopenia. What can be done to prevent fractures, disability, and death from weakened bones? Joe 06:41-07:00 To find out, we’re talking with Dr. Kendall Moseley. She is Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. She also serves as medical director of the Johns Hopkins Metabolic Bone and Osteoporosis Center. Terry 07:01-07:04 Welcome to the People’s Pharmacy, Dr. Kendall Moseley. Dr. Kendall Moseley 07:05-07:10 Thank you so much for having me today. I’m very excited to chat with you both about a topic that’s near and dear to my heart. Joe 07:11-07:48 Well, it’s near and dear to our hearts as well, Dr. Moseley, but I suspect that there’s a tremendous amount of confusion when it comes to bones because we’ve all seen skeletons. We’ve all had interactions with bones, perhaps in food. And it just always seems as if bones are so solid. And yet, in reality, bones are constantly breaking down and building up. It’s a very dynamic process. Could you just give us a quick overview on bone physiology? Dr. Kendall Moseley 07:49-09:21 Absolutely. And I think you’ve highlighted something I always try to stress when I talk to groups of people is that bones are not these inanimate objects. I mean, we’re not these walking, kind of lumbering rocks moving down the street. In fact, we have this very important scaffold underneath our skin that enables us to walk and roll and twist and bend. And without a very strong scaffold, we’re kind of in trouble. So you’re right. Bones are dynamic. Our bones are always building up and they’re always breaking down. And it’s that process of kind of building up and breaking down that allows us to be flexible, right? If we didn’t have remodeling of our bones, we’d be very stiff and brittle. But it’s that balance, that key balance of how our bones build up and how they break down that really dictates how strong our bones can be. Clearly, you would prefer a lot more building up than breaking down. And at different parts in our life cycle or different times in our life cycle, we have different balances in that building up and breaking down. If you really want to get into the nitty gritty of the pathophysiology, which I think is important to understand because there are two very different types of cells that treatments for bone disease sometimes impact, we really boils down to these cells, one of which is called the osteoclast. It’s kind of like a little Pac-Man cell that’s responsible for breaking down our bone if it’s an area of injury or a little micro fracture. So that osteoclast will come in and kind of carve out a pit of bone so that the osteoblast, B as in build, can come in and fill in new bone. Again, to rejuvenate that area and to keep your bones flexible. Terry 09:22-09:34 And I’m assuming that as we get older, there are more osteoclasts or they’re moving faster than the osteoblasts building our bones back. Am I wrong? Dr. Kendall Moseley 09:35-10:58 No, I think that that’s a wonderful way to think about it. You know, the life cycle is complicated. You know, when I meet patients for the first time, and again, I’m in a metabolic bone clinic, so I see patients who generally come already with a diagnosis of osteoporosis or low bone density. And when we’re sitting there talking to one another, we say, gosh, why aren’t your bones perfect? And believe it or not, what we do is we go all the way back to childhood because changes happen throughout the life cycle to bones. We build or gain bone. We’re building more bone than we’re breaking down until about the third decade of life. So those osteoblasts are overtaking the osteoclast to give us nice, strong skeletons. So you might imagine how early childhood insults could impact the bones. In midlife, we have kind of a steady state where the blasts in the clasps are kind of remodeling at a usual rate, generally in balance with one another. At around the time of menopause that women go through, there is a steep decline in bone density, which is driven primarily by those osteoclasts, those Pac-Man cells that break down bone at a much more rapid rate than the osteoblasts are able to keep up with. And men have an inflection point later on in life. They don’t go through a menopause per se, but about the time, about 70 years of age or so, again, that imbalance starts to shift, which favors the osteoclast or bone breakdown, where again, it’s kind of like a tortoise and the hare story that the tortoise is no longer keeping up with the hare and the bones will break down. Joe 10:59-11:46 Dr. Moseley, I’m curious as to how things have changed, because I suspect that our ancestors, and when I say our ancestors, I’m not talking about Neanderthals. I’m talking more about our grandparents and our great-grandparents. they were probably spending a lot more time outdoors. You know, farmers and just workers and, you know, both men and women were just physically more active than we are today. Today, I think we spend a lot of time sitting. And I’m curious as to how our lifestyles have affected bone health over the last, let us say, 50 to 100 years. Dr. Kendall Moseley 11:47-13:01 Now, I think that that is a fair assessment. We know that activity movement is critical for bone health. You know, in fact, when we talk about the tenets of therapy for osteoporosis and low bone density, one of the things we always have to discuss in clinic is how can we get you more active? What kinds of exercises should you be doing? Because movement really stimulates those bones to kind of rebuild, grow, remodel. And so absolutely, you know, back in the days when we were out and about, you know, in the farms or, you know, pushing things, you know, down the street. I think we did have a lot more activity related to our bones. I will also counter, though, you know, we didn’t live as long back in the day. And so that graph that I just kind of talked about with this aging process kind of inevitably causing slow and steady bone loss as we get older, a lot of the implications for weakened bone really don’t occur until that later stage in life where women are postmenopausal or men are older. And so did we really see the full effects of osteoporosis and bone loss, you know, in prior generations when perhaps they didn’t live to be the older ages where the fracture started to manifest or people passed earlier from other conditions that we didn’t have treatments for? Terry 13:01-13:19 Dr. Moseley, I want to just revisit something you said a few minutes ago and really bring it back up because a lot of people think of osteoporosis as a women’s problem. And you mentioned men get osteoporosis too. Tell us a bit more about that. Dr. Kendall Moseley 13:20-14:28 Terry, thank you for bringing that up. It is a very important point. And oftentimes, you know, my practice is a lot of women in my practice, and oftentimes women will bring their significant others or their spouses and they listen to my spiel and they kind of turn to their spouse or significant other and they say, well, gosh, Maybe that means we need to screen you as well. And it’s true. So men do get osteoporosis. It is a misconception that this is a woman’s disease. Statistically speaking, about 10 million Americans in the United States have osteoporosis greater than the age of 50. About 8 million of those individuals being women, 2 million being men, although even that statistic I counter. One big point is that we really under-diagnose osteoporosis. We don’t name it when we see it, and secondly it relies upon screening for osteoporosis and as we’ve just said men really we don’t see this as a man’s disease so are we screening men to even be able to make the diagnosis in that portion of the population so absolutely bones thin at different times in our lives but there are still other factors other disease states other medications that can threaten a man’s Joe 14:28-14:56 skeleton just as easily as it can a woman’s well you mentioned medications and of course a lot of men who are diagnosed with prostate cancer are given hormone suppressing drugs, what we call antiandrogens. And I suspect that has a profound impact on bone strength and not just in men, in women too, because testosterone people think, oh, that’s a man’s hormone, but it’s responsible for bone strength in both men and women. Dr. Kendall Moseley 14:57-16:11 Right, right. No, absolutely. So one of the biggest offenders and we, you know, the term is iatrogenic, meaning sadly, we as doctors do this to patients, I mean, deliberately, because oftentimes we’re treating another disease state and we have no choice, but we do give patients oftentimes medications that have side effects that directly hurt the bone. One of those medications, in fact, is androgen deprivation therapy. So on prostate cancer with a goal to get testosterone levels to zero, we give them these hormone blockers. And it’s kind of like a menopause for men that they go through when we have that low testosterone. We know testosterone is converted into estrogen. So that causes low estrogen in men, which can hurt the bones. Women, there’s a corollary with breast cancer. So our breast cancer survivors, we treat with drugs such as aromatase inhibitors, where again, we render estrogen levels to zero. And we see oftentimes a significant amount of bone loss associated with those medications as well. Probably the worst drug that we use, but oftentimes very, very necessary for patients with chronic inflammation or autoimmune disease would be things like steroids. So steroids, I always refer to as somewhat dirty drugs. You know, if you need them, you need them, just like anti-cancer therapies. But those medications as well can really thin bones through a number of different mechanisms. Joe 16:12-16:36 So the anti-estrogens for breast cancer, the anti-androgens for prostate cancer, and the corticosteroids that are used for so many different conditions, including autoimmune disease and asthma and COPD, all of those medications can have a profound effect. Should everybody who’s taking one of those medications get a bone scan? Dr. Kendall Moseley 16:37-18:07 In my humble opinion, absolutely. And I think most guidelines would agree. I, you know, it depends on timing. So the low hanging fruit, the easy answer would be with your anti-estrogen medications and your anti-testosterone medications. And certainly if you know an individual is going to be treated with those drugs, it’s usually for a longer period of time. So anti-estrogen medications upwards of five to 10 years in many breast cancer survivors. Anti-androgen medications oftentimes not as long, but sometimes two years or more. And in those patients, you absolutely do want to get a screening bone density test and anticipate that in fact those medications are going to thin the bones and ideally jump ahead of that problem. And again, we have interventions we can use pharmacologically and lifestyle-wise to anticipate the bone loss and obviously treat it before it becomes a problem. Steroids are a little bit trickier. Steroids in general, we say that if a patient is going to be on a dose of prednisone or an equivalent of 5 milligrams or more for 3 months or more continuously, that would be a dose at which you certainly would want to get a screening bone mineral density test, potentially treat to prevent bone loss, depending on what that screening bone mineral density test shows, and then follow the patient more closely. We’re not as worried about the inhaled steroids. We’re not as worried about steroid injections that patients oftentimes will get for joint pains and arthritis. It really is the systemic steroids that cause the most problems. Terry 18:08-18:15 You’re listening to Dr. Kendall Moseley, Medical Director of the Johns Hopkins Metabolic Bone and Osteoporosis Center. Joe 18:16-18:21 After the break, we’ll learn the difference between osteopenia and osteoporosis. Terry 18:21-18:24 If you break a bone, does that mean you have osteoporosis? Joe 18:25-18:27 What are the options for treating osteoporosis? Terry 18:28-18:30 Exercise might be helpful. Which ones are best? Joe 18:31-18:33 Should you be wearing a weighted vest? Terry 18:39-18:42 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 18:51-18:54 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 18:55-19:13 And I’m Terry Graedon. Joe 19:13-19:21 Today, we are talking about bones. How would you know if your bones are strong or vulnerable to breakage? Terry 19:21-19:27 What options are available to maintain bone health? Are some exercises better than others? Joe 19:27-19:52 We’re talking with Dr. Kendall Moseley, Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. Dr. Moseley is Clinical Director of the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins. She’s also Medical Director of the Johns Hopkins Metabolic Bone and Osteoporosis Center. Terry 19:53-20:17 Dr. Moseley, I think there are a lot of kind of long, complicated words that we need to deal with in this interview that people may have heard or maybe not have heard, but are not completely certain what does it mean. So let’s start with the difference between osteopenia and osteoporosis. Dr. Kendall Moseley 20:18-24:09 Right. I think that’s a great question. There’s a lot of big words in the bone field, and those would be the big ones that patients bring to the office. So we have to think about bone density and bone health and bone strength along a spectrum. So, you know, spectrums are uncomfortable for a lot of people. We like to have our bins, our diagnoses. And so in the bone world, we divide things into normal. We say osteopenia, although we are getting away from that term. We more so use low bone density and then frank osteoporosis. And the World Health Organization would define those three terms based on a T-score. And what is a T-score? So To make a diagnosis, to screen for osteoporosis, we use a very specialized scan called a DEXA scan. It’s a dual energy X-ray absorptiometry scan. You can see why we call it DEXA. And it’s basically a fancy X-ray. And it’s a 2D interpretation of bone quantity, usually looking at the spine, looking at the hip. And it’s two different locations in the hip. It’s the total hip and the femoral neck. And sometimes we even look at a forearm in certain circumstances and disease states. And it’s that fancy x-ray, again, that we use to follow osteoporosis, but more importantly, to diagnose it in those in whom we’re worried that they have thinner bones. That T-score is really just a standard deviation. And the standard deviation is that individual’s bone compared to that of a 30-year-old, which seems very unfair. But as I said earlier in the segment, we really gain bone until about the age of 30. So we’re kind of comparing that patient to what their ideal should have been back in the day. A T-score, anything between 0 and negative 1 is considered normal, so normal bone density. Anything between negative 1 and negative 2.5 or 2.4, excuse me, is considered low bone density or osteopenia. And anything less than or equal to a negative 2.5, again, negative 2.5 standard deviations from normal is considered osteoporosis. And that’s what spits out on the reports, and that’s oftentimes what patients bring to the clinic. Although it’s very, very important to insert a big caveat here. People with low bone density or osteopenia can still fracture. In fact, the majority of fractures, which is the take-home message, we’re trying to prevent broken bones, the majority of people who fracture actually are in the osteopenia or low bone density range as compared to the osteoporosis range bone density. So if someone comes to clinic and maybe that DEXA scan says the T-score is a negative 1.5 or it’s a negative 1.8, which technically, again, is osteopenia or low bone density. If that same patient has also had a fracture, a fragility fracture, that patient has osteoporosis. So it doesn’t matter to me what this screening scan shows. If that bone has broken in a fragility manner, and gosh, I get that question all the time, too, so I’m going to beat you to it. What is a fragility fracture? This is a fracture of the spine, hip, pelvis, wrist, upper arm from standing height or less. So slipping outside on an icy street and bracing your fall with your wrist, if you break that wrist, that is a fragility fracture. Stepping out of the bathtub and maybe the floor is a little bit slippery and you come down hard on your hip and you have a hip fracture, that is osteoporosis. Falling out of a two-story building or a motor vehicle accident and you break your pelvis, that’s just lucky, you know, walked away with just one broken bone. So, again, fragility fractures, no matter what that bone density test is showing, whatever that score says, if you have a fragility fracture, you have a diagnosis of osteoporosis, that should be treated. It’s akin to having a heart attack, right? I don’t need a cath if you’ve had a heart attack to tell me you have cardiovascular disease and we have to take that seriously. Joe 24:09-24:51 I’ve got a question for you because our grandson, who’s seven, was running the other day at camp and he tripped and he fell and he broke his arm. That happens a lot to kids. You know, they fall off the jungle gym or they fall off their bicycle and they land and out goes their arm and boom, they’ve broken it. Now, they don’t have osteoporosis. Why would a woman who falls in a similar situation, maybe while riding a bicycle, why would she be automatically defined as osteoporotic? Dr. Kendall Moseley 24:53-26:07 Well, a woman who falls off a bicycle, that’s considered traumatic, right? So maybe it’s less than standing height because she’s sitting down on a bicycle, but she’s fallen off of a moving object going presumably at a fairly rapid speed and you get entangled in the wheels, etc. So I would probably talk through the logistics of that particular fall, and I would probably walk away saying that was more traumatic than atraumatic. Getting back to kiddos, they’re a different bird. So again, falling off of a jungle gym, that’s from a height higher than standing height. Kiddos also have just very different bones. So their bones are kind of built to be a little bit more flexible. They’re a little bit more rubbery. They remodel at a faster rate. And so they do oftentimes get these fractures, you know, tripping, falling, bonking their heads. We had that a couple of weeks ago in our household. We know those fractures heal very rapidly. Where we start to worry in kiddos, and this is probably beyond even the scope of our discussion today, is when there are multiple fractures, low trauma fractures, you know, situations in which it doesn’t make sense that that arm or that leg breaks. And then there’s a whole host of genetic conditions that oftentimes we will screen for to make sure that, in fact, that child doesn’t have a metabolic disease. Terry 26:07-26:42 Well, I think it’s important for parents to realize that a situation like that requires extra attention. But we’re not going to follow through on that any further. What I’d like to do is go back to your idea that a fracture might institute treatment. And what I mostly hear from people my age, women my age, is that they have been told by their doctor that they have to take a drug because of the osteoporosis. Joe 26:42-26:47 And a lot of them don’t want to take a drug. Or the osteopenia in some cases. Terry 26:47-27:08 Or the osteopenia. And the most popular drugs are the bisphosphonates like alendronate, which used to be called Fosamax. So what options are there for treating osteoporosis? Is bisphosphonates where you start? Or are there other things people can do? Dr. Kendall Moseley 27:10-29:57 Now, when I talk to patients, I always break it down into, gosh, what are things that you can leave here with? What is your to-do list going to look like? And that can be things like calcium, vitamin D, exercise, protein, other healthy lifestyle interventions, and we can get into that absolutely. And then there’s things that maybe I need to do, you know, when the prescription pad may need to come out. When we think about osteoporosis and how we treat osteoporosis, again, we love our bins in medicine. It helps to organize our thoughts and kind of talk to people about how we’re thinking about their disease state. And osteoporosis is no different. We think about it on a spectrum. So is the osteoporosis mild? You know, in a mild case of osteoporosis, maybe just low bone density, no prior fractures. We sometimes use a tool called a FRAX calculator that comes up in the guidelines. If we’re seeing signals that things are generally fairly positive, we might just recommend lifestyle interventions, calcium, vitamin D, some good exercise, protein, et cetera. As we move further down into the different bins, we get into different categories. So moderate osteoporosis or low bone density, where again, the DEXA scan is giving us data, we don’t like to see the numbers are decreasing. There’s maybe an increased falls happening at home. The FRAX calculations are more elevated. That might be a category in which, in addition to lifestyle interventions, we might recommend medical therapy, usually something more mild. You know, if we think about it as a swimming pool, we start in the shallow end and get a little bit deeper. That might be an oral bisphosphonate. For women, we use things called selective estrogen receptor modulators, which act on the estrogen receptors within the bone. As we wade deeper into the pool, we get into the more, you know, severe osteoporosis or, excuse me, high-risk osteoporosis or severe osteoporosis. In those categories, that’s when we start using, again, in addition to lifestyle interventions, the calcium, the vitamin D, and the exercise, that might be a place at which we do start to recommend more intense pharmacotherapy. That might still just be an oral but it may be an infusion, it may be an injection, depending on the case. What I think, though, doesn’t always matter. I think everything comes down to forming a relationship with a patient and talking through what the patient’s concerns are about their bones, what their concerns are about the logistics of a medication. Because if I think you need a daily injection, but you don’t want to do anything, there’s no point in us kind of not reaching any sort of conclusion in terms of treatment. If you’re in a very high-risk fracture category, we might want to start with a bone-building drug. But if you tell me all you’re willing to do is an oral pill once a week, I’d rather not let perfect be the enemy of good. And we might start with something milder, despite what I think. Joe 29:57-30:24 Dr. Moseley, you’ve mentioned exercise a couple of times, and we’ve gotten all kinds of recommendations with regard to exercise. You know, it has to be bouncy exercise. You have to jump up and down. You have to stress your bones. And then we’ve heard from other experts who say, you know, if you do Tai Chi, it’ll actually be good for your bones. Terry 30:24-30:24 Or yoga. Joe 30:25-30:37 Or yoga will be helpful. And so there’s just a lot of confusion around the best kind of exercise or it’s just exercise in general. Walking, will that be helpful? Dr. Kendall Moseley 30:39-32:45 Yes, yes, and yes. So my take home with patients is always just keep moving. Just keep moving. We all have physical limitations, right? There are patients who can’t, you know, run. They can barely walk. Oftentimes they’ll come in in a wheelchair and a walker, but it’s important that they move their bodies. Walking counts in terms of exercise. There are two, you know, big picture issues when we think about exercise and bone or movement and bone. And the first is, yes, is there a way that we can kind of physically tax or stress bone in a way that promotes healthy bone remodeling and bone building. And there are data in individuals who use high-intensity exercise. There was a trial called the LIFTMORE trial looking at women and men, older women and men, with supervised high-intensity exercise about three times per week and showing, in fact, there was benefit to the bone. And this is heavy weights. This isn’t just your little two or three pounders that you’re using, but in fact, supervise, you know, high weight, high intensity exercise, and they gained bone. Is that possible for all patients, to all patients have access to that sort of exercise and gyms and equipment, et cetera? Not necessarily. So the second thing we need to think about with exercise and the importance of exercise is, gosh, how do we keep you upright and fracture free by virtue of the fact you’re not falling? So if we can strengthen individuals, lower body strength, core strength, and you can get that just through walking or through yoga or through Pilates, you know, really making sure that you have a sense of self in space, keeping you from falling, that’s a victory in and of itself as well when it comes to bone strength. So, yes, I mean, would we love everybody out there lifting, you know, 30-pound weights and a supervised setting and potentially gaining some bone? That would be lovely. But I think realistically speaking, we all bring different limitations to a clinical setting. And just moving, again, just getting those legs working, just getting a sense of balance, sending people to physical therapy for balance training and core and posture, that can be just as important as getting them into a gym. Terry 32:45-33:30 Dr. Moseley, there’s something else I’d like to ask you about while we’re on this topic of physically stimulating our bones. Something that’s gotten some buzz is vibration. And there are people who have purchased pads that they stand on that vibrate to try to help their osteoporosis. there is also a device that I saw, I think it has been cleared or approved, I’m not sure which, by the FDA. You wear it like a fanny pack. It’s a belt called an Osteoboost and it vibrates for half an hour a day, provided you wear it that long. Are these devices of any use? Dr. Kendall Moseley 33:32-35:28 I think the jury’s still out. I get those questions all the time in clinic because, Again, I’m very encouraged that patients want to feel empowered with their health and they want to do things other than just take a pill or do an injection. I think it’s important. It’s a partnership that way. What can you do? What do I need to do to strengthen your bones? So vibration plates and these vibratory belts that are out there now, I think they’re trying to get at the pathophysiology of bone remodeling, which is, again, stressing bone, targeting mechanoreceptors that live in the bone that cause release or non-release of hormones that could be detrimental to bone remodeling and bone strength. And I think there’s promise there in the idea that it’s targeting, again, these mechanoreceptors in the bone. What we don’t have with either the vibratory plates or the belt are fracture data. So there are some data potentially showing stability of bone density with the use of these different devices. There are some data potentially showing some improvement in bone density. With the belt, it was only tested in individuals with low bone density or osteopenia. We don’t know in an osteoporosis population. The vibratory plate data is kind of all over the place. But what we don’t have with those devices is fracture prevention data. And that’s always hard to get. Even in the drug trials, you need thousands and thousands of study subjects to determine if that intervention is going to reduce fracture risk. So we may never have that information. So what I tell patients when they bring those, you know, pamphlets to the office or that printout or that clipping from a newspaper article is they say, I don’t think that these devices are going to hurt you at all. I think, in fact, they potentially could be beneficial to you. And how can we work those devices into our treatment plan so that, Again, you are doing things at home that may be beneficial to your bone, but I’m also keeping tabs on your bone density. And we, again, can decide together if we need to ratchet up your treatment plan to the point where we need pharmacotherapy. Joe 35:28-35:38 Dr. Moseley, I’ve been seeing a lot lately about weighted vests or sort of backpacks that are supposed to be good for you. Any thoughts about that? Dr. Kendall Moseley 35:39-36:37 Weighted vests are going to fall into the vibratory plate category and even these belts. And it’s the idea that you want to put deliberate strain on your bones to encourage them to remodel more actively. And again, this is a space where we maybe have some data showing stability of bone density, maybe a little bit of improvement in bone density. We do not have fracture data showing that weighted vests are beneficial to bone health. My challenge I have with them is depending on the vest, and there’s so many different types out there, they sometimes can cause low back pain. They can cause posture problems. We certainly don’t want anyone falling over from their weighted vest. So if there’s any hint that the vest might cause instability in the patient, I tend to be against them. But gosh, if it’s one more tool hanging by the front door that encourages someone to go outside and take a walk with their weighted vest on, by all means, I’m very optimistic that this could be something, again, to motivate people to take their bones into their own hands. Terry 36:38-37:03 You’re listening to Dr. Kendall Moseley, Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. Dr. Moseley is also Clinical Director of the Division of Diabetes, Endocrinology, and Metabolism and Medical Director of the Johns Hopkins Metabolic Bone and Osteoporosis Center. Joe 37:04-37:08 After the break, we’ll learn about raloxifene as a treatment for osteoporosis. Terry 37:09-37:12 It might reduce the risk of breast cancer as well as of bone fractures. Joe 37:13-37:20 What other drugs do doctors prescribe for osteoporosis? And what are their pros and cons? Terry 37:20-37:24 Are there problems in stopping certain bone-building drugs? Joe 37:24-37:27 Dr. Moseley will share her pillars of treatment. Terry 37:40-37:43 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 37:53-37:56 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 37:56-38:13 And I’m Terry Graedon. Joe 38:13-38:23 There are now numerous medications to improve bone health, but they all have some side effects. Which are the safest and most effective? Terry 38:23-38:41 The FDA first approved a drug called raloxifene in 1997 to prevent postmenopausal osteoporosis. The brand name was Evista. Although other osteoporosis medications approved around the same time are still in wide use, raloxifene has almost disappeared. Joe 38:42-38:52 Why don’t doctors consider raloxifene for osteoporosis? This medication has another important benefit that has seemingly been forgotten. Terry 38:52-39:18 Today’s guest is Dr. Kendall Moseley, Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. Dr. Moseley is Clinical Director of the Division of Diabetes, Endocrinology, and Metabolism and Medical Director of the Johns Hopkins Metabolic Bone and Osteoporosis Center. Joe 39:20-40:00 Dr. Moseley, we’d like to talk about treatment first and some of the medications that you do prescribe. And I’m just curious about a drug that seems to have been forgotten. I mean, it never really gained much popularity, but it’s, I think, kind of an interesting medication called raloxifene because it has both, I’ll call it pro-estrogen and anti-estrogen activity, which seems like an oxymoron. Like, how could that possibly be? But could you just give us a quick overview of a drug that seems to have gotten kind of dusty in the dustbin of history? Dr. Kendall Moseley 40:02-43:08 Sure. I don’t think of it that way as a dusty drug. We actually use a fair amount of it in our clinics because it has a role in osteoporosis care. So raloxifene is what we call a SERM. It’s a selective estrogen receptor modulator. And as you indicated, it has stimulatory properties at the level of the bone and actually inhibitory properties to tissue such as the breast and the uterus. So raloxifene is actually similar to a drug called tamoxifen that many women and men have heard of it that’s used as an anti-breast cancer medication in that patient population. So raloxifene, for starters, because it’s a selective estrogen receptor modulator, is not to be used in men. It is solely to be used in women. And we generally, as I was talking about those bins of risk, the low, the moderate, the high risk, and very high risk, we generally reserve that medication for individuals in a low to moderate risk category. And that’s because we have data showing that raloxifene, in fact, does reduce the risk of vertebral compression fractures. And again, we look at different types of bones and different fractures. We don’t have as much data demonstrating that raloxifene actually reduces the risk of hip fracture. And so when we have patients who maybe have low risk or moderate risk osteoporosis, it’s spine predominant, we see that that’s the lowest site. Oftentimes we will use raloxifene. It’s a daily pill. It’s easy to take. It’s easy to stop. It has a relatively low side effect profile. So probably the first thing I warn women is beware, your hot flashes may come back once you start this medication. Some run for the hills when I bring that up. Others say no problem. It doesn’t typically last forever, but certainly for the first few weeks or so, those hot flashes can come back. The other side effect that’s certainly more serious than the hot flashes would be that it can increase the risk of blood clots and stroke as a result. So if there’s a patient who has a history of blood clots or a clotting disorder or pulmonary embolus, again, that would not be a medication of choice. The reason it is appealing to a lot of women and certainly even our use in clinic is it doesn’t necessarily come with the more scary side effect profile that some of the other drugs have. So, again, you can start it and stop it at any time without any ramifications, no rebound bone loss. You can take it indefinitely as long as the patient is tolerating it without concern for jaw necrosis or atypical femur fractures that, again, come up with some of our other drugs. So it’s fairly easy to use. It’s inexpensive. We don’t typically have to fight the insurance companies too terribly hard to get it prescribed. So that’s helpful. And we actually wind up using raloxifene a fair amount for, again, those patients who come in and they acknowledge that their bones are less than perfect. They’re concerned about their bone health, but perhaps they’re similarly concerned about medication side effects. And again, in the interest of not letting perfect be the enemy of good, if what we decide upon is raloxifene, this daily pill that may not have that hip fracture prevention data, it’s certainly better than nothing. So again, in our bone clinics, we do use it. Joe 43:08-43:51 And the thing that I think a lot of women find very attractive about raloxifene is that it It has a breast cancer prevention piece as well as, as you pointed out, a vertebral fracture prevention piece. So it’s sort of a double benefit. But let’s move on, Terry, to some of the other medications because, as you’ve already mentioned, there are some pretty serious side effects. And you mentioned atypical femur fracture. We want to talk about the tooth problem. And we want to talk about some of the newer drugs that are injectable that once you get them, it may be in your body for six months or longer. Terry 43:51-44:04 But let’s take that one at a time. So let’s start with those bisphosphonates that Joe was alluding to. What drugs are we talking about? When do you use them? What do people need to know about them? Dr. Kendall Moseley 44:06-47:19 Right. So we can start, I guess, with the bisphosphonate category. And bisphosphonates are probably the old guard of the osteoporosis regimen. I mean, they started, you know, greater than two decades ago with use of these. And probably the one most people have heard about is alendronate. Alendronate is a once-a-week pill that’s a little bit challenging to take. You take it first thing in the morning, full glass of water, nothing else to eat or drink for an hour, no going back to bed. And these medications, the way that they work in the bisphosphonate category is they are drugs that effectively get incorporated into the bone, into the hydroxyapatite matrix of the skeleton. And once these drugs are incorporated into the bone and they come in proximity of those Pac-Man cells, see here those cells come back again. When those Pac-Man cells come along and encounter these bisphosphonates, they effectively render the Pac-Man cells, the osteoclast, useless. So they can’t break down bone anymore. they’re incorporated into the skeleton, so they do have a lasting effect. And when I talk to patients about these, we kind of think about it like coats of paint, right? So with each year that you’re on these drugs, you kind of paint the wall once again and once again and once again, and the paint can accumulate, which is why there can be concern about long-term use of these medications. And I’m going to throw five years out there, but there’s no rule that five years is a maximum amount of use you can do these. But after about five years of use, we do start to consider a pause in therapy in the appropriate patient because of these layers of pain and this, you know, potential paralysis of the Pac-Man cell and paralysis of a bone remodeling process can cause adynamic and potentially more brittle bone. You know, if your bones are frozen and they can’t rebuild and remodel themselves, we worry that that’s not healthy either for the skeleton because we do start to encounter very rarely atypical femur fractures where kind of there’s a hip fracture that happens below the, you know, kind of along the thigh, which is not anticipated, or we can see jaw complications with jaw erosion, that things can get infected, all stemming from this idea that brittle old bone can’t rebuild, remodel, and heal itself as easier as, you know, refreshed bone. There’s an IV formulation of that pill now called zoledronic acid. It’s administered once a year. So in patients who really aren’t good at swallowing pills, patients who have esophageal disorders, history of ulcers, which can be a side effect of the alendronate therapy or the oral bisphosphonates, this once a year drug can be quite helpful. It’s given through the vein over about 30 minutes. That one, typically three to five, although again, with an asterisk in the appropriate patient, sometimes we go shorter versus longer. But that drug two, similar side effect profile with rare risk, again, of these atypical femur fractures and jaw necrosis. But I always like to pause there and say, you know, these are rare side effects and we have to always consider the alternative, which are what are our real concerns about you breaking your hip or breaking your spine or losing bone in the context of that new steroid that you’ve been prescribed. So it’s always a balance talking about side effects of medicine, which they all have, and the benefit of the drug at the end of the day and reducing fracture risk. Oftentimes we have to 50 to 60 percent. Terry 47:19-47:32 And I’m supposing that there’s no really good way to predict ahead of time who might be at higher risk for one of those really awful side effects like an atypical femur fracture. Dr. Kendall Moseley 47:33-49:37 Yes, I mean, I wish I had a crystal ball. I mean, we do know that there are certain individuals at higher risk for the more rare but real side effects. So jaw necrosis, in general, the risk will be higher in, let’s say, cancer patients. So they get bisphosphonates at much higher doses, much more frequent doses. But even in osteoporosis patients, and it would typically be in the setting of what we consider to be invasive dental work. So this is if you are having an extraction, you’re having an implant, you’re having a bone graft where there’s kind of deliberate invasion of the jaw bone itself that can become subsequently infected. and the concern is that bone once infected can’t heal itself well and can, you know, erode over time. We get questions a lot about things like root canals or what about, you know, braces. Sometimes our orthodontists are worried about braces or bridges, caps. Those are not invasive. We’re not getting into the jaw in those contexts. So again, we’re less worried about that and the jaw necrosis complication. Atypical femur fracture is something that typically we have observed, and it’s been really since the onset of alendronate. Women used to get a prescription for alendronate in one hand and hormones in the other hand, and it was see “see you again never.” So we’ve learned now that with longstanding bisphosphonate use, we can see these atypical femur fractures. And that’s why I gave that five-year number a little bit ago, which is where after about five years of use, We don’t see a precipitous increase in atypical femur fractures, but we certainly start to consider, is this medication actually necessary? Because that long-term use can be a problem. We see increased risk in individuals on bisphosphonates who’ve also been treated with long-term steroids. Both conditions can cause this adynamic or frozen bone. And we know that Asian women are at higher risk for atypical femur fractures. So that’s something that we always want to consider when meeting with the patient, again, on that yearly basis to decide whether or not it’s appropriate to continue therapy versus discontinue the therapy. Terry 49:38-50:12 Now, Dr. Moseley, let’s assume that your patient has been on a bisphosphonate for five years, has stopped, comes back to you in a year or two, and you say, that osteoporosis, it’s still a problem. We’re going to move on to the next category of drugs. You have those bone-building drugs, but there’s a problem with them as well. You mentioned before that raloxifene, the SERM, is easy to stop, but some of these bone-building drugs, they could be hard to stop. Dr. Kendall Moseley 50:13-50:25 Well, I want to kind of push back a little bit on the bone-building. I think the drug you may be referring to is denosumab, which actually is a drug, which is an anti-breakdown drug, first and foremost. Joe 50:26-50:42 And Dr. Moseley, a lot of people are not familiar with generic names like Alendronate or Denosumab. So we’re talking about Fosamax in the case of the bisphosphonates, and Prolia is the brand name for Denosumab. Terry 50:42-50:46 Or is it pronounced Prolia [pro-LEE-ya]? I’m never sure exactly how, and I’ve heard it both ways. Dr. Kendall Moseley 50:47-52:44 I’ve heard it in both scenarios as well. You could probably use them interchangeably. And I’m glad you said that too. The academician in me has been taught never to use the trade names. But no, the denosumab, the prolia, or prolia, however you’d like to inflect that, that’s the one that’s an anti-breakdown drug that has more anabolic properties. So if you want to gain bone, oftentimes we do see more improvements statistically at the spine and the hip with that every six-month injection. But indeed, and I’m glad you brought this up, Terry, because it’s important, that drug, once you start it, it can be challenging to stop. That drug works very differently from the bisphosphonates. It is what’s called a RANK ligand inhibitor, which basically interferes with how the osteoclast and the osteoblast communicate with one another. But it’s a monoclonal antibody, meaning it doesn’t get permanently incorporated into the skeleton. Rather, it’s given every six months because it’s almost as though the clock strikes midnight when you stop it. And all of these cells, all of these osteoclasts that have been kind of paused for the duration of the use of the medication, if you stop it abruptly, they wake up and have a party and can actually break down your bone at a very rapid rate to the point at which we’ve even seen spontaneous vertebral compression fractures in patients who stop their medication without talking with their doctor first. So that drug gets every six months. It is not impossible to stop. In fact, we’re looking as a society at different transition mechanisms, usually, and almost, actually, I’ll say almost always with the use of a bisphosphonate to try to prevent this rebound effect of the drugs to see if patients can stop the medication. but it can be very challenging. So that drug is not for those who come to see me and don’t want to take anything or those who oftentimes have a difficult time making it to their clinic appointments. That is a drug for individuals highly committed to their bone health and very dedicated to a treatment course of 5, 10 or even beyond that years. Joe 52:45-53:28 Dr. Moseley, what about estrogen? I mean, estrogen, it seems like a roller coaster ride. Back in the, oh, I’d say 1970s, 1980s, Premarin was the number one most prescribed drug in America. Just about every woman who was going through menopause was put on Premarin. It’ll take away your hot flashes. It’ll build your bones. It’ll make you feel sexy. I mean, it’s the greatest. And then of course along came the women’s health initiative and then oh my goodness no estrogen it’s too dangerous and now it seems like estrogen is coming back again tell us a little bit about estrogen and bones. Dr. Kendall Moseley 53:29-55:08 Yes, well I mean, that’s uh, you’re right it’s a very very hot topic now and I think we’re all kind of re-evaluating how we think about estrogen not just for bone health but also women as they’re going through the perimenopause, you know, did we kind of throw the baby out with the bathwater, so to speak? We love estrogen for bones. You know, as I described earlier, women lose a tremendous amount of bone density through their perimenopause due almost entirely to this decline in estrogen. It’s like we take the brake off of the osteoclasts and they wake up and they break down a lot of bones. So we absolutely like estrogen for bones. What’s happened though, is that estrogen is really not first-line treatment for osteoporosis or low bone density, in part due to the fact that we do have these data potentially in older women showing increased cardiovascular risk, increased cancer risk. So we don’t typically use it as a first-line drug to treat osteoporosis or prevent bone loss. But if we do see women who are on estrogen for other purposes, maybe they’re on it for vasomotor symptomatology or mood or difficulty with sleeping, We certainly will keep those women off on their hormones, excuse me, and potentially add additional therapy down the road for bone health if we feel that it’s warranted. So we’re probably going to see that pendulum continue to swing back. There is a committee being formed as we speak to reevaluate this exact question about the role of menopause hormone therapy and osteoporosis treatment to see, again, if maybe we got a little bit ahead of ourselves and underestimated the importance of estrogen and bone health, particularly in younger women. as they go through the early stages of their menopause. Terry 55:09-55:21 Dr. Moseley, unfortunately, I don’t have these generic names on the tip of my tongue, but drugs like Forteo, for example, now, is that a drug that is meant to build back bone? Dr. Kendall Moseley 55:22-57:04 Absolutely. I’m glad we’re spending some time on this because it’s a very important category of medications, these anabolic or bone-building drugs that we use in these high-risk fracture individuals. So very low bone density, multiple fractures, oftentimes failing other drugs, where we have to turn to this category of bone building drugs. And there’s a few, luckily, in that category now. So starting with your self-injection medications for up until about two years, we’ve got abaloparatide and teriparatide, also known as Tymlos and Forteo. And these are subcutaneous injections that patients, in fact, give themselves. And sometimes we see those eyebrows shoot straight up when that seems to be a tall ask for the patient. But it’s a self-injection for up to two years. It’s actually parathyroid hormone, interestingly enough. So we’re harnessing the body’s own hormone, giving it back to patients in a pulsatile fashion, which can increase bone density. And then the other drug that’s slightly newer approved in 2019 called romosozumab or Evenity, which are subcutaneous injections administered monthly in a healthcare setting for up to one year, so 12 sets of injections. It should be noted that all of the bone-building drugs, the abalaparatide, the teriparatide, and the romosozumab, after that one- to two-year treatment duration have to be followed by an anti-breakdown drug. If they’re not followed by an anti-breakdown drug, either an oral bisphosphonate, an IV bisphosphonate, or denosumab, in fact, those patients very sadly can lose whatever bone they’ve gained while on treatment back down to baseline, which is always a very, very sad day when we see those patients in clinic because it’s a wasted opportunity to build good bone. Joe 57:05-57:40 Dr. Moseley, there’s one important area that we have not talked about, and that is fall prevention. You know, we talk a lot about exercise. We talk about other lifestyle changes, but avoiding a fall may be the most important thing of all in preventing a fracture of the hip or even a fracture of arms or legs or goodness knows what else. So how can not just women, but older men avoid a fall that could lead to a fracture? Dr. Kendall Moseley 57:41-59:36 Right. No, I think that’s a tremendous question. In fact, every clinic visit, when I see patients, we go through, have you had any falls this year? The first step is assessing the home. And I think the majority of falls happen in the home and it might be a throw rug. It may be furniture that’s too close together. It may be, you know, plastic toys from the grandchildren underfoot, pets. I’m not saying get rid of the grandchildren or the pets, but we do have to be conscientious about our home environment to make sure there’s grab bars on the shower. Make sure that the impediments to just walking aren’t challenging. Some people choose to move to single-story homes, you know, if stairs become too difficult. I think that’s also something to consider. But then there’s also the strengthening itself, the balance and the posture. So oftentimes we fall when we become unstable. Sometimes we don’t have a choice. There’s neuropathy, excuse me, that sets in due to nerve conditions, diabetes, et cetera. Sometimes there’s low vision that we have very little control over. But those things that we can modify, lower body strengthening, posture, core strength, which certainly over time become weaker, people become more stooped. all of those things lead to increased risk of falls. And then finally, we have to really, as clinicians especially, reevaluate those medication lists. I think geriatricians or, you know, boneheads, people across the board agree that a lot of times falls happen because of the medicines we put people on. And this can be anything from anti-diabetes medications, which can cause dips in blood sugar and cause some dizziness, to different types of nerve medications that may cause dizziness over treatment of blood pressure, where blood pressure is quite low. I see many, many falls in the context of maybe overly aggressive medication regimens, or maybe patients just aren’t talking about how they feel dizzy every single time they stand up after that new blood pressure medicine was added. But we really owe it to our patients to make sure that every drug on that medication list needs to be there, particularly as it pertains to fall safety. Terry 59:37-59:51 Dr. Moseley, we have only two minutes left of time. So I am going to ask you to summarize, please, your pillars of treatment, the things that we all need to take away from our conversation today? Dr. Kendall Moseley 59:52-01:00:03 Oh, so many pillars and so little time. So we started with lifestyle. It absolutely is important that patients really follow as healthy a lifestyle as possible. Calcium is important for bone… Terry 01:00:03-01:00:04 How much? Dr. Kendall Moseley 01:00:03-01:00:09 I know there’s a lot of debate. So calcium, the recommendation… Joe 01:00:07-01:00:09 How much and what kind? Dr. Kendall Moseley 01:00:09-01:01:27 So exactly. So the boneheads and even the cardiologists agree that calcium for those with established bone disease, again, this is not a healthy community dwelling population, but those who make it into a bone clinic who are at risk for fracture, 1200 milligrams a day, ideally through diet, ideally, but there are dietary restrictions. So if you have to take a supplement, calcium citrate is the supplement of choice. It’s better absorbed. You don’t have to take it with a meal. And in fact, it does not require an acidic environment for absorption. Vitamin D, very important. Ideally, we’re shooting for a blood level anywhere between 20 to 30 nanograms per milliliter, depending on what guidelines you look at. And for some patients, that might mean 1,000 units a day. For others, 5,000 units a day. For others, prescription strength. So that’s something to work on with their physician. Exercise so resistance training and walking counts about 150 minutes per week as high intensity is tolerated and then finally protein we really protein is having its moment so we want to aim for 0.5 grams of protein at least per pound of body weight because we know we lose muscle as we get older and that’s critical for bone health so lifestyle factors and then obviously the pharmacologic strategies as we discussed earlier if absolutely necessary. Terry 01:01:28-01:01:33 Dr. Kendall Moseley, thank you so much for talking with us on The People’s Pharmacy today. Dr. Kendall Moseley 01:01:34-01:01:42 Thank you so much for having me. And it’s always a joy to talk to people who are interested in bones. And hopefully people walk away with a few little lessons themselves today. Terry 01:01:43-01:02:08 You’ve been listening to Dr. Kendall Moseley, Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. Dr. Moseley is clinical director of the Division of Diabetes Endocrinology and Metabolism. She’s also medical director of the Johns Hopkins Metabolic Bone and Osteoporosis Center. Joe 01:02:09-01:02:18 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Terry 01:02:18-01:02:25 This show is a co-production of North Carolina Public Radio, WUNC with the People’s Pharmacy. Joe 01:02:26-01:02:55 Today’s show is number 1446. You can find it online at peoplespharmacy.com. The show notes now include a written transcript of this conversation. At peoplespharmacy.com, you can also share your comments about today’s interview and let us know what you do to keep your bones strong. You can also reach us through email. We’re radio at peoplespharmacy.com. Terry 01:02:56-01:03:19 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. In the podcast this week, you can hear how estrogen might be used to make bones stronger. What about other drugs that build bone? What practical steps could you take to prevent falls and avoid breaks? Joe 01:03:19-01:03:43 At peoplespharmacy.com, you can sign up for our free online newsletter to get the latest news about important health stories. When you subscribe, you also have regular access to information about our weekly podcast. We’d be grateful if you would consider writing a review of The People’s Pharmacy and posting it to the podcast platform you prefer. In Durham, North Carolina, I’m Joe Graedon. Terry 01:03:43-01:04:21 And I’m Terry Graedon. Thank you for listening. Please join us again next week. Thank you for listening to The People’s Pharmacy Podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money. Joe 01:04:22-01:04:31 If you like what we do and you’d like to help us continue to produce high-quality, independent healthcare journalism, please consider chipping in. Terry 01:04:32-01:04:36 All you have to do is go to peoplespharmacy.com/donate. Joe 01:04:37-01:04:50 Whether it’s just one time or a monthly donation, you can be part of the team that makes this show possible. Thank you for your continued loyalty and support. We couldn’t make our show without you.
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  Show 1480: The Sleep Reset: How to Fall Asleep and Stay Asleep 16.07.2026 1ชม. 6นาที

