The global wellness industry is estimated at around $7 trillion and it's growing fast.
I guess you could see that as a great thing that so many people have so many resources to devote to their well-being.
We should say that what the industry counts as wellness can extend pretty far from anything to do with your sleep to home cold plunges from high protein everything to biohacking with untested peptide injections from Chinese labs.
Before there was social media or podcasts, books were the primary vehicle for spreading the wellness gospel.
And there are still thousands of books published in the space every year.
But the book we're talking about today has a title that may seem out of sync with the current wellness trends.
Eat Your Ice Cream is the name.
That is Ezekiel or Zeke Emanuel.
He has been on the show before talking about GLP-1s and the dysfunctional American health care system.
He has been a key player in that system.
He is an oncologist bioethicist, a professor at the University of Pennsylvania and a policymaker who helped draft the Affordable Care Act.
In his new book he argues that most wellness advice today manages to be both too complicated and too simplistic.
A lot of the wellness gurus and influencers out there, they have to get on social media daily.
They have to write something and they make things way too complicated because they have to have something.
Quote unquote new to bring people back.
They're too simplistic because most of these wellness things are just focused on the physical and sort of downplay other things physically.
So how does he see wellness?
Wellness is a lifestyle.
It's something you're going to have to do for decades.
And it should be something that easily becomes habitual and that you actually enjoy.
Enjoy?
But what about the suffering, the deprivation, the never-ending search for the perfect collection of self-care tools?
Today, in the next installment of the Freakonomics Radio Guide to Getting Better, Zeke Emanuel offers a different map to the same destination.
So last night, I had a piece of babka cake for dessert with a scoop of very nice ginger ice cream.
It was wonderful.
Are you ready to get on board the babka train?
It's leaving the station now.
This is Freakonomics Radio, the podcast that explores the hidden side of everything with your host, Stephen Dubner.
Zeke Emanuel has a pair of brothers who have also been on this show before the politician Rahm Emanuel, who's currently flirting with a 2028 presidential run, and the sports and entertainment mogul, Ari Emanuel.
The way Ari pursues wellness might fall into what Zeke calls the complicated category.
Here's Ari on the show a couple years ago, and I asked him to describe his fitness routine.
How long does this podcast last?
I mean it's so stupid what I do.
I'll give you this morning.
I woke up.
I think 445.
I take either, depending on the day, Thai helmets or UK helmets, which are live microbes for my gut.
I then get a cup of coffee.
Today I did bike hypoxia training.
I sprint on the bike for a minute at a very high level, take it down to a very low level, put a mask on.
That takes me up to 22000 feet for three minutes.
I do that for 25 minutes.
Then today I did a weight program, chest, tris, shoulders, legs, and stomach.
Then I went in and I did a sauna.
I meditated for, I think today was 17 minutes.
Got in an ice bath for four minutes, steam, got out, take my vitamins.
And then usually Fridays I don't eat.
I'll have dinner Thursday night.
Won't eat until Friday night.
The wellness craze that we're in says a lot about the social moment that we're also in.
And that again is older brother, Zeke Emanuel.
About 150 years ago in 1870, there was this enormous wellspring of interest in wellness, also with lots of books and new magazines and exercises.
And it was the result of rapid urbanization a lot of immigration, consequent xenophobia and a lot of economic inequality.
The Vanderbilts, the Rockefellers, the Carnegies and a lot of poor people.
Questions about the integrity of food.
So Upton Sinclair's The Jungle.
And we're in exactly the same moment.
Including the Gilded Age, yeah.
Yeah, we've got the Gilded Age.
We've got a lot of immigration, consequent xenophobia, people worrying about the food supply in terms of ultra-processed foods, and the world feeling topsy-turvy like people can't control their own environment, much less the direction of their lives.
And what you have is, I think, people looking inward like, What can I control my wellness?
My own life is something I control.
Back then we had books like the manual of hygiene, which was an exercise book, or the new science of healing.
We had my system, a 15 minute daily workout.
And now we have the New York times, you know, seven minute daily workout.
Okay.
The full title of your book is eat your ice cream, six simple rules for a long and healthy life.
Tell me how this book came into being and why.
The reason it came into being is that I began doing work on this book.
And one of the things that I became much more convinced of is the importance of dairy.
And then, several years ago, there was this article in The Atlantic about ice cream being actually good for you.
And when you uncover and chase that down, you know, dairy has a lot of advantages.
If you eat dairy as a young kid, societies that eat a lot of dairy generally taller.
You actually get a lot of protein from eating dairy.
By the way, dairy is also good at preventing colon cancer.
It's good at many other things.
Now, there are some downsides to dairy and one shouldn't hide them.
It's high in saturated fats, but it does appear that those saturated fats are not used by the body in the same way.
There was just a recent report of cream and full fat aged cheeses actually decreasing risk of dementia.
So in general, dairy has, I think, been undersold in American society.
Ice cream is a good thing, not only because it's this dairy component, but it also is this joyous component.
And we don't have to lead our lives in self-denial.
I can't have that ice cream.
So last night I had a piece of babka cake for dessert with a scoop of very nice ginger ice cream.
It was wonderful.
And you're still alive to speak with me.
Amazing.
Not only that, I'm thrilled.
It was a great evening.
You just mentioned a few things about dairy preventing colon cancer, perhaps warding off or delaying dementia.
Also diabetes.
And diabetes.
Okay.
I want to ask you about these concepts generally, because you write in this book about a lot of benefits or associations with different foods behaviors, exercise and so on.
But let's just back up for a minute and address a fundamental question I have, which is in the healthcare realm, especially in the.
I feel like there is a lot of operating on associations right.
Eating more dairy is associated with a lower rate of colon cancer, let's say.
You write that there's an association between loneliness and premature death.
And what I want to get at Zeke, before we get into the particulars of your argument about the book, is how reliable you feel these associations are.
Because, as you know well when you hang out with economists, an association or a correlation is a very nice step in the right direction, but it doesn't fill in the entire sentence.
