Which Country Has The Best Healthcare? | Dr. Zeke Emanuel

What is discussed, and when

1. 0:00 – 10:00: Eat Your Ice Cream
2. 50:00 – 1:00:00: Kevin Hall, Norwegian University
3. 1:00:00 – 1:10:00: Kevin Hall
4. 1:10:00 – 1:20:00: Eat Your Ice Cream

Notable quotes from "Which Country Has The Best Healthcare? | Dr. Zeke Emanuel"

• He's also the author of a new book called Eat Your Ice Cream: Six Simple Rules for a Long and a Healthy Life.

  about Eat Your Ice Cream · at 1:04

• For ALS, HIV, you could name all the conditions across the board are being cut. Kevin Hall, phenomenal metabolism researcher, metabolic researcher, was a guest on this podcast…

  about Kevin Hall · at 53:02

• Spend a lot of time in Norway because I have a research project with Norwegian University. so I love Norway. It's a beautiful, beautiful country. If you haven't been there, I haven't. I got to go check it out.

  about Norwegian University · at 57:43

Who and what is mentioned in this episode?

People

• Kevin Hall — Person · 2 mentions · first at 53:06
• Louis Pasteur — Person · 1 mention

Books & papers

• Eat Your Ice Cream — Book · 2 mentions · first at 1:06
• Eat Your Ice Cream: Six Simple Rules for a Long and Healthy Life — Book · 1 mention

Companies & orgs

• Norwegian University — Company · 1 mention · first at 57:49
• Eli Lilly — Company · 1 mention

Full transcript with timestamps

0:00 I'm curious if you had to be born today what nation would you be born in because of their healthare system?

0:09 I, wouldn't, want, to, be, born, in, a, country only because of their healthare system.

0:12 Well,, if, in, this, hypothetical, you, have to choose. Well,, look,, first, of, all,, let's, be, I, I do have a book called which country is the world's best healthcare? But I only I only went to 11 countries. I didn't go to every country in the world. Um uh so the big winners were the

0:26 Welcome, to, the, Checkup, podcast., Today's guest is Dr. Zeke Emanuel, an oncologist who amongst many other things helped design the Affordable Care Act or Obamacare, currently America's entire health care system. So, you can blame him the next time you accidentally book a doctor that's out of network. All kidding aside, Dr. Emanuel has been extremely influential in establishing the structure of the average American's healthcare, both the good and the bad. Providing coverage for Americans with pre-existing conditions, that's Zeke.

0:56 having to enroll in a new policy every year for the rest of your life. Well that's also kind of Zeke, too. But he's not just a physician and bioethicist. He's also the author of a new book called Eat Your Ice Cream: Six Simple Rules for a Long and a Healthy Life. It's full of great tips to improve your health, including The Dietary Benefits of Eating Ice Cream. Am I reading that right? Yeah, we'll dive into that for sure. Everyone in America seems to hate our health care system, me included. And while people throw out suggestions like universal health care or let the free market decide, the reality is that providing health care for over 300 million Americans is more complicated than social media comment sections might have you believe. So given we've all had frustrations with receiving healthcare in this country, I want to ask what he thinks the real problems and solutions are and which countries he thinks are

1:49 actually doing things much better. Please welcome Dr. Dr. Zeke Emanuel to the checkup podcast. Dr. I'm so happy to be here with you today.

1:56 It's, great, pleasure to, uh, to, chat, about, the, state, of, the world as it exists today with biohacking, health insurance, health prevention, the way news media covers um our medical stories. What's at the forefront of your mind these days? What's what's keeping you up at night? What are you concerned with?

2:16 Well,, I, think, that, there, are, two separate things. Okay., The, thing, that, keeps, me, up, at night is frankly the health system and the fact that it's cracking and there are lots and lots of problems and we have no path from here to realizing any of the goals of a health care system. Universal coverage at reasonable cost with high quality decreasing disparities and satisfaction by everyone. Every one of those goals we don't fulfill. Many other countries get two, three, even four. Uh but we can't get to any one of them. So that keeps me up.

2:52 Why, do, you, think, that, happens? Oh,, I, think, I, think, that's, a, first, of all, it's the book I'm working on now. And I think it's a direct result of the structure we have created.

3:04 It's, so, complicated., Um, there, are, so many different ways of getting insurance and therefore falling through the cracks. It raises cost because of all this uh duplication uh and it has a lot of opportunities for gaming which also raises costs tremendously and so we have we have no way to get everyone covered. We raise costs and we take our have taken our eye off the ball of health. And the problem there is goes to the second topic which is we've actually created a society uh where ill health is actually kind of built in and we see it all around us.

3:42 The fact that our life expectancy is shorter than almost every other country. Uh the fact that uh we have you know 40% obesity, 30% uh overweight. uh we have all these distractions, high levels of mental health. So those are the two things that worry me. Um they obviously overlap, but they also have differences. You know, if you really want to get people healthy, it's not only about the health care system. It's about the food system. It's about school. It's about a lot of other things.

4:11 Yeah., And, you, played, a, a, major, role, in the ACA. Can you take us through that?

4:17 How, long, do, we, have, here?, I, thought, this um free, flowing., Let's, go., So,, I, was, uh, uh lucky enough to be asked to come into the administration uh the Obama administration to work as an adviser on the ACA. Um obviously lots of things took 15 months to get it uh passed. Uh but it got passed.

4:38 Were, you, happy, with, what, was, passed? Uh, what, passed, improved, the, health, care system? Am I happy it didn't solve the problems? it and it you know in retrospect now created some additional problems because it's very comp we added complexity to the system instead of simplifying things but look look we added 24 5 million people got coverage through Medicaid the exchanges employer sponsored insurance we kept health care costs flat alone did the ACA keep health care cost flat no was it a major factor in that absolutely those are two big achievements that no one else as uh uh uh realized we're now 15 years out with a lot of opposition by the Republicans no help in trying to actually improve it. And there's no business in the world that I know of that would put in place a plan to go forward and not revise it over time. We in the United States in our public policy, we put in a plan and

5:37 we sort of let it go and we don't come back to it. We don't build in a way of making modifications and improvements in general. Sometimes they do. Massachusetts when they implemented Romney Care uh in the early uh 21st century, they actually had a mechanism for making minor modifications constantly and that was really important. So, we're seeing cracks and and we're seeing problems that have to be addressed and will be addressed. I

6:03 I, had, Senator, Schumer, sitting, across from me not too long ago uh during the peak of the shutdown talking about his fears of premiums rising for individuals, for couples. Is that a fear of yours given what's going on in government these days?

6:17 Oh,, it's, not, a, fear., It's, a, reality. It's horrible. So, today for 2026, the average family premium from an employer $27,000 for a family. $27,000. That's a new car every year for health insurance for a family where, you know, you probably have two adults working, uh, two children. They're relatively healthy. They're not pro probably using a ton of health care. That's outrageous. Um and we can't I mean that's

6:49 how, does, that, compare, to, the, year, prior? Uh, it's, up, about, $1,000, or, $1,500. Okay. Um but you know that just it and the projections for the future are up up of that mo I mean in the econ economists will tell you the worker pays for it all either visibly through wages where they have to pay their pre part of the premium or invisibly through wages they don't get or otherwise would and that's you know even if we could cut that back three four $5,000 a family there's almost I don't know any single family except the, you know, top 5% where three or four $5,000 would go a long way towards making them just a lot calmer, reducing a lot of the financial stress that I think is a that is the major issue. You know, if if the shutdown did anything, it uh catapulted healthcare affordability to the top of the agenda. Now, in that context, a lot of what the Democrats wanted was the enhanced subsidies for the exchanges to

7:50 be maintained. Only 24 million people in the exchanges. really important for them to get financial relief. But there's 150 million people with insurance from their employer who would get zero relief. We have to deal with the whole system, not just a small part of it. And you know I've written uh a new oped about that. And I think it's really important that we focus on everyone in the country having affordable healthcare, not a small segment. in this oped or perhaps otherwise have you come up with some ideas of how to address it more globally or uh nationwide?

8:24 Yes,, I, think, there's, a, two-step, process. The first step is we have to put in some things that can reduce costs. Uh importantly in the next few years capping h hospital costs doing what's called sight neutral payments where you pay the same price for a hip replacement whether it's in an ambulatory surgery center hospital outpatient or hospital fees are insane.

