Beyond the Prescription

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Hundreds of you tuned into my live conversation with Shannon Watts on Saturday. While neither of us claims to have all the answers, we discuss some coping strategies to manage distress. You can watch the full conversation above.

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Disclaimer: The views expressed here are entirely my own. They do not reflect those of my employer, nor are they a substitute for advice from your personal physician.

Life transitions are sprinkled with possibility. They invite adventure and hope. They can also force us to look inward, to reevaluate our life choices. They can beget sadness and regret, a mourning over the passage of time.

There’s nothing like kids getting older to remind us how it goes so fast.

Mary Louise Kelly writes out these very issues in her memoir It. Goes. So. Fast. It is a heartfelt chronicle of her eldest child’s final year at home, the death of her father, and other curve-balls in her life that forced her to reckon with her evolving roles as a parent, mother, daughter and wife. On this very special episode of Beyond the Prescription, Mary Louise describes the emotional and physical manifestations of grief, the bittersweet moment of sending a child to college, and the heartbreak of losing a parent and ending a marriage.

It turns out that even a woman who “has it all” isn’t immune to feelings of regret and sadness over the passage of time. Mary Louise’s authentic voice provides reassurance and hope that we are all caregivers at heart, doing the best we can with the time we are given.

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In a special video episode of today’s newsletter, my friend Shira Doron, MD, and I discuss the state of COVID—new variants, testing, treatment, boosters, and long COVID.

Shira is the Hospital Epidemiologist at Tufts Medical Center, an infectious diseases doctor, and Professor of Medicine at Tufts School of Medicine. She is a nationally recognized expert in antimicrobial stewardship and infection control. During the COVID-19 pandemic, she played a key role in helping the general public separate fact from fiction. 

I hope you take a listen above!

In addition, here is Dr. Doron’s take on the current state of COVID & respiratory viruses in the U.S.:

Respiratory viral season is upon us. It’s likely that you know several people who are sick right now. These days, it can be hard to figure out how worried to be. Is this a “normal” flu season? Is COVID-19 “surging”? The media is paying more attention to respiratory infections than they did before the pandemic, and the headlines are often designed to garner clicks, which is to say they are sensationalist. Let’s cut through the hype.

Here are a few things to know:

Current state

There are many respiratory viruses circulating right now, most of which are always more prevalent in the winter. You cannot tell the difference between them without a test. Health authorities track a metric called “ILI” which stands for “influenza-like illness.” This metric encompasses all of the respiratory viruses including but not limited to COVID-19, influenza (“flu”) and COVID-19. Right now, where you live determines how much ILI you are seeing.

source: CDC.gov

Trends show that ILI peaked in the last week of 2023 and is coming down. The peak this season was lower than the year before, and comparable to the year before the pandemic, despite the fact that we have a new virus in the mix. In other words, this is a “normal” respiratory virus season in terms of severity.

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Testing and treatment

Health authorities still recommend that everyone test themselves for COVID-19 even if they have mild symptoms. That’s because everyone is still advised to stay home for 5 days if they have COVID-19 infection (plus another 5 days of mask wearing). Testing is especially important for people with risk factors for progression to severe disease (such as those over 65 years of age, who have multiple medical problems, are immunosuppressed, or are pregnant), because there are highly effective antivirals like Paxlovid for those who qualify. You should be aware that, while the accuracy of home tests hasn’t changed, widespread population immunity means that the levels of virus in your nose might not reach the detectable threshold until later in your illness, as late as day 4, so keep testing.

If you haven’t gotten the latest round of free tests from the government (announced November 20, 2023), they can be obtained at https://special.usps.com/testkits.

Testing for influenza is indicated if you are within 48 hours of symptom onset and have risk factors for severe disease. Antivirals for influenza can shorten the duration of symptoms. Talk to your doctor if you think you have the flu, which is characterized by sudden onset fever, body aches, fatigue and cough.

It is rarely necessary to test for other respiratory viruses, including RSV, because there are no available treatments for them.

Prevention

Updated annual vaccines are available for COVID-19 and influenza. For the first time, we now have immunizations for RSV too.

COVID-19 vaccines

No longer to be referred to as a “booster,” the 2023-2024 annual vaccine was reformulated to target more recently circulating strains of the virus. Everyone age 5 and older who is not moderately to severely immunocompromised is recommended to receive one annual dose. While vaccination is recommended for all individuals over the age of 6 months, those at highest risk stand to benefit the most. There are three options: the Pfizer vaccine, the Moderna vaccine, and the Novavax vaccine which is a good option for people who need or want an alternative to the mRNA vaccines.

RSV immunizations

Almost overnight, an entire arsenal of preventative strategies have been approved for RSV. They are:

* The Pfizer and GSK vaccines for adults over age 60—public health authorities recommend that people in this category discuss with their doctor whether the RSV vaccine is right for them.

* The Pfizer vaccine for pregnant women—all women should receive this vaccine if they are between weeks 32 and 36 before the end of January. This will protect their newborn baby from RSV infection. Fortunately, the RSV season is almost over for the year.

* The monoclonal antibody, Nirsevimab, for newborns—this preventative treatment has been in very short supply. Talk to your pediatrician if your baby’s mother did not receive the RSV vaccine during pregnancy.

Influenza

Annual flu vaccination is recommended for everyone over the age of 6 months. Patients age 65 and older should receive a high-dose, recombinant or adjuvanted vaccine for greater potency. People with egg allergy may now receive any vaccine (egg-based or non-egg-based) that is otherwise appropriate for their age and health status without the need to be vaccinated in a medical setting. 

Other preventative measures

If you are high-risk or risk-averse, you may want to avoid crowded indoor spaces where the risk of respiratory virus transmission is higher. You can protect yourself with a well-fitting high-quality mask.

Maintaining your general health will go a long way to helping you successfully weather a respiratory infection, as it is inevitable that everyone will catch one at some point. Remember to eat well, get plenty of sleep, exercise, manage your stress, and optimize your underlying medical conditions like diabetes and high blood pressure.

-Shira Doron, MD

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You can also listen to this episode on Spotify!

The new weight loss drugs such as Ozempic are stunningly effective at helping patients lose weight and improve their metabolic health. Their existence also seems to have intensified polarizing rhetoric around weight, health and BMI. 

On one end of the ideological spectrum, there is the “Healthy at Every Size” (HAES) movement that aims to decouple weight from worthiness—and argues that doctors who recommend weight loss to their patients with obesity do more harm by enabling body shaming without evidence to support the benefits of weight loss on health. On the other end of the spectrum is the camp that believes obesity is a result of poor health and life choices—and that patients with obesity should simply eat better and exercise more rather than succumb to the pharmaceutical industry’s latest fad. 

Emily Osteris a Professor at Brown University, a best-selling author, and a leading voice in health economics. In her wildly popular newsletter, ParentData , she tackles pressing health issues of the day, helping people frame risk in order to make everyday decisions. Dr. Oster joins Dr. McBride on this week’s episode of Beyond the Prescription to discuss the data on BMI and health, and how to empower readers and listeners with nuanced information to be healthy, inside and out.

They review the data on the health benefits of exercise, independent of weight loss; the arbitrariness of BMI cut-offs; and the importance of focusing on health habits over a specific target weight. They agree that doctors do harm when they narrowly define health as a number on a scale—and the metabolic health involves addressing the medical, nutritional, behavioral or social-emotional elements of people’s health. As Dr. McBride says, “Sometimes that includes weight loss medication. Sometimes it’s a prescription to stop dieting and start eating lunch.”

The transcript of our conversation is here!

[00:00:00] Dr. Lucy McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor, I've realized that patients are more than their cholesterol and their weight.

[00:00:31] We are the integrated sum of complex parts. Our stories live in our bodies. I'm here to help people tell their story and for you to imagine and potentially get healthier from the inside out. You can subscribe to my free weekly newsletter at lucymcbride.substack.com and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts.

[00:00:57] So let's get into it and go Beyond the Prescription. Today we have an amazing guest joining us, my friend Dr. Emily Oster. Emily is a renowned economist, a bestselling author, and a professor at Brown University. Emily is one of the leading voices in health economics. Her superpower is applying data to some of society's thorniest health questions, including why people don't always make rational health decisions.

[00:01:30] In her wildly popular newsletter called Parent Data, Emily tackles pressing issues about pregnancy and parenting, helping decisions. I grabbed Emily today because I wanted to talk with her about her recent piece on body weight and health: What is the relationship between BMI and health? She pulled together a lot of data, and because weight is something I talk about with my patients every day, I thought I'd grab her for a chat. Emily, thank you so much for joining me today.

[00:02:03] Emily Oster: Thank you so much for having me. It is a delight as always to see you. It's such a treat.

[00:02:09] LM: Emily, you are no stranger to controversy. In fact, I was with you in the proverbial bunker during COVID, hiding from the haters who didn't like that you and I were trying to help message about risk. We were trying to help people better calibrate their degree of anxiety around COVID to their level of actual risk.

[00:02:31] By the way, I stand by everything I said and wrote. I hope you do too. And it was so fun to work with you then as it is now. So when I think about sensitive subjects, I think also about weight. And so, why did you want to write about weight? Is it just that you like putting your finger in the electrical socket? Or, did you have something to say?

[00:02:49] EO: So I've actually written about weight a bunch of times. So it is a topic that I work on in my academic work. So as a professor in economics, the work that I do is about health economics and statistical methods. And I actually work a lot on diet and dietary choices and why people make the dietary choices they do.

[00:03:07] And so it's not specifically about weight, but it really is about food. And so this is a kind of source of data that I think about a lot. And as a result, I've written about a lot in many different ways. And every time I come at this and I've come at it from all of the angles. So I wrote a piece once called what's the best diet?

[00:03:31] And it was just like the diet that you can stick to which is a sort of standard finding. But the frame was, you know, a lot of people are interested in diet. And when I write that, many people are very angry. They're sort of like, no diet works, we should never talk about dieting, is kind of what comes back.

[00:03:48] I did an interview with Virginia Sol Smith, who I really like, and we don't always agree but is just one of my favorite people to talk to. She always makes me think about her book Fat Talk, which is very much in the other direction, sort of very much in the space of, we should definitely not be talking about BMI, we should throw away our scales, all foods are neutral.

[00:04:10] And when I published that interview, I got it from the other side. I got the, you know, how could you possibly say this, cake and apple are not the same, like this is, this is insane. And I've written about Ozempic, so just anything, I mean, you know this—anytime you write about it in this space, there's really, really strong feelings from both sides.

[00:04:26] So this piece was trying, as I always do, more or less, sometimes more successfully than others, is to try to thread the needle and say, look, let’s look at the data and see between the view of BMI is completely meaningless and correlated with nothing, and the view that your BMI is completely deterministic of your health and that is the only information we should use.

[00:04:49] Where is the truth? And how can we use the data to get to that?

[00:04:52] LM: It is such a crucial question because everybody who's paying attention reads the headlines and understands from their doctor even that weight and weight management is good for your health. We have diet culture seeping into our pores. I mean, it's sort of in the air we breathe, everything you look at on the covers of magazines, on Instagram, and in doctor's offices is about weight, or it feels like it's about weight.

[00:05:20] I see people all the time who have avoided coming to see me, even if I've known them for decades, because they thought they would feel better about themselves, and I would feel more proud of them if they had just lost weight before they came in. And as I say to patients all the time, weight is one piece of a larger puzzle.

[00:05:36] It is not a reflection of your value, your worth. And it certainly doesn't tell us everything about your health. So I'd love to hear about your findings about the relationship between BMI and actual health.

[00:05:50] EO: In my mind, the most, the sort of most important thing to note here is that something can be correlated and can have some explanatory power and not be all of the explanatory power. So one version of this question is to say, on average, if your weight is higher, are you more likely to have other health conditions?

[00:06:13] And I should say, that's actually different from the question of whether weight causes other health conditions. But purely taking this from like a correlational standpoint, if you saw one piece of data about someone, you saw their BMI, would you learn anything about their health? And the answer is, yes. On average, there is a relationship, particularly at the upper end of BMI, between increasing BMI and worse health.

