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Welcome to the Healthy Brain Toolbox. I'm Dr. Ken Sharlin, neurologist, and host for this show. In each episode, I interview influential people whose work impacts how we live and how we think. My guests are leaders in the health and fitness industry, physicians, scientists. Here, you'll find conversations that break down barriers, expand your horizons, and give you the tools you need to protect your health and nourish your aging brain.

Dr. Ken Sharlin 0:30

Welcome to the Healthy Brain Toolbox podcast.

Meet Dr. David Katz

Dr. Ken Sharlin 0:34

Today's guest is Dr. David L. Katz, a physician, public health expert, and internationally recognized leader in preventative lifestyle and integrative medicine, with particular expertise in nutrition. He is the founder and former director of the Yale Griffin Prevention Research Center, past president of the American College of Lifestyle Medicine, and founder of the nonprofit True Health Initiative. Dr. Katz is also the founder and CEO of Diet ID, a digital platform designed to make dietary quality measurable and manageable in clinical care and population health. He's authored or co-authored approximately two hundred and fifty peer-reviewed publications and nineteen books, including How to Eat, written with Mark Bittman. His work focuses on translating nutrition science into practical strategies that add years to your life and hopefully to your brain, and of course, life to your years. Welcome, Dr. Katz, to the Healthy Brain Toolbox Podcast.

Dr. David Katz 1:48

Thanks so much, Ken. Great to be with

Why Prevention Beats Treatment

Dr. David Katz 1:50

you.

Dr. Ken Sharlin 1:51

Well, Dr. Katz, before we even discuss Diet ID, I'm just curious what first drew you toward preventative medicine and nutrition rather than a more traditional disease treatment model?

Dr. David Katz 2:03

So a couple things. I had an interest in nutrition that actually preceded medical school. I discovered that, Ken, as a teenager. I got into sports in high school. I was doing some long distance running. So it initially, I think it was the typical adolescent boy's interest in sports. And my dad's a cardiologist, and had some orientation to health protection and thinking about the heart and cardiovascular fitness. And it was just enough. There wasn't a strong emphasis really at home on that issue, but just enough that I started thinking if I want a high performance body, it stands to reason I should put in high performance fuel." So I acquired an interest in nutrition to service my own efforts at sports and so forth. And then it took on a life of its own, and it started to evolve. And then, I was trying to figure out what I wanted to be when I grew up, and I decided to go to medical school and become a doctor, and it followed me there. and in fact, at one point, I went to Dartmouth as an undergrad, and I loved rural New Hampshire, and then I went to Albert Einstein for medical school, so I was living in the Bronx. It was a harsh transition for me. I'm a country boy at heart. So that and a number of other reasons made me think, "Geez, I made a terrible mistake. I need to get out of here." And I started thinking, if I'm gonna just barely make it through medical school and then get the heck out, what am I gonna do?" And I thought I'll become a chef." I really, I love food, and I love what food can do. I'll be a doctor who then goes to the Culinary Institute of America, becomes a chef, and knows about health effects of food. And then I got on the wards in my third year of medical school, and I fell in love with patient care and rediscovered all the reasons I wanted to be a doctor in the first place and said, "Nah, that's it. I really am gonna be a doctor." And then when I was doing my internal medicine residency my penchant for the big picture kicked in. Most of my career has been spent as an academic physician, and academia really rewards the reductionist. That's how science has advanced in the modern era. People become highly expert in the smallest part of the very small part of the small part of the thing, and become the world's leading expert and get their Nobel Prize and so forth. and there are some really bright academics who likely couldn't find their way out of a paper bag. Just incredibly great depth of knowledge, but no breadth of knowledge. academia does tend to reward that. And so we have those expressions, failing to see the forest for the trees and tunnel vision and all that. I'm the exact opposite, and frankly, it's something of a liability an academic. I'm a big-picture guy. I always see the forest. I may overlook the details of an individual tree, but I

The Problem with "Humpty Dumpty" Medicine

Dr. David Katz 4:42

always see the forest. So when I was in my internal medicine residency, spending, 100-plus hours a week in the hospital taking care of really sick people, I fully appreciated the privilege of patient care and being the person who shows up in a person's hour of greatest need at the bedside. I really did love that But I also noticed that I was being trained to be one of the king's horses and one of the king's men, because hospital beds just kept filling up over and over again with, different names, different faces, but the same conditions: heart disease, cancer, stroke, diabetes, dementia, and of course, back in those days, AIDS too. And all of that was overwhelmingly preventable. W- we knew that most of the heart disease could be prevented and most of the strokes could be prevented. And I was basically seeing people desperately ill and, we were the king's horses, king's men, and essentially, we didn't give Humpty balance training. We didn't put a seatbelt on the wall. We didn't put cushions at the base of the wall. We just lined up the ambulances and waited for the next person to topple off. And I thought, we could do better than this because, we can do wondrous things in medicine, but we can't unscramble an egg. We need to prevent the next Humpty from falling off the wall in the first place. I wonder if there's a way to do that. how do I do something in medicine that's about preventing these hospital beds filling up over and over again in successive birth cohorts with all the same conditions?" So I found my way to preventive medicine, which up until that time I didn't even know existed as a specialty. Lifestyle medicine hadn't been invented yet, but preventive medicine was a board-certified specialty. So I did a second residency in preventive medicine public health, focusing on chronic disease epidemiology and the prevention of chronic diseases, and the rest is history. And then I brought my interest in nutrition and lifestyle into that, and those are the most powerful means at our disposal to prevent chronic diseases, to add years to lives, add life to years. So that constellation of interest became the focus of my career, leveraging the power of diet and lifestyle factors to amplify longevity, vitality, and prevent chronic disease. I've done the best I can. we got miles to go before we sleep 'cause, the burden of chronic disease has only ever gone up, not down, so I haven't had great success, but that's what I'm trying to do.