  Do you have trouble sleeping? An occasional late night or early morning is probably not dangerous, but too many people get too little sleep on a regular basis. How does that affect their health? Even more importantly, what can they do to change the situation? You’ll want to listen to find out if you need a sleep reset. At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, July 18, 2026, through your computer or smart phone (wunc.org). Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on July 20, 2026. The podcast will be available on Monday (July 20, 2026) Do You Need a Sleep Reset? Why is sleep so important for good health? Our guest is a sleep medicine specialist who uses a metaphor of Disneyland. Crucial maintenance on the theme park happens at night, when there are no visitors. Streets are cleaned, flower beds are weeded, and rides are inspected and, if needed, repaired. None of that can happen while the park is open for business. Our bodies and brains also need time for maintenance and repair, and some of that happens while we are sleeping. When we don’t get the rest we need, we may find ourselves at increased risk for diabetes, cardiovascular problems, cancer, cognitive challenges and even premature death. Unfortunately, anxiety about not sleeping can keep people awake all on its own. How can people break that cycle? We’ll also discuss ways that people can get help avoiding screens at night. That is an important part of a sleep reset. Blue light from the screen signals the brain to be alert instead of relax. Scrolling social media can often be emotionally upsetting, which also makes it more difficult to fall asleep. Is Your Diet Keeping You Awake? Most of us recognize that a big midnight snack, á la Dagwood Bumstead of the Blondie comic, is probably not conducive to sleeping well. How does nighttime eating affect our circadian rhythm? Are there diets that we should avoid because of their impact on sleep? Dr. Seheult describes a study in which volunteers had their sleep stages monitored closely during the time they were consuming different diets (Obesity, July 2023). When they followed a high-fat, high-sugar diet, it disturbed the pattern of their brain waves during what should have been restorative sleep. How Do Sleep Problems Affect Eating Habits? A lot of us are aware that when we are sleep deprived, we are more inclined to become hangry and we may be less discerning about what we eat. A recent study shows that the sleep deprivation can have an effect even if it is fairly mild and short-term. Scientists recruited people who normally sleep seven to eight hours a night and asked them to stay up an extra hour and a half (Annals of Internal Medicine, July 7, 2026).  During the six weeks of that part of the experiment, people were less active during the day. They also ate more, so they gained about a pound, on average, during those six weeks. Presumably, disrupting sleep for a longer period of time would result in greater weight gain and metabolic disruption. Would a Ketogenic Diet Help with a Sleep Reset? A ketogenic diet, in which the body relies on ketones rather than glucose for energy production, may be helpful. In particular, fasting overnight for at least 14 hours helps the body do what it must during sleep time. To figure out when you should stop eating, identify when you usually start to feel sleepy. That should be your bedtime. Having your last meal of the day about three hours before that will generally offer enough time for digestion so that you don’t experience reflux in the middle of the night. Morning Light and Afternoon Naps Your sleep reset may depend on getting your own circadian rhythm to synchronize with the rest of the world. That is where early exposure to morning light comes in. It’s beginning to feel a bit like The People’s Pharmacy is on repeat: get morning light exposure! It sets your system up for feeling awake and alert during the day and starting to feel sleepy as the light fades in the evening. Obviously, this is most helpful for people who work during daylight hours. Those working overnight shifts would have to organize their days differently. People who have trouble falling asleep may be tempted to take a nap in the afternoon to make up for the lost sleep. That could be a mistake, as it relieves the sleep pressure that helps people fall asleep without trying. Learning to Fall Asleep If you interact with parents of very young children, you may have heard of sleep training. People have strong feelings about this, both pro and con. Adults rarely need sleep training, though. What we are more likely to need is “not-sleeping un-training.” Too many people approach the bedroom as though it were a stage, and sleep is the performance. No wonder they may develop some performance anxiety about sleeping! Other individuals have learned to associate the bedroom with tossing, turning and watching the clock. Consequently, their bodies tense up instead of relaxing when they get between the sheets. There is no easy quick fix for this problem, but cognitive behavior therapy for insomnia has been proven effective for most people. How About PM Pain Relievers? Even though there isn’t an easy fix for sleep troubles, many people want one. They reach for the PM pain reliever and hope it will offer them a good night’s sleep without a prescription. The “PM” part of that pain reliever is an old-fashioned antihistamine called diphenhydramine. You might be more familiar with its brand name: Benadryl. You’ll also find it in Tylenol PM, Advil PM and all the other PM meds because it tends to make people feel drowsy. What’s wrong with that? To start with, it isn’t clear that it remains effective after a week or two. In addition, people with restless leg syndrome often find that it makes their condition worse. Other folks report that diphenhydramine can result in an unpleasant “hangover” the next day, in which they feel drowsy though not asleep for a good part of their waking hours. What Wakes You Up at Night? If your sleep problem is waking in the wee hours and having trouble getting back to sleep, you should consider the possibility that you have sleep apnea. The REM sleep of those early morning hours is not as deep as some other sleep stages. Consequently, an alarm signal from your brain saying you haven’t taken a breath for 20 or 30 seconds may be more likely to wake you. Sleep apnea may be treated by providing air so that the pressure props the collapsing airway open. We discuss this in greater detail along with a new alternative to a CPAP machine in the podcast for this week. This Week’s Guest Dr. Roger Seheult is an Associate Clinical Professor at the University of California, Riverside School of Medicine. He is also an Assistant Clinical Professor at the School of Medicine and Allied Health at Loma Linda University. He is quadruple board-certified in Internal Medicine, Pulmonary Diseases, Critical Care Medicine, and Sleep Medicine through the American Board of Internal Medicine. His current practice is in Beaumont, California. He is a critical care physician, pulmonologist, and sleep physician at Optum California. Dr. Seheult lectures routinely across the country at conferences and for medical, PA, and RT societies. He is the director of a sleep lab and the Medical Director for the Crafton Hills College Respiratory Care Program. He is co-founder and presenter for MedCram.com, a site that offers concise and easy-to-follow medical videos on a range of topics. Roger Seheult, MD, MedCram, Loma Linda, UC-Riverside Listen to the Podcast The podcast of this program will be available Monday, July 20, 2026, after broadcast on July 18. You can stream the show from this site and download the podcast for free. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.
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  Show 1479: Must You Shun the Sun to Save Your Skin? 10.07.2026 1ชม.

  When sunny summer days come around, it makes some dermatologists shudder. They would prefer we behave like bats and hide in caves until nightfall. Failing that, they stress the importance of always applying (and re-applying) high SPF sunscreen, wearing sun-blocking clothing with long sleeves and keeping a big-brimmed hat firmly on the head. A beekeeper’s outfit might be perfect. But must you really shun the sun completely to save your skin? Our guest describes how to practice moderation safely. He also explains why some people are addicted to sunshine, while others are allergic to it. At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, July 11, 2026, through your computer or smart phone (wunc.org). Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on July 13, 2026. Can You Really Be Addicted to Sunlight? Dermatologists do their best to discourage people from using tanning beds. They describe the damage that ultraviolet light can cause, ranging from wrinkles to skin cancer. For some people, though, those arguments just don’t make a difference. Our guest, Dr. Steve Feldman, conducted a study several years ago. The volunteers were accustomed to using tanning beds. In the study, there were two beds, one with the usual ultraviolet light and the other, identical in appearance and temperature, had its UV blocked. After a session in each bed, volunteers were allowed to choose their bed for the last session. They almost invariably chose the bed with the active UV. To follow up, the researchers administered naltrexone, the opioid-blocking medication. When volunteers had taken it, they were no longer able to distinguish which bed was active. It seems that, for these people, ultraviolet light activates pro-opiomelanocortin, which in turn triggers the production of natural opioids called endorphins. Further research imaging the brain during tanning sessions confirmed that the UV exposure was activating areas of the brain associated with pleasure (Psychiatry Research. Neuroimaging, May 30, 2016).  Dr. Feldman and a colleague found that excessive indoor tanning is similar in pattern to substance use disorders (Journal of Cutaneous Medicine and Surgery, May-June 2025). Can You Save Your Skin and Still Enjoy the Outdoors? Dr. Feldman offers advice on avoiding sunburn that is tempered with this fact from epidemiology: people who go out in the sun live longer (International Journal of Environmental Research and Public Health, July 13, 2020).  The goal here is not to shun the sun completely, but rather to exercise enough caution and good judgment to avoid burning your skin. (Who wants to burn, anyway? It hurts, and it looks bad.) Timing your sun exposure carefully is crucial to save your skin from sunburn. You may also be interested in the new sunscreen ingredient the FDA just approved, bemotrizinol. What Can You Do About Heat Rash? When the weather gets hot and bodies get sweaty, heat rash becomes a common complaint. Sweaty skin may develop bumps that can sometimes be very itchy. What do you do to ease the discomfort? If you can cool the skin off, it might help a lot. Of course, people may also suffer from other types of rash. Babies get diaper rash. Women sometimes experience under-breast rash, just as men may develop jock itch. Zinc oxide ointment can often be helpful for these types of rash. Managing Psoriasis Psoriasis is one of Dr. Feldman’s special research interests. The red scaly plaques of this skin condition have raised borders. They look a lot like a fungal infection, but there is no fungus present on the skin to cause them. Something else seems to trigger the skin’s immune system to react along the same pathways as if there were a fungus. Most of the time, psoriasis is mild enough to manage without costly medications. It actually responds very well to ultraviolet light exposure. UV downregulates the immune system’s over-response. While many dermatologists offer UV exposure within their office walls, in the summertime patients could get exposure to sunlight outdoors. This is practical if they avoid the middle of the day, when they might get burned. Another option? Tanning beds also offer an easy way to calibrate the appropriate amount of UV exposure to save your skin from psoriasis. (Most dermatologists don’t approve of this one, so don’t tell.) One other practical but unorthodox tip for dealing with mild psoriasis. OTC cortisone may not be strong enough to help heal up a red spot. But you could buy Flonase nasal spray or a generic version, fluticasone, over the counter. Spray it on your skin and appreciate the relief. In fact, this could work for a mild case of poison ivy or other skin irritation as well. Severe cases still need a dermatologist’s care. What to Do About Atopic Dermatitis Atopic dermatitis is the medical term for eczema. People with allergies or asthma also appear to be more vulnerable to eczema. Dysregulation of the immune mediators interleukin 4 (IL4) or IL13 may be responsible. This condition may appear in a mild form, which can be readily managed, or a more severe form that might require prescription medication. A topical corticosteroid such as triamcinolone will often clear it up. Or you could try spraying on some Flonase nasal spray for a cost-effective low-key approach. Those will actually help the majority of people with mild eczema. Using mild soap rather than detergent-based body wash, moisturizing well and following an anti-inflammatory diet are the pillars of home management. People with more severe atopic dermatitis covering a large portion of the body may need powerful prescription medication rather than topical steroids. Trying to cover so much skin with steroid would probably result in side effects from the cream. Dupixent (dupilumab) is a relatively new self-injectable medication that blocks IL4 and IL13. It works well for most people with atopic dermatitis and has a good safety profile. Certain other drugs in this category, such as Skyrizi (risankizumab), are also pretty safe but very pricey. Stelara (ustekinumab), has been around longer. Biosimilars for Stelara have been approved and are more affordable. Ustekinumab blocks IL12 and IL23. TV ads tout other medicines for this condition as well. Rinvoq (upadacitinib) is three or four times more effective than Dupixent, but it is also super expensive. It is a Janus-kinase (JAK) inhibitor. Xeljanz (tofacitinib) is another potent prescription JAK inhibitor, but it carries an elevated risk of heart attack. Beware of Bug Bites Another summer skin hazard is bug bites. Here unquestionably the best approach to save your skin is avoidance. Appropriate clothing is key. (That beekeeper’s suit will come in handy here again.) Dr. Feldman recommends spraying DEET on your pants legs, socks and sleeves rather than directly on your skin. If there are grasses or brush where you have walked, run or played, a tick check immediately upon coming inside is critical. Can AI Help Patients with Skin Problems? It doesn’t make sense to tell people to stay off the internet. Some searches can be quite helpful and guide patients in asking their dermatologist the right questions. Dr. Feldman is enthusiastic about DermNet, a New Zealand dermatology website. https://dermnetnz.org  Joe and Terry recommend SkinSight. This Week’s Guest Steven R. Feldman, MD, PhD, is Professor of Dermatology, Pathology, and Social Sciences & Health Policy, at the Wake Forest University School of Medicine.  His research has been published in over 1,000 peer reviewed, Medline-referenced articles. Expertscape.com ranks Feldman among the top experts in the world on psoriasis, acne, dermatology, and treatment adherence. Steve Feldman, MD, in Dermatology clinic, Country Club Commons Listen to the Podcast The podcast of this program will be available Monday, July 13, 2026, after broadcast on July 11. You can stream the show from this site and download the podcast for free. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.
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  Show 1412: Beyond Amyloid: The Science That Could Change the Course of Alzheimer Disease (Archive) 02.07.2026 1ชม. 14นาที

  This week, we look at the new pharmaceuticals that the FDA has approved for treating Alzheimer disease. Although they are effective at removing amyloid plaques from the brain, they don’t seem to help patients function better. Is it time to turn away from an exclusive focus on amyloid to consider other factors that might affect cognitive decline and change the course of Alzheimer disease? At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen You could listen through your local public radio station or get the live stream at 7 am EDT on your computer or smart phone (wunc.org). Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on July 6, 2026. Changing the Course of Alzheimer Disease Even though pharmaceutical firms have spent billions of dollars developing drugs to reduce amyloid in the brain, they haven’t changed the course of Alzheimer disease. Perhaps we need to be looking beyond amyloid at other risk factors. Dr. Dale Bredesen says he and his colleagues have identified more than 36 risk factors. He asserts that when these these are addressed, people can slow or sometimes even reverse their cognitive decline. According to Dr. Bredesen, Alzheimer disease is multi-factorial and it needs a multi-pronged approach. Considering Physiology Instead of Pathology The plaques and tangles that are characteristic of the brain disease first identified by Alois Alzheimer more than 100 years ago only show up in pathology slides. Past studies have hinted that some individuals who have plaques or tangles in their brains don’t have serious cognitive difficulties. Dr. Bredesen urges us to look beyond amyloid pathology and use a physiology lens. What are the main drivers of problems? Energetics Our bodies need to make, use and transfer energy efficiently. That involves the mitochondria, the energy factories within the cells. Nutrition is also critical here, as missing vitamins can block appropriate metabolism. The cardiovascular system is also crucial for the transfer of energy within the body and to the brain. Sleep apnea, which interferes with oxygen uptake overnight, is another big culprit. Inflammation Inflammation in the brain or even elsewhere in the body puts a huge strain on the neurons. Identifying and removing the sources of inflammation is important in treating someone struggling with cognitive problems. Where is the inflammation coming from? It might be an infection. Treatment can make a difference there. It might be dietary, in part. Changing the diet could change the course of Alzheimer disease. Wouldn’t that be worth the effort? Toxicity Heavy metals such as lead or mercury are definitely neurotoxic. However, other substances can also put neurons at risk. Toxins produced by mold are common and very difficult to treat. Additional Factors to Consider There are at least three additional categories that should be considered. Do we have the essential ingredients to create the neurotransmitters we need? One example would be choline for acetylcholine, an essential neurotransmitter that may be in short supply in Alzheimer disease. Most American diets are not rich in choline. Second, how are the neurotrophins doing? These are substances such as BDNF, brain-derived neurotrophic factor. It supports the growth and differentiation of neurons. Third, and possibly most common, is chronic stress. Occasional acute stress is expected and shouldn’t be considered harmful. But chronic stress can damage neurons and make it harder to think even if your neurons are not damaged. High cortisol levels are associated with brain atrophy, which is a clear indication of damage. Fixing the Leaks Dr. Bredesen uses a metaphor of the brain as a house with a leaky roof. If you have a lot of places where the roof leaks, you need to fix all of them to stay dry. But your roof may leak in different places from your neighbor’s roof. Finding the weaknesses and addressing them with personalized medicine is key to changing the course of Alzheimer disease, in Dr. Bredesen’s opinion. It may require attention to diet, exercise, sleep (with adequate oxygen saturation), stress management, brain training, detoxification and possibly supplements such as omega-3 fats or vitamin D. You can learn more from his books and his recent publication in Biomedicines (Aug. 6, 2024). This Week’s Guest Dale Bredesen, MD, is an internationally recognized expert in aging and neurodegenerative diseases. He is the Senior Director of Precision Brain Health at Pacific Neuroscience Institute, and former Professor of Molecular and Medical Pharmacology at UCLA. Dr. Bredesen is also the founding President and CEO of the Buck Institute for Research on Aging and the Co-founder of MPI Cognition. Dr. Bredesen is the author of the New York Time’s best seller The End of Alzheimer’s: The First Program to Prevent and Reverse Cognitive Decline and The First Survivors of Alzheimer’s: How Patients Recovered Life and Hope in Their Own Words. The People’s Pharmacy is reader supported. When you buy through links in this post, we may earn a small affiliate commission (at no cost to you). Listen to the Podcast The podcast of this program will be available Monday, July 6, 2026, after rebroadcast on July 4. You can stream the show from this site and download the podcast for free. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.
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  Show 1478: The Outdoor Prescription for Fighting Dementia, Depression and Heart Disease 25.06.2026 1ชม. 5นาที

  Too many of us are spending our days staring at screens. Little screens on our phones, big screens on the television, medium-size screens on our computers at work. Our modern lifestyles mean that we spend the vast majority of our time indoors–93%, on average. What is the time inside doing to our health? Is there an outdoor prescription to reverse dementia and depression? At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, June 27, 2026, through your computer or smart phone (wunc.org).  Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on June 29, 2026. What Is Our Indoor Time Doing to Us? Humans used to spend a lot of time outside and had their circadian rhythms synchronized with sunlight. Living indoors as most of us do can disrupt that natural rhythm. Bright indoor lighting as well as our favorite screens in the evening can make sleep more elusive. Another consequence of focusing on screens rather than on a distant horizon of land, sea or sky is an increased risk of nearsightedness. Beyond that, screen exposure can increase the chance of brain fog, insulin resistance and immune system abnormalities. If you are spending all your time inside, your body may process that as captivity and begin to rebel. The Outdoor Prescription Dr. John La Puma pioneered culinary medicine, making the connection between what we eat and the state of our health. His analysis of the research indicates that spending just 17 mindful minutes outside each day can help reverse the damage we suffer from living indoors. He offers seven types of outdoor prescription, starting with morning light. Greeting the Sun as the Day Begins Dr. La Puma encourages us all to start our day by stepping outside for at least a few minutes under the open sky. Before coffee, before screens, morning light gets us off to the right start and helps us sleep better at the end of the day. That light exposure, even on an overcast day, helps us with deeper sleep at night. Deep sleep is critical for maintaining the brain with the glymphatic system as well as for bolstering the immune response. Before checking your email or your social media, perhaps while the coffee is brewing, make it a point to step outside for a few minutes. If that is too difficult, standing in the doorway or just looking outside through a window screen (not glass) may be enough. Bright morning light exposure is helpful in treating major depressive disorder (JAMA Psychiatry, Jan. 2016). Although the study utilized standardized indoor lights, natural light outside is brighter, even on a cloudy day. New research shows that bright light during the day reduces the risk of dementia among older people (General Psychiatry, June 24, 2026). The benefit was especially clear for those who spent more time in brighter light (at least 5,000 lux) such as one would get on an overcast day. It was even able to mitigate some of the risk associated with APOE4 genes. What Is Forest Bathing? Another practice in Dr. La Puma’s outdoor prescription pad is forest bathing. This idea comes from Japan. Spending time outdoors in a forest environment is extremely healing. It can help modulate the immune system, lower blood pressure and counteract stress. Forest bathing does not require a huge investment of time, either. One Japanese study found that spending just two hours a month in a forested environment can lead to lower blood pressure and reduce techno-stress. A review has found forest bathing beneficial against stress and burnout (International Journal of Environmental Research and Public Health, July 28, 2017). https://pubmed.ncbi.nlm.nih.gov/28788101/ No Forest? No Problem Many people do not have an actual forest handy. Dr. La Puma describes his outdoor prescription for Sarah, who felt stuck inside her city apartment all the time while she cared for her elderly mother. What he prescribed for her was mindful time in the courtyard of her building, starting with very short periods of five to ten minutes. Gradually her heart rate slowed and blood pressure lowered and she began to recover from some of the chronic problems she had been suffering. Forest-bathing doesn’t really require a forest. One tree, or in a pinch, a shrub, can be pressed into service. Meet Your Friends Outdoors There are few things better than spending time outdoors. One outdoor prescription that improves on spending time in nature by yourself is spending some of that outside time with friends. Walking, playing tennis, going for a picnic all help your system recalibrate. Human friends are important, but animals such as dogs or horses can also contribute to our well-being (as we contribute to theirs) when we spend time with them in a natural space. Taking Your Physical Activity Outside We all have heard how important it is for us to stay active if we want to maintain good cardiometabolic health, diminish our risk of depression and enhance our chances of staying cognitively sharp. There are advantages to outdoor activity that include but go beyond the benefits of exercise. You can accomplish the same amount of exercise with less perceived effort. In addition to light, and possibly horizons, you also get beneficial microbial exposure and a lot of joy. Gardening as an Outdoor Prescription A healthful diet begins with healthy organic soil. Gardening is a great way to experience this for yourself. We asked about people who do not have space for a backyard garden and heard about Greg, who learned to garden starting with a single basil plant indoors. Minimum Effective Dose for the Outdoor Prescription Dr. La Puma tells us that the minimum dose to get the benefits of being outdoors is just 17 minutes a day. That’s not very much compared to all the time we spend inside. This Week’s Guest Dr. John La Puma is a board-certified internist, trained chef, and regenerative farmer who pioneered the Culinary Medicine movement. He is now leading the charge behind Outdoor Rx, the evidence-based response to the indoor epidemic. Dr. La Puma’s latest book is Indoor Epidemic: 93% Inside Steals Sleep, Focus & Years—The 7% Outdoor Rx Restores Them The People’s Pharmacy is reader supported. When you buy through links in this post, we may earn a small affiliate commission (at no cost to you). Get his free 7-Day Outdoor Reset at IndoorEpidemic.com His book is featured in the June “Touch Grass” challenge from the New York Times. John La Puma, MD, advocates for the Outdoor Rx Listen to the Podcast The podcast of this program will be available Monday, June 15, 2026, after broadcast on June 13. You can stream the show from this site and download the podcast for free. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.
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  Show 1477: Answering Your Questions About Vision Problems 18.06.2026 58นาที

  Humans have five senses, but for most of us, sight dominates. That’s why vision problems are so distressing. Have you been dealing with difficulties with your eyes? During this broadcast episode, our guest expert is ready to answer your questions about vision problems. At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, June 20, 2026, through your computer or smart phone (wunc.org).  Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on June 22, 2026. On this episode, we will be taking calls from listeners. You can ask your question ahead of time by emailing radio@PeoplesPharmacy.com. Or call 888-472-3366 directly between 7 and 8 am EDT on Saturday, June 20, 2026. Are More People Nearsighted? Myopia, the technical term for nearsightedness, is increasing at a rapid rate. Globally, 23 percent of the world’s population had myopia in 2000. By 2020, that rate had risen to 34 percent. Some experts estimate that it could reach 50 percent by 2050. Rates among children and adolescents are even higher in some places, reaching 70 percent among East Asians and an alarming 86 percent among Singaporean Chinese youth 15 and under (British Journal of Ophthalmology, July 2016).  Why are so many people, including young people, myopic? Are there implications beyond a need for corrective lenses (glasses or contacts)? Can we reverse this trend by limiting screen time or encouraging more time outdoors? Are there treatments that can help children and adolescents improve their vision? Which Vision Specialist Should You See? Eyes are complicated, and caring for vision problems has become increasingly specialized and technically sophisticated. As a result, ophthalmologists (eye doctors) now often treat just one part of the eye, such as the retina or the cornea. Some surgeons specialize in removing cataracts. Others, like Dr. Sharon Fekrat, are expert in retinal surgery. There are also pediatric ophthalmologists who treat children. In addition, some people need to consult a neuro-ophthalmologist or someone who specializes in inherited retinal degenerations, uveitis or ocular oncology. How can you determine which type of eye doctor you should see to address your particular problem most effectively? What Is in a Complete Eye Examination? Dr. Fekrat will describe the elements of a complete eye examination. Why is each one included? What further steps are needed if trouble is detected? This will give you an idea of how vision problems are assessed and where to turn for treatment. Managing Dry Eyes One of the most common complaints is dry eyes. This condition is uncomfortable as well as common, affecting up to half of adults in the US. What are the causes? Are there treatments? People often use eye drops to alleviate the discomfort. Which ones work best? What can a person do if they have severe dry eye problems and are referred to a dry eye specialist with an appointment months in advance? Is it dangerous to postpone dry eye care? What to Do About Blepharitis When the problem is more the eyelid than the eye itself, doctors call it blepharitis. One typical symptom is crust on the lids, which may feel itchy or scratchy. Some people find that applying warm compresses morning and evening is helpful. Others need medication. You may have seen ads for Xdemvy, which is aimed at reducing the population of Demodex mites living in the follicles of the eyelashes. Mites are not the only problem, however. Sometimes bacterial infections are the underlying cause of blepharitis. Rosacea and seborrheic dermatitis that affect skin elsewhere on the face may also show up with the same symptoms.  Topical ivermectin cream has been used off-label on the eyelid margins and may help reduce Demodex mites, but it is not an FDA-approved eye treatment and should only be used under an eye clinician’s direction because it is not intended for instillation into the eye. How Will the Doctor Diagnose Glaucoma? Glaucoma is generally understood as a condition in which pressure inside the eye rises and damages the optic nerve. This disease can lead to vision loss. That’s why intraocular pressure measurement should always be part of the eye exam. But this simple diagnostic technique alone may be incomplete. We’ll ask Dr. Fekrat about additional approaches that might pick up normal-pressure glaucoma. How is it treated? Age-Related Macular Degeneration Deserves Treatment Another of the vision problems that can cause serious impairment is age-related macular degeneration. In this disorder, the central part of the retina, the macula, loses its ability to focus. Patients may notice that the central part of the vision is blurry, and it may be harder to see under low light conditions. Ophthalmologists now have a range of medications to inject to slow the progression of macular degeneration. Dr. Fekrat can describe the difference between “dry” and “wet” macular degeneration and the drugs used to treat them. What Other Vision Problems Are Troubling You? This is a chance to ask questions and get answers about vision problems from an expert. You can send email to radio@PeoplesPharmacy.com or call in your questions to 888-472-3366 between 7 and 8 am EDT on Saturday, June 20, 2026. This Week’s Guest Sharon Fekrat, MD, is a retina surgeon at the Duke Eye Center of the Duke Health Integrated Practice and vice chair of faculty affairs and the Robert Machemer MD Distinguished Professor of Ophthalmology at the Duke University School of Medicine. She is associate chief of staff at the Durham VA Healthcare System and past interim chief of surgery there. She is Director of Duke iMIND Research Group and Chief Editor of the book All About Your Eyes as well as the Digital Journal of Case Reports of Ophthalmology. Dr. Fekrat is past President of the NC Society of Eye Physicians and Surgeons. The People’s Pharmacy is reader supported. When you buy through links in this post, we may earn a small affiliate commission (at no cost to you). Sharon Fekrat, MD, FASRS, Duke Eye Center Listen to the Podcast The podcast of this program will be available Monday, June 22, 2026, after broadcast on June 20. You can stream the show from this site and download the podcast for free. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.
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  Show 1476: Tell Me Where It Hurts: A Roadmap for Managing Chronic Pain 11.06.2026 1ชม. 12นาที

  Pain is an important warning signal, helping you protect your body from damage. That’s why we can view acute pain as an asset. Chronic pain, though, can be debilitating. In this episode, a pain psychologist offers a roadmap for managing chronic pain. At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, June 13, 2026, through your computer or smart phone (wunc.org). Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on June 15, 2026. Managing Chronic Pain Nobody likes feeling pain. Joe remembers that as a child, he would ask the doctors and nurses if the procedure was going to hurt. They always lied and told him it would not. As a result, he ended up not trusting them. We often think of pain as located in the body part that hurts (hence, tell me where it hurts). In actuality, though, pain is a complex phenomenon the brain and its interpretation of the situation at least as much as the body. That is why Dr. Rachel Zoffness maintains that pain is biopsychosocial–the result of three overlapping circles in a Venn diagram: biological, psychological and sociological. The biological circle includes our genetics, tissue damage, diet, sleep and movement. Psychological factors are never just psychological. The brain uses the same limbic system to process emotions and pain, so our feelings about our situation have a major impact on our pain experience. In the sociological realm, we find access to care, a history of trauma, and factors like racism or poverty. One result is that pain is incredibly subjective, varying from one individual to another and even from day to day. Another example of the power of the brain to generate pain is phantom limb pain. You may have heard of someone whose foot hurts even though the leg was amputated. Dr. Zoffness tells us about a boy with hand pain after a fireworks accident that resulted in his arm being amputated. The hand wasn’t there, but the pain was real. What Is Your Pain Recipe? In managing chronic pain, it helps to know what your pain recipe is. What factors contribute to a bad pain day? A few common ones are poor sleep, too much junk in the diet, lots of stress, too little movement. Once you have the recipe for a bad pain day, you may be able to turn that around to find the recipe for a low pain day. If you get enough sleep, does that turn down the pain dial? How about diet? We also discuss the power of self-hypnosis and biofeedback. If you can practice warming your hands up, as Dr. Zoffness has learned to do, you can also practice making yourself more comfortable. She shares another story of a teenager who suffered from crippling migraines, social anxiety and generalized body pain. He had not been to school in years, but taking very small steps at first–just standing in the sun on his front porch–he was gradually able to build himself a low-pain recipe. Taking the dog to the dog park helped him move his body and his brain started producing chemicals like dopamine and serotonin. Eventually Sam was able to return to high school, even graduating. Using Pain Medicines in Managing Chronic Pain Physicians have often learned that managing chronic pain is something of a prescription puzzle. Which drug will work best for this patient? A decade or more ago, the answer was frequently opioids. That’s no longer the case. As a result of the overdose epidemic, doctors usually try to prescribe some other type of medication. Two of the most popular are gabapentin and tramadol. When our listeners tell us about their experience with gabapentin, the results range widely. For some people, it seems to be a life-changing medication. For many others, it is lackluster at best, and for some, the side effects of brain fog, dizziness, breathing problems, edema and an increased risk of dementia are too much. Dr. Zoffness has heard similar reports about gabapentin. Her guideline for pain medicine is to try it for three months and see if it makes a (positive) difference. If not, ask the prescriber to help you taper off. Stopping any pain medicine suddenly could be a mistake. For managing chronic pain, people need a healthcare professional who can help them create a personalized pain management plan. For improving sleep, which is often a key ingredient in the pain recipe, she recommends cognitive behavioral therapy for insomnia (CBTI). The sleep hygiene protocol she suggests can also be helpful, dimming lights and gearing down as the day comes to a close. The Roadmap for Managing Chronic Pain The last section of Dr. Zoffness’s book is a detailed pain protocol. She reminds us that there is no quick hack for pain. If trauma is part of the pain recipe, addressing the trauma will be useful. Medications are important tools, but they are not a permanent fix for chronic pain. She wants us all to remember that if the brain can change, pain can change. It is in our power. This Week’s Guest Dr. Rachel Zoffness is a leading global pain expert, pain psychologist, speaker, author, and thought leader in pain medicine. She is faculty at the UCSF School of Medicine, teaches pain science at Stanford, and is a winner of the prestigious Mayday Fellowship. Dr. Zoffness is the author of Tell Me Where It Hurts: The New Science of Pain and How to Heal. Her website is www.zoffness.com Dr. Rachel Zoffness, pain expert at UCSF The People’s Pharmacy is reader supported. When you buy through links in this post, we may earn a small affiliate commission (at no cost to you). Listen to the Podcast The podcast of this program will be available Monday, June 15, 2026, after broadcast on June 13. You can stream the show from this site and download the podcast for free. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.
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  Show 1475: Your Allergy Survival Guide: What Works, What Doesn’t, What’s Risky 03.06.2026 1ชม. 10นาที