[00:06:41] And in particular, worse metabolic health. So things like, there's a strong correlation between high weight and diabetes. That's just true in the data. Now, those relationships... are there, but they're actually not as big, I think, as many people think. And that's sort of the other thing that comes out of this.

[00:06:58] And that, that has two parts. So one is actually, even to the extent that there's a positive relationship there, it doesn't show up until you start getting to sort of higher levels of BMI. So sometimes we talk, we talk about overweight being 25 BMI versus 24. Actually, the health differences between people with a BMI in the 25 to 30 versus 20 to 25, if anything, probably favor the 25 to 30, but you're certainly not seeing much in that range.

[00:07:30] As you get into a BMI of 35-40 you do see some of those, some of those correlations. But it's also true that in almost any health outcome you look at there is variation within a group and that's the thing I was sort of trying to illustrate in the piece is you look at something like diabetes or the distribution of blood pressure, like the distribution of blood pressure, it's shifted up for people who are higher BMI, but there's a lot of overlaps.

[00:07:56] Plenty of people with high blood pressure whose BMI is 19 and plenty of people with low blood pressure whose BMI is 38. And so that's the sense in which like this number Tells you maybe a little bit, but really not that much.

[00:08:12] LM: let's talk about what BMI is. BMI, I mean, you define it for us here, Emily.

[00:08:17] EO: BMI is a weight in kilograms divided by your height in meters squared. It's just a number.

[00:08:22] LM: So what you pointed out so beautifully in your piece is that medicine does this weird thing where we say that a normal BMI, body mass index, is between 20 and 24.9, and overweight is 25-29. 9

[00:08:37] EO: You guys love a sharp cutoff. It's your, it's your favorite. You love it.

[00:08:42] LM: I don't, but fine. The medical establishment loves these arbitrary cutoffs. There's nothing magical or particularly different between somebody who has a BMI of 24.9 and 25 and moreover, there are so many different elements that go into this whole person's health. That to call it a diagnosis point X and not a diagnosis at X minus .1 is ridiculous. So, you know, herein lies why we're here to talk about pulling back the curtain on what this actually means.

[00:09:18] EO: Right. And, and so I should say, like, you might wonder why have any cutoffs in this at all? I think the answer to that is that when people are describing, not even doctors, when population health scientists are describing characteristics of populations, it can sometimes be useful to define categories.

[00:09:40] So, you see this in weight, you also see it in something like low birth weight is another good example which has some cut-offs, right? So when we talk about baby weight, there's a number, 2,500 grams. And if a baby is below 2,500 grams, they're classified as low birth weight, and if they're above 2,500 grams, they're not.

[00:09:56] There's nothing special about 2,500 grams, obviously, but it’s helpful when we sort of describe a population. You want to say, does this, you know, is the low birth weight share in this population bigger than this population? We want to have a common language. And so saying, like, that's the cutoff we're going to use, so we have some number to compare, is helpful, it can be helpful. The same thing happens here. You want to describe characteristics of a population. I think the problem, and it actually shows up in the birth weight also, but the problem comes when we start, we take that, which is just away to use a number to make some descriptive statements about some population.

[00:10:35] When we take that number and we decide it's meaningful. It's like a somehow a meaningful number that we would, that would tell us something if you were on either side of it. Of course it's not. And when you're using it for populations, for individuals and populations on which it was not based, I mean, this is a much deeper issue, but when we talk about BMI in particular, this is something, these are sort of cutoffs that were developed with reference to like a white European population, they may have very different meanings and relationships with health for different populations off of which they are not based. So there's a sort of whole other can of worms there.

[00:11:14] LM: Totally. It's, I mean, to make an analogy briefly that you and I are familiar with is, you know, COVID risk, right? It's not that a 65-year-old, every 65 year old is at so much higher risk for outcomes. Then every 64-year-old, but there is truth to the fact that older people tend to get sicker on a population level when I'm talking to a patient who has just turned 65 and who is generally very healthy and active. I'm not going to counsel them in the same way. I'm going to talk to a 64 year old who's technically not at higher risk, who has myriad health problems. So population level data is one thing and then individual risk calibration and counseling.

[00:11:58] EO: Yeah, and I think the piece of this that my senses provoke so much anxiety and discomfort in people is that it is true that, and I don't think you do this, but it is, I think, an experience people either have or fear having in their doctors. They'll be weighed, their BMI will be calculated, and then they'll be told, you know, well, you just, you edged up above, you know, 20, now you're 25.1, and like this is how we're going to define you, and that becomes such an important, like, number in the conversation, and so salient, and the words, I mean, the words we use, overweight versus normal weight, obese, those take on an attention and a meaning, and they didn't just label them BMI category one, BMI category two, which, Maybe would have been more helpful.

[00:12:46] You're really using words that suggest that there's a way to be, which is normal, and then other ways to be. And that, that's, it's just not helpful. It's not, I don't think it's a helpful part of counseling. It starts people off on, on a bad, on a bad foot.

[00:13:00] LM: Yeah, I mean, I think people, for better or worse, look at doctors as authority figures and people who, whose judgment matters. And if you have a doctor who is doing a little tsk, tsk, tsk, ooh, you're getting up there, that has real power in many ways. And so I think that has real power and can do real harm.

[00:13:20] Which is not to say that doctors shouldn't be honest about the data in that patient's situation and what they could do and help to arm them with tools and information to be healthier. It's to say that shame is not appropriate or meaningful in any space, not to mention

[00:13:37] EO: Yeah, and I think the other, the other piece that I sort of spent some time on in, in this, and is actually quite closely related to stuff I work on, is that it's actually, It's very hard for most people to lose weight. Like, we know, I mean, we can sort of put Ozempic, Wegovy aside, but for people just changing diet, changing habits, consistent long term weight loss happens for a very small share of the population.

[00:14:04] And so, when we sort of start with the advice, you should lose weight, which people get, you know, in these situations, often that's just not possible. So it's like giving people a set of advice that they just... They're just going to fail on and then giving it as if, well, if only you could have this kind of willpower, if only you could achieve this, like that would be so important.

[00:14:24] I think the whole dynamic ends up in a place where you're giving people advice they can't follow based on a number that may or may not be that meaningful and isn't very nuanced, and you can easily see why that generates frustration, sadness, discomfort, lack of productive conversation with your doctor.

[00:14:43] And then by the way, turns off your ability to have a productive conversation because now we're like in defensive. Now you're like, well, you know, screw you, don't tell me what to do. What do you know?

[00:14:54] LM: Right? If we learned nothing else during the pandemic, that trust is precious. And when you don't have trust between the doctor or patient, and there's a moralization of human behavior, we're just at a standstill. And so how do you see the data that you've pulled together in this piece and before this piece helping people, individuals who are reading your stuff and then going to the doctor's office, understand better what their weight.

[00:15:21] EO: The piece I pulled out at the end that I thought was really meaningful was, in this piece I'm actually pulling data from the NHANES, the National Health and Nutrition Examination Survey, which is a very big survey of, of people, it weighs them, it measures them, collects a lot of biomarkers, which is why we can say all this stuff about, about health.

[00:15:39] They also collect information about their exercise. And so if you look at people, if you sort of take a, a second, uh, almost a second metric of health and you ask like, okay, does this person do like some, some moderate amount of exercise a week and it's like some cutoff and you look at that relationship.

[00:15:57] One of the things I show in the piece is that doing more exercise is correlated with better metabolic outcomes, better kind of health outcomes in various ways. And it's quit informative on top of BMI, and so people who are doing sort of exercise who have a BMI of like 40 actually have sort of similar metabolic health to people who like aren't doing any exercise and have a BMI that we would consider, you know, normal or, or thin.

[00:16:26] And so I think for me that has sort of two pieces of it. One is that it just again emphasizes like this is one other thing you could like if you said like you can only learn two things about people It's like well, how much more could I add with a second thing? Well, actually like quite a lot the characteristic knowing somebody's BMI and whether they have exercised rigorously or moderately in the last week that tells you a lot more about their health than knowing their BMI alone You could add on top of that smoking… it's just one simple illustration of like how much more you could learn if you ask some more questions The other thing, and here I'm going to reveal what my husband is always saying, it's just like, just because you like to exercise, fine.

[00:17:08] But like, actually, I think we should tell people to exercise. I think that we spend too much time telling people to lose weight with their diet, which is something we know is really difficult, and I think we should spend more time telling people, like, you should go take a walk after, like, try to walk for ten minutes every day.

[00:17:27] You know, actually, it's not saying, like, you need to go run a marathon. But just some aerobic exercise. I think we have a lot of evidence from a lot of different places that that's associated with better health. And I think if we started telling people that and talking about that, we would then get to the questions like, well, how can we make it possible for everyone to do that?

[00:17:45] How can we make there be safe places for people to do that? How can we increase access to sports? How can we be in a position where everybody is welcome to... to go running no matter what, you know, their race or body size or anything? And I think that's, you know, for me, that's something that's pretty, that's pretty important. And I think we're kind of missing with this focus on food.

[00:18:08] LM: I totally agree. And what I love about the NHANES data is what you earlier said, which is that there's an incredibly tight correlation between the amount of exercise and health outcomes, even more than BMI and health outcomes. So when I'm talking to a patient who wants to lose weight or, you know, Needs to lose weight, perhaps I often tell them, let's not think about the number.

[00:18:35] In fact, I commonly say, let's not think about the number. That's not our end point. And, and I'm not saying that to be politically correct, to pussyfoot around hard conversations is because the number on the scale is immaterial. When we were talking about this whole person, we are the complex sum of these integrated parts.

[00:18:57] And you can, as you said have a BMI of 40, which is technically obese. But if you are exercising on a regular basis, first of all, your mood is better, your sleep is going to be more efficient, your blood sugar control is going to be better, your blood pressure is going to be better, most likely. And so, I focus, with my patients, less on the number and more on the behaviors.

[00:19:21] The relationship with food, not just what you're eating. The cadence of how you're eating. Sometimes you don't need a fancy diet, you just need to have lunch. I just wrote a piece about that. Lunch is an underrated food group, like eat lunch. Honestly, that is huge. Sometimes we don't need to, you know, go to the doctor and be told that our weight is technically higher than it should be.

[00:19:43] We need to be given materials and information on the benefits of exercise. Not just on our weight, but on our mental health, our metabolic health, our cognition, and not just... Are you told to exercise, but to help people figure out where to put it and how to incorporate it in their everyday life. Because as you know, telling someone to exercise is one thing, helping them figure out what to do is another.

[00:20:10] So I think you're absolutely right, Emily. We need to treat people, not just as a set of metrics and data, but as people. And as you know, from your research, human behavior is complicated. We do things that don't serve us all day long. Even doctors do, which is again, ridiculous, why I would shame anybody for a behavior that's part of the human nature.

[00:20:30] So to do a lot of shooting with patients or to say you should do this is less productive than to say like, how do you think you could incorporate a little more movement because of the data on the benefits of regular movement into your whole health?

[00:20:44] EO: I actually think, you know, when we do this kind of counseling and when people hear this counseling and they hear, they sort of hear the phrase diet and exercise, like you should improve your diet and exercise. They think of that as improve your diet and exercise so you'll weigh less. And that's the link we should sever.

[00:20:59] It would be, I think there's a place to say, improve your, let's think about are there changes you could make to your diet that would make you feel better? Are there ways for you that you could incorporate exercise, which by the way, like 10 minutes of walking slightly faster than you would otherwise, that's exercise.

[00:21:16] That's an exercise activity, so just like making it clear that these things are possible. But also without saying, and if you did that then the number will look better on the, no, if you did that maybe some of these elements of health, metabolic health, maybe some of this would improve, your sleep might improve, your mood might improve, that's what we're aiming for. We're not aiming for some number.

[00:21:37] LM: That's right. And by the way, when you're sleeping better and your mood is better and your dopamine hormone axis is being triggered by the lights of being outside and feeling more fit and getting the endorphins going that is good for our metabolic, metabolic health too. But I also want to be clear that I don't shy away from talking about a number when it is relevant.