The Pillars of Lifestyle Medicine

Dr. Ken Sharlin 7:08

First of all, I would say that we have a similar, entry into an interest in lifestyle medicine, functional, for me also some regenerative medicine, but I was a triathlete, marathon runner, long-distance cyclist, and just got interested in the whole picture, not just, what I was doing on training day, but how to fuel, sleep, measure my biological stress, and know whether it was a good day to take an active rest day rather than get out there and push again. I definitely understand that. But at the same time, I realized that my own body was changing, my perspective was changing, and yet I was going to the clinic and doing what, most of our colleagues do, make the diagnosis, assign the drug, see you in six months, et cetera, and maybe winning the battle, but generally losing the war. then came that aspect of communication because early on, and I will say this, my own personal bias, but I think there is to some degree and overemphasis on diet in the sense that diet is absolutely critical, but we need to include the whole picture. We need to include sleep, we need to include movement, et cetera, relationships, all those things to create-- help our patients create health. then it was finding the right language to communicate to the patient because going back to see typically in an office note that maybe comes my way from the referring provider, patient advised to change their diet. Patient advised to adopt a Mediterranean diet. That's not really how it actually works, right? That's not why we make changes. And discovered that if I use the term healthy, like I wanna talk with you about a healthy diet, it created an immediate barrier that said, "Oh, wait a minute, I already eat a healthy diet. I don't need to listen to that." wonder what your experience has been along those

Dr. David Katz 9:16

Wow, there's so much to unpack there, Ken. It's cool that we had a similar trajectory into all of this. Similarly, I took care of patients for 30 years. As a primary care internist, I made the diagnosis and prescribed drugs too. Probably worth digressing just a moment to say that's really important too, right? We talk about putting out fires in primary care, and there are a lot of fires. People have acute problems, and being able to see a qualified, competent, compassionate health professional who can deal with that is important. So I don't think either of us is in any way dismissing what we do in primary care. We're just looking beyond that and saying, in addition to addressing today's acute need, there's that longitudinal issue of how healthy and vital are you? What is your health span likely to be, and how can I contribute to that? it's hard to do both. and shout-out to all our colleagues who are in the clinical trenches and who maybe are just making the diagnosis and prescribing the drug. It's hard to break out of that model because that's really what prevails. I agree with you. I'm a past president of the American College of Lifestyle Medicine, as you mentioned, and we elevate the concept of six domains. I summarize them as feed, forks, fingers, sleep, stress, and love. So feed is physical activity, forks is dietary patterns, fingers is don't bring toxins to your face like tobacco and excess alcohol and all the rest. Sleep, you need enough. Stress, you need to avoid too much and mitigate it. And love, social connection. So the same things that you're emphasizing. And these are often referred to in lifestyle medicine as pillars. I call them domains because they're interactive, highly interactive. If you're stressed, you're not gonna sleep well. If you're stressed and not sleeping well, you have no energy, it's hard to exercise. When you're not exercising, it affects your self-esteem, the round and round you go. Couldn't agree with you more that they're all important. I'm not sure I agree with you that diet's overemphasized for two reasons.

Why Nutrition Comes First

Dr. David Katz 11:08

One, of all the domains of lifestyle medicine, diet's the only one where there's prevailing pseudo confusion, right? So I'm not saying everybody gets the physical activity they should get, but nobody debates whether or not being physically active is better than sitting on your rear end all day.

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Dr. David Katz 13:19

There's a general societal consensus that physical activity is good for us. It's debated how best to get there from here, which exercise is better than what, who should do which one, how do you fit it into your schedule. Lots of questions to answer, but no fundamental confusion. I would argue there's no fundamental confusion about diet either, but there is a fundamental pseudo confusion. Everybody is in on the notion

Why We Need to Market Health

Dr. David Katz 13:43

that we don't know what diet is best for health, and the diet that was best last week isn't the diet that's best this week. So one reason to emphasize diet is it's the one domain of lifestyle where pseudo confusion prevails. So people it's not just a matter of you can't get there from here. People don't agree where there is. That's really important. And two, it really is a unique exposure in the sense that Food is both the fuel that runs every aspect of this wondrous human machine and its construction material too. That's a really unique relationship. So when we say you are what you eat, we really literally are. You don't eat french fries and turn into french fry or spout french fry antennae, but you do break down what you've eaten into its component parts and use those component parts to build component parts of yourself, which in a growing child is, you're literally manufacturing the child out of that construction material. In an adult, it's less obvious. But we are using up and expending hundreds of millions of cells and enzymes and hormones every day, and we need to replenish those. It's a balanced supply of nutrients that allows us to rebuild a balanced supply of those materials. If the incoming supply is not balanced, you get an imbalance in what you can build. Just imagine a construction site where you're building a house and you have more lumber than you need, but not enough wire or not enough plumbing material or not enough roofing shingles. the construction will be impaired. You need what you need, and the human body's the same. I would argue, if anything, we don't emphasize diet enough because we allow this pseudo confusion on the topic to prevail. so we can come back to that. but otherwise, we agree completely. it's all those domains that are important. And yes, it's not enough to simply advise you should eat a different diet or you should eat a Mediterranean diet. I think one of the areas where we fail, Ken, just to pick up on that theme, is I don't think we do a good job, and I mean this both in the house of medicine but also at the level of culture, in selling health, in marketing health. Because I think all too often health seems to be something that comes at the end of an admonishing finger. Virtuous people are healthy. You should do what I'm... I'm a doctor, you should do what I'm telling you because that's what good people do. That's completely wrong. I think, first of all, the doctor's not the boss. We're a coach. it's our job to know what's what and to empower our patients with options, but the patient's the boss. I don't know that we make that clear enough. If you prefer a life where you take the risks of not addressing lifestyle you take your chances because you're perfectly happy that way, It's not the choice I would make, but it's your life. You're the boss, so we have to respect that But I think the other critical consideration is that other things being equal, healthy people have more fun. Health is not the prize. A better life is the prize. You decide what you wanna do. But whatever it is you like to do,

