The People's Pharmacy

Millions of people suffer with foot trouble. Some have heel pain when they first get out of bed. Others complain of flat feet or bunions. Athlete’s foot is very common, though it doesn’t always respond as expected to antifungal medications. Speaking of fungus, toenail fungus can be extremely stubborn. What are your feet trying to tell you about what they need? How can you keep them healthy, especially in the summertime?

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, August 1, 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 August 3, 2026.

What Are Your Feet Trying to Tell You?

Most everyone looks forward to summer vacation, but that special time away from the usual routine may pose challenges for your feet. Whether you are hiking in the mountains or running on the beach, you may need to pay attention to your tootsies.

Time at the Beach

Beach time can inspire long walks on the sand, but soft sand could really put a strain on foot muscles that aren’t accustomed to it. Our expert guest, podiatrist Jane Andersen DPM, recommends wearing good running shoes for walking long distances on sand. Choosing to walk where the sand is hard-packed when the tide is low can also be helpful.

Possibly the most important but easily overlooked step to protect feet at the beach is to apply sunscreen. The tops of the feet are easily overlooked, but they can burn pretty readily. And if you are planning to spend time sunbathing prone, you might even want to apply sunscreen to the bottoms of your feet. They never see the sun, and walking on sunburned soles could be quite painful.

Protecting Bare Feet

Another consideration at the beach is how you will get from the parking lot or boardwalk to the water. How hot is the sand? If it is hot enough to burn the soles of your feet, you might consider using water sandals.

In general, going barefoot can be risky. Whether you’re at the beach, at a campground, in your own backyard or even inside your home, there are potential hazards underfoot. Bits of glass shards, little pieces of wire, tiny pebbles or nails could all cause havoc if they end up embedded in a sole. Protecting your soles by wearing good flip-flops makes a lot of sense. To find a list of flip-flops that provide appropriate arch support as well as sole protection, consult apma.org.

Treating Black Toenails

During this episode, Joe describes a trip to the beach with a long walk. By the time he removed his shoes, his longest toe had a black toenail that was rather painful. Although the pain faded before too long, it took about a year for the dark color to disappear from the nail. Dr. Andersen suggests that it often takes at least nine months to regrow a toenail. She emphasizes that if the nail turns black due to sudden trauma (like dropping something heavy on the toe), a podiatrist should check it out. Sometimes there is a fracture under that discolored nail that requires medical attention for proper healing.

What Is the Story on Flat Feet?

Joe has always had flat feet. Perhaps your feet are flat, too. The condition is pretty common. If Joe gets out of a bathtub or swimming pool and leaves footprints, they are almost oval. There is very little indentation in the center. Other people with higher arches may leave footprints that are nearly C-shaped. Flat feet can benefit from arch support such as orthotic inserts for shoes. High arches can also cause trouble, especially if they are linked to a genetic condition called Charcot-Marie-Tooth. It is a nerve disorder that can also lead to muscle weakness. Consequently, people with high arches may also need podiatric care for their feet to stay comfortable and healthy.

Plantar Fasciitis Is a Pain

The bottoms of your feet have thick connective tissue called fascia that run from the heel to the ball of the foot. Inflammation of this tissue causes pain, typically at the heel but sometimes along the arch. Often, more supportive footgear or special orthotics can help. Getting a shoe with the correct heel drop is important. That is the difference between the height of the shoe at the heel and at the toe. A podiatrist can recommend the most appropriate heel drop for your feet.

Stretching is also useful, particularly pulling the toes toward the knee or stretching the calf in a runner’s stretch pose and holding for 30 seconds or so. Rolling the bottom of the foot on a frozen water bottle helps with the stretch at the same time that the cold eases the inflammation. Plantar fasciitis is common and treatable. If left untreated, it may last a long time.

What Can You Do About Stinky Feet?

A couple of listeners shared their experiences with smelly feet, and we asked Dr. Andersen for her opinion. Jan described using a topical erythromycin antibiotic prescription that came as a roll-on. She also got rid of all her stinky shoes and is careful to wear socks that will wick sweat away. Dr. Andersen noted that erythromycin is very effective against a bacterial infection with Corynebacterium minutissimum. This organism glows coral under ultraviolet light and can definitely raise a stink.

Sophia wrote about developing smelly feet after walking around in wet shoes. She finally solved the problem by treating her feet with rubbing alcohol. Dr. Andersen agreed that rubbing alcohol could be helpful. So can soaking the feet in a strong solution of tea. Other tips include cleaning the floor of the shower stall frequently and always wearing socks that wick–not cotton, which absorbs sweat but traps the moisture. Acrylic or wool work better. Another tactic is to alternate shoes; don’t wear the same shoes day after day but give them at least a day to dry out.

How Should You Treat a Sprained Ankle?

There has been controversy lately about the standard RICE protocol for a sprain: rest, ice, compression and elevation. Some experts now recommend warmth instead of ice and gentle motion rather than rest immediately after a sprain. Of course, the first step is to ascertain that it is really a sprain and not a fracture. The treatment for those two injuries is completely different and the person suffering the problem may not be able to tell just from the way it feels. An X-ray is prudent.

Bunions and Hammer Toes

If you don’t suffer from bunions, you might not know what they are. In a bunion, the bone that supports the big toe (the metatarsal) moves out of alignment and starts to point more towards the midline of the body. To compensate, the rest of the big toe ends up pointing back toward the rest of the foot. This creates a bump on the edge of the foot that might be painful. There doesn’t seem to be any clear correlation between the size of the bump and the amount of pain it causes. Bunions seem to be hereditary, at least to some extent. Conservative management entails choosing footwear with a roomy toe box, not pointy-toed shoes. Podiatrists also correct bunions surgically. They can choose from a wide range of surgical approaches.

In hammer toes, one of the toes (typically the second toe) curls over so that the end that would normally face forward points downward. This too can be corrected surgically, but the recovery can be pretty lengthy. A roomy toe box is also a good bet for living with hammer toe.

Taking Care of Your Feet

We asked Dr. Andersen for general advice, and she suggested that one very important consideration is to buy your athletic shoes in person, preferably at a store that caters to athletes. Buy the proper shoes for your activity; in other words, don’t try to play pickleball in running shoes. One nationwide chain that does a good job fitting the shoe to the athlete is Fleet Feet. Locally, she recommends Bull City Running.

This Week’s Guest

Dr. Jane Andersen, Board Certified, American Board of Foot and Ankle Surgery, is in practice at Chapel Hill Foot and Ankle, part of FASMA, Foot and Ankle specialists of the Mid Atlantic, in Chapel Hill, North Carolina. Dr. Andersen specializes in Foot and ankle care for Children, Adults, Athletes and Geriatric Patients including surgery and conservative care. She is a Trustee of the American Podiatric Medical Association. January 18, 2025, Jane Andersen, DPM, was awarded the Edwin B. Martin, Jr., Award for Podiatrist of the Year. https://www.chapelhillfootandankle.com/dr-jane-andersen

Jane Andersen, DPM, Chapel HIll Foot and Ankle

Listen to the Podcast

The podcast of this program will be available Monday, August 3, 2026, after broadcast on Aug. 1. This week’s podcast has additional information on smelly feet as well as foot and nail fungus. What remedies or medications work best? How long does it take for nail to grow out? What are the best toenail clippers? (Miltex) You can stream the show from this site and download the podcast for free.