[00:22:00] So if somebody has bilateral knee osteoarthritis, bone on bone, and their BMI is 40, and they're resistant to, you know, getting a knee replacement, we have to talk about weight. So it would be irresponsible for me to say, oh, weight loss isn't going to matter to this gravity-dependent set of joints. And so that is where it gets really hard, but it is where I actually like for me it's my like superpower is never to have judgment about it because by the way when you have bone-on-bone arthritis in your knees As a result of age and genetics and weight all together you can’t exercise and You gain weight more easily.

[00:22:43] And so this is what happens. So there's no shame about it. It's just, let's figure out what to do. But we have to talk about the number, not just the number, but we have to talk about what weight might make sense to that offset pressure on the knee.

[00:22:56] EO: Yeah, I mean, that's such an interesting, like, it's, this conversation is so hard because it takes, like, it's so hard to have that conversation. And I bet you are really good at this, but I think for me, it's very hard to have that conversation without it feeling like shame because of the, as opposed to just saying, look, there are a bunch of things, like, there is a physical reason why this, this number matters, not because this number has to do with whether you're a good person or not a good person or have willpower or whatever, it's just like, this is putting pressure on your knees.

[00:23:23] LM: Well, and that's why I'd really like to reinvent the healthcare system to have doctors incentivized to have more time with their patients to understand their story and to build trust and rapport and for patients to feel comfortable and then to train doctors on sensitivity on these subjects. Which, by the way, doctors went into medicine, the field of medicine to do that, but it's just people don't have time and then people don't trust and then there's diet culture and then it's just lose weight, exercise more, see you next year.

[00:23:50] EO: This is totally off topic. I mean, it's a little bit off topic, but, but one of the things that's been pretty effective in, you know, obstetrics is these group prenatal care. People have exactly this sort of same complaint about, like, there isn't enough time to talk about all the issues that have come up, da, da, da.

[00:24:05] And so they do these things where it's like six people, but you get two hours, you know, and we do, like, there's this sort of examination component that happens, like, that's short for each person, but then we all, they, people all talk together, and it turns out to actually be, some good evidence on the relationship between that and preterm birth, particularly for black women.

[00:24:20] So I wonder if there's like, I almost think there's like a parallel care model, where it's like, we have a group of people here for counseling about, you know, whatever it is, improving their heart disease metrics or something.

[00:24:33] LM: Yeah, stay tuned for some courses I'm going to be offering in 2024. One of my little kind of mantras is that health is about more than BMI. It is about having awareness of our health ecosystem, which includes ur story, it includes our data, it includes understanding our genetics, and then sort of a laddering up to acceptance of the things we can't control.

[00:25:01] Maybe we are predestined to have a higher-than-ideal body mass index because of our genetics. And we have to accept that. We have to accept that we are predisposed to diabetes. And then agency over the things we can control. So, arming yourself with tools and information to carve out space in your life to work on the things you have control over, which are a lot.

[00:25:26] But if you're stuck in the acceptance bucket where you're not accepting hard parts of your genetics or your story that you can't control and you're then listening to a lot of kind of wellness gurus who are telling you that, you know, thin is better or whatever, even just all this messaging. And then you're spending a lot of brain space trying to accept things you really need, or trying to control things you can't control, that's where people run into trouble, and that's where shame is born, and that's where people, frankly, binge on things like food and alcohol, and that's where we land in trouble. And so if we could just help people understand they're not alone, they're human, and that we all have our challenges. One of them, for a lot of Americans, is weight.

[00:26:12] And that they're not alone, and that there are things they can do to be a lot better off. So... What was the takeaway from this piece you wrote? Like, what was the reaction? Because, as you said, like, there's sort of two camps. It's like health at every size, there's a movement, which I agree with in many ways, except that there are certain medical realities we have to acknowledge.

[00:26:32] And then there's the sort of, weight is genetic, and there's nothing you can do about it. And, I mean, there's just, there's just these false dichotomies.

[00:26:39] EO: So I think like with most things, most people are in the center. And so this kind of like, I think that many people found this interesting. You know, I'm not sure everybody thinks about this data quite the same way, and sort of seeing some graphs about it, it made some people think. A bunch of the comments were like, yes, like I started exercising, and I felt like this is very validating, because like, that, you know, that totally changed, but then my weight didn't change, but still I feel better, and I was trying to understand that.

[00:27:08] So there was like some good stuff there. And then I did get, certainly, some people who said, you know, talking about BMI at all is very fatphobic and I am, like, I will say, like, I'm a relatively thin person and so I think, you know, I don't know, I guess that's part of, part of it. And then certainly there were people on the other side who said, you know, this whole thing is like, you know, anybody who's overweight is just, you know, is just lazy and I don't agree with that at all. But some of those people fought with each other and, you know, that's what comments are for.

[00:27:39] LM: That's what's comments are for. And that is why Emily Oster is here. Emily is here to help us get to these story issues, and ask the questions that... People are wrestling with every day, like, can you have a glass of wine when you're pregnant? Can you have bluebean cheese when you're pregnant? Can you jettison some of the shame about parenting and the parenting industrial complex?

[00:28:01] And thank God for you because I think you're doing so much good, Emily, and you're reassuring people based on evidence. You're not reassuring people for the sake of reassuring them for you to look good. You're reassuring them because you have the data to show. How to calibrate risk to, or sort of how to calibrate anxiety to the actual

[00:28:21] EO: Yeah, I mean, I see a lot of what I try to do is sort of help people see what those risks are and make the choices that work for them, which [are] going to reflect our own risk tolerances and preferences and, and what's important to us.

[00:28:33] LM: Yeah. I mean, at the end of the day, as we talked about during COVID quite a lot, it's about framing risk. It's not about telling people how to feel or telling people how to choose. It's about framing risk. And then it's like, you do you, and that's fine. And if you do something that's not healthy for you, that is fine too. As long as you're armed with the data, then that, that, that is, that is great. Emily, thanks for joining me. And by the way, how can people sign up for parent data?

[00:28:56] EO: So, parentdata.org, you can find me there, we have a newsletter that goes out, we have an enormous volume of writing for pregnant people and parents and, and some things for people who are not parents, and we have like a little search AI, so parentdata.org is the best place, or you can find me on Instagram at profemilyaster.

[00:29:20] LM: Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download, and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you liked this episode to rate and review it. And if you have a comment or question, please drop us a line at [email protected]. The views expressed on this show are entirely my own and do not constitute medical advice for individuals. That should be obtained from your personal physician.

You can also listen to this episode on Spotify!

Dr Devika Bhushan is a pediatrician and public health leader who has lived with bipolar disorder for the last 13 years. She has served on Stanford’s faculty and trained at Harvard Medical School and Johns Hopkins. She's a firm believer that life’s trials and tribulations not only improve our self-awareness, they help us flourish.

While serving as California’s Acting Surgeon General last year, Dr. Bhushan publicly revealed her diagnosis in an effort to reduce stigma and spread hope for people suffering with mental illness:

I believe that our struggles can be the source of our superpowers. They can show us our capacity for vulnerability and strength, and that we can endure and overcome hard things.

Through her popular newsletter, Ask Dr Devika B, she is growing a community to help break down the stigma associated with mental illness. As she says, "Stigma festers in the dark and scatters in the light.”

On this episode of Beyond the Prescription, Dr. Bhushan shares her advice for mental wellbeing. The two doctors also discuss the complex roots of emotional distress; the shame around mental health diagnoses; and the possibility of post-traumatic growth.

Join Dr. McBride every other Monday for a new episode of Beyond the Prescription.

You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.

Please be sure to like, rate, and review the show!

The transcript of the show is here!

[00:00:00] Dr. Lucy McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor, I've realized that patients are more than their cholesterol and their weight. We are the integrated sum of complex parts. I'm here to help people tell their story and for you to imagine and potentially get healthier from the inside out. You can subscribe to my free weekly newsletter at lucymcbride.substack.com and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts. So let's get into it and go beyond the prescription. 

[00:01:02] Today I'm joined by the amazing Dr. Devika Bhushan. Devika is a pediatrician and public health leader who has lived with bipolar disorder for the last 13 years. Devika served as California's acting Surgeon General in 2022, where she focused on initiatives around equity, resilience, and innovation. She's a firm believer that our trials and tribulations can help us flourish, and she's learned this through her own experience living with mental illness. Today we will talk about what it's like to face a mental health diagnosis and the individually oriented lessons she's learned along the way. Devika, thank you so much for joining me today.

[00:01:42] Dr. Devika Bhushan: It's so great to be here with you, Lucy. Thanks for having me.

[00:01:46] LM: So in your op ed for the LA Times last year, you wrote some pretty powerful words. You said, I believe that our struggles can be the source of our superpowers. They can show us our capacity for vulnerability and strength, and that we can endure and overcome hard things. Can you expand on that a little bit? What do you mean by our struggles being our superpowers?

[00:02:11] DB: So my toddler, his name is Rumi. And so it's very apt. I'm going to borrow a quote from Rumi. The wound is the place where the light enters us, and this also hearkens on this Japanese tradition whereby when a ceramic bowl breaks rather than throwing it away, they will actually patch it back together with gold.

[00:02:37] And so at the end of that break, what you're left with is a stronger bowl, a more unique bowl, and a more beautiful bowl. And I firmly believe that when you have a chance to walk through a really difficult time in your life, whether that's because of mental illness, whether it's physical health, whether it is an early experience of adversity, whatever it might be, I firmly believe that once you have emerged through that, and walked through it and come out the other side, you become much more self aware, number one. You know exactly where you're able to stretch and flex and accommodate and where you're going to break. Right. And so that knowledge when you acquire it is something that will never leave you and will always make you a better whatever you decide to do after that. 

[00:03:29] So, for instance, like for me, I know that. I can endure a lot. But one thing that my brain, and anybody with bipolar disorder's brain, might not be able to tolerate is actually a lot of circadian rhythm shifts. So, for instance, when I was in residency training, I didn't really internalize this. The fact that I should, from the get go, be really careful about day night switches, about 28 hour calls.

[00:03:53] And I learned the hard way that those experiences led me to have mood episodes that required me to be out for three months, two months and really struggle to find an equilibrium again. And so that's number one, right? Like you learn exactly what you're capable of and what you cannot do, where your boundaries need to be as a person.

[00:04:13] Number two, I think you learn that there are superpowers that come from enduring really difficult things. So for me, one of those is that I'm a really deep empath and I really understand other people's struggles and vulnerabilities in a way that I don't think I would have if I hadn't had such deep and dark experiences of my own.

[00:04:36] And so when, you know, when I was a practicing pediatrician sitting with patients, sitting with families, walking through very challenging things, I could connect with how they were feeling and sometimes give them lessons from my own experiences when those were relevant in a way that really helped me be a better pediatrician. And I similarly found that when team members of mine, when I was the leader of a team, when folks would go through stuff in their own personal lives that was difficult, and impacted their work because we're all human beings first, and whatever's happening for us at home or outside of the work context does show up for us at work, I was able to connect again with what they were going through and help them make the space for whatever that was in a way that maybe a leader who hadn't had their own struggles wouldn't have been able to do. So I think on both of those levels, people don't always, acknowledge or talk about the ways in which struggles lead to superpowers.

[00:05:39] But that's a firm sort of belief of mine. And when I'm, for instance, interviewing podcast guests of my own on my podcast called spread the light with Dr. David Gabby, also published in my substack. One of the questions I always ask people is, “So how do you feel like this experience led to your unique strengths or superpowers?”

[00:06:00] And people always love reframing their experiences and distilling those strengths down for people. And I'll tell you, when I published my LA Times op ed, which you quoted from, that was the line that people most resonated with. And that was a line where people specifically said to me sometimes, “You know what? I never thought about my chronic PTSD or my... OCD or my borderline personality disorder as giving rise to these superpowers that I have. But you are so right. That's exactly how I experienced this. So I think it's a very empowering frame and it's an important one,

[00:06:35] LM: I think you're right. And I think mental health is having this moment, rightly so in the popular vocabulary, right? We've been talking about the mental health toll of the pandemic. We've been talking about the, the grief, the loss, the trauma people have experienced. And I think it's fantastic that we're finally identifying mental health as part of whole health.