  You may think of allergies as causing sniffly noses and congestion in the spring or fall. But allergies can go far beyond that. As Dr. Kari Nadeau points out in this episode, allergies can affect us from head to toe, including eyes, nose, throat, lungs, sinuses, skin and gut. In the most dangerous instances, the whole body is threatened with an anaphylactic reaction. That’s a medical emergency! One in three Americans will develop allergies at some point in our lives, so it’s important to know what works to control them. At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, June 6, 2026, through your computer or smart phone (wunc.org).  Here is a link so you can find which stations carry our broadcast. (Welcome, Huntsville, Alabama!) If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on June 8, 2026. What Are Allergies? We begin our discussion of your allergy survival guide with an explanation of what is happening during an allergic reaction. The immune system perceives some foreign compound, usually a protein, as dangerous even though normally it would not be. So it reacts by trying to flush the invader out by producing extra mucus. The turbinate sinuses can make one to two gallons of mucus a day, and naturally, it has to go somewhere. That’s why you might be congested. Having all that mucus in the sinuses can also encourage bacterial growth, so if the allergic reaction persists, some people have to deal with sinus infections. Emergency Treatment In determining what works, you need to know the nature of the reaction. If you have two or more organs involved, if you are having trouble breathing or if you feel dizzy, you may be in the midst of an anaphylactic reaction. What works for that is an epinephrine injection and immediate medical attention. This is potentially life-threatening, so you will want to figure out what triggered the reaction so you can avoid it in the future. Once someone has suffered one anaphylactic reaction, they should keep epinephrine with them at all times in case of another episode. Epinephrine comes as a self-injector pen or a nasal spray (neffy). Can You Spot Drug Allergies? In the warnings that are rattled off as part of a TV ad for a pricey new drug, we often hear viewers cautioned not to take the medicine if they are allergic to it. That sounds like simple common sense, but it also has a Catch 22 quality. How do you know you are allergic to a medication unless you take it–and experience an allergic reaction for which you might need treatment. Most of these presumably are immune system-mediated reactions, in which the body produces IgE. That is how allergies to penicillin or sulfa drugs work. Some drugs cause a different type of reaction, not IgE-mediated but dangerous nonetheless. Lisinopril is the most commonly prescribed blood pressure medicine in this country. Like other ACE (ACE is short for angiotensin-converting enzyme) inhibitor medications, lisinopril can trigger angioedema. This swelling can affect the face, lips, tongue and throat, where it can compromise breathing. The most insidious aspect of this reaction is that it can occur after the person has been taking the drug without problems for weeks, months or even years. “Red man syndrome” or infusion reactions in people taking vancomycin can likewise occur without warning. The last type of drug reaction is not actually an allergy at all, although people occasionally use that terminology. It is better described as sensitivity. For example, a stomachache is a common reaction to the antibiotic erythromycin. Some people are disabled by this abdominal pain and try to limit their exposure to erythromycin thereafter. What Works and What Doesn’t? Since the immune system is acting inappropriately to cause allergic reactions, treatment should involve immunotherapy. Eye drops can help eyes feel less itchy and irritated. Likewise, OTC nose drops or nasal sprays can often help the nose. The corticosteroid Flonase (fluticasone) and the antihistamine Astepro (azelastine) are good examples. During allergy season, some people find that a daily nasal wash (with a neti pot or NeilMed device) can help reduce the mucus and remove the allergens such as pollen causing the reaction. There are also oral antihistamines and inhalers for asthma. For decades now, allergists have offered their patients shots to help desensitize them to the allergen causing their trouble. Joe had these as a child and teenager and has been largely free of allergies since. Not everyone gets such lasting relief. Complications from Current Therapies Medications have side effects, and that is true of allergy medicines as with other drugs. Antihistamines, especially the older ones like Benadryl (diphenhydramine), are notorious for causing drowsiness. That’s one reason it is often included in nighttime pain relievers as the “PM” in drugs like Advil PM. We worry about regular use of such antihistamines because it has been linked to a greater risk for dementia. A second-generation antihistamine such as Allegra (fexofenadine) is much less likely to make someone feel sleepy. However, Dr. Nadeau has seen patients on antihistamines suffer worse allergies if they stop suddenly. The People’s Pharmacy has received hundreds of reports from people who experienced unbearable itching upon discontinuing Zyrtec (cetirizine) or Xyzal (levocetirizine). This can last for weeks. Doctors don’t usually worry much about steroid nasal sprays like Flonase because they are topical. Presumably, nasal tissues pick up most of the dose. Just the same, using such a nose spray day after day for a long time could result in systemic steroid exposure that is not trivial. Stronger Medicine Dr. Nadeau is enthusiastic about the benefits of two potent prescription medicines. One is Xolair (omalizumab). It was originally developed to prevent asthma, but is now approved for chronic sinusitis, food allergies and chronic hives. Paradoxically, Xolair is one of those medicines that could cause a severe allergic reaction even on the first dose, so the FDA warns that the initial injection should be given in a healthcare setting prepared to treat anaphylaxis. This is uncommon, though, occurring in 0.1 to 0.2% of patients. The other medication Dr. Nadeau is prescribing for allergy patients who don’t respond well to other treatments is Dupixent (dupilumab). The FDA has approved this medicine to treat a wide range of conditions, including eczema, asthma, chronic sinusitis, allergic reactions affecting the esophagus and chronic hives, among other things. Most insurance companies will not cover this pricey injection unless the patient has failed all other therapies. Fighting Air Pollution: What Works Air pollution makes allergy symptoms worse, so using an effective air filter inside the home is a good step. A HEPA (high-efficiency particulate-arresting) filter is ideal, especially as part of the air-handling system. If that’s not possible, utilizing a MERV 13 in the part of the home where you spend the most time is a good second choice. Sonu One new option for treating allergies is acoustic resonance therapy with the SoundHealth Sonu headband. It uses vibration from sound to loosen mucus from the sinuses so that they can clear. The FDA has approved its use for children as well as adults. New research was just published demonstrating its helpfulness in treating children with nasal congestion (Oto-Open, April-June 2026). SoundHealth has underwritten The People’s Pharmacy podcast. Dr. Nadeau has also been compensated for her role in conducting studies of this device (International Forum of Allergy & Rhinology, Dec. 2025). Since it does not employ medications, there are no drug side effects. This Week’s Guest Kari C. Nadeau, M.D., Ph.D., is Dean of the UCLA Fielding School of Public Health ( starting July 1 2026). Until then, she holds many other positions. At Harvard T. H. Chan School of Public Health she is: John Rock Professor of Climate and Population Studies; Chair of the Department of Environmental Health; and Director of the Allergy, Extreme Weather, and Exposomics Lab. Dr. Nadeau is Professor of Medicine at Harvard Medical School and serves in the Division of Allergy and Inflammation at Beth Israel Deaconess Medical Center. She is an Adjunct Professor at Stanford Medical School. Dr. Nadeau is also the co-author of The End of Food Allergy, which provides strategies for treating and preventing food allergies in children. Here is a link to the research underway in her Harvard laboratory. PHOTO CREDIT: STACY GEIKENTaken in April 2017 at Kari Nadeau’s professorship dinner The End of Food Allergy: The Science-Based Plan That Turns Food into Medicine The People’s Pharmacy is reader supported. When you buy through links in this post, we may earn a small affiliate commission (at no cost to you). Listen to the Podcast The podcast of this program will be available Monday, June 8, 2026, after broadcast on June 6. You can stream the show from this site and download the podcast for free. This episode has additional information about Nasalcrom (cromolyn sodium nasal spray) and its effect on mast cells; alpha gal allergy to red meat; and the latest thinking on preventing peanut allergy among young children. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.
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  Show 1474: Treating the Cause, Not Just the Symptoms, with Functional Medicine 29.05.2026 57นาที

  Over the years, we have spoken with scores of healthcare experts about chronic illness. Many of them attribute the problems to inflammation, which is after all a natural response to infection or injury. But not everyone has a system for locating and addressing the source of the inflammation. If you want to treat the cause, not just the symptoms of your disease, you might want to consider functional medicine. At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen: You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, May 30, 2026, through your computer or smart phone (wunc.org).  Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on June 1, 2026. What Is Functional Medicine? Many people have heard of integrative medicine. We asked our guest, Dr. Susan Payrovi, how this differs from functional medicine. (She practices both.) According to Dr. Payrovi, while both approaches embrace lifestyle therapies, integrative medicine may focus on individual organ systems, just as conventional medicine does. Functional medicine, on the other hand, is more likely to focus on how the body works. What functional systems are involved when a person experiences fatigue, for example? If there is a problem with the way the body produces energy, how could that be resolved? If you are dealing with a problem caused by underlying inflammation, you could prescribe a potent anti-inflammatory or even a medicine that counteracts the immune system’s response to danger by blocking interleukins, for example. Or you could search upstream for the disturbance that is causing the immune system to overreact. Going upstream to find the cause is the functional medicine approach. Sending the Body Safety Signals If inflammation is a response to a danger signal, how can we let the immune system know that the body is safe? Lifestyle therapies offer some powerful interventions, even though they may sound very ordinary. Getting adequate sleep can make a huge difference for the immune system and lower inflammation dramatically. Stress management is another potent non-pharmaceutical approach. Consuming a diet rich in anti-inflammatory foods or even medicinal herbs could also contribute to a sense of safety and reduced inflammation. The Silo Problem of Modern Medicine We have spoken with many people who have struggled with a disease that manifests in multiple symptoms. They end up seeing a variety of specialists who don’t seem to communicate with each other. NO tool manages every condition. Too often, specialists pay attention only to the specific organ that they are assigned, and as a result, nobody puts the big picture together for a long time. The hope is that functional medicine would do a much better job for such patients, including those whose suffering has an emotional, psychological or spiritual aspect. Functional Medicine and Chronic Fatigue Syndrome One example where patients are demanding more of their medical care is chronic fatigue syndrome. Conventional medicine has a notoriously difficult time treating such patients. Coaching patients on small but important lifestyle changes is one approach that functional medicine can offer. Pacing and learning to prioritize are vital skills for such patients. Dr. Payrovi learned a lot about the value of such approaches in dealing with her own illness, multiple sclerosis. Finding a Functional Medicine Practitioner People looking for a functional medicine practitioner can consult the Institute for Functional Medicine. The organization lists practitioners on its website, ifm.org. So does the Academy of Integrative Health and Medicine, aihm.org. This Week’s Guest Susan Payrovi, MD, is a physician practicing Integrative and Functional Medicine at Stanford’s Center for Integrative Medicine. Dr. Payrovi is board certified in Anesthesiology, Hospice and Palliative Medicine, as well as Integrative Medicine. She has additional training in Functional Medicine and acupuncture. https://med.stanford.edu/profiles/susan-payrovi. Her website is drsusanpayrovi.com. Susan Payrovi, MD Listen to the Podcast The podcast of this program will be available Monday, June 1, 2026, after broadcast on May 30. You can stream the show from this site and download the podcast for free. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.
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  Show 1473: How Music Heals: The Neuroscience Behind an Ancient Medicine 21.05.2026 1ชม.

  What do you conjure up when you think of music? Perhaps you imagine a singer-songwriter telling her story. On the other hand, you might imagine a parade with a marching band, an orchestra playing an outdoor concert or a mother singing her baby to sleep with a lullaby. Regardless of the format, music acts on the brain in unique ways. Neuroscientists are learning how music heals and why healers around the world have integrated music into their rituals for millennia. At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen: You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, May 23, 2026, through your computer or smart phone (wunc.org). Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on May 25, 2026. How Music Heals Dr.Elizabeth Margulis directs the Music Cognition Laboratory at Princeton University. This scientific endeavor is devoted to understanding how our brains react to music. One discovery is that music has a lot in common with infant-directed speech. It is highly repetitive with exaggerated pitch modulation. When people talk to babies, they may slow their words down a bit and raise the pitch of their voices. All of these properties make infant-directed speech a lot more like music than the rest of our everyday utterances. Caregivers around the world adopt this sort of “baby-talk” because babies pay attention longer when they do. Is music tapping into the same primal brain responses? Another characteristic of music is that it can trigger emotional responses. These are culturally conditioned; bagpipes do not have the same effects as Tibetan singing bowls. Howe er, the reminiscence triggered by music can be remarkably complete, putting us back in time not only to the place where we heard it before, but even to the bodily sensations that we experienced at that moment. Musical memories are exceptionally persistent. Older people with dementia who can no longer remember important facts about their own lives can often join in singing a popular song from their youth. The Downsides of Music Music may have social and political ramifications. Just imagine a chorus singing “We shall overcome,” and you will probably make assumptions about the singers and their values. As a result, we should not be surprised to learn that people may fight over music. Frequently entire generations have genre preferences such as hip hop or rock that are not shared by adjacent generations. How do we approach the music we love to hate? Can we understand how music heals even if we don’t like it very much or at all? Musical Daydreams Help Us Understand How Music Heals Dr. Margulis has studied and written about musical daydreams. What does she mean by this? As you watch a movie, you may appreciate the score. But even if you don’t notice it at all, the sound track influences how you understand the action on the screen. Likewise, when most people listen to a piece of music, they may create a visual to go with it. Dr. Margulis offers us an example of a snippet of music by Liszt that evokes for many people an image of a cartoon cat chasing a cartoon mouse. Needless to say, that is not what Liszt was thinking when he composed it, since cartoons did not exist at the time. Choosing Music for Healing Joe mentioned the unobtrusive but soothing music playing in the background when he has an acupuncture treatment. Dr. Margulis suggested that music activates motor areas of the brain, and that might help explain the benefit in this setting. We are still learning more about how music heals. This research may some day guide healthcare professionals in choosing music for their practices, even in the hospital. This Week’s Guest Elizabeth Margulis,PhD, is Professor and Acting Chair in the Department of Music, with affiliations in Psychology and Neuroscience. Dr. Margulis directs the Music Cognition Lab at Princeton University. Her research pursues questions that lie at the intersection of the humanities and the sciences. She was also trained as a pianist. Her most recent book is Transported: The Everyday Magic of Musical Daydreams.  Her website is https://www.elizabethmargulis.com/about This link takes you to the publisher’s page. Elizabeth Margulis, PhD, Princeton University The People’s Pharmacy is reader supported. When you buy through links in this post, we may earn a small affiliate commission (at no cost to you). Listen to the Podcast The podcast of this program will be available Monday, May 25, 2026, after broadcast on May 23. You can stream the show from this site and download the podcast for free. Download the mp3 or listen to the podcast on Apple Podcasts or Spotify.
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  Show 1428: The Hidden Power of the Unconscious Brain (Archive) 14.05.2026 1ชม. 5นาที

  In this episode, a renowned neurosurgeon shares what he has learned in decades of working to restore ailing brains. His new book covers a vast range of neuroscience. Our dilemma was what to pay attention to in all those options. In a sense, that is always the human situation. We are capable of conscious processing of approximately 200 bits per second (bps) of information. Our unconscious brain deals with as much as 11 million bps. At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen You could listen through your local public radio station or get the live stream Saturday, May 16, 2026, at 7 am EDT on your computer or smart phone (wunc.org).  Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on May 18, 2026. (This show originally aired April 25, 2025.) The Power of the Unconscious Brain Our senses feed us a tremendous amount of information all the time, but we don’t have the bandwidth to pay attention to more than a small fraction of it. That’s where the unconscious brain is so valuable, juggling millions of bits of information while we focus our conscious attention on what seems important. One surprising outcome of the research on how our brains function is a re-assessment of what is going on when people are unconscious. For centuries, doctors thought there was really no brain activity while a person was comatose. Then, a few decades ago, a scientist was recording the brain waves of a patient in a coma. The activity was very peculiar, as if the person were watching a ball being lobbed back and forth across a tennis court. In actuality, a television set in the room was broadcasting a world championship match between Roger Federer and Rafael Nadal. The neuroscientist recognized that this individual was following the match and was not nearly as deeply unconscious as had been thought. Further research showed that this kind of unconscious brain activity is not uncommon. It may hold keys to determining who has the best potential for recovering from their coma. Freud and the Unconscious Brain If you hear the term the unconscious mind, you may think of Sigmund Freud. He really popularized the concept that some very important brain activity takes place outside of our conscious awareness. It still has a powerful influence on our behavior. By the way, if we recognize that our conscious attention is indeed a limited resource (200 bps, remember), we won’t try to multitask. Humans actually aren’t very good at multitasking; instead, we switch our attention from one thing to another. Some people can do that fairly easily, but for most of us, it is less effective than staying focused. Three Stages of Brain Development Evolution likes to build on what it’s already got in place, so it shouldn’t surprise us that we can track three different evolutionary stages to our human brains. The reptilian brain came first, of course, and is there as a base, operating mostly on reflex. It’s definitely an important part of the unconscious brain. The mammalian brain brings in emotions. The hormone oxytocin is relevant for this discussion. It is critical for birthing and nursing young. As it turns out, oxytocin can also be put to other uses, such as bonding mates together and creating friends. Finally, we have the primate part of our brain. We humans, like other primates, can exercise empathy because our mirror neurons allow us to relate to another creature’s experience. In fact, mirror neurons were discovered by scientists studying macaques and eating gelato. Listen for a great story! Speaking of empathy, we wondered about empathy fatigue. We started hearing about empathy fatigue during the COVID pandemic, when healthcare providers were overwhelmed by extreme demands with inadequate support. Research shows that “constant, repetitive exposure to the pain of others leads to empathy fatigue.” Lack of empathy can lead people to do terrible things. Wonders of the Unconscious Brain Our brains are full of clocks. To some extent, these are shaped by how we use them. Musicians who play percussion instruments can perceive time differences of just a few hundredths of a second. All of us are entrained to a 24-hour a day cycle, whether we observe sunrise and sunset or not. But if we are deprived of connection with that cycle, our internal clocks can’t keep good time, and our brains may get far off track. What About Premonitions? Some people think premonitions are a fantasy. Yet this is another area where our unconscious brain may be more capable than we imagine. Dr. Hamilton describes an experience in the Swiss Alps where he and his wife had a choice of which path to take down from the summit. One appeared to be a shortcut, and they did have some time constraints. But as soon as they had taken a few steps that direction, he had a premonition of something terrible. They took the other path and learned later that there had been a landslide on the shortcut that would have swept them helplessly down the mountain. According to Dr. Hamilton, some people have the ability to influence the output of random number generators. Those of us who can’t may wish to reject that idea, but it has been documented. The Princeton Engineering Anomalies Research lab has run many studies demonstrating an impact on random number generations, not to mention remote viewing. In this way, some of the hidden power of the unconscious brain appear as cerebral entanglements, analogous to quantum entanglements at the sub-atomic level of matter. This Week’s Guest Dr. Allan Hamilton, MD, FACS, is a neurosurgeon who has specialized in treating brain tumors. His extraordinary journey from janitor to Harvard-trained neurosurgeon is just the beginning of his remarkable story. A decorated Army veteran, he now holds four professorships at the University of Arizona and has been recognized as “One of the Leading Intellects of the Twenty-First Century.” As the only American honored with the Lars Leksell Award for pioneering scientific discovery in stereotactic neurosurgery, Dr. Hamilton’s groundbreaking work has revolutionized the field. He has had a life-long interest in the application of computer technologies to enhance surgical care and reduce avoidable medical adverse events. In addition, he has served on two White House Advisory Committees under two presidential administrations. Allan Hamilton, MD, FACS His expertise extends beyond medicine, having studied creative writing under Rod Serling and serving as a senior medical consultant for Grey’s Anatomy for nearly two decades. Dr. Hamilton’s seven non-fiction books have garnered numerous awards and international translations, offering insights that have inspired leaders across various fields. Dr. Hamilton’s 7th non-fiction book is Cerebral Entanglements: How the Brain Shapes Our Public and Private Lives. The People’s Pharmacy is reader supported. When you buy through links in this post, we may earn a small affiliate commission (at no cost to you). Listen to the Podcast: The podcast of this program will be available Monday, April 28, 2025, after broadcast on April 26. You can stream the show from this site and download the podcast for free. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.
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  Show 1472: Beyond Lyme: Stealth Infections from Flea and Tick Bites 07.05.2026 1ชม. 16นาที

  Tick season is well underway in many parts of the country. It seems that a mild winter and a warm spring have brought the nymphs out seeking blood. If that blood is yours, you may be exposed to a range of pathogens. What’s more, ticks are not the only creatures ready to bite you. Fleas are an even bigger problem when it comes to transmitting bacteria called Bartonella. That genus is responsible for cat scratch disease and trench fever. When the infection goes chronic, it’s called bartonellosis. What are the dangers of flea and tick bites? At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen: You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, May 9, 2026, through your computer or smart phone (wunc.org).  Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on May 11, 2026. You can watch us interviewing Dr. Breitschwerdt on YouTube.   The Hazards of Flea and Tick Bites Ticks can transmit a dizzying number of pathogens, including viruses, bacteria and protozoa. Rocky Mountain Spotted Fever, for example, occurs when a tick injects Rickettsia rickettsii into a person through a bite. If not treated properly, it can be fatal. Fortunately, however, it usually responds to doxycycline. The NCSU laboratory has developed a reliable diagnostic test that picks it up quickly. Another tick-borne disease that has become familiar over the last few decades is Lyme disease. It is carried by deer ticks infected with Borrelia burgdorferi. If treated promptly, most people clear the disease, but sometimes it morphs into a stealth infection that is quite controversial. You may not think much about flea bites, but they too could be the source of a stealth infection. Fleas transmit Bartonella (and so do body lice, ants, pigeon mites, rat mites and sand flies). Cats can be infected (with three different species of Bartonella) and so can dogs (only two species). When people develop bartonellosis, it can cause liver disease and neurological problems such as headaches and memory loss. In some cases, infected people suffer seizures. Preventing Flea and Tick Bites Once Bartonella get into the body, it likes to hide. The bacteria can enter virtually any cell in the body and make itself at home. As a consequence, the immune system may have difficulty tracking it down and eliminating it. Antibiotics don’t always get to it, either. Treatments of entrenched infections need to be very intensive. So it is better to prevent flea and tick bites. One way is to make sure that pets are protected. Veterinarians can prescribe preventive medicine for them, either oral or topical. Another important step is to protect yourself. Wear effective insect repellent when outside or cover your long pants with permethrin-treated gaiters. And absolutely do not skip the tick check when you come inside. If you find a tick that has bitten you, remove it with tweezers, seal it in a plastic bag, date the bag and put it in the refrigerator. That could provide useful identification if you begin to feel ill over the next several days. When the type of tick is identified, it helps to point the infectious disease expert in the correct direction for what condition you may have. This Week’s Guest Dr. Edward B. Breitschwerdt is a professor of medicine and infectious diseases at North Carolina State University College of Veterinary Medicine. He is also an adjunct professor of medicine at Duke University Medical Center, and a Diplomate, American College of Veterinary Internal Medicine (ACVIM). Dr. Breitschwerdt directs the Intracellular Pathogens Research Laboratory in the Institute for Comparative Medicine at North Carolina State University. He also co-directs the Vector Borne Diseases Diagnostic Laboratory and is the director of the NCSU-CVM Biosafety Level 3 Laboratory. Dr. Breitschwerdt’s clinical interests include infectious diseases, immunology, and nephrology. https://www.galaxydx.com/about-us/meet-the-team/edward-breitschwerdt-dvm-dacvim-saim/ Dr. Ed Breitschwerdt, NCSU College of Veterinary Medicine Listen to the Podcast The podcast of this program will be available Monday, May 11, 2026, after broadcast on May 9. In this week’s podcast, we talk about developing treatments for these challenging conditions. A major focus for Dr. Breitschwerdt is prevention, so he and his colleagues are working on a vaccine that could prevent Bartonellosis. We also discuss the possibility that Bartonella might contribute to arthritis. Find out about the complications of another vector-borne infection, Babesiosis. You can stream the show from this site and download the podcast for free. This episode of our podcast was sponsored in part by MUD\WTR. Start your new morning ritual & get up to 43% off your @MUDWTR with code PPOD at mudwtr.com/PPOD
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  Show 1471: Broken Bills: Why Americans Pay Twice as Much for Less Care 30.04.2026 1ชม. 9นาที

