Latest / Wellness, Actually with Emily Oster & Perry Wilson, MD / What's the deal with Botox?

Transcript

What's the deal with Botox? · Wellness, Actually with Emily Oster & Perry Wilson, MD

• 0:01
  Speaker 1: Emily, for the past week, in preparation for this episode,
• 0:05
  Speaker 1: I've been staring at everyone's foreheads as I watch. I'm
• 0:09
  Speaker 1: watching for any signs of eyebrow movement. And now I'm
• 0:13
  Speaker 1: staring at your forehead.
• 0:14
  Speaker 2: Oh, look at that. No, I don't. I am a
• 0:17
  Speaker 2: no-go on Botox. I am afraid of needles in my face.
• 0:22
  Speaker 1: Okay. Well, that I understand, but- Are you a Botoxer?
• 0:26
  Speaker 1: I've never done it, but you know what? After this episode,
• 0:29
  Speaker 1: I might have to change my tune. We'll see. We'll
• 0:31
  Speaker 1: see how it shakes out. But I have a fun
• 0:32
  Speaker 1: little activity for us before we get started.
• 0:34
  Speaker 2: Okay.
• 0:34
  Speaker 1: I have a quiz for you because as you may
• 0:38
  Speaker 1: know by now, botulinum toxin is the single most toxic
• 0:45
  Speaker 1: thing in the entire planet. Gram for gram. So it
• 0:49
  Speaker 1: is incredibly, incredibly toxic. So of course we should inject
• 0:53
  Speaker 1: it into our faces.
• 0:54
  Speaker 2: What could go wrong? Good plan.
• 0:57
  Speaker 1: My quiz for you is for you to tell me
• 1:00
  Speaker 1: how much more toxic is Botox than a couple of things.
• 1:04
  Speaker 2: Okay.
• 1:05
  Speaker 1: So here we go. Take your best guess. So we're
• 1:07
  Speaker 1: going to start with arsenic. How many more times more
• 1:11
  Speaker 1: toxic is Botox than arsenic gram for gram? 10. That's
• 1:18
  Speaker 1: a good guess. But the answer is actually, it is
• 1:21
  Speaker 1: 15 million times more toxic than arsenic. Okay, so I was.
• 1:24
  Speaker 2: Off by a few orders of magnitude. But now I'm prepared.
• 1:28
  Speaker 1: All right, you're ready. Cyanide, that's pretty bad.
• 1:31
  Speaker 2: 10 million.
• 1:33
  Speaker 1: Okay, all right. I think you're getting it now. It's
• 1:37
  Speaker 1: only 6 billion times more toxic than cyanide. What about
• 1:41
  Speaker 1: sarin gas, notorious chemical warfare agent?
• 1:48
  Speaker 2: I'm going to go with 50. I feel like this
• 1:50
  Speaker 2: one's bad.
• 1:51
  Speaker 1: 50. It's bad. It's bad. Sarin is bad. Is that
• 1:54
  Speaker 1: the one from The Rock? I think it might have been.
• 1:56
  Speaker 2: Oh, no.
• 1:56
  Speaker 1: That was like VX or whatever. But botulinum toxin is
• 2:00
  Speaker 1: 100,000 times more toxic, gram for gram.
• 2:03
  Speaker 2: Again, I overcorrected.
• 2:05
  Speaker 1: Than sarin gas. Uranium. Radioactive uranium.
• 2:10
  Speaker 2: This is like if you ate it? Yeah. Like if
• 2:14
  Speaker 2: I ate the uranium.
• 2:15
  Speaker 1: Or I injected you with uranium.
• 2:18
  Speaker 2: Again. 3,000. Okay.
• 2:21
  Speaker 1: Botox is 200 million times more toxic than uranium. Last one.
• 2:26
  Speaker 1: Tetanus toxin.
• 2:28
  Speaker 2: Tetanus. 6 billion.
• 2:32
  Speaker 1: Only twice as toxic. So tetanus toxin is actually incredibly
• 2:39
  Speaker 1: toxic and also comes from a clostridium genus of bacteria.
• 2:43
  Speaker 1: So those bacteria know what they're doing when it comes
• 2:45
  Speaker 1: to killing humans. This is just the tip of the
• 2:48
  Speaker 1: iceberg of the, interesting stuff that Botox can do that
• 2:52
  Speaker 1: we need to talk about today.
• 2:53
  Speaker 2: I'm very excited for this episode because of course we
• 2:55
  Speaker 2: are going to get to your face. But I think
• 2:58
  Speaker 2: the basic, I am just so interested in the question
• 3:02
  Speaker 2: of how we got from this is the most toxic
• 3:05
  Speaker 2: substance known to man to like, let's inject it into
• 3:08
  Speaker 2: various parts of our body and see how that goes.
• 3:10
  Speaker 2: Like what, what could go wrong?
• 3:13
  Speaker 1: Isn't science awesome?
• 3:18
  Speaker 2: I'm Emily Oster. I'm an economist and a data expert.
• 3:21
  Speaker 1: And I'm Perry Wilson. I'm a medical doctor.
• 3:23
  Speaker 2: It is Thursday, October 8th, 2026, and this is Wellness Actually.
• 3:28
  Speaker 1: Because you're getting a staggering amount of health and wellness
• 3:32
  Speaker 1: information nowadays from every source imaginable. And some of it
• 3:36
  Speaker 1: is awesome.
• 3:36
  Speaker 2: And some of it is, well, actually bullshit. Fortunately, we
• 3:42
  Speaker 2: are both people who know how to read studies... how
• 3:44
  Speaker 2: to parse the data, and can tell you what's worth
• 3:47
  Speaker 2: thinking about and what you can safely ignore.
• 3:50
  Speaker 1: But before we dig in, a note that this podcast
• 3:52
  Speaker 1: is for educational purposes and should not be construed as
• 3:55
  Speaker 1: medical advice. We don't know your unique situation, so talk
• 3:58
  Speaker 1: to your doctor for personal health decisions.
• 4:01
  Speaker 2: This week, we're asking, what's the deal with Botox? Perry
• 4:04
  Speaker 2: and I will give the official smash or pass, and
• 4:06
  Speaker 2: we'll get to your question of the week. But first,
• 4:09
  Speaker 2: let's do the health news roundup after the break. And
• 4:23
  Speaker 2: now for the health news of the week. Perry, it's
• 4:25
  Speaker 2: Nobel Prize week. We are recording this on Monday, and
• 4:30
  Speaker 2: the Nobel Prize in Physiology and Medicine was just announced.
• 4:36
  Speaker 2: This is always very exciting. They always give it for
• 4:39
  Speaker 2: something that is difficult to understand. Do your doctor story
• 4:44
  Speaker 2: about who won it this time and whether this was
• 4:48
  Speaker 2: the person you had in the Kalshi voting pool.
• 4:50
  Speaker 1: I always love Nobel Prize week. It's very exciting. I
• 4:52
  Speaker 1: love learning about these people. So Nobel Prize in Physiology
• 4:56
  Speaker 1: or Medicine awarded to Carl Deseroth, Peter Hegemann, and George
• 5:00
  Speaker 1: Nagel for their work on light-gated ion channels and optogenetics.
• 5:05
  Speaker 1: Need I say, I think we all know about optogenetics.
• 5:08
  Speaker 1: And so let's move on.
• 5:08
  Speaker 2: Moving on.
• 5:10
  Speaker 1: This is super cool, actually. So these guys discovered channels
• 5:14
  Speaker 1: on nerve cells that open and let ions in, in
• 5:19
  Speaker 1: response to wavelengths of light, as opposed to like things
• 5:22
  Speaker 1: binding them, which is typically when you think of a
• 5:24
  Speaker 1: channel in a cell, it's like something binds to the channel,
• 5:27
  Speaker 1: like a key and the channel opens and lets in
• 5:29
  Speaker 1: calcium or something else. And that's how signaling happens. But
• 5:32
  Speaker 1: these channels responded to light, which is just really neat.
• 5:35
  Speaker 1: But they not only discovered that, they realized that they
• 5:38
  Speaker 1: had really cool applications. So where they took that was
• 5:42
  Speaker 1: cloning those proteins and putting them in viruses that could
• 5:46
  Speaker 1: then genetically get those proteins to be expressed in cells
• 5:50
  Speaker 1: that don't normally express light-gated ion channels, specifically nerve cells
• 5:57
  Speaker 1: and certain clusters of nerves. The practical upshot of which
• 6:00
  Speaker 1: is when you do that, now you can activate nerve
• 6:03
  Speaker 1: cells and clusters of nerve cells by shining laser beams
• 6:07
  Speaker 1: at them, as opposed to trying to bathe them in
• 6:09
  Speaker 1: a chemical or something like that. And this is a
• 6:11
  Speaker 1: really huge advance because Light is really precise, right? You
• 6:15
  Speaker 1: can shine it for a split second and let the
• 6:18
  Speaker 1: channel open for a fraction of a second, and then boom,
• 6:21
  Speaker 1: it's closed again, which you can't do with chemical ligands
• 6:24
  Speaker 1: to receptors. And it allowed them to begin to understand
• 6:28
  Speaker 1: the really complex web of connections that form the basis
• 6:33
  Speaker 1: of all of our brains. And now we've got mice
• 6:36
  Speaker 1: that have these proteins expressed in their brains, and I
• 6:39
  Speaker 1: put a picture on Twitter of this. You can see
• 6:40
  Speaker 1: like little mouse with a little like laser drilled into
• 6:44
  Speaker 1: its head, which they can like turn off and on
• 6:46
  Speaker 1: with radio waves. Okay, it's not, that's, you know, the
• 6:50
  Speaker 1: poor mice. But we are learning a ton about how
• 6:52
  Speaker 1: the brain works from this line of fascinating research. So
• 6:56
  Speaker 1: big congratulations to them.
• 6:57
  Speaker 2: Incredibly cool. Yeah. The Economics Nobel Prize, it's actually not
• 7:02
  Speaker 2: a regular Nobel Prize, but it's on Friday. So, or no,
• 7:05
  Speaker 2: next Monday. So the economists are all getting very excited.
• 7:08
  Speaker 1: I'd like to think that you're in contention, Emily.
• 7:11
  Speaker 2: Yeah. I think I'm like maybe 25%, 30% chance. So
• 7:16
  Speaker 2: fingers crossed. I'll let you guys know next week if
• 7:19
  Speaker 2: I'm the winner. Absolutely.
• 7:20
  Speaker 1: Absolutely. We said we wanted to do more good news
• 7:24
  Speaker 1: for Health News of the Week, but you know what?
• 7:26
  Speaker 1: Forget that. It's over. Nobel Prize is all we're going
• 7:29
  Speaker 1: to give you, folks. The next news item that I
• 7:32
  Speaker 1: wanted to talk to you, Emily, about is the plague.