[00:06:59] I think sometimes though people are confused about what mental health means or what it is. And I think sometimes we think that mental health means that you're happy or mental health means that you're content, mental health means you're not anxious And so I'm very clear with my patients and with my own kids and hopefully with myself as well, that mental health is really about that laddering up from self awareness that you described to acceptance of the things We can't control like we cannot control, for example, genetic predisposition towards bipolar disorder or breast cancer or what have you, and then leaning into the agency that we have and so mental health to me is really about self awareness.

[00:07:45] It's about sort of an understanding of where we can flex, where we have that extra Reserve and then where we need to hold a boundary. And so I think it's important to recognize what health, what mental health is. It's about having the resilience, the self awareness to weather the storms that inevitably come our way.

[00:08:06] It's not about being happy all the time. Happiness is great. We're not against happiness. We're all for happiness. I'm believer in contentedness, but I think it's those tools and that we have to get sometimes the hard way that are the most kind of beautiful and that the things we don't often count in our kind of resume of life skills.

[00:08:25] And I also want to say that Rumi is an old soul. Clearly he understands that even at two years old, when we break is when we repair as well… can shed some wisdom on our resilience. So let's talk about kids for a minute. So in your role as the acting Surgeon General in California, you did quite a lot of work on adverse childhood experiences or ACEs.

[00:08:49] And many people who are listening understand that there's an abundant amount of literature about the effect of adverse childhood experiences or ACEs on social, emotional, mental, and physical health issues later in life. So some of those are my patients, people who have had some sort of childhood experience of neglect, abuse, trauma, that shows up in their bodies in the form of hypertension, an anxiety disorder, binge eating. Our stories live in our bodies. And I commonly try to help patients with various physical problems by looking back at what happened, what's behind the curtain that we can then kind of connect to their current physical state. And it's often the case that a patient who's struggling with binge eating disorder and diabetes gets better when we put them on metformin and we get them in trauma therapy to work on kind of pulling the curtain back on what happened.

[00:09:48] And helping them understand that hypervigilance that was organized around a traumatic childhood experience shows up later in life. And that's, I mean, that's the most kind of fun part of my job, if you will. So adverse childhood experiences show up as social, emotional, mental, and physical health problems in patients later in life. And so I'd love to hear about your work on adverse childhood experiences and do you agree with me that they show up in our bodies, that our stories live in our bodies?

[00:10:18] DB: That is such a beautiful way to put that. And I could not agree more. Our experiences, whether positive or negative, end up living in our bodies, and they end up living in our bodies at a cellular level, at a organismal or organ level, um, systems level, and even for all, for the whole body, right, the whole system.

[00:10:39] And what we recognized around ACEs, so all of the folks listening, are probably well acquainted with this term, but these are essentially 10 experiences that are really difficult before you turn 18 years. So child abuse, neglect, growing up in a household where maybe somebody had an untreated mental illness, intimate partner violence between adults in the home, things of this nature.

[00:11:02] And basically what happens is that you're exposed over and over again to a threat and a stressor that is extreme. And so your threat response system and your stress response systems end up being activated and have trouble getting regulated and have trouble turning back off. And what happens is that can change the way that your brain develops, your hormonal cascades, your immune system, even your genes and the parts of your genes that regulate cellular aging.

[00:11:34] So those are called telomeres for those who are aware of this term and familiar with it. And so, you know, when you look at a population level, there is this dose response relationship between the number of ACEs you've had and all sorts of health outcomes, anything from cancer to heart disease to, of course, mental and behavioral health disorders.

[00:11:53] There's about 60 or more health conditions that you're at risk for. But equally, we know that being really intentional about turning off the stress response and using that, just as you mentioned, as part of the treatment plan for a patient who's coming in with a history of trauma and let's say diabetes or heart disease. If you are not intentionally looking at that toxic stress response that's in the background that has been with them potentially for years since their childhood and you're not specifically intervening on that toxic stress response, then you're leaving part of the physiology on the table. 

[00:12:32] So the ACEs Aware initiative, which we launched at the end of 2019, just before some of the biggest traumatic events of our lives were to unfold during the pandemic, the plan there was to really help health care workers of all kinds understand toxic stress physiology. And so, you know, there's a lot of talk about ACE screening, whether, you know, universal ACE screening is worth it on an individual level.

[00:12:59] We know all of this stuff is true at the population level, that ACEs will put you at risk for these health conditions, that sometimes the link gets lost. So the point of ACEs Aware Initiative is not, in fact, to say, do you have ACEs or do you not have ACEs? It is actually to say, hey, are you coming in with health conditions and symptoms today that are rooted in a toxic stress response? And if so, if you're at risk for a toxic stress response, how can we specifically cater your healthcare to be more individualized, and to not only give you the metformin for your diabetes, but also to help you understand that trauma therapy, as you mentioned, or anti inflammatory nutrition, or certain exercise habits, sleep habits, connection, etc., that there are these other evidence based behavioral strategies that we have in our toolkits as healthcare providers, as individuals that we can start to use to specifically turn off the toxic stress response as a way of treating somebody. 

[00:14:02] And so that, that message of hope is, I think, really important because we often talk about ACEs as posing risk for health, but we don't spend equal time sometimes talking about the fact that we do have these evidence based tools for enacting resilience if you do have toxic stress. In other words, toxic stress is preventable. And once it's in place, it's very treatable. And so that was the overall mission that we were working on at the ACEs Aware Initiative.

[00:14:31] LM: I love it. And then on top of it, there is the opportunity to make meaning and to find out where you can flex and where you need boundaries based on the self awareness from the work you might need to do on your toxic stress. So, let's talk about your childhood. Do you look back, Devika, on your childhood and see threads of your bipolar illness that predated the actual diagnosis? And, you know, to the extent you want to share that, I mean, how do you make sense of things that may have happened to you, good and bad, and the evolution of your mental health story? 

[00:15:10] DB: It's a really important question. As we know, most people who have mental health symptoms, it's most common to start to have the first symptoms when you are in your teenage years or in your early 20s. And for me, my very first symptoms happened when I was in medical school. I didn't have any kind of sign of mental health instability or any kind of mental health symptom when I was growing up. I did have a very unusual childhood in some ways. So I spent… my first 21 years about a third in three different countries. So the first one was India, which is where my family is from originally and where my majority of my family actually still lives.

[00:15:52] So we started there. I was seven when I left India, and then we came to the US for a few years where my parents were grad students here. Very stressful set of circumstances financially and otherwise. And then we went to the Philippines for my parents’ jobs, which were in health and development. And we didn't know anyone in the Philippines when we first arrived, and we were supposed to have spent three years just trying it on for size.

[00:16:18] And my parents ended up spending over 20 years there. So it was a big part of our lives and big part of their careers. And so, within each one of those countries, even there was a lot of moves. So by the time I was in fifth grade, I was 11, but I had been to seven schools in three countries. So there was a lot of changes and a lot of transitions and a lot of figuring out who I was culturally, you know, where I belonged.

[00:16:45] There were these kind of deep existential questions taking place, although I will say my four person family, so it's my sister and I and two parents are a very close knit unit, and so that unit kept us grounded and it made us feel like we were in home, wherever we were and you know, that, that made all the difference because I think I felt very grounded growing up despite the fact that things were changing on us so often.

[00:17:14] And I felt like a lot of folks who have multiple cultural influences, multiple languages. I grew up speaking Hindi, then had to learn English and. You know, uh, the whole, uh, getting made fun of for my accent in the U S and trying to get rid of that accent overnight, you know, all of those different pieces of like, am I Indian? Am I American? Do I have influences from the Philippines, but I'm not quite Filipino, even though I've spent so many years here, there's all of that stuff growing up, but I will say kind of back to your question, nothing that really would qualify as a mental health symptom, just sort of common experiences around moves and cultural identity that I think anyone would have with a similar set of circumstances.

[00:17:59] And it wasn't until I hit medical school, as I was saying, I was 23 and my first symptoms were of the depressive variety. And I didn't have a family history of bipolar disorder. I didn't have a personal history of either hypomania or mania. And so it looked for all the world, like garden variety, unipolar depression, right?

[00:18:19] And I was treated with antidepressants, which ended up over the course of three years, not working and making my brain worse, which is typical when a brain is on the bipolar spectrum. So often what'll happen is you'll induce sort of the little bit of activation that's not recognized. It's actually hypomania in retrospect, but might just look like anxiety on top of the depression, right?

[00:18:42] And that's essentially what happened to me. I had about three years where I was on the wrong meds. And I tried 20 different meds, you know, in that span of time. And luckily, you know, three years in, I was on three different activating meds and had a frank manic episode. And that really saved my life because it allowed people to understand that I was somebody who had a bipolar spectrum disorder rather than a unipolar depression with anxiety on top of it, which was the working hypothesis.

[00:19:12] And that led me to have the right condition diagnosed and also the right treatments then in place, which, which really, really truly saved my life.

[00:19:21] LM: I want to interrupt you to say, well, I don't want to interrupt you, but I would, I want to say thank you for sharing that because I think there are a lot of people, I don't know the number. I don't think we know the number of people who are suffering with bipolar disorder, who are called. Depression and anxiety, right?

[00:19:39] I mean, depression and anxiety are extremely common conditions. You know, certainly if people have enough depression, they can be anxious about it. If people have enough anxiety, they can get depressed. But I do think there is a subset of people who are inappropriately treated who actually are on that spectrum and they didn't have that manic moment or the doctor to understand that's what that was.

[00:20:02] And then they get further medicated and then sort of down a pathway that isn't appropriate for their diagnosis. So, I mean, did you have trouble recognizing sort of activation, the activation driven by the antidepressant that was then maybe the beginnings of your, of mania? Or did your doctor, like, did it go for a long time without being recognized? Or how did you make sense of those initial failures of the antidepressants?

[00:20:30] DB: It was much more clear in retrospect, you know, we had these three years where I did not feel like myself and I wasn't, you know, depressed for all of that time. At some points I was, you know, hypomanic where I might have been euphoric, right? And just tripping too quickly in terms of the energy and the thought processes.

[00:20:49] Or I had periods where I was hypomanic, but in a sort of dysthymic state of mind, meaning I was just activated and energetic, but I was irritable and angry and anxious. And it wasn't really recognized. Now in retrospect, it's very clear that, okay, all of that was hypomania. But at the time, when you're dealing with, you know, a 23 or 24 or 25 year old, because I crossed all of those numbers as we were seeking treatment, it just felt like, okay, this person is not responding to treatment.

[00:21:24] And as a patient, you feel very vilified because the statistics will tell us that most people with bipolar 2 disorder end up having symptoms that are mistreated for an average 11 years from the first time they're symptomatic to the time that they get the right treatment in place. And I was lucky that mine was only three years, but I will tell you, they were the hardest three years of my life, like, I was considering dropping out of med school, I didn't think I could hack it, I thought it was something about medicine, potentially, that was kind of triggering these symptoms that I'd never faced before, I was also pretty convinced that, like, the person that I thought I was pre symptoms, was completely gone, inaccessible, lost.

[00:22:11] Like, I would never find that person again. That I was just somehow stuck in this place of unwellness. And I think that's something that most people who have ever had any mental health symptoms can really relate to. Like, in the midst of it, you feel like you are never gonna be well again. And whoever you once were is no longer a person that you can access. I think that is the hardest part when I look back at that period of my life of true terror that I was never going to be myself again.

[00:22:39] LM: There's so many things I want to react to that with. First and foremost is deep gratitude for saying that because I think as I talk to patients with mental health issues, as I talk to family members with mental health issues, as I've talked to my myself when I've been struggling with mental health myself, there is this hijacking of our own brains that happens where you [become convinced that you're never going to feel good again.

[00:23:03] You're never going to feel okay. You're never going to be that person that you thought you were. And it's terrifying. And I think to see someone like you, Devika, who is, I mean, beautiful, healthy, accomplished mother and physician, it just gives people hope that this is not a death sentence. That it truly is a hijacking of your brain that is not a permanent condition and that you can get better.

