In this episode, I am speaking with David Katz, MD – who is a preventive medicine specialist and globally recognized authority on lifestyle medicine, the founding director of the Yale-Griffin Prevention Research Center, President, founder of the nonprofit True Health Initiative and Founder and CEO of Diet ID, Inc. We will talk about whether “flattening the curve” works, vaccines, how you can change your lifestyle to upgrade your health.
Table of Contents
In this podcast, Dr. Katz will cover:
- The critically important frame-shift we all need to make to protect ourselves.
- What happens after the ‘curve is flattened’? Is the right goal to keep flattening the curve?
- Debunking some commonly held myths and misunderstandings.
- Why we might actually WANT to get the virus. (This may shock you! And it’s individual specific.)
- Katz’ thoughts on the vaccine (should we count on it, and is it the answer?)
- The single leading predictor variable of all-cause mortality in the United States today (and how you can dramatically reduce your risk in months).
- What can you do today to boost your immune health, now and for the rest of your life.
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Ari: Hey there. Welcome back to the Energy Blueprint Podcast. Today’s guest is Dr. David Katz, who I’ve been a fan of for a very, very long time. He’s been a major influence on my thinking, and I’m grateful for all the work that he does. He is a preventive medicine specialist and globally recognized authority on lifestyle medicine.
He’s the founding director of Yale University’s Yale-Griffin Prevention Research Center, past president of the American College of Lifestyle Medicine, President and Founder of the nonprofit True Health Initiative and Founder and CEO of Diet ID, Inc. Welcome, Dr. Katz. Such a pleasure to finally speak with you. I was just telling you, I’ve been trying to do this literally for probably three years now.
Dr. Katz: Well, very kind intro. Great to be with you. Thank you.
The problematic misconception with flattening the curve
Ari: I want to talk first about COVID-19. You’ve obviously been working, I think 12, 15-hour days, you’ve had a lot of demands on you. I thank you for taking the time out of your day to do this with me. I want to ask you first about a couple, I think widespread misconceptions that are out there on this topic. You wrote an op-ed piece in the New York Times a month or two ago. That was–
Dr. Katz: Feels like lifetimes.
Ari: Yes. That was, I personally loved. I know a lot of people that loved it, but some people were very critical of, and some people had a hard time accepting. I think now the tide has shifted. I think a lot more people are open to that line of analysis that you were trying to open discussion on at that time. You said something in a recent interview, I think that’s a good way of conceptualizing this, you said if all we do is flatten the curve, you don’t prevent deaths, you just change the timeline, the dates of the deaths. I think that’s a good way of broaching into this territory of misconceptions. What do you mean by that?
Dr. Katz: Yes. I want to give credit where it’s due, I really learned the details of this from Wes Pedgen in particular who’s a professor at Carnegie Mellon, and his partner, Maria Chikina, who’s at the University of Pittsburgh, who are experts in mathematical modeling. We had been discussing this and a number of others, risk modelers from MIT and elsewhere.
So, very early on, I really was trying to get an understanding of the big picture, all the implications, what do we need to do? When do we need to do it? How do we minimize total harm? I think the misconception, because people obviously everybody’s passions were inflamed by fear more than anything else, everybody went to their native corner. If your native corner was the sky is falling, we should all be hunkering in our cellars, anything opposing that tended to stir people up, make them upset.
If your native corner was, we’re going to destroy lives by shutting down the economy, you went there and basically, you wanted everything opened up all along. I didn’t want either of those things. I wanted to minimize the total harm to people. To the best of my ability, I congregated with lots of people who knew a lot of stuff I didn’t know, including these risk modelers, although many of them found me after the New York Times op-ed, and my education continued.
What I learned from Wes and Maria in particular, is that even if you go into the models, the very models that were used in the media to argue for flattening the curve, for example, used in the New York Times, and you turn those very models back on, the minute you release the clamps, in other words, the minute you let people back out after flattening the curve, since you’ve been keeping people away from people and everybody away from the virus, everybody’s still vulnerable and the virus hasn’t been eradicated.
The minute you release the clamps, all the bad stuff you were trying to prevent happens immediately. It didn’t happen on these dates. It all happened on these days and it was no better. You didn’t save any lives, you
postpone by a very little bit, however long you were willing to shut down your society to [unintelligible 00:04:06]. That was the argument, but it didn’t originate with me, it originated with the very risk modelers who are telling us why we needed to flatten the curve. My response is, they’re not wrong until you can figure out a better way.
A better way, obviously, is to risk stratify the population. Until you know how to do that, sure, you have to flatten the curve so you don’t overwhelm medical systems as happened in Italy, as happened in New York to some extent. Then you have to have a phase two, you have to have something to transition to and we didn’t, and that was the concern.
The issue then became, okay, we hunker in our bunkers, what? Forever? Until there’s a vaccine, which could be years, who knows, in which case, devastate the economy, devastate lives, ruin social determinants of health, wreak havoc, and maybe harm orders of magnitude more people with our interdiction efforts that are harmed directly by the virus, or, open up in a haphazard way, we don’t think about managing risk, and we expose a lot of people to the virus, we don’t flatten the curve at all. That also is mayhem. We’ve got to be thinking about, where do we go from here to minimize total harm?
Ari: Absolutely. I think this concept of total harm minimization is critical. There’s also something there that I think is part of why there’s such widespread misunderstanding on this idea of when you flatten the curve, the total area under the curve doesn’t change the total number of infections. That is when they were presenting on stage, for example, Tony Fauci was presenting this model at the outset of this, here’s what the curve looks like and here’s what it looks like if we flatten it. Literally, on that picture it said, 2 million deaths versus 150,000 deaths. When they were proposing this, they were absolutely saying, this is going to massively reduce the total death toll. They were not saying the total area under the curve and the total number of infections doesn’t change.
Dr. Katz: [unintelligible] because essentially what they did and people I really like and admire at the New York Times did the same thing. Essentially, you run your flattened curve up to a given date, and then it’s as if what? The world stops turning? God steps in to save us all, and what happens on that day? Dr. Fauci did the same thing.