• 7:36
  Speaker 1: We're recording this on Monday, October 5th, and this is
• 7:39
  Speaker 1: sort of breaking news, so I think we might get
• 7:41
  Speaker 1: some developments over the next few days. But seeing a
• 7:44
  Speaker 1: lot of chatter now that there has been an outbreak
• 7:48
  Speaker 1: of plague from a lab in Russia sounds to me
• 7:51
  Speaker 1: like the start of a very scary movie. Emily, what's
• 7:55
  Speaker 1: going on?
• 7:56
  Speaker 2: So this is the same plague from medieval times. It
• 8:00
  Speaker 2: killed a very large number of people over a long
• 8:04
  Speaker 2: period from, well, 300 AD, probably before that, through kind
• 8:10
  Speaker 2: of the 1600s. So I think one thing to note
• 8:14
  Speaker 2: before I get into what happened is that we do
• 8:16
  Speaker 2: have antibiotic treatment for the plague. So the plague is
• 8:20
  Speaker 2: now treatable if you start treatment I actually have a
• 8:25
  Speaker 2: friend who got the plague a number of years ago.
• 8:28
  Speaker 1: Really? Yeah. From an armadillo, perhaps? That's the, in the US,
• 8:32
  Speaker 1: that's the- He was in India.
• 8:33
  Speaker 2: I'm not sure if there was an armadillo involved. All right.
• 8:36
  Speaker 2: So what is going on now is that there is
• 8:39
  Speaker 2: a lab worker in Russia, in, it's Kursk, Russia, who
• 8:45
  Speaker 2: has died after a lab accident, which released a dangerous infection,
• 8:50
  Speaker 2: a pneumonia of unknown etiology. They haven't said that it's
• 8:53
  Speaker 2: the plague. We know this lab studied the plague. It
• 8:55
  Speaker 2: seems like it's very likely it was the plague. They've
• 8:58
  Speaker 2: quarantined about 200 people. There are several hospitals under quarantine.
• 9:06
  Speaker 2: It's very difficult to know exactly what is going on
• 9:09
  Speaker 2: because Russia has not been extremely forthcoming about what what
• 9:14
  Speaker 2: is going on and how many people are ill and
• 9:17
  Speaker 2: what was going on inside this lab. So as you said,
• 9:21
  Speaker 2: I think we will know more about this. Certainly it
• 9:25
  Speaker 2: is very scary. It is also, again, in contrast to COVID,
• 9:32
  Speaker 2: we do have a lot of research on how to
• 9:35
  Speaker 2: address the plague. So hopefully this will be something we
• 9:39
  Speaker 2: don't need to discuss again. We'll just go away.
• 9:42
  Speaker 1: I hope so too. You're going to see some scary
• 9:44
  Speaker 1: stuff online, you know, as you might expect with this
• 9:49
  Speaker 1: kind of thing. This lab is not a Russian government
• 9:52
  Speaker 1: lab as far as we know, but that doesn't necessarily
• 9:55
  Speaker 1: mean the government isn't involved. And of course, the Soviet
• 9:57
  Speaker 1: Union had a pretty significant biological warfare. research program that
• 10:02
  Speaker 1: may or may not continue to exist. I did see
• 10:05
  Speaker 1: some things on the Twitter suggesting that the course of
• 10:09
  Speaker 1: this disease, she was exposed on September 25th, died October
• 10:14
  Speaker 1: 1st or 2nd. It's like, oh, that's so fast. This
• 10:16
  Speaker 1: is not actually plague. It's like super plague or it's
• 10:19
  Speaker 1: some biological weapon. That's not true. Pneumonic plague, which is
• 10:23
  Speaker 1: the lung form of the disease, which is almost certainly
• 10:26
  Speaker 1: what someone would have acquired in this scenario, because I
• 10:29
  Speaker 1: don't think they're getting bitten by fleas, which would cause
• 10:31
  Speaker 1: the bubonic plague. that is, it's, it's very fulminant. Like,
• 10:35
  Speaker 1: like it really is like you get infected and then
• 10:37
  Speaker 1: six days later you could be dead. So this doesn't,
• 10:39
  Speaker 1: to me, this doesn't read as like, Oh, brand new
• 10:41
  Speaker 1: super flu, super plague thing. Um, but obviously we'll keep our,
• 10:45
  Speaker 1: keep our tabs on it.
• 10:47
  Speaker 2: Okay. In the not great news, but more ridiculous, uh,
• 10:51
  Speaker 2: there is a new abstract that I saw suggesting that
• 10:56
  Speaker 2: GLP ones, uh, lead to detached fingernails. That they make
• 11:01
  Speaker 2: your fingernails attach.
• 11:02
  Speaker 1: This creeps me out. I have to say. This is
• 11:05
  Speaker 1: body horror. What was that movie that we talked about
• 11:07
  Speaker 1: before where Demi Moore?
• 11:10
  Speaker 2: Oh, yeah. So first of all, I just want to
• 11:13
  Speaker 2: say I lose toenails all the time. I'm really not
• 11:17
  Speaker 2: thinking that losing your fingers and toenails is like a
• 11:19
  Speaker 2: super big deal. I have barely any.
• 11:21
  Speaker 1: That's a Tuesday for Emily.
• 11:23
  Speaker 2: I'm not concerned. Yeah. Okay.
• 11:27
  Speaker 1: For endurance athletes.
• 11:28
  Speaker 2: I will say when I first read this headline, I thought, well,
• 11:31
  Speaker 2: that seems plausible in the sense that, you know, people
• 11:34
  Speaker 2: like lose. I thought this was like a mild, tiny effect.
• 11:38
  Speaker 2: And I could say, you know, people sometimes lose more
• 11:40
  Speaker 2: hair when they lose a lot of weight. I can
• 11:42
  Speaker 2: imagine that, you know, fast growing cells like your fingernails
• 11:46
  Speaker 2: could be somehow affected by this. But The size of
• 11:51
  Speaker 2: the effects in this abstract, which provides no additional detail,
• 11:55
  Speaker 2: are so ridiculous that it seems impossible.
• 11:58
  Speaker 1: I cannot believe the amount of credulous reporting that is
• 12:03
  Speaker 1: happening about this. It's like if you put GLP-1 in
• 12:06
  Speaker 1: the title of your abstract, you're going viral, guys. It's wild.
• 12:12
  Speaker 1: So again, this is not peer-reviewed. We don't have the
• 12:15
  Speaker 1: whole paper. We can't review the methods. But what the
• 12:17
  Speaker 1: abstract says is they compared 600 GLP-1 users versus 1,500
• 12:22
  Speaker 1: people who had diabetes and obesity but weren't using GLP-1s.
• 12:26
  Speaker 1: And they found that the people that were using it
• 12:29
  Speaker 1: had four times higher fingernail problems. We have no idea
• 12:32
  Speaker 1: how they were assessing this, by the way, like whether
• 12:34
  Speaker 1: it's like coding in the chart or the direct survey,
• 12:37
  Speaker 1: not in the abstract. And again, okay, I'm like you, Emily.
• 12:40
  Speaker 1: I'm like, okay, four times, I'm sure the baseline rate
• 12:43
  Speaker 1: is low, four times something very low, maybe, yeah, nutritional
• 12:47
  Speaker 1: stuff like iron, zinc, I don't know, maybe we'll figure
• 12:49
  Speaker 1: it out.
• 12:49
  Speaker 2: Okay.
• 12:50
  Speaker 1: And then you read further and it says, the multinational
• 12:54
  Speaker 1: study found that 39% of GLP-1 users reported nail detachment
• 13:00
  Speaker 1: compared with 9% of controls, while two-thirds experienced at least
• 13:04
  Speaker 1: one nail disorder. 40% of GLP-1 users had their fingernails.
• 13:09
  Speaker 1: That is insane.
• 13:11
  Speaker 2: One in six people in America is on these. If
• 13:14
  Speaker 2: this were true, America would be littered with fingernails that
• 13:18
  Speaker 2: just were falling off everywhere. Yeah. It's just.
• 13:22
  Speaker 1: This is something... This is just a sanity check. It's
• 13:27
  Speaker 1: like whenever we do research in our lab, our clinical
• 13:31
  Speaker 1: research lab, and I've got trainees and stuff and they
• 13:33
  Speaker 1: get a result, I'm like, okay, the first thing isn't
• 13:35
  Speaker 1: to be like, oh, what does this mean? The first
• 13:37
  Speaker 1: thing is just to look at the actual numbers and
• 13:39
  Speaker 1: be like, is this possible? And it is not. Like,
• 13:44
  Speaker 1: look around you.
• 13:45
  Speaker 2: I tell my students, I'm like, sometimes I'm just like,
• 13:47
  Speaker 2: they'll show me something, I'll be like, data doesn't look
• 13:49
  Speaker 2: like that. So come back to me with, because that's
• 13:53
  Speaker 2: not how data looks. Like, that's just like, I can
• 13:55
  Speaker 2: tell that's wrong.
• 13:56
  Speaker 1: I can guarantee you that there are more people with
• 13:59
  Speaker 1: frozen foreheads from Botox than there are with their fingernails
• 14:03
  Speaker 1: falling off. And I've been checking that too. I'm looking
• 14:05
  Speaker 1: at your fingernails, people.
• 14:06
  Speaker 2: I did start thinking, like, is the GLP, people are
• 14:08
  Speaker 2: going on GLP-1s, then are they like running more? And
• 14:10
  Speaker 2: is that, but I still think it couldn't possibly be.
• 14:12
  Speaker 1: You can't get to 40%.
• 14:13
  Speaker 2: And it's those fingernails.
• 14:15
  Speaker 1: Yeah. So.
• 14:16
  Speaker 2: Nope. Anyway, don't worry about your fingernails, people on GLP-1s.
• 14:22
  Speaker 1: All right. Let's, let's talk Botox. I'm excited.
• 14:27
  Speaker 2: Let's talk Botox.
• 14:29
  Speaker 1: Emily, would you inject not your face? You'd inject not
• 14:32
  Speaker 1: your face.
• 14:34
  Speaker 2: Oof. I mean, I, I got a flu shot this weekend.
• 14:37
  Speaker 2: Like I'll, I'll put, yes, I would, if there was
• 14:39
  Speaker 2: Botox was helpful for something I would consider, I would,
• 14:45
  Speaker 2: I would use it. Yes, of course. I like medical care.
• 14:47
  Speaker 2: I just, uh, I don't, I don't know, even though
• 14:51
  Speaker 2: I'm like my, my whole job now is like to
• 14:53
  Speaker 2: have my face on Instagram. I just can't, I can't
• 14:56
  Speaker 2: get exercised.