The Hidden Risks of Diet Obsession

Dr. David Katz 16:39

you can do more of it and do it for longer, and probably do it better if you're healthy than if you're not healthy. And if you're healthy, you have more control over your life, 'cause when you're not healthy, you wind up spending your time in hospitals and doctor's offices, and that's not a choice anybody would make. It's a choice that's imposed. So you have more autonomy, more agency, more control over your life if you're healthy, other things being equal. Healthy people have more fun. And I can help you get that, and then you can decide how to spend that currency on whatever it is you like to do. Are you in? I don't think we have that conversation. I don't think we ask our patients what health is for. I don't think as a culture we do a good job of marketing health. We do a great job of marketing wealth. Everybody wants more money. I don't know that everybody thinks that I should want more health. And by the way, I would contend that health shares a lot of the great attributes of wealth. You can pay it forward. You can bequeath it. as a parent, if you make health part of your life experience, you absolutely get to share it with your kids. And what greater gift to impart to your children than a higher probability of a long, healthy, vital life? So I think viewing health as, A, a currency you can spend on having a better quality of life, B, a chance to have more fun, and C, something you can pay forward and share with the people you love, completely changes the dialogue. And then our patients ask us, "Okay, help me. How can I get there from here?" And, then it's an invitation for us to talk about whatever it is, the Mediterranean diet or physical activity or better sleep. It's not us wagging our finger and saying, if you were a virtuous person, you'd do what I tell you." So I completely agree with you. It's the communication is neglected and doesn't really flow in the channels where it would have the greatest impact.

Dr. Ken Sharlin 18:26

Where I would say that the issue, certainly, diet is, as I said earlier, is absolutely critical. The problem that I run into sometimes is that there is such an almost, not orthorexia per se, but this obsession with really getting things dialed in. I'm a neurologist, and one of the thought leaders in my sphere is my dear friend Dr. Terry Wahls. So people, read her book and see her, on podcasts and go to her website or hear her speak, and they want to follow the Wahls diet And some of them do it extremely well, and some of them give lip service, but that's fine. We'll work on that. and hats off to Dr. Wahls, who I know would say that, the diet is a centerpiece of what her message is about. On the other hand, when a person says, "But I've really got it down," and I listen to the story, and indeed they probably do, absent perhaps some nutrient testing and things like that. I said "how are you sleeping?" Or, "tell me a little bit about your-- what I call a stress resilience practice," because obviously, we all have to live with certain types of stressors in our lives, and it's more about how we manage that. In fact, in some cases, those stressors are actually quite good for us. and then things start to fall apart because it's in reality, I don't sleep that well. And, in reality, I've never actually just sat down for ten minutes and just focused on being present, or my relationships are not where they need to be. And if we just call on, for example, the SuperAgers work that Northwestern University. The thing that stands out for this remarkable group of individuals is their capacity for socialization. Their diets are diverse, and some of them aren't the best, but the capacity for social connection is remarkable. And so all I'm saying is that, yes, we absolutely need to educate, and we need to inspire and motivate our patients about food. And I always say food is fun. It's a couples thing, Go to the farmers market together, cook together. I sometimes tell them food is sexy because, that gets our dopaminergic attention. And, I say, to the guys, it can lead to certain things, so no doubt about it, it's critically important. What I'm saying is it's so important to make sure we're embracing the whole picture. What I do find is that food is often this sort of relatively easier in. It's the lower barrier. There are all kinds of issues with, getting people to take a moment and just be or, perhaps, work on their sleep, but food is something we have to do every day

Dr. David Katz 21:19

Yeah. Yeah, I think fundamentally we're agreeing they're all important, and you have to be holistic. Frankly, I've found in my patient experiences that it's difficult to fix one of these without addressing the other. Stress, sleep impairment, they sabotage the effort to improve diet anyway. So I've never had great success improving one domain of lifestyle without thinking expansively about them all. They're highly interactive. In terms of that interaction, by the way, I think that's a really important notion because otherwise it can feel quite daunting. If you're listening into this conversation and you're in the position of patient, oh, okay, it makes sense what these guys are saying, but gee, there's so much to fix, right? I have to fix my diet. I have to fix my stress. I have to fix my sleep. I have to fix my relationships. So I think helping people appreciate that actually physical activity may be the way you relieve your stress. And physical activity and the stress relief associated with it. so for example, I've never been good at meditating. I've been told I should meditate, and then when you say, "I don't have time to meditate," you're told then you should meditate twice as often." and I fully accept that's true. But I've tried, and, all I ever accomplish

What Blue Zones Teach Us

Dr. David Katz 22:30

when I try to meditate is how many emails could I have been answering now?" I just never really get past that. But I love being outdoors in nature. I have dogs, I have horses, I hike every day. I ride as often as I can. I work out, and it frees my mind and it relieves my stress. So I'm double-dipping. My physical activity is my stress relief, and that combination of physical activity and stress relief is a big part of my formula for sleeping better. I'm now halfway through the list of six lifestyle medicine domains, and I've really only just done one thing, but I got benefits that reverberate across all three. So yeah, we completely agree. Our perspective as clinicians has to be holistic, and these are highly interactive domains. I also agree with you, sadly, about the orthorexia fixation. People get, so preoccupied with their diet. And it's worse than that. we are fractious and we've divided up into different views about which diet is best. In this age of internet and social media and echo chambers, it's turned into an endless feud. My diet's better than your diet, so we wind up dividing up into diet tribes which hurl diatribes at one another instead of listening to one another and saying, what is the common theme? What are the fundamentals of healthy eating?" There's no one best way that absolutely everybody should eat, but we are all the same kind of animal, so there are fundamentals of feeding homo sapiens well. We should all embrace that, and then agree to disagree about which way we like to do it best, right? The Mediterranean diet works great if it works great, but if you're from Japan and you prefer a traditional Okinawan diet, just as good,

What Does It Mean to Be Healthy?