So it could be that sicker people, for instance, are lonely because when you're sick you have a much harder time having social circles and so on, and not that loneliness makes you sick, which I think is the conclusion that a lot of people will come to when they read findings like that.
So can you just talk for a moment about loneliness?
Let's say the strength of evidence throughout your book with associations versus something that might be established as purely causal.
Yeah, my daughter is an economist and pounds on me all the time that in economics you do associations and you're not getting into the top five journals and therefore you're not getting tenure and you can forget all about it.
So I understand it's the economics part of the Freakonomics that we're now in.
So, first of all, to be fair, even if I were not a fan of economists and economics, I would say that it's a good thing to establish cause in as airtight a way as possible because look, here's an example.
When it rains, you see a lot of people out there with umbrellas.
If I came down from Mars and I saw all these umbrellas every time there was rain, I think oh, if people had only put away their umbrellas, it would stop raining.
They must be causing it.
That's a very good association, but it's not causal.
You're 100 percent right.
Association is not causation.
And you need to be careful.
And we make mistakes.
On the other hand, many of these issues like diet, you can't do the randomized trial, or you can do a randomized trial for a short amount of time.
So you're not going to be able to do the causal studies.
The second thing I would say is, if you get multiple studies in multiple different contexts in multiple countries worldwide, you begin to believe it.
And then if you have a plausible biological mechanism, you begin to believe it as well.
A lot of these associations.
They've begun to look mainly in the UK biobank study and see the molecular mechanisms by which, for example, loneliness turns on certain genes.
Those genes actually cause chronic inflammation and you have a mechanism that begins to make sense.
So I'm totally with you.
If I had one association study, I would say, oh yeah, you're right.
Once you've got a lot going in the same direction and you have a plausible biological mechanism and you're beginning to tease out the genes that are involved, I'm more likely to believe it.
Many of the predictions I say turn out not to be right.
Yeah.
But look, diet is one of those things.
OK, take butter as an example.
Butter was evil for about 20 years there, wasn't it?
Butter has been very negative, saturated fats, blah, blah, blah.
And my mother cooked Only with margarine, right?
And then guess what?
Well, if you use butter, it's got the saturated fat.
But then if you substitute margarine, it's even worse.
And so one of the things about diet that is very important, it's not just the thing you eat.
It's also what is it substituting for?
What's the alternative that you might adopt?
We often don't think that way.
So we only think of one category of food, not the entire diet we're eating.
Okay, Zeke, the subtitle of your book is Six Simple Rules for a Long and Healthy Life.
I'll go through them.
Number one, don't be a schmuck.
Number two, talk to people.
Three, expand your mind.
Four, eat your ice cream.
Five, move it.
And six, sleep like a baby.
There's also really seven.
The conclusion is called be a mensch.
So let's start chapter one, don't be a schmuck.
What are some common schmuck behaviors?
And why do people do them?
Do you think is it that they lack willpower?
Is it that they don't know better?
Is it peer pressure, etc.?
?
Well, smoking is a very good case of where it is a schmuck move, as is vaping.
And it's not because people don't know.
I mean, actually, smokers know the dangers of smoking better than the rest of us.
Partially, that's an addictive element.
And partially, it's a social system.
Until recently, society was actually pushing people to smoke through advertising, through pricing and the social acceptability of smoking.
We've changed that.
What we haven't changed is we really need to increase the taxes on tobacco.
We haven't increased them since 2009 at the federal level, and I think that's very important.
But we switched to vaping.
Now, vaping has some advantages.
It appears to be less dangerous than smoking.
I said appears because we've only had about 20 years of vaping.
And who knows what's going to happen?
But there's no free lunch.
Vaping still has adverse side effects on people.
I think there's other items I like to mention.
Climbing Mount Everest.
I can go as a tourist.
I can pay $100,000 and do it.
And it turns out it's incredibly dangerous.
I mean all comers, including the expert climbers.
You know, the chance of dying on Mount Everest is one in 100.
And if you're over 59, it's one in 25.
That is a total schmuck move.
Yeah.
Who would take a one in 100 chance for what?
Bragging rights?
Just seems crazy to me.
Also, the actual most dangerous job I've seen is being president.
We've had 45 people president, and four of them have been successfully shot and killed and eight of them have been shot at.
They may not have died, but that just seems like a very, very high number of people attempts on people, despite great Secret Service protection.
Okay.
Note to myself.
Don't run for president.
I'm not going to become president.
Yeah.
Okay.
Chapter two is called Talk to People.
Most of the advice in this chapter, it seems, comes from your father, which I very much enjoyed reading about.
Chapter three is called Expand Your Mind.
Here's something you wrote.
Accumulating a reserve of brain function can protect from the inevitable losses that occur with aging.
Is that real?
Is there a reserve of brain function?
And if so, what's the evidence for that?
The evidence is that people who've gotten more education and therefore more brain connections, have the same rate of decline.
But because I start from a higher plateau, it's noticeable as a cognitive decline and loss of function much later in life.
There is very good evidence on that.
Just think about how the brain works.
The main thing way that you get cognitive being cognitively intact, is you have a lot more connections between your neurons.
It's called brain plasticity, your ability to make more neuronal connections.
And then as you age, you lose those neuronal connections and you lose cognitive function.
What we're trying to do is push the date at which we lose cognitive function, and it becomes noticeable, out as far as possible.
There are some people who are remarkable, who are productive and creative into their 70s and 80s.
Ben Franklin is my quintessential example.
He's your spirit animal.
Can we just say?
Yes.
Well, I have a whole course on him.
I know.
And you're writing a Franklin book as well, correct?
Or plan to?
I plan to.
Yes.
Are there not enough Ben Franklin books in the world?
They're very long.
And I want to target young adults because I think they don't emphasize him as a role model for living.
The chances.
He took, the initiative he took, the constant creativity he engaged in where everything in the world was OK.
Okay, how does that work?
And him spending a lot of time trying to puzzle things way out of his expertise.
He once walked through a hospital and noticed a lot of people and they had these common symptoms.
He says, you know what they all have in common?
He said to the doctor, they all work with lead.
It took us another 150, 200 years to figure that out as doctors.