• 14:57
  Speaker 1: I think you do have, you, you do have nice
• 14:59
  Speaker 1: skin though. I will, I will say that you must've
• 15:01
  Speaker 1: used a lot of, um, like SPF when you were younger.
• 15:05
  Speaker 2: I one time got such a bad sunburn on my
• 15:06
  Speaker 2: face that I had like large blisters. Oh yeah.
• 15:10
  Speaker 1: That's not good. Yeah.
• 15:12
  Speaker 2: Okay. Let's talk about Botox guys. Let's discuss it. Let's
• 15:15
  Speaker 2: start with how we know about this toxic substance and
• 15:19
  Speaker 2: where it comes from. Perry, tell me about sausages. Yeah.
• 15:24
  Speaker 1: It all starts with sausages as I think most medical
• 15:27
  Speaker 1: stories do. Um, Let me take you back to Germany.
• 15:30
  Speaker 1: We're in the 1820s and a physician named Justinus Kerner
• 15:36
  Speaker 1: documents a wave of deaths that a little bit of
• 15:40
  Speaker 1: old school epidemiology determined was related to badly made blood sausage.
• 15:47
  Speaker 1: The Latin word for sausage or casing, I guess, is botulus.
• 15:51
  Speaker 1: And so botulism is literally sausage-ism. Like that's the disease.
• 15:57
  Speaker 1: It's a sausage disease. That's what they call it. The
• 16:00
  Speaker 1: disease was the same type of botulism that we get today.
• 16:04
  Speaker 1: It was characterized by a paralysis. And really interestingly, Kerner himself...
• 16:09
  Speaker 1: suspected that there was some poison. Obviously, they didn't have
• 16:12
  Speaker 1: the technology at the time to figure out what the
• 16:14
  Speaker 1: poison was or how it worked or anything like that.
• 16:16
  Speaker 1: But he actually thought that someday we might be able
• 16:20
  Speaker 1: to use this poison, which paralyzes people and kills them,
• 16:23
  Speaker 1: for overactive muscles and nerves, which I just think is
• 16:28
  Speaker 1: kind of like he's a clever guy, just a little
• 16:30
  Speaker 1: bit ahead of his time.
• 16:31
  Speaker 2: Yeah, so this was a single batch of badly made
• 16:35
  Speaker 2: blood sausage or a whole badly made blood sausage company?
• 16:39
  Speaker 1: This particular one apparently was from one place, one geographic location.
• 16:46
  Speaker 1: But the disease had been certainly existed before that. But
• 16:51
  Speaker 1: it was just this guy who kind of put the
• 16:52
  Speaker 1: pieces together and was able to tie it. Remember, back
• 16:55
  Speaker 1: in the 1820s, people are dropping dead of foodborne illnesses. Like,
• 16:59
  Speaker 1: similar to rates we see today. No, just kidding. We're
• 17:02
  Speaker 1: much better today, but we're on the rise.
• 17:05
  Speaker 2: So what is this? It is a rod-shaped... Bacteria. Bacteria.
• 17:13
  Speaker 2: It is killed by oxygen, lives in soil. There's spores
• 17:17
  Speaker 2: kind of everywhere, and they actually survive boiling. The spores
• 17:24
  Speaker 2: are not toxic, but when they wake up and start
• 17:28
  Speaker 2: to grow, that is when you generate the toxin.
• 17:31
  Speaker 1: Right. I think the bacteria is called Clostridium botulinum. There's
• 17:36
  Speaker 1: a Clostridium tetani, which makes the tetanus toxin. So they're
• 17:39
  Speaker 1: sort of related toxin forming bacteria. And it's everywhere. It's
• 17:43
  Speaker 1: like in the soil, like it's all over your surfaces.
• 17:45
  Speaker 1: You're touching some right now. It's everywhere, but it's in
• 17:48
  Speaker 1: the spore form. And I think of spore like seeds,
• 17:51
  Speaker 1: like they just are inert and then they need to
• 17:54
  Speaker 1: be in proper environment to sprout and produce live bacteria
• 17:58
  Speaker 1: that produce the toxin. And that environment is hard to
• 18:00
  Speaker 1: come by because as you said, they're anaerobes. Oxygen actually
• 18:03
  Speaker 1: kills them and are, our world is full of oxygen
• 18:06
  Speaker 1: and that's nice unless we put them in like a
• 18:10
  Speaker 1: can that has other bacteria that will eat up all
• 18:14
  Speaker 1: the oxygen. And then when that's gone, the botulism can
• 18:18
  Speaker 1: take over. And that's how you get from, you know,
• 18:21
  Speaker 1: botulism from improperly canned food, which is, you know, the
• 18:25
  Speaker 1: main source of infection in adults, at least. But Emily,
• 18:32
  Speaker 1: this feels like I'm sure you're familiar with the risks
• 18:36
  Speaker 1: of botulism in babies and honey.
• 18:39
  Speaker 2: Yeah. So this is a very common piece of advice
• 18:43
  Speaker 2: that parents are given. Do not give your baby honey
• 18:45
  Speaker 2: before the age of one because it– the infant gut
• 18:52
  Speaker 2: flora is not like able to process the spores in
• 18:56
  Speaker 2: the way that adults are. So for adults, you have
• 18:59
  Speaker 2: botulism in the spores in honey and your gut processes
• 19:02
  Speaker 2: them and it's fine. The infant gut is less advanced.
• 19:06
  Speaker 2: And so there's a concern about these spores in honey.
• 19:10
  Speaker 2: I will say that link is much more tenuous than
• 19:15
  Speaker 2: many people think. So this was a sort of when in, in,
• 19:19
  Speaker 2: infants are generally more susceptible. Infantile botulism is one of
• 19:22
  Speaker 2: the more common, this is one of the more common
• 19:24
  Speaker 2: risk groups for botulism. And honey is sort of like,
• 19:29
  Speaker 2: was a suspected cause, but in fact, it, The sort
• 19:34
  Speaker 2: of follow up on that has not been real compelling. Like,
• 19:37
  Speaker 2: you know, don't give your what I sort of tell
• 19:39
  Speaker 2: people is like, it's perfectly reasonable to not give your
• 19:42
  Speaker 2: baby honey when people freak out because their mother-in-law gave
• 19:45
  Speaker 2: their kid a half a graham cracker, it's like, actually, first,
• 19:48
  Speaker 2: botulism is extremely rare. And second, like, it's not like
• 19:52
  Speaker 2: every graham cracker contains it.
• 19:54
  Speaker 1: Yeah, there are a couple hundred cases of infant botulism
• 19:58
  Speaker 1: in the U.S. per year. So we are talking very rare. But,
• 20:00
  Speaker 1: you know, you've got other options than honey, certainly. I
• 20:02
  Speaker 1: did try to figure out, like, what's so special? Like,
• 20:04
  Speaker 1: I eat honey. Like, why, you know, what makes infants
• 20:08
  Speaker 1: so uniquely special?
• 20:10
  Speaker 2: Infants are uniquely susceptible to consuming these spores. It is not,
• 20:15
  Speaker 2: it's just that these, that honey has these. This is
• 20:17
  Speaker 2: like a, it's like, this is a source of botulism
• 20:20
  Speaker 2: spores because of, I don't know, I guess probably the
• 20:23
  Speaker 2: same reason honey can like live in Egyptian tombs for
• 20:26
  Speaker 2: a long time or whatever. And infants are, so you
• 20:29
  Speaker 2: also see, for example, botulism, there was a number of
• 20:32
  Speaker 2: cases in the last year from formula. So it can
• 20:35
  Speaker 2: grow in formula. And again, if adults drink that formula,
• 20:39
  Speaker 2: no problem. infant consumption of formula more complicated.
• 20:43
  Speaker 1: And we have a little... Our acid in our stomach's
• 20:46
  Speaker 1: a little bit stronger than infants, and we have some
• 20:49
  Speaker 1: competing gut bacteria that the infants might not have, which
• 20:53
  Speaker 1: also makes them a little bit more susceptible. The roots
• 20:58
  Speaker 1: of disease are essentially that, right? It's worth really thinking
• 21:02
  Speaker 1: about botulism, the disease, as a poisoning as opposed to
• 21:05
  Speaker 1: an infection, because that's really what it is. It's the toxin.
• 21:08
  Speaker 1: And But it's a pretty scary syndrome, a poisoning syndrome, right?
• 21:15
  Speaker 2: Yes.
• 21:15
  Speaker 1: I don't want to, like, get too horror show here, but.
• 21:19
  Speaker 2: The descending symmetric flaccid paralysis.
• 21:23
  Speaker 1: Yeah. So what that means is it paralyzes you from
• 21:28
  Speaker 1: the head down. You are wide awake when this happens.
• 21:33
  Speaker 1: Because it's not like an infection. It's not like fever
• 21:36
  Speaker 1: and sepsis and your blood pressure is dropping and you're delirious.
• 21:39
  Speaker 1: It's just like you are slowly going paralyzed. You are
• 21:42
  Speaker 1: wide awake. And when the paralysis hits the nerves that
• 21:47
  Speaker 1: innervate your diaphragm, you stop breathing. And in the 1820s,
• 21:52
  Speaker 1: that's how you would die, sort of wide awake suffocating. Nowadays,
• 21:57
  Speaker 1: we can put you on a ventilator. But you're typically
• 22:02
  Speaker 1: on a ventilator until the botulinum toxin wears off. And
• 22:06
  Speaker 1: for anyone who's used Botox, you know that that does
• 22:09
  Speaker 1: not happen overnight. People are on the vent for months
• 22:14
  Speaker 1: until they can breathe on their own again. Not a
• 22:16
  Speaker 1: great disease.
• 22:17
  Speaker 2: It's not a great disease.
• 22:18
  Speaker 1: It's bad.
• 22:19
  Speaker 2: I will say, and again, I think for parents of infants,
• 22:25
  Speaker 2: it is very rare for babies to die of botulism.
• 22:29
  Speaker 1: Very rare.
• 22:30
  Speaker 2: It does require a period of treatment for these reasons,
• 22:34
  Speaker 2: but this is treatable in the sense of like, not
• 22:38
  Speaker 2: that they give you something, but that you, I mean,
• 22:42
  Speaker 2: there's an antitoxin, but that you still need a fair
• 22:45
  Speaker 2: amount of time in a ventilator where babies and adults
• 22:49
  Speaker 2: caught in time typically do recover.