  Americans often boast of having the best health care in the world. It is certainly the most expensive health care. We pay twice as much as people in many other industrialized nations. Are we getting our money’s worth? Some population statistics, such as life expectancy, suggest we could be doing much better. How can we make sense of the complexity of American health care? At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen: You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, May 2, 2026, through your computer or smart phone (wunc.org).  Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on May 4, 2026. Why We Pay Twice as Much for Health Care One reason Americans pay twice as much is the complexity of our health care services. We often call it a health care “system,” but it often doesn’t feel as coordinated as a system ought to be. Many other countries have universal health insurance coverage in one form or another (and there are many). That means the government has an incentive for keeping costs down. With so many different payers and players in the US, the incentives frequently go in the other direction. You may notice this if you examine an explanation of benefits from Medicare or a private insurance company. There may be a sizable gap between what the provider charged and what insurance approved. Who pays the retail price? Only people who don’t have insurance, who are usually those least able to manage a big bill. If you find yourself faced with a hospital bill and no insurance coverage, it is important to talk with the billing department. Nonprofit hospitals should have a mechanism for patients without coverage to negotiate a lower total or a longer time frame in which to pay. Even some for-profit hospitals and medical practices are open to negotiation, but starting the negotiation as early as possible is key. How Much Does an Emergency Cost? Nobody plans for a medical emergency. That is the nature of emergencies–they are unexpected. If you need an ambulance to get you there, if you have to be transferred to another hospital with a better ability to care for your problem, if the doctors must do multiple tests to make a diagnosis will all influence your bill. As a result, emergency visits could cost from tens of thousands of dollars to a million or so. With high-deductible health insurance, a person or their family could end up owing more than they can pay. That is how some cases of bankruptcy are rooted in high healthcare bills. We Pay Twice as Much Because Providers Make More In the US, doctors were once in the same category of professionals as teachers or firefighters. Those days are long gone. Healthcare providers here are compensated more generously than providers in many other places, such as Canada, Japan or Israel. Moreover, just as there are middlemen in the prescription insurance business (called pharmacy benefit managers, PBMs), health insurance has its own middlemen. The result is a great deal of complexity, very little transparency, and a lot of parties trying to make money on each transaction. That also leads to a great deal of administration, which further increases the cost. Why Don’t Market Forces Control Costs? Some analysts suggest that the free market should be able to control costs. But for market forces to work, you need competition and transparency. Over the last decade or so, there has been increasing consolidation in every sector of health care. Competition is limited in most areas. Moreover, transparency is in very short supply in health care. For years we have been talking about how hard it is to do comparison shopping for health services like MRI scans or colonoscopies. If consumers cannot compare costs or value, they cannot make the rational decisions that would help moderate prices. How Administrative Costs Increase Bills Part of every insurance premium goes to paying administrative costs. Insurers pay people to review claims (and deny some). Preauthorization also adds to administrative costs. Manage the Hospital Bill So You Don’t Pay Twice as Much as You Should Years ago, we interviewed Marshall Allen, who titled his book Never Pay the First Bill.  Our guest for the current episode counters always request an itemized bill. That way you can check it to make sure that simple items such as names, dates and insurance policy numbers are correct. Then look at whether the services billed are actually the services received. An estimated nine of ten hospital bills contain mistakes. The sooner you catch them and contest them, the less likely you are to have to pay them. To determine what you must pay, you may need to review the summary of benefits on your insurance policy. That lays out in detail exactly what the insurance will cover. What Can Patients Do So They Don’t Pay Twice as Much? Ask for an itemized bill and check it carefully in every detail. If you find a mistake, contest it. Sooner is better, even though you may be trying to recover from a serious illness. Ask the billing office about patient assistance or a negotiated payment plan. Check with the Patient Advocate Foundation. They may be able to help in an individual case. Find out if your state has a consumer assistance program in the department of insurance. Notify an intractable billing department that your story will appear in your social media feed. This should probably be the last step if the previous ideas don’t work. But hospitals really don’t like bad publicity, so it might give you leverage you wouldn’t have otherwise. This Week’s Guest Linda J. Blumberg, PhD, is a research professor at Georgetown University’s McCourt School of Public Policy. She is an expert on private health insurance (employer and nongroup), health care financing, and health system reform. Linda J. Blumberg, PhD, describes why we pay twice as much for healthcare Listen to the Podcast he podcast of this program will be available Monday, May 4, 2026, after broadcast on May 2. On this episode, Dr. Blumberg discusses the importance of the summary of benefits in your insurance policy in greater detail. You’ll hear about a situation in which an emergency department overcharged a patient egregiously; the summary of benefits was key in resolving the problem. You can stream the show from this site and download the podcast for free. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1471: A transcript of this show was created using automated speech-to-text software (AI-powered transcription), then carefully reviewed and edited for clarity. While we’ve done our best to ensure both readability and accuracy, please keep in mind that some mistakes may remain. If you have any questions regarding the content of this show, we encourage you to review the original audio recording. This transcript is copyrighted material, all rights reserved. No part of this transcript may be reproduced, distributed, or transmitted in any form without prior written permission. Joe 00:00-00:01 I’m Joe Graedon. Terry 00:01-00:05 And I’m Terry Graedon. Welcome to this podcast of the People’s Pharmacy. Joe 00:06-00:27 You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. Medical bills can be mysterious or infuriating. How can you make sense of the complexity and pay a fair price? This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34 Here in the United States, we pay more for our health care than people in any other comparable country. Despite this, our longevity statistics are worse. Joe 00:46 We’ll talk with an expert about how we got ourselves into this mess and what we might be able to do about it. Terry 00:54 She’ll help us better understand medical billing and how to challenge mistakes. Joe 00:59 Coming up on The People’s Pharmacy, why Americans pay twice as much for less care. Terry 01:15 In The People’s Pharmacy Health Headlines: An estimated two-thirds of American adults drink coffee every day. Now scientists have an idea why coffee is so popular. Researchers recruited 31 coffee drinkers and 31 people who do not drink coffee for a detailed study. They compared the composition of their gut microbiota and found some striking differences. Then the coffee drinkers abstained from coffee for two weeks. During this time, the investigators noticed changes in their gut microbiota. After two weeks, coffee drinkers were once again provided with their beverage. Half the volunteers got regular caffeinated coffee, the other half got decaf. Neither researchers nor participants knew who got which beverage. Non-coffee drinkers did not participate in this part of the experiment. Coffee-drinking volunteers reported less stress and depression whether the coffee had caffeine in it or not. People drinking decaf had improvements in learning and memory, possibly due to the polyphenols. Those getting caffeine in their mugs reported less anxiety but better attention and vigilance. The scientists note that coffee is much more than a caffeine delivery mechanism. Coffee consumption also has an effect on the immune response. Joe 02:37 Vertigo can be a disorienting and disturbing symptom. A recent overview published in JAMA describes one of the most common forms, benign paroxysmal positional vertigo, abbreviated BPPV. It’s caused when calcium carbonate crystals inside the ear move out of position. A sensation of non-spinning dizziness or lightheadedness occurs when people lie down or change position. The diagnosis of BPPV relies on observing eye movements called nystagmus that occur when the head moves. It can be treated with a set of prescribed head movements called the Epley maneuver. Although physicians often prescribe the antihistamine meclizine for vertigo, this drug is not effective for treating BPPV. Patients can also self-treat this condition by performing the Epley maneuver at home with good results. Terry 03:34 Levothyroxine is one of the most prescribed drugs in America. That’s because millions of people have a sluggish thyroid gland. The condition is called hypothyroidism. Medical experts have worried that it is being over-diagnosed, especially in older people, based solely on thyroid function blood tests. The investigators set out to examine whether de-prescribing levothyroxine is feasible. Study participants were all 60 or older and had been taking levothyroxine at the same dose for at least a year. The doctors began gradual dose reductions. Over the course of a year, 25% of the 370 volunteers were able to get off levothyroxine without having TSH or T4 levels go out of range. Joe 04:24 One of the most contentious issues among nutrition experts in recent years has revolved around fat, in particular, the benefits and risks of omega-6 polyunsaturated fatty acids, or PUFAs. The AHA has long promoted PUFAs found in vegetable oils because they’re heart-healthy. Critics suggest that an imbalance with excessive omega-6 fatty acids could be harmful. Nutrition scientists distinguished between one specific omega-6 fat, linoleic acid, and all the others. Researchers used data from nearly 274,000 volunteers registered with the UK Biobank. These middle-aged, healthy people had no dementia when the study began. Blood tests revealed the balance between linoleic acid and other omega-6 fatty acids. Over the next 15 years, 5,800 individuals developed dementia. Those with the highest levels of linoleic acid were almost 20% less likely to come down with dementia. In contrast, those with the highest levels of other omega-6 fats were about 20% more likely to have a dementia diagnosis. The scientists call for research on whether increasing dietary linoleic acid might help protect people from dementia. And that’s the health news from The People’s Pharmacy this week. Terry 06:15 Welcome to The People’s Pharmacy. I’m Terry Graedon. Joe 06:18 And I’m Joe Graedon. Have you ever received a confusing medical bill? Actually, let me correct myself. Have you ever received a bill from a hospital that was not confusing? Terry 06:30 Most of us have had, oh, maybe a moment of alarm when we’ve had to try and decode a complicated medical bill. Why is the American system so hard to navigate and so difficult to afford? We pay far more for our health care than people in any other comparable country, and we have much less to show for it. Joe 06:53 To learn more about health care in America and how it compares to other countries, we turn to Dr. Linda Blumberg. She is a research professor at Georgetown University’s McCourt School of Public Policy. Dr. Blumberg’s expertise is in private health insurance, health care financing, and health system reform. Terry 07:17 Welcome to The People’s Pharmacy, Dr. Linda Blumberg. Dr. Linda Blumberg 07:20 Thank you so much for inviting me today. Joe 07:23 We are delighted to be able to talk to you about, I think, one of the most challenging issues facing health care in America, and that has to do with our system for paying. So perhaps you can explain briefly how our payment system in the U.S. compares to most other advanced countries. Dr. Linda Blumberg 07:47 Well, it is much more complicated than in most other advanced countries, probably in all other advanced countries. And that’s because we have so many payers and so many different sets of prices that are used for providers, for insurers, for different plans, et cetera, and how employer plans work. So the variation is enormous, which causes a lot of confusion for consumers. And frankly, it often causes confusion for the providers as well. Terry 08:17 I wonder if you would explain, Dr. Blumberg, you say so many different prices, which implies that if I were to go in for a CT scan of something, I might get one price and somebody else who has the exact same procedure done maybe charge something completely different. How does that work? Dr. Linda Blumberg 08:39 That’s absolutely correct. And it all boils down to what type of insurance you have and what plan you have. So if you are somebody who is enrolled in Medicare, the program in the U.S. for those who are 65 and over or who have particular disabilities that qualify them, there are prices that are regulated by the federal government in terms of what a provider can charge for each service. If you have private health insurance, however, there is no regulation on the prices. And so a lot of it depends on what the market will bear for the particular provider that you happen to be using and the negotiations that they have completed with the particular insurance plan you have. And so you may have a United Health Insurance Plan and somebody else may have a United Health Insurance Plan, but they’re two different plans and those would pay different prices for the same procedure. Joe 09:34 Well, we’ll talk about billing in a minute, but what has always confused me is the idea that if you have insurance and you have to go into the hospital for some sort of a procedure, you would get bill X if you have insurance company Y. But if you have no insurance and have to pay out of pocket, it can be substantially greater. I mean, like dramatically more expensive, which seems like it’s just [bleep]-backwards. Pardon my language. I mean, it just seems upside down. How do they figure out these crazy prices? Dr. Linda Blumberg 10:20 Well, first of all, we do not have a rational basis for deciding the prices that an insurer is paying to a particular provider or what a particular provider is going to charge to someone who’s uninsured. And you’re right. If you walk in the door without any insurance coverage, you are likely to be charged the highest price of anybody that’s walking in the front door of a hospital. And that is because there is no insurer or third-party administrator that is negotiating any prices on your behalf. So you’re basically being charged the, you know, the retail rate, which is the highest that there is. What a lot… as you say, it makes no sense because usually people without insurance are the people with the lowest incomes, right? And they have the least ability to pay for these services. And oftentimes the hospitals, in particular, the nonprofit hospitals are required to have programs that lower prices for people with modest incomes that are coming in without insurance. However, they often don’t even advertise that these programs exist. They’re hard to find even on their websites. And so people who are walking in without insurance are being charged huge prices, and they have to know to say, “Listen, well, I have low income and I need to have access to someone who’s going to help me with whatever program you have for low income people walking in the door.” So it is a lot of hit and miss in terms of what people understand about what might be available to them and what negotiated deals a particular hospital has made with a particular health insurance plan. And it’s often a function of how much market power the insurer and the health care providers, the health system have in that particular area is going to drive whether the prices are lower or higher. Terry 12:22 Dr. Blumberg, you mentioned the retail price of a procedure or a hospitalization. And you also mentioned that Medicare prices are regulated, even though all these other prices are not. I’m going to mention, as a Medicare patient, I occasionally look at my explanation of benefits and I find them very confusing and/or alarming because what I see is that my provider, for example, might charge $355 for something. So that’s the retail price. And Medicare approves, let’s say, $128, you know, as that’s the approved payment, but it doesn’t pay that full amount. And then the supplemental, I happen to have Blue Cross, picks up usually most of what Medicare doesn’t pay on the amount that Medicare has approved. But there’s such a mismatch between that retail price and that approved price. How does that work? Dr. Linda Blumberg 13:40 Well, that shows you that when somebody who walks in the door to get the retail price is being charged much more than somebody who’s coming in with Medicare. And that is by federal government law, is that physicians who take payments from Medicare, who participate in Medicare, have to agree to take the rates that are set out in federal law. And these providers know they’ve made this agreement with the federal government. That’s why they’re participating. So this is customary for them. It’s not surprising to them that there is a disconnect between those prices. In fact, very few people end up paying the actual retail price. But if you’re walking in with private health insurance, you’re likely to pay considerably more than or your insurer is going to be paying more and you are likely to pay some more also compared to the Medicare prices. So on average, and this is just on average, hospital payments under private insurance are in the neighborhood of two and a half times what Medicare pays. And for physicians, for clinicians, it’s more on average about 25% above what Medicare pays. So the variation is large even around that. You know, for some procedures and for some clinicians, they may be getting 600% of Medicare or 900% of Medicare. It varies enormously through the system. And that’s why I say we’re not paying privately on any rational set of prices. Joe 15:17 So what has really boggled my mind is that if, for example, you need a hip replacement, as I have had, or a cataract surgery, the provider may charge thousands of dollars. Let’s just make up a number and say, you know, $3,500 for this particular cataract surgery. But Medicare may only pay a few hundred dollars. It’s like the discrepancy is so dramatic. It would be as if the sticker price for your car is $25,000, but you actually only have to pay $18,000. I mean, people are so shocked by these numbers. They seem to make no sense whatsoever. And you kind of wonder, well, how can this system function if these billable numbers are two, three, four times more than the doctor actually gets paid? It seems insane. Dr. Linda Blumberg 16:19 Except for the doctor doesn’t really expect to get paid the amount that they’re showing on the bill, they have negotiated particular rates of payment with insurance plans, and they have accepted the federal government fee schedule, which is public information. So the retail prices that you see are really pretty meaningless because the real prices are the ones that have been negotiated with whoever the insurance company is, whether it’s public or private. Joe 16:50 Unless you don’t have insurance, unless you’re not eligible for Medicare, in which case you’re on the hook for an unbelievable amount of money that you can’t possibly afford. Dr. Linda Blumberg 17:02 Absolutely. But then, you know, I always suggest to consumers when they’re in that situation, first of all, if it’s with the hospital, to explore what programs they have for uninsured people with modest incomes. Because if it’s a nonprofit hospital, they’re required by law to have some kind of program. Whether a particular individual is going to qualify for it is up to what that program looks like. But you always explore that. And absent that, or if you’re talking about care you’ve received from an individual physician, I always suggest that the consumer talk to the physician, talk to the financial manager for the practice and see if there’s some way to negotiate that rate down. Because as you said, it doesn’t make any sense and nobody with private insurance is paying for it. Terry 17:51 You’re listening to Dr. Linda Blumberg, research professor at Georgetown University’s McCourt School of Public Policy. Dr. Blumberg’s expertise is in private health insurance, health care financing, and health system reform. She has analyzed the Affordable Care Act and studied strategies to address remaining health insurance coverage issues. Joe 18:14 After the break, we’ll ask Dr. Blumberg how much an emergency might cost. Terry 18:18 Are we getting any bang for our buck compared to other countries? How do health insurance middlemen affect the cost of care? Some people suggest that the free market should take care of the pricing problems. Joe 18:29 Why haven’t market forces brought health care prices down? Terry 18:43 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Terry 20:45 Welcome back to The People’s Pharmacy. I’m Terry Graedon. Joe 20:48 And I’m Joe Graedon. Joe 21:17 We’re talking about the high cost of health care in the United States. Are we getting our money’s worth? We pay far more than people in most other countries, but our health statistics are abysmal. Terry 21:31 Many families in America go into debt because of huge medical bills. In some cases, people have lost their life savings and their homes because of a health care crisis. Joe 21:42 Will cuts to Medicaid make this situation more challenging? Will hospitals close because of reduced financial stability? Terry 21:52 Our guest is Dr. Linda Blumberg. She’s a research professor at Georgetown University’s McCourt School of Public Policy. Dr. Blumberg’s expertise is in private health insurance, health care financing, and health system reform. Joe 22:10 Dr. Blumberg, in the event that you had an emergency, and let’s say you had to have an ambulance and then you had to go to the emergency department, maybe you thought you were having a stroke or a heart attack, and then you’ve seen multiple specialists and you have a whole bunch of tests, CT scans and goodness knows what else. And then you have to stay in the hospital with maybe a couple of procedures for, let’s say, three to five days. How much might your bill be at the end of this hospital stay? Dr. Linda Blumberg 22:43 Well, a total bill for a hospital stay can be enormous. It depends upon the services you’ve received, how long you’re staying. But, you know, it can often be in the tens of thousands of dollars. But, you know, there are people who have inpatient stays in a hospital for a length of time in serious conditions that could be a million dollars, right? So it all varies a lot, but an emergency department is a particularly expensive place to obtain care, and hospital stays are the most expensive costs that we face in our healthcare system. Joe 23:17 I’d like to ask you about how much bang we’re getting for our bucks in the United States compared to other advanced countries, because, you know, we have done an amazing job at getting smoking down. I mean, turn back the clock about 40 or 50 years and like half of Americans, especially men, smoked. And today it’s down around 12 or 15 percent or lower, maybe around 10 percent. So we’ve made some real progress in terms of health behaviors. But that aside, our life expectancy has not improved dramatically. Other countries, for example, Japan, South Korea, Sweden, and France are all about 83 to 84 years of age. In the U.S., our life expectancy is around 78 years. We spend annually over $12,000 a year per capita per person. In Germany, it’s 8,000. In France, it’s $6,600. And in Sweden, it’s $6,400. So almost half of what we spend. And yet their longevity is much greater. I mean, substantially better. How? I mean, what? Terry 24:37 What gives? Joe 24:36 What is going on? How can it be that we’re paying so much more for so much less? Dr. Linda Blumberg 24:45 Really good question. Part of what’s going on and probably the biggest difference in terms of what we spend compared to other countries, developed countries on health care, is the prices that are paid to the health care providers from, you know, who we’re receiving our care from. So a hospital stay for the same services in the United States is typically going to cost considerably more than if those services were obtained in Canada or in Japan or in Germany or in Israel. So those are systems that… where all of the… There is regulation of the prices that are paid, are paid for medical procedures, regardless of the type of insurance coverage you have. And some of them have, you know, different plans, et cetera, not as much variation as we have here, but some variation. But all of those prices are limited in those countries by government dictate. And we are, as I said, we’re only limiting the prices that we pay for medical care if you’re in a public insurance program like Medicaid or Medicare. If you have private insurance, which most people below age 65 have a private health insurance, those prices are not regulated. In addition, when you think about longevity, we do have a more diverse population in a lot of respects than is the case in most other developed countries. But in addition, we have the issue here of still having a significant number of U.S. residents without any health insurance coverage at all, which is not the case in these other developed countries where they have at least some level of universal health insurance coverage. And sometimes it’s considerably more comprehensive than the types of coverage we have here. And so when you have a significant share of the population, even if it’s only at this point under 10%, about 10% of the population under age 65, you still have a considerable number of people who are not getting access to medical care when they need it. And that is going to affect longevity. Other things like diet and pollution and, you know, various other different issues. We have a lot of gun violence here, which is not the case in the vast majority of other countries. So all of those things go into the difference. But the difference in our spending is completely on the prices that we’re paying to our health care providers on the commercial side. Terry 27:25 Dr. Blumberg, you’ve written about health insurance middlemen. I wonder if you could explain what that is and how it affects the prices we pay. Dr. Linda Blumberg 27:35 Sure. So when we are obtaining medical care in this country, we are paying for the particular services, right? And money is going to the providers who are providing these services to us. But we’re also paying administrative costs. And those administrative costs are built into the prices that we’re paying to hospitals and doctors and other providers. And it’s also built into the premiums that we’re paying for our health insurance coverage. And increasingly in this country, we have moved our healthcare economy into a space where huge numbers of dollars are going for administrative fees that are associated with what I refer to as middlemen. People have heard a lot about prescription drug benefit managers. But the same is true on the medical side. So a hospital is spending large amounts of money on a revenue cycle management company that is trying to figure out how to send in bills and code the services delivered to increase the revenue of the hospital. Same on the physician side. You have various different types of entities that are contracting with insurance companies to do particular types of tasks that the insurance company or the third-party administrator either doesn’t want to do themselves or finds more profitable to contract out to their subsidiaries. So there is a lot of dollars that are going into making the prices higher on the claim side, on the medical service price side, and that are also being built into our insurance premiums through higher claims and through higher administrative loads that are attached by the insurer. So, I mean, we’re talking about an industry that is hundreds of billions of dollars every year that is really extractive, that’s pulling dollars out of every one of the transactions. And there’s billions of transactions that go through our system every year. And so these entities, these administrative and financial entities have figured out how to extract dollars from the healthcare economy by adding some administrative costs to every single transaction that is being processed through the system. Joe 30:07 Dr. Blumberg, I think most people have a real hard time dealing in billions and dealing with middlemen and all the other stuff, but they can relate to an office visit. So for example, if you had to go see a specialist in this country, maybe a gastroenterologist or a dermatologist or a cardiologist, those bills for just a quote unquote ‘regular visit’ could be in the hundreds of dollars. In Sweden, it’s 40 bucks. That’s the maximum a specialist can charge in Sweden. Kids are free in Sweden. I think most parents know that a pediatrician’s visit can be pricey. They have no health care premiums in Sweden. It comes off their tax bill. The average hospital bill in Sweden for a day, this, you know, being in the hospital for a day, is $11. In this country, it can be thousands. And the maximum that a person would pay for all medical appointments annually in Sweden, everything lumped together would be $160. It can cost us $160 for just one visit in this country. So I’m just wondering, when will the American public say enough is enough? Dr. Linda Blumberg 31:38 So I think one important thing to remember is that, yes, when somebody is taking their kid to a pediatrician in Sweden, they’re not paying anything out of pocket. But their taxes are higher, right? Because those providers still have to be paid for the services they’re providing. It’s a matter of how the prices are, how they’re being paid. And in those countries, much more of the dollars are flowing through their national health system, which is funded by tax dollars. And so the tax rates in Sweden, for example, are typically quite a bit higher than we face in the United States. But they, at the same time, obviously the country is regulating how much the providers can earn for providing the services that they’re provided. So there are some limits that lower the incomes, the revenue that the providers receive, but much more of the dollars are flowing through the government and from tax dollars than is the case here. We have always struggled here in the United States with balancing, number one, regulation. How much do we want to regulate prices instead of letting the market decide what a private sector person like a health care provider or hospital is going to receive? And we also struggle with increasing our taxes, right? And so we could create a system where we have greater regulation of the prices and limits on prices that are paid to health care providers to lower our total spending. We can also finance more coverage through the federal government or through state government for more people. But it is a real political struggle to convince people that while they feel like their… that health care is too expensive, they’re afraid of oftentimes of putting limits on what their particular doctor is going to make or their particular hospital is going to make. Because the hospitals and the physicians will let them will tell them whether it’s accurate or not, that their access and their quality of care is going to suffer if they do that. And there are also people in this country are very much resistant to significant increases in their taxes, even if you tell them it’s going to lower other out-of-pocket expenses because they don’t really believe it, right? Or they think they’re going to end up paying more for somebody else to have lower prices. So it is a very complicated political balance here. I think people are getting more and more frustrated with the way that the system works and the increase in the denials and the red tape and the complexity people have to jump through to obtain their medical care. But the political challenge is real in terms of more government regulation of prices and/or financing more care through the tax system. Terry 34:43 Well, you’re absolutely right. It is very complicated politically. And you mentioned that one of the alternatives that is sometimes posited is: let market forces regulate prices, which is, I think, where we are, except that market forces are only making prices higher, not lower. Why doesn’t health care in America work like a market should? Dr. Linda Blumberg 35:12 We have had a tremendous amount of consolidation in our healthcare industries. And so when we talk about hospitals being bought, you know, buying other hospitals and creating hospital systems and, you know, sometimes often now buying medical practices, insurance companies, UnitedHealthcare is now the biggest employer of physicians in this country, right? The insurers and the healthcare systems are buying up these middlemen that are making more money off of, you know, as I was saying, extracting dollars from the claims that are being processed. So there’s been a tremendous amount of complexity added in the financial relationships between all of these stakeholders, the providers, the insurers, the middlemen. Very few of them are independent at this time. Very many of them have conflicts of interest, all directed in the direction of increasing prices on the commercial side and increasing spending. Terry 36:15 Right. Lots of complexity, not much transparency. Dr. Linda Blumberg 36:18 Right. It is basically capitalism run amok. And you’re talking about a product in health care that was already from the beginning of time, much more complicated to shop for than a refrigerator, right? You know, you don’t know necessarily what you’re going to need in terms of services or what it’s going to cost before you walk in the door at the doctor’s office or in the hospital. It is not something that is easy to shop for, whereas I can, you know, spend 20 minutes and figure out what the best price I can get on the refrigerator I want is. That’s just not the way medical care works. And then when you take the consolidation and the hidden fees and the conflicts of interest that have arisen both between co-ownership in the healthcare industry and these financial deals that are being made between the insurers and the middlemen and the providers at this point, you have a situation where there is no competition in these markets or where there is, it’s extraordinarily limited. And so you’re not going to… the more this is allowed to fester and expand, which is what it is doing year in and year out, the worse it’s going to get. You’re not going to have competition driving prices down. You’re going to have greater financialization of the system continuing to drive prices up. And really the only way to interfere with that is for government to put limits on both what prices can be charged for particular services and to eliminate the financial dealings that are interconnecting all of these stakeholders with each other and encouraging higher intensity coding and hidden financial fees that are passing between different entities that are driving costs up for consumers and employers. Terry 38:14 You’re listening to Dr. Linda Blumberg. She’s a research professor at Georgetown University’s McCourt School of Public Policy, and she is an expert on private health insurance, health care financing, and health system reform. Dr. Blumberg has provided technical assistance to states in their efforts to analyze and implement federal reforms and examine the implications of private equity companies’ movement into health care. Joe 38:43 After the break, we’ll discuss why you need to examine your hospital bill extra carefully and with skepticism. Terry 38:52 Hospital bills are complex and they often contain errors. To really figure out the charges, you need to request an itemized bill. Joe 39:01 Surprisingly, your insurance company might not behave like an ally. Terry 39:09 How do you contest a bill that is obviously wrong? Joe 39:12 Sometimes media exposure of outrageous bills can make a big difference. Most hospitals hate bad publicity. Terry 39:31 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Welcome back to The People’s Pharmacy. I’m Terry Graedon. Joe 39:46 And I’m Joe Graedon. Joe 40:16 Are you the kind of person who pays bills as soon as you get them? Nothing wrong with that. But when it comes to hospital bills, you may need to slow down. It turns out they often contain errors that can be tough to track down. Terry 40:33 Medical bills, especially hospital bills, can be extremely complex. And hospitals make mistakes all the time. You’ll need to scrutinize every charge. Joe 40:44 We’re talking today with Dr. Linda Blumberg, research professor at Georgetown University’s McCourt School of Public Policy. Dr. Blumberg’s expertise is in private health insurance, health care financing, and health system reform. She has analyzed the Affordable Care Act and studied strategies to address remaining health insurance coverage issues. Dr. Blumberg has also analyzed approaches for setting standards of affordability for insurance coverage. Terry 41:14 Dr. Blumberg, some years ago, we spoke with a fellow, I think his name is Marshall Allen, who wrote a book. He titled it: “Never Pay the First Bill.” And we found our conversation with him quite interesting. I’m wondering what you think of that advice. Dr. Linda Blumberg 41:34 Well, I think my advice is always be skeptical and look carefully at a bill. Don’t just pay it, because the vast majority of them, whether they’re coming from a hospital, much more likely from a physician, also reasonably likely there’s mistakes in them. And so you do want to approach them with some skepticism and caution. Joe 41:58 Well, actually, that’s not enough. And the reason I say that’s not enough is because most of us, when we look at a hospital bill or a clinic bill, we don’t know what to make of it. I mean, it is really confusing. And as you said, there’s like the bill that the doctor presents and the bill that the clinic presents or the hospital presents. And then there’s what Medicare might pay or might not pay or your insurance. It’s like, how in the world do we make sense of our medical bills? How do we even get started? Dr. Linda Blumberg 42:38 It’s rough and it takes a good deal of patience and time, unfortunately. Hospital bills in particular, I’ve heard estimates that nine out of 10 of them have errors. I’ve heard others say that there’s never a hospital bill that doesn’t have an error in it, right? And they’re the most complex of the bills that an individual is going to receive. My advice is always the first thing you do is request an itemized bill from the hospital, because by and large, what the hospital will send out is a summary bill, not an itemized bill. And you can’t figure out what the errors are in general from a summary. So request an itemized bill. If they don’t send it, you got to ask again, because sometimes they’re a little pokey about it because they just want you to pay. They don’t want you to look at the itemized bill. Joe 43:26 Well, let me ask you this: let’s say you get an itemized bill and it says that you had an ultrasound done on such and such a date of, you know, such and such a part of your body and you go, “No way. I did not have an ultrasound at all.” How did that happen? And then how do you contest something that’s obviously wrong? Dr. Linda Blumberg 43:53 The first stop from my perspective is to call the billing department, to call the physician’s office of the physician that you’ve seen and contest it and say, there’s a mistake. I’m being charged for a service that I never received. An insurance company, if you have an insurer, can also often be helpful when you’re talking about something you’ve been charged for that is something you have not received. But it sometimes will take multiple calls and multiple interactions to resolve a problem like that. You know, one of the most common errors that people see in hospital bills is being billed twice for the same thing or the number of, you know, something that was charged for, you know, some supply or something is, you know, somebody added a zero to it by mistake, you know, assumedly. And that needs to be corrected, and so engaging with the physician who you’ve received services from with your insurer and trying to contact the billing department directly at the hospital… Joe 44:59 Let me ask you one follow-up to that, because you would think that since the insurance company, if you’re fortunate enough to have insurance, would be an ally, would be joining you in fighting an incorrect bill or a bill that was overcharged for some reason or a service that was never provided or a medication that you never got. We’ve heard that insurance companies, they’re not as likely to be enthusiastic about challenging these bills because after all, they’re just going to pass those charges on to their customers and consumers. It’s like, well, why waste our time? Because you, you know, you, you were charged for aspirin, but you didn’t get aspirin. So how do we get the insurance companies fired up to actually challenge mistakes? Dr. Linda Blumberg 45:55 It is sometimes a struggle for sure. One of the things that people should be aware of, and what I talk about when I talk about this complex web of interconnected financial interests across stakeholders in the healthcare industry, is that insurance companies, they can make greater profit the higher the claims. Under the law, they are limited in terms of what percentage of a premium can go to administrative costs, including profit. So since that’s limited as a percentage, the higher the total spend on claims, the bigger the amount of money they have left over for their administrative costs and their profit. And so in a lot of ways, they’re disincentivized to hold down spending, which is contrary to what many people who are using, buying health insurance coverage expect of their insurer. They think their insurer is trying to get the best deal for them. That is not always the case. And so you can talk to the consumer reps with the insurer, but sometimes you’ve really got to go directly to the provider and dispute. And there’s a nonprofit called the Patient Advocate Foundation that is particularly created to help people with chronic illnesses contest incorrect bills and deal with billing issues. There are others who will do it for a fee as a percentage of what savings created. But it becomes sometimes a situation where the consumer themselves needs to do repeated calls and contacts and filing complaints in order to get a bill resolved. But I still always say contact the insurance company as well. They may be in a mindset to help out. Terry 47:52 Dr. Blumberg, you’ve mentioned that patients can and probably should negotiate with whether it’s the physician’s office billing or the hospital billing, especially if they don’t have insurance, but even if they do. Can you tell us about a time when somebody did that? What was the outcome? Dr. Linda Blumberg 48:17 Well, sure. I mean, I think it depends greatly on the health care provider, right? And if you have had a primary care physician for many years and then you’ve lost health insurance coverage or for some reason you have a gap or et cetera, you know, there are ways in which, you know, in circumstances where these providers will either set up a payment plan for you, or they’ll say, “Listen, you know, you’ve been a great patient and I want to help you through this rough spot.” And they’ll negotiate down, you know, hopefully to what at least at a minimum that the private insurer would have paid, right? But it is very much [an] ad hoc kind of decision that’s being made by these providers. Now, in the situation of a hospital, particularly for people who have modest incomes, there are programs that nonprofit hospitals have, as I mentioned before, that are there to help people in financial straits. And those programs, sometimes they’re programs that are funded by state government dollars. Sometimes it’s… parts of it, the hospital themselves, but those are programs that exist explicitly for people in tough situations. And some… but some… The problem is you have to really push to get the information about them to figure out whether you’re eligible. Joe 49:41 Dr. Blumberg, what about media exposure? I mean, every once in a while, somebody sort of blows the whistle on an outrageous bill that just blows everybody’s mind. It’s like, that’s ridiculous. And they contact their, their local TV station or their newspaper, and all of a sudden, you know, it goes, you know, wild on the internet, and it affects the hospital in such a way they say, “Oh, never mind, let’s negotiate a better bill.” Is that something that people can actually do successfully? Dr. Linda Blumberg 50:15 Yes, people have done it successfully. And there’s, you know, ‘bill of the day’ kinds of newspaper reporting, et cetera, where some experienced reporters are doing this repeatedly on behalf of people in particularly egregious circumstances. And it can be really effective at cutting through to the right people at the right moment to get a better deal created. And so, listen, if I was in that situation, I would use whatever options I had at my disposal. You know, in some states, unfortunately, it’s not all states, but in some states, state governments have what are called consumer assistance programs. They were originally funded by the federal government across the country, but that funding has not been reappropriated in many years now. But those consumer assistance programs, if you’re lucky enough to live in a state that has one, can sometimes also be helpful if you contact them, file a complaint with the state. If it’s a problem with the insurance company and it’s a fully insured product, not a self-funded plan from the employer, you can file complaints with the Department of Insurance, et cetera. So there are opportunities for going higher. And I always suggest to people, even if you’re contacting someone at the hospital, if you’re not getting any kind of satisfaction from a consumer rep, you want to escalate to a manager, to whoever. You want to just go as high as you can in the pecking order to try to get some resolution. Joe 51:50 We are concerned about pharmaceutical prices, as you can very well imagine here on The People’s Pharmacy. And we have seen pharmacies disappearing in this country at an extraordinary rate, in part because private equity firms have bought up large chains, and those large chains are now closing not dozens but hundreds of pharmacies. And so the idea of a mom-and-pop pharmacy where the pharmacist was a sole operator seems to be disappearing very quickly. And drug prices, as everybody knows, are way higher in this country than any place in the world. What do you suggest when it comes to the costs of medicine in this country, especially for people who have life-threatening conditions and their bills may be in the tens of thousands of dollars? Dr. Linda Blumberg 52:43 It’s really, really difficult. And I wish I had a good answer for you. I know some people are trying to obtain medications at more affordable prices outside of the country. That’s always challenging and a little bit risky depending upon where you’re going to get the medications. But there are some programs that particular pharmaceutical companies have that lower prices for people with modest incomes or people who do not have health insurance coverage for brand-name types of drugs that they need. And so, you know, I usually suggest to people, first stop if you can’t get satisfaction or help from your insurance company. And sometimes if it’s not on their formulary, you can get evidence from your… help from your physician about why that particular drug is so necessary to try to appeal and get coverage from your insurance company. If you’re without insurance or without good enough insurance to cover costs, I would suggest to people go to the website for the company that makes your drug and see if they have some programs that might be able to help. There are also some states [that] have particular programs for providing financial support for prescription drugs. Joe 54:04 Dr. Blumberg, we only have about two minutes left. If we were to put you in charge of the entire health care system, how would you change things? Dr. Linda Blumberg 54:15 Well, first of all, I would put back a number of the coverage cutbacks that this administration has put in place or that they will be putting in place in the near future in the Medicaid program because every person in this country should have access to affordable, adequate health insurance coverage for their medical needs. Beyond that, I would put limits in place on the prices that are charged by providers, and I would do it broadly across all prices, and hospital level, physician level. I would include prescription drug controls in that as well. I would then make sure that we are monitoring a system to make sure that everybody has the access that they need. And I would do a lot to break up the kinds of integrated financial incentives from co-owned entities in the healthcare system to separate those financial incentives, create more competition and clarity in terms of what people are paying when they obtain care. And I think we’ve also got to go a ways to your point about the prescription drug issues on the private equity side. There’s a lot of practices that private equity typically uses in the healthcare space that are extractive and damaging both to prices, quality, and sometimes the stability of the healthcare providers themselves. And we have to prohibit those kinds of high debt financing and other extractive practices that are often in place there. Terry 55:50 Dr. Blumberg, did we miss anything that we should have asked you? Dr. Linda Blumberg 55:54 No, I think we covered a lot. So, yeah, I think, you know, when people get their bills, they should always make sure that the names, the dates, you know, the insurance information is all correct. Sometimes that stops insurance companies from paying appropriately from like little minor like typo errors in addition to the kinds of things we talked about. And everybody who has a health insurance policy by law has access to what’s called a summary of benefits and coverage or an SBC. This is part of the Affordable Care Act law. It’s an English-language summary of your benefits. And so I always suggest to people to have that in hand so you can make sure that when you get the bill that says this is what your insurance company pays, this is what you owe, that you’re clear that that is really what you owe. So, for example, I had a situation where I was helping somebody and they had gone into the emergency room for urgent care that the doctor told them to go to the ER. And the hospital charged them $2,000 up front on a credit card when they walked in the door. Their summary of benefits and coverage very explicitly said that the only charge they should be charged when they walk into an emergency room for a real emergency is $200. It took me about an hour and a half or two hours and maybe three or four different telephone calls to resolve that. But it was really clear from that summary of benefits and coverage that that person was overcharged. So, you know, knowing, being really on top of what your health insurance plan is supposed to cover and comparing that to what you’re being charged is a really important line of defense. Joe 57:47 Dr. Blumberg, whenever we talk to healthcare professionals, they often complain these days. They complain that they have to see way too many patients in way too little time. They complain about the cost of their education, whether it’s a nursing school or pharmacy school or medical school, that it’s very expensive and that they had to go into debt. And then they complain about the whole fee structure and all the bureaucracy and all the time they have to spend sometimes arm wrestling insurance companies, and it’s not actually practicing medicine the way they would like to. But at the same time, we hear that people earn rather extraordinary incomes. So a, for example, orthopedic surgeon is often making $500,000, $600,000, $800,000 a year. A family practice physician may be only making $150,000 to $200,000 a year. How do the payments to healthcare professionals in this country compare to the healthcare professionals in, let’s just say, the UK or Germany or Sweden? Dr. Linda Blumberg 59:20 We are paying our specialists in particular a lot more than are being paid in those other countries. I don’t have the statistics at hand on those specific salaries, but, you know, I’m not sure we’re paying our primary care physicians, you know, any more or not significantly more than they are paid in other countries. But, you know, those are at the highest levels, you know, as you said, the orthopedic surgeons, the interventional radiologists, the folks that are being paid for procedures at really high levels are paid much more than we see in other countries. And I think my understanding is, and I’d have to look at this more carefully, but my understanding is that education in general, including education for medical professionals, is much more highly subsidized in most of these countries than we do here. And so if you’re going to pay considerably less, then we also have to think about subsidizing the education for some more medical professionals than we do. And that should be part of the thinking if we’re going to put a lot of limits on what these providers can make. Joe 01:00:38 And finally, our listeners learn from stories. And quite honestly, so do doctors. They call them case reports. But it makes the topic that we’re discussing come alive in ways that just talking in a more academic way [does not]. Have you had any experience over your career in which a patient or a family or some situation where the billing was so outrageous that it came to your attention and it was able to be modified? You mentioned spending a couple of hours on the phone because the person was billed so much on their credit card when they entered the emergency department. Is there any other story you could share about billing that would be how I would describe it as helpful for our listeners to comprehend the scope of the problem? Dr. Linda Blumberg 01:01:40 Well, you know, I am an academic researcher, right, and a policy researcher. And so I do not generally work as an advocate for patients. Every once in a while, a family member or a friend or somebody who sees a program that I’ve been speaking on will contact me and ask for help and I’ll do what I can. But that’s the most… The situation with the $2,000 bill instead of the $200 bill is my most recent case of that. But, you know, the other thing that I’ve seen a lot in terms of what’s been in the media is stories of people who go in for an emergency room visit, and it’s a reasonably modest kind of situation. They’re not in there long. Maybe it’s for a child and they were worried, but it’s really not a big medical problem. And the intensity with which that bill is coded is way out of whack with the services that were provided because emergency room visits are coded by the intensity of the situation and the services needed. And so those are situations where people can get bills in the huge range, tens of thousands of dollars for something that should have been a much more low-cost price. And seeing that and having to go back and appeal that is something that is becoming more common, I think, in emergency departments over time. So I don’t have a lot of individual stories where I have particularly intervened because that’s, you know, I’m a data and analytic person more than I am, you know, I’m not really a consumer advocate. Terry 01:03:26 Dr. Linda Blumberg, thank you so much for talking with us on The People’s Pharmacy today. Dr. Linda Blumberg 01:03:32 My pleasure. Thanks for having me on. Terry 01:03:34 You’ve been listening to Dr. Linda Blumberg, research professor at Georgetown University’s McCourt School of Public Policy. She’s an expert on private health insurance, health care financing, and health system reform. Dr. Blumberg has provided technical assistance to states in their efforts to analyze and implement federal reforms. She’s also examined the implication of private equity companies’ movement into health care. Joe 01:04:05 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Terry 01:04:14 This show is a co-production of North Carolina Public Radio, WUNC, with The People’s Pharmacy. Joe 01:04:23 Today’s show is number 1,471. You can find it online at peoplespharmacy.com. That’s where you can share your comments about this episode. We’d love to hear your reports about hospital bills, interactions with the medical system. Please, you can reach us through email, radio at peoplespharmacy.com. We’re also trying to enhance our YouTube channel with videos of our interviews. If you’d like to watch our interactions with guests you hear each week on The People’s Pharmacy, why not go to YouTube and search for People’s Pharmacy? Terry 01:05:01 Our interviews are always available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. In this week’s podcast, we also discuss how easy it is for errors to creep into the bill, even through simple typos. The summary of benefits for the insurance coverage is a crucial document. It lays out exactly what the hospital can and can’t charge you for. One reason health care costs so much in the U.S. is the high cost of specialized medical professionals. How does compensation in other countries compare to what health care professionals make here? You’ll also hear about emergency room coding errors. Joe 01:05:48 At peoplespharmacy.com, you could sign up for our free online newsletter to get the latest news about important health stories. When you subscribe, you also have regular access to information about our weekly podcast. We would be so grateful if you would write a review of The People’s Pharmacy and post it to the podcast platform you prefer. If you find our topics thought-provoking, please share them with friends and family. In Durham, North Carolina, I’m Joe Graedon. Terry 01:06:18 And I’m Terry Graedon. Thank you for listening. Please join us again next week. Thank you for listening to The People’s Pharmacy Podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money. Joe 01:06:55 If you like what we do and you’d like to help us continue to produce high-quality, independent healthcare journalism, please consider chipping in. Terry 01:07:04 All you have to do is go to peoplespharmacy.com/donate. Joe 01:07:10 Whether it’s just one time or a monthly donation, you can be part of the team that makes this show possible. Thank you for your continued loyalty and support. We couldn’t make our show without you.
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  Show 1470: Why Your Doctor Should Prescribe Exercise to Treat Depression, Cancer & Aging 23.04.2026 1ชม. 18นาที

  If you had to name one thing that could contribute to better health throughout the lifespan, what would it be? We think exercise, or at least physical activity deserves the top spot. Yet in 2025, fewer than half of adults met the guidelines for aerobic physical activity. And less than one-quarter were doing both aerobic and muscle-strengthening exercises on a regular basis. Perhaps your doctor should prescribe exercise. What could we expect as the benefits? At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, April 25, 2026, through your computer or smart phone (wvtf.org). Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on April 27, 2026. Would Your Doctor Prescribe Exercise for Depression? Earlier this year, the Cochrane Collaboration published a review of 73 randomized clinical trials of exercise as a treatment for depression (Cochrane Database of Systematic Reviews, Jan. 8, 2026).  Most of these compared physical activity to antidepressants or to psychological therapy for depressed patients. Some of them compared the exercise prescription to no treatment or wait list. Comparing exercise to no treatment revealed an advantage for exercise, although the quality of the trials left something to be desired. Ten trials compared exercise to psychological therapy. In addition, five trials weighed exercise against antidepressant medication. Neither comparison showed a clear tilt for or against exercise as a superior intervention against depression. Exercise in the Cancer Center Dr. Claudio Battaglini of the University of North Carolina at Chapel Hill was not surprised by this finding. The exercise program he oversees for cancer patients often results in lifting their spirits as well as improving their health. That may help explain the very high adherence in his program. Will Physical Activity Reduce the Risk of Cancer? According to a review of the evidence, regular physical activity can reduce the number of people who die prematurely. In addition, it helps with weight control, quality of life and bone health. Older people are less likely to fall or experience declining cognition if they exercise regularly. The review found that physical activity improves quality of life and promotes emotional benefits (European Journal of Cancer Prevention, Jan. 1, 2025). If oncologists should prescribe exercise, don’t cancer patients deserve to have their insurance company cover the cost? Insurers rarely blink twice at cardiac rehab. Although cancer rehab is also super-helpful, insurance companies often don’t choose to pay for it. What Role Could Coaching Play in Guiding Physical Activity? Lots of doctors tell their patients to get more exercise. The patient wants to and intends to, but perhaps they just don’t know how. What activity should they choose? What is the proper technique? How often and how much do you need to move? All these questions can be answered by a coach. The coach will take into account your objectives and preferences as well as your prior experience. What do you love doing? Are there any moves you should avoid to reduce the risk of injury? That’s why when doctors prescribe exercise, they should include coaching to provide this sort of guidance. If Doctors Prescribe Exercise, Will That Help Motivation? Many of us know we should be active, but we don’t always follow through. How can we get motivated to move? According to Dr. Jordan Metzl, the first step is to find something you love doing. For Joe, for instance, having the doctor prescribe exercise of runniing a mile a day is not going to work. But he’ll cover much more than a mile–and quickly–if he is playing a competitive game of tennis. Joe loves tennis. Terry is not a runner either. On the other hand, karate club is a highlight of her week, and she has worked to achieve some skill in it. Dr. Metzl advocates for finding the activity that gets you excited and making it a priority in your life. If you are having fun, that is a great motivation. Reducing the Cost to Act Another thing to consider is overcoming the cost to act. If your activity requires a lot of preparation that feels like a chore, the cost to act is high. If you can make it easier and break down that barrier, you are much more likely to accomplish your exercise. External rewards can also play a role. Joe loves winning, so he likes to play with guys at about his same level of skill. That way, he has a chance to win if he tries. For Terry, there was a progression through belt levels in karate, from yellow to green to blue, and so on. Now, she looks forward to closing the rings in the fitness app on her watch. When Doctors Prescribe Exercise, Does That Give You a Push? For Dr. Metzl, the idea of pushing yourself and maybe your friends is a positive notion. We asked him about people who dig in their heels when pushed. What approach do they need to perceive and pursue their goals? He summarized the three ingredients of healthy motivation as knowledge, emotion and belief. That’s knowledge of the benefits of activity, an emotional response of appreciating and enjoying activity and a belief that you can achieve your goal. This Week’s Guests Claudio Battaglini, PhD., FACSM, is Professor in the Dept. of Exercise and Sport Science at The University of North Carolina at Chapel Hill. He is also Director Emeritus of the Get REAL & HEEL Breast Cancer Research Program and Co-Director of the Exercise Oncology Research Laboratory. Jordan D. Metzl, MD is an internationally recognized sports medicine physician, bestselling author, and fitness instructor who practices at the Hospital for Special Surgery in New York City. He lectures around the world and founded the first physician-led online fitness community, IronStrength, with more than 50,000 members. He created the Ironstrength Workout, a functional fitness program for improved performance and injury prevention that he teaches in fitness venues throughout the country. An elite athlete himself, Dr. Metzl is also a 40-time marathon runner and 14-time Ironman finisher. Dr. Jordan Metzl, author of Push, runs the New York City Marathon 2025 Dr.Metzl’s latest book is Push: Unlock the Science of Fitness Motivation to Embrace Health and Longevity The People’s Pharmacy is reader supported. When you buy through links in this post, we may earn a small affiliate commission (at no cost to you). Listen to the Podcast The podcast of this program will be available Monday, April 27, 2026, after broadcast on April 25. On this episode, Dr. Metzl talks about the joy of teaching medical students to offer an exercise prescription and the challenge of getting specialties other than cardiology to integrate physical activity into their rehab process. Dr. Battaglini discusses the contrast between cardiac rehab, which is covered by insurance, and cancer rehab, which is not. He also describes the value of swimming, especially for older people with sore joints. Walking is good exercise and easy for most people. What if the weather is bad? Perhaps an indoor walk around the mall would be a good alternative, and if you can recruit some friends to join you, so much the better. You can stream the show from this site and download the podcast for free.
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  Show 1188: The Healing Potential of Psychedelic Drugs: New Day! 23.04.2026 57นาที