It seems as though you want to hold him up as a role model for a variety of things.
But one of them is aging, of being productive as you age and also continuing to learn.
In chapter three of your new book, you advise against retiring generally.
But I wanted to ask you, you know you Zeke plainly, like maybe love and are plainly energized by your work.
I'm happy to say that I am lucky enough to feel the same, but many many, many people don't like their work and they don't get that same kind of joy or energy out of it.
So for people listening to this, And they hear Zeke Emanuel say, don't retire, don't ever retire.
And they say, well, I do want to retire from what I do.
How do you think about that next phase?
Were you retiring from your vocation or your occupation?
But how do you set off on a new chapter that's as energizing and productive as the one that you want?
We do have data that countries where retirement is younger, people have a faster cognitive decline.
There's a sociability with work.
There's a schedule and expectations of other people and you.
There's cognitive challenges of how to solve problems at work and there are new things that you have to do.
When you think about retiring, you should think about all four of those elements.
How are you gonna replace them?
What are you gonna do for the sociability?
How are you gonna actually interact with people?
One of the things I suggest to people is I understand if you want to retire, if your job isn't fulfilling.
All right.
Then, how are you going to volunteer and how are you going to do things that give you a schedule, make you interact with other people, make you learn new skills and make you solve problems?
One of the things we know from data that a colleague of mine has collected is that When people retire, the thing that goes up the most is TV watching.
That is not a good place to be.
That is not gonna stimulate you cognitively.
And so I think if you wanna retire from an occupation, you gotta figure out the volunteer activities or the social engagement that you're gonna have as you age.
And unfortunately not a lot of people spend a lot of time consciously thinking about what that's gonna look like.
I'm wondering where you stand on drugs.
Mushroom use is up.
Ketamine use is up.
What's your position generally on mind expanding or mind changing drugs or other methodologies?
Maybe you'll tell me about meditation.
I don't know.
Well on drugs and in particular, on pot legalization.
I think this is one of the three great social experiments we've had without a control group.
And that is probably in the end not going to be good.
Cell phones, social media and pot.
We know that we have a lot of cannabis use disorder.
About a third of people who use cannabis can't control their use.
About 10% of people are actually addicted to cannabis.
They can't get off.
It has the same kind of pathways as other addictive drugs.
I think there might be, and again, I'm not a user.
There might be some conditions.
It might be better than alcohol, but that still doesn't make it good.
Psilocybin is a completely different issue and I've done some research on it, so I should declare that conflict of interest.
Did that research include swallowing?
No.
I've had people advocate, you ought to try it.
I said, no, that's not Zika manual.
I don't know that the world could tolerate me.
Maybe you become more tolerable.
Have you considered that possibility?
Only if I became more boring.
Okay.
You don't want to remove your edge.
No, I like my edge, actually.
There are people who are depressed, people who have PTSD.
We've done some research on what happens when you've got depressed cancer patients.
Give them a dose of psilocybin.
First of all, you see the depression go away in very short order, within a week, much faster than if they took Prozac or some other drug.
And we've done some research to say it can last 18, 24 months, not for all of them, but for many of them.
And that's with one dose.
So I think that can be very therapeutic in precisely a very hard problem to handle, which is resistant depression.
I think in five years, psilocybin is going to be standard of care for probably depression and PTSD.
And how would you describe the plausible biological mechanism of psilocybin and depression?
I've heard a variety of things from people who know quite a bit about this.
Some say that PTSD is a failure of the forgetting mechanism, that you're ruminating on an experience.
Let's call it again and again.
I don't know what psilocybin or other drugs may do to interrupt that trajectory or if it's something else, but why do you think it works?
If it does work?
I'm not an expert on its biological nature, but one of the things we do know is look That it works on the brain suggests that there's a receptor on the brain which is being activated by psilocybin that is supposed to do something in the brain positively.
It was conserved through evolution.
This rewiring of the brain does seem to be something where people attached to something that happened in their past and can let go of it.
Forgetting certain things really important for human beings.
We know that people who have these photographic memories and can forget are actually quite paralyzed.
One of the things my kids say to me is that I don't stay mad at people unless they lie to me.
They stab me in the back after telling me nice things.
Then I get pissed off permanently.
But I'm actually one of these people who you know.
If you offend me, you say something nasty to my face.
I don't get permanently pissed off at you.
And I think it's an important attribute because it allows you to move on with people.
It's an important lubricant to social interaction.
We're all going to offend people at sometimes.
I'm a big offender, and I sometimes say things that hurt people, even when I don't mean to.
We have to learn how to forgive.
That's a really important thing to think about.
I love that you point that out.
I agree.
I think that's really important.
I also however, find it interesting that, while there are some people who offend without even meaning to which you just described yourself as one of those people, there are a lot of other people who work really hard on never offending anyone, and those people I find so boring that I feel I need drugs to be around them.
Well, it's not just boring.
I find them unreliable because they're not telling you the truth.
One of the things I always tell the people who work for me.
They're junior and often somewhat intimidated unfortunately, around me.
I said, listen, tell it to me in part because I have two brothers.
And they have said things to me.
You can't even approach how severe and painful that can be, because they know exactly what pushes my buttons.
So don't worry.
And by the way, I won't hold it against you.
I much prefer when people tell me the truth.
Then I learn something.
When people are lying to me about how wonderful everything is, I don't know how to fix things.
I don't know how to change my behavior.
I don't know how to change the world.
So I prefer the truth even when it's painful because it's always something I can learn from.
I have a thick skin because of my two brothers.
We should say your family system is a little anomalous.
Your brothers are – their edge, if we're going to use that word, is on a scale of 1 to 10.
It's maybe 30.
Yeah.
Rahm Emanuel and Ari Emanuel, right?
I mean, you've been well-trained to deal with things like that.
Yes, but I do think actually having a thick skin is an important element, not to be offended by everything.
One of the things my father, I think, taught us is look, some people may not respond to you positively.
Don't take it personally.
Just understand they may not be having a good day and move on.
I do that a lot.
I'm not perfect at it and I still can be socially awkward about introducing myself to people.