One of the most basic pillars of health is good nutrition. A range of eating patterns might all be considered balanced diets, but in general people do better when they eat less processed foods and more whole foods. Vegetables and fruits play a starring role in at least two diets that have been studied extensively, the DASH diet and the Mediterranean diet. Americans might be healthier if we followed these eating plans, but fresh veggies can be pricey. If your doctor were prescribing produce, would your insurance plan cover it? Might this make healthful eating more of a practical possibility?

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, Jan. 24, 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 Jan. 26, 2026.

Food Is Medicine

Increasingly, healthcare providers are recognizing the critical role of diet in the development of chronic disease. An entire movement is organizing around the concept of Food Is Medicine, both for prevention and for treatment of conditions like diabetes, obesity and heart failure. Scientists have shown that diet makes a difference. Studies have confirmed what many of our grandparents or great-grandparents intuited. On the other hand, translating that knowledge into action that benefits patients has been difficult. One important barrier is the cost of groceries. Our interview with Peter Skillern and Dr. Seth Berkowitz focused on access to fresh fruits and vegetables for lower-income people in North Carolina. Since we spoke with them, we read about an intriguing effort to provide culturally and medically appropriate food for heart failure patients in Navajo Nation.

Traditional Foods for Better Heart Health

Food insecurity goes hand in hand with medical complications, as the authors of a new study note (JAMA Internal Medicine, July 27, 2026). The results demonstrate that making sure people with heart failure have the food they need can cut hospitalizations. The Diné (Navajo) community helped design the intervention, named Medically Utilized Tailored Traditional Foods to Optimize Nutrition in Heart Failure (MUTTON-HF, probably a reference to a favored food among the sheep-raising Navajo).

According to the investigators,

“We partnered with local Navajo farmers and ranchers to source meat and produce and with Tocabe, a Native-run kitchen, to produce the medically tailored frozen meals, practicing whole animal utilization and Native first supply chain when possible.”

The study provided intensive support, including refrigerators and microwaves to families that did not have them. The researchers  recruited 206 heart failure patients at two Indian Health Service sites in Navajo Nation to participate. A total of 206 patients were randomly assigned to receive culturally and medically tailored meals along with their healthcare or to get usual care without meals. The meals were designed to follow DASH (Dietary Approach to Stop Hypertension) sodium-restricted guidelines. For example, one breakfast provided consisted of blue corn meal, blueberries, bison sausage, potatoes and butternut squash. A sample lunch included mutton, steamed corn, blue corn meal and wild rice. People in the control group, who got no meals during the trial, could opt for an equivalent number of meals to be provided after the study assessment was completed. This was deemed fair by the community.

By the end of the two month trial, 40% of those getting meals had needed emergency care or hospitalization. In comparison, 57% of those who did not receive meals needed hospitalization or emergency intervention. The rate of hospitalization for heart failure was sharply different, 4% vs. 13%.

The authors conclude:

“Community-based interventions that leverage protective assets of Native communities are needed to advance Indigenous health.”

What Should We Learn from the MUTTON-HF Trial?

An editorial (JAMA Internal Medicine, July 27, 2026) pointed to some of the unusual features of the experiment that contributed to its success:

 “Success required collaboration between local Diné (Navajo) community-based organizations, kitchens and food producers, working alongside Indian Health Services, clinicians, and academic partners.

“Importantly, the study team prioritized listening to community and prepared meals using foods foundational to Diné cuisine.”

The editorialists note that this food is medicine approach has the potential to be even more powerful than some potent medications:

“The second takeaway is that healthy, Indigenous foods and a community-centered approach resulted in larger reduction in HF-specific hospitalizations than a recent trial of glucagon-like peptide-1 (GLP-1) receptor agonists,2 a medication now driving a $100 billion industry. A medication with trial evidence showing the same results as this meal study, particularly one with such a favorable adverse effect profile, would be a major therapeutic achievement and likely covered by insurance. This framing is not to pit medically tailored meals and GLP-1 drugs against each other, but rather to highlight the scale of improvements observed in this study. Meals and other treatments such as GLP-1 drugs are not mutually exclusive and can have complementary benefits, as GLP-1 drugs do not necessarily improve dietary intake. One treatment represents a marvel of pharmaceutical innovation; the other reflects the power of healthy meals rooted in cultural celebration.”

Doctors Prescribing Produce

In North Carolina, the approach was different. In former times, people could get healthful food in a variety of ways. Past generations often had gardens and grew much of their own produce. That’s not always practical in urban settings or for families with multiple jobs struggling to make ends meet.

Our guests today have tested two ways to get fresh food into people’s hands. One is a debit card that can be used to buy any WIC-approved food at more than 66,000 retail outlets across the country. WIC is the USDA supplemental nutrition program for Women, Infants and Children. WIC-approved foods include fresh fruits and vegetables with no added sugar or salt. In this model, the healthcare provider arranges for certain patients to get access to this debit card, providing $40 worth of purchasing power for healthy foods each month. They are essentially prescribing produce. The idea is to use a business model that supports good food and saves the health system money. This is termed a healthy food subsidy.

The other approach is a food box. This includes vegetables and fruits, and possibly other foods, that providers decide the patients should get. In some initiatives, the person or agency deciding what goes in the food box might also take into account what is available from local farmers. The box may be distributed weekly, every two weeks or every month, but the individual who is going to be eating the food does not choose what is in it.

How Does a Healthy Food Subsidy Compare to Food Boxes When Providers Are Prescribing Produce?

When people don’t know if they will be able to pay for the groceries they need, they are said to be “food insecure.” This complicates a range of chronic conditions, making diabetes more challenging, for example. People with food insecurity have a harder time keeping their blood pressure under control. Our guests collaborated with other colleagues on a recent comparing the food box approach to the healthy food subsidy among North Carolina resident with high blood pressure and food insecurity (JAMA Internal Medicine, Dec. 1, 2025).

The study enrolled 458 individuals. Everyone in the study had a provider prescribing produce. Half the volunteers got the food subsidy debit card and half were provided with food boxes. Those getting the food subsidy had moderately lower blood pressure after six months compared to those getting food boxes. Their blood pressure was also lower after a year and a half. Food insecurity decreased in both groups over time.

Tackling Food Insecurity

One of the outcomes of food insecurity is that people are more likely to need emergency department services. This costs the insurance company dearly. If improving food security and diet quality could reduce ED visits, insurers might become quite interested in the food subsidy approach. This is currently being tested for participants with heart failure.

Special Populations Who Might Need Providers Prescribing Produce

During this conversation, we expressed concern about vulnerable populations that might suffer especially from cuts in government spending. We asked about school lunches and we learned about pilot programs focusing on expectant mothers. Children in foster care are especially vulnerable; a food subsidy program taking a Food Is Medicine approach could be helpful for them.

This Week’s Guests

Seth A. Berkowitz, MD, MPH, is Associate Professor of Medicine at the University of North Carolina School of Medicine. He is also Section Chief for Research, General Medicine and Clinical Epidemiology.

Dr. Berkowitz is a general internist and primary care doctor, studying how food and nutrition interventions can improve health. Dr. Berkowitz is the deputy scientific director of the American Heart Association’s Food is Medicine initiative, Health Care by Food initiative. He is also the author of the recent book, ‘Equal Care: Health Equity, Social Democracy, and the Egalitarian State.’

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).

Dr. Seth Berkowitz of UNC promotes Food Is Medicine

Peter Skillern has pursued a career dedicated to creatively and effectively addressing poverty and inequality in North Carolina and the nation. He serves as the CEO of Durham-based Reinvestment Partners, an innovative nonprofit that works with people, places and policy to foster healthy and just communities. Reinvestment Partners advocates for financial and health reforms to improve people’s lives. The agency has won numerous accolades and is considered a state and national leader in its field.