[00:23:32] I think it's important for people to realize that if they are getting treated for depression or anxiety and they're not getting better, not getting better. You need to ask the question, is there something else going on? I mean, 11 years is too long for people to get a diagnosis. Bipolar 2 is not a zebra.

[00:23:47] I don't know the stats on the commonality of it. I don't know because I don't think we probably have accurate statistics at all. I mean, because it takes 11 years to get the diagnosis, but I know from my own experience seeing patients, I will commonly make a referral to a psychiatrist when I, for example, have tried my patient on Lexapro for what seems like unipolar depression and they're not better, or they have a little bit of an uptick in their energy, irritability, and then we ask the question.

[00:24:12] Because for people who are listening, a diagnosis of bipolar one or two, which are a bit different, we can talk about that, opens the door to another set of medications for treatment. This is one of the things I worry about with online, kind of drive through kind of mental health startups. I mean, I think it's great that people are getting better access, but I worry that we are bucketing people into depression, anxiety, depression, anxiety, when sure there's a lot of depression. There's a lot of anxiety, but first of all, do we need to medicalize all of it? I'm not sure. And secondly, are we making the right diagnosis in the first place?

[00:24:46] Such important points. You know, I think just stepping back, like, from the data, you're absolutely right. There's a whole variety of studies that have been done with differing prevalence rates of bipolar 1 and bipolar 2, depending on sort of what is counted. And it's very common within the bipolar spectrum for you to receive let's say one kind of diagnosis. I was initially diagnosed as bipolar not otherwise specified, which is sort of a soft call it's like somewhere in the on the spectrum. We don't exactly know where and then as people's lives go on you end up realizing like okay You've now had a manic episode off of antidepressants let's say, and now you qualify for bipolar one rather than bipolar two, so there's a lot of shifting along the spectrum and that makes it hard to assess and get true prevalence rates. there's a meta analysis that came out now about 10 years ago, and they said that 2.

[00:25:32] There's a meta analysis that came out now about 10 years ago, and they said that 2.6 percent of the population will meet criteria for bipolar one or two at any given time. But that's not counting the other parts of the spectrum, which we now know is also a sizable portion. But, you know, with depression, when people come in for a first time depressive episode, one in three of them. will end up being on the bipolar spectrum.

[00:25:59] And so if primary care doctors know this, if, you know, other kinds of healthcare providers know this, then we can start to turn the tide on that statistic of 11 years for bipolar 2, and it's shorter for bipolar 1 because it's much more obvious when someone has a manic episode, whereas hypomania can be a little bit more, it can cloak itself as anxiety as you said, and other symptoms that are harder to diagnose.

[00:26:23] LM: So what prompted you to be public about this? I mean, it's a pretty big move. I mean, there's a lot of stigma around mental illness, even though it is having a moment. There's a lot of misunderstanding about what bipolar is. I mean, I think people throw that word around a lot. Like, Oh, she's so moody and crazy.

[00:26:40] She's so bipolar as a derogatory term. You know, we used to call it manic depression. I think patients associate bipolar disorder with someone who's driving a stolen Ferrari a hundred miles an hour down the highway. And then someone who's standing on a ledge about to jump. And there's so much more nuance there.

[00:26:58] There's people in our lives. These are people who are functioning, who are parents, community members, people we know. I think it's, it's very brave of you to come forward as you and I were talking about before we started recording, particularly in a public role, like you had as the acting surgeon general in California, I mean, you're out there. So I'm just going to ask you, what is it that prompted you to go public? And what has that been like?

[00:27:25] DB: I was serving in the role of acting surgeon general in a moment in time when everybody was struggling with something, right? We had been in the pandemic for two years plus at that point. And we all, at that moment, knew somebody who was truly struggling, or we were that person ourselves. And so I felt like it was a really important moment to publicly own my story on a couple of different levels.

[00:27:53] One, to help everyone realize, like, you can walk through a really difficult period of your life and think that you can never bounce back from that, but actually walk through it and then, on the other end, be able to fulfill your own dreams, right, personally, professionally. At a point in my life, I thought I'm never going to have a career.

[00:28:16] I'm never going to be a parent. I'm never going to be a stable partner. But to recognize that even a really stigmatized mental health diagnosis like bipolar disorder, and it does carry a very loaded set of stereotypes with it, that even that, you know, you can look back at your hardest moments and say, those were in my past.

[00:28:36] And... The last 10 years or more, I've been well for the majority of them and now, you know, having figured out what it is that keeps me well, both behaviorally and medication wise, I can hope to be well for the rest of my life and I think that it's an important message because unfortunately, for instance, all of the people I know who are living well with bipolar disorder, there's a very small fraction of them who feel comfortable sharing that truth with their coworkers, with their  with the people in their lives beyond just a few.

[00:29:11] And so, if we all live in secret, once we've figured out how to live well with this disorder, then we have a very skewed sample of who it is that has bipolar disorder and what that can look like. So number one, I wanted people to know that when you've got the right treatments and the other systems in place to stay well, you can do the things that you want to do in your life.

[00:29:28] And then number two, I wanted to reach those people who were truly still in their hardest phases who are struggling to know that there is hope for a better tomorrow. That with the right treatments once more things can turn around very dramatically. And to have hope that can happen. And the way that it all came about, and I'll just say one quick other thing, which was NAMI California was having their annual conference and they invited me to keynote it and it felt like that would be the most authentic moment in which to share this journey. And I… same day also shared it in the LA times and online on social media. And I'm really glad that I did because in the wake of that, hundreds of people reached out to me with their stories of, I have been struggling and this meant so much to me where my son is in the hospital and I have hope now that he might be coming out and he'll be back to himself.

[00:30:29] You know, it just, it really opened. the door to understanding that we all have this commonality. We all have known struggle or known someone who has struggled very intimately. And then also it helped me understand that I had a way of connecting to this community and join in on a few different advocacy projects, which have been really meaningful.

[00:30:53] LM: I think that's incredible, and I think you're living proof that there is a better tomorrow, and that with treatment, that’s not just medicine, it's behavioral, it's environmental, you can have hope.

[00:31:06] DB: Yes.

[00:31:07] LM: What do you think, Devika, is the most important element of your wellness? It sounds like you take medication, it sounds like you prioritize sleep, it sounds like you try to eat healthy and have boundaries. I mean, if you had like a pie chart for you, and this is going to be different for different people, but what occupies the biggest slice of pie? Is it the medicine? Is it the sleep? Is it self awareness? I mean, could you break it down a little bit?

[00:31:35] DB: Yeah. There's a lot of elements of that pie. I think a big chunk of it, more than 25 percent is going to be connection and community, right? So the people that I rely on a daily basis to, to understand me, to support me, to have fun with me, to, you know, laugh with me. Those people keep me well in, in so many small and big ways, right?

[00:31:58] And then the other pieces are the daily habits, the making sure I'm getting enough sleep. At night, I wear blue light blockers. These are orange glasses that supposedly filter out the majority of blue wavelength light, nightlight, or nighttime. And so sleep is a big part of my life. I really try to do a lot to protect it. I'll tell you one other thing. My husband tends to wake up if my son is awake in the middle of the night or early in the morning. And so that's one strategy that we've sort of got in place to help protect my sleep, which is really meaningful. 

[00:32:38] Food, you know, eating a variety of foods. I tend to have sort of a Mediterranean diet over the course of, you know, the day and really, find that important. Exercise… protecting my energy. So, you know, big events, for instance, where I'm spending a lot of time talking about myself, my journey in a conversation like this, it, it tends to be really meaningful and important and also deplete my energy.

[00:33:07] And so I have to be really mindful of how I structure my weeks. So if I know I'm having a conversation like this, I'm going to try not to schedule too many other things in the next week or so. Right. And that gives me some time to sort of rest, decompressed, refill that cup, that energy cup and, and sort of be present and able to do what I need to do in the rest of my life.

[00:33:31] And so just being really aware of what's happening for me mood wise, energy wise. Am I feeling that tension in my shoulders? Like, what can I do differently? Like if I have any red flag symptoms, like let's say I'm starting to feel a little bit on edge or irritable with folks. 

[00:33:46] One of my tells is I tend to respond too quickly and with too many messages on WhatsApp. And remember, my family lives sort of abroad, and so that's a big mechanism of contact. But if I'm doing that, that is often a tell that I'm starting to feel a little bit elevated. And just knowing what it is that I need to come bring to bear in those moments to try to reverse where I'm going mood wise and come back into sort of my baseline mode.

[00:34:14] So it's a lot of kind of those maintenance mode things that we spoke about, but also recognizing red flag symptoms and then having a toolkit in place to intervene, whether that's up or down. And that looks different for different people.

[00:34:28] LM: I mean, that is such good self awareness. I particularly like what you said about the energy allocation. You have this busy life, you're a pediatrician, you're a public health leader, you're writing, you're speaking. You're parenting, you're learning from your own two year old. I think women are, I mean, we are just, I think beyond capable and we're interested in so many different things, but I think, you know, that resonates a lot with me too, is this sort of notion of an energy budget.

[00:35:00] Yes, we can do it all, but like, like with everything, there are trade offs, right? So I think that it's important that you're aware enough about yourself and your tank, where you are, of energy to sort of allocate it appropriately. And I wonder if you find like certain relationships you've had to sort of change or if you, or if there are boundaries that you've had to set.

[00:35:22] I know that as I have gotten older, I just turned 50. That I'm a real empath. I love being around people. I also know when my energy is being drained either by a certain situation or a certain set of people. And it's not their fault. It's just, that's just the way my mind and body work together. And so I'm sort of more aware of who, what, where I can tend to over-expend energy and then when I need to pull back. I wonder if boundaries and relationships are something you think about yourself.

[00:35:51] DB: A lot actually. And you know, it's one of those things that we as women are socialized to be very other oriented, to worry about other people's feelings, sometimes at the cost of our own health and wellbeing. And it's a lesson that I think I learned in my late thirties—I’m 37 now—to really honor my needs, my emotional needs, and sort of to know that with certain relationships. That there do have to be some boundaries in place and at the beginning when I first learned about this concept, you know in therapy, I thought, that's kind of I don't know how that's gonna work in an Indian family. Like we're so close. It's a very communal situation even when we're many miles apart.

[00:36:38] There's this like very open expectation that you will be there and vice versa in lots of ways and the concept of a boundary felt culturally potentially inappropriate and what I realized was that I'm putting this boundary in place not to shut this person out of my life, right? Not to have this relationship wither and die, but actually to have a better relationship, where I'm not resentful of them… of something that they are asking of me that I'm not able to do. I realize like it's been such a powerful, game changing thing because I have closer relationships with those same people now because I'm aware of my own emotional needs and triggers and sort of what those boundaries really need to be.

[00:37:24] Sometimes it's something simple like When I see them, I'm going to see them for this amount of time, and there won't be a chance for, you know, necessarily that build up. But it's been, yeah, it's been huge for me, as I imagine for you too, and for many of us who are listening.

[00:37:39] LM: I mean, I think a lot of what you're talking about pertains to the human condition in general. I mean, I think certainly when you have bipolar illness and certainly when you figure out your kit of coping tools, that's essential. I also think for most of us, we need to be careful about our sleep, our exercise, our relationships saying no, kind of recognizing our internal sort of thoughts and feelings and who drains us and who energizes us and meeting our needs, especially as a physician, as a mother, I'm socialized and trained to be empathetic and I am, I think, intrinsically empathetic, maybe not all the time, but I think I am.

[00:38:20] It is hard. It feels culturally inappropriate in my own family and as a physician, as a woman, to say no and to say, I'm so sorry, I can't do that. But I've also learned, like you, that I'm a better mother, sister, daughter, person when I am meeting my own needs, which is not selfish. It's the way I need to be healthy.

[00:38:42] And, you know, sometimes you get it wrong, right? Sometimes you get it, like, sometimes you get it wrong. Sometimes you say no because that's what it felt right. And then you realize, oh, wow, that was actually... at my own expense, but I think that's something that we as women need to practice and I think it is part of a mental health coping kit is to recognize that our needs matter and then to try to practice establishing boundaries and saying no, and you know, we all know that feeling of when you're talking to somebody, whether it's a loved one or a patient or, and they're asking you to do something that doesn't feel quite right.