8:46 Exactly., Facility, fees, need, to, be, evened out. That's on the doctor on the hospital side. On the pharmaceutical side, we have to bring down the costs. There are multiple things. You know, I think look, why don't we adopt uh a policy they have in Australia and Japan which is at 5 years there's a mandatory price cut, not price increase. Uh we could also think about, you know, making restrictions on PBMs so that their fees are not dependent upon the p the price of the drugs they sell. The flat fee that's the first thing. The second thing is anytime there's a bioimilar for a specialty drug has to be included on any formulary they create. Right now they have a big incentive not to include the biosimilars and in many formularies they don't. That just drives prices up for everyone. Similarly we need uh to tackle administrative costs. In the United States we spend $1 trillion on administrative costs. For your listeners

9:45 who don't spend a lot of time, that's $3,000 per American on administrative costs in healthcare alone. That is insane.

9:52 That, well,, that's, the, great, chart, that, I show so often for to people uh in explaining why health care costs have gone up because they assume doctors are somehow become more rich when in reality the amount of administrators has skyrocketed. Doctor salaries stay relatively flat compared to inflation. Exactly. and uh the administrative not just cost but also burden on doctors on

10:16 everyone, patients, too, the, hassle, factor that you know the technical term for that is sludge

10:23 lots, of, hassles, um, and, we, we, can, I, mean there McKenzie has a report where they say we can probably get a4 trillion dollars out of those administrative costs simplifying the system that's without radical change simplifying the system would help so I think those are some of the areas where I think we have to actually reduce our we implement fast to reduce costs that won't change the underlying system. So that's step one. Step two has to be much more comprehensive reform. And I'll tell you to be perfectly blunt. We don't have a big debate about what is that comprehensive reform going to look like?

10:59 And we need to have that debate starting now because we have to vet ideas. We have to say no that's not going to work. This will will work better. uh becau I really think the affordability thing is becoming so oppressive to people that uh in the 2028 presidential election if not then for sure in 2032 it's going to be top of the presidential debate.

11:20 Yeah., Uh, you, mentioned, uh, PBMs, and, I I've been quite vocal about the lack of transparency uh the way that they even were instituted in the first place in order to save us money and lo and behold that's not exactly what's playing out. they've created basically new billion dollar industry from it. Um what's your take on uh the various ways that uh you see vertical versus horizontal consolidation between uh you know the pharmaceuticals the pharmacies PBMs hospital systems to me there has to be something antirust happening here but it doesn't seem like it's uh addressed enough what are your feelings on that

11:59 yes, I, think, you're, 100%, right, we, have again part of the gaming of the system is more consolidation you see this in uh hospital SE sector that tends to be more horizontal although there's some vertical there where they're buying physician practices and not just buying other hospitals but physician practices ambulatory surgical and ambulatory imaging centers and other things. So that has to be addressed. And then I think I totally agree with you this vertical integration and we've just you know we've had reports about uh companies that are vertically integrated where one part's feeding the other part so that they can charge high and uh the profits stay within the company. that all of that has to be uh addressed and unfortunately uh the FTC and the Department of Justice um haven't had the resources really the manpower to go after this and set new standards for it.

12:54 But if you look at certainly on the hospital side, the consolidation in most markets is terrible. They're not now everyone is one of two systems and that's it. And so you have really no choice. and the payers, you know, we all love to blame the insurers, but they have no opportunity to actually, you know, uh, drive prices down from competition. So, we have to instill more competition. And I think there are again mechanisms. I'll give you one that was originally proposed by a Republican and I think it's a very good idea which is we have to cap hospital prices and the cap that we use how much above Medicare they can be directly relates to how concentrated the market they're in. If the market has a lot of competition and we can rely on competition to keep prices down, we don't have to cap them so low. If there's only one health system or two health systems in the market, then we have to have a lower cap

13:49 because competition won't keep the prices down. So, one or the other. And I have to tell you, people are sufficiently frustrated by hospital prices that you have new legislation in places like Indiana. Indiana, not a blue state, right, about capping hospital prices for commercial insurance because it's like this isn't working. The the system and the competition just isn't working.

14:12 Yeah., I, think, about, uh, you, know, in medical school learning stark laws and then looking at vertical consolidation being like how is this not basically the breaking of those laws

14:22 100%., So, I, I, would, love, to, see, the Justice Department play a role here because it is multiffactorial just like when we were thinking about weight loss. It's not just about exercise. It's not just about diet. Uh I recently had a psychiatrist on who's talking about shifting from mental health to brain health. When we're improving brain health, we're also improving all the other body parts and uh thinking about metabolism improves the brain. So here attacking it on every front seems to be crucial. And yet there's some kind of distraction happening where despite the calls from the people, we're not seeing it play out on an actionable governmental front. Why is the government not listening in this case?

15:04 Uh, well,, it, probably, is, no, surprise, that the healthcare industry is the biggest uh lobbyist in terms of dollars. Um it's also separate from the actual dollars spent, the the friendliness with the Congress people, the importance of a hospital or medical group in their district, those things uh play out. Uh and I would also say the complexity of the system.

15:30 Yeah. And, and, we, have, to, be, really, clear, about this. 995% of Americans don't understand.

15:38 I, would, say, doctors, are, probably, in, a I would agree with you. You know, people ask their doctor, but doctors don't they don't understand how the system works. You know, what's a PBM? You ask most doctors, they couldn't explain exactly what is happening behind the veil. Um and so part of the

15:54 And, that's, not, their, fault, either. No,, no,, not, at, all. Because, they're, supposed, to, know, the science and how to treat healthare.

15:59 Exactly., And, and, so, they're, not, health policy experts. They're health care experts. And part of the issue is it's so complicated that most legislators don't understand the system. They have a few talking points about it. They might understand a corner of it, but they don't understand the whole system. And that I think makes it hard to uh develop reforms that aren't going to, you know uh uh come back and haunt you. Uh as well as makes it hard to develop comprehensive reforms and then by the way sell it to the public. So they get lobbyed by you know some company do this and then it has knock-on effects that are bad for the whole health care system and we're seeing that you know uh uh up coding. So it's rational that we should pay doctors and health insurers more for sicker patients. That's very rational.

16:52 Okay. Now how do you determine a sicker patient? And then you've got a lot of gaming that can go into it and everyone's manipulating uh you here's the system. They'll figure out how to manipulate it because it's complicated. And that I think inhibits more comprehensive reform. So I think we've got to figure out how not everything has to go back to Congress or state legislators because it's hard for them to figure out is this solution going to work and we need a different mechanism for reform. Is is a partial solution to this having more physicians run for office?

17:27 Uh, no., Again,, as, we, pointed, out,, a, lot of them don't understand health policy. Uh have made mistakes. Um so I'm not I'm not sure. I mean, there is good reason to have physicians uh uh add their voice. I think for example, on vaccines not all physicians are good on vaccines but the vast vast majority believe in them. uh and in some other very important roles to say yes or no that's a good idea or not a good idea. Um but I don't think it's physician not physician. I really do think the complexity, of the, system, now, overwhelms anyone who doesn't study it for a long time and most legislators because of the nature of the job can't study it for a long time the way they used to uh in the old days as it were like 20 30 years ago. I've had AI experts on the show and uh I've seen episodes on 60 minutes on AI and everyone's talking about the future robots this that and to me I would just like to see AI remove some of

18:27 the administrative burden in selecting a health insurance plan in removing the need for 16 administrators to bill my outpatient family medicine visit. Why aren't we utilizing these technologies? Are companies not innovating in them because they might cut into profit margins or is there some sort of uh side benefit that I'm missing?