  Many indigenous peoples around the world have developed traditional uses for psychedelic compounds. In Western medicine, these were mostly unknown until Albert Hoffmann synthesized LSD (lysergic acid diethylamide) in 1938. He later tried to figure out how it might be used after having an extraordinary personal experience. By the mid to late 1960s, psychedelic drugs like LSD or psilocybin had become a cultural phenomenon. By 1970, medical research on such drugs was essentially shut down. A personal note: I worked in the Neuropharmacology Laboratory at the New Jersey Neuropsychiatric Institute from 1967 to 1969. My mentors were Dr. Carl Pfeiffer and Dr. Leonide Goldstein. Both were actively involved in basic research into psychedelic compounds such as LSD and psilocybin. Dr. Pfeiffer’s first paper on the topic was published on March 14, 1957 in the Annals of the New York Academy of Sciences. I tested these hallucinogenic compounds in rabbits and rats using a quantitative EEG technology that Dr. Goldstein brought to the US from France. One of our papers was published in the Proceedings of the National Academy of Sciences (Oct. 1969). I share this in an effort to provide full transparency so that you will understand I was involved in basic psychedelic research before it was unacceptable to conduct such investigations. What Scared the FDA and the NIH? After 1970, if a researcher wanted to perform research on psilocybin or LSD, the FDA was not supportive. Neither were funders such as the NIH or private foundations. The memory of the 1960s with the slogan sex, drugs and rock and roll created a no-fly zone for scientific investigation after 1970. That was when the federal government passed the Controlled Substances Act (CSA). The CSA made LSD and related compounds Schedule 1. The meant that LSD and related hallucinogens were categorized like heroin with “no currently accepted medical use and a high potential for abuse.” This made scientific research virtually impossible. But over the last decade or so, there has been increasing interest in the use of such compounds to ease the anguish of post traumatic stress disorder, the existential crisis of a cancer diagnosis, drug dependency or even schizophrenia. But the hallucinatory potential of such drugs continues to discourage many researchers from studying such compounds. President Donald Trump Signs the Psychedelic Drugs Executive Order On April 18, 2026, President Trump signed an executive order titled: “Accelerating Medical Treatments for Serious Mental Illness“ For the first time in decades, investigators will be encouraged to conduct research into the therapeutic potential of hallucinogens such as psilocybin, MDMA and ibogaine. Health and Human Services (HHS) will be encouraged to fund research into psychedelic programs. And eligible patients will able to access such compounds for therapeutic purposes under the “Right to Try Act.” Here is the dramatic reversal: “The FDA and Drug Enforcement Administration shall facilitate and establish a pathway for eligible patients to access psychedelic drugs, including ibogaine compounds, under the Right to Try Act (21 U.S.C. 360bbb-0a), including any necessary Schedule I handling authorizations for treating physicians and researchers, consistent with 21 U.S.C. 823, and any applicable waiver authority under the Controlled Substances Act.” What Does This Mean? First and foremost, it means that psychedelic drugs can now be studied without fear by researchers at prestigious medical institutions. Agencies can now fund such research. The head of the Food and Drug Administration, Dr. Marty Makary, is on the record encouraging the FDA to accelerate review of such compounds. There is growing evidence that psychedelic compounds may help people dealing with severe mental health conditions. You will see research and have access to interviews with investigators that have been studying these drugs for years. Yes, there has been research, even if it was not sanctioned by federal agencies. Current Research on Psychedelic Drugs Over the past decade or so, investigators have been conducting research on the healing potential of psychedelic drugs. Dr. David Nichols, an international authority on these compounds, describes the history of this research. His son Charles Nichols, a pharmacologist, studies the molecular and behavioral effects of hallucinogens in animal models. The Healing Potential of Mystical Experience Dr. Matthew Johnson, associate director of the Center for Psychedelic and Consciousness Research at Johns Hopkins School of Medicine, has conducted a number of clinical trials utilizing psilocybin. He and his colleagues have been exploring the possible uses of psychedelic drugs as medicines for people with life-threatening cancer. They have also examined the possible benefits of a single dose of psilocybin for smoking cessation and overcoming alcohol misuse. Their research was highlighted in an episode of the CBS television show “60 Minutes.” How Psychedelic Drugs Affect Existential Crises When people are diagnosed with terminal cancer or other life-threatening conditions, many become extremely anxious or depressed. While this reaction may seem rational in the face of a frightening diagnosis and foreshortened life expectancy, it can interfere with people actually appreciating the days, weeks or months they have left. Dr. Johnson and other scientists have found that a session with psilocybin that results in a mystical experience can alter people’s lives dramatically. They have far less anxiety and depression and seem to find more purpose in their lives, along with other positive changes. How does this work? Dr. Johnson’s most recent publication (with colleagues) explores the nature of these mystical experiences (PLoS One, April 23, 2019). Our Radio Show Guests David Nichols, PhD, is an adjunct professor at the Eshelman School of Pharmacy at the University of North Carolina, Chapel Hill. David Nichols had an active research program at Purdue University for 38 years prior to his retirement in June 2012. His research interests focused in two areas: the study of hallucinogens (psychedelics), where he was recognized as an international authority, and also discovery of novel D1 dopamine receptor full agonists, which showed efficacy comparable to levodopa in both animal models of Parkinson disease, and in human Parkinson patients. In 1993 he founded the Heffter Research Institute, which has encouraged and supported modern clinical studies of the psychedelic agent psilocybin (from “magic mushrooms”) for treatment of depression, anxiety, and various addictions. His general interests continue in the medicinal chemistry and pharmacology of CNS-active agents. Charles Nichols, PhD, is Professor of Pharmacology at Louisiana State University Health Sciences Center in New Orleans. As David Nichols’ son, he did not begin his career with the intention of studying hallucinogens. However, his current research interests include the molecular and behavioral effects of such compounds on the brain. Matthew W. Johnson, PhD, is Associate Professor of Psychiatry and Associate Center Director of the Center for Psychedelic and Consciousness Research at Johns Hopkins School of Medicine. The photograph of Dr. Johnson is courtesy of Johns Hopkins Magazine. The website is https://hopkinspsychedelic.org Listen to the Podcast: The podcast of this program is available for free. The show can be streamed online from this site and podcasts can be downloaded for free. Download the mp3 Want More? Here is our radio show # 1317: Psychedelic Compounds for Healing You can listen by clicking on the arrow inside the green circle under the photograph of Bryan Roth, MD, PhD at the top of the page. It’s super easy! You will learn about conditions that may respond to psychedelic compounds: Cluster Headaches Substance Use Disorders Depression and Distress Would You Consider LSD If There Were No Hallucinations? Investigators at University of California, Davis have modified LSD so that it does not cause hallucinations. The new compound, called JRT, appears to have some therapeutic benefit, however. That’s because it increases neuroplasticity. So far, the drug has only been tested in animals, but the initial responses appear promising. The hope is that JRT will have fast-acting antidepressant activity and may even be helpful against schizophrenia (Proceedings of the National Academy of Sciences, April 14, 2025). The authors of this research point out that current treatments of schizophrenia leave a lot to be desired. They don’t work very well: “…for addressing the negative and cognitive symptoms, and evidence suggests that they are unlikely to rescue morphological or synaptic deficits.” One of the negative symptoms of schizophrenia often includes the term anhedonia, which is described as an inability to feel pleasure or joy. It is also characteristic of depression. Another negative symptom of schizophrenia is avolition. It means an inability to get motivated to participate in goal-directed activities. That’s psych talk for profoundly disturbing blahs. People just cannot mobilized to get going or stay going. Social activities are just overwhelming. Then there are the “impairments in attention and working memory.” It is hard to function when you have brain fog, little to no motivation, and few, if any, feelings of joy or happiness. JRT and Neuroplasticity: The researchers who helped create the new compound called JRT suggest that this nonhallucinogenic compound promotes “neuroplasticity” in the brain. So does LSD. What is neuroplasticity, you ask. It is, according to Wikipedia: “…the ability of neural networks in the brainto change through growth and reorganization. Neuroplasticity refers to the brain’s ability to reorganize and rewire its neural connections, enabling it to adapt and function in ways that differ from its prior state. This process can occur in response to learning new skills, experiencing environmental changes, recovering from injuries, or adapting to sensory or cognitive deficits. Such adaptability highlights the dynamic and ever-evolving nature of the brain, even into adulthood.” The researchers who helped create JRT note that: “Effective treatments for complex neuropsychiatric diseases like depression, substance use disorders, and SCZ [schizophrenia] are likely to involve multiple targets rather than a single site of action. However, the polypharmacology of such agents must be carefully tuned to maximize benefit while minimizing unwanted side effects. The unique polypharmacology of (+)-JRT might endow it with specific advantages compared to compounds currently in use.” “Despite its lower hallucinogenic potential, (+)-JRT has demonstrated profound therapeutic effects.” It’s a long and winding road before JRT could become available as a medication to treat challenging conditions such as PTSD or schizophrenia. In the meantime, there is a lot of new and intriguing research involving drugs that do induce hallucinations. The Future of Psychedelic Drugs? There is no good answer to that question. No one should undertake treatment with a psychedelic compound on their own. This approach requires well-trained healthcare professionals who actually know what they are doing. It requires a therapeutic setting with experienced therapists. Some people should not undergo such an experience. Despite the fact that I worked in a laboratory that had one of the world’s largest collections of LSD and other psychedelic compounds, I was never interested in a hallucinogenic experience. Some people may not be helped and might be harmed by such a “trip.” That said, I am pleased that the research doors (and funding) are beginning to open. After research was halted because of the “war on drugs,” we could now be entering a psychedelic renaissance. Let’s see what the research produces. Please share your thoughts in the comment section below. If you think friends or family might be interested in this article, please send it along. Thank you for supporting our work.
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  Show 1469: Fresh Air & Sunlight: How Some Hospitals Are Rediscovering This Healing Secret 16.04.2026 1ชม. 6นาที

  Hospitals can be pretty overwhelming. Sometimes you may feel like you need a map to find your way around the maze, not to mention a trusty guide to get you to the department or health professional that could actually help you overcome illness. In addition, being hospitalized often means being deprived of fresh air & sunlight. Could that be a mistake for proper healing? At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen: You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, April 18, 2026, through your computer or smart phone (wunc.org). Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on April 20, 2026. Striving for Person-Centered Care Wouldn’t it be great if healthcare facilities were specifically designed around the individuals they are supposed to serve? Fifty years ago, a group of physicians and former patients started Planetree to do exactly that. At first, Planetree provided information at a time when patients were rarely told what was wrong or how it could be addressed. There was also a Planetree ward in a hospital in the Bay Area that operated on principles of transparency and person-centered care. Over the next several decades, Planetree developed as a network of more than 300 health care facilities in 30 countries that strive to provide a home-like environment for healing. The main value is person-centered care, in which they strive to treat the whole person as well as that individual’s family or significant others. We invited Planetree President Michael Giuliano to tell us about it. He mentioned that one feature is getting your care summary in real time, so you can ask questions and correct errors before you leave the clinic or office. Fresh Air & Sunlight Built In One of the things that sets a Planetree hospital apart from other facilities is the way the values are visible in the architecture. Planetree planners put a premium on access to nature and outdoor space, though of course each facility does it a bit differently, according to its own plan. Rooms are set up so that people have access to fresh air & sunlight. That makes them feel more comfortable, certainly. Might it also promote healing? How Do Fresh Air & Sunlight Promote Healing? More than 150 years ago, Florence Nightingale set standards based on what she observed of soldiers healing from battle wounds and horrible infections during the Crimean War. This was, of course, before the development of antibiotics, so nursing care was paramount. Nurse Nightingale insisted on the primacy of fresh air & sunlight for her patients. Was this just a quaint old-fashioned idea, or is there modern scientific support? The Power of Near-Infrared For more information on the science of fresh air & sunlight (yes, there is science), we turn to Dr. Roger Seheult of MedCram.com. https://www.medcram.com/ He began by describing the brand new Footscray Hospital in West Melbourne. The design is something of a modern take on Florence Nightingale’s hospital plan, since the architects figured out how to get natural light and real ventilation in every room. They prioritized fresh air & sunlight in this $1.5 billion hospital because of their healing properties. People exposed to sunlight leave the hospital sooner because they recover more quickly. So the patient gets better and goes home faster, the hospital has a better bottom line and the insurance company pays less. Everybody wins! Probably a good part of the credit goes to near-infrared light. We can’t see it, but it penetrates our bodies and they react. Exposure to near-infrared at 850 nanometers improves mitochondrial function. You could get this from a device, but it is cheaper and arguably more pleasant simply to go outside and allow sunlight to fall on your skin soon after sunrise (or before 10 am) or just before sunset (probably after 4 pm). An Amazing Story About Fresh Air & Sunlight We’d be tempted to call this an unbelievable story, but Dr. Seheult provided all the details and checked the medical records himself, so we believe it. He told us about a 15-year-old boy with a serious blood cancer, acute lymphoblastic leukemia, ALL. This type of cancer undermines the immune response, and this young man had come down with a terrible fungal infection, mucormycosis. The fungus did not respond to medication, and it rampaged through his left lung. Ultimately, his doctors proposed removing the lung as a last-ditch method of controlling the infection. Unfortunately, when they found that the fungus had invaded his right lung, they were out of options. They figured he probably couldn’t survive much more than two days, so they asked him his last wishes. All he wanted was to go outside; at this point, he’d been cooped up in the hospital for two months. They fixed up a wheelchair to hold all his drips and took him outside. The next day, they did it again. The youth didn’t die as expected. Instead, he recovered completely, over time. We can’t put sunlight in a bottle, but perhaps oncologists and other doctors should consider writing prescriptions to cover it. This Week’s Guests Michael Giuliano is the President of Planetree International, a mission-driven non-profit organization setting the global standard for person- centered excellence across the continuum of care. Michael joined Planetree in 2022 as Chief Operating Officer (COO) following a decade of leadership roles in Australia’s public and private healthcare sectors. https://www.planetree.org/team-member/michael-giuliano Michael Giuliano, President of Planetree International Dr. Roger Seheult is an Associate Clinical Professor at the University of California, Riverside School of Medicine. He is also an Assistant Clinical Professor at the School of Medicine and Allied Health at Loma Linda University. He is quadruple board-certified in Internal Medicine, Pulmonary Diseases, Critical Care Medicine, and Sleep Medicine through the American Board of Internal Medicine. His current practice is in Beaumont, California. He is a critical care physician, pulmonologist, and sleep physician at Optum California. Dr. Seheult lectures routinely across the country at conferences and for medical, PA, and RT societies. He is the director of a sleep lab and the Medical Director for the Crafton Hills College Respiratory Care Program. He is co-founder and presenter for MedCram.com, a site that offers concise and easy-to-follow medical videos on a range of topics. Roger Seheult, MD, MedCram, Loma Linda, UC-Riverside Listen to the Podcast The podcast of this program will be available Monday, April 20, 2026, after broadcast on April 18. On this episode, Dr. Giuliano discusses billing as part of person-centered care. You can stream the show from this site and download the podcast for free. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.
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  Show 1468: Healing Joints and Nerves: The New Science of Regenerative Therapies 08.04.2026 1ชม. 9นาที