[00:39:14] And you're thinking no, but then you end up saying yes, and then you're resentful and you can get angry and it's not their fault. We need to own that power and own that ability to say no.

[00:39:24] DB: Absolutely. You know, I'm reading a friend's book right now… Real Self-Care by Pooja Lakshmin. Yes. So I just finished the part about boundaries and two really insightful things that she has in there. One, don't over explain a boundary when you're giving it to somebody because then it seems like you're asking for permission, right?

[00:39:45] And then number two, to your point, allow there to be a pause between the ask of you, and your response. And in that pause, you will figure out does this feel like the right thing to do? Does this feel like a yes but, or you know, a yes and situation? Or do I have more questions? Do I need to negotiate a different situation, right? Or do I need to say no? And you won't know that if you very quickly respond “yes” which is our gut instinct as women again, and taking that pause is where the boundary can actually emerge meaningfully.

[00:40:19] LM: I think that's right. So what I'm hearing from you, Devika, is that your wellness is external. It's about sort of environmental, everything from your nightshades to your medications, to your therapy, to an internal kind of, checking in with yourself on your energy, on your relationships. It's about connection.

[00:40:42] It's about feeling loved. It's about, it sounds like it's about feeling safe. And I mean, I think those are essential parts of health for all of us and it doesn't have to be fancy or expensive. We don't have to buy fancy leggings and show up with a personal trainer and have exotic supplements and be on a yoga retreat in Bali.

[00:41:04] Although, you know, invite me with you if you're going to go, I think it really is about an internal sense of what we need, what we deserve and what, and how we relate to other people that is at the root of our mental health. So I want to just close by reading one more quote which I love from your LA times.

[00:41:23] You said “by sharing my story, I hope to dispel stigma and internalize shame and to help anyone struggling, know that they are not alone. If you feel comfortable, consider shining a light on your story. Stigma festers in the dark and scatters in the light.” So, for anyone who's listening, who feels like writing, or talking to their friend, or their dog, or just their journal, about their story, I think it's important that we acknowledge that we all have vulnerabilities, we all have grief, we all have loss, we all have fears.

[00:41:56] Some of us have mental illness, some of us have... You know, real relationship struggles. And I think that when we talk about them, we can then start to figure out the path forward. And so I just want to say, thank you so much, Devika, for sharing your story, for being such a role model and for teaching us the ways in which you stay well.

[00:42:13] DB: Thank you so much, Lucy, for having me here and for the wonderful work that you do in your sub stack for the whole community. Really appreciate you.

[00:42:28] LM: Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download, and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you liked this episode to rate and review it. And if you have a comment or question, please drop us a line at [email protected]. The views expressed on this show are entirely my own and do not constitute medical advice for individuals. That should be obtained from your personal physician.

You can also listen to this episode on Spotify!

It’s hard enough for adults to navigate anxiety, lack of privacy, and social relationships in the digital era. How can we expect young people to do it?

On this episode of Beyond the Prescription, media expert Dr. Devorah Heitner presents practical strategies for parenting in an era of perpetual connectivity. 

She offers a refreshing perspective in her bestselling new book, Growing Up In Public: Coming of Age in a Digital World. Instead of panicking about social media’s role in young people’s lives, she argues that parents should accept that it’s here to stay and focus on the benefits of technology. Instead of blaming social media’s role for the uptick in adolescent anxiety, she argues to uncover and address the root causes of young people’s distress.

She offers practical advice to help kids set boundaries, maintain digital hygiene, and learn how to make mistakes—even while everyone is watching.

Join Dr. McBride every other Monday for a new episode of Beyond the Prescription.

You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.

Please be sure to like, rate, and review the show!

The transcript of the show is here!

[00:00:00] Dr. Lucy McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor, I've realized that patients are more than their cholesterol and their weight.

[00:00:31] We are the integrated sum of complex parts. Our stories live in our bodies. I'm here to help people tell their story and for you to imagine and potentially get healthier from the inside out. You can subscribe to my free weekly newsletter. At lucymcbride.substack.com, and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts.

[00:00:57] So let's get into it and go Beyond The Prescription. Today on the podcast, I'm speaking with Dr. Devorah Heitner, who is a bestselling author, speaker, and expert on raising kids in the digital world. In her various capacities, Dr. Heitner offers practical advice that's backed by science and research. She's providing tools that people can use to start conversations with their loved ones about how to use technology in our lives in a healthy way.

[00:01:25] Her most recent book, out in September, 2023 is titled Growing Up In Public: Coming of Age in a Digital World. It's an essential read for parents. In short, Dr. Heitner thinks we're worrying about the wrong things. We see the panic inducing headlines, yet social media can be an excellent way to help learn about our kids and help them learn about the world we live in today.

[00:01:48] Devorah, thank you so much for joining me today.

[00:01:51] Dr. Devorah Heitner: Thank you.

[00:01:53] LM: So, I talk about inputs with my patients every day. I talk about things that we put into our bodies and brains, like alcohol, caffeine, food, of course. And then I talk about screens, because screens are something we ingest. They're ubiquitous. And it's not just about how much screen time we consume, it's about our relationship, sort of like relationship with food or alcohol.

[00:02:17] What I love about your work is not only are you exploring people's relationships with screens, you're taking a somewhat counterintuitive stance that  there's a lot of research out there to suggest that screens are destroying a generation of of youth. That it is the cause for the emotional and mental health despair.

[00:02:38] So, there's a lot of data to suggest that screens are the biggest evil for our kids, that they are the reason that kids are experiencing emotional and mental health problems, but you take a different viewpoint. You take the view that screens are indeed ubiquitous, but they also can be used as a tool. They can be used as a tool to help us shepherd kids through this complicated part of their lives. So talk to me about how you see screens as a boon, as a way to help parents understand their kids. And not just as something we need to be terrified of.

[00:03:20] DH: Yeah, I think we've been really pushed this idea that screens are the big bad that are really tanking kids’ mental health has been really pushed on us and we ignore a lot of other factors and also like, what are the screens bringing our kids? So as you said, it's not just about the quantity, the minutes.

[00:03:36] The minutes are important, too. We want to live in balance with screens and be able to do other things. But we also want to think about the quality of the experience. If your kid is a creator and is making things online, for example, or collaborating with other kids, or has started a business, or is composing music, or is writing a really interesting blog, or fan fiction, and getting a lot of creative juice and community out of that, it could be a really positive thing in your kid’s life.

[00:04:04] So we first want to look at: what is the quality of experience? What is your kid engaging with? Are they finding community there? Are they connecting with people in a positive way? Is it leading them to other interests? And sometimes, especially in the last few years, when so much of our novelty has come from YouTube or Netflix, and we maybe have forgotten about other kinds of novelty. As parents, we may want to look at our kids screen based interests as a clue. Like, oh, they're watching this kind of content on TikTok. What else might be interesting? My kids are very into strategy games on the computer, but we've also gotten into risk and some other deep strategy board games. 

[00:04:41] And part of that was like recognizing these multi layer, multi hour games, you know, with strategy and complexity are really interesting. What can we do as a family that might also be related to that? And then we also want to think about the ways kids are connecting with other humans and how this is supporting their friendships. So there's a lot that's going on socially here and we worry about the negative pieces, but we should also look at the positive ways our kids are finding affinity with other kids. Our kids are finding community and finding people who share the same interests.

[00:05:12] LM: I hear you loud and clear. I think headlines that scream: watch out parents. Your kids have a separate life that you don't know about and it's only nefarious and screens are doing harm and only harm are sensationalist and really put sort of fear in the driver's seat of our roles as parents.

[00:05:32] I do think there's a lot to be worried about. I mean, kids are looking at images that you and I never had access to as children. And I think that kids can certainly get lost in a screen addiction. Just like you can be addicted to marijuana or alcohol, you can get addicted to screens. You can develop a relationship with screens such that you're using it to “medicate social anxiety” or fear of failure or you can be bullied online.

[00:06:02] Of course, I think we all know about the harms. The way I practice medicine as a physician is that I try to be a realist. I recognize that alcohol is ubiquitous in our society. I'm not going to be able to take it away from everybody, nor should I. We have to reckon with these phenomena. We can't just mop up risk and make it zero.

[00:06:21] We have to reckon with the realities of our everyday life and screens are not going anywhere. Screens are, if anything, becoming more and more woven into the fabric of our society. So I think what's important as you're saying is to recognize that there are opportunities here. There are ways that we can use screens as a sort of window into our kids lives.

[00:06:46] And that policing them may do harm in and of itself. I mean, what do you make of this idea of restricting kids access to screens until they're 18? I think there's a new law in Utah, for example.

[00:07:00] DH: I think the Utah law is a particularly harmful example. Like I do think when school districts and other folks are trying to push back on the big companies and say, “hey, when we report bullying, we should get a response right away.” Or when we report that our kid started an account under age 13 when they're supposed to be 13 and you don't take it down or you're not doing anything to even pretend to try to age verify and any eight year old can start an Instagram account if they can do the math to change their birth date, then I think it's important to say, yeah, we do want to push back on these companies. So I'm excited to see some states and school districts pushing back on the big companies. Utah's saying, let's put this all on parents. Like parents don't have enough going on and parents should be in charge of their kids social media up to 18.

[00:07:44] I think that's a problem for a lot of reasons. One reason is that not every kid is lucky to have enlightened, wonderful parents. So, what if I'm a gay kid in Utah and my parents don't know and if they find out, I'm going to become unhoused? It's not safe for me to post on social media if my parents have access to my social media up to 18.

[00:08:04] I think 18 is particularly glaring in a state where kids can work at 16 and drive at 16. I think to say that driving and working a job are, are less responsible than posting on social media is a problem. I think when we look nationally at what's going on, where there are states saying we want kids to be able to work dangerous agriculture jobs with pesticides and work in meatpacking plants at 14, but they shouldn't be able to post on TikTok till they're 18.

[00:08:30] I think we're a little messed up as a society if we're saying that, because if we actually wanna protect kids, yes, I think none of us want our children to see pornography, for example. We don't want our children to see extreme violence, but the companies need to take down some of that content when it's getting reported.

[00:08:47] But putting that on parents and saying parents need to be checking their kids' messages and reading their kids' posts up to 18. I went to college when I was 16. I moved away from my house and went to college. I'm not saying that was necessarily the best thing in the world, but that's what I did.

[00:09:04] And to sort of say that, and many kids start college at 17 because that's when they finish high school. So to say that a college freshman in Utah, their mom should still be reading their direct messages is just a little extreme. And I think we really need to get out of that idea of big brother and think about we need to teach kids to swim, putting the electric fence around the pool is not helpful and kids entire focus will just be saying that they don't live in that state or that they're going to change their age in some way when they sign up and many parents will not be in a position to make that not happen. And again, it also assumes that every kid has a well meaning thoughtful parent on their side.

[00:09:39] So there are tremendous problems with that. What if a kid needs to use social media to report abuse in their home?

[00:09:44] LM: So do you think that the headlines about the harms of social media on kids and adolescents mental health are overblown? Or what's sort of your take, in general, on that sort of frenzy,

[00:09:54] DH I think they are overblown because it's an easy thing to blame, but some of the problems that we're seeing in kids, we have to look at the pandemic. We have to look at school shootings. We also, when we see more kids reporting mental health issues, we have to look at access to mental health care as a plus.

[00:10:09] When I was growing up in the early 90s, and there was a smoking lounge in my high school, and many peers were using substances to self medicate. Very few kids would have self identified as depressed or anxious because they didn't necessarily have that language. I would argue that there are kids who are learning the language of mental health from places like TikTok or Discord and are using that language to describe the way they feel, but I don't know that those problems are new to this generation of adolescents. But I think we're seeing increased access to both language around mental health, and hopefully in many communities, actual mental health care. The thing I would worry about is I don't want kids to get their mental health support from TikTok and Discord. It's one thing to identify, like, maybe I have an issue, and learn about it, or have a YouTuber who talks about ADHD and say “oh, I think maybe I should get neuropsych testing.”