18:48 I'm, very, bullish, on, AI, in, medicine., I, do think it's going to make a big difference. I do think it'll make a big difference on the administrative side. I do think it'll make a big difference on decision supports. I actually do think it's going to make a big difference on delivering care. the more you look at some of the innovations and some of the ways you know there's a lot of AI a lot there are AI systems out there that can do great at a differential diagnosis here are all the possible things when you describe a patient tell you what test to order to efficiently get to an answer tell you what the guideline uh concordant therapy is that's a lot of what medicine's about right there and then even monitor patients so I think the future is going to be very positive the issue issues are uh integrating it into workflow. Pretty mundane issue. All change requires how does the workflow go? How do we adjust it? How do we

19:41 integrate? Making sure that there's payments so that people actually have an incentive to use it. Um those things all of those things are lacking at the moment. They're not all lined up together. I am I do think in the next uh uh 3 to 5 years we're going to see a massive uh impact of AI and healthcare and in exactly the way that you want which is reducing administrative burdens uh making things like scheduling much easier probably even answering a lot of patient questions um from the scenario and flagging ones that are complicated and need uh nurse practitioner physician engagement. So, I think I think that's a big big uh uh likely uh direction, but again, we're going to have to get the payment right so that if you use AI, you actually don't lose a lot of money.

20:31 Sure., And, we're, kind, of, at, this, awkward growth stage where right now the AI that I am uh having access to is making it worse because we're essentially training the models. Yes. And putting in extra work in order for it to develop perhaps into something valuable.

20:45 But, I, I, I, use, open, evidence. Sure. Yeah, up to date has the new AI. Very impressive. Yeah, for sure. No, there is value to be had at times though especially with some apps. I I've been shocked at the things that have come up uh in my time teaching residents. They bring me something and it's completely out there with these hallucinations. So it does happen. So I I would say um uh a big AI expert in California who's a big investor in AI and medicine was telling me he says look you have to understand AI the best analogy to an AI he said is like a car right some cars are tuned for racing formula one okay you're not going to take a car who's going in New York City traffic and put them on a Formula 1 track they have to be tuned right so general AI not good in medicine, right?

21:36 They will hallucinate a lot more. AI that's trained in medicine and trained as you say repeatedly in medical encounters, they are going to be much better. Fewer hallucinations if you force them to give you the citations and you can run and check them. So, I think there is a a training of the AI and a cultivation of the AI that's going to be necessary. Look, generative AI LLMs right? They're three years old. Okay it's like that's right. So, we're in the next few years, I mean, three more years and it's going to be amazing. One of my colleagues at Penn, Ethan Malik, uh, is is fond of saying the AI you use today the worst AI you'll ever use.

22:17 That's, a, good, one. So,, that's, an, important, lesson., So,, it's only going to get better and better and better.

22:24 Optimistic, viewpoint. Yes,, I'm, very, I, am, very, optimistic., I have been, you know, I have not every prediction I make comes out. I I think I my prediction rate is pretty good, but I could be wrong about this, but I I am bullish.

22:37 Mhm., Uh, is, there, a, world, where, AI replaces physicians or cuts their workload?

22:42 Yes. How, so? Uh, I, don't, know, if, you, know, about, Amy, the Google uh uh primary care doc.

22:52 So, they've, developed, this, uh, uh, system. It's called AMIE. And I can I always forget what each

23:00 autonomous, interactive advance, I, think, is, the, word, but, I, could be wrong. Um uh I know the last words explorer. Um anyway they tested it against board certified PCPs primary care physicians um with patient actors who were playing out a clinical scenario. Um the patient actors evaluated them for empathy, confidence in their judgments and a few other things. and specialists evaluated them for the recommendations they gave the management proposals etc. There was not one of I think 27 28 metrics that uh Amy didn't exceed the PCP. There were some where they tied including empathy. So if you combine the ability to have a differential diagnostic test and therapeutic recommendations that are guideline driven with greater empathy than your primary care doc, you're going to have to tell me why we're not replacing primary care docs with uh chat bots. And this is when both were doing chat. So, it wasn't face-toface

24:02 interaction. Nonetheless, that's pretty impressive in my view. Of course, from a technological standpoint and it's not in the clinic so we have to test it out with actual patients in real life scenarios, not made up, not a few, you know, sort of classic patient scenarios. But I think that that does suggest to me that there's a long that, you know, it could be pretty impressive. Yeah. I'm curious how it plays out from the human model of it all because ultimately I've went to school and I've had friends that were the brightest minds in terms of test taking medical knowledge can quote you every substep of the KB cycle with 100% accuracy and they turn out to be crap doctors.

24:51 I, agree., So, I, had, the, same, exact, So, when I was an intern and I had taken four years off for a PhD and so I was a bit of a rusty intern. I had a rotation with another uh uh intern from Hopkins. Um and we were on the oncology war together. We would go into Hodkins disease and I would fumble around a little about and he would just like report out Harrison's textbook, you know, here's a differential diagnosis here's a test you're doing, here's a chemo if it really is how blah blah blah. And I'm like, "God, this guy's great." Then we were on night call together. And he, you know, well, you know what night call is? Someone goes south. Something happens. You've got to make decisions. You've got to implement treatments. Blah, blah. He froze. He just couldn't take all that responsibility for having to make a decision in the moment um and analyze you know, what's this most likely to be and what should our intervention be and

25:43 when do we reassess. Uh he left me internal medicine and went into pathology. Okay. Less patient interaction.

25:51 I, I, I, don't, think, that's, going, to, be, the problem with AI. I don't think that is going to be the problem that that has all the book knowledge and can't apply to scenarios because they're going to find it on scenario.

26:02 I, think, that, they, can, definitely, apply it because it's clear with their winning empathy points. They can clearly apply it. The question is do does the human trust the robot equally long term? And I'll present you a real life scenario that's happening right now with an industry leader, Elon Musk, who has his own LLM, very popular, integrated on X. And you know, Elon Musk is a fan or at least has been a fan historically of Secretary Kennedy. He pushed for his appointment. He says what he's saying is great. But if you ask Elon Musk's own LLM, what are the percentages of accuracy of what Secretary Kennedy uh when he makes a health claim? What is the accuracy? It's zero or uh low percentage points.

26:49 But, Elon, Mus, doesn't, seem, to, care. So, will, humans, care, about, what, the, AI say?

26:57 I, think, so., uh, a, great, proportion, of consulting LLMs relates to uh healthcare and I think people are looking for answers. They look for answers uh at times that doctors aren't available. Um so I do think they're going to trust LLMs especially LLMs that are trained on medical information and give them references so that uh they can be somewhat confident. So in the era of AI that we have right now, we have pretty good LLMs to give us general information. Why is the antivaccine movement growing?

27:34 Oh,, because, I, don't, think, they, This, is, a perfect case of ideology over uh

27:40 Exactly., So, when, they Well,, I, think, most, people, when, they consult an LLM for a medical thing are going to be confident uh want the answer. They're not they don't have an ideology.

27:52 Oh,, I, see., Okay., So, the, ones, that, are consulting will be that'll, use, it., Yeah,, absolutely., 100%.

27:57 So, do, you, think, there, will, be, patients who say like I'm proudly I see a nonI physician and then some patients will say I don't care I see an AI physician.

28:05 I, I, think, that's, right., And, you, know there may be differential in pricing there may be differential in time to access etc. You know, I work with a company and you know that uh has developed uh a platform for children and focus on children and trying to make various therapeutic uh activities gamified that children will engage with. So for example in occupational therapy physical therapy or mental health therapy, they've got a g we've got a gamified system uh and kids love inter interacting with it and it means that uh they can actually see the in-person therapists less frequently because between in-person interventions they're doing these kind of physical therapy uh routines which they were suggested before but of course no one did. Now with the game, they're actually like doing it. We've limited the number of times they can do it so that they don't get addicted to it and it both uh allows

29:05 them to progress faster and lowers costs. That's the kind of intervention I think we're going to see more of uh that doesn't necessarily displace a health care provider, but augments what they're doing in the therapeutic realm. We're very excited about it. Um, and you know you can also see how it might be useful for, well, we know it's useful for behavioral health. We've done it self-regulation of kids and things, uh anxiety and working with them. It be useful for diagnosing autism and things like that where a lot of the diagnosis is already we're going to film you and then, we're, going to, code, it., Well,, the AI can do that better.