• 22:51
  Speaker 1: Yeah. I wanted to touch on the mechanism here of like,
• 22:54
  Speaker 1: Why does it cause paralysis? Because it explains why it
• 22:56
  Speaker 1: lasts so long and also why the antitoxin isn't like,
• 23:01
  Speaker 1: I mean, it's great, but it doesn't help as much
• 23:04
  Speaker 1: as you might expect. So I think what you need
• 23:06
  Speaker 1: to know is that this is all happening at the
• 23:08
  Speaker 1: junction between a nerve and a muscle. So a nerve
• 23:11
  Speaker 1: tells a muscle to contract. That's how everything works. And
• 23:15
  Speaker 1: the way it does that is the nerve terminal releases
• 23:17
  Speaker 1: acetylcholine onto a receptor on the muscle. The acetylcholine binds
• 23:22
  Speaker 1: and the muscle contracts. The botulinum toxin gets into the
• 23:27
  Speaker 1: end of the nerve cell and it binds a very
• 23:30
  Speaker 1: specific protein that it destroys. It cleaves that protein. And
• 23:34
  Speaker 1: that's a protein that's necessary to allow the release of
• 23:37
  Speaker 1: acetylcholine from nerve cells. So it's essentially, it blocks the
• 23:41
  Speaker 1: signal from nerve cells. So all of a sudden the
• 23:43
  Speaker 1: muscle is not being told to contract anymore and it
• 23:46
  Speaker 1: just goes flaccid because that's what happens to a muscle
• 23:49
  Speaker 1: when it's not being told to contract anymore. This binding
• 23:51
  Speaker 1: and damage to the protein is essentially irreversible. The way
• 23:56
  Speaker 1: that the muscle starts contracting again is a new nerve
• 23:59
  Speaker 1: terminal grows. You actually have to wait for the nerve
• 24:02
  Speaker 1: to grow a new little process out to the muscle.
• 24:07
  Speaker 1: And nerve cells don't grow that fast, right? They last
• 24:11
  Speaker 1: a long time. They're very slow-growing cells. So it can
• 24:14
  Speaker 1: take months. That's why Botox injections and botulinum, the disease,
• 24:19
  Speaker 1: takes a long... The antitoxin can bind toxin in the
• 24:22
  Speaker 1: blood before it gets into the nerves. So it can
• 24:24
  Speaker 1: kind of stop the spread. But the paralysis that has
• 24:30
  Speaker 1: happened has happened. And you have to wait for it
• 24:33
  Speaker 1: to come back.
• 24:34
  Speaker 2: Okay. So I will say this disease is very scary.
• 24:39
  Speaker 2: It sounds very scary. It takes a long time to treat. However...
• 24:44
  Speaker 2: There are a couple, like I want to emphasize again,
• 24:46
  Speaker 2: there's a couple hundred cases of this in the US
• 24:48
  Speaker 2: every year. They are mostly in infants. So this is
• 24:51
  Speaker 2: not something that is commonly affecting most people.
• 24:57
  Speaker 1: Unless someone decides to try to kill us all.
• 25:00
  Speaker 2: Right. This is a potentially very good bioweapon due to
• 25:05
  Speaker 2: its incredibly lethalness.
• 25:07
  Speaker 1: It is. It's a great... And it's a bioweapon kind
• 25:12
  Speaker 1: of a name that actually would behave more like a
• 25:14
  Speaker 1: chemical weapon because, again, it's the toxin is more of
• 25:17
  Speaker 1: a poison than anything else. It's not like it's not
• 25:20
  Speaker 1: like this bacteria spreads from person to person. And, you know,
• 25:24
  Speaker 1: I never told I don't know if I've told you
• 25:25
  Speaker 1: this before, but my senior thesis back in college was
• 25:28
  Speaker 1: about like using bioweapons, particularly anthrax, as like as a
• 25:34
  Speaker 1: modified chemical agent. And that was like right before COVID.
• 25:37
  Speaker 1: 2001 and, and when that anthrax thing happened and like
• 25:41
  Speaker 1: my thesis advisor got questioned by the CIA or FBI
• 25:44
  Speaker 1: or something like it was a whole thing. So anyway,
• 25:47
  Speaker 1: I find this stuff really fascinating and it's absolutely terrifying
• 25:53
  Speaker 1: as a bioweapon because of the potency of this thing, right?
• 25:57
  Speaker 1: Botulinum toxin is the most toxic substance, period, full stop.
• 26:00
  Speaker 1: It is the thing. Back of the envelope math, if
• 26:04
  Speaker 1: you had four pounds of Botox, you could kill everyone
• 26:10
  Speaker 1: on Earth with that if you could aerosolize it appropriately
• 26:13
  Speaker 1: and get them to breathe it in.
• 26:14
  Speaker 2: Please tell me it is not that easy to aerosolize.
• 26:18
  Speaker 1: Well, I can tell you that the Aum Shinrikyo cult
• 26:22
  Speaker 1: tried to weaponize it and failed, which is good. So
• 26:25
  Speaker 1: it must be a little hard. They switched to sarin gas,
• 26:28
  Speaker 1: just old-fashioned sarin gas, as you know, much less toxic.
• 26:33
  Speaker 1: But Iraq actually produced around 19,000 liters of concentrated toxin,
• 26:40
  Speaker 1: which was appropriately sized for bombs and missiles. I don't
• 26:42
  Speaker 1: believe there's any evidence that it was used in warfare,
• 26:46
  Speaker 1: but geez, this would be bad. This would be bad.
• 26:50
  Speaker 2: Okay. So that's great. Let's pause on that. And we're
• 26:56
  Speaker 2: going to move next to talking about why we want
• 27:00
  Speaker 2: to inject this into our face and elsewhere. But first,
• 27:04
  Speaker 2: let's take a quick break.
• 27:10
  Speaker 1: We're back. We've talked about the scariest toxin known to man,
• 27:14
  Speaker 1: the most toxic substance in the world, in the universe
• 27:18
  Speaker 1: as far as we know at this point in time.
• 27:21
  Speaker 1: So let's talk about where we can stick it in
• 27:23
  Speaker 1: our bodies and what good it will be. So I
• 27:27
  Speaker 1: think the first thing, the unofficial slogan of wellness, actually,
• 27:32
  Speaker 1: the dose makes the poison. There's perhaps no better place
• 27:36
  Speaker 1: than botulinum toxin. to talk about this because the dose
• 27:40
  Speaker 1: are so small. So Emily, walk me through, you know,
• 27:45
  Speaker 1: if you go to an office and you're going to
• 27:48
  Speaker 1: get some Botox, they'll get out a little vial of Botox,
• 27:51
  Speaker 1: which the typical vial has a hundred units in it.
• 27:55
  Speaker 1: So what are we talking, like, what are we talking,
• 27:57
  Speaker 1: what's in that vial and can it kill everyone on
• 27:59
  Speaker 1: earth or not?
• 28:00
  Speaker 2: Right. So a hundred unit vial has 0.73% nanograms of toxin.
• 28:10
  Speaker 2: So a nanogram is one billionth of a gram, I believe.
• 28:20
  Speaker 2: If you're looking for a lethal IV dose, if you
• 28:23
  Speaker 2: were going to sort of give someone an IV of
• 28:24
  Speaker 2: this in hopes of killing them, you would need about
• 28:28
  Speaker 2: one nanogram per kilogram. So for someone who's like a
• 28:31
  Speaker 2: 70 kilogram adult, you basically need to inject them with
• 28:34
  Speaker 2: a hundred vials of toxin, like right into their veins.
• 28:39
  Speaker 2: If you are fixing the little teeny lines on your forehead,
• 28:44
  Speaker 2: you would typically use about 20 units and they would
• 28:48
  Speaker 2: be injected into a muscle and not a vein. So
• 28:50
  Speaker 2: it would be a tiny, tiny, tiny, tiny fraction of
• 28:53
  Speaker 2: what you would need to kill somebody.
• 28:57
  Speaker 1: The units of Botox have An interesting story. You might
• 29:02
  Speaker 1: assume that the units are just like some measure of
• 29:04
  Speaker 1: the weight or the volume or something like that. But no,
• 29:06
  Speaker 1: one unit is defined as the amount of Botox that
• 29:11
  Speaker 1: you would need to inject into the belly of a
• 29:13
  Speaker 1: mouse to kill a mouse. So when you're getting 20
• 29:16
  Speaker 1: units in your forehead, that's enough to kill 20 mice
• 29:21
  Speaker 1: if you injected it into their bellies. But don't do that.
• 29:24
  Speaker 2: I feel like the other unofficial slogan in this podcast
• 29:26
  Speaker 2: could be like, wow, we don't treat mice great.
• 29:29
  Speaker 1: We do not treat my scrapes, but we appreciate their sacrifice.
• 29:35
  Speaker 2: So the amount that you're getting is very small. but
• 29:39
  Speaker 2: actually the sort of reason that this botulism might work
• 29:46
  Speaker 2: really does connect back to the reasons that it was
• 29:50
  Speaker 2: also potentially very, very dangerous. So the toxin kind of
• 29:55
  Speaker 2: stays where you put it. It's not reversible. It paralyzes
• 30:00
  Speaker 2: muscles and it wears off in about three months. So
• 30:04
  Speaker 2: if you've got a lot of that, you know, eating sausage,
• 30:06
  Speaker 2: you're dead. But if you get a little bit of
• 30:09
  Speaker 2: it in a syringe in the muscles in your face
• 30:12
  Speaker 2: or somewhere else, it actually is a sort of dose
• 30:16
  Speaker 2: temporary on-off switch effect. for one tiny muscle. And that
• 30:22
  Speaker 2: is what makes this such a useful medication. And that's
• 30:25
  Speaker 2: why this guy Kerner was basically right when he speculated
• 30:30
  Speaker 2: in 1820 that, you know, one day we might use
• 30:33
  Speaker 2: his sausage poison for something good.
• 30:36
  Speaker 1: Yeah, super smart guy. And it took 150 years for
• 30:40
  Speaker 1: us to actually, you know, profit from that observation. We're
• 30:45
  Speaker 1: in the 1970s now, and an ophthalmologist named Alan Scott
• 30:50
  Speaker 1: wanted a non-surgical fix for strabismus, which is the medical
• 30:54
  Speaker 1: term for crossed eyes, and thought, you know, there's probably
• 30:58
  Speaker 1: a muscle that's kind of pulling this eye out of alignment.
• 31:01
  Speaker 1: And if we could paralyze that muscle, then we don't
• 31:04
  Speaker 1: have to do surgery. And he came up with the
• 31:06
  Speaker 1: idea of using purified botulinum toxin to do it. He
• 31:10
  Speaker 1: sold that. He tested that. He showed it. worked. I
• 31:15
  Speaker 1: sold the technology to Allergan reportedly for very little money.