  Millions of Americans are in pain. Arthritic joints make exercise difficult, even though moving is one of the best things we can do for joint pain. Pinched nerves can cause excruciating, long-lasting pain. The usual treatments, such as NSAIDs, may help ease the pain momentarily, but do nothing to help heal the underlying condition. What do you know about the new science of regenerative therapies? At The People’s Pharmacy, we strive to bring you up‑to‑date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen: You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, April 11, 2026, through your computer or smart phone (wunc.org). Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on April 13, 2026. You can also watch Dr. Buchheit talking with us on YouTube. The New Science of Regenerative Therapies What is the price of pain relief for aching, arthritic joints? We’re not talking about the drugstore sticker on a bottle of ibuprofen. Instead, we are referring to the potential negative consequences of utilizing such medicines for temporary symptomatic relief when the joint continues to hurt for weeks, months or years. Even more powerful treatments, such as corticosteroid injections into the sore joint, don’t heal the cartilage. In fact, they may contribute to further deterioration as they suppress the immune system. Our guest offers other ways to treat joint pain with regenerative therapies. Immune Mechanisms That Resolve Inflammation Dr. Tom Buchheit is a pain management specialist who has worked with elite athletes as well as seniors to get them moving well again after an injury. One of the reasons exercise can be so helpful is that the right kind and amount of movement creates good inflammation. Unlike chronic inflammation that causes further harm, good inflammation helps the immune system switch to a different phase, one in which destructive pathways are resolved. The three pillars of exercise are aerobic exercise, muscle building exercise and exercise to improve balance. Together, these types of exercise help recovery and healing and can even help heal damaged nerves. NSAIDs like naproxen, celecoxib or ibuprofen can interfere with the good inflammation exercise creates. Rather than taking such a pill before a game or workout, it makes sense to wait and take it afterwards if you need it. Will Exercise Wear Out Your Joints? Injury can damage the joints, but the idea of osteoarthritis as a consequence of wear and tear seems to be a medical myth. Instead, we might think of osteoarthritis as a chronic wound that may need regenerative therapies to heal properly. Immune system building blocks like omega-3 fats in the diet and a wide palette of colorful produce can help with the healing. Movement itself is part of the healing process. What Are the Regenerative Therapies? PRP Some of the therapies we think of as “new” have actually been in use for several decades. One of these is platelet-rich plasma, which was initially developed to help wounds heal. In this treatment, the doctor uses the patient’s own blood. The plasma with as many platelets as possible concentrated in it is then carefully injected into the painful joint. The idea, again, is to cause “good inflammation,” alerting the immune system that healing is needed here and encouraging it to flip into inflammation resolution mode. Not all studies of platelet-rich plasma (PRP) have shown benefit, but some of that may be due to using plasma that is not truly rich in platelets. Properly prepared PRP works especially well for ligaments and tendons, according to Dr. Buchheit. MSC If you hear someone talk of getting a “stem cell” injection, they are talking about MSC. They were originally misnamed mesenchymal stem cells, but would be better termed medicinal signaling cells. They too are derived from the patient’s own body. Rather than rebuilding cartilage, they also signal the immune system to switch from long-term damaging inflammation to short-term healing inflammation. This is also the idea behind prolotherapy, in which the therapist injects sugar water into the joint. That may sound like a placebo, but it can be effective at easing pain and helping healing. Autologous Conditioned Serum Dr. Buchheit describes another of the regenerative therapies, autologous conditioned serum. Blood is drawn and encouraged to clot; then the serum is injected into the troublesome joint. Clotting helps create powerful signals that healing is needed. This therapy is not widely available, as only about ten places in the US have the dedicated laboratories required to prepare ACS properly. Hydrodissection Dr. Buchheit also describes how to use injections to free up trapped nerves in a process called “hydrodissection.” This is often very helpful in alleviating chronic neuropathy. We conclude the episode with a brief reminder of how to stay healthy once you get nerves and joints feeling good again. This Week’s Guest Thomas Buchheit, MD, served as Chief of Pain Medicine at Duke from 2013-2019 and led several NIH- and DoD-funded research studies. His focus is on immune mechanisms that resolve inflammation and pain. In 2025, Dr. Buchheit completed his book, Healing Joints and Nerves: Immune Stimulation and the New Science of Regenerative Therapies, and founded Triangle Regen Medicine and Biologics Center. His overarching goal is to help patients understand and use regenerative therapies to activate their own healing and repair mechanisms. He continues to serve as adjunct associate professor at Duke and collaborates with colleagues at the Center for Translational Pain Medicine. His website is https://triregenmed.com/ Dr. Tom Buchheit The People’s Pharmacy is supported by readers and listeners. When you buy through a link on this site, we may receive a small commission, at no additional cost to you. Listen to the Podcast The podcast of this program will be available Monday, April 13, 2026, after broadcast on April 11. The podcast has additional information about how to use MSC as well as the cost of regenerative therapies. We also discuss the pros and cons of pharmaceutical pain relievers. You can stream the show from this site and download the podcast for free. Download the show on mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1468: A transcript of this show was created using automated speech-to-text software (AI-powered transcription), then carefully reviewed and edited for clarity. While we’ve done our best to ensure both readability and accuracy, please keep in mind that some mistakes may remain. If you have any questions regarding the content of this show, we encourage you to review the original audio recording. This transcript is copyrighted material, all rights reserved. No part of this transcript may be reproduced, distributed, or transmitted in any form without prior written permission. Joe 00:00-00:01 I’m Joe Graedon. Terry 00:01-00:05 And I’m Terry Graedon. Welcome to this podcast of the People’s Pharmacy. Joe 00:06-00:27 You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. Exercise is critical for good health, but when your joints or nerves hurt, it’s hard to keep moving. What can you do? This is the People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:49 Most people rely on non-steroidal anti-inflammatory drugs. Millions take over-the-counter ibuprofen or naproxen every day. Others rely on prescription medicines such as celecoxib or meloxicam. What are the downsides? Joe 00:50-00:54 Our guest today is an expert in regenerative medicine. Terry 00:55-01:00 What does that mean? And how does it differ from the usual way to manage pain and speed recovery? Joe 01:01-01:06 Coming up on The People’s Pharmacy, the new science of regenerative therapies. Terry 01:14-02:05 In The People’s Pharmacy Health Headlines: flu season is pretty much over, but every year it takes a toll, especially among frail elderly people in nursing homes. A new study published in JAMA Internal Medicine asked whether using Tamiflu preventively could reduce hospitalizations and death. Researchers reviewed records covering 404 flu outbreaks in 318 nursing homes. More than 35,000 residents were covered by the study. When Tamiflu was given to at least 70 percent of the residents within two days of the first flu cases, there were dramatically fewer hospitalizations needed within the next two weeks. That’s in comparison to situations where Tamiflu was not provided as a preventive medicine. Joe 02:05-03:06 If you ask most cardiologists what causes heart disease, the answer is likely to be LDL cholesterol. They might also mention triglycerides, lipoprotein A, and high blood pressure. They probably won’t consider lead, but a study of over 42,000 American adults who participated in the National Health and Nutrition Examination Survey tracked lead levels over many years. Those with the highest levels of lead in their bones were more likely to die from heart disease or stroke. People born in the 1930s and 1940s, before lead was removed from gasoline and paint, have the highest lifetime lead exposures. Further reduction in lead exposure should lead to lower rates of cardiovascular mortality. An editorial in the journal suggests that coronary heart disease is in part attributable to lead and other environmental exposures. Terry 03:07-04:00 What is the cause of memory loss as people age? A recent study of mice suggests it might begin in the gut. Specifically, the scientists tracked microbiome aging throughout the lifespan. They found that gut bacteria producing medium-chain fatty acids accumulate with aging and drive inflammation. This, in turn, weakens the signal from the vagus nerve to the brain, with the result that the hippocampus falters. The hippocampus is critical to memory. In this study, the scientists introduced phage viruses to target the parabacteroides, gut microbes, causing the trouble. They suggest such interventions might counteract age-associated cognitive decline, although, of course, mice are different from humans. We look forward to research that might demonstrate its feasibility in people. Joe 04:02-05:08 Fibromyalgia is a painful and chronic condition that affects soft tissue. It also causes fatigue, brain fog, and sleep problems. Millions of Americans are affected by this somewhat mysterious condition. A study published in JAMA Network Open reports that the combination of physical therapy and transcutaneous electrical nerve stimulation, also known as TENS, can reduce pain. Over 380 patients participated in the trial. Volunteers were randomized to receive PT plus TENS or physical therapy alone. After two months, those getting physical therapy plus electrical stimulation reported significantly less pain than those in the PT-only group. The authors note that the findings demonstrate effectiveness of this non-pharmacological intervention in reducing movement-evoked pain and suggest that the benefits of TENS are clinically meaningful in this population. Terry 05:09-06:17 With warmer weather, tick season is right around the corner. In fact, it’s already here in many parts of the country. Most people have heard of Rocky Mountain spotted fever and Lyme disease, but ticks can transmit over a dozen different diseases, from anaplasmosis and babesiosis to ehrlichiosis and alpha-gal syndrome. It’s estimated that more than 500,000 people could be treated for Lyme disease between now and the first freeze this fall. But there is potentially good news on the horizon. Pfizer is teaming up with a French company to produce a vaccine against Lyme disease. It triggers your body to make antibodies to a protein on the surface of the Borrelia bacterium. These antibodies keep the Lyme-causing bacteria from infecting you and causing disease. And that’s the health news from the People’s Pharmacy this week. Welcome to the People’s Pharmacy. I’m Terry Graedon. Joe 06:17-06:27 And I’m Joe Graedon. You’ve heard us praise the power of exercise for good health. But it can be hard to keep moving when your joints hurt. Terry 06:27-06:44 The usual approach is to take a non-steroidal anti-inflammatory drug, such as ibuprofen or naproxen. That is a short-term solution, and it comes with a handful of side effects. What else could we do to alleviate joint pain? Joe 06:44-07:11 To help us understand some new options, we are talking with Dr. Tom Buchheit. He’s done research on immune mechanisms that resolve inflammation and pain. He serves as an adjunct associate professor at Duke University and collaborates with colleagues at the Center for Translational Pain Medicine. His new book is “Healing Joints and Nerves: Immune Stimulation and the New Science of Regenerative Therapies.” Terry 07:13-07:16 Welcome to the People’s Pharmacy, Dr. Tom Buchheit. Dr. Tom Buchheit 07:17-07:27 Thank you, Terry, Joe. It’s wonderful to be here. I have to say, I’ve been listening to your show since 1998 when my wife and I moved to North Carolina, and it’s just a delight to be here. So thank you. Joe 07:27-08:36 Well, thank you so much for joining us. You know, Dr. Buchheit, I’d have to say that if people ask us, and they occasionally do, what’s the one most important thing we should do for good health? The answer is simple. We say exercise. Exercise is absolutely critical. Move your body. Even if it’s just for a walk every day, if you can. And if you can do more, so much the better. Terry is a black belt in karate. I love to play tennis. We love to move our bodies. There’s only one problem. What interferes with exercise? Pain. Injuries. You know, when you exercise a lot, you sometimes hurt yourself, and then you have to take a break. And for people who really enjoy exercising and want to do it, that can be both psychologically and physically very challenging. So help us understand your field and how to help people get back moving again once they hurt themselves. Dr. Tom Buchheit 08:37-10:02 Well, Joe, you brought up a really good point. Exercise plays a very important part of health for all of us. And I think we increasingly know the reasons why. One of the core topics that I talk about and like to focus on is the importance of healing and our body’s innate ability to heal. We turn those healing mechanisms on by stimulating certain immune cells, and one of the most powerful ways of doing so is exercise. Exercise does it. Good inflammation does it. Some other regenerative therapies do it. And these are all bound together by the same healing mechanisms. But you’re right, exercise is core to that. The challenge a lot of people run into is that they have an injury. They have arthritis, a problem in a joint. They’re unable to do that. And their question is, how do they get back to that activity? What I use, I use the phrase orthopedic limbo. That individual is in orthopedic limbo. They have an issue that prevents them from pursuing their tennis or their karate or just walking the dog or spending time with friends. And they’re trying to figure out how to get beyond that and move again, but they’re not necessarily a surgical candidate. So what can they do? And that’s one of the reasons I like to focus on these things that stimulate a healing response and stimulate recovery to function. Joe 10:02-10:11 And we’ll talk a little bit more about some of those strategies because they’re really intriguing. But first, why is exercise so important? Dr. Tom Buchheit 10:13-10:16 Exercise is important because it produces good inflammation. Terry 10:18-10:21 Whoa, whoa, whoa, wait. Inflammation is good? Dr. Tom Buchheit 10:23-11:23 That’s an important topic, right? I think a lot of people hear inflammation, they think immediately inflammation is always bad. We have to get rid of it. We have to suppress it. We have to drive it down. And there are, and I think you’ve talked about this in your show before as well, but there are good components of inflammation. We have to be careful we don’t throw the wheat out with the chaff with that. So chronic inflammation is always bad, right? It damages tissues. It drives arthritis. It drives chronic pain. But short-term, brief, and fairly strong inflammation is how we heal. If I had an ankle sprain and I bled into that ankle sprain, that injury, that inflammation is what heals that ligament eventually. You bleed, you release growth factors, you turn on these immune systems. Exercise does that same thing, but it’s good inflammation. So I think of good inflammation as short, reasonably strong, and able to flip an immune switch that begins a healing cascade. Terry 11:24-11:33 Dr. Buchheit, in “Healing Joints and Nerves,” you talk about the three pillars of exercise. What are the three pillars and why do we need three of them? Dr. Tom Buchheit 11:35-12:23 Well, great question. There are certain tremendous advantages of aerobic exercise. We know that people who have a high aerobic capacity and who can exercise at high levels, it doesn’t matter if it’s running, swimming, playing tennis, that’s linked to longevity. We also know that muscle mass, and increasingly people talk about muscle mass being very important and strength being very important to strengthen joints. And we see this with studies of even arthritis patients who have less joint pain if they can strengthen the support structures of that joint. And then, of course, balance is such a wonderful thing, whether it’s through balance exercises or yoga or tai chi, just such wonderful exercises that brings all this together of strength, stability, and the ability to stay on two feet without falling down. Joe 12:24-12:52 I want to know how exercise helps recovery, because that’s, you know, we often hear, “Oh, ice and rest and, you know, just don’t do anything for a week or two,” because a lot of tennis players, they want to get back on the court as fast as possible, and they’re told, “No, no, no, no, no, no, you got to rest those joints, that you pulled a muscle, you better let it rest.” And you’re suggesting that exercise actually helps with healing. Dr. Tom Buchheit 12:53-13:52 It absolutely does. And it helps with healing because it flips that immune switch and turns on this healing cascade. There was a study that I think showed this well. It was patients who had ankle injuries and they were immobilized in crutches after an ankle injury and they measured the cartilage in their knees as a marker after immobilization. And they found out that those who were in crutches for long enough actually had less cartilage in their knees. Their knees were never injured, but it was the lack of exercise that decreased the health of their joint cartilage. So our bodies need this. They need intermittent stress. And I think this… we have kind of fallen into this trap where we think all inflammation is bad. I would push back on that. I think we need to stress ourselves, whether it’s studying for an exam, whether it is playing a tennis match, whether it’s going for a brisk walk. Our bodies use stress and use these intermittent bouts of exercise to strengthen. Terry 13:54-13:57 I’m assuming we stress ourselves appropriately. Dr. Tom Buchheit 13:57-14:30 Exactly. And that’s the Goldilocks phenomenon, right? If you want enough stress. So to look at it kind of biochemically, if you look, there are a lot of inflammatory proteins that a muscle will release if it’s been exercised. Matter of fact, some of those will go up a hundred fold and they cause some of the aches that we’re familiar with after a strong workout. But those same inflammatory proteins will then flip and help our bodies to produce some of the anabolic proteins and things that rebuild tissues and strengthen tissues. Terry 14:31-14:35 How does exercise help nerves regrow? You’ve said it does. Dr. Tom Buchheit 14:35-16:00 That’s a great question. And that came as a bit of a surprise to me when I started doing research on this a bunch of years ago. We all thought of, and I think a lot of the medical profession thinks of, well, once you have neuropathy, it’s just a done deal. You’re never going to recover from it. Your nerves are gone. And neuropathy is nerve pain. Right, nerve pain and nerve dysfunction from the nerve pain. And it can be different kinds. There can be sciatica somebody experiences after a disc herniation in the spine. There can be dying back of the nerves somebody experiences because of diabetes or they’ve had chemotherapy in the past. Those nerves can recover. And exercise is actually one of the important tools to help those nerves recover. It does a few… through a few things. Some of the growth factors I talked about that exercise releases. It also does it through these very small immune particles called exosomes that we researched in lab that I’ve researched and looked at for a long time now. And they also help nerves recover. [If] we think about it, nerves are energy hogs. And anything we can do to improve their energy supply through mitochondria, mitochondrial function, is going to help the nerve to recover. And so exercise and some of these other therapies can improve nerve function. They may not help a nerve regrow from the back all the way down to the foot, but they can take the nerves that are already there and help them work better and help people function better. Joe 16:00-16:36 One of the things that most physicians, not all, but most physicians, especially the orthopedists like to prescribe are the non-steroidal anti-inflammatory drugs. So if you sprain your ankle, if you hurt your shoulder, if your back is giving you trouble, out come the NSAIDs. And of course, they’re also available over the counter, Aleve, naproxen, ibuprofen, Advil. And so people have come to just love non-steroidal anti-inflammatory drugs. You’ve suggested that they might be counterproductive in some ways. Dr. Tom Buchheit 16:37-17:20 Well, they can be. And anti-inflammatory medications, what we call NSAIDs, they can, in fact, impair the strengthening our body’s experience with a workout. And this has been looked at in patients, this has been looked at in laboratory studies of laboratory animal models, that if you slow down or stop the inflammatory response to exercise, you also impair the muscle building and the strengthening you get from that workout. So NSAIDs, sometimes we may need to take them for a severe headache or a pain that’s keeping us from moving. But if we take them chronically, they impair the very healing mechanisms that our bodies need to stay healthy and recover. Terry 17:20-17:26 Now, if you were to take an NSAID for a workout, when should you take it and why? Dr. Tom Buchheit 17:26-17:30 That’s a great question. So I think the clear answer is after the workout, not before. Joe 17:32-17:42 A lot of my tennis buddies call it vitamin “I” and they take it religiously before they go out on the courts. So you’re suggesting maybe not such a good plan. Dr. Tom Buchheit 17:42-18:06 I think if one can hold off until after the workout and wait as long as you can, it’s better off than before. I think it’s probably better for our joints and our bodies to have a shorter workout without an anti-inflammatory than a longer workout with. Now, that’s never been studied in a randomized controlled trial, but I think it’s a good idea to avoid taking it before whenever possible. Terry 18:07-18:15 You’re listening to Dr. Tom Buchheit, an expert in pain management and founder of the Triangle Regen Medicine and Biologic Center. Joe 18:15-18:28 After the break, we’ll learn about steroid shots in joints. What might work to ease osteoarthritis pain? You may have heard of PRP and stem cells. We’ll get the details. Terry 18:39-18:42 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 20:18-20:21 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 20:21-20:39 And I’m Terry Graedon. Joe 20:39-20:48 Today on The People’s Pharmacy, our topic is healing joints and nerves. What are regenerative therapies and how do they work? Terry 20:48-21:14 Our guest is Dr. Tom Buchheit, founder of Triangle Regen Medicine and Biologic Center. Dr. Buchheit was chief of pain medicine at Duke University from 2013 to 2019 and is an adjunct associate professor there. His new book is “Healing Joints and Nerves: Immune Stimulation and the New Science of Regenerative Therapies.” Joe 21:15-21:50 Dr. Buchheit, corticosteroids, very popular on the tennis court. You know, “Oh, my shoulder hurts. I need a steroid shot. Oh, my back aches.” Another steroid shot. “Oh, my knee is giving me trouble.” Another steroid shot. Doctors love them because people feel better oftentimes immediately after or within a few days and it lasts sometimes a couple weeks for some people maybe as long as a couple of months, but there’s a downside. What is it? Dr. Tom Buchheit 21:50-23:48 Well, there is a downside, and it is true that a steroid injection can produce rapid pain relief, and can be helpful in some people to get them back to the gym, get them back to the workout. My concern with steroid injections or corticosteroid injections is the repeated use of them. There was a study done now almost 10 years ago, and it was a randomized control trial looking at individuals who had osteoarthritis of both knees, and one group had saline injections into the knees. The other group had corticosteroid injections. And at the end of two years, there was no difference in the pain, which didn’t really surprise a lot of people because we know steroid injections tend to be shorter lived. But the individuals that had repeat steroid injections actually had less cartilage in their knees than the ones that had saline. And I feel like that study was a bit of a wake-up call to all of us. And I did a lot of steroid injections at the time as well because patients seemed to do well with it. But it made me start rethinking how I was approaching this concept of how do you treat someone with joint pain, some arthritis, they don’t need surgery, again, the patient [in] orthopedic limbo. We’ve relied on corticosteroid injections as a bit of a crutch, and I think we need to flip this paradigm and think about how do you improve cartilage health, how do you improve tissue health? This year is the 75th anniversary of the first corticosteroid injections that were done for arthritis pain. And it was a remarkable event. But interestingly, I’ve gone back and I’ve read a lot of the historic literature on corticosteroids and their use in arthritis. And the physician who published the paper noted that 37 of 38 of his patients did extremely well after the steroid injections. But what he didn’t emphasize is some of the patients required up to 17 injections per year to maintain that. Terry 23:48-23:49 Oh, my. Dr. Tom Buchheit 23:49-24:00 And I think that’s the part that we’ve been missing within the medical world, is that a steroid injection can be an important tool, but I would argue it’s an overused tool in a lot of settings. Terry 24:01-24:15 Well, 17 injections a year definitely sounds like it’s being overused. And one of the things that steroids do is they suppress the immune system. What’s the impact of long-term immune system suppression? Dr. Tom Buchheit 24:17-25:22 Well, gosh, there’s a lot of things that [it] would do. Obviously, we could go into, you know, bone health and bone density. We could go to the endocrine system and looking at, you know, someone who is borderline diabetic who becomes frankly diabetic after repeated steroid injections. We can look at tissue healing as well. But if I kind of focus on the cycle, I think we need to think of our bodies as cycles, right? We cycle day and night. We sleep. We wake up. And exercise and this immune stimulation that keeps our joints healthy is also a cycle. It’s a cycle of exercise and recovery. And anyone who’s trained knows this inherently. You have hard workout days. You have recovery days. And I think if we use tools like steroids or anti-inflammatories continuously, we remove those necessary cycles of stress and recovery, stress and strengthening. And steroids, I think, act in some ways have similar effects as the anti-inflammatories do. And I can quote, we can talk about a study as well that dives into that. Joe 25:23-25:52 Well, I’d like to talk about one of the reasons that a lot of people get steroid injections and one of the reasons why they take a lot of the anti-inflammatory drugs, and that’s osteoarthritis. And it can affect your fingers. It can affect your shoulders. It can affect your knees. It can affect your hips. It can affect just about every joint in your body. And I remember someone saying a long time ago, well, exercise is going to make it worse. Dr. Tom Buchheit 25:53-27:48 Right, that’s the old wear and tear hypothesis and that was the hypothesis about osteoarthritis for years which is that well you just you’re just wearing your joints too much and they’re just wearing down. That ignores the fact though that exercise restores cartilage health, and you know some people talk about well someone loses weight and they have less joint pain and it must be less weight on their joints and less wear and tear. But the hand arthritis also gets better if you lose weight. And so I think it’s an issue of a systemic chronic inflammatory problem that’s improving with weight loss. We’ve then moved from the wear and tear hypothesis to the inflammatory hypothesis of arthritis. And it made sense. We can see inflammation on ultrasound if we do an ultrasound exam of a joint. You can pull out fluid, and it looks inflammatory if you look at it under biochemical analysis. The patients feel the inflammation, but if you treat the inflammation, it doesn’t improve the disease state. And that’s been shown so many times. There have been at least four studies of strong inflammation suppressors in the rheumatoid arthritis drugs that have been looked at for osteoarthritis. They did not work. There have been studies of corticosteroid injections. Again, they tend to worsen the problem, not make it better. The concept that I think we need to focus on is osteoarthritis is a chronic wound. And we need to think about how to heal the wound. If you heal the wound, the chronic inflammation also improves as well. And that explains, I think, the chronic wound concept explains why studies have failed in the past and why some of the therapies we do now, such as some of the regenerative therapies, can actually have a role. Terry 27:49-28:09 Well, maybe you could tell us a little bit about what could work for osteoarthritis, because so far, we’ve talked about things that are less than ideal. The steroid injections, the NSAIDs, those are the most common. And there have to be things, maybe even a lot of things, that can be useful. Joe 28:09-28:22 Well, first, what the heck is regenerative therapy? And second, why would exercise, because you’ve sort of alluded to that, be helpful for osteoarthritis? So give us the one-two punch. Dr. Tom Buchheit 28:23-28:36 I always think of it as we start with a healthy diet, healthy fruits, vegetables, healthy fats, and exercise to that. And that is the core, I think, of keeping joints and nerves healthy. Terry 28:36-28:37 And the rest of us. Dr. Tom Buchheit 28:37-30:03 And the rest of the body as well, right? What’s good for your heart tends to be good for your joints as well, right? It’s enough for a lot of people, but it’s not enough for everybody. And it’s not enough for people who have had injuries in the past. It’s not enough people who have a systemic inflammatory issue going on. And that’s when I think about layering on what some people call regenerative therapy. Some people may call it an ortho-biologic. These are ways of stimulating those immune cells I talked about and pushing them into a state where they are resolving and building tissues again, where they’ve been suppressed in the past and they’re kind of low level. They’re chronically inflamed. They’re not behaving well. You need to push them into a new state, this resolving state. And I think of it not as suppressing inflammation but resolving it. And it might sound like a little bit like splitting hairs a bit. But if I think of suppressing inflammation or fighting inflammation, I think of you’re putting a drug on it to tone it down temporarily. When I think of resolving inflammation, I think of our body’s natural processes that resolve it. There are some wonderful fats that do this. They’re called SPMs. They’re derivatives of omega-3 fatty acids. Our bodies use those and other compounds to naturally resolve inflammation. Matter of fact, in the lab, some of those compounds are more powerful than morphine in animal models of nerve pain to resolve inflammatory pain in models. Joe 30:04-30:07 Wow, that’s amazing. Tell us, how do you do that? Dr. Tom Buchheit 30:08-30:10 Well, our bodies make these compounds. Terry 30:10-30:22 And you say they make them from omega-3 fats like fish oil or walnut oil or the fats that we get in very small quantities from dark green leafy vegetables. Dr. Tom Buchheit 30:23-30:53 Precisely. If we eat a diet rich in healthy fats, as you pointed out, from walnuts, nuts, cold water fishes like salmon and anchovies and tuna, as long as it’s not too high in mercury, our bodies take those fats and they make other compounds from them. And those other compounds will resolve inflammation. They work with the leafy green vegetables and all the colorful vegetables that you all have talked about that are so important to overall health. Terry 30:53-30:55 We love talking about colorful vegetables. Dr. Tom Buchheit 30:56-31:13 But that all works together. And that, to me, is the foundation of really regenerative medicine is what our bodies are already doing and how can we promote those activities themselves. A lot of people focus on a procedure and injection, and they can be helpful, but we have to start with our own bodies. Joe 31:13-31:43 So it sounds like diet is critical and the healthy fats, the omega-3s are especially beneficial. So your body can do this resolving stuff. And exercise is also important, presumably if it’s, you know, mild exercise, if you’ve injured yourself so that you don’t re-injure yourself. But what are some of these other agents, this regenerative process that you’re talking about that you practice when you see patients who have had injuries? Dr. Tom Buchheit 31:43-33:05 Yeah, great question. I would put them in three different categories, things like platelet-rich plasma, which we’ll talk about, stem cells, or something called autologous conditioned serum. Some people know it as the Regenokine program. PRP or platelet-rich plasma is probably the one I’d start with because it directly activates our own healing cascade. Interestingly, back to my analogy of the wound in a joint, PRP was first used to treat wounds. It was first used by a wound surgeon published in 1986. It’s been around for a while. Then it was used in the oral surgery field to heal non-healing wounds. And then it kind of leapt into the world of arthritis and nerve issues and things like that. But what it is, is if you take blood and you spin it down and you collect the platelets and the white blood cells there, they can act with the growth factors and act in a way to flip that immune switch I was talking about to start to rebuild tissues. So it’s a way to almost use that, almost like exercise. It’s almost like exercise in a tube in a way. You take that blood product and you inject it onto a knee or a shoulder or hip, and it further turns on those healing mechanisms that our body can have, but aren’t always strong enough by themselves. Joe 33:05-33:17 Now, let’s make it very clear. We’re not talking about someone else’s blood. We’re talking about our own blood is being removed. And I assume it’s not gallons. It’s just a little bit. How much? Dr. Tom Buchheit 33:18-33:30 Well, actually, that’s a very good point. You need a fair amount. You need a fair amount because you have to make sure the PRP dose is right. So how much is 60 to 120 milliliters? Joe 33:31-33:33 So for people who are not metric. Terry 33:34-33:40 So a cup is roughly 250 milliliters. So we’re talking less than a cup. Joe 33:40-33:44 Less than a cup. Right. So it’s not gallons. It’s a little bit of blood. Terry 33:44-33:46 Maybe a half a cup, more or less. Half a cup, a cup. Joe 33:47-33:57 And you’re removing that blood, and then you’re spinning it down, and you’re extracting the platelet-rich plasma. Dr. Tom Buchheit 33:57-33:59 Exactly. Now… Joe 33:59-34:00 And re-injecting it. Dr. Tom Buchheit 34:00-34:20 And re-injecting it. PRP has become quite controversial. One of the reasons is because there have been a couple of very large trials that have shown it hasn’t worked. But if you go back and analyze the studies, which I’ve done with some colleagues, it turns out that if the plasma isn’t rich in platelets, it doesn’t work. And it sounds a bit, you know, axiomatic. Terry 34:21-34:26 Right. So you have to have the right stuff in order for it to work the way it’s intended. Dr. Tom Buchheit 34:26-34:26 Exactly. Joe 34:27-34:31 So is it a little less controversial now? Are there studies demonstrating benefit? Dr. Tom Buchheit 34:32-34:44 There are with high doses, and I think that’s the key. If the dose isn’t right, it just doesn’t work. And that’s why it’s important. And one of the things that I do is I measure the doses of every PRP to make sure that dose is correct. Joe 34:45-35:03 So our listeners and a lot of your colleagues learn from stories. Can you share a story with us about somebody who came to your practice in pain and maybe not able to exercise, and that person benefited from PRP? Dr. Tom Buchheit 35:05-35:24 I think it’s a common scenario. I would use the scenario of someone who’s had a prior ACL tear or a lot of knee ligament tear. Especially young women athletes seem to have this quite commonly. The problem with these tears is that it sets them up for early arthritis. Joe 35:25-35:28 And we know the surgery itself has some issues. Dr. Tom Buchheit 35:29-36:15 Right. Well, joint replacement surgery can be very successful, but you also don’t want to do that when you’re 45 years old and still active because you may wear out your joint. You might wear out the replacement. And that to me is a good candidate for what I would call regenerative therapy or biologic therapy, where you can turn this inflammatory process, this chronic wound of a knee that’s had a prior injury and can’t quite get into the healing mode, and you can add PRP or another therapy to it to really turn the corner of that knee and allow it to start healing. What other joints benefit? Really any joint can benefit. Most of the studies have been done in knee osteoarthritis because it’s so common. Terry 36:15-36:18 So common and so troublesome if you have it. Dr. Tom Buchheit 36:18-36:39 Precisely. Precisely. But shoulder, hip, other joints, and actually some of… there’s some very good literature for PRP for ligaments and tendons. So for the outside of the hip, the trochanter or tennis elbow is a very common, very common scenario. Again, that’s a scenario where a tendon is there and it’s just not healing up and you want to add growth factors to it to get it to heal. Joe 36:39-36:45 Are the orthopedic surgeons embracing PRP these days or are they still a little resistant? Dr. Tom Buchheit 36:45-37:06 Well, I think the orthopedic community is embracing this to a fairly significant extent. And it does compete. There’s a question of does it compete with surgery for some people, but I think it has a clear role. And as we understand what makes a regenerative therapy more effective, they’re going to, I think, gain more and more acceptance. Terry 37:06-37:09 What about side effects of PRP? Dr. Tom Buchheit 37:09-37:25 The main side effect for PRP is a flare-up of pain. If you think about it, you’re turning on an immune system, you’re turning on these white blood cells. So I tell people it’s an expected side effect. They’re going to have oftentimes discomfort, sometimes even swelling for a few days afterwards. Terry 37:25-37:30 So you’re creating short-term inflammation to overcome the long-term inflammation. Dr. Tom Buchheit 37:30-37:31 Just like exercise. Terry 37:32-38:05 You’re listening to Dr. Tom Buchheit, author of “Healing Joints and Nerves: Immune Stimulation, and the New Science of Regenerative Therapies.” Dr. Buchheit founded the Triangle Regen Medicine and Biologic Center. His research has focused on immune mechanisms that help resolve inflammation and pain. From 2013 to 2019, he was chief of pain medicine at Duke University, and now he is an adjunct associate professor there. Joe 38:05-38:14 After the break, we’ll consider the case of a long-distance runner who has developed hip arthritis that interferes with his running. Terry 38:14-38:20 Do stem cells help cartilage grow back? If not, what are they doing to ease pain? Joe 38:21-38:36 What is prolotherapy and how does it work? Injecting dextrose, that’s sugar water, sounds almost like a placebo treatment. Is it effective and how long has it been available? Terry 38:36-38:45 It does sound like a placebo. You’ll also find out about autologous conditioned serum. What is that? How does Dr. Buchheit use it? Joe 38:46-38:53 Some of the same therapies that work for joints can also help nerves. How do they work for that? Terry 39:06-39:21 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Welcome back to The People’s Pharmacy. I’m Terry Graedon. Joe 39:21-39:38 And I’m Joe Graedon. Terry 39:39-39:57 Today, we’re discussing some new therapies for arthritic joint pain. We’ll also find out what can be done for trapped nerves. Have you ever heard of prolotherapy? It involves the injection of sugar water into an injured joint. How could that possibly be beneficial? Joe 39:57-40:33 To learn more about prolotherapy and PRP, as well as other new options, we’re talking with Dr. Tom Buchheit. He’s done research on immune mechanisms that resolve inflammation and pain. He founded the Triangle Regen Medicine and Biologic Center. Dr. Buchheit serves as an adjunct associate professor at Duke University and collaborates with colleagues at the Center for Translational Pain Medicine. His new book is “Healing Joints and Nerves: Immune Stimulation and the New Science of Regenerative Therapies.” Terry 40:34-41:33 Dr. Buchheit, I’d like to ask you about a scenario. I know a person happens to be related to me, not Joe, not Dave, but this individual actually dislocated his hip on a construction site when he was in his early 20s. He is now 75. He has been a long-term, long-distance runner, and he has recently had a problem with hip pain on the hip that he dislocated back when he was a young guy. So he went to the doctor, and the doctor said, yeah, you’ve got a lot of arthritis there. What would you advise this fellow for relieving his pain? He said, well, I don’t think I’m going to be running anymore. He does walk. But what advice do we have? Joe 41:33-41:37 And he loves to run. I mean, this is a long-distance runner for decades. Dr. Tom Buchheit 41:37-42:08 It’s a common scenario. And to me, there are a couple of questions. What is their level of function they’re at now? What do they want to be? How much cartilage do they have? It’s easier to use some of these regenerative therapies for people who have some cartilage left. And I always think of this as a way to improve tissue health, improve the health of tissues and cartilage that’s already there. It’s not going to regrow cartilage. Even stem cells don’t regrow cartilage. And that’s something we can talk more about, but that’s a misconception out there. Terry 42:08-42:11 So people think that stem cells will regrow cartilage. Dr. Tom Buchheit 42:11-42:27 People think that they do, but they don’t. And there’s, I think, a couple of reasons why. The stem cell story is a really interesting story of great science that’s been misinterpreted over the years, and we can talk a bit about the details of that but… Joe 42:27-42:56 But I’d like to get back to the PRP alternatives. So you’ve made a strong case for plasma rich… for platelet-rich plasma, PRP. What other regenerative strategies do you have and how else can they help either osteoarthritis or an injury or some other situation that is interfering with exercise? Dr. Tom Buchheit 42:57-43:16 It all kind of depends on the severity, what’s going on, what the joint looks like. And when I say it looks like, what does it look like under MRI, under x-ray, under ultrasound? And what does it feel like to the patient? It can be from a, if it’s a tendon or ligament issue, you can use things like prolotherapy to stimulate a healing response. Terry 43:16-43:19 That’s great. We want to know what prolotherapy is. Joe 43:19-43:20 What is it? Dr. Tom Buchheit 43:22-43:27 Prolotherapy was commonly used. Now we use it… Dextrose, actually. Joe 43:27-43:30 That’s sugar. Sugar water. Sounds like a placebo. Dr. Tom Buchheit 43:32-43:41 Amazingly, it does sound like a placebo. But if you put sugar water in high enough concentration, it will set up an inflammatory reaction in that same immune response we’ve been talking about. Joe 43:42-43:44 And prolotherapy’s been around for decades. Dr. Tom Buchheit 43:44-43:49 It’s been around for, yes, it’s been around for 70, 80 years. Absolutely. Joe 43:50-43:56 And a lot of times, I think some of your colleagues have said, “Yeah, that’s nonsense.” But you believe it works. Dr. Tom Buchheit 43:57-44:08 I do. And I use it most often for tendons and ligaments that need, again, they need to flip that switch and they need to go into healing mode because it will set up that immune response. Joe 44:08-44:13 So you’re injecting sugar water, dextrose, into the area that is painful. Dr. Tom Buchheit 44:14-44:51 Exactly. Now, it’s partly what you’re injecting. It’s partly how you’re injecting because you do a technique that actually purposefully does minor injury to the tendon or ligament. People call it a fenestration. It has different words to it, but you do a little bit of a peppering technique of the tendon and you add this high concentration of sugar water. The body responds to that inflammatory cascade and says, we have a problem here to fix. And the body sends in its messengers, just like it’s been an ankle sprain or another injury, sends in white blood cells, and then they start to get to work. So it’s really a calling card for immune systems. Terry 44:51-45:06 So here again, you’re creating a short-term inflammation to overcome this chronic inflammation that is causing the pain. You’ve said a couple times that the body needs to flip the switch. Can you tell us a little bit more about that, please? Dr. Tom Buchheit 45:07-46:10 Yes. And your description is perfect. That’s exactly it. If we go back to the healing cascade and back to, say, the ankle sprain, there’s bleeding, there’s platelet release. The platelets not only release growth factors, but they pull in white blood cells. One of those white blood cells is called a monocyte or macrophage. There’s been a lot of research into the macrophage that can change personalities. I liken it to the kind of the Incredible Hulk, Bruce Banner becoming Incredible Hulk. He’s uh mild-mannered in the bloodstream. He finds an injured tissue, becomes the Incredible Hulk and very angry. But once he can resolve that anger, the anger of that macrophage, he can become kind of a subdued Hulk and start rebuilding these tissues. And so to me, it’s the work of the macrophage, which is this white blood cell that is key for healing. And when I refer to the switch, I’m referring to the macrophage switch. Joe 46:11-46:24 So we’ve talked a little bit about PRP. You’ve mentioned prolotherapy, which is injection of dextrose into the area of pain and discomfort. What other regenerative therapies are there? Dr. Tom Buchheit 46:25-46:31 There’s stem cells, and then there’s autologous conditioned serum, which is one that I’ve researched in lab and clinically as well. Joe 46:31-46:32 What is that? Dr. Tom Buchheit 46:33-46:51 That is a therapy that was developed in the 80s and 90s by a German orthopedic surgeon, Dr. Peter Wehling. And they were looking at ways to, again, resolve inflammation. And they found that if you take blood and let it clot over an extended period of time, again, the blood clot being important here. Terry 46:51-46:52 Platelets. Dr. Tom Buchheit 46:52-47:55 Exactly. Platelets and the things that the immune cells… Actually immune stimulation, if you stimulate that system in a test tube and then you pull off that serum, it has all kinds of inflammation-resolving proteins in it and growth factors. And it’s been studied. It’s been used to… There are a lot of athletes that fly to Germany for this therapy. I use this therapy as well in my clinic now in Chapel Hill. But there was part of it that didn’t make sense because it was lasting longer than you’d expect just a growth factor or an anti-inflammatory protein to work. So that’s when we started looking at the mechanisms. We found out that actually a lot of the effect of it is driven by these tiny immune particles called exosomes that can reprogram how cells behave. So in a way, it’s kind of reprogramming tissues and how tissues behave. And that, to me, I think was the kind of the secret of the sauce, which is it’s allowing cartilage, allowing a tendon or ligament to become more youthful, for lack of a better term, because it’s being reprogrammed. Joe 47:55-48:32 So how would somebody who’s either injured themselves, as Terry’s relative… [we] won’t mention any names… with his dislocated joint, and the osteoarthritis that has resulted, or an athlete who is elite, you know, one of the great basketball players at Duke University who comes to you and says, “Oh, I got to get back in the game next week.” How do you do this autologous thing that you’re talking about? How do you make this stuff and how safe is it? Dr. Tom Buchheit 48:32-49:06 Well, right now we make it in the lab. We built a lab for this and it’s actually quite safe. It’s been used for 20 years, a couple hundred thousand patients across the globe. It’s been used more in Europe than it has in the United States, but it has a very long track record, partly because the quality control of it is just so tight. There are only a couple of places, there are only about 10 places in the United States where you can get it. And the lab, our lab technique, and everybody’s trained very highly. So I think the key to it is the standardization of processing and the quality control of the processing. Joe 49:06-49:07 And what exactly is it? Dr. Tom Buchheit 49:08-49:10 It’s a serum product, so serum from blood. Joe 49:10-49:15 So again, we extract some blood from the individual and you do the magic sauce thing. Dr. Tom Buchheit 49:16-49:27 Yes, exactly. And then occasionally things are added to that magic sauce, depending on the individual in front of you. And it’s injected in several different times, usually over the course of a week or so. Terry 49:27-49:49 We have spent most of our time together talking about joints, bones, cartilage, and tendons and ligaments. And I would like to ask about nerves because healing joints and nerves, you’re talking about nerves, and nerve pain can be really awful. Why does it last so long? Joe 49:50-49:51 And what can you do about it? Dr. Tom Buchheit 49:51-50:16 Right, importantly. Why is it there and what do you do about it? A nerve will cause pain if it’s firing on its own. It has different names, autonomous firing. But if a nerve is compressed, strangled, or otherwise restrained, it tends to fire on its own spontaneously. And that spontaneous firing we feel is pain. Terry 50:16-50:21 So sometimes we call that entrapment or impingement. They’ve got fancy terms for it, but it’s trapped. Dr. Tom Buchheit 50:22-50:56 Exactly. If you trap a nerve, if you trap a nerve with a disc herniation in your spine, you’re going to have rip-roaring sciatica down your leg, and that’s an entrapped nerve. If you have carpal tunnel and you have a trapped nerve in your wrist, that’s going to cause nerve pain in your hand. If you have a nerve that’s entrapped around an old surgical scar, that’s going to become entrapped. And so the key is there are ways to decrease the firing of the nerve with drugs. But to me, that’s an important part to free the nerve up so it’s no longer entrapped. And so that’s a lot of things that a lot of things that I do are freeing nerves up. Joe 50:56-50:56 How do you do that? Dr. Tom Buchheit 50:57-51:50 There’s a technique that’s called hydro-dissection that we do. And basically, it’s kind of gently injecting fluid of one of several different types around a nerve to open the space around that nerve so it can glide more freely through that space. And it’s a technique that makes sense. You know, years ago you know I was… I’m old enough to have been done doing nerve blocks before ultrasound was ever used, and occasionally we’d see patients who got better longer term after a nerve block, and I kind of scratched my head trying to figure out why is this person better long term because all we did was shut the nerve off for a few hours. In retrospect we were probably doing hydro-dissections without knowing it. Now we can see it. So under ultrasound, you place a needle very carefully around the nerve and you use a fluid to open the space up. So you don’t have to do it surgically now. You can just do it through a needle and through ultrasound. Terry 51:50-51:54 So that’s what the ultrasound is for, to be able to visualize what you’re doing. Dr. Tom Buchheit 51:55-51:55 Precisely. Terry 51:55-51:56 How to do it right. Dr. Tom Buchheit 51:57-52:04 Precisely. And to make sure you get good separation of the tissues with it. Because you can see it almost looks like a halo around the nerve when you’re done. Terry 52:04-52:05 How well does it work? Dr. Tom Buchheit 52:06-52:32 It depends on the nerve and depends on the entrapment. If there’s a true entrapment around a scar, it can work wonderfully. And once or twice, it can completely relieve pain. Other areas, if the nerve is sick for other reasons, for, you know, because of diabetes or other issues, it may work partially. But my philosophy is if there’s ever an entrapped nerve, you want to release the entrapment first before you start adding drugs to it. Terry 52:33-52:36 And one other thing, what about side effects? Dr. Tom Buchheit 52:37-52:57 Side effects of hydrodissection are very low as long as the person doing it has a good view and experience doing it. Because if you put a needle into a nerve, you can injure the nerve. So you have to be very delicate and very confident in being able to place the nerve gently around it but not in it. And that’s the key. Joe 52:57-53:02 Are there any nutritional supplements that can be helpful for people with neuropathy? Dr. Tom Buchheit 53:04-53:14 I’m not an expert in supplements, but there are a few that I look at. I look at things that make nerves healthy and make mitochondria work better. Joe 53:14-53:15 Such as? Dr. Tom Buchheit 53:15-53:20 Well, one of my favorites, partly because so many people are taking statins, is making sure they’re on CoQ10. Joe 53:21-53:21 Right. Dr. Tom Buchheit 53:22-53:40 So I look at that. I am a big believer in omega-3 supplements unless someone is eating sardines daily, which most people don’t do. And I’m also a believer in things like turmeric and some of the other supplements, especially if they allow us to take fewer anti-inflammatory drugs. Terry 53:42-53:52 Dr. Buchheit, I wonder if you could tell us a little something about stem cells. What are they and how should they be used? Are they useful at all? Dr. Tom Buchheit 53:53-55:14 It’s a great question. And stem cells have captured the imagination of many Americans and people across the globe. That story started with a scientist named Dr. Arnold Kaplan. And he found these cells that were growing in our bone marrow that he could grow and turn into cartilage. And this was in the 1990s. Everyone thought he had a cure for osteoarthritis at that moment. The challenge is that when you take those cells and inject them into a joint, they live for a while, but then they die off. And it’s really very clear now that what we call stem cells have a benefit for our immune response. So, for instance, we talked about that macrophage that flips a switch. They will flip that macrophage switch, but stem cells are actually working through our own immune systems. So the cells that someone gets injected into a knee, a hip, or a shoulder, they’re not living long-term. They’re not growing new cartilage. They’re turning on our own repair systems. And that’s the myth that’s been out there for a very long time is someone thinks that they’re going to have a stem cell injection. They’re going to grow new tissues. They may have much healthier tissues, but those cells that are injecting aren’t living long-term. Terry 55:15-55:19 But what I’m hearing you say is there still could be benefit. Dr. Tom Buchheit 55:19-55:50 Absolutely. Absolutely. The cells can be very beneficial in a lot of ways. There’s many ways to harvest them. You can harvest them from bone marrow. You can harvest them from adipose tissue. Now, stem cells have also become controversial because they can come from our cells, like PRP or the autologous conditioned serum, or they can come from a donor. And those donor products, you might imagine, need to go through a higher level of regulatory scrutiny to make sure that there’s no infection that occurs in that process. Terry 55:50-55:52 I would want them to be regulated. Dr. Tom Buchheit 55:53-56:12 Absolutely. And so there really are yet to be any approved stem cell therapies from donors in the United States. If you hear of people going overseas to overseas clinics, various countries around the United States, they can do those incubated products over there, but you really can’t do it in the United States right now. Joe 56:13-56:43 I’d like to ask you about cost. I guess, but I could be completely mistaken, that insurance companies are going to do their best to deny things like prolotherapy or PRP injections, or maybe even the autologous conditioned serum. If they could say, no, no, no, no, no, we don’t really pay for that, how much would it cost if somebody had to pay out of pocket? Dr. Tom Buchheit 56:44-57:07 Well, it’s a whole spectrum, right? There are certain things, prolotherapy is very inexpensive and stem cells and autologous conditioned serum are much more expensive. And it is true, insurance doesn’t cover any of these right now. Now I think eventually they will. My way… I look at it is insurance covers therapies that suppress the immune system. They don’t cover therapies that augment the immune response. Joe 57:08-57:09 That sounds crazy. Dr. Tom Buchheit 57:10-57:56 But it’s true if you think about it, right? If you want a steroid injection, it’ll be covered. If you want an anti-inflammatory medication, it’ll be covered. But if you want prolotherapy or PRP or any of the other therapies we’re talking about, it’s not. We also need to redo some of the studies. I mentioned before some of the PRP studies that were negative because what they were using really wasn’t strong enough. And the insurance company can very easily go to that… point to that study and say, “Look, here’s a large randomized control trial that says it doesn’t work. It’s experimental. We will not cover it.” So it’s I think it’s incumbent on the field to redo these studies and redo them in a strong way, in a multicenter way with good products and then have the evidence. And I think that will happen, but I think it’s going to be a few years. Terry 57:57-58:28 Dr. Buchheit, we’ve talked today about arthritis and what you do about it. We haven’t really talked as much about what causes it. We have talked about chronic inflammation. And so I want to ask you about one potential cause, which would be infection. For example, a Staph aureus infection, a Borrelia burgdorferi infection. Do you have anything to say about that? Dr. Tom Buchheit 58:28-59:24 It’s not an area that I know deeply. I know it is one of the things looked at, and it makes sense. Any driver of chronic inflammatory change is going to chew up cartilage. And if you think about it, so if you have a chronic inflammatory state, regardless of what’s driving that inflammatory state, your body’s going to produce enzymes that digest cartilage tissue. And that’s what osteoarthritis is. It’s the enzymes. The inflammation releases the enzymes. The enzymes digest the tissue. And so we need to find a way to prevent that from happening. But any chronic inflammatory state would do that. A chronic infection would do that. A chronic inflammatory state would do that. An injury that hasn’t quite recovered would do that. So I’m not an expert in the infectious cause, but if a chronic infection causes chronic inflammation, absolutely it could drive osteoarthritis. Joe 59:25-01:00:39 Dr. Buchheit, I’d like to ask about pain because pain gets your attention very fast. And people want relief and they can’t sleep. Their back hurts or their shoulder’s giving them trouble. They can’t lie on their shoulder. It used to be that doctors prescribed opioids in massive quantities, Percocet, hydrocodone, oxycodone. And of course, now because of the opioid epidemic and all of the people who have died, there’s a tremendous reluctance for both physicians as well as patients to rely on opioids, especially long-term. What’s replaced opioids, however, is gabapentin. It’s [an] anti-seizure drug. At least that’s how it was originally developed. And another medication that has both sort of antidepressant-like activity as well as some subtle opioid-like effect called tramadol. These are the big pain relievers these days. Your thoughts about gabapentin and or tramadol and what we should be doing instead? Dr. Tom Buchheit 01:00:40-01:01:36 That’s a great question. So I’ve been using and I’ve been using and seeing people on gabapentin since the late 90s when it came out, right? And it came out, as you pointed out, as a seizure drug. It does, and it can reduce nerve pain. We talked about nerve pain being from, if you have a nerve that’s entrapped, it starts firing on its own spontaneously and gabapentin can quiet that down. The challenge with gabapentin, and the concern about gabapentin, though, is that it will affect the brain. It was designed to affect our brains as a seizure drug. And so I think it’s a bit of magical thinking to think that we’re not going to have cognitive side effects to gabapentin over time. And that’s my concern. Some people can do very well with it. Some people need it because they cannot function because of a neuropathy or another issue. But a lot of people are on it, and I do have concerns about the cognitive side effects. Terry 01:01:36-01:01:41 And the person who says gabapentin gives me such brain fog, I can’t function, they shouldn’t be taking it. Dr. Tom Buchheit 01:01:42-01:01:45 If they can avoid taking it, it sounds like a good idea to avoid taking it. Joe 01:01:46-01:02:28 We like to say that pain is personal. Everybody’s different. And my mom, for example, if she had a bellyache, it would be like a 10 out of 10. I mean, she was just incapacitated. Terry’s mother, on the other hand, you know, cut to the bone and she’d say, “Oh, maybe my pain’s at two.” You know, she was a tough old bird. And so the idea that we can generalize about your pain is very challenging. Some people get great benefit from gabapentin. Other people say it didn’t work hardly at all. How do we find the right strategy for pain relief? Dr. Tom Buchheit 01:02:28-01:03:56 Oh, it’s hard. It really is hard. And this has been decades and decades of pain research trying to identify therapies based on symptoms. I tend to look also at function. The reason is that if I have someone who is having 6 over 10 knee pain and can walk a quarter of a mile, if we do a therapy on them and they can walk now 3 miles, but their pain is still 6 over 10, that’s still an improvement, right? Their function is better. And my hope is that as the function improves, the pain will eventually follow. But it is hard because, right, pain is in us and it is subjective and no one can experience it outside of the individual. And that makes it hard to gauge, right? But the other part of this is that we’ve tried to objectify osteoarthritis, for instance, by looking at an x-ray and saying this is grade 1, 2, 3, 4, depending on how big the space is between bones. And it turns out that there’s very little relationship between someone’s function, someone’s pain, and how much space is between the bones. So our attempts at defining treatments based on x-ray is equally as poor. So I think pain is an important part of this. And it’s a very important part of helping someone to function better. And you’re right, there’s no other way of doing it other than just asking them and talking to the patient. Joe 01:03:56-01:04:21 Well, we only have about two minutes left, and so this gives us the opportunity to summarize all the things that we should be doing and some that we should not be doing to allow us to keep moving which is critical to your game plan and to reduce our likelihood of ending up in pain for a long period of time? Dr. Tom Buchheit 01:04:22-01:04:50 Well, I think first off is figure out where you’re starting. Everybody starts at a different place, but I like to say, you know, measure where you are and maybe you can walk a quarter mile. Maybe you can only walk a few steps. Maybe you can go and do aqua therapy, find out where your, where your level is of exercise and then work on building that, but build it slowly. You know, if you have someone who can’t walk more than a quarter mile and they go walk two miles, they’re going to be in bed for three days and then they’ve lost ground, right? Joe 01:04:51-01:04:58 And walking is good. You don’t have to be a marathoner to benefit from just plain walking. Dr. Tom Buchheit 01:04:58-01:05:03 Exactly. And the studies for osteoarthritis are very convincing. Walking is good for joints. Joe 01:05:04-01:05:05 What about diet? Dr. Tom Buchheit 01:05:07-01:05:27 Live like the folks that are in the Mediterranean basin. So I always think of fish, fruits, vegetables, nuts, olive oils as the foundation for food. And that diet that’s good for our hearts is also very good for joints and nerves. And it’s been shown and studied to actually decrease arthritis pain as well. Joe 01:05:27-01:05:42 And when we sprain an ankle or injure a shoulder or our back is hurting, what can we do to avoid taking all those NSAIDs or getting those steroid shots to ease the pain and get us back moving again? Dr. Tom Buchheit 01:05:42-01:06:17 Well, that’s a great question. And I would argue that we should not soak ourselves in steroid injections and anti-inflammatories. And I had this personal experience of having had a couple of knee injuries. And one, the first one a bunch of years ago, I soaked in anti-inflammatories. And then the second one, I didn’t. And I can tell from personal experience, it hurts more, but my healing was faster. And I would encourage when people can do it and go without the steroids and the anti-inflammatories to minimize or avoid them if they can. Terry 01:06:17-01:06:24 Dr. Tom Buchheit, thank you so much for coming and talking to the People’s Pharmacy today. Dr. Tom Buchheit 01:06:24-01:06:27 Thank you, Joe and Terry. It’s been a pleasure to be here. Thank you for having me. Terry 01:06:28-01:06:48 You’ve been listening to Dr. Tom Buchheit, author of “Healing Joints and Nerves: Immune Stimulation, and the New Science of Regenerative Therapies.” Dr. Buchheit founded the Triangle Regen Medicine and Biologic Center. He collaborates with colleagues at the Center for Translational Pain Medicine at Duke University. Joe 01:06:49-01:06:58 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Terry 01:06:59-01:07:06 This show is a co-production of North Carolina Public Radio, WUNC, with the People’s Pharmacy. Joe 01:07:07-01:07:23 Today’s show is number 1,468. You can find it online at peoplespharmacy.com. That’s where you can share your comments about this episode. You can also reach us through email, radio, at peoplespharmacy.com. Terry 01:07:23-01:07:54 Our interviews are available through your favorite podcast provider, whichever one that is. You’ll find the podcast on our website on Monday morning. In this week’s podcast, you can learn more about stem cells and PRP. We discuss the pros and cons of pain relievers, including opioids and gabapentin. Pain is so personal. How can we find the right strategy for pain relief for each individual? Joe 01:07:54-01:08:02 And because we are so individual, the one size fits all does not work. We have to individualize it. Terry 01:08:02-01:08:02 Exactly. Joe 01:08:03-01:08:32 At peoplespharmacy.com, you could sign up for our free online newsletter to get the latest news about important health stories. When you subscribe, you also have regular access to information about our weekly podcast. We would be so grateful if you’d write a review of The People’s Pharmacy and post it to the podcast platform you prefer. If you find our topics thought-provoking, please share them with friends and family. In Durham, North Carolina, I’m Joe Graedon. Terry 01:08:33-01:09:09 And I’m Terry Graedon. Thank you for listening. Please do join us again next week. Thank you for listening to the People’s Pharmacy Podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money. Joe 01:09:09-01:09:19 If you like what we do and you’d like to help us continue to produce high-quality, independent healthcare journalism, please consider chipping in. Terry 01:09:19-01:09:24 All you have to do is go to peoplespharmacy.com/donate. Joe 01:09:24-01:09:37 Whether it’s just one time or a monthly donation, you can be part of the team that makes this show possible. Thank you for your continued loyalty and support. We couldn’t make our show without you.
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  Show 1429: How to Love Your Liver and Protect its Superpowers (Archive) 02.04.2026 1ชม. 9นาที