29:43 I worry about uh private equity being so involved within the health care space because I feel like the health care space unlike a traditional consumable product it's life or death. So it's not a choice of whether or not people want the luxury of this toy or this jacket. It's their insulin that they need. So when people start messing around with that I get concerned and I've seen it play out negatively like even in the teley medicine space as an example. Tele medicine was to me when I was uh studying in my residency a great option for patients who needed to see a subsup specialist to look over labs and imaging and give guidance about chemotherapy from a distance. Uh from patients that didn't need to take a day off work and can remotely connect to me and I can go over their hemoglobin A1C with them and manage their diabetes virtually change their insulin dosage. Great. Then companies started popping up where they

30:38 use tele medicine for everything and they basically become uh a prescriber mill for opioids but for uh finasteride for hair loss for Viagra for antibiotics. Like there's websites now you can go on and literally self diagnose without really talking to a physician and request whatever prescribed medication you want. Um, I saw a commercial playing when I was on Fox and Friends the other day, um, for a travel kit that includes all sorts of antibiotics and antiparasitics that you could just call in and basically get now any concerns that world taking over a

31:20 there, are, two, things, there., one, is,, you know, calling in and getting medications which have I mean the the problem with antibiotics and antiparasitics and there's a lot of uh consequences for the rest of us antibiotic resistance when it's used incorrectly etc. Um the issue of PE is a is a in some ways a separate issue. Um I think that is uh a real problem and I I you know I I just taught my class on PE and I said look I don't know of one area in healthcare where the entrance of PE has actually improve care improve quality and reduce cost just you can't point to a single area they either reduce cost or they drive cost I mean they reduce

32:06 cost, increase, profit quality, reduce, quality, increase, cost right um and some kid said, "Well, you know, there's IVF uh clinics and I so we looked into the data. The data are not that PE improves IVF. They improve uh

32:19 access, well, they, they, consolidate. There's, also, not, for, profit consolidation. It turns out that consolidation is good because they bring the same standardized care. They also quantitatively measure outcomes. Turns out that PE is actually not better at the ultimate outcome. are you having a baby then private uh not for-profit uh chains

32:42 so, even, in, that, scenario, which, was raised to me by one of my students not not improved the system um so I don't think anyone in PE can point to an area where they've actually improved the system yes they consolidate they bring you know whether it's dermatologists emergency room doctors etc together typically they raise the prices uh in multiple different ways they change the patient mix uh the kinds of uh visits that they're getting to raise more money. So I am quite skeptical that there's a place where PE has a good role um in health care. Uh I think their model and the healthcare model as you point out don't mix. Um so I I'd love to be

33:29 Well,, are, you, concerned, about, that mixture of AI and PE merging to create a Marvel Thanos, if you will?

33:39 Um,, no,, maybe, I, should, be,, but, I, I, I'm not I'm not that concerned. Uh, you know, I do I actually think many of the big tech companies have uh they have to make it in healthcare. hither to their track record in healthcare um can be summed up in one word sucks uh you know whatever it is it's verily at Google no real successes it's you know Amazon uh no real successes uh it's uh whatever Sigma's bought uh some uh products Microsoft doesn't have any successes um but healthcare and AI is different if the trillions of dollars evaluation are going to be justified uh in the uh AI space. They have to succeed in one place and healthcare is the place that they can succeed and generate hundreds of billions of dollars in annual uh revenue. That I think is they have to focus there. You know, you can focus on law and trying to disrupt law. How big is law? $400 billion. You know, medicine dwarfs law. It's 12 times bigger. So, I

34:54 think if they're going to justify all the investment and the excitement they're going to have to succeed in healthcare.

35:00 Despite, the, fact, that, you're, so, bullish on AI, you're quite bearish on biohacking.

35:09 That, seems, a, little, paradoxical. Explain. Oh,, I, don't, think, they're, related actually. I think

35:13 I, think, if, you, were, to, take, a, subset, of individuals who are bearish on AI almost all of them are bearish on biohacking.

35:21 That's, probably, true., And, that, just, cuz they don't understand biology at all. Yeah. I I mean I I think this idea that we're going to outsmart the body and you know if uh omega-3s or whatever, pick your best favorite supplement is good more has got to be better. Well, you and I know in biology that doesn't work. more often is worse, right? You create problems and we know this from the, you know, simple model of the immune system. Oh, we've got not enough immune system function. Okay, we're liable to infections and other problems. We've got too much immune system function. We're liable to, you know, autoimmunity diseases um and other sorts of problems.

36:03 You know, a lot of biology is about a very uh uh complicated balancing act. And so overdoing it, which is mainly the direction biohacking goes, not a good idea. And so I think they've got, again it's a typical tech approach. They've got the wrong model. I mean, in AI throwing more and more compute power is how they've succeeded, right? Throwing more and more supplements or more and more stuff at the body is not how we're going to succeed. So if you ask a lot of the LLMs, even the medical ones about these medications, uh, supplement ones

36:39 biohacking,, they'll, be, honest, and, say what you said because they look at the available data. But the founders of AI companies are take a completely different approach. So are they not trusting the current evidence that exists or they're just trying to jump ahead? Is it a mortality crisis?

36:59 I, I, think, I, think, it's, two, things., I think it's narcissism and a little uh excessive belief in their own uh brilliance and infallibility. Um you know they think they've succeeded in this area LLMs and therefore they must be a genius across the whole realm. I mean you've met these kind of billionaires right that that's their view. You know I succeeded here you know I know everything. Um, and so I think they don't actually pay attention to the they don't really have the time to pay attention to the underlying data, the underlying uh understanding. Um, and they think, oh, well, we haven't tested this. That's right. We haven't tested that. That doesn't mean your hypothesis about more is better. Um, and we do know in the supplement world that uh, in fact, um, most supplements, I mean, not all, but most supplements are not helpful. There are contexts and cases and you and I know them where it's it's

37:53 really important you know woman who's trying to get pregnant thinking about pregnant or is pregnant you know got to make sure that she has folate she has enough iron etc vegans well they un you know unlikely to get enough vitamin B12 right they've got to take supplements there are other areas older people same thing they might not be able to generate um uh absorb absorb the B12. So, we do need people to take or some people to take some supplements. That is far from the millions of dollars in multivites and although I mean I'm always shocked I go into CVS and you know probably the single biggest thing they're selling there supplements and they're all always reduced because you know it costs nothing to make and they charge 2030 bucks per bottle

38:46 for, the, label., Yeah., Yeah., Um,, do, you think there's ever a world where the FDA gets involved in uh the supplement space?

38:54 What, do, you, mean, there, was, a, world, and then Orin Hatch took that world away because a lot of the supplement makers were based in Utah? You know, could we go back? I don't know. You you know maybe as part of some comprehensive uh um healthc care reform uh package, it would be kind of important. You know, I do think if we had a situation where supplements were contaminated, a lot of people uh died from it, um in a visible way, um that actually could generate interest in going back to regulation.

39:24 Yeah., A, person, I, was, debating supplements with the other day, uh their argument was way more people die as a result of pharmaceuticals than they do supplements. And I'm like, but that doesn't tell you nearly the full picture.

39:36 Right., Right., Depends, what, diseases, you were treating. And mostly supplements are for healthy people, right? And mostly pharmaceuticals are for sick people.

39:44 Yeah., And, the, idea,, at least, my, notion is when people say supplements are fully safe when they're trying to sell you they're like, "This is natural. It's safe." To me, anything that's 100% safe has no action. Because in the body every action has a reaction. So if it's fully safe, that means it's It's not doing anything to begin with.

40:02 So, my, version, of, that, exact, point, is there's no medical intervention I know of that doesn't have side effects.

40:08 Yeah., just, doesn't, even, a, simple, blood draw can have serious side effects. Okay. So, it's low low probability but not zero probability and that is definitely true. You are as you point out you're trying to provoke a reaction by the body in a good for a good but sometimes it goes ary either because of your genetics or because you know maybe you've injected that medication and it didn't get into the vein. There are all sorts of reasons of course uh you could have a problem.