Dr. David Katz 24:08

right? There isn't just one way to do this. So I agree with you. It's critical to connect the dots. And again, the American College of Lifestyle Medicine is very explicit about these six domains and how important they all are And yeah, we are social animals. and, maybe John Donne said it best, "No one is an island," right? we need to be connected to one another. We thrive when we have a supportive network and good social relationships. Loneliness and isolation are devastating to health and,\ the rewards of life. And again, remember, what is health for? Health is not the ultimate prize. Health matters because when you have it, your life can be better. But if your life isn't better because you're lonely and isolated and sad, that's the critical issue. And of course, it's not necessarily an easy thing for clinicians to fix. We need some help. we need to have a reach that extends beyond the clinic, right? A lot of the lifestyle elements that contribute the most to years in life and life in years are cultural issues. You look at the Blue Zones. The Blue Zones are not places where people live to be 100 and avoid chronic disease because their doctors are terrific. They're places where people don't go to the doctor in the first place. It's just because their culture tends to support them in routine physical activity, eating a healthy diet, avoiding toxins, getting enough sleep, mitigating stress or not having enough stress to cause health harm in the first place, and a strong sense of community. Dan Buettner, the founder of the Blue Zones, really emphasizes that issue of community. it's a critical issue.

COMMERCIAL BREAK 25:51

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Dr. Ken Sharlin 27:53

So you've used the word health and healthy repeatedly, and we probably all have different ideas about what that actually means. It seems self-evident, but at the same time, like I said, I had one yesterday, with a couple who came. The husband was the patient, but the wife came, and they had both been in a very frightening motor vehicle accident. I will say, we're challenging this word a bit, that neither of them looked particularly healthy. But as neurologist, the reason they were seeing me was they were had experienced some post-concussive type symptoms. For those listening, this could be anything from in, disturbed sleep to mood changes, headache, dizziness, irritability, that kind of thing. At any rate, there's no pill for that. Not really. So when I am referred these individuals, I quickly and, get into a discussion with the patient about understanding neuroinflammation and why the brain can get stuck in that pattern. And then we start to break it down into lifestyle medicine strategies. And in my world, sometimes targeted supplementation help that along, say, a higher dose of some omega-3 fatty acids. The bottom line was, I had that conversation, and it was, "We need to tell you, Dr. Sharlin, that we do take supplements. We do try to eat clean." Of course, I respected that and listened to what they said they were doing. But I think there was still somewhat of a disconnect between my perception what was healthy in terms of having this interaction with this lovely couple, and their perception of what was healthy.

Why Purpose Is Essential for Health

Dr. Ken Sharlin 29:50

And so what is healthy? And how do we communicate that in a way through the clinic? 'Cause here we are, we're clinicians, and our mission is to prescribe health, right? Prevent disease, and even in my world, treat disease with lifestyle.

Dr. David Katz 30:07

There are lots of formal high-level debates about the optimal definition of healthy. You can look at the AMA's definition and the American College of Physicians and the World Health Organization. In some sense, at the end of it all, it's one of those things that is easier to recognize when you see it in yourself or others than it is to define. But the formal definitions encompass both the avoidance of the bad and the embrace of the good, right? So healthy is feeling well physically, emotionally, spiritually, socially, feeling energetic and capable, so essentially empowered to do the things that you want to do. It's not healthy if there are things you want to do and you are disabled with regard to those things, right? So having the ability, the capacity, the agency to do things you want to do. Vitality is often encompassed, and feelings of sufficient energy and so forth. And then in addition, health encompasses the avoidance of the things we don't want to have happen. And so that would be the avoidance of major chronic diseases and impairments and so forth. And no matter how healthy one is in general, there can be setbacks, right? Everybody can trip and fall and break a leg no matter how healthy you are. And in fact, if you're healthy and energetic and involved in sports, you're probably more subject to injuries. I'm

Hope, Stress, and Human Resilience

Dr. David Katz 31:33

a good case in point. I'm both a lifelong alpine skier and an equestrian. Some of my best friends weigh 1,300 pounds a piece and when you're literally horsing around, the periodically stuff gets broken. So I have a very long litany of injuries. Health is not the perfect avoidance of misadventure, but it's the avoidance of chronic disabilities, frailties, and impairments. There's often reference to something that is known formally in gerontology as the rectangularization of the morbidity curve. That's the idea that you mature and then your health stays at a high plateau and doesn't degrade. A high plateau until you're really very old and all your body parts are worn out, and then you just quickly decline, and ultimately we're mortal and we die. But the idea is not to spend a long period with impairment and disability. And famously that, that is what Dan Buettner has represented to all of us with the study of the Blue Zones. People who are still doing everything they always did. If they were herding sheep in the mountains, there still are