In recognition of his leadership, he was selected as a William Friday Fellow for Human Relations and as an Eisenhower Fellow for International Relations. He holds North Carolina General Contractor and Real Estate Broker licenses. He received his B.A. from the University of California Santa Cruz with Highest Honors. A 1991 graduate of the Department of City and Regional Planning at UNC Chapel Hill, he was recognized as a Distinguished Alumni by the UNC

faculty in 2020.

Peter Skillern, CEO of Reinvestment Partners

Listen to the Podcast

The podcast of this program will be available Monday, Jan. 26, 2026, after broadcast on Jan. 24. 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 1459

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.

Good nutrition is an undisputed pillar of health. Sadly, it seems to be out of reach for too many Americans. This is the People’s Pharmacy with Terry and Joe Graedon.

Terry

00:34-00:40

What if modern medicine made nutrition a priority? How would that change what we eat?

Joe

00:40-00:54

The food industry has learned how to make ultra-processed food tasty and accessible, even in food deserts. But is it contributing to our epidemic of obesity, diabetes, and heart disease?

Terry

00:55-01:00

How is the Food is Medicine movement changing our approach to fresh fruits and vegetables?

Joe

01:01-01:06

Coming up on The People’s Pharmacy, should your doctor be prescribing produce?

Terry

01:14-02:11

In The People’s Pharmacy Health Headlines: The CDC is reporting that the flu season might have peaked. Laboratory testing suggests a downward trend in flu cases. That said, this federal agency is estimating that 18 million people have caught the flu so far and 230,000 patients have been hospitalized. We’re also nearing an approximate 10,000 deaths from the flu.

The CDC has classified children as experiencing high severity influenza this season and adults moderate severity. Some experts are challenging the CDC’s numbers. That’s because the data are delayed by about two to three weeks. We may still be in the early stages of this influenza outbreak. Australia’s flu season, for example, started early and lasted a long time. In the U.S., February is often our peak month for flu.

Joe

02:11-02:55

A report in JAMA Internal Medicine suggests that older people who get high-dose influenza vaccines are better protected against infection. Over 300,000 Danish citizens participated in a study that randomized to either high-dose or standard-dose flu shots. The investigation covered three flu seasons.

This analysis considered how well the vaccination protected against heart failure and other cardiovascular complications, as well as influenza. Those who got the bigger dose had fewer hospitalizations for cardiorespiratory problems. People with diabetes also fared better on the high-dose vaccine.

Terry

02:56-03:53

Measles continues to spread at an alarming rate. Earlier this year, there was a large, long-lasting outbreak that started in Texas. While that one has calmed, South Carolina is now in the midst of a serious outbreak.

Cases have doubled over the past week or so, and the total number is above 560. While most cases have been seen among children, at least two university populations are also experiencing cases. Both Clemson University and Anderson University are dealing with confirmed measles cases in the student body. There are also cases being reported in North Carolina that seem to be linked to the South Carolina outbreak.

Public health authorities point to vaccination rates below 90%, which is not enough to provide herd immunity for people unvaccinated against this extremely contagious and potentially dangerous disease.

Joe

03:54-04:20

Last fall, the administration warned pregnant women to avoid acetaminophen because of concerns about autism. A new systematic review in the British journal The Lancet included 43 studies. The authors concluded that there’s no evidence that taking acetaminophen during pregnancy significantly increases the risk for autism spectrum disorder, ADHD, or intellectual disability.

Terry

04:21-06:17

Falls are dangerous for older people and can result in injury, limited mobility, and even death. For decades, scientists have wondered whether vitamin D might help with muscle strength and balance and thus prevent falls. The results of studies have been inconsistent.

Finnish researchers took advantage of an existing study called the Finnish Vitamin D trial to investigate this question. Nearly 2,500 healthy older participants were assigned to take vitamin D3 at 1,600 international units or 3,200 international units a day or placebo. The investigators collected data on falls and injuries at baseline and at 1, 2, 3, and 5 years. Blood levels of 25-hydroxyvitamin D increased among the individuals taking vitamin D supplements.

Over 5 years, just over half of the volunteers had taken a fall and 11% had sustained injuries. Those proportions did not vary much between any of the groups, including those on placebo. The scientists concluded five-year vitamin D supplementation of 1,600 international units a day or 3,200 international units a day did not affect the overall risk of falls or fall injuries among generally healthy, largely vitamin D-sufficient men and women.

And that’s the health news from The People’s Pharmacy this week. Welcome to The People’s Pharmacy. I’m Terry Graedon.

Joe

06:17-06:43

And I’m Joe Graedon. Our topic today is food. And I have to admit that I’m biased. My earliest years were spent on a dairy farm in eastern Pennsylvania. Even after we moved, visiting Uncle Leo was a highlight because of the vegetables and super fresh whole milk. Uncle Leo and my mom, Helen Graedon, lived into their 90s and prized real food.

Terry

06:43-06:55

Good fresh food is a delight that’s not available to everyone. Should we also be thinking of food as medicine? If so, how could we make it affordable and accessible?

Joe

06:56-07:02

We have two distinguished guests today who are at the forefront of the food as medicine movement.

Terry

07:03-07:37

Dr. Seth Berkowitz is Associate Professor of Medicine at the University of North Carolina School of Medicine and Section Chief for Research, General Medicine, and Clinical Epidemiology. He’s a general internist and primary care doctor studying how food and nutrition interventions can improve health.

Dr. Berkowitz is the Deputy Scientific Director of the American Heart Association’s Food is Medicine Initiative. His book is “Equal Care: Health Equity, Social Democracy, and the Egalitarian State.”

Joe

07:38-08:03

We’re also talking with Peter Skillern, CEO of the nonprofit agency Reinvestment Partners, an innovative nonprofit that works with people, places, and policy to foster healthy and just communities. In recognition of his leadership, Peter was selected as a William Friday Fellow for Human Relations and as an Eisenhower Fellow for International Relations.

Terry

08:04-08:06

Welcome to The People’s Pharmacy, Peter Skillern.

Peter Skillern

08:07-08:08

Thank you so much, Terry. It’s good to be here.

Terry

08:09-08:12

Welcome to the People’s Pharmacy, Dr. Seth Berkowitz.

Dr. Seth Berkowitz

08:12-08:13

Thank you. I appreciate the invitation.

Joe

08:14-08:25

We are delighted to be able to talk about one of our favorite topics, which is food. And, you know, Terry’s grandparents were very involved with food a very long time ago.

Terry

08:26-08:41

That’s true. My grandfather was the butcher in the little town in western Nebraska where they lived. And my grandmother had a huge garden and raised chickens. I mean, it wasn’t a hobby. It was just, you know, what you did.

Joe

08:41-09:09

And my grandfather, at the early part of the 20th century, was a back-to-the-land kind of guy. He bought a farm in Pennsylvania, and my uncle Leo ran that farm for decades. He was a dairy farmer. And my mom and dad were always very big on gardening. They had a huge garden, and they prized their fresh vegetables. Like you would eat them in the garden because they were so delicious.

Terry

09:10-09:43

Well, you know, most people today don’t have that experience. They don’t have the space. They don’t have the time to do a garden. They may not have the knowledge. So how can people get the food? What they do is they rely on supermarkets, but produce is expensive. So when budgets get tight, often what people do is they cut back on the fresh fruits and fresh vegetables and they look for food that’s cheaper, which often is more processed.