But it's a great attribute, I think, because it allows you to actually survive in a lot of circumstances that other people get paralyzed by.
Coming up after the break.
Zeke Emanuel on Trump administration, health care policy and when to give technology a rest.
I'm Stephen Dubner.
This is Freakonomics Radio.
We'll be right back.
We'll be right back.
Zeke Emanuel has spent a lot of time in and around the political left, including the Obama and Biden administrations.
But he has also worked with the Trump administration during Trump's first term.
I asked Emanuel what he thinks of the current Trump administration's health policy.
Everything is for in Washington, but the guys running Medicare and Medicaid.
As I did not predict it, he has actually done a very good job of attracting the right people and doing the right thing.
Emmanuel here is talking about Mehmet Oz.
He is running CMS, the Center for Medicare and Medicaid Services, way better than Biden did.
Biden's person came and went and I asked everyone, I said, so what did they do? silence.
And these guys, they're actually doing good stuff.
Why were you so skeptical of Mehmet?
Because I thought he was willing to prostitute himself and say stupid stuff to make a lot of money on TV.
And I didn't know whether that's why RFK Jr. brought him in, that he would do his bidding.
And he hasn't.
He really has said, how are we going to make health care better for people?
And the other thing which I greatly actually appreciate is They don't care.
And I wrote this about exactly a year ago.
I said, you know, these guys are coming in.
The best thing that could happen is that they don't give a what the interest groups, what the AMA says, what the hospital association.
And that's actually really important, because you can't reform it if you, you know, constantly trying to placate everyone.
And I'm impressed.
I'm very impressed.
These guys are actually doing good.
Name a couple of things that they've done.
So they've initiated some prior authorization that is going to tamp down on some abuses.
They have initiated new programs aimed at getting better management of chronic illness and using apps and technology that we know work to do it.
There's just a recent report about AI getting people who have diabetes on the right dose of insulin in 15 days, as opposed to doctors doing it taking more than 56 days.
OK, that's really valuable.
And that also means the doctors can focus on other things and the AI can handle the patient through Alexa.
And I'm like, that's fabulous.
Let's do more of it.
And they are on that path to doing more of it.
They've launched a program called Access, which is very likely to go exactly in that direction.
So if you roll up, let's say, Robert F Kennedy Jr and Marty McCary at FDA and Mehmet Oz at CMS, and roll them up into one class, the first year of the second Trump administration's health and science policy, what's a letter grade?
D. D. Oh, that's still pretty poor.
Because you have to average an A at CMS, but an F at everything else.
RFK Jr. is going to make a lot of people die. through just the vaccine thing alone.
He hasn't done anything really on the food system.
I mean, taking dyes out is not going to save a single life.
He's undercut the entire structure and scientific review process that we have.
They have the focus on chronic illness, very good, but they haven't actually done that much on it.
I wonder whether you try to be apolitical or not really.
In your book, You give a hard time to Casey Means, Trump's nominee for surgeon general.
You ridicule her health and wellness obsessions, which you seem to think are pretty flaky.
And I get that.
But a couple elections ago, one of the Democrats running for president was the self-help guru Marianne Williamson.
So...
Matthew Feeney Jr, and whether you become too partisan a thinker, even in the health and wellness arena.
That's not true for me.
My goal is to fix the American healthcare system for the American people.
That means five things getting universal coverage, making costs reasonable for everyone, having consistent, high quality, diminishing disparities like rural, urban disparities, black-white disparities.
And having people fully satisfied.
You can't do those things without bipartisanship.
That's the first thing.
The second thing is Early on.
I talked to President Trump in 2016, in November and December 2016, trying to talk to him about how I thought he could improve the American health care system.
And I was pushing him to focus really on drug prices.
So we had a number of meetings.
I was happy to work with them.
Then when COVID hit, I wrote him a memo about how to begin approaching COVID.
Joe Biden called me and said, we'd like you to help.
And I'm like anyone who wants to make an improvement in the American health care and address this pandemic.
I'm open to it.
I told Biden I was working with Trump and he said, fine, we don't care.
But Trump, that was not the same attitude.
And he got upset and cut off discussions.
Did you try again with Trump, too, in 2024?
We are regularly working with Trump, too, about trying to address American health care problems.
Who's the we, Zeke?
Me.
Me and my team.
So we're trying to work on, you know, focusing on hypertension.
We're trying to work on this upcoding problem and getting Medicare to do a better job of risk adjusting.
We've actually developed a better risk adjustment model than they use now and trying to get them to adopt it.
I am—I don't know whether nonpartisan, bipartisan—
There is a big problem and we need to solve the problem.
And this problem isn't going to be solved by one ideological view.
You have to work and keep working at it.
There are people on the Republican side who I've learned a lot from.
There are people on the Democratic side who I've learned a lot from.
There are people on the Republican side who, I think, have wacky ideas about how to fix this system that aren't going to work.
And the same thing's true on the Democratic side.
I am willing to work with anyone to help solve this problem, in part because we are now at 18 percent of GDP.
That's one out of every six dollars that we spend.
It's a major cause of the unaffordability problem for every American.
If we could bring our health care spending down to 13 percent, that's a five percentage point drop.
Five percent in a 30 trillion dollar economy is 1.5 trillion dollars.
That's $5,000 for every American.
Just imagine what would happen if we could bring our spending down to the top of Europe.
A family of four would suddenly have $20,000 more to spend on everything else they need in life.
It would radically change how Americans live.
Now I don't know that I could in my lifetime get us down five percentage points of GDP, but we should be able to get down two or three percentage points of GDP.
And even that is a huge amount of money for people.
Last time we spoke Zeke, we focused on GLP-1 drugs, their efficacy, access to them affordability, potential downsides.
Can you just give me a quick update?
What have you learned about the GLP-1 drugs in the last year?
I do see, for instance, that Novo Nordisk, the Danish multinational pharma firm, recently won approval to sell Wagovi in pill form in the US.
That'll be the first GLP-1 that I'm aware of. pill form.
So there's obviously a lot of momentum in that area.