Essentially, you show over this time span, 30 days, 40 days, 60 days, pick whatever you want, if we clamp down on everything, if we social distance and everybody stays home and everybody stays away from [unintelligible] and businesses stay shut, total deaths for that time period with doing all of that, all these interdictions, versus not doing all that, well, obviously– Again, all of this was guesstimates anyway, nobody really knew how many people were going to get infected, we know a lot more now.
You look at Sweden and you say okay, might have been higher but maybe not that much higher, so there’s more to talk about. But giving the benefit of the doubt back then when we knew less, okay, for that time period, many fewer deaths if you keep people away from the virus, what happens the next day? Well, either you keep flattening the curve, which means you don’t get your lives back, you don’t open businesses up, you don’t restore the economy.
Basically, we wind up with the great depression on steroids, or you do open the economy back up, you let people have jobs and incomes and be able to put food on the table and the curve shoots way up. It spikes on that day. The very next day. So the total area under the curve actually hasn’t been fixed the minute you release the clamps. That’s the part they weren’t talking about. That’s the part that presentations in major media outlets like The New York Times weren’t talking about. It’s absolutely crucial because we are talking about where do we go from here?
What is the path back to anything like lives we knew before the pandemic and just flattening the curve provides no path other than hoping that we will produce highly effective vaccine faster than has ever been done in history, mass produce it and universally distribute it and it will work more or less perfectly. It’s a very high bar to clear while we’re all hunkering in our bunkers and hoping.
I really was literally thinking about people like my mother, who is 80 years old and was saying, “I really don’t want to get this infection and die, but I really don’t want to die of something else before I ever again get to come out of my house and hug my grandchildren. What are you going to do about it, son?” I was out there trying to do something about it.
Should we wait for the vaccine?
Ari: Yes, absolutely. I think what you just said there about the vaccine hunkering in the bunkers, a nice segue into the next question, which is, we have people like Tony Fauci, people like Bill Gates who have said things like, I mean, literally, I think this is, if not a direct quote, almost a direct quote, “We can only get back to normal when we have a vaccine.”
On the other hand, you’re basically saying, and you actually said this in a recent interview, you said, here’s the odd part that people have a hard time confronting and accepting. We actually want to get this and get it over with and be immune. That is the path to an all-clear that doesn’t require us to wait for vaccines. Again, you said we actually want to get this. What you’re saying is not at all what Bill Gates and Tony Fauci are saying, so why the difference of opinion?
Dr. Katz: Honestly, they’re not guys I really want to argue with. I’ve had tremendous admiration for how Bill Gates has turned his wealth and power to doing good in the world. He’s done a lot of terrific stuff. I think Tony Fauci is doing yeoman’s work and has really stepped up and been the hero in this. By the way, I don’t know for sure, but I think if we had grown-ups running the country, and we had responsible leadership, and people weren’t so afraid that any reasonable thing would get immediately converted into a totally unreasonable tweet, as happened to me, by the way, after my op-ed in The New York times.
They might be more moderate, they might be more temperate in their perspectives. I think, frankly, people in positions of great influence are really careful about what they say, lest it be prone to misrepresentation. One way to avoid that is to say, no, no, I’m in the opposite corner, completely. The virus is dangerous, we have to respect it, period, end of story, but the reality is the virus usually isn’t dangerous. It’s dangerous to old people, it’s dangerous to sick people and it’s dangerous periodically for reasons we can’t explain.
Some really bad outcomes in some seemingly young healthy people, but they’re exceedingly rare. Frankly, all kinds of other diseases that usually don’t afflict young healthy people, sometimes do. I can’t help when I’m giving an interview on that topic to think about a dear friend, a close colleague, we worked together almost daily for 15 years, he died at 42 of esophageal cancer. Never smoked, ate perfectly, exercised, was lean, beautiful family, did relaxation tests, I mean, everything, textbook, why? I have no idea.
Are there going to be cases of COVID like that? Yes, but what’s the denominator, one out of a million, one out of three million, one out of 10 million, I mean just bad stuff sometimes inexplicably happens, but mostly bad stuff happens with COVID if you were previously quite sick or very elderly because frankly, old sick people are prone to have bad stuff happen to them, under any circumstances, with a pandemic, without a pandemic. The overlay of COVID is significant, clearly. Again, my heartfelt condolences to everybody who’s been impacted by this.
I think most of us have to one degree or another, but the reality is it’s not all that dangerous for most younger healthier people. For them to get this and get over it, means it was flu-like, and some tell you, “I had no symptoms,” and some tell you, “I had very mild symptoms,” and some tell you, “It kicked my ass,” and they got better. If enough of us who are young and healthy get exposed and do that, we have antibodies, we can’t spread it and that is the all-clear the grandparents need to be able to come out and hug their grandchildren because if we can’t transmit it, they can’t get it from us.
So they don’t need antibodies, they just need to be– they need the firewall. We are the firewall. The same is true, by the way, Ari, that’s what a vaccine does. Essentially, the older sicker people who get a vaccine, they have a less robust antibody response to a vaccine. Even then, even if you vaccinate them, mostly their protection depends on the rest of us having a robust antibody response, whether we have it through a vaccine or we have it through native infection, either way works. The difference is, the virus was out there now, is out there now. Our exposure could happen now, we can get this over with.
If we’re waiting for a vaccine, we have absolutely no idea how long it’s going to take. We’ve heard optimistic stories, a very promising study in 8 people, but 9 times out of 10, the very promising phase one trial does not lead to the result you were hoping for in phase three, maybe it will, I hope it does, but do we really want to risk everything about life as we knew it before on a hope?
Ari: Yes. Which begs the question, given what you just said, why are we talking about the vaccine as if it already exists and there’s already years of research showing it’s perfectly safe, showing it’s perfectly effective. It seems to me that it’s a widespread assumption. People think if there’s a vaccine, then it’s [unintelligible] effective.