[00:10:56] What we don't want to do is self diagnose from YouTube or TikTok, and I'm sure you see that as a physician all the time. Like, that, Is concerning, but the fact that more kids are self identifying with mental health issues, I think is partly that we as a society have shifted to destigmatize that conversation and I actually think social media is part of that in a positive way for kids. But it sounds scary to adults to hear like this many kids say that they're depressed or anxious, but it's not that kids in the past were not depressed and anxious. I think they were self medicating in the smoking lounge at their high school.

[00:11:28] I think adults were turning a blind eye to drug use and other things and alcohol use. So I think we're in a really different place as a society where we're looking harder at adolescents. And there are many reasons adolescents are feeling anxiety. For example, if your kid is looking at their social feed or at the news and information about school shootings, that's distressing, but taking away Instagram doesn't take that distress away. They're going to get that news another way. Their phone may be, in fact, the source of where they're getting that stressful information, but that doesn't mean that if we just take away the phone, they're not going to be worried about it anymore.

[00:12:07] So I think it's really important that we look at, is this a vehicle for getting access to stressful information? When we see the apps themselves encouraging things that are stressful, like the apps themselves may be a problem when they encourage us to location share and we can see that our friends are out without us. And that is a problem that I blame more on social media, versus, you know, that's not just getting information. That's kind of random. That's like, hey, this app is really encouraged us to do this very human thing, which is to want to know where the people we care about are, which is very human. But it's kind of trading on that brain what we want to do.

[00:12:41] And it also trades on parental anxiety when parents put Life360 on their kids devices to track their kids all over town. But that may also not be great for our relationships. There may be ways where that undermines trust and undermines relationships. So I think there are times where what we in the tech world call affordances, but it's basically like what the apps let us do become a problem. And that's where I think we should be looking at do we want to change our own behavior or do we want to make some feel really empowered in relation to an app? Like, yeah, I want to use Snapchat, but I'm going to turn off Snap Maps. I don't want that feature. Or I'm going to turn off location sharing on another device, or I'm not going to use Life360 unless someone actually has disappeared and I haven't heard from them way past curfew.

[00:13:20] I'm not just going to use it to see if my kid might have relationships or errands to do that. I don't know about right now to kind of resist, in other words, the possibility of what apps let us do and make choices about how we're going to use tech that might be healthier for us mentally. So to come back to the headlines, I really don't think we should panic about the ways kids are using social, we need to also just look at our own kids. Like if you have a kid who's predominantly using discord to connect with their three best friends to play a game every day after school, then my worry is, are they getting their homework done? Are they getting enough sleep? But I'm not worried that social media is making them depressed because it's clearly functional for them.

[00:14:02] LM: Right? I think as parents, the screen landscape can make us feel very out of control. Kids in their adolescence are naturally kind of differentiating themselves from their parents and they are behind closed doors a lot of the day and we don't always know what they're looking at. But that's always been the case. And that's part of growing up. That's part of developing our identity is being around our peers. And sometimes that's online. So what do you say to a parent who has, for example, an adolescent who's kind of less accessible verbally, who's spending a lot of time on screens, who you may be worried that they're spending too much time on screens.

[00:14:44] How do you even begin to sort of query whether or not you're doing a good enough job as a parent vis a vis this child and their screens? They don't want to talk about it and they don't want to share with you what they're doing online and you feel completely anxious. And then you look at the headlines and you think, Oh my God, I'm the worst person alive. What do you say to that parent?

[00:15:02] DH Well, it depends on the kid and what your specific worries are, but I do think you could have especially a younger kid who's newer on some apps, like walk you through some of the things they're doing. Like, “hey, can you show me some of the things you love?” You know, like my 14 year old will absolutely show me, you know, things that he thinks are funny from YouTube sometimes and like just getting a sense of like, oh, I can see you're diving into some political satire here.

[00:15:24] I see you're diving into some remixes of the culture and things that you're interested in and movies that you like over here and just getting a sense of like, what is the content? You can decide if the bedroom is a place for screens. Certainly with sleep, I would strongly recommend not having connected devices in bedrooms overnight, especially for younger adolescents who will really struggle to self regulate, or tweens, or younger kids.

[00:15:47] And the challenge is sometimes kids are getting phones so young that they're still little and compliant. You know, your 5th grader, if they get a phone, might be super compliant and put it away at night. But you gotta think ahead to that 8th or 9th grader in love and think about, do I want them texting their sweetie all night?

[00:15:59] Do I want them, you know, on social media late at night? And so it may be that the bedroom is a place where tech doesn't go or it doesn't go during sleep and overnight. And I think that's important to think about. So some of their tech use hopefully is around the house for younger kids. If they're gaming with friends, I would suggest not having headphones on all the time.

[00:16:17] It may be annoying. It was definitely annoying for me living in a small apartment through a lot of remote school in the pandemic. And my kid was gaming without headphones. It was extremely annoying, but I knew what the friends were talking about. And when some things came up on Roblox, where they ran into some content that was a little bit of a surprise, as in, like, naked blocky people having sex in Roblox.

[00:16:38] When I heard them start to talk about that, I was like, walking over to the computer, like, what's that? And so I think that's, that's a helpful way. It's a little bit less big brother-y than using your device to kind of spy on or get your kids data later, but just being in a place where you're adjacent, you can overhear some of the activity can help you know.

[00:16:57] As kids get older, their privacy is going to be more and more appropriate, but you can still check in with them when they're in the car. We have a no phones in car rides rule for under a certain amount of time. So, you know, my kid can't like put on a podcast and listen to it with his headphones for a five minute ride if I'm driving him somewhere.

[00:17:14] If we're going on a road trip to another city, podcast and listen together. And some of his time might be in the backseat. with music on or something. But shorter rides, we have to talk to each other. And some of that is like, he gets to pick the topic because he doesn't like to share about school, but he has to tell me about something, right?

[00:17:32] And it might be the video game he's playing, but we have to talk to each other. And family meals are important. Finding a time that actually works. And with busy teenagers who do a lot of activities, that might be late at night. And that's when your kid's ready to spill and you might be ready to fall over, but if your kid is ready to tell you about things, that's a good time to be listening.

[00:17:52] If there's a specific where you have, like, say you think your kid is. checking out pornography or something where you're like, this is a specific worry. I do not want you doing that. Then I would address it directly. A lot of us are uncomfortable there, but if you have evidence that your kid has looked at pornography, I would definitely talk to them directly about it and talk to them about why this isn't where you want them to learn about sex and consent and relationships.

[00:18:14] And we can do that in a non-shaming way. We can normalize and humanize that human beings have been preoccupied with the body and sexuality and art for a long time. This is not new. For an adolescent to be curious about sex and what that looks like and what people do is very typical and normal.

[00:18:30] But this isn't a useful way to get information and it can actually be misleading. It can offer misleading ways to get information about what partners might actually like. It's very misleading on the consent front. And so I think we, and we want to make sure they get alternative information. The older your kid is, the more I would  want them to read… certainly younger kids should get have books about puberty and sexuality.

[00:18:52] Hopefully you live in a place where they can also get good sex ed in school, but we know that's not the case everywhere. So we know kids need to be able to talk to their pediatrician and other things. But we need to make sure that they have good information. And then for older kids, like reading a steamy love scene in a young adult or even an adult novel is preferable to me by a lot.

[00:19:12] I mean, there's a lot of books I would want my kid or be comfortable with my kid reading as opposed to seeing pornography. And I think that's really important to make sure that kids do have access to information. And we need to know that it's not just boys looking at porn. Girls will look at it too. A lot of kids are accessing porn for, for sex ed purposes, or that's what they think it is.

[00:19:30] LM: Yeah. And one of the other specific worries I think that comes up for parents of girls in particular, not that boys are immune to this, is the focus on bodies and thinness and diet culture and comparison culture. And I think it's really hard to avoid those, the constant barrage of images of… and now that we have AI where these faces can all of a sudden look perfect and you can see your real face compared to what your face might look like if you had plastic surgery and you were on the red carpet in Hollywood. I mean, that is a pervasive phenomenon and it's concerning as a mother of a daughter and sons, this constant sort of focus on appearance. But again, as I think you're saying, lwe cannot take screens out of their hands.

[00:20:19] We cannot make risk zero. We can do what we can as parents to help our kids kind of have a relationship with screens. So, I was counseling a patient last week who's a mother of a teenage girl who's struggling with her eating. So she's got some binge eating and some restricting behaviors and she's on screens all the time and Focusing on her appearance and the girls, her friends are in bikinis and she's not included in all the events where the girls are wearing bikinis and it's just, you know, it's torture as a mother to watch her daughter kind of go through this and you think to yourself, Gosh, I could just get rid of the screens and everything would be okay.

[00:20:57] Let's acknowledge that wouldn't be the case. And let's acknowledge that's not realistic. So my advice to her was to have a conversation with her daughter that's led with curiosity and empathy. So instead of saying, you really need to get off your screens, that's bad for you, ask the question: “honey, I wonder what it feels like when you're sitting at home and feeling uncomfortable about maybe your body or your social life and you see your friends looking perfect because they've got this curated image of themselves and you're not there. What, I wonder what that feels like.” I mean, and you might offer even an example of what you might feel like. Like it might make me feel awful. You know, when I was a kid and I knew my, my friends were hanging out together and living this so called perfect life, it, it hurt. I wonder what that feels like to you. So curiosity is always a good way to lead a conversation. And then also with empathy and say I just feel bad for you guys that this is such a hard thing to have to navigate. You can't avoid looking at these images.

[00:21:54] You can't avoid comparing yourself to other people. And then sort of open the conversation like that instead of going at it as you really need to get off screens. You need to not look at these images. You need to just stay away from that friend group or stay away from that social media feed. These are their friends.

[00:22:07] These are their lives. But I think it's very hard to know how to have those conversations as parents. And I think the world we live in as parents consuming social media seems to suggest that there's the right way to talk to our kids and the wrong way to talk to our kids. That we have to read the right parenting book.

[00:22:25] We have to follow the right expert on Instagram. We have to listen to the right podcast and that our kids are so fragile and so vulnerable that if we say the wrong thing by just two phrases, then we're doing all this harm when I think that for parents is scary and we need to understand that just by showing up as parents, and just by being empathetic and curious about who our kids are, and showing them that we love them no matter what, that is good enough. Sure, there are parents who are doing harm. Sure, there are parents who need help. I need all the help I can get with parenting, but I also have learned to trust my instincts and intuition, and I need to listen to my kids and meet them where they are.

[00:23:06] There's no parenting book that is going to tell me how to parent child one versus two versus three. So this is a long winded way of asking you, are you saying that parents need to be able to read the room with their kid, they need to be able to understand the person they are talking to, and have a relationship at baseline with their child that involves discussing who they are, what their interests are, and understand that screens are going to be an inevitable part of it.

[00:23:34] DH: I think that empathy and curiosity as you say, is huge and just slowing down, like really saying, what do you notice when you look at Instagram and letting your kid talk. Ideally not even leading with like exclusion or your own feelings, but you can go there and in a conversation, but I would let them what it's like for them and see what insights you can get from there.

[00:23:59] And certainly with body image, as the example you used it can be an exacerbating factor. Like it probably didn't originate with screens, the eating challenges you're talking about, but that doesn't mean that screens couldn't exacerbate. And if a kid is in treatment for an ED, for a substance, for anxiety, for another mental health issue, 100% with that therapist, I would be working on a screen plan with that therapist.

[00:24:25] Especially with a teenager, it's helpful to have someone that's not a parent coming up with, like, if you are going to change the screen plan and your kid is in treatment for an ED or coming home from the hospital even or something. Those are kids who are going to need some support. And sometimes it's apps we don't think of, like Pinterest is actually filled with diet content that is quite toxic.

