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January 09, 2024
America Dissected
New Year, New You?

In This Episode

America’s most common New Year’s resolutions focus on health–weight loss, fitness, or something else. While almost all of them focus on physical health, they all run through our mental health. Abdul reflects on how essential health is to everything else we do. Then he sits down with psychiatrist and author Dr. Jud Brewer to understand the mind-body axis and how mastering it can help us nail down those resolutions.

 

TRANSCRIPT

 

[AD BREAK]

 

Dr. Abdul El-Sayed, narrating: Scientists have discovered a new antibiotic in the fight against drug resistant superbugs. North Carolinians rushed to enroll in expanded Medicaid, prompting other conservative holdouts to consider expanding too. The FDA approves mass drug importation from Canada. And Covid test positivity, hospitalizations and deaths are up as the JN.1 sub variant surges. This is America Dissected. I’m your host, Dr. Abdul El-Sayed. And welcome to 2024. [music break] By the end of last year, folks, your host was running ragged. Between my day job, this one, and general goings on in this sometimes awful, sordid world. I was really feeling it. The usual spirit that I try to bring to my work faded. Every email became an annoyance. Every issue at work, a drag. Vacation couldn’t come soon enough. Michigan around this time of year. Let’s just say it’s not its most inspiring. The sun barely comes up and then it’s down again by 5:00, leaving you in a dark, desolate freeze. So we booked a trip to L.A. and though Angelinos may complain about highs in the 60s, it does come with sun. And look, this Michigander will take it. Our trip was proceeding as planned. Jaunts to different eateries and attractions built around our one year old’s sleep schedule, and playdates for our six year old. The best we can do as parents of two. Until day four, when after a day spent at Universal Studios, I came down with a rip roaring fever up to about 106. Both our daughters had had low grade fevers earlier, so we thought I was getting the grown man version of whatever ubiquitous virus they’d had. I was Covid negative, but took to wearing a mask in our hotel room anyway. And then the fever just wouldn’t go away. I’d spike three to four a day, but only after I started to get a really bad sore throat on the third day, did we two doctors step back and think this might not be the same run of the mill virus. I checked into an urgent care to get a throat swab to learn that I’d had strep throat. To this day, I still have no idea how I got it. Neither kid had had it, or thankfully got it afterwards. Masks work. But even after three days of antibiotics and round the clock aspirin and Tylenol, I was still spiking fevers. Nine days later, I’m feeling a bit better. But those nine days well, they really sucked. For those first few days, I felt really sorry for myself. I needed that vacation and I didn’t want to spend it shivering under hotel covers. But I’m not sharing with you so you feel sad for me. Okay, maybe just a little. But because of what it reminded me, I’m really lucky. Blessed not to have to think too much about my or my family’s health most of the time. Thankfully, none of us live with chronic illness or disability. So when I do get really sick, it registers as unusual. And when I did get sick, my insurance covered most of my urgent care visit and antibiotics, and I could easily fork over the $60 copay for the visit and a buck something for the meds. That’s not the case for too many people in our country and around this world. For millions of people, illness is an everyday occurrence. That pain, discomfort, forgoing of joy, that’s their normal. For so many others who may not be plagued by serious illness, getting treatment if they do, wouldn’t be as easy as handing over an insurance card and a credit card. It means they go without the care they need or risk financial catastrophe if they tried to get it. Shivering under a comforter in a Courtyard Suites in L.A. reminded me why we talk about these issues every single day. If you’re like me and you’re lucky and blessed enough not to have to worry about your health or how you protect it every day, remember that millions of others don’t have that privilege. And this work is about shining spotlights on those experiences, because they’re all too normal for too many people. And if you’re someone who struggles with your health or the financial consequences of trying to protect it, I hope you hear your experience in our work. And if you don’t, I hope you’ll share your experiences with us so that we can make sure you do. What does all this have to do with today’s episode? Well, New Years happens to be a time where many of us think again about our health, but the things we’d like to improve about it. Lose a few pounds. Start working out again. Run a marathon. Slow down on that drinking. These are just four resolutions friends of mine have already told me about. Nationally, the three most common resolutions all center around health in some way or another. But while those resolutions usually center our physical health, they sometimes miss what brings them together. And that’s the fact that they start with our mental health. Our guest today has been thinking about the physical manifestations of our minds for a while now. He’s a psychiatrist and author of three books, Unwinding Anxiety, The Craving Mind, and his forthcoming book, The Hunger Habit. I sat down with Doctor Jud Brewer to learn more about the mind body axis, the ways our diet culture is doing more harm than good, and how we harness our minds to heal our bodies. Here’s my conversation with Doctor Jud Brewer. 

 

Dr. Abdul El-Sayed: Okay. Can you introduce yourself for the tape? 

 

Jud Brewer: My name is Jud Brewer, I’m an addiction psychiatrist and a neuroscientist, a professor at Brown University, and out here to try to help the world. 

 

Dr. Abdul El-Sayed: We appreciate you and we appreciate you joining us. Um, you know, you, uh, study mindfulness and its connection to addiction. Can you just as a, as a, as a place to start, define those terms for us because I think they they tend to be thrown around in some less than specific ways. 

 

Jud Brewer: [laugh] I agree. Let’s start with addiction. When I was in residency, I learned this great, simple definition that I still use to this day. So addiction is continued use despite adverse consequences. And I like that definition because it applies to much more than the chemicals. It applies to the behaviors. It applies to all the things that are trying to get us hooked these days, from social media to food to porn to everything. 