40:38 So, I, imagine, you, have, uh, really, smart friends, you have billionaire friends uh your family is in the upper echelons of society. What do you do when someone comes to you really saying come on you got to say this IV therapy that I get after a night of drinking or uh these supplements really work uh I want to get a full body MRI. How do you talk them out of it? Uh I don't know that I succeed to the billionaires because again they think they know everything. They're rich. Okay. Um but I I do get asked questions about all sorts of things. Uh and I try to explain the data. First of all, I say why do you want that? The most important question is what are you worried about? Okay, you know,, you're, a, 33, year old, person,, no health problems, you want a full body MRI. Are you crazy? You know, first of all, there's nothing there. Um, and and if there's something that shows up, it's most likely to be a false positive. So

41:36 now you're going to go through a bunch of, other, tests, for, nothing., All right? You have to target what you're doing. Uh, and just shooting, you know randomly getting a bunch of quote unquote predictive blood tests or gene markers doesn't tell you anything. And then you have to know, do we have a treatment for whatever it is that you're coming up with? And I think people don't think, you know, the my experience is a lot, of the, people, who, ask, me, these questions don't either know the data which is one reason they're coming to me, and that's fair. I'll I'll tell you what I know, and if I don't know, I'll look it up. Someone actually recently sent me an article. He says, "You know you said melatonin is no good for sleep but I have these these data that suggest it might be good for endurance. What do you think?"

42:25 Well,, turns, out, it, might, be, good, for endurance. I, just, covered, a, study, that, it, causes heart failure. So

42:31 I, guess, it, depends, what, you're, studying. Well,, I, but, that's, part, of, the, issue, is, you know, we've got to actually look at the comprehensive set of data. Um, so I try to give people the data. I try to give them my best recommendation uh about whether this is a good idea for them given their situation, their age in general. Um uh we overdo it and for I I would say two things. A lot of people uh especially probably people listening to your podcast are probably already healthy and they just need to be reassured you're doing the right thing.

43:06 You're going in the right direction. don't get diverted by all this other uh stuff. And I think that's very important. One of the problems we have as human beings and there's a some interesting research. Our natural tendency is we got a problem, we want to solve a problem, let's add something right? So we add a supplement, we add an exercise, we add, you know, a sleeping aid. um that I find that in wellness at this moment um what we mostly have to do is take away stop doing the bad stuff because we have a lot of bad stuff in our lives. Uh whether it's food and nutrition, uh it's risky behaviors that are out there, it's things that have people have been doing forever but the risks have become much more obvious like alcohol. So I think part of what I try to convince people in the wellness space is chill out and actually focus on getting rid of bad stuff. There's some really good stuff you you should do and

44:07 then we can make it easy a few steps. The other thing I like to emphasize to people is we know that will you know you can't do this by willpower. You have to develop a habit and the habit you have to be able to stick to it. And one of the problems is you got to stick to it for life. So someone that you know it's extreme self-denial or that's you're not going to stick to that or if you do stick to it you're going to have a very unpleasant unhappy life. That's not a formula for success. You know you want to enjoy the 75 85 years you have on the planet. Um, so I try to say, let's figure out what the habits are that you can do or work towards and that you're going to enjoy and you're not going to suffer. That's one of the reasons I really like to emphasize for wellness social interaction. Social interaction is good for you. It's good for the other person and you get the results today immediately as well as long-term results

45:05 in terms of health and longevity. So it's, it's, a, it, it it, you, got, to, I, mean, I think people are nervous at this moment. They're feeling like the world's out of control, which it is, and they're going to control the part they can in in terms of their own wellness. Well that's good, but, you know, don't go overboard.

45:26 Yeah., The, the, hyper, hyper, optimization of it all is where I think it goes wrong. Like it's all right to try and optimize your health, but once you're in that hyper stage, that's where you're getting into now the opposite end of homeostasis where you're getting the negative repercussions of that.

45:39 Yeah. I, I, remember, uh, there, was, an, ER, doc, that I tra trained under where we were uh doing some cautery off of a nose bleed for a patient and we got it to mostly stop and I said, "But it's not perfect. Let's let's get it perfect." He said "The enemy of good is trying for perfect in healthcare." And that really stuck with me because I think it applies in a lot of these biohacking scenarios.

46:00 Totally., Totally., I, agree, with, you., And also, you know, we might know optimization on a population basis, but for in an individual, yeah, we don't know what optimal for you is or me given our, you know, genetics.

46:12 Well,, now, you, can, buy, a, kit, that, will tell you what's right for you. It it'll check your stool for the microbes. And my favorite is what a lot of these companies do is they'll check your stool or your microbiome and they'll say, "You should eat more fiber." I'm like "Hey I could have told you that for free."

46:26 Yeah,, exactly., 7%, of, Americans, haven't get enough fiber. I love those raspberries and Brussels sprouts.

46:32 Exactly., Um,, I, have, a, concern., I'm curious if you share it. Um, if you look at the specialties that young doctors want to enter usually, and it's not onetoone, but the pattern is higher paying specialties end up receiving the most attention. primary care psychiatry, pediatrics, the most important specialties really, if you ask me, the foundation of a good health care system get reimbursed the least least amount of attention. And I think about how that's playing out today and I see what kind of physicians and gurus are making good financial outcomes and I worry how this is going to impact the future education of students. where are they going to see the model we're talking about this boring old yell at the clouds mantra that we're doing versus Brian Johnson's live to 150 model and say even if his is a little off he's still telling people to be healthy and I can become a millionaire doing that. Do you think

47:36 that might shift the way young brilliant minds might uh end up entering the health sphere?

47:41 Oh, I, you, I, don't, think, it's, a, future thing. It's a current thing. I mean when we look at the number of students going into pediatrics uh or the number of students going into uh internal medicine or going into psychiatry as you point out you don't have to be a wealth maximizer to say that the 5x difference between an orthopedic surgeon and a primary care doctor per year um which is going to be compounded over 30 or 40 years of an entire career. That's going to drive people especially if they come in with 200,000 300,000 debts. We have to change the model. You know, in the Philadelphia area where I'm at, the insurers are paying 4 cents of every healthcare dollar to primary care and I keep chastising them. That is absurd.

48:25 You are going to hollow out and then you're going to bemoone. Oh, we have no primary care doctors. Yeah, you caused it. And we have to change that reimbursement system. And I've been arguing for a long time that we need a different model. You know, if we took just two or 3% from uh hospitals and we took another two or 3% from specialists we could double primary care doctor pay. And then you would see a very different scenario. And not just internal medicine, but as you point out pediatrics is way underpaid, especially pediatric specialists are way underpaid.

49:01 And those are things where it it's a real going to be it's a problem now. It's going to be a huge problem in 10 years. And there's problems you can't fix overnight. It takes decades to fix that because of the, you know, long pipeline of medical training. So, I totally agree with you. You know there's good evidence more adding more primary care doctors to a community uh increases longevity, decreases mortality. Adding more specialists does the reverse. Actually increases mortality. Not a good scenario. And so we need more primary care doctors. And again, they don't have to be wealth maximizers to say, you know, we got to narrow this gap between us and the orthopedic surgeons or the urologists or the neurosur whoever. You got to get them closer to that money. So maybe the difference is two times, not five times.

49:49 Yeah., The, idea, of, insurers wanting to focus on primary care to me makes so much sense because if you invest in primary care, you're investing in preventive care. You're saving yourself as an insurer money down the line. However, what I've seen happen is that rarely the same person is covered by the same insurer after 5 years. So as a result, there is no incentive to invest in prevention when you know you're going to lose this person to another plan. Has there ever been talk on the back end of making not maybe a a lifetime plan for an individual, but some kind of policy where insurers have to stick around with a person. So you're uh I've written a lot about this. Um uh you're 100% right. This churn you switching insurance companies totally undermines the financial incentive of an insurance company. Not just to invest in prevention, primary prevention, but to invest in anything where the payoff is

50:52 going to be a year or two down the line. The rotation among plans is pretty high 15% per year. So, you're absolutely right. Churn is a problem. My solution to, that, is, you're, not, going to, get, a lifetime plan, but you could get five-year contracts uh where someone signs up for an insurance company for five years and you know if you change you lose a job, you move, you get married, whatever, you can change uh plans. Um that changes the financial incentives as you point out to invest for uh the long term, not forever but for longer term. And I think that's a very important uh model for us. So I agree with you. Why do we have annual reenrollment? It seems crazy. Uh exactly. Wild. They don't sign annual contracts with docs. Typically they sign three years or fiveyear contracts. We should do the same. And by the way, as we're at it, maybe what we do is, you know, same premium for 5 years. We're

51:54 not going to increase the premium for 5 years. So everyone's got some predictability. You create an incentive for people. Well, you'll tell them you can't change the premium. They'll just raise the co-ay or whatever other

52:05 I, have, other, ideas, about, that, too because you know you could say co-ay for visiting the primary care doc zero for three visits a year. Well, that again changes the incentive of people about how they're going to use their health care plan. Um but I I think you're you know absolutely right. Uh the if if we believe prevention is important, you know, we have to think about why aren't we getting it? Well, we're not get turn is one of the major factors. Um, you know, I love politicians when we were doing the ACA, they would say, you know we have a sick care system, not a health care system. I said, do you understand why you pay for sickness? You don't pay for health.