• 31:22
  Speaker 1: And we're very sorry, Alan Scott, because I think he'd
• 31:25
  Speaker 1: be really, really rich if he had recognized what he
• 31:29
  Speaker 1: had in his hands there. It took a while to
• 31:31
  Speaker 1: go through FDA and get approved and whatnot, but it
• 31:34
  Speaker 1: was approved in 1989 for two indications, strabismus, cross-dyes, and blepharospasm,
• 31:41
  Speaker 1: which is an involuntary twitching of the eyelid. So two
• 31:45
  Speaker 1: things that kind of make a logic. And that was
• 31:52
  Speaker 1: how it all got started, but it didn't take long, obviously,
• 31:55
  Speaker 1: for people to say, oh, wait, if we have an
• 31:58
  Speaker 1: on-off switch for a muscle, what other muscles in the
• 32:02
  Speaker 1: body might be firing too much? What other things could
• 32:05
  Speaker 1: we turn off? And it turns out there's an awful lot.
• 32:09
  Speaker 2: And once, of course, once something is FDA approved for this,
• 32:11
  Speaker 2: then it becomes much easier to sort of start experimenting
• 32:14
  Speaker 2: and using it for different things in a kind of
• 32:16
  Speaker 2: off-label way. And it has turned out there's a pretty
• 32:22
  Speaker 2: large number of uses, which I think are worth running
• 32:26
  Speaker 2: through a bit. And then, yes, we will talk about
• 32:28
  Speaker 2: your face. So we started with the strebismus and can you,
• 32:33
  Speaker 2: how do you say this word?
• 32:33
  Speaker 1: Blepharospasm. Blepharospasm. Blepharospasm.
• 32:38
  Speaker 2: This has also been used for spasticities after strokes. It's
• 32:43
  Speaker 2: been used some in cerebral palsy. It is used often
• 32:47
  Speaker 2: in excessive sweating. So people who have excessive underarm sweating
• 32:52
  Speaker 2: can get Botox injections in their underarm, which actually sounds
• 32:55
  Speaker 2: really painful, but I think is very effective at reducing
• 33:00
  Speaker 2: excessive sweating.
• 33:02
  Speaker 1: And that's because sweat glands also... Are signaled with acetylcholine.
• 33:06
  Speaker 1: So it's the same mechanism.
• 33:08
  Speaker 2: Signaling, but it's not a muscle.
• 33:09
  Speaker 1: Yeah.
• 33:10
  Speaker 2: Overactive bladder, spasmic dysphonia, which is a vocal issue. It's
• 33:15
  Speaker 2: actually the vocal issue that RFK has. So there are
• 33:19
  Speaker 2: many different places where muscles are firing when they shouldn't,
• 33:23
  Speaker 2: and this is just a way to turn them off.
• 33:26
  Speaker 2: The big one, though, I want to talk about is migraine,
• 33:29
  Speaker 2: because this is the indication that I think is the most...
• 33:35
  Speaker 2: probably the most common medical use. A lot of people
• 33:38
  Speaker 2: struggle with migraine and where we have reasonably good data.
• 33:44
  Speaker 1: Right. And it's not one that you would necessarily think
• 33:47
  Speaker 1: of because migraine is a very complex syndrome. There's clear
• 33:55
  Speaker 1: brain stuff going on with migraine. Functional MRI shows these
• 33:59
  Speaker 1: spreading depressions of migraine syndromes and things like that. So
• 34:04
  Speaker 1: It's not like, oh, this is clearly a muscle thing. Nevertheless,
• 34:07
  Speaker 1: we've got, you know, reasonable randomized controlled trial data to
• 34:11
  Speaker 1: suggest that Botox works for at least for chronic migraine.
• 34:15
  Speaker 1: These are trials called the PREEMPT trials, which were funded
• 34:19
  Speaker 1: by the pharmaceutical companies. But PREEMPT enrolled 1,384 adults and
• 34:26
  Speaker 1: randomized them to Botox versus placebo injections and Emily, I'm
• 34:31
  Speaker 1: sure you'll have a comment on that. But before we
• 34:33
  Speaker 1: get there, so the doctors injected seven like pre-specified sites
• 34:37
  Speaker 1: in the head and neck. They also injected, they had
• 34:40
  Speaker 1: the option to inject sites based on the patient's pain.
• 34:42
  Speaker 1: So if they described like, oh, it, you know, my
• 34:44
  Speaker 1: migraines hurt right here or something, you know, right in
• 34:46
  Speaker 1: my upper forehead, they did have the ability to sort
• 34:49
  Speaker 1: of follow the pain. And the primary outcome here was
• 34:52
  Speaker 1: headache days per month at 24 weeks in the major trials,
• 34:58
  Speaker 1: combining all the data. The Botox group had 8.4 fewer
• 35:02
  Speaker 1: headache days per month. The placebo group had 6.6 fewer
• 35:07
  Speaker 1: headache days per month. So that's the difference there is
• 35:10
  Speaker 1: about 1.8 headache days a month. So that's statistically significant,
• 35:15
  Speaker 1: although maybe it's not as 8.4 sounds great. I definitely
• 35:20
  Speaker 1: want 8.4 fewer days, but 1.8 fewer days on the
• 35:24
  Speaker 1: margins compared to placebo maybe doesn't sound as impressive.
• 35:26
  Speaker 2: What do you think? Yeah. I mean, I think this
• 35:28
  Speaker 2: is a really interesting trial. It is an example of
• 35:32
  Speaker 2: a trial where I find the placebo effect quite impressive.
• 35:37
  Speaker 2: I mean, that's really very large. placebo effect. Not inconsistent
• 35:42
  Speaker 2: with some of the places we most commonly see placebo effects,
• 35:44
  Speaker 2: which is when we're talking about pain, when we're talking
• 35:47
  Speaker 2: about things where there's a sort of perception aspect. There's
• 35:53
  Speaker 2: also an issue with this trial, which is that it's
• 35:57
  Speaker 2: basically impossible to blind it. So yes, they were doing
• 36:01
  Speaker 2: injections of saline, but as anyone who has had Botox
• 36:04
  Speaker 2: will tell you, you can tell if your face is
• 36:07
  Speaker 2: moving or not moving. And so there's, you know, if anything,
• 36:12
  Speaker 2: sort of 1.8 feels like an overstatement of the actual
• 36:16
  Speaker 2: treatment effect. But on the other hand, yeah, I've always
• 36:20
  Speaker 2: looked so it's like, okay, so it's, it's 1.8 over placebo,
• 36:23
  Speaker 2: but it is 8.4 in the sense that when you
• 36:26
  Speaker 2: get this, you are getting both the placebo effect and
• 36:29
  Speaker 2: the real effect. And so, and I'm not sure that
• 36:32
  Speaker 2: people would get as much placebo effect if you didn't
• 36:34
  Speaker 2: tell them that they were getting the placebo effect. So,
• 36:37
  Speaker 2: so I don't really know, like from a decision standpoint,
• 36:40
  Speaker 2: this is potentially quite large if you are a person
• 36:44
  Speaker 2: struggling with migraine. Yeah. Yeah.
• 36:47
  Speaker 1: And I mean, for what it's worth, it's entered into
• 36:51
  Speaker 1: common practice. Like headache clinics all around the country are
• 36:55
  Speaker 1: injecting Botox for this. I don't know that I could
• 36:58
  Speaker 1: say it's 100% standard of care, but it's quite common.
• 37:02
  Speaker 1: It's pretty common. Yeah. I did find some weird uses
• 37:09
  Speaker 1: for Botox, some experimental uses. One that is sort of
• 37:13
  Speaker 1: interesting is to prevent atrial fibrillation after cardiac surgery. There's
• 37:17
  Speaker 1: some CT surgeons who are injecting Botox in the epicardial
• 37:20
  Speaker 1: fat pads around the heart. The idea being kind of
• 37:23
  Speaker 1: calm down the nerves there, and maybe they don't angry
• 37:25
  Speaker 1: up the heart after surgery. Atrial fibrillation, abnormal heart rhythm
• 37:29
  Speaker 1: after surgery can be a problem. The results on this
• 37:32
  Speaker 1: are mixed. And I also found some small trials on
• 37:37
  Speaker 1: using Botox for premature ejaculation.
• 37:41
  Speaker 2: Because as soon as you have a medication, the question is,
• 37:44
  Speaker 2: how can we improve the penis? Let's get focused, guys.
• 37:48
  Speaker 2: We're not focused enough on men's sexual pleasure. Just as
• 37:52
  Speaker 2: a society, we are not focused enough. Let's get focused.
• 37:55
  Speaker 1: Thank you, Emily. You're very brave for saying that. I
• 38:00
  Speaker 1: think sticking needles into your penis... is a natural cure
• 38:04
  Speaker 1: for premature ejaculation. I don't know. I'm not actually sure
• 38:07
  Speaker 1: what the timing of the needles is here. I think
• 38:09
  Speaker 1: if you time it right, you're going to be just fine.
• 38:14
  Speaker 1: Hold on, honey.
• 38:16
  Speaker 2: Moving on. Okay. Okay. What about depression? Yeah.
• 38:25
  Speaker 1: Depression's an interesting use here. Cards on the table. I
• 38:29
  Speaker 1: believe this could work.
• 38:31
  Speaker 2: So, okay, the hypothesis for why this– there's like a
• 38:35
  Speaker 2: hypothesis for why this might work for depression, which is
• 38:39
  Speaker 2: facial feedback. The idea is like if you can't frown,
• 38:42
  Speaker 2: maybe you feel less sad. And actually there is, although
• 38:44
  Speaker 2: in some ways that sounds totally ridiculous, actually there is
• 38:48
  Speaker 2: a fair amount of evidence in psychology that like you–
• 38:52
  Speaker 2: in sort of social psychology that like forcing yourself to
• 38:55
  Speaker 2: smile makes you happier. So there's like a sort of
• 39:00
  Speaker 2: feedback because there's like a feedback loop there. And so
• 39:05
  Speaker 2: it's not as totally ridiculous as it seems. There are
• 39:09
  Speaker 2: some small RCTs. The effects here to me read much
• 39:14
  Speaker 2: too large.
• 39:17
  Speaker 1: To be real. What effects are you talking about?
• 39:19
  Speaker 2: So the sort of pooled analysis of RCTs, which ends
• 39:22
  Speaker 2: up being about 150 people, 160 people total, found a 54%
• 39:24
  Speaker 2: response rate versus only 10% on placebo. Again, difficult to blind.
• 39:33
  Speaker 2: And then in some of the larger follow-ups, it's much smaller.
• 39:38
  Speaker 2: So there's kind of like, this feels like we could
• 39:41
  Speaker 2: really afford to have a much larger trial to try
• 39:45
  Speaker 2: to nail it down. I don't know. But you're more optimistic.