Surviving the Internet Age

Dr. David Katz 32:40

goats. They're still doing that at 98 and 99. Then they go to sleep one night and their body gives out and they don't wake up the next morning. it's a beautiful way to check out. So I think, the likelihood of longevity, so many years in life, the blessings of vitality, a lot of life in those years And a gentle exit in the fullness of time, ideally passing away in our sleep because our body just gives out after it's been well used for all those decades. I think that's a full definition of health. This is the healthy brain conversation. Clearly it encompasses all the aspects of brain health, which I also take to mean mind health, right? All the issues of mental health and social health. Feeling gratified. I think fulfillment is a part of health, right? This notion of purpose and feeling my life was meaningful. It's meaningful to me and meaningful to the people who are meaningful to me. I think all of that's part of health as well. So in some sense, there's kind of the bedrock, definitions of health, and you could go shopping among them. And then there's your personal overlay, which is, to me, what's ,,particularly important is blank." and I think, the issue of purpose that comes up in discussions of health actually think is of variable importance. I think some people live a very purpose-driven life, and it's all about that. And they don't feel fulfilled and consequently aren't maybe perfectly healthy unless they really are clearly driving toward a specific purpose. And I think other people are more comfortable, maybe it's a little bit more Buddhist, letting go and just being. it's a softer connection and, I just happen to be here, and I want to appreciate the people that are part of my journey and the experiences that are part of my journey, but my journey isn't about changing something specific in the world. I think that's personal. So I don't think there's any way we can define all aspects of health in a one-size-fits-all manner. I think we can lay the foundation and then invite people to say, "What does healthy feel like to you?" 'Cause again, you, the patient or the boss. Once we agree on both the bedrock and whatever you choose to construct on top of that bedrock, that's the house you wanna live in, then we can work together to figure out, all right, how do we get you settled there?

Dr. Ken Sharlin 35:07

I think that purpose comes in many shapes and sizes as illustrated in the blue zones that, where perhaps there was no necessarily concept of retirement

Building Resilience in the Next Generation

Dr. Ken Sharlin 35:18

that I have a role in my community. I take care of the grandchildren. I'm responsible For the community garden. But then there's also the aspect of hope that I think really overlaps considerably with this sense of purpose. When people just have that sense of hopelessness, then it often does lead to biological failure.

Dr. David Katz 35:42

Yeah, I think that raises the issue, Ken, and you mentioned earlier that not all stress is bad. that important actually to differentiate distress from eustress. And the easiest way to think of eustress is straining a muscle by exercising it, which causes it to get stronger and grow. You're tearing it down to build it up. The mind is the same way. There are stressful exposures that make us more resilient, more capable, more resourceful, and then there's distress, which wears us down. I think one of the great challenges in this time is there's a lot of distress. There's some of us, it's worry about the planet, worry about politics and discord and wars and but also just the massive exposure to information flow, much of it wrong. It's not just information, it's information, misinformation, disinformation, malinformation, propaganda, now all being amplified by use of AI. This is an uncontrolled experiment upon the human psyche. We've never dealt with anything remotely like this in all of human history before. It's almost hard to imagine that you and I lived most of our life, including most of our professional life, in a pre-internet era because it's been so radically transformational. Can you even remember what it was like on a weekend to not know what the whole world was thinking? You'd wake up on a weekend morning and there was just nothing. It was just, sound of birds outside your house or-- And there was nothing. You could read the newspaper, but unless someone came to your house or called you, there was just... that was it. you had some downtime. It doesn't exist anymore. The first thing I do every morning is check my barrage of emails and clean up my inbox and connected all the time to everything. It's an untried, uncontrolled experiment upon the human psyche and consciousness, and difficult, I think, for all of us to deal with. There's a lot of distress in the mix there. I think we're still figuring out how do we process that? How do we react to that? How do we defend ourselves and our patients against all of that? I don't know the answers to that, but it's definitely a massive disruption in the human experience that's prevailed. And things always change. I was a liberal arts major at Dartmouth and so read all the great classics. Plato used to complain about how the world had radically changed from the generation before. So even in people were already upset by the changes in society. But the pace of change that we have to deal with now, that our kids have to deal with, that our grandkids have to deal with just keeps accelerating. You'd have to plot it on a logarithmic scale because it keeps accelerating at an accelerating rate. And again, we're just at the dawn of the AI era. Who knows what that's gonna do? these are great challenges and a huge, I think both obstacle and opportunity in your field of focusing preferentially on brain and mental health, because we have to figure out how to absorb and respond to these massive new challenges.

Dr. Ken Sharlin 38:46

Yes. and I think we would probably agree that distress and eustress are not necessarily completely mutually that sometimes in those moments of really true awfulness, in the spirit of the hero's journey, we have to go to hell to come back sometimes. Those experiences, if they're processed in the best possible way, can lead to growth, they can lead to a deeper understanding of oneself or one's community and one's connection and all those other things. Passing on the gift of food, the gift of lifestyle to our children, and passing on the realization that life does have its painful moments, and sometimes those moments can go on for a while. I think about my own father,

Why Food Is Powerful Medicine

Dr. Ken Sharlin 39:37

who, by the way, is a pediatrician, and cared for my mother with an undifferentiated, widely metastatic, carcinoma that eventually took her life, and this went on for a few years. This wasn't a week or two even. I can't even begin to imagine, what that journey was like, or I really probably should have a serious conversation with him at some point about, ultimately, as awful as that was, what does it mean to you now, having emerged on the other side? How did it change your perspective on life? How you live your life? Eventually, he remarried. He met a lovely woman, and they've been together for quite a few years now. So that's just one example, of course. But to be clear, we in our clinic often meet young people whose probably the biggest issue for them is very low stress resilience. Smallest things really just put them in freeze mode.

Dr. David Katz 40:35

That may have something to do with changes in the world around us, the nature of the stress to which we're exposed, the frequency, and we're struggling to catch up and figure out how to adapt to all of this. We as clinicians, we as human beings are all struggling to figure it out. Yeah, I agree with you. What is distress today could prove to be eustress over time if you adapt to it. That's really the issue, resilience and adaptation. So if it's adversity that you can turn into a life lesson

Should Diet Quality Be a Vital Sign?