  This week, Joe and Terry discuss liver health with two specialists. You may not have spent much time thinking about your liver. It is, however, an absolutely essential organ. When the liver is working properly, every part of the body gets the nutrients it needs and no parts are exposed to damaging toxins. These are among its superpowers. Find out why you should love your liver. At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen You could listen through your local public radio station or get the live stream on Saturday, April 4, 2026, at 7 am EDT on your computer or smart phone (wunc.org). Here is a link  so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on April 6, 2026. Love Your Liver: Nutrients don’t go directly from the intestines to the rest of the body. Instead, they pass through the liver first. There, this master organ breaks them down into compounds that can be recognized and utilized by individual tissues and cells. Moreover, if it finds nasty chemicals that shouldn’t be there, it utilizes its superpowers to transform them into less damaging compounds that can be more readily excreted. You should also love your liver because it can store nutrients for unanticipated periods of fasting and hold off starvation. This was a tremendous benefit during earlier periods of human evolution. These days, we have less need for a hedge against starvation. In fact, when we overload our livers with alcohol or sugar, even its superpowers may not be adequate. The liver’s response to this kind of insult is fibrosis, a condition in which it stiffens and stores fat. Liver Disease: One of the liver’s superpowers is that it can regenerate itself so long as we remove the source of injury. That’s pretty remarkable! But what if we keep on eating ultra-processed foods (Nutrients, May 10, 2023) and drinking soda or alcohol?  In that case, the liver continues to try to repair itself. That can change the architecture of the tiny blood vessels that run through the liver, raising the pressure within them and ultimately leading to serious complications. Fatty liver disease, correctly termed metabolic-associated steatohepatitis (MASH), is the first step; cirrhosis and ultimately liver failure might follow. How Do You Know If Your Liver Is Healthy? The liver is so effective at maintaining the body in balance that most people don’t develop symptoms of trouble until liver disease is quite advanced. As a result, the best way to keep tabs on liver health is through blood tests. Tests for the liver enzymes called ALT and AST are common and often used to assess liver health. Agents That Can Help or Harm the Liver: If you love your liver, consider drinking a cup or two of black coffee daily. This has been shown to help the liver fight inflammation and overcome early-stage liver fibrosis (Redox Biology, March 2025). Another precaution to take: avoid excess acetaminophen. This is the pain-relieving ingredient in Tylenol and hundreds of other over-the-counter medications. Doctors consider it safe for occasional use at doses under 4,000 mg in a day. Chronic use might call for lower doses yet. Because it is so widespread, people may mistakenly take several different medicines containing acetaminophen (paracetamol in the rest of the world) and end up exceeding the maximum dose by accident. Liver experts like our guest Dr. Ahmad treat such emergencies with a medicine called N-acetylcysteine. Other pain relievers, such as NSAIDs, are less likely than acetaminophen to damage the liver. Dangerous reactions to such drugs are unpredictable, however, which can make them harder to manage. Fluoroquinolone antibiotics such as Levaquin and corticosteroids like methylprednisolone also fall into this category. Oral antifungal drugs can also be very hard on the liver. Herbs That Can Challenge the Liver: Pharmaceuticals are not the only compounds that may test the liver’s detoxifying superpowers. Botanical medicines can also cause challenges. Dr. Ahmad has treated people whose liver injuries were caused by green tea extract, turmeric, kratom or ashwagandha. Most people taking such supplements are attempting to improve their health, so discovering that instead they have developed liver damage is a nasty surprise. If you love your liver, stick with drinking green tea and eating curry rather than taking pills with concentrated extracts. This Week’s Guests: Meena Bansal, MD, is Professor of Medicine, specializing in liver diseases, at the Icahn School of Medicine at Mount Sinai. She is System Chief of the Division of Liver Diseases and Director of the MASH/NASH Center of Excellence at Mount Sinai. Meena Bansal, MD, Professor of Medicine Mt. Sinai, photo courtesy of Mt. Sinai Jawad Ahmad, MD, is a professor of liver diseases at the Mount Sinai School of Medicine. He is co Primary Investigator on the NIH/NIDDK research initiative to study cases of severe liver injury caused by prescription drugs, over-the-counter drugs, and alternative medicines, such as herbal products and supplements. For more information on the Drug-Induced Liver Injury Network (DILIN) visit: https://researchfunding.duke.edu/drug-induced-liver-injury-network-dilin-clinical-centers-u01-clinical-trial-optional Jawad Ahmad, MD, Professor of Medicine at Mount Sinai, photo courtesy of Mt. Sinai Listen to the Podcast: The podcast of this program will be available Monday, April 6, 2026, after broadcast on April 4. You can stream the show from this site and download the podcast for free.  
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  Show 1467: Can You Disagree Without Fighting? Building Bridges, Not Battles! 25.03.2026 1ชม. 6นาที

  A chance encounter with a stranger on an airplane offers lessons for all of us in how to disagree without fighting. Infectious disease expert Morgan Goheen, MD, was wary when the person in the seat next to hers struck up a conversation with questions about the origins of Lyme disease and the value of being vaccinated against COVID. His views were quite different from hers. Yet they managed, in the course of the flight, to exchange perspectives in a respectful manner. Can we all learn how to do that? At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, March 28, 2026, through your computer or smart phone (wunc.org). Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on March 30, 2026. Can You Disagree Without Fighting? Dr. Goheen did her best to answer the questions her seatmate had. She also listened carefully to his description of life during the pandemic, particularly his objections to mandatory vaccination and his fears of a reaction to the vaccine. As a health care provider, she had been working in a hospital that was overwhelmed with COVID-19 patients. Far too many of them died, and at the height of the pandemic, most died alone rather than with family nearby. She was able to recognize that this had colored her perception of the pandemic and had led her not to give enough attention to the real economic hardship some public health mandates triggered. The Value of Vaccines Before the polio vaccine was developed, parents lived in terror of polio epidemics that would tear through communities, leaving some children paralyzed and a few dead. We no longer have to fear polio, pertussis, diphtheria or measles because vaccines can protect children from these common diseases. In a sense, though, their very success has led to skepticism of their value. Most Americans do not know anyone who has died of pertussis (aka whooping cough) because the majority of children have been vaccinated against this pathogen. Recently, there have been few birth defects caused by rubella because pregnant women can be protected from the infection. Can Trust Be Regained? During the pandemic, opinions became polarized. People who would once have trusted the FDA or the CDC became suspicious. Public health messages about masking were initially based on conjecture, because no one had conducted actual studies until later in the pandemic. The nature of this new virus and its transmission was not yet well understood. Yet authorities occasionally made dogmatic pronouncements, possibly out of fear. Some opportunities to build trust were squandered, and it will take time and patience to get it back. Learning to disagree without fighting is a great place to start. Learning to Disagree Without Fighting After talking with Dr. Goheen, we turn to Dr. Laura Gilliom. She is a clinical psychologist active in the Braver Angels movement. This organization brings people together to bridge the partisan divide. The volunteers run workshops in which people with divergent viewpoints discuss issues of the day. They model basic approaches to good communication, including treating the other person in the conversation with respect. It is important to listen for understanding of the intellectual and emotional bases for their perspective. After all, people have reasons for their opinions. Even if you don’t understand them, those reasons make a lot of sense to them and are usually the result of significant life experiences. When you speak, the aim is not to win the argument, but to be heard and understood. That is also the goal as you listen–to understand where the other person is coming from. When Braver Angels bring people together, all agree to state their views freely and without fear. That isn’t always the case in other situations. Sometimes people fail to speak out because they are afraid of the possible reaction. Another rule for Braver Angels interactions is that people treat each other, including those who disagree, with honesty, dignity and respect. Curiosity and kindness are also critical when we talk with people whose views are very different from ours. In some situations, it may be appropriate to reflect back what you have heard and ask if that is a fair representation of what they said. Before sharing your own ideas, you might ask permission. One other point to keep in mind: humans sometimes make mistakes. That might apply to those on “our side” as well as to those on a different side. Humility can help. This Week’s Guests Morgan Goheen, MD, PhD, serves as faculty Instructor in the Section of Infectious Diseases within the Department of Internal Medicine at Yale School of Medicine. As a physician scientist, her current research focuses on the mosquito vector’s role in malaria transmission dynamics and drug resistance spread in sub-Saharan Africa with lab work based in the Epidemiology of Microbial Diseases Department in the Yale School of Public Health. Within her clinical specialty of infectious diseases, Dr. Goheen has specific interest in tropical medicine and helped start the Travel and Tropical Medicine Clinic at the Yale Center for Infectious Diseases. Dr. Goheen is a Public Voices Fellow of The OpEd Project in Partnership with Yale University. https://www.theopedproject.org/fellowships. https://www.huffpost.com/entry/infectious-disease-doctor-anti-vaccine-airplane_n_68d2e961e4b03fb4d93463e7 Laura Gilliom, PhD, is a licensed clinical psychologist in Chapel Hill, North Carolina, a State Coordinator for Braver Angels, and a member of the Central NC Alliance of Braver Angels. https://nc.braverangels.org/ Listen to the Podcast The podcast of this program will be available Monday, March 30, 2026, after broadcast on March 28. You can stream the show from this site and download the podcast for free.
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  Show 1466: Could Hidden Infections Be Driving Chronic Disease? 19.03.2026 1ชม. 23นาที