• 39:48
  Speaker 1: I don't know. I sort of agree. The physiologic feedback
• 39:52
  Speaker 1: of depression and anxiety, I think, is very real. We
• 39:54
  Speaker 1: have reasonable data, for example, in anxiety that taking beta blockers,
• 39:57
  Speaker 1: which just kind of reduce your heart rate and stuff,
• 40:01
  Speaker 1: makes people feel a little bit better. And it's like,
• 40:03
  Speaker 1: they're not anti-anxiety med. They don't do anything in the brain,
• 40:06
  Speaker 1: but they just like, if you don't feel your heart
• 40:08
  Speaker 1: racing as much, you just kind of, it, it breaks
• 40:10
  Speaker 1: some cycles. And so I sort of believe it, you know,
• 40:13
  Speaker 1: if it's harder to frown or, you know, it's harder
• 40:15
  Speaker 1: to make that face, maybe you feel better. And I mean, Emily,
• 40:18
  Speaker 1: I just want to speak out again for men here.
• 40:21
  Speaker 1: Like when we tell you, Hey, you know, you should
• 40:24
  Speaker 1: smile more. Uh, that is just a therapeutic bit of advice.
• 40:29
  Speaker 2: Um, you know, it's just like you're, you're concerned about
• 40:32
  Speaker 2: our mental health.
• 40:33
  Speaker 1: I just want you to be happy. You'd be, you know, um,
• 40:36
  Speaker 1: so smile more ladies. Okay. That's a joke. All right. Um,
• 40:44
  Speaker 1: let's remember facial feedback. We'll come back to it. But
• 40:50
  Speaker 1: all of that was, here's a muscle that's like doing
• 40:53
  Speaker 1: something that we don't want it to do. Now it's
• 40:55
  Speaker 1: time to move on to the muscles that are doing
• 40:58
  Speaker 1: what they are supposed to do, which is to move
• 40:59
  Speaker 1: your face around. We don't like it. We don't like that.
• 41:03
  Speaker 1: So let's talk about the face. And Em, did you
• 41:06
  Speaker 1: see how we sort of figured out that like, ooh,
• 41:11
  Speaker 1: this might work for wrinkles.
• 41:13
  Speaker 2: Yeah, it's like many, so this story is like many
• 41:16
  Speaker 2: of these kinds of things in medicine where it's basically
• 41:20
  Speaker 2: a side effect. So they're treating, there's an ophthalmologist, Jean Caruthers,
• 41:24
  Speaker 2: she's treating people for blepharospasm. And people notice, hey, like
• 41:28
  Speaker 2: my frown lines look better. Her husband, conveniently a dermatologist,
• 41:36
  Speaker 2: and they published this- And you fast forward 10 years,
• 41:42
  Speaker 2: the FDA approved this for the, I didn't know this
• 41:46
  Speaker 2: was what they were called, but these are globular lines,
• 41:49
  Speaker 2: which I believe are the lines right between your eyebrows,
• 41:53
  Speaker 2: which I now learned are called the angry 11s. Mm-hmm.
• 41:58
  Speaker 1: Yeah, I love that. Yeah, so I can do it.
• 42:00
  Speaker 1: Your skin is so much better than mine.
• 42:02
  Speaker 2: No, no, I have them. It's just you're not zoomed
• 42:04
  Speaker 2: in enough. But people are really like, this is a
• 42:09
  Speaker 2: really successful venture. This is a $ 13 billion market. I
• 42:15
  Speaker 2: will say this is by far the most common question
• 42:19
  Speaker 2: I get from people in my work in pregnancy and parenting,
• 42:24
  Speaker 2: which is, can I get Botox while I'm breastfeeding? People
• 42:26
  Speaker 2: are like, It wears off after three months. I got
• 42:29
  Speaker 2: it before I got pregnant. It's been nine months. My
• 42:31
  Speaker 2: dermatologist wouldn't shoot this in my face while I was pregnant.
• 42:34
  Speaker 2: Now I'm breastfeeding. I'm like desperate. I just pushed the
• 42:36
  Speaker 2: baby out. Like, can I get the Botox person in
• 42:39
  Speaker 2: the delivery room to fix my face right now?
• 42:44
  Speaker 1: What do you tell them?
• 42:45
  Speaker 2: Yeah, it's fine. I mean, so, so it doesn't, uh,
• 42:47
  Speaker 2: we actually have some pretty good evidence on, on breastfeeding.
• 42:49
  Speaker 2: It doesn't pass at high rates into, or really at
• 42:52
  Speaker 2: all into the breast milk. So it's, it's fine to
• 42:55
  Speaker 2: get it. I, first I tell them your face looks great.
• 42:58
  Speaker 2: And I don't think you need to do this. And
• 42:59
  Speaker 2: then I explain that it's fine to do it.
• 43:01
  Speaker 1: And then they're like, yeah, yeah, yeah. That's very nice. Yeah.
• 43:04
  Speaker 1: I mean, I think biologically that all makes sense. I
• 43:07
  Speaker 1: will say I wouldn't be surprised. Doctors get real skittish
• 43:10
  Speaker 1: around pregnancy and breastfeeding. So I wouldn't be surprised. They
• 43:12
  Speaker 1: won't do it.
• 43:13
  Speaker 2: Actually, there's pretty good evidence it would be fine also
• 43:15
  Speaker 2: in pregnancy because when people get botulism poisoning during pregnancy,
• 43:19
  Speaker 2: it doesn't affect the fetus. But no one will do
• 43:24
  Speaker 2: this during pregnancy.
• 43:24
  Speaker 1: Yeah. We're a little too risk averse for that.
• 43:28
  Speaker 2: Sorry. Okay.
• 43:29
  Speaker 1: So going through Botox for the face, the use here
• 43:34
  Speaker 1: is for dynamic wrinkles, right? It only works for the
• 43:37
  Speaker 1: lines and creases that change when your muscles move around.
• 43:41
  Speaker 1: And you can see what those are. But of course,
• 43:42
  Speaker 1: we all have lines and wrinkles that just stay. Not
• 43:44
  Speaker 1: we all. I have lines and wrinkles that stay no
• 43:47
  Speaker 1: matter what, that are just due to skin aging. Won't
• 43:51
  Speaker 1: work for that, but there are plenty of other cosmetic
• 43:53
  Speaker 1: products like fillers and things that you can inject into
• 43:56
  Speaker 1: those to fill them out. And maybe we should do
• 43:58
  Speaker 1: a whole episode on the other stuff you can inject
• 44:00
  Speaker 1: into your face. But Botox, we're talking about dynamic lines
• 44:03
  Speaker 1: and wrinkles. Boy, there are a bunch of brands out there.
• 44:05
  Speaker 2: So many.
• 44:07
  Speaker 1: I know. It's really expanded. I listed four. Em, have
• 44:10
  Speaker 1: you come across these? Have people asked you about these?
• 44:13
  Speaker 2: People just like this Botox is like Kleenex. Botox is
• 44:17
  Speaker 2: the major brand. People refer to everything as Botox. There's Dysport,
• 44:22
  Speaker 2: there's Zmovin, there's Daxify. There's all this different stuff. When
• 44:26
  Speaker 2: people ask about or talk about it, they just talk
• 44:28
  Speaker 2: about Botox, but like the details of these things have
• 44:31
  Speaker 2: slightly different units. They may be, some of them might
• 44:34
  Speaker 2: last longer, you know, it's all the same basic idea. Yeah. Yeah.
• 44:39
  Speaker 1: And I will say I, I dug it like, um,
• 44:42
  Speaker 1: You know, Daxify is supposed to like last longer. And
• 44:46
  Speaker 1: I think Dysport is the one they market as starting
• 44:48
  Speaker 1: quicker because Botox actually doesn't work right away. It takes,
• 44:51
  Speaker 1: you know, a few days to a week to sort
• 44:53
  Speaker 1: of kick in and paralyze the muscle. Actually, the data
• 44:55
  Speaker 1: is not terribly supportive of that. Like, I think this
• 44:58
  Speaker 1: is a lot of branding and marketing and they all
• 45:01
  Speaker 1: kind of work similarly. So, you know.
• 45:04
  Speaker 2: You tell somebody this works faster and then you get
• 45:06
  Speaker 2: the placebo effect for a couple of days and then
• 45:08
  Speaker 2: it really does work. And so it's like, whatever. Yeah.
• 45:10
  Speaker 1: So let's look at some pictures. And we'll put this
• 45:15
  Speaker 1: in YouTube for those of you who are watching the video.
• 45:17
  Speaker 1: But Emily, I'll ask you to describe this because I
• 45:20
  Speaker 1: did find one really famous. So when we ask like,
• 45:23
  Speaker 1: does Botox work? You know, most of wellness actually is like, ooh,
• 45:26
  Speaker 1: this weird health trend or wellness trend. Like, is it real? Like,
• 45:29
  Speaker 1: does it actually work? But okay. Botox for wrinkles works.
• 45:35
  Speaker 1: It does work. There's not much controversy here. You can
• 45:38
  Speaker 1: see it all around you, especially if you're of a
• 45:40
  Speaker 1: certain age. So the question really here isn't efficacy, but
• 45:44
  Speaker 1: the question surrounding that. And one of the big questions is,
• 45:47
  Speaker 1: is there such a thing as preventative Botox? Emily, you're
• 45:51
  Speaker 1: an economist. Do you think there's an economic motivation for
• 45:56
  Speaker 1: people to argue for preventative Botox? Just asking.
• 45:59
  Speaker 2: I do. Baby Botox, yes. I mean, look, one of
• 46:03
  Speaker 2: the problems with something like Botox is you're limited to...
• 46:09
  Speaker 2: a time period in which people have wrinkles and also
• 46:11
  Speaker 2: still care about how they look. So that's actually like,
• 46:14
  Speaker 2: you know, I mean, of course everyone cares about how
• 46:15
  Speaker 2: they look, but like at some point it just is like, okay,
• 46:18
  Speaker 2: most people are going to be like, you know what?
• 46:19
  Speaker 2: I'm going to age, age gracefully. So let's say, you know,
• 46:22
  Speaker 2: you start, maybe it's like people from 45 to like 55,
• 46:25
  Speaker 2: you know, that's, that's not that long. But if only
• 46:28
  Speaker 2: you could push that, like, could we get a 17
• 46:30
  Speaker 2: year old and be like, Hey, get your Botox in
• 46:33
  Speaker 2: before it's a problem, you know, and then you've got
• 46:36
  Speaker 2: them and then you tell them what's great about preventative
• 46:38
  Speaker 2: Botox from a marketing standpoint is you get people in
• 46:41
  Speaker 2: and then you tell them if you stop doing it,
• 46:44
  Speaker 2: then it, it gets worse. Now you're like sucked in,
• 46:46
  Speaker 2: which I think is just a total also.
• 46:48
  Speaker 1: Totally made up. That seems BS to me. Yeah.
• 46:51
  Speaker 2: But they really, this has pushed like younger and younger
• 46:54
  Speaker 2: and younger.