Dr. Katz: All will be well. In a society that is riddled with anti-vax conspiracy theories. I mean, the double thinking is almost unfathomable. If we were a society that respected vaccines routinely, which by the way we should, effective immunization is one of the greatest advances in the history of public health, full stop, mike drop, thanks for coming. I mean, everybody really needs to get over that, but the simple fact is we have massive resistance to vaccines that are highly effective.
The very same society that wants no part of vaccines that are safe and effective, is banking on one to this new exotic disease having no idea whether it will be effective. Even if it’s effective, having no idea for probably years to come, if it was truly safe, maybe there’ll be late consequences. Maybe we’ll have all sorts of fall out from a vaccine, but most likely not, most likely it would be effective and most likely it will be safe, but here’s the other thing that contaminated the public discourse on this topic.
I was hearing all kinds of reports that maybe you don’t get immunity after you’re infected with SARS-CoV-2, maybe you can get re-infected. Now, it turns out there’s nothing to support re-infection and a lot to support that you do have immunity, to some degree and for some period of time, those are basically to be determined, but here’s the thing. Vaccines always only approximate the immunizing power of the native infection. The most robust immunity we ever get to an infectious disease is when we’ve had it.
A perfect example would be measles. The measles vaccine, which is one of the most effective vaccines is what’s called the live attenuated vaccine. In other words, the measles virus is not killed nor is it ground up into bits and only bits used in the vaccine. It’s the whole thing and it’s alive. It’s basically just made punchdrunk, they just beat up the virus badly enough so it can’t make you very sick. The reason for that approach, the live attenuated virus is that’s the closest approximation to actually having the measles, and even so, it’s not as good.
If you get the measles and get over it, you’re immune for life as best we can tell. If you get the vaccine, it’s really, really good. You’ve got robust immunity for 10 years, but then it does start to fade after that. If it’s not a live attenuated vaccine, if it’s a killed virus vaccine, less robust, and if it’s just part, if it’s just a protein, less robust still. So, absolutely. Basically there was misrepresentation of almost every concept related to vaccines throughout the conversation.
Ari: Absolutely. I think it’s also interesting to mention a few points of context, I’m curious to get your thoughts. One is past attempts at coronavirus vaccines in animal experiments resulted in antibody-dependent enhancement and the vaccinated animals in general actually fared worse than the unvaccinated where they had cytokine storms and died for the most part. There’s been a long history of attempts at coronavirus vaccines that have failed.
There’s also this issue of mutation, the rate of mutation and keeping up with it and if the vaccine would even be effective in that regard, I mean, we have a flu vaccine and it’s been around for decades and I think the stats from the last Cochrane review I saw were about 40% efficacy over the last 14 years. Then you even have the most staunch pro-vaccine advocates in the world like Paul Offit saying, “Hey, I’m really concerned about the fact that we’re rushing this so fast without adequate safety testing.”
What are your thoughts on the potential dangers of a vaccine? I mean, you recently wrote this article about maybe the harms of the lockdowns might potentially outweigh the benefits, or the harms from the virus itself, is there a potential for this vaccine to be potentially dangerous if they don’t do adequate long-term safety testing?
Dr. Katz: The obvious answer is yes, but I think, to be blunt about it, the last thing people need now is another theoretical to worry about. I think there are grownups in charge of vaccine generation and I don’t know when it will be done and I don’t know that the first one that looked promising in a study of eight people will be the one. I don’t know if it will be 12 months or 18 months or 24 months or five years or never. I don’t know if it will be completely effective or partially effective. The notion that it could amplify the immune response in a detrimental way, possible, unlikely.
Obviously that will be part of the multi-phase testing of it. It’ll be pretty easy to see during the early phase testing if actually outcomes are worse with the vaccine. I think that’s unlikely. The idea that it may not be a perfect defense because this is a coronavirus and it’s hard to immunize against them, absolutely true. The idea that this could be something like flu, where the virus mutates, and the vaccine– either you need a new coronavirus vaccine every year, like you get a new flu vaccine every year.
Although there is work on a universal flu vaccine, it’s just not ready yet, which, by the way, another precautionary tale. We’ve had massive outbreaks of flu, even in fairly mundane years, forever, and we still haven’t managed to create long-term protection with a vaccine. It’s every year we guess what strain it’s going to be. You get immunized, you get partial protection at best as you noted. This could be like that.
I guess the argument would be okay, not great, but still a heck of a lot better than shutting everything down and hiding in our basements. We don’t do that for the flu. It’s bad, but it’s not pandemic bad. Even a partially effective, reasonably safe vaccine would be better than no vaccine at all, but it’s not a panacea and it can go awry in many ways. It just may not happen. We may not have an effective one.
It may look effective. Then there may be unacceptable side effects and went back to the drawing board and we could be talking about years, and it’s just unacceptable that people like my mother, you don’t have to wait years wondering, do I die of natural causes before I’m allowed out in the world, allowed to have my grandchildren. What will allow people to come back to the world on mass life, as we knew it before? Well, the all-clear.
The all-clear is effectively, we either know everybody who is vulnerable has gotten this thing and gotten over it and has antibodies and they are the dead end. They are the firewall. You and I are the firewall that lets the older generation come out and play or, for whatever reason, and you talk to leading experts in pandemics, like Michael Osterholm’s, University of Minnesota, he’ll say, for whatever reasons, we don’t necessarily know why these things are seasonal and why they phase out and phase back in.
For whatever reason, whether it’s what we did or in spite of what we did or neither, you get near zero community transmission. In other words, the damn thing just goes away. Now, the problem with it going away is if we don’t know why it went away, we don’t know if it’s coming back. When people like Mike are quick to append, we need to be prepared for subsequent waves. We’ve seen them in prior pandemics. No, I can’t tell you why. I really can’t tell you why.