Joe

09:44-10:05

And not very good for you. So let’s go back a couple thousand years to Hippocrates, who is reported to have said, let food be thy medicine, let medicine be thy food. So let’s start at the very beginning. Peter Skillern, what is the Food is Medicine movement?

Peter Skillern

10:05-10:21

It’s an initiative that’s nationwide of practitioners, health care providers, insurance companies, and I think most importantly patients who are asking that the health care system assist them with their health by helping them pay for food.

Joe

10:22-10:24

How did you get interested?

Peter

10:24-10:49

Well, I run an anti-poverty organization, and we’re committed to helping improve people’s lives, their health, and their food security. But an important component of that is to find a business model that sustains it. We have to move beyond simply grant-based or charity. We need to find a business model where the health care system says it’s in our financial interest and in our obligations for good health care to help provide food.

Terry

10:49-10:51

Tell us a little bit more about that business model.

Peter Skillern

10:53-11:18

Well, ideally, we’re trying to show that we can save the health care industry money. About 80% of health care costs are created by this treatment of chronic diseases related to unhealthy food, diabetes, cardiovascular, liver disease. So if we can help show an improvement in those conditions, reducing costs, we hope that the health care system will pay for food like it pays for medicine.

Terry

11:18-11:24

So going to another old aphorism, an ounce of prevention being worth a pound of cure.

Peter Skillern

11:25-11:27

It’s both prevention and it’s treatment.

Joe

11:27-11:56

Well, let’s turn to Dr. Berkowitz. Dr. Berkowitz, you have a medical degree and a PhD. You’re an internist. You see people with cardiovascular disease and diabetes and all sorts of other conditions. Are there any studies, any science to support what we’ll call the food is medicine movement that fruits and vegetables actually make a difference in people’s outcome?

Dr. Seth Berkowitz

11:56-12:41

Yeah, I think there are a lot of studies, actually. So one of the things that we think about for food as medicine is how can we use various ways of providing healthy food resources to overcome barriers people might have to healthy eating.

And as we were alluding to, there are a lot of different conditions where that might be relevant. And so there’s been a real burgeoning of studies across a number of different clinical populations that try to use food as medicine principles to improve health outcomes.

That could be improving things like blood pressure or blood sugar. That could be improving things like a reduced need for emergency department visits or hospitalizations and really a number of different clinical outcomes that might be affected by food is medicine study or food is medicine intervention.

Joe

12:41-12:59

It sounds like medicine is, I’ll say, rediscovering what our great, great grandparents knew, you know, almost intuitively from the time they were young kids until the time they died. It was like, yeah, food, food is essential for good health.

Dr. Seth Berkowitz

12:59-13:59

Yeah. I mean, I think there’s no doubt that nutrition is, you know, a key part of health. An analogy that I sometimes like to use for food as medicine is with physical activity and exercise. So we know that physical activity and exercise are also key parts of health. They go on throughout our lives and are not necessarily connected to health care or the health system, even though they help make us healthy.

But there are certain circumstances, say after an injury where you might get physical therapy or after a heart attack where you might have cardiac rehab, that physical activity and the health care system intersect to promote health. And I see food as medicine analogously. Food means lots of different things, lots of different people. It’s culture, it’s celebration, it’s nutrition. And some of that might not be in any conjunction at all with the healthcare system, and that’s totally fine.

But there are certain situations, maybe with high blood pressure or with diabetes or other things, where the intersection of food and the healthcare system might produce a health benefit in a way that’s analogous to how physical therapy can produce health benefits.

Terry

13:59-14:20

You’ve mentioned high blood pressure a couple times, and Joe asked about research. And we know that there is a diet that can help people lower their blood pressure. It’s called the DASH diet. Tell us a little bit more about that and the pretty robust research backing that it has.

Dr. Seth Berkowitz

14:20-15:10

Yeah, so the DASH diet, I think, is one of the best studied dietary interventions. It focuses on things like having lower sodium content in the diet, higher potassium content, which generally comes from eating fruits and vegetables, using healthy fats, not having a lot of refined grains or carbohydrates, and things like that. It’s been shown to lower blood pressure in a number of randomized trials. It’s an overall healthy dietary pattern and likely has impacts on other types of cardiometabolic disease, things like heart attacks or strokes or things like that, even though it was originally designed for high blood pressure.

And if there are ways to help people follow a DASH diet, then that’s likely to have very big health impacts. Also just to say, I think that’s one example of a healthy dietary pattern, but there are lots of diets that is not something that is preferred or culturally appropriate or things like that.

Joe

15:11-15:43

Peter, we have all been told by every healthcare professional that we’ve ever interviewed, don’t smoke, exercise, and eat a well-balanced diet. It’s sort of like a mantra. And yet it doesn’t mean much to people.

It’s sort of like, ‘Oh, yeah, okay, I’ve heard that a dozen times, a hundred times. How do I implement that in my life? How do I make that part of my real-world experience?’

Terry

15:44-15:48

Can I balance my diet with potato chips in one hand and chocolate cake in the other?

Joe

15:49-16:00

So how do you make it possible for people who are on the edge sometimes in terms of their finances to be able to get really healthy food?

Peter Skillern

16:02-16:20

The biggest obstacle to eating healthy for low-income people is the cost of the food. And our program in providing a $40 benefit or $80 on a card that’s restricted for healthy fruits and vegetables at almost any retailer allows them to choose and buy that healthy food.

Joe

16:20-16:22

How does it work? Tell us about that card thing.

Peter Skillern

16:23-16:45

Yeah, so we do a debit-restricted card that can purchase any WIC-approved fruits and vegetables at almost any retailer in the country. So it empowers people both the purchasing power, but also the choice of where they purchase it, what they purchase, when they purchase it.

And that high agency that’s been given those participants leads to higher compliance with eating healthy.

Terry

16:45-16:52

Now, Peter, you said WIC approved. WIC, I think that stands for women, infants, and children. What does it mean?

Peter Skillern

16:53-17:03

It means that you can do produce that does not have any additives to it. So it could be canned or frozen as long as there are no salts or sugars added.

Joe

17:03-17:11

So let me see if I understand this. You get a card, a debit card, and you can go anywhere?

Peter Skillern

17:12-17:31

We have this particular card. It is recognized at 66,000 retail outlets across the country. So most food as medicine efforts are very locally based, perhaps food boxes from locally grown food. And what we’re trying to do is to reach the scale and impact that the health care system needs.

Joe

17:31-17:32

Do people like it?

Peter Skillern

17:33-17:40

They love it. We have a 95% net promoter score, which means that they would refer it to their family and friends.

Terry

17:42-18:11

You’re listening to Peter Skillern, CEO of Reinvestment Partners, a nonprofit based in Durham, North Carolina, working to foster healthy, just communities. The agency is a state and national leader in its field.

We’re also talking with Dr. Seth Berkowitz, Associate Professor of Medicine at the University of North Carolina at Chapel Hill. He is the author of the recent book, Equal Care, Health Equity, Social Democracy, and the Egalitarian State.

Joe

18:12-18:17

After the break, we’ll find out if getting rid of the cost barrier can make people healthier.

Terry

18:18-18:23

Doctors are accustomed to prescribing medications; they might not be used to prescribing produce.

Joe

18:24-18:32

When you compare produce debit cards to a food box, what are the differences? And what is food insecurity and how does it affect health?

Terry

18:39-18:47

You’re listening to The People’s Pharmacy with Joe and Terry Graedon.