What's the state of the union with GLP-1s in your mind?
In the last year we have learned more and more about the positive benefits and we've cleared up suggestions that they don't have certain effects like reducing the risk of dementia.
People were very hot on that, at least in the first set of studies, does not appear to be the case.
But One of the biggest home runs, I think, is they have this enormous effect very quickly in terms of reducing cardiac risk factors and cardiac mortality.
That's amazing.
20% reduction in a year.
That's pretty amazing results.
What's the plausible biological mechanism for that?
You're reducing weight.
You're reducing the cardiac risk factors for causing plaque.
You end up reducing blood pressure as well.
And that also reduces renal disease and kidney failure risk.
I think the second thing that has become quite clear is...
No one predicted when they began researching GLP-1s decades ago that it would cross the blood-brain barrier and it would affect the central nervous system and, in fact, affect the reward system.
And now we know that it somehow does all that.
So there's less positive reward from food, but also alcohol tobacco alcohol, drugs.
That, I think, is going to turn out to be an amazing result that we're only going to learn a lot more about how you can use it to regulate these other addictions.
And it gives more plausibility also to some element that food can be addictive as well.
I'll just tell you, I have a very dear friend from college.
And I suggested he go on a GLP-1.
He went on a GLP-1.
And the next day he called me up and said, you know, my relationship to food is very different.
I no longer have this battle with it.
And then I talked to him just the other day and he said well, you know, I've had to go off the GLP-1s because we had a change in insurance and I can't afford it.
$1,200 a month.
I just can't afford it.
And the problem is we have this miracle problem.
And people who need it and can benefit from it aren't able to get it because of the cost.
We need to be more creative in our society when we have these really big breakthroughs for a large number of people of getting it at a reduced rate.
Me and my group have been advocating for thinking about subscription models of GLP-1s because you know we can lower the cost.
The marginal cost of production is very small and increase the number of people by maybe even an order of magnitude.
But the pill form I've read, and I would assume anyway, is going to be much, much cheaper, correct?
I'm reading Wagovi monthly pill form will be about 150 a month for what they call the starting dose, versus about 1350 a month.
That tenfold difference is not production costs.
It's profit.
And I think, you know, Novor Nordisk has been losing market share and needs to gain market share.
And this is an easy way.
But I think that's the kind of...
If we had under 100 so we're talking maybe 1000 per person per year, kind of if we got to that level it would be a home run.
I mean, it seems like we're heading in that direction, yes?
Yes, we're heading in that direction.
And I think within 10 years we're going to have a lot more options with a lot fewer side effects that are more targeted.
And the price will come down.
And I think that'll be fantastic for American society.
But let me just say, that's not the way to solve our obesity problem in America.
So let's talk about that for a moment, because all these things you're saying about GLP-1s are phenomenally good and or promising.
On the other hand, I hate to be the skeptic and I hate to bring the economists into the conversation where they may not be welcome.
I don't know.
But economists, as I'm sure you know, have this phrase moral hazard to describe a situation like this where, when you lower the risk or the cost of potentially potentially hazardous behavior like overeating or eating a lot of unhealthy food, that you maybe encourage people to do more of the same because you're giving them a kind of safety belt.
How do you feel about that?
In other words, you've just written a book promoting sensible, good nutrition diet sleep, etc etc etc.
But If there are pharmaceutical solutions that obviate the need to change behaviors, where do you fall on that?
Well, I totally agree with the economist, not on the moral hazard problem, and I'll explain why, but on the idea that GLP-1s are not the solution to the obesity epidemic.
Although we should acknowledge that in the last year, the percent of adults who have been obese has dropped 2, and we've not had a drop in decades since.
In the number of American adults who are obese.
So something is happening with GLP ones.
So here's one important way in which I think actually having the GLP ones are not going to lead to moral hazard but actually might change the psychology of people.
One of the things that happens, I think, when people gain weight is they become despondent about themselves, about life, about the future.
And I think if you now recognize well, I lost 20 of my weight, body weight, my body image is better.
I now see the future differently.
I have hope.
I have hope that I can control things.
I have hope that I can actually change my life.
I'm going to invest in my life differently.
I might adopt exactly what we want them to do exercise, better nutrition, better sleep.
You know the sleep apnea will go down.
All of these things suddenly become different and the valence, my ability to see hope in the future and therefore invest in the future, is going to increase.
We need to figure out more about how to appropriately use GLP-1s.
You might be able to get people to drop 20 of their weight inside of a year.
Then go on a much smaller dose of GLP-1s for the long term.
We also don't know how, giving them simultaneously diet and nutrition advice as well as exercise coaching, how those will intersect.
I suspect they're actually going to be synergistic for all the reasons I say.
So what's interesting to me Zeke, is that you write about this age.
We're in this wellness industrial complex.
You describe it as a tsunami of information that's coming to us.
Some of it too complex, some too simple.
But one big point you make is that most of the behaviors that you want people to follow, which is eating sensible food, getting sensible exercise, sleeping well, et cetera, et cetera you can't make a profit by prescribing that.
And that runs up against –
Not just the wellness industrial complex, but really the health care system where, as you know better than any of us many physicians, the way their incentives are laid out is to treat illness and not to encourage wellness.
So if you take a step way back.
Do you see any philosophical or theological adjustments that might be worth making?
Oh, absolutely.
A lot of people think, well, wellness is an individual thing, but that's wrong.
And we all know it, because the whole issue with ultra processed foods is we've got a whole food system that is incentivizing through food subsidies to corn and soybeans and wheat and rice and as well as many other aspects that make ultra-processed foods cheaper.
We don't subsidize fruits and vegetables.
We don't subsidize other very nutritious elements.
That's one area.
The other area is we have a whole— system now that is making us lonely.
We've got cell phones and social media, video games.
So people are no longer interacting and they're no longer talking to people.
I prohibited cell phones in my classroom as well as computers.
And you come into the classroom and it's a lot louder than it used to be, because people are actually talking to each other.
Apparently in New York where they've bell to bell prohibited cell phones, what they've noticed is that actually the volume's gone up and that's a positive because you've got more students talking to each other.