[00:24:44] If I had a kid with an ED. I would be thinking about, like, how can we encourage them to maybe avoid Pinterest? This may not be a good place for them. If I had a kid who's really into redecorating her bedroom, or a kid who's really into crafting, Pinterest could be fine. So it's not about the app. It's about what experiences and connections and content your kid will seek out within that app. Because I could say the same thing about discord, you know, discord could be totally positive for a kid Who's using it to connect with other anime fans? It could be very negative if kids are doing like how to on an eating disorder or something or self harm. So I don't want to scare people but there are places on the internet and and communities and sub communities that aren't going to be a positive place to be if you're struggling in those ways and asking kids to reflect on their experience, asking kids to consider taking a break.

[00:25:35] Cutting a kid off completely from an app is a pretty big step, but even taking it off your most frequently used device without closing your account can be helpful. And for some kids doing that, even for a few days, just to take that app off your most frequently used device for a weekend and spend a weekend where in order to see that app, you would have to go to your computer and log in. 

[00:25:55] I have that suggestion for a lot of kids who are stressing about their grades and actually over checking their grading app. I'll say actually take your grading app off your phone. If you're checking your grading app multiple times during the school day and getting distracted in one class because you saw a test score come in from another class, that's too much. And so some kids are compulsively checking those apps. So I do think in those cases, again, it's not like we never want to see the grading app again. You may need to check it at some point, but like if you have to go to your desktop or your janky school laptop that you don't use that much and check it there, but it's not on your phone, which for 99% of teens is going to be the most frequently used device...

[00:26:32] That's really helpful. So creating those friction moments to make it less automatic and less habitual to go to the places that maybe are kind of death by a thousand paper cuts—maybe it's not like, you know, your phone is hitting you over the head and giving you a substance use disorder and eating disorder, but it's not helping either.

[00:26:51] Maybe that's where change your access. And the more kids feel empowered about that and the more… I talked to several kids who were intentionally following size positive models, people who made them feel good about their bodies. So going in the other direction, using the algorithm intentionally. So for Growing Up In Public, I did talk to some kids who felt like it wasn't great for them.

[00:27:11] And they started using those apps more just for messaging and not posting pictures as much and kind of feeling like they had to post. And again, the people who are curating first, you know, either size positivity or following athletes that they felt like were more body positive and not giving them kind of kicking off or catalyzing feelings that were more negative was so important. But that's a lot of sophistication. Even adults often don't recognize this content is adjacent to this content. But for any kids, I would say fitness content is always going to be adjacent to diet content and diet content is not safe for children. I think it's toxic for all of us, but definitely for kids, you know, if you're looking at your eating or anything with fitness, like talk to your physician. Do not get that from TikTok because it's all very dangerous on there.

[00:27:57] LM: Absolutely. And there's a sort of moralization of human behavior that happens that's just hard not to internalize. I love what you said about suggesting these breaks from screens. I mean, I find it hard as an adult to do that myself, right? When I'm standing in line at the grocery store and it's taking too long, I'm tapping my toe, you know, I'm kind of like scrolling through Instagram to pass the time and it becomes this habitual thing you just go to your phone when you have time to kill and there's a downside there. And so what I sometimes will ask my patients, I will ask myself this too, is what does it feel like internally, and how do you feel sort of mentally and physically when you take a break from, say, Twitter or Instagram for a weekend?

[00:28:38] When you take it off your phone, you don't delete your account, but you take the app off your phone, do you feel less tense in your jaw, less tense in your back? Do you sleep better? Do you find yourself drinking less alcohol because you're less kind of outraged or kind of overstimulated? Do you find yourself gravitating to the book that you put down six months ago? So I think it's not just about restricting the apps. It's about noticing how you feel mentally, physically, how are your behaviors different? If you could give up some apps that you frequently use or gravitate to for a week, what does that feel like?

[00:29:13] So I think what we're talking about really is control. Are we in control of the screens and our utilization, or are they controlling us? It's the same thing I talk about with alcohol. 

[00:29:23] DH: I always say that to kids. Yeah, I always say that to…

[00:29:25] LM: It's the same thing I talk about with alcohol, you know, sugar, like, are we deciding how to use it? Or is it deciding for us? And when it is deciding for us when there's a Twitchiness in our brain that gravitates to the phone when you're standing in line at the grocery store or you're lying in bed and you can't fall asleep and you pick up your phone just to kill more time, that may be a sign that is controlling you. And so that's a moment to decide, let's pull back, not because we can't come back into our lives at some point, but let's recalibrate that relationship. Let's put us in the driver's seat of this relationship because it's such a slippery slope, even for grownups.

[00:29:59] DH: Yeah, what I say to kids is you want to be running your devices, not letting them run you. And that's, I absolutely feel that way. And that could be my inbox some days. It's like, wait, I need to set my priorities and not let my inbox set my priorities, right? I need to not just be reacting. I need to be planning and prioritizing and doing things in a way that makes sense like most of us check email too often too frequently throughout the day. So it's really important to talk with kids about that. And when I talk with kids about running our devices and not letting them run us I talk a lot about distraction and even what are the intentional things I do as an adult and as a writer like when I go Speak at schools or is like she wrote books like I'm like, oh, yeah like that's so easy because most kids find writing hard and guess what?

[00:30:38] I do too. I have to give myself rewards for every 500 or 1000 words I write. Like, it's not easy. And if I have to do an edit, which is even a next level challenge, often I will print it out and do it offline because of distraction, because I would much rather check the news or I mean, check the weather or scroll Facebook and see somebody's cute baby, whatever, then do that edit. And so I talked to kids about what do I do to set myself up for success? And when we as parents see our kids going down that rabbit hole, I mean, A) we have to look at how did we spend our time as teenagers? Did we always spend our time in the highest and best way? We did not.

[00:31:14] Like you probably spent some time sleeping very late. You probably spent some time, you know, like I spent time like playing songs on the radio for my friends over the phone. Wasn't like the highest and best use of, you know, our time. Like I wish I had been more like Greta Thunberg. We'd be in a much better place now if my generation had been environmental activists instead of playing songs for each other on the phone.

[00:31:35] But that kind of downtime and like watching a TikTok video with friends isn't necessarily bad for kids. They need some of that. But if you feel like it's a huge rabbit hole for a kid, your kid, and they're losing time that they need on other things like sleep or homework or, you know, any physical activity, chores around the house, Then we can talk to them about how can you choose your time? Especially when you have something with no ending cues, like a TikTok or an Instagram. How can you decide I'm going to do my hardest subject homework first. And then maybe I am going to scroll Instagram for a few minutes. And then I'm going to do another subject.

[00:32:09] And then maybe I will look at TikTok, but I'm going to set a timer on myself. Because there's no end to it. And the algorithm is really good. They're going to give you something you like. Like if they know what you like, they know what you like. They've got your number.

[00:32:21] LM: Yeah, I think at the end of the day, it's incredibly overwhelming, as you know, incredibly stressful for parents to think that we can put our arms around this behemoth of social media. And we really can't. And so I think what you're saying, Devorah, is to know our kids, to have those open lines of communication, to lead with empathy and curiosity for who they are, how they spend their time, what social media means to them, and then to recognize the good of social media, the good, the practice it can offer kids, setting boundaries and setting limits, and where to spend their time. It sounds like you also think that we can kind of tap into their interests.

[00:33:02] If you notice your kid on, you know, baking shows, then hey, maybe it's time to take a cooking class together. I mean, that would be sort of... The dream is that your teenager would want to take a cooking class with you, but I think we can use it as a road. 

[00:33:14] DH: Even they could just make dinner. I mean, honestly, like if you're, if your kid is watching cooking shows, like have them make dinner. I want to eat those cupcakes. I want to, you know, eat that homemade pasta and truly like your kid will be the most popular kid on the floor of their dorm if they can make a good meal or even just some nice cookies.

[00:33:30] And so, and, and even if they're watching like how to make slime, like I want to see some slime. Like I don't want endless how to content filtering into a kid's brains without them putting it out. And the other thing we really want them to remember is there's other human beings on the other end. So when they are connecting with kids, those people have feelings too. If you're going to make a snarky comment on somebody's YouTube, that's a real person. And not only is it to that person, but you're also dealing with the people who will read it. So if you can't say something nice, it's not a good thing.

[00:34:00] You don't want to put that out there. And if someone is really bringing about your ire and your rage, and there are people on YouTube that bring, and Twitter and other places, that bring out my rage and my frustration, but my frustration is best channeled finding people I agree with and doing something to solve the problem.

[00:34:14] If somebody's being a racist or misogynist mouthpiece on YouTube, responding to their YouTube with a comment criticizing them isn't going to fix it. They're not going to say, “Oh, well, Devorah in Chicago thinks I should change my ways. I'm having a mea culpa moment. Here I go. I'm going to go down a new road.”

[00:34:31] Instead I want to do, think about like, what can I do in my own community to fight racism? What can I do in my own community to build an accepting school district for LGBT plus students? What can I do in my community to fight misogyny? And make safe spaces for women and girls? So I think it's really important to focus on what we can do to make the world better when we see things that enrage us and not get into like an outrage cycle online. And I think unfortunately that is another thing that the algorithm is really good at is like churning us up in that way. And that's something we want to resist.

[00:35:03] LM: That's right. And being in control of our own emotions. Recognizing that it wants us to be afraid and outraged. Fear and outrage is how they, how the social media algorithms work. So if we can say, look, I'm of course entitled to be afraid. I'm of course entitled to be outraged, but I'm going to calibrate that to my understanding of the facts and not calibrate it to what the social media algorithms are serving up.

[00:35:28] Now that's a tall order for kids. It's a tall order for adults, but I really like what you're saying again, just to frame it is that we as parents need to understand that there's good, there's value in social media. We have to feel that way because it's not going away, but it's true. There is good. There is value.

[00:35:47] In fact, during the pandemic, I was grateful in many ways for social media, for my kids to be able to connect with their peers and classmates, despite being out of school. So let's end with this question. What do you think a healthy relationship with social media looks like? What is the sort of definition of healthy social media habits?

[00:36:06] DH A healthy social media relationship is one where you're using it if you want to, because you want to, and you're getting pleasure and distraction and entertainment from it. You're getting maybe ideas and inspiration from it as well. And you can have a sense of humor about it. You know, everybody's posting about living their best life, because nobody wants to see you unloading the dishwasher.

[00:36:28] But the reality is most people's lives are a lot more about cleaning the cat box and unloading the dishwasher and running around and getting things done or if you're a kid like doing your homework or whatever and that very little of your time is on top of the mountain with the sunset or at the party.

[00:36:43] And so it's good to remember that it's a performance and to just have that sense of humor about it. I mean, I try, even though, of course, like my publisher wants me to be famous and get likes as well. Like I have that pressure as an author and a speaker, but I also have to have a sense of humor about it and say like, okay, this time, I'm not going to do the reel and chase the numbers, or this time I'm going to do it, but I'm going to try not to keep checking my phone to see how many likes I got, because I know that's the app getting me where I'm the most human, where I want to be seen and regarded. And that's where we all are.

[00:37:12] So if we can let our kids know that we have empathy for them, and that we see them, and make sure that they have things that they're doing outside of social media that bring them real self esteem, which is being helpful at home and in the community. to balance out that sense of chasing that algorithm or the numbers or the followers or the likes, I think that's a healthy relationship with social media. So use it for what it's good for. 

[00:37:34] LM: I love it. I love it.

[00:37:35] DH: And be able to take some space.

[00:37:38] LM: And as we've talked about earlier, acknowledging that it is. An input, just like food, water, screens are now, you know, sort of part of our sort of nutrition, sometimes good, sometimes bad, but we have to metabolize it and we have to be aware of how it affects our bodies and minds.

[00:37:56] DH When it makes you feel bad, definitely put it away. That's I mean, That's definitely time. When it makes you feel bad, that's the time. If you're watching other people do stuff without you and it's making you feel terrible, put it away.

[00:38:05] LM: So Devorah, thank you so much for joining me today. It's been a pleasure and I've learned a lot.

[00:38:09] DH: Thank you so much. It was great talking with you.

[00:38:16] LM: Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download, and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you like this episode to rate and review it. And if you have a comment or question, please drop us a line at [email protected]. The views expressed on this show are entirely my own and do not constitute medical advice for individuals that should be obtained from your personal physician.