You want me to tell you it’s the summer and the heat, but then explain to me, this is Michael Osterholm speaking, “Explain to me why tropical countries have the same flu outbreaks as everybody else.” Equatorial countries, they have the same amount of sunlight all year long. They have the same temperatures all year long. There’s no seasonal variation. They get flu outbreaks. If it were sunlight and heat that were relevant, they should never get flu, but they get flu.
The connection between health and vitamin D?
Ari: I will say one confounding variable in that discussion. I worked on a fish farm in Israel for six months on a kibbutz, which you’re probably familiar with, communal farm. There was a group of Southeast Asians, I think mostly Thais or Vietnamese, people that were working right alongside me. On literally 110-degree days of blazing hot sun, they were wearing sweatshirts.
The reason why they were wearing sweatshirts was to prevent the sun from hitting their skin so that they wouldn’t get darker skin, which was associated with lower social class. I think that factor combined with the fact that this transition from outdoor ways of life to indoor ways of life has led to-
Dr. Katz: [crosstalk]
Ari: – even areas like– like I was just looking at some stats on Ecuador on the rate of vitamin D deficiency and even among children, it’s 80% vitamin D deficiency. I think transition to indoor lifestyle may be potentially this factor of people not wanting to have dark skin to be associated with low social class, I think might also be a factor in, even if it’s sunny, people still aren’t getting much sun
Dr. Katz: Interesting segue, particularly since we’re dealing with race riots in the United States that talk about skin pigment. Let me say everything you just said is interesting, relevant to discussions of both perceptions of bias in societies around the world related to skin pigment, which by the way is absurd. The importance of vitamin D to immune function and the importance of vitamin D to viral susceptibility. If I may, it’s still something of a non-sequitur when you’re talking about viral transmission through the air.
The argument is, in the United States, in any particular latitude, there tends to be a massive drop off in flu circulation with the seasonal variation. It seems to be related to sun and heat and people being outside, it’s not vitamin D levels that suddenly change massively. It’s literally that sunlight is a disinfectant, that the virus circulates as well. Regardless of the sweatshirts and regardless of vitamin D, that may very well be a relevant factor for the susceptibility of the host, doesn’t change is the virus circulating through sunlit air?
If yes, then why does it go away in the summer in New York, and if no, then why do tropical countries that have long hours of intense sunlight year-round and high temperatures, why do they have flu outbreaks at all? The issue simply is, you raised some interesting points, but I think they’re beside the main point I was making. We really don’t know if this thing is going to go away and come back. If we have an all-clear that simply related to near-zero community transmission, but we don’t know why we have near-zero community transmission.
It’s not because of the vaccine and it’s not because of achieving herd immune. It’s just because the virus went away for some unknown period of time. We’re going to have to be really vigilant about monitoring so we catch it the minute it’s back because it may come back. I don’t mind if it comes back and the people out in the world or the young healthy people who can get it and be mildly symptomatic or asymptomatic and get over it, fine, problem is, we don’t want to live that way. We don’t want to live walled off from our parents. We don’t want our grandchildren walled off from their grandparents.
If we live, as we knew it before, where people can interact freely with one another, we have to be extremely vigilant, because if the virus comes back under those circumstances and you and I, and people younger than us have not gotten it and gotten over it, then the older people and the people with chronic illness we associate with are potentially exposed. That worries me. This is why the argument about total harm minimization was never radical. It really shocked me that it was a provocative or controversial [unintelligible].
Ari: I agree. I was shocked by the provocative [crosstalk]
Dr. Katz: If you don’t want total harm minimization, what are you arguing for? I want some harm, bring on the harm.
Ari: Well, people conceptualize [unintelligible] just lives versus money.
Dr. Katz: Right, and [crosstalk].
Ari: What you were saying that I think a lot of people didn’t get is, it’s not just money, there’s lives also that are at stake from economic devastation and unemployment.
Dr. Katz: In fact, the funny thing is it’s the camp that’s made the biggest fuss about it. Basically the extreme left, it is the very camp that is most sensitive to the pernicious effects of poverty, and is usually most attentive to the massive effects of social determinants on health. If kids miss a year or more of school and are left back educationally, massive impact on their life trajectory and people can’t earn a living and food insecurity, and on and on it goes, exactly. It was never about money for me.
I’m not an economist, I’m a public health physician and a humanist. I guess my mistake was not anticipating that people could misinterpret it that way. I didn’t specifically say it has nothing to do with money other than the fact that whether or not people can earn any money, massively influences their lives. We’re talking about desperation, destitution, food insecurity, hunger addiction, suicide, [unintelligible] child abuse, domestic partner violence. It’s amazing, Ari, as I think about it.
Amazing how we [unintelligible] from one crisis to another, we went to yet another one now as we’re having this conversation. The big epidemic before we had COVID to worry about, was the opioid epidemic. Maybe everybody’s forgotten already, but the opioid crisis was declared a national public health emergency. Was that big a deal.
It had actually caused average life expectancy in the United States to go down, reversing a trend that had been in place for decades and a trend in place in developed countries all around the world. Life expectancy in developed countries only ever goes up. It was going down in the United States. Colleague of mine, Steve Woolf at Virginia Commonwealth University among others reported that in January last year. Well, massive disruption in people’s ability to earn a minimum wage, desperation, the very GRS that you’re going to produce with this shut everything down approach.
If there was ever a perfect storm for people to turn to whatever drugs they could get their hands on, this is it. How did we manage to forget how ruinous that epidemic was while dealing with this? We’ve got to stop thinking in these narrow tunnels. It’s massively detrimental to public health. That’s all I was trying to do and say, “Okay, are there people more experts than me in virology?” “Hell yes, but they don’t know anything about social determinants of health.”
Are their people more expert than me in social determinants of health? Maybe, but they probably know less about disease epidemiology than I do. I know enough about both to step back and say, there’s more than one way for this situation to hurt people. We should care about all of them.
Ari: We needed a panel of experts with expertise-
Dr. Katz: Multidisciplinary. Exactly.