I have noticed that the whole cohort of my students.
They're sort of socially awkward because they don't know how to talk to each other.
They don't know how to navigate conflict or disagreement between themselves, and That is a very bad thing.
We've created lots of social barriers to actually wellness, not just in the health system.
And, believe me, I could go on for the next two three, four days talking about the problems of the health care system and the promotion of wellness.
But we also have other social systems like health.
There is this age old wisdom and.
And part of our issue is we have to constantly rediscover it, as you point out.
And I don't think that's new.
You know, what's the Renaissance?
Well, they rediscovered the verities of the ancient Greeks and Romans.
Okay.
Wellness is about biology and the core elements of we're really social beings.
Aristotle knew this, right?
Two books of his famous Nicomachean ethics are devoted to friendship.
And how important friendship is, both for virtue but also for a good life.
Hippocrates understood diet and exercise.
It strikes me that one prescription that I'm not hearing from you or anyone is that people need to read again.
When you talk to college professors, they say that even at good universities they can't get students to really do any real reading, even 100 pages of a book.
Forget about the whole book.
Have we just given up on that notion, do you think?
I hope not.
And I was just bitching about that problem of reading yesterday.
It's very hard to get students to read and they complain no matter how short your reading lists are.
And I think it's super important.
And we've lost that art.
And that also means we've lost part of the art of critical thinking to read something we don't agree with or to follow a detailed argument that's a little more complex.
And one of the things I bemoan over and over is how simplistic the lack of nuance in social media posts.
How can it be nuanced?
And I was terribly against social media for that exact reason.
You can't have a prolonged discussion.
I have an avocational interest in American history.
And you think about how long the debates were of the Lincoln-Douglas debates.
And then you're like oh, in American presidential debates now there are two minutes on each side and then a 30-second rebuttal.
They're not 45-minute speeches that are subtle and have a long development of arguments.
I mean, this is maybe Pollyannish and I'm not even sure it's desirable, but do you see a way to get back to – I'm not talking about Lincoln-Douglas debates, necessarily – but do you see a way to get back to a longer attention span, more attention to detail, more nuance, etc etc.
?
Obviously, there is a layer of society that still engages in all that stuff.
And I would argue that probably many people who listen to this program are part of that layer.
But having a thin layer at the top is not very good, I think.
Do you have any thoughts for making that layer deeper?
Well, I do have thoughts and I think one of the reasons that an electronics Sabbath is a good idea one day a week where you just shut down the computer, you shut down the phones is good is that can be a day where you read.
For the last two years, I have pledged my New Year's resolutions to have a full electronic Sabbath.
I have yet to reach that.
I'm about 70% of the way there.
I hope 2026 is the year I can actually fully realize it.
But I think that's an important step in the right direction for us, a day when we're not distracted.
And what this really is, Stephen, is it's about time allocation.
And it's about prioritizing deeper thinking and deeper reflection, including time with ideas that you don't necessarily share, to understand why someone might advocate that and to give them the most charitable reading you can so that you can think through.
Well you know, maybe I'll change my life.
Maybe this is a perspective I need to adopt.
Coming up after the break, has Zika manual figured out the meaning of life?
I'm Stephen Dubner.
This is Freakonomics Radio.
We'll be right back.
Let's talk about chapter four, Eat Your Ice Cream, which is also the title of the book.
And I find that chapter four is kind of the meat of this book, because it is about what to consume and not consume and how to behave and not behave and so on.
You describe a sort of vicious circle where people trying to do better with their nutrition and health and exercise and so on, they often get so stressed out about how to do it that it adds more stress to their lives and that can have a negative impact on their health.
So can you just walk us through that vicious circle and how to get out of it?
First of all, we have to remember wellness is for decades.
It's not for a moment.
Wellness is going to be your lifestyle, how you live and the habits you adopt on a daily basis.
They have to be things that don't require willpower, because if they require willpower, you're going to exhaust them and you're not going to follow through.
So that's the first thing.
The second thing is there are a lot of things we're doing that are anti-wellness.
And one of the interesting things about human beings that I think doesn't get enough play is we're an additive species.
When we confront the problem or a puzzle or something, we tend to solve it by adding things.
One of the important things I think about wellness is we have to actually take away the bad stuff we're doing.
And we don't do enough of that.
Look, there are a lot of negative things in our diet.
The top one is sugary beverages sodas, because they are 140 calories per 12-ounce can.
10 teaspoons of sugar with absolutely no nutritional value.
Don't do them.
They're not good for you.
And the good news in America is, if we need good news on nutrition, is we're actually decreasing our soda consumption.
The second is snacking has increased to 500 calories a day over the last 30 years.
We've got to...
Bring it way down.
I'm not telling you no snacks, but bring it way down.
Those two things alone will actually improve things.
And then one positive, which is eat more fermented food, eat more fiber.
Those are the two big things we're lacking in our diets on a regular basis.
You will be a lot healthier.
Just those things.
Take away two items and add two items.
Let's talk for a minute about the gut microbiome, which is something that, for reasons I can't explain, I've been interested in for a long time.
And also it's one of those topics that I feel we've been promised a lot more good research over the past 10, 15 years than we've actually gotten.
I know there are many many, many people working on it, but it seems as though the microbiome is a much more important driver of overall health than people 100 years ago may have imagined.
I don't know.
For all I know, maybe they were way ahead of us then.
Can you just talk for a minute about the state of gut microbiome research and what you think we'll be learning over the next 10 or 15 years?
That might be really useful.
Oh, absolutely.
I totally agree with you.
For most of the 20th century.
The idea is bacteria bad, they cause illness, they kill you, and antibiotics good.
And then what we've learned over the last 30 or 40 years is...
They're way oversimplified.
Those bacteria, they're really there.
They're good.
We've grown up with them and we've adapted to them.
Just think about it from an evolutionary standpoint.
We have more bacteria in our gut than we have cells in the rest of our body.
They got to be there for a reason.
That's very important.
And we also know that the diversity of microbiome is a very important sign.
Exactly the function of each species.
We're beginning to elucidate this.