 

Dr. Abdul El-Sayed: Before we talk about mindfulness, that’s interesting because I know that there’s a there’s a debate among psychiatrists and psychologists. I know only because my wife, Sarah, is a psychiatrist. And, um, and there’s a debate about whether or not you can truly be addicted to things that are not chemically addictive. And, uh, clearly your definition falls on one side of that. Um, can you can you tell us why, uh, you feel so strongly about, uh, about being more inclusive about about some of those things that can be addictive? 

 

Jud Brewer: Well, if they look at psychiatry, look at the diagnostics and statistics manual, the DSM. Almost every condition has something about how it’s affecting somebody’s life. Right. So causing problems in their social life, causing problems in their personal life because otherwise something could be seen as an eccentricity or something like that. So I think this definition well pragmatically, it works extremely well in my clinic where, you know, is my patient suffering or not basically. And that continued use despite adverse consequences really helps to kind of focus the conversation around, well, is it causing problems for you or not? Now, for example, you know, with smoking. Cigarettes, pretty straightforward. You know, all the withdrawal in the nicotinic receptor, you know, agonism and all those things. Right. So we can say, okay, somebody goes into withdrawal from nicotine, you know, physiologic. They go into psychological withdrawal. Cigarettes aren’t aren’t good for you. Right. There’s there’s nothing like hey you should smoke at least three cigarettes a day to live longer. Right. It’s the opposite. [laugh] So if we look at things that get a little more challenging, like food, where we need to eat to survive, it gets a little more complicated. Because here are people getting addicted to junk food or this or that, you know, all this food that’s engineered to get us really, you know, to eat more than you know, what’s the Lay’s potato chips saying? Bet you can’t eat just one? You know, that came out back in 1963, by the way. You know, so it’s like these things have been around for a long time and people are getting diabetes. People are having clinical obesity issues where, you know, their their weight is just not healthy. Uh, and this is where, you know, there’s a I think of this as the slow burn. Um, so it’s not, you know, cigarettes they’re going to they’re going to kill you in the long term one way or the other, whether it’s emphysema or or cancer or whatever. And you can look at diabetes in the same way where it’s not going to, you know, it’s not going to be like if you overdose on, you know, it’s hard to overdose on Oreos. Uh, although I’m sure people have felt like they have. 

 

Dr. Abdul El-Sayed: Yeah. 

 

Jud Brewer: At times. Uh, but you can certainly over overdose on opioids, you can overdose on alcohol, etc.. So you can say, well, you know, alcohol, uh, opioids, that’s, that’s a problem. And, but it’s really a part of the time scale. But all of it comes back to this, you know, suffering question, is it causing problems for someone? I don’t know what how does that how does that ring with you? 

 

Dr. Abdul El-Sayed: I mean, I think it ring rings true. I, I you spoke to I think some of the controversy there which is that. There are addictive substances where there is no positive use, right? I mean, you could argue that, um, that you do have the analgesic effect of opioids, but in barring some, uh, preexisting pathology, there’s no circumstance where anybody needs to have an opioid. I mean, you could argue that if you’re in extreme pain, you still don’t need an opioid. It can it can do a certain thing for you but you don’t need one. Whereas with food and sex, uh, those are those are profound human needs. And I would it complicates things because, you know, the definition you shared was about a use, uh, despite, um, causing problems for you and I, you know, one will always need to use food, per se. I guess it’s the, the nature and degree. And then you also, um, spoke to the other point, which is to say that there is, uh, an overuse that is more dangerous in the chronic versus in the acute, right? You know, you can overdose on opioids, uh, acutely. Um, whereas you’re not, like you said, going to overdose on Oreos, though I, I’ve come pretty close to feeling like it. [laughter] Um.

 

Jud Brewer: Yeah, totally. Uh, who hasn’t? Right. With whatever their Oreo equivalent is. 

 

Dr. Abdul El-Sayed: Because they’re right. Like, I, you know, I couldn’t eat just one. Um, and the reason, I guess I, uh, I wanted to pause here because, uh, because it becomes such an important question about that line between use and overuse for those things that are, uh, natural human needs versus, um, completely exogenous to the human experience unless one introduces them. Um, I wanted to. So, you know, just as we think about this question and um I swear we’ll move on, you know, this this, this question of, um. Of compulsive use, I think is also, uh, important. And the reason I bring it is because what I appreciate about your definition is that so much of what, um, we’re, we’re defining is addiction for the sake of this conversation is imposed on us by our surroundings, by our environment. And I think we take for granted that we live in in an extremely addictive environment. I think people talk about having an addictive personality that may or may not be true to some degree, and I’d love to hear your perspective on that. But we we decidedly live in addictive times, in addictive spaces. And, you know, being entertained, for example, is a human want and need. You see it in in the smallest children, you see it in the oldest adults. But the degree to which we have our, uh our most, um, interesting and engaging entertainment literally on our pockets and can can get to it at any given time. That is a new thing. And our brains, I don’t think have really developed around that. I’d love to hear your thoughts on, um, on the nature of sort of addictive personality versus addictive context. 

 

Jud Brewer: Yes, I would say, you know, I think there’s controversy around addictive personality, but I don’t think there’s any controversy around addictive context where, you know, in this attention economy, it’s extremely lucrative to get people addicted to their phones, for example, as you highlight, you know, I like to think of these as, uh, billboards in our pocket that we pay for. [laughing] You know?

 

Dr. Abdul El-Sayed: Ain’t that the game though? 

 

Jud Brewer: So it’s like–

 

Dr. Abdul El-Sayed: They, like, figured out how to get us to pay for our own advertisement. [laugh]

 

Jud Brewer: Yeah, absolutely. And they’ve been dialing it in for years and, you know, have really nailed the formula and are still improving upon it. You know, I think it’s more incremental at this point where they’ve hit the big the big buttons so far. 