Ari: – in many different specialties to have that debate, to come up with a plan for total harm minimization, and that’s what didn’t take place.
Dr. Katz: It did at our shop, but it didn’t in any way that could directly influence– The so-called coronavirus task force that our federal government allegedly had. Yes, it should not have been our president spouting nonsense. It should have been that and consensus opinions and policy and plans and practices and timelines emanating from multidisciplinary perspective experts in infectious disease, chronic disease, social determinants, poverty, vaccine development, on and on it goes, best thinking ,if grown-ups were in charge.
Ari: Yes. My last question to you, and just to check-in, are you okay on time?
Dr. Katz: Yes, we’re good.
The link between nutrition and lifestyle and health
Ari: Okay. My last question to you, which is a big one, is, it seems to me that the big elephant in the room right now that’s not being discussed is nutrition and lifestyle. This seems like, to me, the absolute most important context, this entire discussion of COVID should have been taking place within, and yet it’s not happening.
People are ignoring nutrition and lifestyle in the media. We even had all these doctors, writing articles, and major media outlets at the beginning of this saying its nonsense that you can boost your immune system and nutrition and herbs, vitamins; none of that stuff has any relevance to immune function. It won’t make any meaningful difference. It’s a myth that you can boost your immune system. Just this intense fixation on the vaccine as the only thing that can save us.
From my perspective, the big picture of COVID, it seems to me that 80%, 90%, maybe you can tell me the proper numbers, of the people who develop severe sickness are elderly people who are immuno-compromised people, who are older and chronically diseased in some way, have poor metabolic health, whether it’s poor blood lipids, high blood glucose, high blood pressure, diabetes, obesity, things like that.
It seems like that same constellation of factors, which are largely driven by nutrition and lifestyle, also are the main cause of deaths from cardiovascular disease, cancer, neurological disease and infectious diseases. In total, there are millions of deaths per year contributed by those root causes of nutrition and lifestyle factors that also result in increased susceptibility to dying from infectious diseases. This seems like, to me, the big picture context that should be getting discussed, but isn’t. Am I wrong about that?
Dr. Katz: No. Amen. You packed a lot in there, so let me unpack it a little bit. My most recent column was why two pandemics are better than one. I had written on this topic before, the fact that we had pandemic chronic disease, diabetes, hypertension, obesity, cardiovascular disease, stuff that does not need to happen. It’s related to lifestyle, which is in turn potentially related to [inaudible 00:31:51] determinants, but it’s totally preventable stuff. I’ve written about this multiple times.
I have, and I agree with you, it’s not getting enough attention yet, maybe we can turn there. Again, if grownups were in charge, there has never been a better time for national, Let’s Get Healthy campaign and let’s talk about why. The issue is this, Ari; I’m a preventive medicine specialist. My career has been devoted to disease prevention, which is a very frustrating enterprise, because people get religion after the bad stuff happens.
You talk to people about preventing heart attacks, preventing heart attacks, preventing heart attacks, years go by, they have a heart attack and they say, “What were you saying? Could you tell me again?” They have their first stroke. The problem is, the timeline is just too slow. If you tell somebody, “I’m going to shoot you now,” they panic immediately, don’t want to get shot. Now, if you tell them, “You’re going to have heart disease in 10 years,” they say, “I can fix that next week,” week after, week after that, and tomorrow never comes.
By the way, I and colleagues have two papers in the peer reviewed literature now looking at the distribution of these chronic diseases, diabetes, heart disease, obesity, et cetera, that massively elevate the risk of severe COVID outcomes. It’s more like 95% of deaths to COVID are concentrated in people who had major maladies to begin with. In some cases, it’s extreme old age, but mostly, it’s a burden of chronic disease one or more.
What we found is that, 56% of the total population in the US has one or more of these chronic diseases, and over 40% has two or more, massively elevating their risk of a bad COVID outcome. You could make the case that what COVID has done is finally, activate the fight or flight response about stuff that was hiding in plain sight all along. Nobody has the fight or flight response to type two diabetes. It’s too slow. Nobody has the fight or flight response to coronary artery disease. Do they have it to an acute MI? Hell yes.
Basically you feel your adrenal glands kick in and you’re panicking when you have chest pain and can’t breathe, but the idea that you’re going to get heart disease because of your lifestyle, too slow. This is hardwired into us from evolutionary biology. COVID takes the chronic and makes it acute, so from my point of view, not only is all of this extremely relevant, but this is a teachable moment. We have everybody’s attention. Nobody wants to die tomorrow of COVID.
Everybody’s asking, “Tell me how to stay safe,” and absolutely a huge part of the answer is, “How about getting healthy?” You can’t change your chronological age, but you can change your blood pressure. You can change your lipids. You can clean out your coronary arteries with lifestyle. You can prevent reverse, manage type 2-diabetes, and on and on it goes. Every one of these things can massively alter your risk of a severe COVID outcome and can do it quickly.
Several things we’ve been working on. I have colleagues, associates at a company called Everest Health that are finalizing a personal risk calculator where you can enter in all these factors about you personally, and it translates directly into, if you were to get COVID, the percent probability that you would get hospitalized is, the percent probability that you would die is, then it shows you which entries are modifiable. At my company, Diet ID, we’re a business-to-business platform.
We can measure diet, we can track diet, we can help you identify gold diet, we can coach you, and we do this all in seconds. It’s a complete revolution in how a diet gets measured and assessed; you don’t have to log foods or any of that. But we’re a business-to-business platform, but for COVID, we made this available direct to consumer. People can learn more at dietid.com, and what we wanted to do was say, you can know what your diet is.
We can compare that for you to what a diet that’s optimal for immune function, and I’ll finish my answer with that bit, and we’ll show you, personally for you what the differences are that you can work on to make a difference. Back to your original point. A lot of experts were dismissing the relevance of nutrients and diet. Here we have the traditional problem in a highly polarized divisive, “dumb it down, give me a sound bite, tweet me the answer” society, Ari, and you know this as well as I.