Dr. David Katz 41:07

and it enriches your experience and enriches your capacity, then ultimately you have evolved it from distress in the near term to new stress over time. That can certainly happen. But I think my general impression as a parent, a public health person, is that the levels of distress we're seeing in young people are rising alarmingly. I think that's because we're raising them in a world not prepared to deal with. We don't know what to teach them about it. Again, the internet was imposed upon me. I was already a mid-career physician when that happened, and it did change everything for everybody. In the early days of my clinical practice, the most likely experience with a patient was they didn't know, and they came to a doctor who did know. And they had opinions, but they would-- Doctor, what should I do?" Enter the internet, and it was a complete 180. Everybody knew and this just keeps getting worse with social media and AI. Everybody knows everything, and most of it's wrong. Totally different clinical practice experience, right? If a patient comes in and acknowledges, "You went to medical school and residency and had years of postgraduate education and know stuff I don't know, so I don't know if I'm gonna do what you tell me, but I recognize that you have knowledge I don't have. So tell me, and then let's talk about it." That flipped to, "I did a Google search, and I know everything, and here it is. So now, what are you gonna do about that?" It's a totally different conversation. It changed everything. So even figuring out how to deal with that in clinical practice is a challenge. Let alone figuring how do we adapt our parenting style to accommodate the fact that we've got kids and grandkids who are growing up in a world of TikTok, right? It's all new.

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Dr. Ken Sharlin 44:41

Perhaps we can circle back around to food, Diet ID. Since we're both clinicians,

The Story Behind DietID

Dr. Ken Sharlin 44:48

what are the challenges physicians like you and I, who've been doing this, our work for a long time, and now medicine is changing. There's more interest in systems biology, multimodal causation, and the realization that we can't address these complex diseases without bringing in diet, among other things. How do we teach doctors, whether they're in medical school, the young, up-and-coming doctors, the present doctors who, "I've been doing this way for thirty years, why are you asking me to change?" And how best do we communicate our patients about food as medicine?

Dr. David Katz 45:32

So lots to unpack there. To be clear I've been engaged in this battle my entire career. So I taught a nutrition elective at the Yale Medical School when I was still a resident, and then that stuck, and I became involved with that for many years. I have written or led the writing of four editions of a nutrition textbook for health professionals and it's called Nutrition in Clinical Practice, in an effort to get nutrition into clinical practice. I was a residency director at one point and emphasized nutrition and lifestyle there. It's a career-long quest to give nutrition the respect it deserves. But then along the way, for many reasons, I had the epiphany that in medicine, as in the world of business where the aphorism comes from, we manage what we measure. And I started wrestling in particular with the elusiveness of measuring nutrition, in particular an objective measure of diet quality. I started to think how important that could be. And the analogy that took shape in my mind was blood pressure. Just a quick historical reference here. The house of medicine at large knew the importance of blood pressure before the invention of the blood pressure cuff in the 19th century. In other words, we knew that elevated blood pressure, abnormal blood pressure, was a major contributor to heart attack, stroke, kidney failure, blindness. The house of medicine knew that. But the blood pressure cuff had not yet been invented, so how could you measure blood pressure? We could do it. You could do it with an intra-arterial catheter, and nobody thanks you for putting in an intra-arterial catheter if they're conscious. So that tends to be used in the ICU where people are not conscious, but it's very painful or you could guesstimate. The guesstimation involved palpating the tongue and the eyeballs and feeling pulses and trying to come up with a ballpark figure for blood pressure. It didn't work very well. The blood pressure cuff, the invention of the sphygmomanometer, theoretically was a complete transformational event because it made this relatively painless. It's a little uncomfortable when you blow up a blood pressure cuff, but no big deal. Non-invasive, quick, efficient, reliable. The reaction of the House of Medicine was to reject it outright because it was new, and the prevailing view in medicine, is if we weren't using it yesterday, we couldn't possibly need it tomorrow. But ultimately, the blood pressure cuff did catch on because it was so important, and it changed absolutely everything. Because before the blood pressure cuff, we knew blood pressure, could cause heart attack, stroke, kidney failure, blindness, but we never knew it was broken in an individual. So how did you know blood pressure was broken in an individual? You waited for them to have a heart attack, stroke, kidney failure, blindness, and said, "Ah, your blood pressure may be the problem here. We should look into that." So you never got ahead of the problem. You never got upstream. You waited to go all the way downstream to calamity and then said, "Ah, must've been problems upstream." Where are we with diet now? We're exactly there. We know that diet quality in America is

How DietID Uses Pattern Recognition

Dr. David Katz 48:37

poor, in much of the modern world it's poor. According to the Global Burden of Disease study, the single leading predictor variable for premature death from all causes in the modern world is impaired overall diet quality. But in whom do we measure diet quality? Just about no one. Unless you're in a research study, almost nobody completes a two-hour semi-quantitative food frequency questionnaire. Almost nobody does three non-consecutive 24-hour recalls. Almost nobody writes down everything they've eaten for seven days We measure dietary intake and diet quality in a rounding error of the overall population, and so what's the result? Just like blood pressure before the blood pressure cuff, how do we know diet's broken? We wait for the obesity, the type 2 diabetes, the metabolic syndrome, the coronary disease, In other words, we wait for downstream disaster instead of getting upstream. If we could measure diet reliably and at scale efficiently in a user-friendly way. We could get upstream and say, "We don't just know that diet is broken in America in general. Here's your diet quality. Here's what we'd like it to be. Here's the difference between the two, and here's what we'd like to change." So with DietID, we invented that. So I had an epiphany in 2016 when I was on my elliptical working out. I saw in my mind a completely different way to measure diet assessment than these recall methods that take hours or days. And I saw it perfectly formed initially, a three-dimensional object, a thing of beauty. Then it played out in my head like origami in reverse, 'cause I said "It can't be that simple." So I started to unfold this three-dimensional thing and said, "What about this and what about that and what about this?" By the time I had a flat sheet of paper in my brain, it still looked like it would work. And then I conferred with colleagues who are world-leading experts in nutrition, the current chair of nutrition at Harvard, the former chair of nutrition at Harvard, others of that caliber, and we agreed it sounded like it could work, and then the game was afoot. I wound up, looking at the intellectual property space. It turned out this was completely novel. we got multiple patents. I wound up founding a company to bring this thing to daylight. I wound up leaving academic medicine because I had become accidentally an entrepreneur and a CEO. We now have multiple patents, additional patents pending. We have a bibliography