 

Dr. Abdul El-Sayed: Mm hmm. 

 

Jud Brewer: And you know dialing it in. But the bottom line is you know these things have been exquisitely engineered to get us to keep looking, you know texting you know people we can go into all the details of it’s helpful. But you know texting has now been shown to be more dangerous than drunk driving. And yet people can’t stop doing it. 

 

Dr. Abdul El-Sayed: Mm hmm I raised this because I think it’s helpful to think about addiction as being about context, as we think about trying to protect ourselves from that context. I mean, we know that when it rains, you need an umbrella for the rain. And the other term that we’re going to talk a bit more about today is mindfulness. Can you tell us about how you define mindfulness vis-a-vis what we just talked about? Which is like an extremely addictive space and time in which we occupy. 

 

Jud Brewer: Yeah. And I think you highlighted this earlier. There are many different definitions by many people. I like to keep things simple for, you know, I’m a simple guy. So I like to think of two components of mindfulness this component of awareness and this attitude that comes with it, where we’re bringing this attitude of curiosity uh to whatever we’re being aware of. I think of these as kind of two sides of the same coin. You can’t really separate them. You can certainly pay attention to something and judge it. Right. But that’s not what I would think of as mindfulness. But if you’re if you’re aware of something and you’re curiously aware of something, that’s that’s kind of the crux of what I think of mindfulness as. 

 

Dr. Abdul El-Sayed: And when you talk about the curiosity, I’ve certainly heard the awareness part, but the curiosity piece is new to me. Do you think about it as curiosity internal to the advent of a new thought? You know, why did I think this? And what’s driving this? Or is it curiosity about the space in which you’re occupied? Or is it both? 

 

Jud Brewer: I wouldn’t. So I’m glad you bring that question up because it’s a really important differentiation. It’s not about the why, it’s about the what. And so what’s happening right now and bringing that curiosity to what’s happening. And in fact, there I don’t know. Did you know there are two different types of curiosity? 

 

Dr. Abdul El-Sayed: Mmm. Explain. 

 

Jud Brewer: Yeah. Okay. Well what does it feel like not to know that there are what the different types are? How does that feel in your body? 

 

Dr. Abdul El-Sayed: I think I feel frustrated and I I know now desperately want to know what you mean. [laughter] 

 

Jud Brewer: Yeah, yeah. So that’s called deprivation curiosity, we’re more deprived of a piece of information. And there’s research showing that it activates some of the same dopaminergic mechanisms in our brain as food. Right. So think of food as being nourishing–

 

Dr. Abdul El-Sayed: Like I’m hungry for the idea. 

 

Jud Brewer: Exactly, exactly. 

 

Dr. Abdul El-Sayed: Got it. 

 

Jud Brewer: And it’s even been shown in primate studies that they will forego food and drink for information. Right. So think of that as like food for our brain. Right. We’ve got to know and it helps us survive. Right. If you hear a rustling in the bushes, can’t be like, ah, it’s I’m sure it’s my brother and not the lion. [laughing] You know, you got to go figure out what that is. And so that deprivation that need to know is a nice survival strategy. The other type of curiosity is called interest curiosity. And this is the type of curiosity that I see as inherent to mindfulness practices. So that’s that’s the the joy of discovery. 

 

Dr. Abdul El-Sayed: Hmm. 

 

Jud Brewer: I think of these two, the easy way to remember this is deprivation is about the destination. When we get that piece of information, when we get there, we scratch that itch and it’s no longer gone. We’re no longer deprived of information. So that’s truly about like getting some specific piece of information when we don’t have it. Interest curiosity isn’t about anything in particular, anything specific. It’s about that journey. It’s like that journey of discovery as we go. We’re not, you know, we’re not trying to get somewhere in particular, although we could be going somewhere in particular, but we can be curious along the way, like, oh, no destination in mind, but it’s really that journey and not those. The two types of curiosity feel very different, and there’s a critical difference between the two. Both again, both helpful for survival, but just have a very different feeling tone to them. Well, you yeah. And let me ask you, when you’re just truly curious about something, you know, how does that feel compared to the deprivation curiosity that you just described? 

 

Dr. Abdul El-Sayed: You know, it’s interesting because immediately when you shared that the, uh, the way I thought about them were, you know, the difference between playing to win and playing not to lose. Deprivation curiosity is about the downside of not knowing where, whereas. Whereas the other form of curiosity feels a lot more like the joy at knowing or the joy in learning. And uh, yeah, there’s it and the highlighted emotions are are, you know, almost an anxiety that, I don’t know, a thing that I feel like–

 

Jud Brewer: Yes. 

 

Dr. Abdul El-Sayed: –I need to know that could potentially–

 

Jud Brewer: Yes. 

 

Dr. Abdul El-Sayed: –hurt me. And then the joy at being able to know a thing and to learn a thing, and the entertainment of twisting and playing with an idea in my mind, which is, I think, such, such a human thing. I mean, I watch my, my, uh, 11 month old now and, um, and I watch her play with something she just found and it. You can just see that this is this is just a innate human joy. Nobody taught her to be, um, wondrous about this little toy that she’s playing with. But you just see the wonder in her eyes. And it is such a beautiful, pure kind of emotion. 