Terry

20:37-20:40

Welcome back to The People’s Pharmacy. I’m Terry Graedon.

Joe

20:40-20:49

And I’m Joe Graedon. The topic today is food is medicine. That’s a message we’ve been preaching for decades here on The People’s Pharmacy.

Terry

20:50-20:58

Americans spend more on health care than any other nation, but we lag far behind most other developed countries when it comes to longevity.

Joe

20:59-21:14

Many health professionals praise the Mediterranean diet because of its fresh produce and emphasis on real food. But many Americans find it difficult to afford fruits and vegetables. How can we change that?

Terry

21:14-21:36

Peter Skillern is CEO of the nonprofit agency Reinvestment Partners, an innovative nonprofit that works with people, places, and policy to foster healthy and just communities. In recognition of his leadership, Peter was selected as a William Friday Fellow for Human Relations and as an Eisenhower Fellow for International Relations.

Joe

21:37-22:00

We’re also talking with Dr. Seth Berkowitz, Associate Professor of Medicine at the University of North Carolina at Chapel Hill. Dr. Berkowitz is the Deputy Scientific Director of the American Heart Association’s Health Care by Food Initiative. His recent book is Equal Care, Health Equity, Social Democracy, and the Egalitarian State.

Terry

22:02-22:56

Dr. Berkowitz, I am assuming, and I should never do that, that in order for people to embrace this idea of food is medicine, you have to be able to prove it. If we want people to start eating more fruits and vegetables, we have some evidence already that eating more fruits and vegetables is good for you.

We talked about the research on the DASH diet. There’s research on the Mediterranean diet. Both of those diets are very heavy on produce. So what we’ve got are barriers. And Peter has mentioned that the big barrier is cost. How do we prove that getting rid of that cost barrier can actually make people healthier?

Dr. Seth Berkowitz

22:57-24:44

I think that’s a great question, and I think that’s a great way to frame it as well. I don’t think we need any more research that a healthy diet is healthy. I think we generally know what healthy foods are and what it will do for us. But the question is, how do we overcome those barriers to following a healthy diet that so many people face? Some of those barriers are knowledge-based, and so things like educational programs and things like that make sense.

But as you point out, affordability is a key barrier for a lot of people in the United States. And I think that’s the key innovation of Food is Medicine programs, is there’s not only the sort of knowledge and skill building that educational programs have been providing for a while, but there’s the provision of healthy food resources that make it easier for people to overcome that affordability barrier. But also, as you say, overcoming the affordability barrier means that there’s going to be an input of financial resources into the health care system or through the health care system to an organization like Peter’s to run programs and those kinds of things.

And so people are going to be looking for strong evidence that doing that really will improve people’s health. And that’s a lot of the work that I do. So I’m a physician by training. I’m a practicing primary care doctor. But I also do research. Some of that is observational research, but a lot of it is interventional research, randomized clinical trials, evaluations of interventions that are being done across our state in North Carolina and really across the country now, and looking for that evidence that shows, all right, this is the right interventional approach in the right population for the right duration of time to make it a truly covered benefit in the same way we might say that, oh, if you have a certain type of infection, you don’t just need antibiotics broadly. You need some type of antibiotics in a certain dose for a certain period of time. And that’s what turns it into a real medical intervention that can be covered through insurance benefits or things like that. And similarly, there’s a body of research that’s being built around food as medicine interventions to do that same kind of thing.

Joe

24:45-25:50

Well, Terry said that everybody knows that food as medicine is good for you and making the right choices. But I would actually take an exception to that because I think our grandmothers great-grandmothers knew that. I’m not sure that everybody recognizes how powerful food is, especially, and I hate to say this, Dr. Berkowitz, your colleagues, because a physician is trained, let’s be honest, to write a prescription. They’re trained to look for double-blind, randomized, placebo-controlled trials in the New England Journal of Medicine or fill in the blank journal.

And so the idea of spending any time at all with a patient talking about food choices seems like a waste of time. You know, I’m busy. I’ve got 10 minutes to see this person. Let me just write a prescription for, I know, atorvastatin. That’s the answer, because it’s got science behind it.

Terry

25:50-25:55

And possibly the physician is assuming that the patient knows how to eat.

Joe

25:56-26:13

There are a lot of assumptions that are made. So, you know, how do you, as a health care provider, help your colleagues begin to embrace the idea that, you know, you could perhaps help people lower their blood pressure with a food-as-medicine approach?

Dr. Seth Berkowitz

26:14-27:39

I think that’s a very fair question. I think your description of the constraints that people are facing in practicing medicine is very accurate. I think there are these time constraints. I think there is a historic focus on pharmaceutical treatments and, you know, surgical interventions and those kinds of things, but for what physicians are doing.

But I don’t think that means that the healthcare system overall is not able to do this. For example, you know, we have professionals who have a lot of expertise in doing exactly what you’re saying, registered dietitian nutritionists. And I think we could be doing a lot more to bring those folks into the care team even more than they already are. Expand the number of situations in which they’re being used.

But I do think physicians need to recognize the importance of diet for both preventing and managing chronic disease. And I think there are gains being made in that area, but it’s not exactly where we want it to be. I also think we need to recognize the complementarity between a lot of these different interventional approaches. I think we’re fortunate to have the amazing science that we have that has brought medications that can lower cholesterol or lower blood pressure or lower blood sugar.

But we also are fortunate to have the science that is proving that there are ways to use diet to do similar things. And it’s not an either-or situation. You’re probably even better off, at least in the appropriate circumstances, using both approaches to get as much benefit as possible.

Terry

27:40-27:54

Well, let me ask. You all have recently collaborated on a couple of publications showing your research. Would you tell us about that, please?

Dr. Seth Berkowitz

27:58-28:38

Sure. I’m happy to start and let Peter join in. So there have been two recent, you know, sort of studies that I think are worth talking about. One is a randomized trial where we compared two different types of food as medicine approaches. One approach used a food subsidy provided by reinvestment partners and compared it to the delivery of a food box and looked at whether one was better than the other in terms of lowering blood pressure.

And we found that people in both groups had their blood pressure go down from baseline. But the food subsidy had blood pressure, the people in the food subsidy group, I should say, had blood pressures that went down even more than in the food box group.

Joe

28:39-28:45

Let me ask you to pause there. Peter, tell us the difference between these two groups because a food box, I don’t understand.

Peter Skillern

28:46-29:04

A food box is typically put together with the provider determining what goes in the box, produce or meats, proteins, dairy or not. Maybe it’s just the produce. And it’s typically whatever is in season at the time in that region. And then they deliver that to the client.

Terry

29:04-29:08

So it’s a little bit like your CSA box.

Joe

29:08-29:09

Which stands for?

Terry

29:10-29:41

Community Supported Agriculture. And that is a program in which you pay the local farmer up front. You pay him $100, $200, and every week for the next four or five weeks during the season, you get a box of whatever it is he or she has grown. But what you’re saying is for this food box, it isn’t whatever the farmer has available, which is how the CSA usually works. It’s whatever the doctor says you need to have, huh?

Peter Skillern

29:41-29:42

No, actually, I’m not saying that.

Terry

29:43-29:43

Okay.

Peter Skillern

29:43-30:16

Ideally, you would have kind of a detailed nutritional prescription for which vegetable, for what diagnosis, for what dosage, for what duration, for what demographic, and it’s very specific. A food box is typically an anti-poverty, anti-hunger program where it’s also trying to support local farmers and local food system.