If you let the hucksters have the run of the land, basically they’ll be peddling mega doses of every nonsensical, pure Dumbo’s feather, pixie dust, and that’s bad. On the other hand, in opposition to the charlatans and the hucksters is the closed-minded conventionalists who say, “If it’s not the result of a meta-analysis of randomized control trials, it can’t possibly be true,” which is of course nonsense. Every parent knows it’s a bad idea for children to run with scissors, you show me the meta-analysis on that topic. Some stuff, it’s too obvious to overlook.
Ari: To that point, I actually got into a bit of a debate with a guy who’s a renowned statistics expert, not a health expert, but a statistics expert, who objected to the idea that obesity, diabetes and poor metabolic health increase the likelihood of severe COVID outcomes. Because he said, “There’s no randomized controlled trial that has tested this,” and I’m like, “You have to have an understanding of physiology and health to be able to logically put some pieces together here.”
Dr. Katz: Incredible [unintelligible 00:37:27]. There’s no randomized controlled trial that says it’s better to put out a campfire with water than gasoline either. Actually, just an aside, one of the things I’m interested in doing with some of the greatest minds I’ve been privileged to meet, is a colloquium, which we’re calling A Stand For Understanding. My nonprofit, the True Health Initiative plan is to do this when we emerge from COVID and have the bandwidth with experts in, not just research methods and nutritional epidemiology, but cognitive psychology, developmental psychology, artificial intelligence, neuroscience.
Because there is now a tyranny of the RCT. Forgive me for saying it so bluntly, but nincompoops say things like that. You can’t know it’s true, unless there’s an RCT. We have no RCTs for running with scissors. We have no RCTs for looking both ways before crossing busy streets. We have no RCTs for putting out campfires with water rather than gasoline, and on and on it goes. Almost everything important about being a functioning human being comes from observing patterns in the world around us, not RCTs. It’s absurd.
Anyway, back to our regularly scheduled program. The conventionalists who are too narrow-minded pushed back against the hucksters, just like at the beginning of this, there were two opposing camps about policies, “Shut it all down, liberate my state,” both absurd frankly. Two different ways to hurt people, so too with the idea that nutrition was important. “Megadose, Echinacea and all will be well,” absurd. “Diet and lifestyle make no difference to your COVID outcomes,” also absurd. Truth is in the middle.
Of course, overall dietary pattern and quality makes a massive difference. Just think about it. It’s both A, the fuel that runs every organ system in your body, and B, the construction material for everything your body needs to replace every day. How could it not matter? Of course, it matters. The very structure of our cells is dictated in part by the distribution of construction materials in our diet.
Your cell membranes either have a proper balance of fatty acids or an imbalance in fatty acids, which makes them leaky and hold their integrity less well and function less well, and it goes on and on. How could it not make a difference? We have massive evidence that makes a huge difference. Again, everything about our society that is so highly polarized that the sense in the middle is overlooked is a shame and it’s costly. We do that at our collective peril.
Ari: If I might add to this, you’re obviously much more in the system, so I don’t want to be the criticizing, but I’d love to get your perspective on it. It also seems absurd to me that as you’ve pointed out many, many times in articles in your books, 80% of the chronic disease burden in this country is diseases largely driven by nutrition lifestyle. We have a medical education system for medical doctors where they receive almost no education in nutrition and lifestyle. This seems to me almost the pinnacle of absurdity.
Dr. Katz: Yes. It’s hypocrisy, right? You’re supposedly training people to participate in the healthcare system that is overlooking the major determinants of health. Diet is the single leading predictor variable of all-cause mortality in the United States today. Even as we’re freaking out about the COVID pandemic, which has killed over 100,000 people in the United States, terrible, absolutely terrible.
Poor diet, on purpose, kills 500,000 people in the United States every year. It was an op-ed in The New York Times on August 26 of 2019 by Dariush Mozaffarian, dean of nutrition at Tufts, and Dan Glickman, former Secretary of Agriculture of the United States. If you haven’t seen it, I commend it to you and everybody listening, the title is Our Food Is Killing Too Many Of Us. Just Google that, you’ll pull it right up.
They cite the peer-review literature establishing diet as the single leading predictor of premature death in the United States, period, and it’s on purpose, and it’s for profit. That’s unconscionable, and then we don’t train doctors to deal effectively with that. The only defense I can make of the medical system is it’s hard to fit new stuff into a curriculum already so crowded.
This is one where once again, I’ll be controversial without meaning to be. I was president of the American College of Lifestyle Medicine and a big part of my platform was yes, we want lifestyle in medicine. In other words, we want to train health professionals to be good at addressing diet, and physical activity, and stress management, and sleep, and social connections, and the stuff that matters most, avoiding tobacco. But we really want lifestyle as medicine.
There is no example. As far as I know, Ari, anywhere in the world of an entire culture thriving, enjoying a bounty of years in life, a bounty of life in years, because their doctors counsel so well, but there are many examples. We can all think of the five examples of the Blue Zones where people do exactly that. They live long and prosper with vitality. Not because of great clinical care, but because of great cultural care, because their culture makes healthy living the norm.
So, yes, we need doctors to be the tip of the spear. Yes, we need health professionals in on this, but only to help get culture, to call-out culture so that the culture does the right thing. If you think about it, food has always been a huge part of life, why should it be clinical? We should eat in a way that nurtures and sustains us. That should be a given. That should be the default. If you’re doing that, it drops right out of the clinical discussion.
Oh, you’re eating like everybody eats in this country, then we don’t need to talk about your diet because everybody eats well. We’re done. Now, why is there something wrong with you? That’s the way it would be in a Blue Zone. That’s the way it ought to be. Yes, until we get from where we are to where we ought to be, I think health professionals need to be well educated so they can help facilitate the transition, both for individuals by empowering them, and as agents of change for the culture.
During my presidency of the college, I said, “Lifestyle in medicine is good. Lifestyle as medicine is better.” If lifestyle is the medicine, the most effective spoon to get that medicine to go down is culture, not clinics. We’ve got to fight this war on two fronts.