Every Doctor Is a Health Coach

Dr. David Katz 50:55

of roughly 20 peer-reviewed publications validating this method against every other method. some of the studies, the early ones were done by us, but many of the recent studies are done by unaffiliated researchers. DietID's been deployed into dozens of federally funded research studies, including two ongoing studies at the NIH. And in the last two years alone, we completed comprehensive dietary intake assessment in over 250,000 people. The US government tracks dietary trends in a study called NHANES, National Health and Nutrition Examination Survey. They don't do it every year, but the years they do it, they assess dietary intake in 5,000 people in a year because that's as many as they could manage given their methods. We did over 250,000 in two years, and we could have done 250 million just as easily if we'd had access to that many people. So it's a complete game changer. So my personal aspiration, my sense of purpose, and consequently an element of my health, is the pursuit of diet quality as a vital sign, just like blood pressure. And then, to answer your question, Ken, what should we do? I think if we could get traction there, and that's what we've been working to do at DietID. Make diet quality a vital sign integrated into the electronic health record I think the rest just follows. So again, I've spent 40 years trying to get nutrition to get mainstream attention in the house of medicine with very little success, and many of my colleagues have done the same. But what if diet quality were a vital sign? I think it would do to medical practice what the blood pressure cuff did to medical practice. Once that information, that not just blood pressure is important in general, but here's your blood pressure and here's what it ought to be, that's something clinicians can't ignore. That's something policymakers can't ignore. That's something credentials can't ignore. So you look at what the routine measurement of blood pressure did to the house of medicine. We didn't know how to treat it, but when we had that information in front of us, we had to learn how to treat it. We had to develop drugs to treat it. We had to develop lifestyle interventions to treat it. We had to change medical education. We had to develop specialists who were good at treating it when it was hard to treat. Nephrologists, for example, that you can refer to when you've got refractory hypertension. Cardiologists who could deal with the downstream consequences of it. Neurologists who are working to prevent stroke and manage the consequences of hypertension. You can't be a practicing clinician and not measure blood pressure in your patients. You just can't. Every clinical encounter, there's a blood pressure cuff that gets measured. That cue to action reverberated through every aspect of medical practice and changed the standard of care. I think moving upstream with diet quality is that every patient's diet quality is captured, quantified, recorded. We have a Healthy Eating Index 2020 score for everybody in America. Transformational. So that's my current journey. The method we use, which is based on pattern recognition rather than recall. So in other words, we built a diet map, diet type on one axis, diet quality on the other. Every cell in the map is an image you can look at, and we show you two images at a time on a smartphone screen and say, "Which of these looks more like stuff you routinely eat, A or B?" And you pick, and we say, "How about now?" It's like the eye test. Anybody's ever gone to the eye doctor and you look through a phoropter, two images, and they ask us, "Which of these is more in focus, one or two?" And you say, "Two." They say, "How about now?" "One." about now?" "Two." "How about now?" "One." "How about now?" "One." We're done. We've got a perfect fit for the correction of your visual acuity in diopters. We do that for diet. So we play that game. Which of these looks more like how you eat, A or B? Takes about 60 seconds. It's easy. It's effortless. You don't have to remember exactly how many french fries or broccoli florets you've eaten in the past six months. You just have to recognize the basic appearance of your diet in general. We can use the same method to help you identify a personalized goal diet based on two key considerations. What would you like a better diet to do for your health? What are your specific health objectives? And of the diets that are responsive to your health objectives, here are pictures of them all. Which one looks like something you'd actually enjoy eating? So we run people through those two filters so we can identify a goal diet, compare their goal diet to their current diet, show them the exact difference, and help coach them from here to there. We have a clinician-facing dashboard which summarizes all that information in a really easy-to-use manner available to the clinician. So my answer to your question, how do we help address this? We take a lot of the burden off the physician who's already too busy and say a lot of this can be appified. You need to be aware of the information, you need to track the information, and you need to have some knowledge of the journey your patient is on. But we can shift a lot of that burden off your shoulders 'cause you've got plenty to do as is. But you will need to be educated about basic principles of nutrition and having effective conversation on the topic, just as the blood pressure cuff obligated us all to know the difference between a healthy blood pressure and an unhealthy blood pressure, and the steps we could take to narrow the divide between the two. Diet should be re- treated with that same respect.

Dr. Ken Sharlin 55:55

You used the word coach in the beginning of our conversation. I've heard it was, my wife is actually a certified health coach nationally and internationally, among many things. But, she was listening to a podcast where the speaker said, are "consultants, not coaches," meaning that they need to be more like coaches. And I like the word you used just a moment ago of effective communication I think those really go hand in hand. I wonder as we round out our discussion, if there are some physicians who are listening or nurse practitioners, people who can influence the behavior of their patients, their clients, what would you say to them is the most important thing when it comes to food behavior?

Dr. David Katz 56:49

Well, first of all, in

Eat Food. Mostly Plants.