  Chronic diseases make up the bulk of the problems that modern health care must address. Each condition seems to have its own drivers–cholesterol for heart disease, airway hyperreactivity for asthma, neurotransmitter imbalance for depression and other psychiatric disorders, a buildup of amyloid beta in the brain for Alzheimer disease. What if all these conditions had similar origins? Today we’ll consider the evidence suggesting that hidden infections may be driving many chronic diseases. At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen You could listen to this conversation through your local public radio station or get the live stream at 7 am EST on Saturday, March 21, 2026, through your computer or smart phone (wunc.org).  Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on March 23, 2026. How You Can Watch our Interview with Nikki Schultek: Here is the YouTube video podcast of our interview with Nikki. We think you will find it compelling. Treating the causes of chronic diseases instead of the symptoms makes sense to us. How Could Hidden Infections Be Driving Chronic Disease? Nikki’s Story We begin this episode with the personal account of Nikki Schultek. She is a patient who has transformed herself into a research leader after a horrendous experience with unexplained chronic disease. She was a healthy active young mother whose lifelong well-controlled asthma suddenly took a dramatic turn for the worse. She then developed atypical pneumonia, heart arrhythmia and interstitial cystitis, along with a slew of autoimmune conditions. All the doctors could tell her was that these were idiopathic conditions driven by inflammation. As she notes, “idiopathic” basically is doctor-speak for we don’t understand what is going on here. When she developed neurodegenerative symptoms that made her physician suspect MS, she was terrified. That low point became a turning point. Her background had equipped her to read scientific studies, so she began trying to figure out what was driving chronic disease in her own situation. A search linking atypical pneumonia and interstitial cystitis led her to the clinician who was able to help her regain her health, Dr. Charles Stratton. He had conducted a small study linking both conditions to a respiratory infection caused by Chlamydia pneumoniae. What Is Chlamydia pneumoniae? When people hear “Chlamydia,” they think immediately of the sexually transmitted infection caused by Chlamydia trachomatis. Although the organisms are related, they have completely different modes of transmission. People catch C. pneumoniae (Noo-mo-knee-eye) simply by breathing in air that contains infectious respiratory particles. These bacteria are extremely common, but it is difficult to detect an infection. That’s because C. pneumoniae hides out inside human cells. It doesn’t show up in blood tests or urine cultures. The study that caught Nikki’s eye used PCR, polymerase chain reaction, which detects DNA. That analysis revealed that 80 percent of the women in the study with interstitial cystitis had C. pneumoniae. The researchers concluded that this sneaky pathogen can lead to chronic inflammation. The Link Between C. pneumoniae and Asthma Remember that Nikki’s troubles started with a severe asthma exacerbation. Research has shown a link between that infection and hard-to-treat asthma (PLoS One, April 19, 2021). When Dr. Stratton tested Nikki, they discovered that she indeed harbored a C. pneumoniae infection. The treatment required multiple antibiotics over a prolonged period of time. Luckily, it eventually cleared the interstitial cystitis, the neurodegenerative symptoms, the other autoimmune problems and brought her asthma back under control. Other Pathogens Causing Trouble C. pneumoniae was not the only germ lurking in Nikki’s body. She discovered that she also carried Borrelia burgdorferi, the organism that causes Lyme disease. In addition, an examination of her red blood cells revealed both Babesia and Bartonella, possibly transmitted by the same tick bite that gave her the Lyme disease. These experiences inspired Nikki to start the Intracell Research Group, the Pathobiome Research Center and the Alzheimer’s Pathobiome Initiative. All are aimed at discovering if hidden infections such as C. pneumoniae or Babesia or Borrelia burgdorferi could be driving chronic disease such as dementia. More Research on Covert Pathogens Driving Chronic Disease One of Nikki’s colleagues at the Alzheimer’s Pathobiome Initiative as well as at the Philadelphia College of Osteopathic Medicine is Dr. Brian Balin. He has spent more than 25 years studying the connections between C. pneumoniae infections and brain inflammation. This, in turn, has been linked to neuroinflammation and dementia. Dr. Balin points out that respiratory pathogens like C. pneumoniae are accustomed to entering the body through the nose. The nose offers access not only to the respiratory tract, but also to the brain. However, it can be difficult to detect microbes in the brain while the patient remains alive. This has limited research on infection and cognitive impairment in the past (Alzheimer’s & Dementia, Nov. 2023). The COVID pandemic poses another huge risk. Like C. pneumoniae, the SARS-CoV-2 virus often enters the body through the nose. From there, it has ready access to the brain (Frontiers in Aging Neuroscience, June 13, 2025). Further, when the immune cells called macrophages respond to these infections, they engulf the pathogen and may carry it throughout the body. Might long COVID be the latest example of unacknowledged infection driving chronic disease? What Are the Implications for Treatment? If it can be firmly established that pathogens trigger the inflammation driving chronic disease, that offers several different approaches for treatment. First, we would need to use a high level of suspicion and appropriate technology (such as PCR) to detect infection. These bugs don’t show up through urine cultures or other typical diagnostic techniques. Secondly, we would need to figure out treatment strategies. Antibiotics can be useful, but they may not be the only tools. Vaccines could help the body fight off these pathogens. Specific antibodies might also be developed to block them. In addition, phage therapies targeted to specific bacteria may also work when antibiotics cannot. If you are unfamiliar with the idea of phage therapy, you might want to listen to our radio shows on this topic. Just think of these viruses the way you think of the enemy of my enemy. That entity becomes your friend! Here are some interviews you may find intriguing: Show 1155: Can Bacteriophages Save Your Life? Show 1407: Battling Superbugs with Nature’s Viral Warriors This Week’s Guests Nikki Schultek is Founding Director of the Pathobiome Research Center, and Research Assistant Professor at Philadelphia College of Osteopathic Medicine , Executive Director and Co-Founder of the Alzheimer’s Pathobiome Initiative (AlzPI), and Principal and Founder of Intracell Research Group, LLC. A former life sciences professional with Pfizer and Genentech, she now works to unite global researchers studying infection-associated chronic illnesses, including Alzheimer’s disease and other brain diseases. Following her own recovery from Lyme Disease, Chlamydia pneumoniae and co-infections, Nikki builds and leads patient-centered interdisciplinary research collaborations to examine microbial drivers of chronic diseases. She has catalyzed philanthropic funding to launch AlzPI research at multiple academic centers and co-lead authored a 2023 roadmap in Alzheimer’s & Dementia outlining a rigorous strategy to investigate infections in brain disease. www.PCOM.edu/research/pbrc www.AlzPI.org www.IntracellResearchGroup.com Nikki Schultek, founder and director of Intracell Research Group, LLC Brian J. Balin, PhD, is a tenured Professor of Neuroscience and Neuropathology at the Philadelphia College of Osteopathic Medicine. He directs the Center for Chronic Disorders of Aging (an Osteopathic Heritage Foundation Endowed Center), and the Adolph and Rose Levis Foundation Laboratory for Alzheimer’s Disease Research. An internationally recognized Alzheimer’s researcher, Dr. Balin has spent over 25 years investigating links between infection—particularly Chlamydia pneumoniae—and neuroinflammation, blood–brain barrier dysfunction, and neurodegeneration. His NIH- and foundation-funded work has significantly advanced the “pathogen hypothesis” of Alzheimer’s disease and Dr. Balin is regarded as a global expert and pioneer in this research field. Dr. Balin is a Co-Founder of The Alzheimer’s Pathobiome Initiative (AlzPI). Brian Balin, PhD, Philadelphia College of Osteopathic Medicine Listen to the Podcast The podcast of this program will be available Monday, March 23, 2026, after broadcast on March 21. You can stream the show from this site and download the podcast for free. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1466: A transcript of this show was created using automated speech-to-text software (AI-powered transcription), then carefully reviewed and edited for clarity. While we’ve done our best to ensure both readability and accuracy, please keep in mind that some mistakes may remain. If you have any questions regarding the content of this show, we encourage you to review the original audio recording. This transcript is copyrighted material, all rights reserved. No part of this transcript may be reproduced, distributed, or transmitted in any form without prior written permission. Joe 00:00-00:01 I’m Joe Graedon. Terry 00:01-00:05 And I’m Terry Graedon. Welcome to this podcast of The People’s Pharmacy. Joe 00:06-00:27 You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. Chronic diseases continue to plague humans. We’re good at treating symptoms, but the root causes often remain a mystery. This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:45 Are pathogens responsible for many of our most troubling and persistent conditions? We don’t think of heart disease, arthritis, or Alzheimer’s disease as having an infectious origin, but might they? Joe 00:46-00:52 Our guests today are studying the connection between infection and chronic disease. Terry 00:53-01:00 Not every pathogen is obvious. Some like to lurk inside cells where we have a hard time detecting and eradicating them. Joe 01:01-01:07 Coming up on The People’s Pharmacy, how hidden infections can lead to chronic disease. Terry 01:14-02:26 In The People’s Pharmacy Health Headlines: The American Heart Association and the American College of Cardiology have just issued new guidelines for preventing heart disease. For one thing, the experts suggest starting cholesterol testing much younger, possibly even in childhood. Younger adults, between 20 and 30, should aim for LDL cholesterol levels below 100. People at higher risk will be encouraged to get their LDL level below 70. Cholesterol is not the only risk factor addressed by the new guidelines. They also recommend testing for lipoprotein A, also known as LP little a. This is an independent risk factor for atherosclerosis. The cardiologists who compose the guidelines want their colleagues to use a new risk calculator that evaluates a much longer risk period than the previous calculator did. People with heart disease and those with diabetes need more intensive treatment than those at low risk. The guidelines also suggest measuring coronary artery calcium in cases where there’s any question about starting a statin medication to lower cholesterol. Joe 02:27-03:22 Harvard researchers and their Mongolian colleagues have just published a study of vitamin D3 supplementation during COVID infection. Patients from both the U.S. and Mongolia were recruited. Over 1,700 volunteers with newly diagnosed COVID-19 infections participated. They were randomized to receive either vitamin D3 or placebo. The dose of vitamin D was 9,600 international units for the first two days and 3,200 IUs daily for the next month. There was no difference in symptom severity or chance of hospitalization while people were taking the vitamin or placebo. There was, however, an intriguing hint that people who were taking vitamin D3 were less likely to develop long COVID after their infection. This reduction was not statistically significant, but the signal was strong enough that it deserves further study. Terry 03:23-04:28 For decades, doctors have prescribed metformin to help people with type 2 diabetes control their blood sugar. Some studies have suggested that this compound may also help reduce the risk of developing certain cancers. Now, researchers have analyzed data from five Nordic countries to compare 13,050 people newly diagnosed with esophageal squamous cell carcinoma to 130,500 healthy people of similar age and sex. Esophageal cancer is quite dangerous with low survival rates. The scientists report that people taking metformin had a 36% lower likelihood of being diagnosed with esophageal squamous cell carcinoma than those who were not. Higher doses were associated with even lower risk, about 48%. The authors note the observed association between metformin use and a significantly decreased risk of this cancer suggests a possible role of this drug in cancer prevention and treatment. Joe 04:29-05:14 Influenza cases are trending down at long last, though the CDC reports overall seasonal influenza activity remains elevated nationally. The agency notes that hospitalizations from influenza were the third highest since the 2010-2011 flu season. The CDC estimates that there were 27 million illnesses, 350,000 hospitalizations, and 22,000 deaths from flu so far this year. How well did flu shots work? Well, not so good. The H3N2 subclade K variant surfaced after the vaccines were in production, so the shots were far less effective than usual. Terry 05:14-06:17 Americans have made some important health changes over the last several decades. In particular, smoking is down dramatically. Life expectancy has improved over that time, except during the pandemic. Even before that, though, life expectancy in the U.S. had kind of flattened. Now, analysis shows that younger generations, born since 1970, have higher mortality from cancer, cardiovascular disease, and other causes than previous generations. If these trends continue, the U.S. could experience a sustained decline in life expectancy. And that’s the health news from The People’s Pharmacy this week. Welcome to The People’s Pharmacy. I’m Terry Graedon. Joe 06:17-06:34 And I’m Joe Graedon. Many of our most challenging conditions remain hard to cure. That’s because modern medicine has become very good at treating symptoms. We can ease the pain of arthritis, open airways for people with asthma, and overcome urinary tract infections with antibiotics. Terry 06:35-06:43 But we often don’t know what’s actually causing these chronic health problems in the first place. Is there a connection with hidden infections? Joe 06:44-07:18 To help us answer that question, we turn to Nikki Shultek. She’s founding director of the Pathobiome Research Center and research assistant professor at the Philadelphia College of Osteopathic Medicine. Nikki is also principal and founder of IntraCell Research Group and executive director and co-founder of the Alzheimer’s Pathobiome Initiative. She worked as a life science professional for Pfizer and Genentech at the start of her career. Then she had a devastating personal experience with chronic illness. Terry 07:19-07:22 Welcome to The People’s Pharmacy, Nikki Shultek. Nikki Shultek 07:22-07:27 Thank you so much, Terry and Joe, for having me. I’m incredibly grateful to be here today with both of you. Joe 07:28-07:43 Nikki, you have had quite a journey. Could you please share with our listeners your chronic illnesses associated with pathogens? Because I think this is still a field in evolution. What happened? Nikki Shultek 07:43-09:52 Absolutely. So I like to say my journey began 10 years ago, closing in on 11 years. And I went from being essentially a relatively healthy, athletic, I was a runner, mother of two children, enjoying my early 30s to being someone who was just one diagnosis after another, chronically ill. And if anyone has seen that show Mystery Diagnosis, it was sort of like that. I had about a dozen specialists helping me. And I, you know, really was unable to get a clear picture of what was actually driving the different diagnoses I had. So what I will fast forward with today is essentially I have what is known as infection-associated chronic illness. That is what was happening to me at the time. But at the time, I was just being diagnosed with one autoimmune condition after another. And I ended up having this terrible respiratory symptom. So I’d had asthma my entire life, and I developed something that was different than my typical asthma. Yes, my asthma had become incredibly severe suddenly, but also I had a symptom called air hunger, which was truly like a desire for oxygen. And this symptom came along with another odd symptom, which was one swollen joint in my finger. Terry 09:03-09:04 Huh, just one. Nikki Shultek 09:04-09:26 Mmm Hmm. At that time. And so I went to my asthma and allergy physician who had seen me for years. He said, oh, you must be having an asthma exacerbation. And I was totally, that’s a reasonable conclusion, right? Prescribed prednisone, which is not uncommon for people that have asthma. And unfortunately, 20 milligrams turned to 40, 40 turned to 80. Joe 09:26-09:27 Whoa. Nikki Shultek 09:27-09:52 And I continued to go the wrong direction with my breathing. And I got this rattle in my lung and I’m going, oh, my goodness gracious, what’s happening here? So I ended up, to make a long story short, with multiple pulmonologists just on the lung issue alone, a scan to look for pulmonary clots, pulmonary emboli. I was then subsequently having strange heart palpitations, found out I had developed an arrhythmia. Joe 09:53-09:55 And how old were you at that time? Nikki Shultek 09:55-09:57 I’m 34 at this point. Joe 09:57-09:58 So that’s pretty unusual… Nikki Shultek 09:58-10:00 Well, 33, about to be 34, yeah. Joe 10:00-10:04 …for a healthy, middle-aged woman who exercised? Nikki Shultek 10:04-10:40 Non-smoker, actually a runner. I had taken up running half marathons, so probably the best physical shape of my life. And my asthma had been previously very well controlled on GlaxoSmithKline’s purple disc, the Advair, for like years. Didn’t have an exacerbation or a serious turn in my illness. What happened next was systematically the illness spread around my body, essentially. And I went from having just respiratory symptoms to developing what is known as one of the top 10 most painful conditions someone can have, a bladder pain disorder called interstitial cystitis. Terry 10:40-10:45 Oh, yes. We have heard of this. It sounds awful. Nikki Shultek 10:45-11:37 Yeah, it’s essentially for the listeners that have had a urinary tract or bladder infection, it’s like walking around like that in perpetuity. And so when that happened to me, you know, I was quite frankly crushed. I had also started to become increasingly fatigued. I noticed cognitive symptoms. I noticed changes in my mood and my affect, which of course, now I’m walking around with difficulty breathing and bladder pain. And at this point in time, you know, it was really scary. My kids were just three and five. And I remember vividly the day my bladder pain began was on a Halloween morning. And later that day, trying to focus on just enjoying taking the little guys trick-or-treating in their cute outfits. And just being, you know, deeply concerned over why I had this pain. And the word idiopathic became my enemy. Idiopathic is a fancy way of saying we don’t know. Terry 11:37-11:38 Exactly. Nikki Shultek 11:38-12:23 Why, right? And I’m going, inflammation, inflammation. You know, I start thinking about this. And one thing that I noted was antibiotics. I ended up getting prescribed antibiotics for the terrible lung situation. People are very familiar with the Z-Pak. So that drug is azithromycin. I was placed on it first for 10 days. My air hunger went away. And then I relapsed. So they treated me again and again. And then I got a month-long prescription for that drug. And that kind of got my breathing in sort of like a serviceable but not great place. But at least I wasn’t gasping for air every night. And then the worst thing that happened to me during this horrible year was it was closer to my 34th birthday. I developed neurodegenerative symptoms that my primary care doctor thought could be MS. Joe 12:24-12:24 Wow. Terry 12:25-12:26 Oh, that’s scary. Joe 12:26-12:37 Super scary. I mean, that’s kind of a challenging diagnosis. As bad as you were, now all of a sudden somebody’s saying, well, maybe you’ve got MS as well. Nikki Shultek 12:38-14:14 Yeah, it’s one of the hardest things I’ve ever had to experience. I would truthfully go to church in sweatpants, sit out in the parking lot, and cry and pray in the parking lot because I felt like I was too much of an emotional wreck to go inside. At this point, I was, you know, when I thought that MS could be, you know, waiting for a neurology appointment, of course, you can’t get those very quickly when you’re a new patient. I had had a brain MRI and I just, I’ve, I, it never felt more of a sense of terror in terms of fear. And it was mostly fear because I was a mom, not like fearing my own existence, you know, being, you know, very limited and painful, but more so how it would impact my children and my husband. And so I started making plans someone in their early 30s shouldn’t have to make. I started, you know, writing things down that I, in case I lost more of my faculties, because I had previously worked for a pharmaceutical and biotechnology company. I knew a lot about medicine and health care, and I knew that I was an unwell person without a proper diagnosis. So at this point in time, once the desperation part kind of faded, it turned into this like sense of resolve, right? Like I accepted that I might have MS. I actually came to terms with that. I don’t, by the way. You know, I had no lesions on my MRI and didn’t feel like a really beautiful answer. It felt like, why am I still so sick, right? I didn’t really have an answer. I had knowledge. The neurologist said to me, well, it doesn’t mean you don’t have it. I see people like you all the time that may for 10 years have symptomatology, and then eventually they develop the lesions. Terry 14:15-14:17 Oh, boy, how helpful is that? Nikki Shultek 14:17-15:29 It was hurtful. It felt cold. And at that time, I remember saying, do you know anything about Lyme disease? And we’re in Connecticut. I was living in Connecticut at the time. I was at the Hartford Hospital. And he said, I don’t know much about that. And, you know, he could have just been having a terrible day. You know, I mean, health care is not an easy environment. And so I try to, my experience has taught me to approach everything with kindness and curiosity. You never know what someone is experiencing. But in a nutshell, what happened next was very important. I decided to turn into the researcher part of me. I was always an intensely curious person that loved science. And I wanted to live. So I did a Google search. And the first thing I looked up was actually atypical pneumonia and interstitial cystitis. One of my diagnoses with the respiratory issue was atypical pneumonia. Okay. And what came up was a study that saved my life. A small study. Dr. Charles W. Stratton from Vanderbilt, the late Charles W. Stratton, and a urology colleague of his, he had been studying this unusual bacteria transmitted through coughing and inhaling infected respiratory particles called Chlamydia pneumoniae. Terry 15:30-15:39 People hear Chlamydia, they think sexually transmitted infection. But that’s a different bacteria in the same family, in the same genus. Nikki Shultek 15:39-16:06 They’re relatives, and it’s the respiratory form. What people don’t realize is how common it is in the human population. It’s really ubiquitous, meaning we’re nearly all exposed to it in a lifetime. And I had never heard of it. And I read the study and it was sort of startling. It was a small cohort, a small group of women with my bladder pain diagnosis tested using PCR, which we all became very familiar with during COVID, right? Looking for… Joe 16:06-16:08 Polymerase chain reactions. Nikki Shultek 16:08-16:26 Indeed, Joe. And then they didn’t do typical urinalysis, which would never pick up on something like chlamydia because it has to live inside our building blocks, the human cells. So it wouldn’t be just floating around, free floating in the urine, and it wouldn’t be detectable this way. Terry 16:26-16:27 And you can’t culture it out of urine. Nikki Shultek 16:27-17:34 No, you can’t. So they did this PCR of the urine, and 80% of the women had evidence of Chlamydia pneumoniae. And the conclusion was this. The study’s too small to have any really meaningful results come from it, but that this organism can lead to chronic inflammation. And that got me deeply curious next. Oh, boy, I’ve had asthma my whole life. This is a chronic bacterial infection. So I did a search on PubMed for Chlamydia pneumoniae, the bacteria, and asthma. And I will say it changed the trajectory of the rest of my life. You know, I decided to start reaching out to the people publishing in the space. There were hundreds of thousands of publications on Chlamydia pneumoniae and asthma, and quite a compelling association with severe asthma, which I had been diagnosed with. And at this point in time, I ended up reaching out to some of the what would become today the founding members of a global team focused on interdisciplinary collaboration and the doctor, Dr. Charles W. Stratton, who saved my life, as well as the wonderful Dr. David Hahn, who spent his career studying infection and asthma. Terry 17:36-18:06 You’re listening to Nikki Shultek, founding director of the Pathobiome Research Center and executive director and co-founder of the Alzheimer’s Pathobiome Initiative. She’s also research assistant professor at the Philadelphia College of Osteopathic Medicine and principal and founder of IntraCell Research Group. As a former life sciences professional with Pfizer and Genentech, she’s now working to unite global researchers studying infection-associated chronic illnesses. Joe 18:06-18:09 After the break, we’ll learn more about C. pneumoniae. Terry 18:10-18:11 How did Nikki recover? Joe 18:11-18:16 Some doctors are quite wary about sustained antibiotic treatment. Why did they object? Terry 18:17-18:19 How long did she have to take the medicine? Joe 18:19-18:28 We’ll also talk about silos in medicine. How could we break them down so doctors could treat the root causes of illness? Terry 18:39-18:54 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Welcome back to The People’s Pharmacy. I’m Terry Graedon. Joe 18:54-19:11 And I’m Joe Graedon. Terry 19:11-19:28 Many healthcare professionals have been taught that antibiotics can kill off most pathogens, such as Borrelia burgdorferi, within several days. That’s the bacterium that causes Lyme disease. For many patients, two or three weeks of doxycycline solves the problem. Joe 19:28-19:44 But there’s growing evidence that 10 to 20% of people who catch this bacterial infection experience post-treatment Lyme disease syndrome. Could this kind of infection connection also be responsible for many other health problems? Terry 19:45-19:59 The infection connection should not be a big surprise. People who catch chickenpox as children are susceptible to shingles many decades later. The virus hibernates in the body until conditions allow it to cause trouble again. Joe 19:59-20:26 Our guest is Nikki Shultek. She’s founding director of the Pathobiome Research Center and research assistant professor at Philadelphia College of Osteopathic Medicine. Nikki is also principal and founder of the IntraCell Research Group and executive director and co-founder of the Alzheimer’s Pathobiome Initiative. She has just described her personal experience with infection-related chronic illness. Terry 20:27-20:52 Nikki, that sounds like a really amazing and frightening situation that you were in. And now, as you have found out that Chlamydia pneumoniae is very common, what else did you learn about it? And how did you recover? Because it looks to us as though you’re doing much better today. Nikki Shultek 20:53-22:06 I am. So to fast forward a bit, Dr. Stratton, Charles Stratton from Vanderbilt, ended up diagnosing me officially with Chlamydia pneumoniae infection. I did have it. I also had Lyme disease and various co-infections that I acquired living in Connecticut. So I believe it was a multi-hit for me, quite honestly, Terry. It was a tipping point. I’d likely had the Chlamydia and Mycoplasma pneumoniae infections my whole life, having childhood asthma and a lot of illness, a lot of strep infections. And then, you know, multiple antibiotic therapy placed me in remission. And at the time, I was a little uncomfortable with the idea of using multiple antibiotics for a prolonged period of time. However, Dr. Stratton, being an unbelievable educator, provided me with evidence to suggest that in certain severe cases, particularly when neurodegeneration was at hand, and that was the symptomatology that I was really most worried about, that it could be warranted when the risk of the disease outweighs the risk of the treatment. And so I’m very lucky to be here and be well and have found an answer to it. Although I will say I’m not as well as I was before all of this happened to me. I have to take quite good care of myself. Joe 22:06-22:23 The idea of sustained antibiotic treatment is a little challenging for most physicians, including some of the infectious disease experts, because it’s like, well, 10 days, one and done, you know, you should be fine. And you weren’t fine. Terry 22:23-22:37 Well, and of course, they worry about antibiotic stewardship and what will we do when, not if, but when all of the antibiotics we currently have available lose their effectiveness. Joe 22:37-22:47 So how long did you have to take, for example, azithromycin, Z-Pak, and some of the other antibiotics to finally rid yourself of these pathogens? Nikki Shultek 22:49-25:12 You know, my answer will not be appealing to some. I’m not really of the belief based on the literature and our research that you can actually get rid of some of the infections once they have been on board. So people are very familiar with the use of long-term antibiotics and physicians are comfortable with it in certain settings. And it’s a bit nonsensical. If you ask me as a patient, you can have prolonged doxycycline or minocycline for acne, many years of therapy. For chronic urinary tract infections that are recurrent, patients will be placed on antibiotics in perpetuity at times. They’re used for chronic obstructive pulmonary disease, which can be very serious. They are used for asthma. We have a 3,200 patient clinical trial enrolling. One of the study sites is Chapel Hill as we speak. That’s called I Treat PC. But then for people suffering with neurodegenerative symptoms and crippling bladder pain and, you know, that it could be considered potentially controversial, and that comes to a bigger problem. And Terry, you mentioned stewardship. So I had the privilege at Pfizer to work in the antibiotic space. I launched a drug for MRSA infections, which is that drug-resistant staph. And I used to attend ID grad rounds, which is the infectious disease specialists, you know, Uber meeting where they talk about tough cases and learning. And I loved it. I was very disturbed by the idea of taking prolonged antibiotics when it was suggested to me by Dr. Stratton. And he knew my background and he was an infectious disease specialist and a medical microbiologist. But you have to actually, when you talk about stewardship, you have to stay in reality. 80% of antibiotics in the United States are used in agriculture. Okay. So the animals. Absolutely. So you should not prescribe antibiotics to people that have upper respiratory tract infections that are viral, right? That’s the low-hanging fruit for stewardship. And it’s not to say that it’s not important, but I do believe the emphasis on stewardship has led to under-treatment of certain very detrimental infections, including the bacteria that causes Lyme disease, Borrelia burgdorferi. And it’s an economic problem. Antibiotics are not profitable. And so this has been a really, you know, where understanding the business side of things is critical for me in my current work, you know, building research collaborations to unravel how infections can drive chronic diseases with emphasis on the brain is understanding the economics that are at play and the politics. Joe 25:12-25:19 And sometimes you have to take these antibiotics, not for weeks, but for months, and in some cases for years. Nikki Shultek 25:19-26:19 Yeah. So for me, just to answer your earlier question, for a number of years, I had multiple antibiotics. My case has been constantly evolving like many patients like me. Because of my enrollment in a IRB study at North Carolina State, I learned I have chronic babesiosis, which is a chronic parasitic infection that is transmitted by the same tick that I likely got Borrelia burgdorferi, Lyme disease bacteria from. This little sneaky parasite likes to hang out inside your red blood cells. And it is the likely culprit of my air hunger 11 years ago. That was a symptom that never made sense indeed, because asthma doesn’t normally, my asthma, the etiology of it, it had never had air hunger. And I remember saying to my doctor, something is different here. And that is the thing that I’ll, I like to impress upon people listening that could have illnesses. You as the patient have an intuition and a level of intimacy with what your body is experiencing. And you need to find a clinician that listens and hears you and sees you. Terry 26:19-26:28 So you have the experience of what your body has done before, and you need to pay attention when it does something different. Nikki Shultek 26:28-26:59 Absolutely, you do. And for me, unfortunately, I have previously relapsed any time antimicrobial drugs have been removed. So I have a maintenance therapy plan with my doctor, and I’m very fortunate that I actually have because Dr. Charles Stratton passed away four years ago. I’m under the care of a ILADS physician, International Lyme and Associated Diseases, which is the only infection-associated chronic illness practitioner group in the world. Joe 26:59-27:39 One of the problems that we’ve encountered over many decades of interviewing a variety of patients and physicians is the silo problem. So there are specialists, super specialists. And the cardiologists may not be talking to the infectious disease experts. And the dentists may not be talking to the cardiologists. And so you have all of these different specialties and the dentists are saying, well, yes, you do have gum disease, but they’re not talking to the cardiologist to say, well, if there’s a gum infection, that may be affecting the heart valves and that may be affecting the vessels in the heart. Terry 27:39-27:46 And of course, we know, but cardiologists don’t always remember that Lyme disease can affect the heart as well. Nikki Shultek 27:47-30:55 Absolutely. Joe and Terry, such an astute observation. And literally what you just said encapsulates my observation as a patient, a human hockey puck, as I call it, going through the medical system, being passed from one specialist to the next to address these different bodily systems that were all not working properly, you know, including my food stopped digesting properly during this horrible year. So now I’m having a colonoscopy. No one was talking to each other. And I remember thinking, who’s going to piece it all together? There’s an underlying driver. And so when I found the information about chronic infection and illness, it made so much sense. And then, you know, talking with Dr. Stratton, Dr. Hahn, and beginning to informally, in a grassroots manner, start bringing people together, I had this thought. It wasn’t a new thought for me. I had always been a collaborative person. And in my time in pharma and biotech, I was working in this manner, too, trying to connect stakeholders so that we could advance outcomes for patients. Well, what I decided I could do to help when I went into remission on the multiple antibiotics, I knew I needed to help, right? This is a huge problem. I wondered how many MS cases were indeed infections that were undiagnosed. So I knew we needed to advance research around it and raise awareness. And I thought the best thing I could start doing was introducing these folks to one another if they didn’t already meet. So the infection and asthma people with the infection, looking at bladder pain disorders, looking at neurological disorders, looking at musculoskeletal or, you know, joint disorders. Let’s start there. And I like to joke that we arrived to the space on the chlamydia train, this bacterial infection. Most of the people in the initial group, which was started in 2017, IntraCell Research Group, by me. And, you know, it was really to begin introducing folks to one another. I didn’t know what it would turn into, quite honestly. I’d been a stay-at-home mom for eight years. And, you know, I’d been extremely ill. And the idea of research collaboration was born, multidisciplinary research collaboration. Fast forwarding to today, in 2023, I had the privilege with a number of amazing colleagues from around the world, incredibly diverse in experience in all ways, the Alzheimer’s Pathobiome Initiative. And I guess I’ll start by saying, what is a pathobiome? So people know microbiome. And I think the word microbiome gives off kind of like a fuzzy, warm vibe of like everyone collaborating with one another, kind of like my team, you know, commingling happily. The pathobiome is your unhappy state. It refers to potentially, you know, different infections or organisms that might be in your body that now for one reason or the other are having a bad reaction with your immune system. They’re making your immune system angry. And so the pathobiome, I sometimes refer to these as the organized criminals. You know, they’re infections that become disproportionate and can cause inflammation and other consequences. So this idea of a pathobiome takes into account each unique response that a person’s immune system can have to an infection. And we saw this with COVID. Some people got little to no symptoms, tested positive. Other people died. Terry 30:55-30:55 Yes. Nikki Shultek 30:55-30:57 Some people remain ill today. Terry 30:57-30:58 Yes. Nikki Shultek 30:57-31:48 It’s the number one pediatric illness. It surpassed asthma as the number one chronic illness in kids is long COVID. So this research consortium of ours is comprised of, we have Dr. Ed Breitschwerdt, who’s a doctor of veterinary medicine. We have microbiologists, people focused on fungi, like Dr. David Corey, who’s also an immunologist. We have folks like Dr. Brian Balin, focused on intracellular bacteria, virologists like Kevin Zwezdaryk, neuroscientists like Dr. William Eimer, respiratory infection experts like Dr. David Hahn. And our team has more than 30 people globally collaborating actively with one another in order to essentially accelerate innovation and raise awareness, but also to bridge silos. Terry 31:49-32:05 Nikki, you have mentioned that you have this international collaboration. You’re looking at conditions that may be caused by the pathobiome. And I’m wondering if you could outline for us a few of those potential conditions. Joe 32:05-32:08 And in particular, perhaps Alzheimer’s disease. Nikki Shultek 32:09-34:24 Absolutely. So our Alzheimer’s Pathobiome Initiative team is actually working quite broadly in brain disease and infection. So over the holidays, we received a grant to study actually five brain diseases in relation to infection. ALS, Alzheimer’s, Parkinson’s, epilepsy, and conditions that affect children called PANS and PANDAS. These are pediatric neuroimmune infectious syndromes that can lead to perfectly healthy children having literally crippling anxiety, OCD, and some of these children die. So we take this incredibly seriously. Some of the infections that have been associated with Alzheimer’s disease and other diseases, and this is an important distinction. We believe it’s so important to look at the whole human lifespan, at the diseases that are occurring that are associated with infections. That’s everything from MS to schizophrenia, you know, two diseases typically associated with advanced age. And it’s literally pathogens from every category. Parasitic infections like Toxoplasma gondii have been linked with schizophrenia, have also been linked with Alzheimer’s disease. It’s organisms like herpes viruses, HSV-1 and HSV-2, the cold sore virus, that has been linked very strongly with Alzheimer’s disease and other chronic neurological and chronic illnesses. Chlamydia pneumoniae, of course, is strongly associated with Alzheimer’s disease, but also asthma, atherosclerosis, multiple sclerosis, reactive arthritis. There are also fungi that have been associated. Indeed, when we published our research roadmap for the AlzPi team, the Alzheimer’s Pathobiome Initiative in 2023, we identified 86 cases of infectious dementias of all different types in which some of these were reversible with antimicrobial therapy. One of them was a stunning case of a person with a healthy immune system. They did not have HIV that got a rare fungal infection called Cryptococcus neoformans, and this person ended up getting antifungals and getting better. Their neurodegenerative symptoms went away. Terry 34:24-34:51 Nikki, I’m so excited that you have taken your vast and deeply unpleasant and frightening experience, and turned into a researcher. So you are a patient. You are leading a research collaboration. Tell us more about patient-led research because I think it’s not widely appreciated that patients can do this. Nikki Shultek 34:51-36:25 Absolutely. I have had such a privilege to learn over the last decade and to try to turn, you know, pain into purpose, truly. And I’m not alone by any stretch of the imagination. There are quite a few people out there like me that have not only had these journeys, but then become subject matter experts in a domain, can even be rare disease. You see this quite a lot. You see parents like me, you know, looking for a better future for their children. And thus, what is the greatest motivator? I think it’s love. And so out of love, I think patients can become an unbelievable tool to researchers and become researchers themselves, which is the case for me. I was very privileged that our president, Dr. Jay Feldstein at PCOM and Dr. Brian Balin, with whom I’ve collaborated for nearly a decade, saw the value in, you know, me becoming a, you know, bona fide member of the research team. I’m publishing in the space with the researchers. I’m creating, you know, and generating hypotheses, serving as a principal investigator on NIH submissions. It is the gift and blessing of a lifetime. And I think that, you know, more purposeful integration and patients having a seat at the table, knowledgeable patients. There’s a book that I read called Range by David Epstein that I’m absolutely obsessed with, and it talks about remaining a generalist and how patients, actually, there are chapters of the book, whole chapters, about how patients and their experiences led to transformative change in particular disease domains. Joe 36:28-36:50 Nikki, there’s a term that is used throughout medicine that ends in “-itis.” And “itis” means inflammation. And so we’ve got arthritis, bronchitis, colitis, sinusitis, dermatitis, gastritis, myocarditis, which is the heart, and cystitis. Terry 36:50-36:52 And lots of other “itises” as well. Joe 36:53-37:15 You know, the pharmaceutical industry, of which you once were a part, has become extraordinarily successful at dealing with “itis” conditions. Not the root cause, mind you, but the inflammatory reactions. So there are IL-2s and IL-4s and IL… Terry 37:15-37:17 What does IL mean, Joe? Joe 37:17-38:10 Interleukins. These are anti-inflammatory drugs and they’re impacting the immune system, which is why when you look at the commercials on TV for the rheumatoid arthritis drugs and the inflammatory bowel drugs and, you know, name it. The psoriatic arthritis drugs, they all say, well, yes, you could catch a bad infection, and that infection could be very dangerous, oh, and possibly cancer. And you’re talking about attacking the problem downstream, at its earliest phase rather than at its ultimate phase when people are already in terrible shape and in pain and inflamed. Can you help us better understand what you’re trying to accomplish by ‘the root cause’ and dealing with that, rather than the end result? Nikki Shultek 38:11-38:42 So what you said is so astute about the commercials on television, you know, with the various drugs. My children who, of course, you know, get to talk with me about various topics all the time in science. They both enjoy science and they drive me. You know, it’s my boys that really push me forward to help, you know, motivate me on a daily basis to make the world better. They’re 14 and 16. They’ll go, “Mom, didn’t you say that some of these conditions can be triggered by infections? And the commercial says if you have an ongoing infection, not to take the drug. Isn’t that….?” So it’s so funny. Terry 38:42-38:44 How smart of them. Nikki Shultek 38:46-40:23 Another favorite question of my son, “Mom, if there’s a vaccine for human papillomavirus that can prevent cancer, wouldn’t we look at other viruses and other bacteria and cancer?” This was when he was 12. I was like, yes, and please do that for the rest of your life. Ask those questions. So, you know, what’s really interesting is what we talk about isn’t just limited to infection, right? There are other potential root cause drivers. We talk a lot about the exposome, which is your exposures across the human lifespan, not just germs, but pollutants, toxins, your diet, etc. We think these things are all important root causes to look at, inclusive of infection. But infection is, just so you know, the number one driver of any “itis” in the human body. And that is not me saying that. That’s in medical text sort of 101. If you look up inflammation in the National Library of Medicine on NCBI, you will see that the number one thing should be ruled out as an infection with any “itis.” We believe, though, here’s an interesting caveat. So with diseases which have been accumulated over a lifetime, right, like Alzheimer’s disease, multiple hits potentially with different pathogens, different infections that come and go, relapses, we may indeed need some of those other drugs that were developed targeting various pathways as a multifaceted approach, because it’s not to say that the immune reaction isn’t harmful. It can be. And that’s the caveat and the reason we believe it’s so important to have the immunology perspective and the diversity of these silos bridged while understanding infections because it may need to be a multifaceted approach like the way that we approach sepsis. Terry 40:24-40:51 And as you’re talking, I’m thinking about the early part of your story in which you’re describing that you are having such difficulty breathing and they kept increasing the dose of prednisone that you were on. And I’m thinking prednisone. Prednisone interferes with the body’s ability to respond to pathogens. So counterproductive, no? Nikki Shultek 40:51-41:23 Absolutely. In my case, it absolutely was that time. And again, I don’t fault the clinicians. Actually, you have to fault the whole system, right? So in Connecticut, the state where Lyme, the town of Lyme is literally situated, you know, if you ask the majority of clinicians, what would you think if you saw someone with air hunger that had prior asthma, but they’re telling you it’s different and one swollen joint? They should be thinking tick-borne illness. They should know that babesiosis has a hallmark symptom of air hunger. Terry 41:23-41:26 And Borrelia, perhaps, or just babesiosis. Nikki Shultek 41:27-41:51 Really it’s clinically significant for Babesia. And the most common one is Babesia microti. And that is what I have confirmed by North Carolina State, direct detection, so not antibody-based testing. So, you know, this is what’s key really is the education, but it’s across the whole spectrum. It’s patient awareness, it’s clinicians being educated in medical school. So there needs to really be a sea change. Joe 41:52-42:34 So I do have a pet peeve, and that is the infectious disease experts should be embracing your research, should be really excited about the idea that infectious agents could be responsible for a great many chronic conditions. And yet, a lot of the infectious disease experts seem to be obstructionists. Like, oh, no, there’s no such thing as long Lyme. And no, this thing about chronic fatigue syndrome, it’s all in your head. Terry 42:34-42:45 And ILADS physicians, you’ve got to be very careful about them, right? That’s what some of the infectious disease experts have been telling us. They may be changing their tune now. Joe 42:45-42:53 But how do you convert the ID, the infectious disease experts, from skeptics to allies? Nikki Shultek 42:54-44:59 It’s such a great question. So if you look at medical history, it just sort of repeats itself. This is human nature 101. When doctors Warren and Marshall, you know, they eventually win the Nobel Prize for linking a bacteria in the gut called Helicobacter pylori or H. pylori to the development of ulcers; for like a decade prior, they were called madmen. And these are by the thought leaders in the GI space. So thought leaders, human nature is, you know, to attach ourselves to something. If we have a hammer, we want to see nails. And we have to become super aware of this. We try to be aware of this all the time as a research team, not to drink so much of our own Kool-Aid that we don’t see other ideas as being important. The infectious disease, you know, sort of gaslighting of the chronic Lyme issue, I believe is about to change. You know, we have the current administration, HHS, Secretary Kennedy, Dr. Jay Bhattacharya, Marty Makary, and Dr. Oz all saying, you know, they’re emphasizing Lyme. So there are some very exciting developments happening. That was beginning December 15th, 2025. And I do believe that there has to be adequate patient pressure and advocacy, very much like how HIV is now something that one can even prevent getting, right? There’s a preventative. You can have HIV. There has been such a huge federal investment due to a patient-led movement, right? Now, HIV hurts people fast and really it’s very virulent and very quick if unopposed. And so it was so blatant, right? But even if you read back on the history of that, that required quite a movement from patients. Lyme and these infection-associated chronic illnesses are more like the simmering pot not boiling over. You know, it’s a chronic inflammatory process. It makes the person miserable, may rob them of quality of life, but they may not imminently die from it. And thus, it sort of has been underemphasized. But I do believe it’s changing. Joe 45:00-45:44 I do have a particular question about cardiology, because if you were to poll 100 cardiologists, 99 out of 100, maybe 100 out of 100 will tell you heart disease is caused by cholesterol, in particular, LDL cholesterol. And if you ask them, well, what about LP little a? They’ll go, oh, yeah, yeah, that’s coming along, and we’re getting a drug for that. And so, yes, we’re paying more attention because one out of five patients, they do have elevated LP little a, lipoprotein A. And then if you ask the question, what about gum disease? What about those bacteria that cause… Terry 45:45-45:46 Periodontal disease? Joe 45:46-45:48 Yes. What about those bacteria that cause… Terry 45:48-45:50 Porphyromonas gingivalis? Joe 45:51-45:51 That cause, yes. Nikki Shultek 45:52-45:52 Gingivitis. Joe 45:52-45:53 Gingivitis. Terry 45:53-45:53 Yeah. Joe 45:54-46:00 They look at you like you’re from Mars. Like, well, yeah, well, that’s not that important. Terry 46:01-46:04 But actually, the research establishes a pretty strong connection. Joe 46:05-46:06 So this idea… Nikki Shultek 46:05-46:06 Very compelling. Joe 46:06-46:20 …that infection could be connected to cardiovascular disease, it seems alien to the cardiology community and to the infectious disease community. How do we begin to change that? Nikki Shultek 46:21-47:15 We’re, I believe, and I am an eternal optimist, so take this with a grain of salt, we’re at a tipping point right now in history. There are so many favorable things happening in this space all at once, not just our work, but others. For example, a $49 million National Institute of Aging grant just went to a company developing a therapy targeting Porphyromonas gingivalis and targeting gingipains, which is the virulence factor that is believed to assault the brain. Now, you mentioned gum disease. That bacteria, Porphyromonas, actually can affect how your blood-brain barrier that’s supposed to provide protection, it impacts it negatively. It also has been linked with, as you pointed out, other conditions. And so the federal investment for this, I think, is a big signal that this particular company, Lighthouse Therapeutics, has that support is evidence of a shift. Terry 47:16-47:38 So the blood-brain barrier is supposed to keep stuff that doesn’t belong in the brain out of the brain. And you’re saying the impact of Porphyromonas gingivalis is to essentially make it more permeable, sort of like some infections make the intestines more permeable, and you get intestinal permeability, also known as leaky gut. Nikki Shultek 47:39-48:30 Indeed, yeah. Permeability of barriers is a big issue. One of the things that we’re studying within AlzPi and we have grants to look at is why are women two-thirds of Alzheimer’s cases? And we know that estrogen actually helps the immune system and that as women age, we lose estrogen and barriers of different types become less sufficient. We have not enough information on what happens to the blood-brain barrier. But I want to add the caveat is this. I heard at the National Academies when I presented, one of the other speakers referred to it as a portal. Indeed it is. It’s not really a barrier as much as it is a passageway that should be selective. Now our immune cells can traffic in and out through the blood-brain barrier. And if you have an infection like a virus or a Chlamydia pneumoniae or a Borrelia burgdorferi or Bartonella henselae inside your immune cell, it’s like a Trojan horse. Terry 48:30-48:32 Right. It would be exactly. Joe 48:33-48:49 So Nikki, as we wrap up our conversation, what would you like our listeners to take home as the message when we start speaking about the infection connection with all of these conditions and all of these nasty pathogens? Nikki Shultek 48:50-50:03 You know, just to read and educate yourself as much as you can. I realize that having certain educational level is a great privilege. Our team tries to write op-ed pieces, not just medical literature. You know, it’s a passion of mine so that it increases the accessibility of information. Always trust your gut. If you don’t feel heard by a physician, find another physician. You are, indeed, your instincts are, they can be very correct. And that if you need help with something that you think could be an infection-associated chronic illness, there are ILADS physicians, www.ilads.org. There’s a provider search with the caveat, many of these physicians do not accept insurance. That is a challenge. That’s one thing that I really hope that Health and Human Services and RFK Jr. can help impact changes is how the payers, you know, reimburse for complex chronic illness triggered by infection so that other physicians can do what the ILADS doctors do and get training like the ILADS doctors have provided. And so really look for and consider root causes. Joe 50:03-50:15 And if we put you in charge of medical education today, what would you like to tell all of the physicians and nurse practitioners and physician associates who may be listening, what should they be learning? Nikki Shultek 50:16-51:31 I think they should have infection-associated chronic illness in the differential. When they are presented with a patient that has multiple idiopathic disorders particularly, and if they’re waxing and waning, not to immediately go to a purely psychiatric diagnosis. Although I would argue that the field of psychiatry is riddled with evidence that infections can indeed impact our behaviors, such as the development of OCD from Streptococcus infection in kids with PANDAS. Overnight, suddenly, you have a kid that’s counting. So I think looking for infections, but then that gets to another caveat, which is what tests you order. So we do need better testing for some of these infections, but serology or, you know, looking simply for antibodies, antibody-based testing for herpes viruses, for Mycoplasma pneumoniae, Chlamydia pneumoniae, a tick-borne panel, which is offered by Quest or LabCorp, it’s a place to start. There are better labs, one right here in North Carolina, Galaxy Diagnostics, offering, you know, world-leading tick-borne infection testing. However, you know, it’s outside the bounds of insurance is a challenge. IGeneX, too, out in California. But, you know, again, these are barriers for patients where they won’t be able to access it, and that’s not okay. Joe 51:33-52:00 As you begin to look to the future, because you’ve described a whole bunch of conditions where there are specialists in each area in their silos, not talking to one another very effectively. What would you like to see for the future? What is your hope for your initiative, in particular around Alzheimer’s disease, but some of these other conditions as well? What does the crystal ball tell you? Nikki Shultek 52:00-52:42 We really need a large federal investment from the National Institutes of Health. I don’t know that all Americans realize, but the most powerful engine for medical innovation in the entire world is our National Institutes of Health, our government. You know, the emphasis has to be on funding this type of work. And we call that team science, and so does the NIH. There are certain mechanisms, you know, that allow research teams like ours that are incredibly diverse. And just to let everyone know, I did found a center at the Philadelphia College of Osteopathic Medicine a year ago. It’s called the Pathobiome Research Center. We essentially need more philanthropists and the government to step up to fund work that allows teams like ours to unlock root causes of these diseases. Joe 52:43-52:47 Why is the root cause so important in the 15 seconds we have left? Nikki Shultek 52:48-53:11 It is that we stop focusing on the downstream effects. You know, a lot of drugs that you see today predominantly are targeting various pathways to intercept downstream effects that are largely inflammatory or pathology. You know, like let’s target the plaque in Alzheimer’s. Targeting the root cause allows us to understand why the human immune system developed that response in the first place and allows us to intercept. Terry 53:13-53:17 Nikki Shultek, thank you so much for talking with us on The People’s Pharmacy today. Nikki Shultek 53:18-53:22 It has been an absolute pleasure. Thank you for helping us shed light on these issues. Terry 53:23-54:02 You’ve been listening to Nikki Shultek, founding director of the Pathobiome Research Center and executive director and co-founder of the Alzheimer’s Pathobiome Initiative. She’s also a research assistant professor at the Philadelphia College of Osteopathic Medicine and principal and founder of Intracell Research Group, LLC. She was previously a life sciences professional with Pfizer and with Genentech. Now she’s working to unite global researchers studying infection-associated chronic illnesses, including Alzheimer’s disease. Joe 54:03-54:10 After the break, we’ll turn to Dr. Brian Balin, an internationally recognized researcher on Alzheimer’s disease. Terry 54:10-54:23 We’ll find out how he took a different path from most Alzheimer’s disease scientists to focus on the infection connection rather than considering amyloid accumulation as the prime mover. Joe 54:23-54:32 C. pneumoniae is bad for the brain, but it might not be the only pathogen with long-term impacts. What else has Dr. Balin studied? Terry 54:32-54:38 Might there be bacterial origins for many chronic diseases? Could this change our treatments for heart disease and stroke? Joe 54:39-54:42 Find out more about the pathobiome and the infection connection. Terry 54:48-55:04 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Welcome back to The People’s Pharmacy. I’m Terry Graedon. Joe 55:04-55:20 And I’m Joe Graedon. Terry 55:21-55:42 Can hidden infections lead to chronic disease? A few examples are quite well known. For example, the bacterium Helicobacter pylori causes stomach ulcers that in turn can lead to gastric cancer. And gum disease caused by Porphyromonas gingivalis has been linked to heart disease and even Alzheimer disease. Joe 55:42-56:09 We just spoke with Nikki Shultek about her experience and her work on hidden infection and chronic disease. We turn now to her colleague, Dr. Brian Balin, professor of neuroscience and neuropathology at the Philadelphia College of Osteopathic Medicine. He directs the Adolf and Rose Levis Foundation Laboratory for Alzheimer’s Disease Research and the Center for Chronic Disorders of Aging. Terry 56:10-56:13 Welcome to The People’s Pharmacy, Dr. Brian Balin. Dr. Brian Balin 56:14-56:16 Thank you very much for having me talk today. Joe 56:18-56:56 We look forward to speaking with you. We have just spoken with Nikki Shultek about her experience. It was quite enlightening. But I’m wondering if you can put everything into perspective because for decades now, neuroscientists such as yourself and researchers within the pharmaceutical industry have focused on what I call the amyloid garbage disposal approach when it comes to Alzheimer’s disease. And you’re moving towards the infection connection approach. Can you put us in perspective of what has changed? Dr. Brian Balin 56:56-01:00:04 Yes. So years ago, we, through a lot of serendipity, came across an issue about [an] infectious agent. The one in particular that I’ve been studying is a respiratory Chlamydia organism called Chlamydia pneumoniae. And we found that this organism was in brain tissues that were examined postmortemly from Alzheimer’s individuals, or people that died from Alzheimer’s disease. And we felt that there was some issue here with this particular infectious agent being in the brain tissues of these individuals. And over time, what we’ve realized is that this type of infectious agent can actually enter into brain tissues through our sense of smell, but also through the blood-brain barrier. And we think that it actually acts as a trigger for the early pathology that occurs in Alzheimer’s disease. And the early pathology that shows up is in the area of the brain called the entorhinal cortex, where you have direct input from the olfactory system, which basically is coming from our… originating in our noses through our olfactory nasal epithelium, olfactory neuroepithelium. And because of that issue, we think that infectious agents actually can be the triggering type of process or lead to a triggering type of process that can actually lead to early change in the brain. And in this case, leading to the pathology, the early pathology of Alzheimer’s disease. Now, this is in contrast to others that have studied the amyloid hypothesis for years, the amyloid cascade hypothesis. And that all originated from evaluation of genetic Alzheimer’s disease or familial Alzheimer’s disease, which is about one to three percent of all the people that get Alzheimer’s disease having that form. And that originated from looking at those individuals and determining that there were genetic mutations that led to the deposition overall of the amyloid peptides that accumulate in Alzheimer’s disease very early on. Well, in our work, we also see those same amyloid peptides accumulating early on in brain tissues. And we’ve also seen that infection can actually turn on cells to process the larger amyloid precursor protein into these peptide forms. So now we have a contrast. One is a genetic process that leads to this pathology, and the other is an infectious process leading to pathology. And this is why we think this is an underrepresented arena of understanding how infectious agents, and there may be many, that actually can lead to the same type of disease entity. Terry 01:00:06-01:00:18 So you’re suggesting that this bacteria, Chlamydia pneumoniae, is not the only pathogen that might be affecting the brain? Dr. Brian Balin 01:00:18-01:01:45 That’s correct. So we think that of the work that’s been done over many, many years, there’s been evidence for the herpes simplex virus 1. There’s been evidence for Borrelia burgdorferi, the agent of Lyme disease. There’s evidence for SARS-CoV-2 to actually be involved as well. And then there are oral organisms. There could be systemic organisms. There could be gut organisms that could also be involved. But what’s interesting about what we found was that this type of organism, this Chlamydia pneumoniae, is an intracellular bacterium. So it’s going to act very similar to a virus, actually, where it infects inside of our cells. Once it’s infected inside of our cells, it’s hidden from the immune response, just like the herpes virus would be or other types of viruses. If these migrate into our brains, and also this would include also the SARS-CoV-2 virus, if these migrate in, they can then stimulate change in the cells within the brain proper. And this could be anywhere from changing the infected cell itself or getting response from the glial cells like the microglial cells that would lead then to an inflammatory response that would also then lead to more damage within the brain. Joe 01:01:46-01:02:26 Dr. Balin, you just said something that sends shivers up and down my spine, and that is SARS-CoV-2, i.e. COVID. I mean, tens of millions of people in this country and hundreds of millions of people all around the world have caught COVID. And the question that you’re sort of raising is, well, will some of them develop Alzheimer’s disease as a result of this, what we’ll call viral infection that has really affected the whole wide world? Dr. Brian Balin 01:02:27-01:04:00 Yes, this is one of our greatest fears is that this is opening the scenario that there could be millions on the globe that may be destined for this type of change. And it may be that it’s not just from the SARS-CoV-2 virus, but also from other agents like what we’ve also found that are acting in concert with one another. And then you have the inflammatory response itself. If it’s generated and it’s maintained in a chronic fashion, now we have a chronic, potentially smoldering type of process that is occurring quite readily, I think, could be occurring in our brains without us knowing it because we are not having obvious symptomatology. Now, with the SARS issue and COVID issue, brain fog, memory issues, long COVID, these are things that may be giving us a clue that something is more chronically developing, along with then these other insults that are potential in our environment. For instance, pollution, air pollution, particulate matter, the diets that we have, the genetic risks that we have. These may be acting in concert to now drive the process, unfortunately, into a neurodegenerative arena leading to a dementia. Terry 01:04:01-01:04:07 Dr. Balin, I wonder if you would tell us about your recent research collaboration with Cedars-Sinai, please. Dr. Brian Balin 01:04:09-01:06:22 Yes. So with the Cedars-Sinai’s work that was led by, or coming out of Tim Crother’s lab, we actually aren’t collaborating directly with them. However, our work really is compatible with what they’re finding with the Chlamydia pneumoniae organism in the retina. So this organism, this goes to the organism’s ability, we believe, to actually become systemic as well. Once it’s inhaled into the lungs, this organism can be picked up by white blood cells that are surveilling all the vasculature in the lung tissues. And if it’s picked up this way, now you can traffic the organism within the white blood cell because the white blood cells will phagocytize the organism inside and traffic it around the bloodstream. So we think that that’s one of the ways that it’ll get into the vessels throughout the body and can also show up in the retina. The other aspect of this is that in atherosclerosis, in cardiovascular disease, the Chlamydia pneumoniae organism has been recognized and involved and sought to be involved with aspects of that disease leading to the atherosclerotic process. So we know that this organism is one of those insidious types of organisms that can traffic around the body and use multiple mechanisms for actually getting into tissue sites. So the Crother work is very significant and really follows from a lot of the early work we did where we found that the organism in human tissues, now we didn’t identify it in retina per se, but we found it in the olfactory regions of the brain, of human brains, and deeper in the brains themselves in Alzheimer’s disease. But we also did animal modeling. And with animal modeling, we showed that the infection with this organism intra-nasally can get into the brain very quickly, but also they can get into the bloodstream fairly quickly. Joe 01:06:22-01:07:15 Well, Dr. Balin, I’d like to just ask you the implications of this research, because it sounds like, well, if this nasty pathogen, C. pneumoniae, is getting into the brain, but also circulating through the body and maybe getting into the heart, there may be a bacterial origin for a lot of our chronic diseases. I think most cardiologists blame you know, LDL cholesterol, but maybe there’s a bacterium that is also contributing to atherosclerosis and maybe to strokes. How do we begin to change our mindset to recognize that chronic infection may be contributing to a lot of our ailments? Dr. Brian Balin 01:07:15-01:08:53 Well, it’s an excellent question. And I think what we need to do is to start having a better diagnostic approach to this question. And this would be something that we need to actually start instituting into the population at a much earlier age before any symptomatology actually starts to accumulate or starts to manifest. And this goes to the sampling issue. So how do we sample for these types of agents? The typical sampling approach would be to look for a presence of antibody responses in the bloodstream to these different types of agents to see if we’ve been exposed that way, to see if antibodies have been developed to the organism. But we should be also sampling saliva and urine along with blood and maybe even doing nasal swabbing as well for some of these organisms too, as these are routes of entry into our bodies. The other could be even stool sampling, for instance, and for instance, with the COVID issue, we found that the SARS virus, SARS-CoV-2, was showing up in wastewater. And these are ways then that we could actually evaluate different types of fluids from an individual to actually evaluate what is on board in a particular individual and whether those ingredients that are on board have been identified with other chronic issues that have shown up in the population. Joe 01:08:53-01:09:05 So really quickly focusing on the outcome, it sounds like if we can identify these pathogens, we might be able to come up with treatments such as antibiotics. Dr. Brian Balin 01:09:05-01:10:25 Yes. And the antibiotic approach would be probably the original approach to be taken. I actually think, though, that we may be able to also manipulate our immune responses. Now, could that be through vaccines? It could be that as well. It could also be through phage therapy, for instance, for some of the bacteria, where phage therapy, different types of bacterial phages or viruses that infect bacteria actually can be and are being designed, by the way, to actually change how an infectious agent could actually propagate in us so that it could be a phage that’s developed to kill off a particular type of bacterial strain. There are many different ways of approaching this problem. Also, there’s novel ways of looking at the components of how bacterium and virus and fungi and parasites, how they infect our cells or our bodies, cavities or tissue sites, and blocking those capabilities through either potentially using antibody blocking to using protein-protein interaction types of blocking. So these methodologies are being developed now beyond even the antibiotic approach. Joe 01:10:26-01:10:39 Dr. Balin, I wonder if you could give us the historical perspective on Schopenhauer’s three stages of truth and why that might be relevant to Alzheimer’s research. Dr. Brian Balin 01:10:40-01:13:56 Oh, OK. Wonderful. Well, the three stages of truth: First, the work being ridiculed, and then violently opposed, and then being self-evident. Well, historically, we’ve actually seen this in the medical arena. And if we take the example of Warren and Marshall actually proposing that Helicobacter pylori, a bacterium, could live in the stomachs of individuals and cause severe disease such as ulcers, MALT lymphoma, gastric carcinoma, and actually being criticized when they came out with those types of findings, criticized to the point that they were vilified. The gastroenterology world thought these people were absolutely crazy. Well, they’re not crazy, okay? It’s been shown that you have an organism that can live in the mucosal layer of the stomach and in the lining and can lead to all these severe diseases. And yet it took about 100 years for that to be accepted. Now, if we look historically here with Alzheimer’s disease, even in the day of Alzheimer and Oscar Fisher, they were considering that infectious agents could be involved with what they were seeing in human brain tissues at autopsy. And yet we’ve gone now over 100 years later, and many of us have been studying this for decades in the more modern age. And yet we still don’t have great acceptance that this is even a possibility. So originally, there’s been ridicule. And then, you know, there’s been opposition because of ignoring what we’ve been doing over time and what others have been doing. And there are a lot of people doing this work, by the way, not just coming from my laboratory or in collaboration with Nikki with the Pathobiome Research Center or the Alzheimer’s Pathobiome Initiative, etc. There are a lot of people that are working on this issue. And now we’re forcing the issue here that we have to accept that there is involvement. Now, understanding the involvement as far as causation goes is the key. And now we’re trying to come up with consensus approaches of how you detect, of how you actually even approach the experimental designs to actually prove causation. The problem we’re faced with is you have chronic diseases and you have chronic infections and you have a combination effect here happening with genetics and the exposome or what we’re exposed to with the environment. So it’s not an easy process. But not to accept that we have infectious components is just keeping one’s head in the sand, I believe. So with Schopenhauer, I think we’re getting close to this, what’s becoming more self-evident. Joe 01:13:58-01:14:39 Dr. Balin, one would think that the infectious disease community would be so excited about your research. And in fact, the idea that infectious agents might be at the causative stage of a lot of our chronic conditions, you know, anything with an itis at the end of it suggests inflammation, whether it’s arthritis or cystitis or bronchitis, fill in the blank “itis.” And so I keep wondering, why has the infectious disease community seemingly been pushing back rather than embracing this approach? Dr. Brian Balin 01:14:40-01:17:21 I believe that one part of this is that with the infectious disease community, the traditional way of thinking about, for instance, a brain infection is that you would have a meningitis, an encephalitis, a meningoencephalitis, or an abscess that would be now forming from some type of infection in the brain. What is not well accepted, I think, but should be, is that we have chronic infectious agents that can act in a very subliminal and very insidious manner to infect anywhere in our bodies, first of all. In the brain, we already know that there are a lot of organisms that can be harbored there, and you can get disease, and at times you don’t have disease. A perfect example is progressive multifocal leukoencephalopathy, PML, which can arise after treatment, for instance, for multiple sclerosis. Well, this is a very severe disease. It is caused by a virus, ’cause the John Cunningham virus, which many of us actually harbor and probably the majority of the population harbors in their brains, but does not actually suffer from disease from that organism. There are other organisms. The poliovirus, it’s an enterovirus, can be harbored in the brain and can lead to a post-polio syndrome, but it can also be harbored in the brain and you don’t have obvious deficit. The herpes simplex virus can be the same way. So we know that there are a number of different agents that can be harbored in brain tissues without obvious disease. However, we also think that they can be activated to be involved with disease. The degree to which this is happening in our nervous system is something still in the discovery process. And that’s why the consideration of a pathobiome and even at times a microbiome, which I really still am questioning whether that could even exist in the brain. But a pathobiome for sure would be present there. But this falls outside of the typical designation an infectious disease person would actually be considering in this case. Joe 01:17:21-01:17:36 We have one minute left. What would you like to see unfold over the course of the next decade with regard to this infection connection and this pathobiome? What’s your hope for the future? Dr. Brian Balin 01:17:37-01:18:45 We have tremendous chronic disease throughout our population. We need to start considering how infections and infectious organisms and these microbes are actually interfering with us or competing with us or working with us, how that actually is happening to understand how we are staying healthy or becoming diseased. So these chronic issues are key, I think, for us as a future to really understand our health. So we need to monitor much better than what we’ve ever done before, and we need to start accepting that this is a reality and not continually questioning cause and effect. We have these on board. We still have to understand causation. How are things caused in time? But we are uncovering that to a point where we now have to start monitoring and diagnosing and start affecting change prior to disease onset. Terry 01:18:45-01:18:50 Dr. Brian Balin, thank you so much for talking with us on The People’s Pharmacy today. Dr. Brian Balin 01:18:51-01:18:55 And thank you so much for inviting me to talk as well. It’s been my pleasure. Terry 01:18:56-01:19:21 You’ve been listening to Dr. Brian Balin, professor of neuroscience and neuropathology at the Philadelphia College of Osteopathic Medicine. He directs the Adolf and Rose Levis Foundation Laboratory for Alzheimer’s Disease Research and the Center for Chronic Disorders of Aging. Earlier, we spoke with Nikki Shultek, founding director of the Pathobiome Research Center. Joe 01:19:21-01:19:29 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Terry 01:19:29-01:19:37 This show is a co-production of North Carolina Public Radio, WUNC, with The People’s Pharmacy. Joe 01:19:37-01:19:51 Today’s show is number 1,466. You can find it online at peoplespharmacy.com. That’s where you can share your comments about this episode. You can also reach us through email, radio at peoplespharmacy.com. Terry 01:19:51-01:20:37 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. In this week’s podcast, Nikki Shultek will talk more about patient-led research and help us better understand the root causes of some chronic conditions. Should cardiologists be considering gum disease as a factor in heart disease, as well as the levels of cholesterol and LP little a? What should health professionals be learning about the infection connection during their years of education? Dr. Balin also uses Schopenhauer’s three stages of truth to shed light on Alzheimer’s research. You could watch the interview with Nikki Shultek on YouTube. Look for The People’s Pharmacy. Joe 01:20:37-01:20:59 At peoplespharmacy.com, you could sign up for our free online newsletter to get the latest news about important health stories. When you subscribe, you also have regular access to information about our weekly podcast. We’d be grateful if you’d write a review of The People’s Pharmacy and post it to the podcast platform you prefer. In Durham, North Carolina, I’m Joe Graedon. Terry 01:20:59-01:21:34 And I’m Terry Graedon. Thanks for listening. Please join us again next week. Thank you for listening to The People’s Pharmacy Podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money. Joe 01:21:34-01:21:44 If you like what we do and you’d like to help us continue to produce high-quality, independent healthcare journalism, please consider chipping in. Terry 01:21:44-01:21:49 All you have to do is go to peoplespharmacy.com slash donate. Joe 01:21:49-01:22:02 Whether it’s just one time or a monthly donation, you can be part of the team that makes this show possible. Thank you for your continued loyalty and support. We couldn’t make our show without you.