All of us are impatient.
You know, it was 55 years ago that Richard Nixon created the war on cancer.
Now we're getting all these treatments and cures, frankly.
It took 55 years because cancer is complicated.
The microbiome and its effect on biology, the same thing.
It's going to take us probably another 20 or 30 years to really dissect out everything in the circuits and really make a lot of advances.
Nonetheless, we do know just basic principles.
Diversity is good.
The microbiome needs a lot of bacteria, but it also needs a lot of fiber and different kinds of fiber, not just the fiber supplements you get so that the bacteria can grow.
They protect the lining.
It's probably related and here I'm going a little out on thin ice probably related to the rise in things like colon cancer and other illnesses like, especially among young people.
I remember last time we spoke you were pretty surprised and shaken by the rise in colon cancer among people in their even 20s and 30s.
Yeah,
Yes, and I've had a lot of friends who've been diagnosed and unfortunately died from colon cancer in their 30s and young 40s.
When you say that the microbiome is a site of interest there, what do you think is happening?
Do you think this has to do with ultra-processed foods?
Do you think it has to do with antibiotic.
I don't know where to lead you, so I'll let you lead.
I do think ultra-processed foods and the decrease in diversity.
I also think probably pesticides that we've consumed and are on everything also decrease the diversity of our microbiome and the right kind of bacteria that protect the lining of the colon, decreasing
And where do those right kind of bacteria primarily come from?
Nature, all the things that we are supposed to eat.
So this is fermented foods, yogurts, et cetera.
And fiber so that they can grow in the gut and they can out-compete the other bacteria that we have.
This is where I get nervous.
About 60% of calories among adults and children are ultra-processed foods.
That is not good.
We know that decreases the microbiome diversity.
Diet sodas decrease the microbiome diversity.
Only 7% of the American population consumes enough fiber.
That is horrible.
We really need more fruits and vegetables as a regular part of our diet.
I think this emphasis on protein is overdone and the emphasis on fiber is underdone and we need to shift that.
I do think, Stephen.
One of the things we are going to learn is which bacteria are really important and also what the different bacteria do.
The impact on our cognitive function, our cardiovascular function.
I think we're just at the start of it.
We do now know things like fecal transplants can be effective in treating diseases like C difficile, which are caused by over antibiotic use, are going to be really, really important.
The other flip side and I think it's important for the listeners not to forget this is You know we unfortunately have in our food system.
We treat a lot of animals with antibiotics and that's probably a bad thing because of antibiotic resistance.
And also maybe some of those bacteria are not so bad for us to consume.
We do know in some cases, some of the bacteria are really bad.
Raw milk, not a good idea.
But in many other cases I think treating chickens and beef and And other animals with antibiotics is a bad idea and not good for our food system.
And this goes back to the issue we were talking about before.
Being well and having wellness, it's not just what I do.
It's also what the system does.
And unfortunately the American system is focused more on making profits for this part of the economy and externalizing the costs on the rest of society.
What you're describing is what some people might call a wicked problem.
Not just people from Boston, but researchers like to describe a wicked problem as one that's entrenched and has a lot of different players in it who have incentives to maintain their incumbency, and so on.
So any solution that I would think that you would like, whether it's in the health care system and the food system and so on, is inevitably a political solution, is it not?
I agree with you.
We have to change the food subsidy system we have in this country.
Can we change it overnight?
Absolutely not.
We've got farmers who have grown up with this food subsidy, who have created their production, and we have to slowly shift.
Can we do that?
Yes.
We've learned we can do that with tobacco.
We've learned we can do that with coal.
And we have to shift and give them alternatives.
I think that is going to be in every American's interest.
There are a lot of societies out there where only 20 of the calories are from ultra-processed foods.
That's where we need to be.
Let's talk about Chapter 5 for a moment, Move It.
This chapter I liked a lot.
We did an episode once called, What's the Best Exercise?
And the answer was, the best exercise is whichever one you will stick with.
I thought of that because when you're writing about exercise and the benefits and so on, you're really writing about habit formation.
You mentioned earlier in this conversation willpower and how you can't really rely on that.
So just talk about that overlap between between exercise and habit formation and how you would advise someone who wants to be more active, wants to be more regular in their activity but has a hard time getting there.
You have to have the attitude, I want to start this.
That's the first thing.
Initiation, I'm going to start.
The second thing is you have to actually set a date, set a time and make it at least three or four times a week.
You're going to do something.
I often recommend doing it with another person, because they keep you honest and they too want to do it, and you're sort of playing off each other.
The really important thing about exercise is the repetition.
The best data that I have found is four times a week for six weeks really gets you to a stage where it has become a habit and you're more likely to continue it to 12 weeks.
We don't have very long-term.
The important thing there, I think, is by the time you've gone six weeks, you've built it into a routine.
And that is the critical element, the repetition.
So the thing I recommend to people is, and this is what I do, is think.
Vigorous activity.
You need 75 minutes.
That's 10 minutes a day.
Well, I don't do 10 minutes a day.
I do 20 minute chunks.
So in the winter, I get on a stationary bicycle three times a week for 20 minutes.
And I do a lot of other activity.
What's your degree of difficulty on that bike?
I do a Peloton exercise and I end up sweating and my heart rate has to go over about 110.
That's not crazy.
110.
It's not crazy.
And almost everyone can find 20 minutes or you know, with a shower and whatever else 30, 35 minutes a day, three times a week.
That's not that crazy. crazy a time period.
You know, some weeks like this week, the holiday week, I am not going to exercise.
I'm away from home.
I will continue to do my yoga, but I'm not going to get out on the bicycle.
All right, then I'll go back home where I have all the setup and I'll continue it.
Am I going to become suddenly unhealthy?
No, you know, I'll get back onto it.
Let's talk about chapter six for a minute.
Sleep like a baby.
So I'm already a sleep advocate.
I love to sleep.
I'm like Olympic level sleeper.
Everyone in my family is very jealous.
What's your secret, Stephen?
Come on.
So here's the problem.
It's just natural.
It comes to me.