52:41 Yeah., Well,, that's, what, I, was, going, to say. My frustration with the current make America healthy again movement which I don't quite understand what again means cuz when were we healthy and not having issues. Um, if we're going to talk about improving outcomes, we would be investing in primary care, we'd be investing in research, yet NIH budgets for ALS, HIV, you could name all the conditions across the board are being cut. Kevin Hall, phenomenal metabolism researcher, metabolic researcher, was a guest on this podcast after he was fired. Well, indirectly fired, I guess he resigned, but because of them trying to alter his work. These are the people that are going to be doing the work to create preventive programs, to give us guidance on nutrition, to help us get rid of junk food that we so uh often call out as what ails our society, but we're not doing that. And maybe because I'm uh naive, why aren't we doing that?

53:42 cuz it seems like we have this national budget that is in debt and we want to save money and this is a surefire way to do it and while there are not clear ways of doing it there are some basic steps we can take but we're not doing it.

53:55 I, agree., I, I, don't, think, maha, uh, uh, you know I think some of their goals are quite admirable less ultrarocessed foods focus on chronic conditions I I totally

54:07 but, to, say, those, things, and, then, put something into action are two different things. Ah, that you knew exactly where I was going. I I don't think they're consistent in the policies that they're advocating to get there 100%. I mean look, if you want to change the food system and what people eat, you got to change the subsidies we have for the ingredients that go into ultrarocessed foods. You know, we have huge subsidies for corn and soybeans and rice and wheat. Well, you know, what are those doing? Yes, they're making ultrarocessed foods cheap and inducing people to buy them. Do we have the same kind of subsidies for, you know, your pistachios, your raspberries, your blueberries, your apples? Absolutely not. We know those are very nutritious.

54:47 You know, they have good fiber. Go back to your fiber point. They uh enhance the microbiome. We don't have good subsidies for those. So, they are not being consistent. Similarly, you know, we have a lot of pesticides and a lot of additives. You want to make people healthy. we need a robust uh environmental protection agency, but in fact we're undercutting. So I think you're 100% right. The idea and the implementation are divorced and that is a major problem here. Now I understand I'm no expert on the Maha movement, but I understand that there are people within the movement who are who are upset about that. Well, that is good but they have to push for more consistency in what the government does.

55:31 Um, some of it may be their general suspicion. Oh, if the government's doing it can't be good. That's wrong. A lot of this stuff only the government can do. You know, who wants to spend all their time looking at every bottle under their sink? Is it got a toxic or not? I'd rather the government take them out and do it systematically and maybe overreach a little bit that um than my having to take a lot of time and be obsessive about that. Every person doing it individually is not the way to go. That's one of the reasons we have a government. They can do it. They've got the expertise and they can do it effectively. So, we don't have to.

56:07 And, doing, it, at, scale, should, be, cheaper. Yes,, for, sure. So,, there, should, be, financial, savings there.

56:12 Yeah. Um, I'm, curious., If, you, had, to, be, born today, what nation would you be born in because of their healthare system?

56:23 Oh,, that's, not, a, fair, question., I, I wouldn't want to be born in a country only because of their healthare system. Well, if there's a whole you have to choose

56:30 uh, based, on, the, healthare, system., Well, look, first of all, let's be I I do have a book called which country is the world's best healthcare, but I only I only went to 11 countries. I didn't go to every country in the world. Um uh so the big winners were the Netherlands Germany, and uh uh Norway. Um

56:49 what, are, they, doing?, Well, what, are, they, doing?, Well,, uh,, uh, they're definitely, uh, emphasizing especially the Netherlands and Norway emphasizing primary care. To get to a specialist, you really have to go to a primary care doctor. They put controls on prices. They do give you uh especially in the Netherlands, they give you choices of different sickness funds. They call their insurers. They make their primary care doctors uh, manage uh, uh, mental health conditions. So almost all of them have nurses who manage mental health. They have uh doctors uh or nurses who are accessible 247 who have access to your medical records. Um so they have a lot of things that are uh uh going in the and they only spend 11 10 uh 12% of budget. So they have a lot of other money that can be spent on enhancing schools infrastructure, environment and other things that make people uh healthy. Uh I spend a lot of time in Norway because uh

57:47 I have a research project with uh Norwegian University. Uh so I love Norway. It's a beautiful, beautiful country. If you haven't been there, I haven't. I got to go check it out.

57:56 No,, you, got, to, go, check, it, out., I've, got a good apartment you can stay in. Um it really it's a wonderful place and most everyone speaks English. They have great food. Um and

58:08 what's, a, food, tip, in, Norway? What's, the, food, tip?, They, have, a, lot, of fish for one thing. They also have uh really invested in heritage food. So people doing, you know, the old way of uh getting goat cheese. Well, they they've got lot that they invest in people who want to do that. Um and a lot of it's fresh. You know, the the uh fishermen went out and and it's on your plate at dinner. And so that's a pretty pretty special.

58:33 Okay,, that's, a, good, one., Um,, you mentioned earlier that uh avoiding bad habits is more important than trying to biohack your way out of bad habits. Uh what are the three worst habits that folks have these days that are harming their health?

58:47 Well,, let's, just, focus, on, food, for, a second because there are lots of other habits. There's habits related to smoking, habits related to guns. Um, but if you focus on food, so my suggestions on food uh in my book are one uh three don'ts. uh no sugary sweetened beverages. Sodas, for example, you know have 140 calories. That's about 10 teaspoons of sugar. Uh just imagine 10 teaspoons of sugar in that little can. No nutritional benefit. Now, the good thing is Americans are actually decreasing,

59:23 but, then, they're, increasing, their Starbucks frappa frappa frappuccinos whatever.

59:26 Yeah., And, that, problem, is, it's, way, more than 140 calories. about 400 calories

59:31 cuz, then, you're, getting, fat, in, as, well as the sugar in there. The, second, is, to, decrease, your, salty snacks, your package cakes, your muffins, your cookies. Um we have over the last 30 years increased the amount of those packaged sweets that were snacks and sweets that we're eating to be about 500 calories a day. 25 to 5 to 20% of a adult's recommended diet. That is a big mistake. There are good nutritious snacks you can have, whether they're nuts or fruit or hummus. Too many packaged snacks, ultrarocessed foods. Um, and then there's the more general ultrarocessed foods. Uh, just shy of 60% of all our calories are ultrarocessed foods. We have to reduce that uh uh substantially. Uh, that requires a whole social change. What you can buy and afford uh is what you can cook. One of the things I learned from my research assistants who are just fresh out of college is they have no idea how to cook. They have no pots and

1:00:30 pans. Their parents never taught them how to cook. There's no home economics in their uh classrooms. They didn't know. They they can't even I I gave one of my research assistants in frustration. I said, "Here's a roast chicken recipe. It's not complicated. It's about the easiest thing you can get." He had no roasting pan. He didn't know what a whole chicken was as opposed to eight individual pieces. It was like "Are you kidding me? This is ridiculous and a super smart guy. Um, so, uh, we got to change those three things. And then there are some positive things we

1:01:02 I, noticed, you, didn't, say, get, rid, of, dyes in, our, foods. Oh,, looking, getting, rid, of, dyes, is, fine. It's just not going to make us healthy. These other three things are way more important.

1:01:13 And, then, there, are, two, positives, that I'm really hot on as one is fermented foods. yogurts, kimchi, kefir, uh miso sourdough breads, uh aged cheeses, those are very good for the microbiome and they've got, you know, yogurt especially has a lot of protein in it. Uh kimchi has a lot of fiber in it. Very, very good. Um and then this flip side is as we mentioned, fiber is probably it's going to be the next fad, right? Protein at the moment is our fad.