• 46:55
  Speaker 1: Totally.
• 46:56
  Speaker 2: And for, you know, capital because of capitalism, Perry.
• 47:00
  Speaker 1: Yeah, because of capitalism. There's a famous identical twin study
• 47:03
  Speaker 1: that gets trotted out whenever they talk about preventative Botox.
• 47:07
  Speaker 1: This is from the Archives of Facial Plastic Surgery in 2006. Em,
• 47:10
  Speaker 1: I'm going to show you a picture, and I think
• 47:12
  Speaker 1: I did it the right way. So I hid who
• 47:16
  Speaker 1: got what here. But if you look at these pictures,
• 47:18
  Speaker 1: you can see two identical twins. One's on the left,
• 47:22
  Speaker 1: one's on the right. One had 13 years of regular Botox.
• 47:26
  Speaker 1: One did not. And talk to me, which one do
• 47:29
  Speaker 1: you think is which?
• 47:31
  Speaker 2: I think the one on the right is the one
• 47:32
  Speaker 2: with the Botox, like on my right. So that's D, E,
• 47:37
  Speaker 2: and F. I think she's the Botox one. Am I right? Yep.
• 47:40
  Speaker 1: You got it right. For those of you just listening
• 47:42
  Speaker 1: to this, yeah. I love a good identical twin study. Obviously,
• 47:47
  Speaker 1: it's N of two. The argument made by the researchers
• 47:51
  Speaker 1: and marketers about this is like, oh, look, 13 years
• 47:54
  Speaker 1: of Botox and doesn't she look great? Actually, they're both
• 47:56
  Speaker 1: very pretty. But that said, this is not randomized. Just
• 48:01
  Speaker 1: because you're identical twins doesn't mean you're behaving in exactly
• 48:05
  Speaker 1: the same way. And in fact, if one identical twin
• 48:08
  Speaker 1: is committed to getting Botox for 13 years, you might
• 48:10
  Speaker 1: expect that she engages in other behaviors that might be
• 48:14
  Speaker 1: different from her identical twins, such as, you know, wearing
• 48:17
  Speaker 1: more sun protection or moisturizing more, any number of, you know,
• 48:21
  Speaker 1: skin health promoting things. Right. So I don't, I don't
• 48:24
  Speaker 1: see why this is like such compelling evidence.
• 48:26
  Speaker 2: This doesn't tell you whether you need to do Botox
• 48:28
  Speaker 2: for 13 years. This just tells you that Botox prevents like,
• 48:32
  Speaker 2: like we don't know if, what if she did it
• 48:33
  Speaker 2: for six months before these pictures? Like, I don't know,
• 48:37
  Speaker 2: you know, this isn't whatever.
• 48:39
  Speaker 1: Yeah, I don't think you need Botox before you have wrinkles.
• 48:43
  Speaker 1: It works fine when you have wrinkles.
• 48:45
  Speaker 2: There's all kinds of other weird stuff. People like to
• 48:47
  Speaker 2: inject it in their neck to make it longer.
• 48:51
  Speaker 1: Oh, I have a picture of that.
• 48:52
  Speaker 2: Make your neck longer.
• 48:53
  Speaker 1: How would that even work? For you. Okay, this is
• 48:56
  Speaker 1: trapezius fibrosis. Botox. So your trapezius is the sort of strong,
• 49:01
  Speaker 1: like if you shrug your shoulders, that's the muscle you
• 49:04
  Speaker 1: feel contracting that brings your shoulders up towards your neck.
• 49:07
  Speaker 1: And if you really work out that muscle group, it
• 49:10
  Speaker 1: can hypertrophy and you get kind of like a triangle
• 49:13
  Speaker 1: shape going down from your neck to your shoulders. I
• 49:16
  Speaker 1: think in men, you know, many men are kind of
• 49:17
  Speaker 1: actually going for this, but women might feel, Emily's like,
• 49:22
  Speaker 1: Emily's checking right now.
• 49:23
  Speaker 2: Do I have that? Like I have that right now?
• 49:26
  Speaker 1: Well, if you did and you didn't like it, you
• 49:29
  Speaker 1: could inject your trapezius to paralyze at least parts of them.
• 49:34
  Speaker 1: And that would sort of smooth out the line there.
• 49:37
  Speaker 1: And I'll put up the picture. Em, what do you
• 49:39
  Speaker 1: think of this before or after?
• 49:40
  Speaker 2: Yeah, definitely you can see this person has a smoother
• 49:45
  Speaker 2: shoulder after this.
• 49:46
  Speaker 1: Yeah, does it, Matt, like, aesthetically, I don't care. Women
• 49:51
  Speaker 1: are more critical than men about how women look.
• 49:54
  Speaker 2: I don't, I, like, I can barely tell that this, like,
• 49:58
  Speaker 2: if I saw this person in reality, there is literally
• 50:02
  Speaker 2: no chance that I would be able to notice this Yeah.
• 50:06
  Speaker 1: I mean, but to be fair, you know, a lot
• 50:09
  Speaker 1: of these things are for the person themselves, right? Like,
• 50:12
  Speaker 1: like if you feel more confident, if you, if you
• 50:15
  Speaker 1: feel prettier, you'll like be prettier or more handsome or
• 50:18
  Speaker 1: whoever's doing this, right? Like there is that part of it.
• 50:21
  Speaker 1: And I appreciate that. Um, the newest, like sort of
• 50:27
  Speaker 1: off target Botox thing that I saw online was, um,
• 50:31
  Speaker 1: was jawline slimming. I'll put up another picture. hear of
• 50:35
  Speaker 1: a before and after? Do you want to describe?
• 50:37
  Speaker 2: Honestly, I cannot tell.
• 50:39
  Speaker 1: You're not sure who's who? Or is this the same person?
• 50:42
  Speaker 2: Are these identical twins or is this the same person?
• 50:45
  Speaker 1: No, no, no. Same person before and after. Sorry. Yeah.
• 50:47
  Speaker 2: She looks literally the same. It's like she added earrings
• 50:49
  Speaker 2: in one picture.
• 50:51
  Speaker 1: The power of hoop earrings. The idea, at least here, well,
• 50:57
  Speaker 1: I'll tell you what they did. You're injecting the masseter muscle,
• 51:01
  Speaker 1: which is going to help squeeze your jaw when you're chewing.
• 51:07
  Speaker 1: And so the bigger your master gets it, it might
• 51:10
  Speaker 1: make your jaw look a little more square and less pointy.
• 51:14
  Speaker 1: Can I prompt your brain to see that in this?
• 51:16
  Speaker 2: The one with the earrings is after.
• 51:19
  Speaker 1: Yeah, that's right. That's right. So they're sort of slackening
• 51:23
  Speaker 1: this muscle here to give a slightly more, I don't know,
• 51:26
  Speaker 1: maybe more delicate appearance to the lower face. I think
• 51:28
  Speaker 1: this one is very subtle. And I will say that
• 51:32
  Speaker 1: there has been some evidence of actually like thinning of
• 51:35
  Speaker 1: the jawbone itself, secondary deaths, because like you muscles that
• 51:40
  Speaker 1: you the muscles that attach to bones and like move
• 51:42
  Speaker 1: things that are important. And I think I might put
• 51:45
  Speaker 1: the trapezius muscles here, too. like generally like you want them,
• 51:48
  Speaker 1: like they're doing something, doing something that are, that are
• 51:51
  Speaker 1: pretty good for you. Like the muscles in our face
• 51:53
  Speaker 1: are important for facial expression, you know, chewing.
• 51:56
  Speaker 2: So I want to get into that because I think
• 51:57
  Speaker 2: it is worth talking about some of the risks and
• 51:59
  Speaker 2: potential downsides of. Okay. Yeah, yeah, yeah.
• 52:01
  Speaker 1: What are the risks?
• 52:02
  Speaker 2: Yeah.
• 52:02
  Speaker 1: Talk to me.
• 52:02
  Speaker 2: So there's a sort of basic risk associated with injecting
• 52:06
  Speaker 2: things into yourself, bruising, infection. You can get asymmetry if
• 52:11
  Speaker 2: it's done poorly. And so, and, and of course it will, fade,
• 52:16
  Speaker 2: but like over a period of months. So if you,
• 52:19
  Speaker 2: if somebody like overdoes one side of your face and
• 52:21
  Speaker 2: then it's like droopy, you got to wait three months
• 52:23
  Speaker 2: for that to be, uh, for that to be fixed.
• 52:26
  Speaker 1: This stuff is incredibly potent, right? Like, so if you
• 52:29
  Speaker 1: inject it slightly wrong, you know, and all of a sudden,
• 52:31
  Speaker 1: like you have half a droopy eyelid for, for, for
• 52:34
  Speaker 1: three months, because I don't want to go an episode
• 52:36
  Speaker 1: without a Star Trek reference. I'm going to put up
• 52:37
  Speaker 1: a picture of what is known as Spock brow. This
• 52:42
  Speaker 1: is what happens when you're, um, you know, you're paralyzing the,
• 52:45
  Speaker 1: muscles above the eyebrows. And in general, when you're injecting
• 52:49
  Speaker 1: the forehead, the people who are doing this are trying
• 52:52
  Speaker 1: to maintain your ability to lift your eyebrows because it's
• 52:55
  Speaker 1: nice to kind of express surprise. If they don't and
• 52:59
  Speaker 1: one gets paralyzed, but the other can still go up,
• 53:02
  Speaker 1: you get this look. For those of you on video,
• 53:04
  Speaker 1: this is the Spock brow look, which I think is cool,
• 53:08
  Speaker 1: but some people think it's a side effect.
• 53:10
  Speaker 2: People don't like that. So there's also some evidence that
• 53:15
  Speaker 2: this same kind of mechanism, the sort of like almost
• 53:19
  Speaker 2: like frozen face mechanism might actually make you worse at
• 53:24
  Speaker 2: reading emotions on other people. So part of how we
• 53:28
  Speaker 2: recognize emotions is by kind of mimicking the faces around us.
• 53:32
  Speaker 2: So if someone looks sad, it like causes us to
• 53:35
  Speaker 2: kind of our face to get more sad and then
• 53:37
  Speaker 2: to like echo that sadness or happiness. And people who
• 53:42
  Speaker 2: use Botox a lot, actually, there's a little bit of
• 53:44
  Speaker 2: evidence that they rate other faces differently and maybe have
• 53:49
  Speaker 2: more trouble recognizing emotions, like a little bit of neuroimaging
• 53:53
  Speaker 2: for that. So, I mean, I don't know that this
• 53:55
  Speaker 2: is like very strong evidence, but I think it's interesting.