Ari: Yes, absolutely. With that in mind, what specifically can people do to address their nutrition lifestyle, to boost their immune health? If thinking, acutely in the context of COVID, and more broadly, just to also reduce your risk of these other massive killers cardiovascular disease, obesity, diabetes, cancer, neurological diseases that we know are hugely driven by nutrition and lifestyle.
Dr. Katz: Yes. If I may, Ari, and this is where I think we want to avoid aggravating the level of dissent. Boosting immunity does, I think threaten the idea of here, take mega dose of my lotion potion and you’ll be able to leap tall buildings in a single bound. You really want to balance the immune system response. Diet does that. Healthy living does that. Boosting sounds almost like a superpower.
We really want to unleash the native superpower of healthy homeostasis. Everybody will agree, yes you need to put the right fuel in the tank of any organism for it to have healthy homeostasis. Dolphins eat fish and they’re supposed to. Koalas eat eucalyptus leaves, and if you swap their diets, everybody’s in trouble because everybody needs the fuel they need. Herbivores need plants, and carnivores need meat, and omnivores may need some of both, and that’s simple.
It’s obvious, it’s not debatable. I don’t want to waste my time with any nitwit who tells me I need an RCT to prove any of that. It’s a fact. Same for us. Essentially what we’re aiming for is a balanced response. Actually COVID really accentuates the importance of that, right? You mentioned the cytokine storm. You don’t want an inadequate inflammatory response, because that means the virus will have its way with you.
You don’t want an excessive inflammatory response; because that means your immune system will cause you more damage than ever the virus could. You want a balanced immune system response, and a balanced diet can help you achieve that. That’s the goal, balance more than boosting. Yes, there is widespread relative deficiency in vitamin D. I think most people would benefit from vitamin D supplementation.
Not a bad idea to check your level. There’s widespread relative deficiency in zinc, which is a critical nutrient for lymphocyte function. Those are the very cells of the immune system that play the biggest role in defending us against viruses. Frankly, from the start of this, I’ve been taking some extra zinc 30 milligrams a day, there’s an argument for that. Most of us are relatively deficient in omega-3 fatty acids, there’s an argument there.
I take an algae-based omega-3 supplement routinely because I don’t eat fatty fish that often. Maybe an argument for probiotics and some other things. They’ve been arguments for vitamin A, vitamin C, and so forth. The big actor here would be the overall quality of your diet. There are lots of ways for you to work on that. You could choose a healthy diet like the Mediterranean diet and start while you’re sheltering in place, learning some new recipes.
You could decide to become more plant-based. You could decide you want to be a pescetarian. You decide you want to just clean up your diet and eat less junk food. Junk should not be a food group by the way. There are innumerable apps and books and sources, but I’ve got a hammer looking at the world of nail. Let me invite people during this window of opportunity. Visit dietid.com because we are agnostic.
We’re not prescribing one best diet. The theme of optimal eating for human beings is very clearly established. Michael Pollan nailed it in seven words. Eat food, not too much, mostly plants. Still true all these years later, but can it be only plants? Yes. Does it have to be? No. That’s kinder and gentler to our fellow creatures. Arguably the best approach for the environment, which is really important.
As long as you’re in that same neighborhood, you’re okay. Minimally processed food, mostly plants, you’re good and that can be Mediterranean, pescetarian, flexitarian, low fat, low carb, high fat, higher carb, don’t give a damn. You don’t need to either. You can decide which of these diets is something my family and I can live with. Which looks like food that we would actually be able to enjoy, so we can love food that loves us back.
Check out Diet ID, because we’ll take you through that exercise. We’ll help you know what your diet is now. Help juxtapose it to the range of diets that are optimal for immune function, and I would start there. The other thing we can do, by the way, in under 60 seconds, and this is unique in the world. We can report back to you what your nutrient intake level is for 150 nutrients from diet. In 60 seconds, we can do that interactive real-time.
Then you’ll see, am I deficient in terms of my food sourcing in vitamin D, in omega-3, in zinc. If yes, then you can decide to do something about that too. Obviously, we’re not the only resource available but we happen to be my resource. Again, I’m not saying we’re the best but I wouldn’t be doing this if I didn’t feel passionate about it. There’s a lot you can do. There’s never been a better time to focus on your long-term health because it is an acute defense.
Again, you really don’t need to hear it from me. You just need your own common sense to tell you. RCTs are lovely. I’ve heard a lot about them. They sound powerful. They can answer hard questions, but the idea that we can’t know and answer because we don’t have an RCT is absurd as the notion that since we have no proof about looking both ways, we should all just run out into traffic and hope for the best, which is nonsense.
Ari: Yes, absolutely. There’s so many conflicting diets and dietary advice out there. Everything from fruitarianism to all beef, carnivore diets, and everything in between, I think that runs the gamut pretty much. Paleo and Mediterranean and all these different things and anti-lectins stuff, and all these anti-grain stuff, all this contradictory advice. I know that you could talk on this topic for seven hours or a hundred hours, but if you were going to try to summarize your thoughts on practical nutrition advice for people right now, what would you tell them?
Dr. Katz: Well, for one thing, I would tell them where to get the 7 or a $100 dollar version. My latest book with Mark Bittman is called How to Eat. Available online all the usual places. How to Eat: All Your Food and Diet Questions Answered. We literally answer all your food and diet questions. It’s conversational, it’s fun, it’s easily accessible. Nothing in it will shock you if you know a thing or two about diet, but if you’re clueless, it will sort you out. The book I wrote before that, that’s a big one. That will hold the door open in a heavy wind. It’s called The Truth about Food.
Profits from that go to my nonprofit or revenue from that, rather, goes to my nonprofit True Health Initiative. It’s a 750-page book. It’s everything I know, and how I know it. It’s inexpensive, you can get the Kindle version for under $10. It’s a brain dump. It’s literally everything I know after the whole career in the space. If you just want a paper, I would say put my name into Google along with Can We Say What Diet Is Best and you’ll get my 2014 review article. That’s not quite seven hours, but it will take an hour and a half to read the whole thing.