 

Jud Brewer: Isn’t it? It’s so wonderful. Kids, kids nail this. And then we kind of beat it out of them. [laughter] And then, you know, they when they grow up. And so you’re talking about these differences right. There’s frustration, not knowing, scratch that itch, itch is scratched. And then there’s the joy of discovery, the joy of learning. So different both help. And it’s the joy of learning the joy of discovery, that’s that attitudinal quality that I think is critical for mindfulness. Because we’re not we’re not judging what’s happening. We’re we’re really just being curious so that we can learn, you know, we can be with whatever it is without actually judging it. You know, in Zen, they talk about beginner’s mind. 

 

Dr. Abdul El-Sayed: Mmm. 

 

Jud Brewer: And so if we’re not prejudging this moment. Right? That’s where we can just be curious about this moment. It feels totally different. [music break]

 

[AD BREAK]

 

Dr. Abdul El-Sayed: So in your first book, Unwinding Anxiety, you, uh, frame anxiety as a sort of addiction. Um, how do you how do you think about that? I’m I have a sense of where you’re going to go with this, given what we just discussed in these two, uh, definitions. But but how should we think about anxiety as an addiction? And what does that unlock for us? 

 

Jud Brewer: Yes. Well, this is the most important thing that I never learned in medical school. [laughing] So, you know, I didn’t know this, and I was really struggling to help my own patients with anxiety. And it turns out that if you prescribed medication, about 1 in 5 people is going to show a significant reduction in symptoms, like with the best medication. So I was playing the medication lottery, like, okay, next patient. Are they going to benefit? And if oh you know if they don’t what am I going to do? So four out of five you know pretty frustrating. So that’s that’s not the best odds even though it’s better than other medications for other indications. So I started looking back at the literature, and it turns out that back in the 1980s, about the same time that Prozac was introduced into the world. Uh, this guy, Thomas Borkovec, had suggested that anxiety could be negatively reinforced. And that opened my eyes really wide because as an addiction psychiatrist, I’m like, oh, I know what negative reinforcement is. And we’d been doing studies with, with, uh, smoking, for example. And we used mindfulness as a way to help people step out of these negatively reinforcing habit loops with smoking. You know, for example, if somebody goes into withdrawal and they smoke a cigarette, they learn, oh, this makes the withdrawal go away. So it’s negatively reinforcing because it makes something unpleasant go away. So here’s the here’s the interesting thing about anxiety. So anx– the feeling of anxiety can trigger the mental behavior of worrying. And I hadn’t really thought of mental behaviors as counting as behaviors. But oh does this one count [laughing] um big time. Right. So when we worry, uh, research has been is shown that it makes people feel like they’re in control. And feeling in control feels better than just wallowing in anxiety, even if it’s not actually putting them in control, you know, giving them any more control over their situation. I think of it this way. It’s like worrying is doing something and doing something feels better than doing nothing. Although if we look at it carefully, worrying actually just makes us more anxious. So so if we look at this inform the habit of worrying through negative reinforcement, we’re going to get stuck in these anxiety worry cycles. That’s going to be really hard to get out of. And then we’ll start associating this with like oh I need to be anxious to get things done. This whole, you know, this whole Yerkes–Dodson law myth. It’s really more, uh, Yerkes–Dodson legend than myth. Um, around, you know, you need to have some level of anxiety to perform well, to get things done. No research in the literature shown that, I actually talk about this in the Unwinding Anxiety book. But the bottom line is it was based on a 1908 study of Japanese dancing mice. And people extrapolated this to anxiety. So you can you can they can read the deals details if they want to geek out about it. But the bottom line is that worrying doesn’t actually help. It makes things worse. And so with that in mind, I started changing how I treated my patients in my clinic with anxiety. And then we developed a digital therapeutic, an app to to see if we could actually test that methodology and help people clinically. The bottom line there is we got a 67% reduction in anxiety in people with generalized anxiety disorder, whereas when we added this to usual clinical care in a randomized controlled trial, and then when you just look at usual care, it’s about 14%, which is about, uh, on par with that number needed to treat at 1.5. So we’re getting this much better results by simply having people apply some of these, uh, you know, mental technologies, let’s call it that, to working with their anxiety habit loops. 

 

Dr. Abdul El-Sayed: You know, you just unlocked something for me. So in Arabic, the term for important is mohim and mohim gets you at this notion if something’s mohim, it’s important. It’s something that should be prioritized. And then the term for anxiety is hem, which comes from the same root word. And it’s interesting because if you think about the over prioritization, trying to like completely reshuffle the cards over and over and over and over again to find what’s important. You get hem, which is like the anxiety that comes with trying to reprioritize everything, and I, I only really, um, you know, when you were talking, I was like, that actually makes a lot of sense because what is an anxiety loop except for being like, if I think about this enough, then I’m going to unlock some kind of insight, which is going to help me solve it, which is the, as you talked about, almost the mirage of the way that worry makes you think you’re in control, right? I’m going to I’m going to figure it out if I think enough about this. But really it’s it just it reinforces this notion, uh, that this is just something that makes you worried and, um, and, you know, it was a sort of an interesting reflection that that came to my mind as you, uh, as you shared that. 

 

Jud Brewer: Well let’s double click on that, because a lot of people think that worrying actually helps them come up with solutions or solve problems. And I want to highlight something here for anybody that worries a lot. So if somebody is worrying all the time and they come up with a solution, their brain is very likely to correlate the two and say, well, I worried and I came up with a solution, but if they’re worrying all the time, the solution could pop up randomly and they’re going to make this correlation equal equals causation fallacy outcome, you know, and and think, oh, because I was worrying, I came up with a solution. So I want to highlight that for anybody out there saying but no, no, no. They’re you know, worrying is really helps me. No no no. If you worry all the time randomly you might come up with a solution. And I would also suggest the more you worried, the less likely you are to come up with a good solution because like you’re highlighting or getting stuck in these ruts. So we’re less likely to be able to be creative or think outside the box, or actually have proper thinking because we’re filling up our working memory with these, with these same grooves that we’ve been going over and over and over and over. 