• 54:02
  Speaker 1: I mean … I, again, I, I think it's fascinating
• 54:05
  Speaker 1: that like we mimic people and we, we empathize with
• 54:09
  Speaker 1: them through our own bodies. Like that's kind of neat
• 54:12
  Speaker 1: if it's true. It's, it's, it's, that's interesting to me.
• 54:15
  Speaker 1: I mean, the flip side of it is also true,
• 54:17
  Speaker 1: which is like in your relationships, right? Like if I'm
• 54:21
  Speaker 1: really upset about something and my partner has a bunch
• 54:24
  Speaker 1: of Botox and can't make the, like, I'm sympathizing with
• 54:27
  Speaker 1: you face, like, could that potentially, you know, just like.
• 54:31
  Speaker 1: be bad for the relationship.
• 54:33
  Speaker 2: I don't know. Maybe. Maybe. It's like now Botox is
• 54:38
  Speaker 2: ruining your relationship, but fixing your square jaw problem.
• 54:42
  Speaker 1: At least your jaw and your premature ejaculation is fixed.
• 54:47
  Speaker 2: Okay. So the other thing to say is that like,
• 54:53
  Speaker 2: you know, you should get, if you were going to
• 54:55
  Speaker 2: be doing Botox, and I know you are because everyone
• 54:57
  Speaker 2: does seemingly, One wants to be careful about where you
• 55:03
  Speaker 2: do this. So people, there's a lot of like random, unlicensed,
• 55:07
  Speaker 2: counterfeit Botox in your house. Somebody comes to your book
• 55:12
  Speaker 2: club to do your Botox. Like there are some case
• 55:17
  Speaker 2: reports of people having serious reactions, including quite serious reactions
• 55:21
  Speaker 2: after things that are counterfeit or in some other way problematic.
• 55:24
  Speaker 2: So you do want to be kind of like a
• 55:26
  Speaker 2: little careful. Yeah.
• 55:28
  Speaker 1: I mean, this is... in case we haven't mentioned it,
• 55:30
  Speaker 1: the most toxic substance on earth. You want people who
• 55:35
  Speaker 1: know what they're doing. You want things to be stored
• 55:37
  Speaker 1: in proper places. You don't want them to be buying
• 55:39
  Speaker 1: them from shady labs and shady countries and things like that.
• 55:43
  Speaker 1: So be a little careful. You probably don't want to
• 55:46
  Speaker 1: look for the best deal out there on Botox. That's
• 55:49
  Speaker 1: not necessarily the right pathway.
• 55:51
  Speaker 2: All right. Are you a smash or pass on Botox?
• 55:54
  Speaker 1: Botox. I'm a smash. I mean, I think... great uses
• 55:59
  Speaker 1: from the medical uses we talked about.
• 56:01
  Speaker 2: Sure. Good.
• 56:02
  Speaker 1: Useful. Lots of cases for facial aesthetics and stuff. I think, yeah,
• 56:07
  Speaker 1: it makes you feel better about yourself. I got no
• 56:09
  Speaker 1: problem with it. How about you, Emily? Smash pass.
• 56:12
  Speaker 2: Yeah, I am a smash. I mean, I think this
• 56:15
  Speaker 2: is a very interesting space medically because it does feel
• 56:18
  Speaker 2: to me like there are probably a lot of other
• 56:21
  Speaker 2: things that we could do with this that might be
• 56:24
  Speaker 2: interesting and useful for different medical problems. So yeah. And
• 56:29
  Speaker 2: it's like the science here is very cool. So I'm
• 56:32
  Speaker 2: a smash, even though I'm, I'm not a user.
• 56:36
  Speaker 1: All right. That's it for Botox. Your mailbag question of
• 56:38
  Speaker 1: the week after the break.
• 56:45
  Speaker 2: Hi, Perry and Emily. I have a question. What's the
• 56:49
  Speaker 2: deal with the COVID vaccine? Should healthy adults and children
• 56:54
  Speaker 2: get a vaccine every year or What are the risks
• 56:58
  Speaker 2: and benefits? Thanks. I love your podcast.
• 57:02
  Speaker 1: Okay. We are in vaccine season, Emily. And this is
• 57:07
  Speaker 1: a question I think very appropriately about the COVID vaccine.
• 57:09
  Speaker 1: So I'm getting this question a lot. I'm sure you're
• 57:12
  Speaker 1: getting this question a lot. What are we doing about
• 57:15
  Speaker 1: COVID vaccines this year?
• 57:16
  Speaker 2: So I think what I have told people based on
• 57:19
  Speaker 2: my read of the evidence is everyone should get a
• 57:23
  Speaker 2: flu vaccine. I realize that's not the topic of this question,
• 57:25
  Speaker 2: but that everyone should get a flu vaccine, and that
• 57:28
  Speaker 2: people over 65 should also get a COVID vaccine. And
• 57:32
  Speaker 2: for sort of healthy adults and children, the COVID vaccine
• 57:38
  Speaker 2: is a little more dealer's choice. I would not recommend
• 57:42
  Speaker 2: it to adolescent boys because of some of the small pericarditis,
• 57:49
  Speaker 2: myocarditis risks. And I think for healthy adults and kids,
• 57:52
  Speaker 2: the risks of COVID are quite small. You might slightly
• 57:55
  Speaker 2: reduce your chance of getting it by getting the vaccine,
• 57:58
  Speaker 2: but it's relatively mild. But I don't think everybody sees
• 58:02
  Speaker 2: this the same way. I'm curious what you do. Yeah.
• 58:05
  Speaker 1: I mean, I see this actually at this point quite
• 58:09
  Speaker 1: similar to the flu vaccine, both in terms of efficacy
• 58:13
  Speaker 1: and risk. Actually, I think, you know, The major reason
• 58:18
  Speaker 1: I get a flu vaccine, well, I'm a healthcare provider,
• 58:21
  Speaker 1: so I have to, but I would anyway, even if
• 58:24
  Speaker 1: I wasn't, is because having the flu sucks. I'm not
• 58:26
  Speaker 1: going to die of influenza. I don't have comorbidities, but
• 58:29
  Speaker 1: it just sucks and it takes me out of the
• 58:31
  Speaker 1: game for real flu is bad and so is real COVID.
• 58:34
  Speaker 1: And so I feel very similarly, which is that basically
• 58:39
  Speaker 1: everyone should get a COVID and a flu vaccine this
• 58:41
  Speaker 1: time of year because having the disease is suck and
• 58:45
  Speaker 1: are unproductive. And of course, yes, in some small number
• 58:48
  Speaker 1: of people, they can be quite serious. I also agree
• 58:52
  Speaker 1: that the signal of myocarditis in adolescent boys and young
• 58:56
  Speaker 1: men bears extra consideration that we don't have for the
• 59:00
  Speaker 1: flu vaccine. So I'm more ambivalent about that, and I
• 59:05
  Speaker 1: wish we had some more data. That being said, there's
• 59:08
  Speaker 1: a non-zero rate of myocarditis from COVID infection as well. Honestly,
• 59:13
  Speaker 1: the mechanisms are probably the same. We don't know fully,
• 59:16
  Speaker 1: but it's probably across antibody reaction to the spike protein,
• 59:19
  Speaker 1: which you can get from infection or from the vaccine.
• 59:23
  Speaker 1: And so I sort of let it be dealer's choice
• 59:25
  Speaker 1: for healthy young men, but otherwise I would get both.
• 59:28
  Speaker 2: Yeah, I think, let me just, I will say just
• 59:30
  Speaker 2: one more thing about why I see these a bit
• 59:31
  Speaker 2: differently is that I think that the age profile flu
• 59:35
  Speaker 2: is very different than the age profile of COVID. Flu
• 59:39
  Speaker 2: is very bad in both kids and in older adults,
• 59:43
  Speaker 2: which is why I think the flu vaccine is quite
• 59:44
  Speaker 2: important for kids. Whereas COVID is really just, I mean,
• 59:48
  Speaker 2: always a little higher risk. Everything's a little higher risk
• 59:50
  Speaker 2: in babies, but like, you know, kids, sort of school
• 59:52
  Speaker 2: age kids, COVID risks are very, very low and it
• 59:54
  Speaker 2: really increases a lot. The age profile is really, really sharp.
• 59:57
  Speaker 2: for older people. And the other thing is that the
• 1:00:00
  Speaker 2: sort of side effect profile of the vaccine is lighter
• 1:00:03
  Speaker 2: for flu than for COVID. So many people have a
• 1:00:07
  Speaker 2: sort of stronger mRNA vaccine. But I think certainly if
• 1:00:10
  Speaker 2: people said, like, I'd like to get it, it's like, great,
• 1:00:11
  Speaker 2: get them. And you can certainly, the other thing is
• 1:00:13
  Speaker 2: you can get them at the same time. So people
• 1:00:15
  Speaker 2: are asking, like, can I go and get these at
• 1:00:17
  Speaker 2: the same time? Is that a problem? Absolutely not. If
• 1:00:19
  Speaker 2: you're going to get both of them, don't waste your time.
• 1:00:21
  Speaker 2: Just get them at the same time. I had my
• 1:00:23
  Speaker 2: flu vaccine yesterday. Excellent.
• 1:00:28
  Speaker 1: All right, that's it for us today. Stick with us
• 1:00:30
  Speaker 1: next week when we'll ask, what's the deal with intermittent fasting?
• 1:00:37
  Speaker 2: Wellness Actually is produced in association with iHeart Media. Our
• 1:00:41
  Speaker 2: senior producer is Tamar Avishai. Our executive producer at iHeart
• 1:00:45
  Speaker 2: is Jennifer Bassett. Our theme music is by Eric Deutsch.
• 1:00:49
  Speaker 2: And our content is for educational purposes only.
• 1:00:52
  Speaker 1: If you like the show, help other people find us.
• 1:00:54
  Speaker 1: Leave a rating and review on Apple Podcasts or your
• 1:00:57
  Speaker 1: podcatcher of choice. And help us spread the word about
• 1:01:00
  Speaker 1: the show. You can follow us on Instagram at wellnessactuallypod.
• 1:01:04
  Speaker 1: And don't forget, we want to hear from you. Head
• 1:01:07
  Speaker 1: over to wellnessactually.fm and leave us a question for our
• 1:01:10
  Speaker 1: mailbag or suggest a topic for a future show.
• 1:01:13
  Speaker 2: We'll let the influencers have the last word.
• 1:01:15
  Speaker 1: Samantha didn't need a man to make her feel positive,
• 1:01:18
  Speaker 1: but she did need a man to inject her forehead
• 1:01:20
  Speaker 1: every so often.
• 1:01:21
  Speaker 2: We like to warn our patients that some people find
• 1:01:25
  Speaker 2: it difficult to register emotion on their faces after the injections,
• 1:01:30
  Speaker 2: so you might have to say, I am so angry.