Ari: Excellent review, by the way. I’ve spent a lot of time teaching from that review.
Dr. Katz: [laughs] Thank you. Thank you very much. We’re currently working on the fourth edition of my nutrition textbook for health professionals, Nutrition in Clinical Practice. The fourth edition will be ready in about a year and published sometime thereafter. I mention that just to indicate I am staying current and I am going before a jury of my peers. Now, here’s the one-minute answer. There’s all of that. For 7 hours or 100 hours or however deep a dive you want to make, but for the one-minute answer now, there are two critical axes. One is ultra-processed to totally unprocessed, and everything in between.
The more you move from ultra-processed, which is now operationally defined, thanks to my colleague Carlos Montero in Brazil and others, we actually have the Nova classification for food processing. So, ultra-processed, bad. Unprocessed, generally good. Some degree of processing, okay, but the more you move your overall diet from ultra-processed, stuff that you can’t pronounce and don’t know what it is or what part of the universe it came from, to the stuff that your grandparents and their grandparents would have recognized as food, better.
For the sake of human health and planetary health– By the way, you can’t have human health without planetary health. The other axis is animal food to plant food. You look at the blue zones. These five very diverse populations around the world where people routinely live to be 100 and their diets are overwhelmingly unprocessed food plants. They’re not plant-exclusive. They vary widely in fat content. Ignore this issue of macronutrients threshold. Silly, distraction. Diets can be good or bad, high or low in fat, high or low in carbs. Low-fat is good.
What if low-fat means jelly beans and Coca-Cola? There’s no fat in that diet. Is that a good diet? The idea that you can define the quality of a diet with a macronutrient threshold is silly. You have to define it with foods in balanced assemblies, but move everything from more processed to less, good. Move everything in general from more animal foods, so meat, dairy, eggs to less of that, and more vegetables, fruits, grains, beans, lentils, nuts, seeds and, by the way, when thirsty, drink plain water. That’s the formula.
Then build whatever variant on that theme you like because the only diet you’re going to stick with for the rest of your life is one that you actually enjoy eating. I’m opposed to all of these fad diets that show you you can lose 32 pounds in 27 minutes. Who cares? You could do that on a cocaine binge, that doesn’t make it a good idea.
The issue is, will it add pleasure to your life, because you actually enjoy the food and can enjoy it with your family and people you love? And will it add health to your life because healthy people have more fun. If we think about it right, it’s just not that confusing. Mark Bittman and I in How to Eat, as we were working, we would turn to one another opposite, “Don’t people know this already? This is not rocket science.” There you go. There’s the short answer.
Ari: Last thing just to wrap up, in the wake of everything that’s been going on for the last several months with COVID, what is the one or two final tidbits of thoughts or advice that you want to leave people with, with everything that’s going on?
Dr. Katz: Well, I guess one critical one is for people to realize that we don’t live a zero-risk existence. The distortions of risk associated with COVID made it seem like nobody ever dies of anything else. For example, you talk about sending kids back to school and the questions that come up are will there be zero-risk? It’s as if, unless there’s guaranteed zero-risk, millions and millions of kids can’t go back to school. Well, here’s the thing. Putting kids on a school bus involves risk and that risk, sadly, tragically, is realized at times. Kids are injured or killed because of car crashes or school buses crossing train tracks.
Letting kids walk to school involves risk. Letting kids ride their bike outside involves risk. Whether it’s kids or adults or older adults, there cannot be zero-risk. We never thought that way before, but we’ve been so focused on the risks of COVID that we’ve gravitated to responding to it from the opposite extreme, “Okay, we’re willing to go back to the world when that risk is zero.” That risk will never be zero because living involves the risk of dying of something every day. You want it to be small, you want to minimize that risk, but it can’t be zero.
The other thing that I would append is that yes, this pandemic deserves great respect. This virus deserves respect. but because it has populated every news cycle for weeks on end, the overall magnitude of risk to you or me has been massively distorted. If we got national news every time somebody died in a bathtub, we would be ripping bathtubs out of our houses. There’d be a national moratorium on bathing. Seriously. Somebody dies in a bathtub in the United States every day.
It makes local news. It’s a tragedy. By the way, many times it’s children, but it doesn’t make national news because it’s not a national news story, but if that child dies of COVID, national news every time a child died of COVID. We’ve done a lot to distort risk. As we interpret the daily sensation, we need to invoke our sense. Even science cannot work without sense.
Science has the power of a freight train to drive us toward otherwise unattainable truths since lays the tracks. If you’ve got a powerful freight train and no tracks, you’ve got a train wreck. Do not underestimate the power of that inner voice, the power of your sense. When it starts saying, “Could I have your attention for just a second?” Give it. Listen to it. It’s valuable.
Ari: Dr. Katz, this was absolutely brilliant. You are brilliant. Thank you so much for sharing your wisdom with my audience. I really, really appreciate it. Thank you for taking the time out of your very busy schedule, I have no doubt. Thank you. I’ve been a fan of your work for many years. This was a great pleasure and honor to finally do this, so, thank you. For people who are interested in following your work and getting your books and things like that, they can do that on Amazon, but where’s the best website to go to?
Dr. Katz: Well, first of all, my pleasure to be with you. I’m sorry it took so long. Thank you for the very kind words. My website which is a portal to everything I do is davidkatzmd.com. Then everything related to COVID, and a lot of this stuff I’ve written but a lot of it’s not. It’s these excellent risk models and peer-reviewed papers and blogs and a lot of really thoughtful stuff. All under the rubric, Total Harm Minimization at the website of my nonprofit, The True Health Initiative and that’s truehealthinitiative.org.
Ari: Beautiful. Thank you so much, Dr. Katz. I really appreciate it.
Dr. Katz: My pleasure. Stay well.
Ari: You too.
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