 

Dr. Abdul El-Sayed: You know it’s interesting when, um, you know, to, to use some psychiatric speak, the little that I learned in med school. Right. We talk about disordered thinking and I, I almost think about this as over ordered thinking. Right. You’re like you’re like too intensely focused on this one thing where you know that natural capacity of your brain to connect things in your subconscious kind of goes away because you’re so focused on this thing. Um. I uh–

 

Jud Brewer: Totally agree, we call that perseveration because I wouldn’t even I wouldn’t call that, you know, certainly it’s thinking because there are thoughts happening. But when people think about thinking like, oh, I’m thinking about this, you know, it usually means there’s some progression in the thought [laughing] as compared to perseveration, which is getting stuck in that groove over and over and over. 

 

Dr. Abdul El-Sayed: Um, so tell us a little bit about how mindfulness intervenes. What what is the mechanism by which engaging in in mindfulness, which, you know, you often get, uh, you hear analogized to, you know, a mental gym, uh, how does that intervene against this, um, perseveration anxiety, uh, doom loop? 

 

Jud Brewer: Well in this study that we did, uh, with people with generalized anxiety disorder, we could actually measure this. Where we could look at the different mediators that might affect the results. So if we look at, at mindfulness, we have this hypothesis that it helps people be with their emotions instead of try to do something about them, to make them go away or whatever. You know, I like this saying what we resist persists. And so for like, I got to get rid of that thought or I’m going to worry about this. We’re just grieving those, those habit patterns even deeper. So here we we had the hypothesis that helping people not be as emotionally reactive. So there’s a measure for emotional and non reactivity. And there’s also a measure for worrying. It’s called the Penn State Worry Questionnaire. And we can look to see we actually found basically that uh mindfulness uh increased people’s ability to be emotionally non reactivity non-reactive. And that mediated a reduction in worry. And that reduction in worry mediated a reduction in anxiety because anxiety and worry are very tied together. So one mechanism, one psychological mechanism might be that people are you know they’re they can notice that feeling of anxiety. They can notice the worry thoughts and not get caught up in them. And that’s anecdotally what we hear people talk about. 

 

Dr. Abdul El-Sayed: It’s almost like um, rather than letting the, the worry rumbling on the sea carry your boat away, you just it kind of just goes under the boat and you see it, you feel it for a second, you might might move the boat up and down, but it doesn’t carry the boat away. 

 

Jud Brewer: Yeah, yeah, you ride that wave. And often people describe mindfulness or meditation in particular, as as setting an anchor so that in the present moment, so that we can notice when we’re pushed or pulled by thoughts or emotions or body sensations and not get, uh, carried away in the current of the thinking, you know, or, or hop on that thought train and get carried away. 

 

Dr. Abdul El-Sayed: So as as we think about applying mindfulness to other addictions, specifically food, which is the subject of your, um, of your new book, I almost feel like the you know, the analogy is clear, but there are some, some pretty clear differences. Um, and that I mean is going to sound absurd, but like hanger is one of them. Like, if you haven’t eaten, you get extremely hungry. Um, I find it really difficult when I haven’t eaten for, like, you know, 12 hours or so not to let my hunger just completely own me. And then part of me says, okay, well, this is like a, a natural human response to not having eaten, because well eating is critical to my life. But, um, but it, it feels like that ability to, uh, to nuance the sources and, uh, and strengths of your cravings. Um, is probably crit pretty critical here. Can you, can you talk a little bit about that? 

 

Jud Brewer: Yeah, I’d be happy to. And I give all the details about this in the in the Hunger Habit book, but I find eating fascinating and just for many reasons. But one of them you highlighted, which is, you know, we have to eat to survive. Yet we can get caught up in all of these different ways where we’re eating not out of hunger, but actually out of emotion. Like with we, you know, when we’re angry, when we’re lonely, when we’re tired, you know this and that. And that is so prevalent and so well studied now that there are actually two different terms for hunger. Uh, one is homeostatic hunger, which is the one that helps us survive. You know, go get that food. And there’s then there’s hadronic hunger, which is driven purely out of emotion, not actual physiologic hunger. So I’ll give an example of this. I was working with, uh, a group of people who had binge eating disorder in my clinic. I was running a group medical visit, and for the first month or so, we’d meet weekly. [laugh] For the first month or so, I was like, what am I missing? What am I missing? Because I was trying to trying to help them by using mindfulness to help them work with these, these habit loops of binge eating. And it turned out that they had no idea how to tell the difference between homeostatic and hedonic hunger, and that one of them put it beautifully. She just said, well, I have an urge and I eat. And that I have an urge and I eat really said everything, because their brains had just mushed together homeostatic and hedonic hunger. And some of them I I one patient that I’m thinking of in particular. It took years for him to start to dial back into his homeostatic hunger because he was so divorced from his body, and he was so used to just having that, that itch of an urge and scratching it by eating, you know, itch scratch. Itch scratch itch scratch, as compared to just sitting with that itch and asking, am I hungry? And even being able to tell the difference. You know, like you can we can ask the question if we’re hungry, but if we’re divorced from our bodies, then we, um, then it’s really hard to do. I highlight this quite a bit in a chapter in The Hunger Habit. Um, where I start that chapter with this great quote from James Joyce. You know, this is this is not a new problem. There is a, uh, there’s a short story he wrote, uh, called A Painful Case, and there was a person in that called Mr. Duffy, and he starts this story with this line, I love it. Mr. Duffy lived a short distance from his body. 