Even if all the food is bought from a retailer, someone else other than the participant is making the decisions. So the recipient receives collards or cauliflower or lettuce or whatever vegetable they may or may not choose.

Terry

30:16-30:25

I was going to say, I can already see that there could be some problems with that, because if you get collards and you don’t like collards, it doesn’t help.

Peter Skillern

30:26-30:34

And so the card, the food subsidies, allows and empowers the participants to choose which produce they want them to buy.

Joe

30:34-30:45

Okay, so we’ve got the food box and we’ve got the card that allows me to make the decision what I’m going to buy. It’s a debit card, basically. What’s the result of the study again?

Dr. Seth Berkowitz

30:45-31:06

Yeah, so again, we found that blood pressure went down in both groups. So both interventions, or at least people who received both interventions, had lower blood pressure by the end of the study. But it went down even more amongst people who had the card, the food subsidy, suggesting that maybe that element of choice and being able to match your preferences for what you’re getting could be providing some extra benefit.

Joe

31:06-31:10

And how did you feel about the results of the study, Peter?

Peter Skillern

31:10-32:33

You know, I never felt like the comparison between food boxes and the card were the essential element. The essential element was, are we reducing hunger? Are we improving blood pressure? Are we able to do that at an affordable rate that makes sense for the healthcare sector?

And I think that’s what was so powerful about this study was that our initiative reduced blood pressure of 5.4 over 6.8, which is very significant. It reduced hunger. Both interventions reduced hunger by 40%. And, you know, we were able to do that for about $40 a month. The benefits lasted beyond the intervention. And so while we provided the food for six months or 12 months, it would last 18 months.

You know, the comparison I would offer is what is our traditional medical interventions, such as blood pressure, how could this complement those pharmaceutical interventions? How can we help change behavior with this so that people aren’t needing blood pressure medicines? So those are some of kind of the bigger opportunities and questions.

To the extent that we’re helping address people’s food needs, let’s give them either source of food, boxes or cards that’s available that there’s support for. But if we’re looking to have it prescribed as an intervention, then we need to look at it for it to work across all requirements.

Joe

32:33-32:37

And it sounds like you’ve made a really good first step.

Peter Skillern

32:38-32:47

I think very significant first step. Dr. Berkowitz’s research which is unparalleled, and having it published in JAMA is kind of building the body of evidence.

Joe

32:48-32:50

And what do your colleagues say, Dr. Berkowitz?

Dr. Seth Berkowitz

32:50-33:31

I think people are excited about these findings. I mean, one of the reasons I got into this line of work or this line of research as a primary care doctor is seeing the problems that unhealthy diets cause, seeing the problems that lack of affordability of healthy foods cause, people who want to make changes to improve their health but are just unable to, but feeling like I didn’t have a lot of clinical tools to offer. And a lot of my colleagues feel the same.

So now, you know, as we’re seeing, well, hey, maybe there are some interventional programs that can make a difference, that can address these issues, that can address both hunger and food insecurity, along with improving the clinical outcomes and reducing the numbers and those kinds of things. And I think people are very excited about that.

Terry

33:32-33:35

Let me ask you, what do you mean by food insecurity?

Dr. Seth Berkowitz

33:36-34:09

It’s a great question. So food insecurity is uncertain access to the food needed for an active, healthy life. It’s considered a leading public health indicator. So up until recently, at least, it’s been tracked in the United States every year annually for the last 25-ish years or so. And it’s a way to look at what percentage of people in the population in the U.S. have a secure, a stable source of food and aren’t worrying about where their next meal is coming from or whether they’re going to be able to put food on the table at the end of the month.

Terry

34:09-34:11

What are the outcomes associated with food insecurity?

Dr. Seth Berkowitz

34:12-34:56

Food insecurity is associated with a large number of negative outcomes very consistently across a very large body of research. So it’s associated with greater prevalence of diet-related diseases like more diabetes, more high blood pressure, more heart attacks. It’s associated with more complications of those conditions once you have them.

So not only might it lead to diabetes, but it might lead to diabetes that’s out of control and results in, say, an amputation or needing to go on dialysis. It’s associated with worse mental health because it’s a very aversive condition. So stress, depressive symptoms, anxiety. It’s associated with worse learning outcomes in children. So you can think of lifelong impacts there. Essentially, almost any condition you can think of adding food insecurity into the mix just makes things worse.

Peter Skillern

34:57-35:30

One of the key indicators is the usage of the emergency room services, which is expensive for both the hospital and the insurers. We did a study with Atrium Health, which showed that with our intervention, the odds of high utilizers, visitations of three times more in six months, was reduced by 36 percent.

You know, that’s a better health care outcome. That’s a better financial outcome. And it’s a better quality of life for the health of those individuals who aren’t spending their time in the ER. And almost all of that is directly related to food insecurity. Wow.

Joe

35:30-36:08

Well, emergency department usage is unbelievably expensive. I mean, if you had to pay out of pocket for a visit to the emergency room, it would be very challenging. And it’s not good care in the sense that if you could prevent that emergency room visit, you’d be way ahead.

So you’re actually suggesting, am I hearing this right, that food security and good choices can reduce emergency department visits? Is that even possible?

Peter Skillern

36:08-36:31

That’s what our study found, but other studies as well. I think most importantly was a study that Dr. Berkowitz did on the Section 1115 Medicaid waiver, Healthy Opportunity Pilots, where food was provided to Medicaid members. And he evaluated the health outcomes and savings and found that there was significant savings primarily in the ER usage. How do your colleagues feel about that?

Joe

36:31-36:36

I mean, that’s, you know, reducing the number of visits to the emergency room. That’s huge.

Dr. Seth Berkowitz

36:37-37:21

Yeah, I think it’s a really important indicator of people being in better health when issues like food insecurity are addressed. There’s very strong evidence that food insecurity is associated with more acute health care utilization, emergency department visits, hospitalizations, higher health care spending. On average, someone who has food insecurity, their health care spending will be something on the order of $1,500 per year, more than a similar person who was food secure.

And we now have interventional evidence that programs that address food insecurity and other health-related social needs like housing and transportation barriers can have exactly these impacts that Peter is talking about. Fewer emergency department visits, fewer inpatient hospitalizations, lower spending on health care services.

Joe

37:21-37:29

You would think that health insurers would be totally on board with this project because they’re trying to cut costs.

Peter Skillern

37:30-38:26

Well, the particulars matter. You know, for which population do we need to provide this service to? What other related services need to go with it? What diagnosis are we trying to treat? So as an example, we’ll be running a randomized clinical trial with Duke Health to look at those who have cardiovascular failure and have recently been admitted to the hospital. That’s a very specific population. They have a very high cost associated with their treatment, and we believe will be very sensitive and responsive to a healthier diet.

So those are the types of questions. I think we have to, more broadly, food is medicine, more specifically, for whom? Underneath what conditions? With what additional services? Gets us to the health care outcomes that help us to save money in our system. We can’t really afford to continue our current trajectory on health care costs. And this is a new, innovative approach to help us solve a bigger problem.

Terry

38:29-38:57

You’re listening to Peter Skillern, CEO of Reinvestment Partners, a nonprofit based in Durham, North Carolina, working to foster healthy, just communities. The agency is a state and national leader in its field.

We’re also talking with Dr. Seth Berkowitz, Associate Professor of Medicine at the University of North Carolina at Chapel Hill. Dr. Berkowitz is the Deputy Scientific Director of the American Heart Association’s Food is Medicine Initiative.