1:01:41 I, don't, know., Fiber, is, big, now, with pasta and chickpea pasta and all this stuff. Fiber is very important and we have too little. It probably its most important thing is to nourish the microbiome, increase the diversity and taking the supplements is no supplements have one kind of fiber rather than a whole diverse range of fibers.

1:02:02 Yeah., And, what, I've, seen, is, now, people are popping up with fibrous drinks. Oh

1:02:07 which, have, tricked, the, FDA, definition, of what fiber is. Yeah., Well,, I, think, I, think, look, that, is almost invariably if it's going to taste good and it it's not going to be take your fruit and and water, coffee or tea. Don't don't try to mix them together. Not not a good idea.

1:02:25 Makes, sense., Um what about ice cream? I really like ice cream. That's, the, title, of, the, book, for, a reason. Ice cream is so it's a dairy and dairy is good for you. Um I'm a you know not everyone agrees with me. one of my old professors from Harvard School of Public Health, Walt Willlet, who's a real pioneer in nutrition. You know Walt is not high on dairy. He's got a very objective analysis of it in the New England Journal a few years ago. I would say he's not a wild fan. Partially that's because the US has pushed dairy for its calcium, but it's not to do with calcium. It's good protein, right? It's it's got saturated fats, but it saturated fats are contained in globules and don't have the same effect. Um it decreases uh the risk of diabetes. Uh in the case of kefir and the case of um uh yogurt very good nutritionally got a lot of protein in it. Uh we know that kids who have uh uh lots of dairy as children

1:03:26 actually grow taller. One of the reasons the Dutch are probably the tallest people in the world. Um so I'm a big fan of and then you've got ice cream and it tastes good, right? Yes, it does have sugar. uh as long as it doesn't have emulsifiers and other things, you know every night a big scoop. No, there are some people who've done it. Uh but, you know, couple times a week, great. It's a good thing. Um and you know, it's it's a good for you treat uh to have. And you know, my wife's grandmother had ice cream every day of her life. She and she lived to a hundred in her own house. And

1:04:06 that's, not, a, great, way, to, look, at, it. And cuz, that, could, be, weaponized, the, other way very easily.

1:04:11 What, she, said, is, there's, always, room, for ice cream. It just squiggles in on the side of your stomach. Uh it was her last meal. She enjoyed life.

1:04:20 Well,, that's, great., Um, the, the, issue that I run into with people talking about certain foods or individual ingredients is uh a study comes out showing an association of consuming whole fat ice cream or whole fat milk uh with a lower association of heart failure, whatever cardiovascular disease and then people jump to the conclusion of

1:04:40 oh, it, lowers, the, risk., Well, that's, the causation hasn't yet been proved or elucidated. So how do we take this bit of knowledge that comes out every so often with the nutritional study an observational one? What do we do with that knowledge?

1:04:57 So, I, think, that, there's, let, me, make three points there. The first is the point you're making which is look an association is not causality. On the other hand you get you know five six seven eight studies in different countries with different populations where you see an association. you're gonna have to really really convince me that this is just all artifact. So I don't think every association study is the same and obviously bigger association studies done more rigorously help. The second thing you would like to see is some plausible mechanism. So one of the things we're beginning to see a lot of as so there's a you know association seen in the observational studies as you point out that aren't causal and then you see people going to like the UK bio bank this is very common and they're looking well how does this potentially uh uh affect the physiology such that the outcome you know preventing diabetes

1:05:53 actually occurs and once you see that you're like wow that really adjusted the inflammatory markers and it really looked looks like it's more than just an association. The third thing is we've seen now in some other studies uh like for example of diet uh of artificial sweeteners uh there's a study out of the whitesman in Israel published in cell where they took people put them on artificial sweeteners in in sodas and uh they showed that it uh there was a microbiome change and then they took the microbiome from the people who had the diet sodas and put them in mice And the exact same phenomena happened. They gained weight. Um their microbiome uh uh was reduced. Uh so that lends a lot of plausibility to the physiological approach. So I like to see are there lots of studies done differently different populations. Um if they're all observational, I put a lot of uh a lot of strength in it. And then you know is

1:06:55 there a po plausible biological mechanism done in a bio bank or some other kind of uh uh study. So th that's the way I like to assess them.

1:07:06 Yeah., Nutritional, research, historically has been hard to apply generally because it's so culturally dependent. Uh what foods are you consuming at the same time you consume this specific ingredient? Uh are you talking about the American standard diet versus a culture that eats uh wild caught fish? you know, so it's it's very hard to

1:07:26 take, one, bit, of, data, and, then, uh extrapolate it to the general population. That's where I struggle.

1:07:31 I, I, I, totally, agree., And, also, one, of, the points and and you were hinting at it here is what are you substituting? So you know, you've got fish. What are you taking away? Are you taking away red meat or are you taking away vegetables? Right? So, part of, you know, a lot of this stuff is

1:07:48 we, look, at, it, in, isolation,, right?, Milk in isolation. Well, what is it substituting for? Sodas? Oh, then it's probably going to be better. It's substituting for water. Oh, then it might not be. So, we don't we have to put it in a larger context. Um, uh, and the other thing is, and I think people who are skeptical of all this nutrition research, and there are plenty of of people, they often say, well, you know are you doing just a diet diary where people are remembering what they ate which has a lot of flaws in it, like what was the last meal I ate? uh or are you actually monitoring it? You know you mentioned Kevin Hall, one of the great uh uh researchers, and you know he puts people in which he controls everything so they can't even tell if they're gaining or losing weight.

1:08:34 Exactly., And, so, I, think, that's, a, very big uh important question that you know again if you've got five or six studies different populations, um that that lends more support I think to

1:08:48 you, don't, like, the, blue, zones., No,, I, do like the blue zone. Oh, you do like the blue. I do I actually believe so there's a lot of criticism of the blue zones like you know it's a lot of fakes and blah blah blah.

1:08:57 Actually, if, you, look, at, the, original findings of the blue zone they have one of the absolute best Belgian epidemiologists most rigorous guy not just look at birth certificates but look at uh um church records and school records and other things and really confirm the ages of people. um you know then it became commercialized and you know that but I think uh a a fair amount of that data uh especially initially uh very very good highquality observations about the diets of those people actually I I praise them I I think the blue zones are more accurate I think the current criticism is not as rigorous as the uh initial studies that they did

1:09:42 okay, um, you, mentioned, milk, feelings, on raw milk. Are you going to take shots with Secretary Kennedy in the White House?

1:09:51 There's, a, reason, we, celebrate, Louis Pasture and think he's one of the great geniuses of all time. It's called pasteurization and it saved us from terrible things like getting TB or other infections from milk. Raw milk is not nutritionally substantially different from regular milk and homogenized pasteurized milk. and it has no proven advantages and it's got plenty of infectious disadvantages.

1:10:18 So,, are, you, concerned, that, now, certain states are moving forward to uh allowing the sale of raw milk?

1:10:24 I'm, concerned, actually, that, RFK, has changed the attitude and changed the threshold and convince people like uh you know to roll back vaccine mandates. We've just seen some of that happening recently. to roll back fluidation uh so that uh kids don't get cavities to permit things like raw milk uh that have uh serious uh dangers and we're going to see a lot more of this uh and I'm worried what's the end result. Well we're already beginning to see it with the measles vaccine but people are going to suffer. Children are going to suffer.

1:10:57 People are going to die as a result. This is not the direction we should be going.

1:11:02 Yeah., Do, you, think, he, should, resign? I don't think he should have been uh approved in the first place. And I think Bill Cassidy, Senator Bill Cassidy from Louisiana, got a piece of paper. It's clear that piece of paper was worth nothing and he should be his conscience should uh plague him.

1:11:20 Things, he, believes, in., Senator, Cassidy, he's a physician. I respect him a lot. He's actually quite thoughtful. Um and uh he just the pressure on him to vote yes. And we have all suffered because of it. Yeah. So, you want him to stay in office?

1:11:36 No. So,, you, want, him, to, resign, now? I, just, However, however, we, can, get, him, out,, you're, happy with it

1:11:43 because, I, I, did, a, whole, uh, video, and article actually we got it published in Fox of all places uh calling for his resignation because

1:11:52 he's, just, doing, anti-science, work, in, a position that requires the highest integrity of science.