Dr. David Katz 56:50

terms of that distinction between consultant and coach, the word doctor comes from Greek and means teacher, right? So at its origins, our profession is about educating and empowering, coaching essentially. So I don't think we can step away from that. However, I fully embrace the concept of working with health coaches in team care because given the nature of medical encounters, we can't do the whole job. We may not have the knowledge to do the whole job, but even if we don't have the time to do the whole job. So we need a, a depth of support from other members of the multidisciplinary team. And then in terms of addressing nutrition in limited time, there is a very important theme in the literature on smoking cessation and tobacco. When everybody in America smoked, the single greatest public health threat was tobacco. The only reason it's not still the greatest threat to years in life and life in years is so many fewer people smoke. But when they do smoke, it remains incredibly important to address it. The evidence is clear that just endorsement of

Final Thoughts & Closing

Dr. David Katz 57:58

quitting by physicians made a difference. Didn't guarantee that a patient was gonna quit. When you say, "You know what? this is really bad for your health. It's a real concern for me. I would really consider it a priority that, that you do everything you can to quit smoking." That brief exchange made a difference. I would say we should pick up that baton and run with it with regard to nutrition too. There are lots of places people can go to get help with nutrition. They can search the internet. They can use AI. A doctor should be involved in that discussion. If you don't have the knowledge or the time to do that, ideally somebody who does, a health coach, a dietician, should be involved. But entry level for physicians is to say, I'd like to be clear with you that, we have limited time today, but nutrition and lifestyle are really important to me because it's my job to empower you to have the best health, the best life you can have, and these are going to make a difference. So it's really important for you to look into those areas and make them a priority for you if you want to achieve your best possible vitality. In any way I can help, I want to be involved in that journey. That just took 10 to 15 seconds. That's a heck of a lot better than nothing. Just acknowledging this is really important. And then come back to me with questions. When you are inclined to do it, look into some changes you might wanna make in your diet, and then bring that back to me and let's interact. And if we need additional help, health coach, dietician, we'll pursue that together. Just that invitation to explore the topic together is where I would recommend starting. Obviously, if you've devoted your whole career to nutrition, you take it a lot deeper than that. And I do think a tool like DietID could facilitate that because you would actually measure diet quality. You'd have an objective measure on a quantitative scale. Here's your diet quality. Here's what that means for likely health outcomes over time. Here's where we'd like to be, and here's what that means. And, major differences in projected health outcomes as you shift objectively measured diet quality. So I'd like to move from where we are to here. There are different dietary patterns that can help you get there from here. That's a matter of your personal preferences and priorities. But, I'd like to be involved in that journey with you. So I think we can rely on tools to help, but that endorsement, that's entry level. That would be a place to start.

Dr. Ken Sharlin 1:00:16

I like that. And I would add, as I observed and listened to you, that the way that you communicated there was very heart-centered, was very empathetic. I'm gonna look you in the eye, and I'm gonna speak from the heart about the importance of this, as opposed to saying, "It's good to meet you, and here's your prescription for metoprolol, and my nurse is going to provide you a handout about healthy diets." Right.

Dr. David Katz 1:00:47

Yes, exactly. If we expect to make a difference, we have to show that we are invested both here and here. I really care about this. as a clinician, it's my job to help you have the greatest probability of years in life in years. It's my job to empower you. I'm not gonna empower you unless there's power in the connection between the two of us, unless I'm really engaged and committed. I'm not gonna impose my will either. It's your life, you're the boss. But if there's a way I think you have a better likelihood of a long, vital life, I'm duty-bound to address it with you not just to throw it at you, but to actually reach out to you with it. I think that's really important. So that would be the place to start with nutrition. I think a lot would unfold from that point forward. And I think the way we do behavioral coaching can evolve. I think the tools we use to help people get there from here can evolve. The basic theme of supporting Homo sapien health with diet was articulated by Michael Pollan in seven famous words: "Eat food, not too much, mostly plants." And as pithy as that is, I would argue it could be reduced to four words, because if you really do eat real food, whole foods, mostly plants. In other words, mostly eat vegetables, fruits, whole grains, beans, lentils, nuts, and seeds, and mostly drink water when thirsty, the not too much tends to take care of itself, because one of the many virtues of more wholesome foods and sensible assemblies is they fill you up on fewer calories. So it could've been four words: eat food, mostly plants. But that is the theme. Mostly eat vegetables, fruits, whole grains, beans, lentils, nuts, and seeds, and mostly drink water when thirsty. Everything else is negotiable, that is the bedrock. It really is that simple, and if you do that, you can't go too far wrong. Get that out there.

Dr. Ken Sharlin 1:02:39

Yes, I know we could have spent the whole podcast debating individual diets. I'm probably more aligned with what you're saying and more the essence of what is food than a specific prescriptive diet. Dr. David Katz, it's been such a pleasure to visit with you on the Healthy Brain Toolbox podcast. Perhaps, we can visit again in the future and continue this excellent conversation. I hope the listeners and viewers have gained some helpful information. We'll search out Diet ID, your books, your publications, and really the inspiration that you share in this vision of a healthy America and a healthy world through food

Dr. David Katz 1:03:22

Thank you so much, Ken. Pleasure being with you, and thank you for doing what you do.

COMMERCIAL BREAK 1:03:26

Hi everyone. Dr. Ken Sharlin here with the Healthy Brain Toolbox. I'd love to hear from you. If you have general questions about brain health, neurology, or the science of keeping your brain sharp. Send them to questions@healthybraintoolbox.com. I'll be reading your questions on the upcoming episodes. Please remember, these need to be general questions, can't answer personal medical questions, or provide individual medical advice. So if you've ever wondered about brain health strategies, lifestyle tips, new research, or the future of neuroscience, send those questions in. I look forward to hearing from you and who knows? You might even hear your question featured on the show. Thank you for tuning into the Healthy Brain Toolbox podcast. I hope today's conversation gave you new insights to protect and nourish your brain. Be sure to subscribe, leave a review and share this episode with anyone looking to take control of their health. Until next time, stay sharp and keep learning.