 

Dr. Abdul El-Sayed: Mm. 

 

Jud Brewer: You know, it highlights it, right? How we’re just these walking [laugh] walking heads with the body to propel ourselves around. Especially if we’re not happy with our bodies. Whether how they look or how they function or how they feel. You know, we’re going to try to get away from them, except that we’re stuck in them. 

 

Dr. Abdul El-Sayed: Stuck in them. Hmm. I want to ask you, because you know you talked about indulging that, uh, will to worry as a means of attaining power and using that that same point when you talk about food, you you spend some time really deconstructing willpower based diets. Can you can you define what you mean by that? And you know why these actually can be can do more harm than good?

 

Jud Brewer: I’d be happy to. And there’s a huge amount of research around this. So there are books written about it, there are TED talks, there are lots of studies. But the bottom line is when we take these calorie restriction diets where we say, I’m, you know, it’s it’s the food rules type of thing where I’m just gonna eat this and not eat this. You know, it’s like calories in, calories out. Uh, a lot of people can get some momentum and lose some weight, and then their body goes into starvation mode because it says, hey, hey, where’s the food? What are you doing? You know, and so our bodies are built to hold on to calories when there’s a lack of calories around. So our metabolism shift and it actually makes it extremely hard to lose weight. And so this is now has a term for it because it’s so common. It’s called yo yo dieting. And you can imagine you lose some weight. You gain it back. You lose some weight, you gain it back. You, you know, yo yo yo yo yo. So the problem. There are many problems with this. Um, but one of them is that, you know, we think, oh, it’s, it’s I just have to stick with the diet and there’s something wrong with me. If I can’t do it, I don’t have enough willpower. 

 

Dr. Abdul El-Sayed: Mm hmm. 

 

Jud Brewer: You ready for this? If you ask a neuroscientist. Right. So if I put my neuroscience hat on and not my clinician hat. So in medical school, I learned calories in, calories out, you probably did as well. But and they’re like, oh, duh it solved problem. [laugh[ But if it’s a solved problem why are why are clinical obesity rates going up in the country? Right. So there it’s not a solved problem. Uh, the formula is correct. But if somebody feels like it’s their fault, they’re going to judge themselves and blame themself for not being able to stick with the diet as compared to asking this critical question, which is, hey, is this how my brain works? The answer is no. That’s not how our brain works. So from a neuroscience standpoint, we when you look at habit formation and habit change, there is no variable in the equation for willpower. It’s a myth. 

 

Dr. Abdul El-Sayed: Mmm. 

 

Jud Brewer: And so people there’s more of this correlation equal equals causation thing going on where people think, oh I just don’t have enough willpower. Or if something worked there like that was because of my willpower. This is likely that we’re just telling ourselves stories. You know, if you look at an Alzheimers patient, um, you know, they’re perseverating all the time or a lot, you know, if they have advanced disease. Well, it’s likely that we tell stories [laugh] about our lives after something happened and you’re like, yeah, I did that. Right, [?] or I didn’t do that or I couldn’t do that. One reason I want to highlight this is that often people, they judge themselves, they blame themselves, and then they get into these blame shame cycles, which often leads them to eat. You know, I had a patient who had binge eating disorder who I won’t go into the details, but she had, you know, some emotional trauma as a young person and had been she developed this coping mechanism of eating to, as she put it, numb herself from her emotions. By the time she came to see me, she was about 30. She was bingeing on entire large pizzas in one sitting, about 20 out of 30 days a month. And the only thing her brain knew how to do was to binge as a way to cope with her unpleasant emotions. So after a binge, sometimes she would feel bad about the binge and then she would binge again, because that was it would trigger that, oh, feel bad binge, feel bad binge. So she had tried willpower. You know most all most of my patients have tried and failed willpower. And this is where I get really excited about science, because we can sit step back and say, well, willpower is not working so well. So what does work? Well, if you look at the neuroscience and you look at the equations, it turns out that there is a variable, an error term, uh, that will help us change behavior. And that is critically dependent upon one thing, which is awareness. So this comes back to mindfulness. Let’s use a pragmatic example. Let’s say that I have a new bakery that opens up in my neighborhood, and I’ve got a certain reward value of how good chocolate cake is in my brain. You know, I’m like, here’s this is good chocolate cake. So I go in there and I eat, go to the bakery and eat some of their chocolate cake. And it’s like the best chocolate cake I’ve ever had. My brain gets what’s called a positive prediction error. This is that error term where it’s better than expected. I get a dopamine spritz in my brain and I learn hey, good bakery. On the other hand, if I eat the cake and I’m like, meh, I’ve had better, I get a negative prediction error. Dopamine spritz, learn. So both of those help me change my behavior. If it’s good, do it again. If it’s not so good, don’t do it. Notice how both of these are critically dependent on me paying attention. If I’m on the phone while I eat the cake, and I go home and my wife’s like, hey, how was the cake? I’m like, I don’t know. [laughing] I, I didn’t taste it. So we actually did a study and I highlight this in The Hunger Habit. So folks, you know, they could read the details in there. But basically we built this app called Eat Right Now and built in this tool to help people pay attention as they overeat. One of the questions we wanted to ask in that study was, how quickly does this reward value change, and do people start changing their behavior? We found that as we helped people pay attention as they overate, it took only 10 to 15 times of somebody overeating for that reward value to drop below zero. They’re getting these negative prediction errors. That said, don’t do this. This is not helpful. Why are you doing this? And they would shift their behavior surprisingly quickly, even if they had had the habit of overeating for 30 or 40 years. Which also fits pretty well with the evolutionary, you know, think of it as we don’t have 20 times to get chased by the tiger to learn that it is dangerous. You know, we our brains are tremendously plastic, so that neuroplasticity helps us adapt and we can even adapt to something that we’ve been doing forever. As long as we pay attention. 