1:11:57 I, totally, I, I, I, totally, agree, with, you and, he's, been, a a, big, danger., uh, you know this all this vaccine I mean he may

1:12:05 I, mean, the, Tylenol, autism, press conference was the biggest disaster I think I

1:12:08 I, and, he's, creating, a, situation, where, we might not have manufacturer of vaccines he argues I'm not taking vaccines away from people but you're going to create a environment where no uh vaccine manufacturer can make a profit that is going to take vaccines away from people

1:12:25 how, do, you, feel and, that, by, the, way, on, a, day, or, I, guess it was yesterday where we got data that the shingles vaccine mean you know slow dementia right I mean it's like what it this is crazy the uh human papilloma virus you know prevents cancer

1:12:42 I, think, he, doesn't, believe, this, is, my personal belief that he doesn't believe in germ theory

1:12:48 interesting, interesting because, like, the, whole, HIV, poppers, thing is just strange to me and it just seems like he doesn't believe bacteria is an issue or viruses are an issue so um most people either love or hate. I rarely see someone who is indifferent. Uh GLP-1s what are your feelings on them as a class of medications?

1:13:09 I've, written, a, lot, about, them., I, am actually quite bullish on GLP1s. Um if you look at the data, they make a big difference of people with obesity, a big difference of people with diabetes. Uh and looks like they have big impacts on addiction now. And uh because of the impact on diabetes and heart disease you've got a big impact on cardiovascular mortality. You got a big impact on renal disease. You got a big impact on arthritis and the need for hip and knee replacements. Do they have side effects? Yes. Probably the major most worrisome side effect is muscle mass loss. Um and we still don't know the optimal way of using them. You know, how much diet wraparound do you have? Can we sort of treat people for a year, get them to 15 to 20% weight loss, and then micro dose them and maintain it? We've got a lot to learn, but they are

1:14:00 and, there's, new, ones, on, the, horizon. They're, remarkable,, remarkable, drugs. I'd like to say that there are, you know, five big innovations uh since the uh uh uh human genome project. Um you know, there's crisper technology there's uh gene editing which was done at Penn, uh there's CARTT therapy which was done at Penn, there's mRNA therapy which was done at Penn, and there's GLP1s. All of those are huge breakthroughs and it's a huge breakthrough.

1:14:30 Philosophical, question, about, GLP-1s. Given that we as society love shortcuts is there a world where we fall in love with GLP1s to a level where it perhaps becomes an unhealthy medication even though it has so much process for these conditions?

1:14:49 No. And, I, I, think, you, know, people, are especially in the maha movement, we shouldn't use GLP1s. people should have responsibility and they should eat better and exercise. You know, one of the things I think that might happen with GLP1s is people actually improve and their entire attitude towards life changes. They now see a future. They see themselves in a different place. They might then begin to invest in wellness. you know, eating better, exercising sleeping better, having more social abilities because their body image has changed, um, and the like. So, I actually think that could be, uh, a real positive, you know, uh, self-reinforcing cycle. What bothers me is that people who are, you know, have a BMI of 25 or 26 are not use.

1:15:40 Oh,, that, is, awful., Yeah., Awful., And, I and, you know, I don't want to pay for that. Uhhuh. And through our health insurance system, I don't think that's right. Uh but I I do think people who need it, who have a BMI of 35 or god forbid 40, um they definitely uh should be trying it now. They might not be able to last. The side effects might be too great, etc. But there are real real benefit

1:16:08 and, costs, are, still, an, issue, even, though we have this wonderful press conference. Well look um, it could be a gamecher for the whole health care system if we could get the cost under $100. One of the biggest problems, it seems to me, is that we haven't thought creatively about the cost. Um, and you know, let's face it Eli Liy, I think last quarter made10 billion in revenue of10 billion on GLP1s, and a lot of that was profit. Um but we there are lots coming on the market. Um and hopefully there will be more competition. We'll be able to drive the price down especially when uh semiglutide goes off patent. Yeah because I've seen the prices uh that they announced not exactly hold true a for everyone's plan, but I even had patients who have a a commercial plan working in a in a hospital system, let's say. They were getting their WGOI covered and then once this announcement came out, they said, "Oh, well, now the

1:17:09 out of pocket is only $300. You can pay for it yourself." So people who have gotten it covered now are paying out of pocket in order to make up the difference from the loss of the insurance company. So it's like all these shifting budgets as we said earlier in the episode. So

1:17:23 very, but, I, do, think, the, drugs, themselves are a big positive. Yeah., And, we, we've, seen, it, in, our patient population. I've even had a physician on the show who talked about how food noise destroyed her life to the point where she couldn't focus in school. She had to make the choice between being morbidly obese or failing out of med school. And by trying Wgoi it allowed her to be human during uh a dinner with her husband to allow her to focus on research and now she works with the US figure skating team. So it just shows how for some individuals who especially have this issue with food noise. That's where the word game changer really needs to be used. I

1:18:05 I, agree., I, h, have, a, friend, from, college, very dear friend, and I suggested to him, you know, you should think about going on uh uh Monero uh uh Zebound. And um

1:18:19 he, said, the, next, day, his, obsessions, with food, his need to constantly combat uh eating more totally changed and his relationship with food has changed and he's dropped uh about 10% already. Yeah

1:18:32 you, know,, it, is, a, dramatic, dramatic medication. Well,, you, know,, the, the, research surrounding willpower being a limited resource is not clear and there's some good book there's good books on it and I I've read them as well, but there's been some conflicting reports based on how you grew up and adverse childhood experiences and how all that plays into it.

1:18:51 But, the, reality, is, your, brain, is, still has a finite amount of energy and decision-making capacity. And I think that's a prime example of that.

1:18:58 I, agree., And, somehow, it,, you, know,, the reward system, GLP1s interfere with the reward system. And it's not just rewards for food. It's rewards for many, many other things. You know, whether it's alcohol or smoking or drugs. We're going to find out that it's

1:19:16 what, exactly, it, is. You, know,, no, one, predicted, it, would, have a central nervous system effect

1:19:22 but, here, we, are. Yeah., Well,, doctor,, this, was, a, very, fun conversation uh for me. very cathartic in some ways. Um I don't think we quite solved the healthare system, but I think there's room for part two of our conversation. Perhaps when some uh exciting news comes out or another book of yours comes out.

1:19:38 Great., Wonderful. Tell, us, uh, real, quick, where, uh, listeners can find your work, where can they follow along.

1:19:45 So, I, I've, begun, to, be, on, Instagram, and Tik Tok. Uh my book is uh Eat Your Ice Cream will be available January 6th. Uh you can pre-order it now. Uh, I hope it's a fun read. I've been told it's a fun read. Uh, it actually was a uh, so I wrote it out of anger uh, at a lot of these uh, wellness gurus, but I tried to infuse a lot of humor and a lot of my family stories and uh, stuff into it. And I'm working on another book uh, and so uh, I publish every few few times a month I guess and op-eds and various new the New York Times, the Atlantic, the Washington Post.

1:20:23 Perfect., All right., Well,, thank, you, so much for your time. Great. It was been a lovely interview. Thank you so much.

1:20:28 Awesome. Eating, ice, cream., Okay., How, about someone who only eats syrup? Yes, that's real. Click here to check that out. And as always, stay happy and healthy.

Questions about this episode

What is discussed in "Which Country Has The Best Healthcare? | Dr. Zeke Emanuel"?

In order: 0:00 Eat Your Ice Cream; 50:00 Kevin Hall, Norwegian University; 1:00:00 Kevin Hall; 1:10:00 Eat Your Ice Cream.

What is mentioned in this Doctor Mike episode?

6 people, works and ideas are mentioned, including Eat Your Ice Cream, Kevin Hall, Norwegian University, Eat Your Ice Cream: Six Simple Rules for a Long and Healthy Life, Eli Lilly, Louis Pasteur. Each one on this page links to its own page with every episode that mentions it.

How long is "Which Country Has The Best Healthcare? | Dr. Zeke Emanuel"?

The episode runs 1 h 21 min; the transcript is about 14,326 words in 185 timestamped sections.

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