So I feel a little bit guilty about it, because I have a lot of friends and family who really do have a hard time sleeping.
And therefore, they reach out to what strike me as often absurd aids for sleeping.
And you're not a fan of some of the absurd sleep aids as well or sleep advice, I guess.
So Why don't you give me the do's and don'ts of the Zeke Emanuel sleeping program?
First of all, this is one where everyone has to be forgiving of themselves.
Every other wellness behavior you can will yourself to do.
You can will yourself to exercise.
You can will yourself to eat well.
You cannot will yourself to sleep.
You get in bed and you're willing yourself to go to sleep.
It will not happen.
We all know that.
Second, we are all prone to quick fixes.
That's the American way.
We reach for the melatonin or we reach for the magnesium or whatever our pill of choice is.
The American Academy of Sleep Medicine, no, they do not work.
Do not do them.
That's not the approach to take.
There are two things we can do.
One is we can set the bed and set the room up, make it dark, make it cool, tape over those lights or get those things out, put the phone in a different room, get in bed, read an actual book, not on a computer screen, and then go to sleep.
No guarantees that way.
Right.
And then if you're still having problems after you've done that for a while, cognitive behavioral therapy for insomnia is the most effective treatment.
You don't seem to put a lot of stock in apps that track your sleep.
Why is that?
I get up in the morning.
Anyone, you get up in the morning, you feel well or you don't feel well.
And let's say the app tells you something different.
Well, you're going to believe the app more than your body.
No, your body is the ground truth.
Are you feeling like you can concentrate, like you've got the energy for the day?
If you don't.
I don't care what the app says.
If it's anxiety provoking, which I think most of the sleep apps are, it's unclear what advantage you're getting.
It's not like wearing an Oura ring or a Apple watch that they're actually going to make you sleep.
They're not solving your problem.
They're not therapeutic.
They're giving you data.
And sometimes that data just makes you more anxious.
And that data is not more valuable than what your body is telling you.
So a lot of the advice out there around health and wellness, or the wellness industrial complex as we're calling it, has to do with things you shouldn't do.
Some you should, but a lot that you shouldn't.
And one thing that I just liked about your book was that you focused on some of the do's beyond just the foods that are good for you and the exercise that is good for you, but also the notion of joy and and celebration and setting out to actively celebrate yourself for others, and so on.
Can you talk about how to make that more of a routine for more people?
We're on this earth for 75, 85, 90 years.
That's it.
You can practice a lot of self-denial.
You can practice a lot of anxiety over getting everything right.
Or you can live a meaningful life where meaningful is mostly, I find, it's about being other people.
It's about doing good in the world.
It's about connecting to people.
When I have a dinner party and I have people over and we're having a really good conversation, that's great.
My joy is up.
It's also good in the long term because, you know, sociability is good.
And third, It's virtuous because the other people are gaining that sociability, that good conversation.
We're all in it together and we're all actually making wellness part of our everyday life.
It's like a trifecta.
It's a wellness trifecta.
It's good today.
It's good for tomorrow.
And it's good for the other people.
What could be better in life?
You quote the late British Chief Rabbi, Jonathan Sachs, who wrote We defeat death not by living forever which, as we know is impossible, but by living by values that live forever.
Your book Zeke, is mostly about personal behavior and not values per se, but my sense is that the values are always just underneath the surface.
So I'm wondering what you have to say about that.
If I asked you to synthesize or summarize Zeke Emanuel's values to live by beyond the eating, the exercise, etc etc.
What would that be?
You're 100 percent right.
And I don't think they're that much beneath the surface.
To go back and quote Ben Franklin, his great thing is be useful.
And by be useful, he meant how are you making the world better?
One of the things I think my parents instilled in me and my brothers and now you're going to make me cry when I think about my parents is look.
You are privileged.
You came into this great world.
You came into it at a great moment.
And the real challenge for you is how are you going to make it better for people who aren't as privileged as you are?
And how are you going to make it a better place going forward?
I think I've dedicated my life to trying to make the world better, whether it's by improving the health care system, by mentoring kids and putting them on the right way.
There are so many ways we can make the world better in our daily life, cheering people up, just growing things.
Ben Franklin challenges us, be useful.
How are you being useful?
How are you making the world better is the most important thing we can commit ourselves to.
And it'll give us joy because that's part of having a meaningful life.
And if there's anything that makes our life better.
It's having meaning in it.
Zeke, I enjoy every conversation with you, but I think this is my favorite.
So thanks.
I'm honored, Steve.
And you are the best interviewer.
Thank you so much.
Let me just say, for the record, I'm pretty sure I am not the best interviewer.
So if Zeke Emanuel is going to get that wrong, maybe we should just discount everything he said today.
I'll let you be the judge.
Again, his new book is called Eat Your Ice Cream, Six Simple Rules for a Long and Healthy Life.
Let us know what you thought.
Our email is radio at Freakonomics.com.
Coming up next time on the final installment of the Freakonomics Radio Guide to Getting Better.
Are we about to take a giant leap forward in medicine?
It's happening in eight emergency departments in the greater New York area.
They're automatically being screened by the AI model for heart disease.
As we all know, the healthcare system could use some serious disruption.
There are a lot of reasons that we are pretty static.
And we like technology, but we like it in very, very specific ways.
So how much and in what ways will AI remake medicine?
That's next time on the show.
Until then, take care of yourself.
And if you can, someone else too.
Freakonomics Radio is produced by Stitcher and Renbud Radio.
You can find our entire archive on any podcast app also at Freakonomicscom, where we publish transcripts and show notes.
This episode was produced by Alina Kullman and edited by Ellen Frankman.
It was mixed by Jasmine Klinger with help from Jeremy Johnston.
For background research help.
Special thanks to Corby Kummer, David Wendler, Govind Prasad, Marion Nessel, Suzanne Roweter and Zach Cooper.
The Freakonomics Radio Network staff also includes Augusta Chapman, Dalvin Abouaji, Eleanor Osborne, Elsa Hernandez, Gabriel Roth, Ilaria Montenacourt, Teo Jacobs and Zach Lipinski.
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