 

Dr. Abdul El-Sayed: Yeah. 

 

Jud Brewer: You know, we can adapt and change, I should say. 

 

Dr. Abdul El-Sayed: So I want to I want to come back to this, this notion of mindfulness. Right. Because awareness really does modulate so much of the way we engage our experiences. And as you just shared, whether it’s food or anxiety or, um, you name all of the other, uh, things that that we can, uh, develop, uh, an addiction to. How does one and how should one go about building uh, mindfulness? I mean, you know, meditation apps are are are everywhere. And, um, you know, as, as, as you think about what the what the sort of least common denominator of effective mindfulness exercise looks like, how would you define it? And what should folks be seeking out? 

 

Jud Brewer: I love that in terms of like, let’s keep it simple, because simple is going to be what works in the clinic and in everyday life. So more and more, you know, I’ve been studying this stuff for a couple of decades now, and it gets simpler and simpler and simpler. So I would say the the minimum necessary component, let’s say, or ingredient is curiosity. So let’s unpack that a little bit. If we’re in a habit loop where we over eat, um, let’s, let’s just say overeating, we could use an anxiety like stress eating habit loop where we can go through both of them. Let’s just use the overeating. If we are in the habit of over eating, and we pause enough to pay attention and notice that we are overeating, right? Because if we don’t, then we’re just going to keep doing it. That’s the definition of a habit is automatic behavior. So we’ve got to pause. And often that pausing can come from the overeating causing problems for us. That’s often where we’re going to start waking up and saying, hey, I got to make a change here. So if we get curious and we start just paying attention to what it feels like when we overeat, we’re going to get this negative prediction error. And that is a moment of mindfulness where we’re learning, oh, this isn’t so helpful for me. And then we can start to bring that curiosity to the urge to overeat. You know, it might be completion bias where it’s like we’ve been you know, we’ve been part of the Clean Plate Club forever. And so we can go, oh, this is what I always do. And so it’s uncomfortable to change, right? Because change is scary to our brains. Our brains are saying, hey, this is dangerous. You know, or is this dangerous when when something’s different. So we can start bringing that curiosity into those moments of cravings and go, oh, is this dangerous? Or is it just different? And then we can start bringing curiosity to the craving itself and ask, oh, what does this craving feel like? And we can start to notice these are thoughts. These are emotions. These are body sensations. And if I just get curious about them, I don’t have to do anything to make them go away. Why? Because they will go away on their own. And one of my favorite examples of this was a patient I saw when I was working in the VA hospital, and he comes in and he’s like, doc, if I don’t smoke, my head’s going to explode. Like, oh, crap. First, first case, you know, chief complaint of head exploding from craving. So I fall back on my whiteboard because that’s me. You know, as the professor. Um, you know, my habit is to go to the whiteboard and start mapping stuff out and start diagramming it. So I start to ask him to describe what his craving feels like. And he’s like, it’s tightness, it’s tension, it’s burning, it’s heat, it’s restlessness. And I was asking him to describe the intensity, and I was drawing an arrow because he said, it’s going up, it’s up, it’s up. And then at some point it hit this inflection point where it peaked and his eyes got really big, and he said, oh, you know what? I always smoke a cigarette. But I didn’t smoke a cigarette. And I realized this craving goes away on its own. Oh, tremendous power in that. In helping him see that he didn’t have to smoke. He could simply get curious about what that craving felt like, and it was going to come and go on its own. So yet again, what’s the simplest denominator here? It’s curiosity, you know, being aware of these habits, being aware of what we’re getting from them. I call this, you know, asking the simple question, what am I getting from this? Being curious and then bringing that curiosity in it, uh as its own superpower to help us be with whatever our thoughts are, whatever our emotions are, whatever our body sensations are. And that’s really the crux of what mindfulness is. You know, it’s like helping us be with our experience. I think of I think of it as being as the new doing. Right. What do you what do I need to do? Well, be learn to be with this and it will change on its own. And you can change. You can be in relationship with it differently than you have in the past. 

 

Dr. Abdul El-Sayed: So it’s almost like, uh, when we think about our cravings, whether it’s for food or for our smartphone. We’re so quick to be carried off by that, that cresting urge that we almost never see the natural history of it through. So what would happen if I didn’t? And that ability to ask that question and to be present enough to ask that question and to see it through, is critical that our own awareness is like, well, that wasn’t actually that bad. And when we do see it through, to actually just be aware of being like, okay, so this is what it feels like to get carried away. Why do I feel like after I do this while I’m doing it, you know, as I’m doing it? And then after I did it, um, and uh, and that really captures a lot of our ability to, to sort of to activate that neuroplasticity to help us to make decisions that are ultimately the better for us. 

 

Jud Brewer: Yeah. And I’ll just add. How cool is that? Like, our brains are so amazing, you know, and if we just learn a little bit about how they work, we can put them to work for us in the service of learning and changing and growing without forcing anything. That’s the power of curiosity. 