Joe

38:58-39:07

After the break, we’ll talk about some of the highly processed foods that also seem highly addictive. How does the idea of food as medicine combat that?

Terry

39:08-39:13

When we look at cutting government spending on food programs, we wonder how that affects children in particular.

Joe

39:13-39:15

Will it affect school lunches?

Terry

39:24-39:43

you’re listening to The People’s Pharmacy with Joe and Terry Graedon. Welcome back to The People’s Pharmacy. I’m Terry Graedon. and I’m Joe Graedon there used to be a

Joe

39:43-39:49

potato chip commercial that challenged viewers with the slogan, betcha can’t eat just one.

Terry

39:49-39:55

Nobody says that about apples or carrots, but chips can be addictive.

Joe

39:56-40:10

Ultra-processed foods are designed to be tasty and affordable, but not particularly nutritious. What is the Food is Medicine movement doing to counteract the appeal of junk food?

Terry

40:10-40:42

We have two guests today who have worked together on some important projects. One is Dr. Seth Berkowitz, Associate Professor of Medicine at the University of North Carolina at Chapel Hill. Dr. Berkowitz is the Deputy Scientific Director of the American Heart Association’s Healthcare by Food Initiative.

Our other guest is Peter Skillern, CEO of the nonprofit agency Reinvestment Partners, an innovative nonprofit that works to foster healthy and just communities.

Joe

40:44-42:04

This is a question for both of you because the food industry has spent an awful lot of time, money, and research into making foods addictive. And I’m talking about snack foods. I’m talking about this vast majority of foods in the middle of the supermarket that is so tasty that you just want more and then more still.

And a lot of those foods have chemical names that you couldn’t possibly pronounce or understand. And they’re high in salt and they’re high in sugar and they’re high in all kinds of seed oils, which is a particular issue for us because we’ve just recently talked to some experts who say those seed oils may be pro-inflammatory and therefore increase the risk for heart disease and diabetes and maybe even cancer.

So in a sense, you’re fighting this massive and very successful food industry that has packaged foods to taste great. And we, as people, are always susceptible to yummy tasting foods, even if they’re not good for us. How do you combat that with the food is medicine idea?

Dr. Seth Berkowitz

42:05-44:23

So I think this is a great question, and I think it’s worth thinking about both the problems and the solutions at multiple levels. A lot of what we’ve been talking about in food as medicine I see as essentially treatments, things that come in after the fact, after people are already existing and have lived maybe a lot of their lives in an unhealthy food environment, in a society where economic resource distribution is not very equal, and so they experience food insecurity and things like that. And you’re trying to use food as medicine interventions to treat the consequences of that, or at least mitigate them to the extent you can. And these are effective treatments for that.

But as you said earlier, you know, we all know that prevention is probably better than treatment. And so then you get into this higher level question of how do you sort of create a system of social relations, a structure of society, so that people are in environments that promote their health. You know, we focus, I think, too much in medicine on individual solutions. The individual should resist with willpower those tasty treats or those kinds of things. And to a certain extent that that can happen.

But I think we also need to think structurally. Why is it that those foods, which have a lot of different labor inputs and other things like that, why are they more affordable than foods that seem simpler to produce in some ways, right? You know, an apple or grapes or something like that. Why is it that so many people are, you know, struggling to make ends meet and really have to choose, you know, to get their 100 calories through soda rather than 100 calories of broccoli, because it’s a lot cheaper to get your calories through soda than it is through broccoli.

And so then these structural questions, I think, really get at bigger questions around social policy and how you might use social policy to promote people’s health overall. And that will involve an element of programs that, what you might call incomes policy, distributing resources so that people have income they need to be healthy. That will involve elements of policies that target what you might call the commercial determinants of health, the ways that food industry and other industries will create products and affect people’s health in that way, and I think really is a bigger picture question that’s ultimately the really important question to be asking for what you might call population health, the overall health of the American people.

Joe

44:25-44:26

Peter, thoughts?

Peter Skillern

44:26-45:19

What problem are we solving here? Are we solving the commercial production of food and how that’s regulated and distributed? Or are we looking for this particular food as medicine about helping to address people’s individual health and then scaling that up so that it can affect our population health? That we’re using the health care system for payment, for enrollment, for treatment. And that’s a really more narrow problem to solve.

And I think that one of the challenges our food is medicine movement faces is there are so many interrelated challenges that we have. We’ve got to stay focused on what are we solving today for this type of initiative. So through providing a food is medicine food subsidy, we’re enabling individuals at scale and millions of folks to be able to make better choices. But we still have to make their… they have to make those choices and the industry has to respond.

Joe

45:20-45:21

And who’s paying?

Peter Skillern

45:21-45:44

Well, so in the publicly insured healthcare space, it’s Medicaid and Medicare and the Veterans Administration. But the majority of people are covered by commercial plans through their employers or through the American CARES Act. So that’s kind of different payers all have different standards for who will pay for this, underneath what conditions.

Joe

45:45-46:01

Because you kind of could imagine an insurance company saying, you know, if I can keep people out of the emergency department, I’m going to save money. And if it’s what, $40, $50 a month, is that how much you said for your debit card?

Peter Skillern

46:01-46:01

That’s right.

Joe

46:02-46:23

That’s a huge investment. But I’m also wondering about the government. You know, we’re continuing to hear, well, we need to slash these programs. And what will happen when that is implemented, especially with a food is medicine type program like yours?

Peter Skillern

46:23-47:07

Yeah. We say that we’re trying to meet the business regulatory and health care requirements of the health care sector. We also have to meet the political requirements, which is a broader issue. We think that this intervention addresses some concerns around efficient use of resources, emphasizing individual choice, showing greater returns. And as this research, it’s evidentiary that it’s making a difference. This food is medicine movement is not a simple task.

It is a cultural change. It’s a political change. It’s a technology change. It’s a medical practice change. It’s an individual change. And so let’s recognize the complexity of it and stay focused on those things that we can affect through this strategy.

Joe

47:08-47:37

What about kids? Because, Dr. Berkowitz, you said prevention. And prevention is always better than trying to catch up and deal with treatment. I think a lot of school lunches are, you know, what are tasty, you know, pizza, macaroni and cheese. Maybe the broccoli is not as popular.

How do we begin to get kids involved in the food is medicine movement?

Dr. Seth Berkowitz

47:37-49:38

I think getting kids involved is very important, but I’ll actually point to the National School Lunch and School Breakfast Program as an area where we’ve made a lot of improvements, actually. So throughout the 2010s, there’s been a change in the nutritional standards for school meals. Again, anytime you’re cooking at large scale for lots of people on, you know, very tight budgets, things might not be, you know, exactly what everyone would want. But a lot of studies show that the meal that kids get at school is often the healthiest meal of the day they get compared with home cooking.

And the bigger picture point, even though I think there is still room to improve, is that there has been real progress there. And so it’s been a win in a lot of ways and points to the fact that if we do make a concerted effort to change these things, we can improve the nutritional quality of the food that’s being provided.

And I think there’s a lot that the food is medicine movement can learn from the way that policy has been used in the national school lunch and school breakfast program. But to your larger point of, you know, should be should kids be involved in food is medicine programs? I think there’s a lot of potential for that.

However, the evaluation of it, I think, needs to be a little bit different for an adult with heart failure, or someone who is currently on dialysis, their short-term consequence of eating an unhealthy diet is very high. And so the healthcare costs associated with that in a couple months span is very high. And so if you’re doing a study that follows people for a few months, you’re likely to be able to see a difference between a healthier diet and a less healthy diet.

Kids, you’re talking about years, are really preparing them for adulthood and maybe their older age and things like that. And so if you use the same standards and say, well, I want to, you know, if I’m going to, you know, choose the adult program over the child program because the adult program saves me money in six months, but the child program doesn’t, you’re going to, you know, not take advantage of what could be a very large long-term impact because you’re being a little bit short-sighted about it.

So very important to include children in food as medicine interventions, but you also have to think about the specifics and the nuance of the situation when you’re evaluating it.

Peter Skillern

49:39-49:55

One area that we found is we did a pilot with Atrium in Mecklenburg County with expectant mothers, you know, and the response that mothers gave as far as the impact of food security on themselves and their newborns, you know, it was pretty tremendous.

Terry

49:57-50:10

And this is a wonderful place to do an intervention because expectant mothers mostly are very interested in doing whatever they can to promote the health of their growing fetus.

Peter Skillern

50:10-51:01

And it’s a particular area where the insurance is involved, right, with medical experience. Another population of youth are those in foster care who are often covered by Medicaid insurance underneath the behavioral health sections. That’s a Medicaid expense. 70% of young women 13 to 21 become pregnant underneath the foster care system, right? Food insecurity is extremely high among foster care children.

There’s an area for where we can provide Medicaid-provided food assistance that will help the direct health outcomes of foster care children. So there are different ways of looking at this problem of how can we intersect between the health care sector, insurance, the providers, and the patient. You know, it’s got to work for all three, and I think we can solve those problems.

Terry

51:01-51:19

Dr. Berkowitz, I’m wondering how the food is medicine movement would compare or compete or possibly complement the conventional pharmaceutical approaches to problems like you have diabetes, you want to get your A1C level down, or how about GLP-1s?

Joe

51:22-51:25

Explain GLP-1s, Dr. Berkowitz.

Dr. Seth Berkowitz

51:25-52:07

Sure, yeah. So GLP-1s are a group of medicines that work in receptors for a hormone called incretins–the hormone is called incretin–and they have a lot of effects on the body, but in particular, they have large effects on appetite and satiety and tend to result in a large amount of weight loss, and for people with diabetes, large drops in the blood sugar. And so have been a really important category of medicine over the last decades or so, the last about a decade, and really kind of taking off in the last few years for use beyond people with diabetes, but also as a weight loss medication.

Terry

52:08-52:17

And so the question is, food is medicine. How does it interact with the use of these potent pharmaceuticals?

Dr. Seth Berkowitz

52:17-53:31

Yeah, I think there’s a lot of complementarity to it. And there are a few issues involved. The GLP-1 medicines are very powerful, but they’re sort of blunt appetite suppressants. And so the quality of what you eat, even though you’re eating less overall, is still very important. And if you only use GLP-1s but don’t pay any attention, let’s say, to the quality of what you’re consuming, you know, maybe you’re only having 1,200 calories a day, but it’s only a milkshake or something like that, then that’s going to have bad health impacts, even though there might be some benefits from the weight loss overall.

The actual components of what you’re consuming will have health impacts in other ways. And so I think there’s complementarity in using food as medicine interventions for people who are on GLP-1s to promote better diet quality for the foods that people are eating. A number of people have side effects with GLP-1s and so can’t tolerate them long-term.

And so food as medicine interventions might be an alternative. And a lot of people may want to stop taking a GLP-1 at some time. They might have lost the amount of weight that they’re looking to lose and would like to sort of stay at that weight or, you know, slow the regain of weight to the extent possible. And so food is medicine interventions can be helpful in that situation as well, I think.

Joe

53:31-53:57

I’d like you both to look into your crystal ball and say, okay, if we were in charge, if they gave us a lot of money to make food is medicine kind of the primary way that both the public as well as health professionals would look at this whole process, what would the future look like for you and how would you implement it?

Terry

53:57-53:59

And you each have one minute.

Joe

54:01-54:03

Starting with you, Dr. Berkowitz.

Dr. Seth Berkowitz

54:03-55:03

Okay. Well, maybe this will be my curveball. So I think food as medicine programs are very important and I think it’s important that they have a place in the healthcare system. But I really don’t think that we can lose sight of the question of why are food as medicine programs needed for so many people.

And so if I really have a lot of control and everything, though, so if I really have the control that you’re giving me, while one aspect of that would be making sure that evidence-based food as medicine interventions are available as insurance benefits for people, another piece would be to really sort of question, well, why is it that, you know, so many people find it so difficult to follow a healthy diet?

And are there things that we can do to address income and resource distribution in the U.S.? Are there things we can do to address commercial determinants of health? Are there things that we can do to address the reasons that people find it difficult to follow a healthy diet so that maybe they don’t even need a food as medicine intervention in the first place? But if they need it, I do want it to be there.

Joe

55:04-55:04

Peter?

Peter Skillern

55:06-56:22

Again, I focused around where the health care sector aligns with food support, around the health outcomes, around the financial incentives. You know, as a person who’s trying to address poverty at scale, I certainly support a broader safety net, right, to help people purchase that.

But within that, where does health care find its motivation? And it’s motivated by patients asking for it from providers like the clinicians saying this is needed. There is research that shows it’s impactful. And for health insurers to say we have an incentive to do this at scale.

And it may not be for everyone. Even a small population as a percentage, when you scale it across all of America and our population, we serve millions of people. Those with uncontrolled diabetes or cardiovascular failure or even smaller issues. It makes a difference at an enormous level.

So I’m not looking for the revolution. I’m looking for the incremental difference that we can make in people’s lives, but do it at a systems level across this country. So I think food is medicine has huge potential for both political and practical reasons.

Terry

56:22-56:30

Peter Skillern, Dr. Seth Berkowitz, thank you both so much for talking with us on The People’s Pharmacy today.

Peter Skillern

56:31-56:33

Thank you so much for having us.

Dr. Seth Berkowitz

56:33-56:34

Yeah, it was great to be here. Thank you.

Terry

56:35-57:04

You’ve been listening to Dr. Seth Berkowitz. He’s Associate Professor of Medicine at the University of North Carolina School of Medicine and Section Chief for Research, General Medicine, and Clinical Epidemiology. Dr. Berkowitz is a general internist and primary care doctor studying how food and nutrition interventions can improve health. He’s also the author of the recent book, “Equal Care: Health Equity, Social Democracy, and the Egalitarian State.”

Joe

57:05-57:30

You’ve also heard Peter Skillern, CEO of the nonprofit agency Reinvestment Partners, an innovative nonprofit that works with people, places, and policy to foster healthy and just communities.

In recognition of his leadership, Peter was selected as a William Friday Fellow for Human Relations and as an Eisenhower Fellow for International Relations.

Terry

57:30-57:40

Lyn Siegel produced today’s show, Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music.

Joe

57:40-57:47

This show is a co-production of North Carolina Public Radio, WUNC, with the People’s Pharmacy.

Terry

57:48-58:05

Today’s show is number 1,459. 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.

Joe

58:05-58:13

Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning.

Terry

58:13-58:34

At peoplespharmacy.com, you could sign up for our free online newsletter, and that way you get the latest news about important health stories. When you subscribe, you also get 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.

Joe

58:35-58:38

In Durham, North Carolina, I’m Joe Graedon.

Terry

58:38-59:14

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

59:14-59:24

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

59:24-59:29

All you have to do is go to peoplespharmacy.com slash donate.

Joe

59:29-59:42

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.

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.

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.

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.