 

Dr. Abdul El-Sayed: Hmm. I love that and that’s a it’s an amazing, uh, place for us, uh, to end. I really appreciate you making the time. Uh, Doctor Jud Brewer is a New York Times bestselling author, and his two books include Unwinding Anxiety and the Hunger Habit. Uh, he is a neuroscientist and psychiatrist. And we really, really appreciate you joining us today. 

 

Jud Brewer: Thanks for having me. It was my pleasure. [music break]

 

Dr. Abdul El-Sayed, narrating: As usual, here’s what I’m watching right now. Zosurabalpin, say that three times fast, is the first of a whole new class of antibiotics. And good thing too, because it’s a pretty damn dry research and development pipeline out there. The new drug can destroy highly drug resistant strains of Acinetobacter baumannii aka crab when it causes pneumonia and sepsis in mice. And now it’s in human trials, though it’s pretty far from being approved for human use. Don’t be alarmed if you’ve never heard of crab. It causes extremely drug resistant hospital infections. Though infections with crab aren’t aggressive, they’re extremely tough to treat, which is what makes this new medication such an important breakthrough. Notably, Zosurabalpin is the first new antibiotic that targets gram negative bacteria in a half a century. In other good news, hundreds of thousands of North Carolinians got health care late last year because Obamacare. A little late, right? Well, it only took 14 years for the North Carolina legislature to finally agree that taking billions of dollars in federal money to provide hundreds of thousands of people health care was a no brainer. 280,000 people enrolled in expanded Medicaid in get this the first week of the program. North Carolina is the 40th state, including D.C., to expand Medicaid. That leaves another 11 holdouts. That said, given the success the program is having in North Carolina, it may just have been the final trickle before the dam breaks. Several other state holdouts have signaled that they, too, may finally embrace Medicaid expansion. The Speaker of Georgia’s House, John Burns, recently urged his colleagues to consider expanding quote, “health coverage,” though he’s being conspicuously careful not to call it Medicaid or Obamacare. Similarly, top legislators in brick red Mississippi have also signaled extending Medicaid after Governor Tate Reeves nearly lost his reelection over the issue. 2024 could be full of political surprises, and we’ll be watching. If you listen to the show, you know that U.S. drug prices are way too damn high, and that has nothing to do with the price of manufacturing them. It has everything to do with public policy that favors the interests of the drug manufacturers over the affordability of drugs here in the U.S.. Case in point, my office in downtown Detroit overlooks Windsor, Canada. There, the price of the same exact drugs I could buy at a pharmacy down the street are way, way cheaper. And that implies an obvious arbitrage problem. Arbitrage is what economists call it when you can buy something for really cheap and sell it for expensive without that much work. So why can’t we just buy drugs from Canada and bring them to the US, you ask? In fact, that’s something folks here in Michigan have been doing for a long time. But the FDA just cleared the way for mass import of prescription drugs from Canada in a letter to the state of Florida that plans to start buying directly from Canadian wholesalers. As you can well imagine, pharmaceutical companies are up in arms. They obviously want more Americans to keep buying at inflated American prices because, well, that means they make more money. Canada, for their part, don’t like it much either, as the Canadian drug supply is far smaller than ours here in the U.S. but being Canada, they’re probably going to apologize for that. And all of this should force a really obvious question, why go through all the trouble of buying prescription drugs at Canadian prices when we could just change public policy here in the US to reduce American pricing? Well, because the prescription drug industry spends hundreds of millions of dollars a year making sure Congress won’t do exactly that. Finally, while Covid hasn’t been making headlines, it sure has been making its way around our country. Covid test positivity, hospitalizations and deaths are up as the JN.1 subvariant has climbed to the top of the heap. JN.1 is yet another Omicron sub variant. It’s actually been around since August and is a close relative to the previous king of the heap, BA.2.H6. These Omicron sub variants, as you recall, are all mildly different from the last one, each exploiting tiny differences in our immunity to get to have their moment. Remember, whenever you hear about a new variant, ask three questions. Is it more transmissible? Is it more immune evasive? And does it cause worse disease? The answer, thankfully, to all three of these questions appears to be no. That said, the increasing case positivity, hospitalizations and deaths we’re seeing is probably a function of the weather. Remember, it’s getting colder in much of the country, as I can attest, and folks are spending more time indoors. On top of all that, we’ve been congregating in medium to large groups for holiday gatherings, all in the context of an abysmally low vaccination uptake. And so JN.1 has been loving it, even if we haven’t. So look, if you haven’t gotten your vaccine, please go do that. And if your loved ones haven’t either, have a gentle, kind, earnest conversation with them about why you love them and why they should. That’s it for today. On your way out, don’t forget to rate and review the show. It really does go a long way. Like right now, please go just five stars, Abdul’s great. Or good information. I really appreciate the show. Also, if you want to rep us drop by the Crooked store for some American Dissected merch, and don’t forget to follow us at Crooked Media and me at @AbdulElSayed no dash, on the gram, TikTok and at Twitter. [music break] America Dissected is a product of Crooked Media. Our producer is Austin Fisher. Our associate producers are Tara Terpstra and Emma Illick-Frank. Charlotte Landes mixes and masters the show. Production support from Ari Schwartz. Our theme song is by Taka Yasuzawa and Alex Sugiura. Our executive producers are Leo Duran, Sarah Geismer, and me. Doctor Abdul El-Sayed, your host. Thanks for listening. [music break] This show is for general information and entertainment purposes only. It’s not intended to provide specific health care or medical advice, and should not be construed as providing health care or medical advice. Please consult your physician with any questions related to your own health. The views expressed in this podcast reflect those of the host and his guests, and do not necessarily represent the views and opinions of Wayne County, Michigan, or its Department of Health, Human and Veteran Services.