What's the Deal with Botox?

Perry: [00:00:00] Emily for the past week in preparation for this episode, I've been staring at everyone's foreheads as I watch. I'm watching for any signs of of eyebrow movement. And now I'm staring at your forehead. Oh, look. I don't.

Emily: [00:00:16] I am. I am a no go on Botox. I am afraid of needles in my face.

Perry: [00:00:22] Okay, well, I that I understand, but.

Emily: [00:00:24] Are you a Botox?

Perry: [00:00:26] I've never I've never done it. But you know what? After this episode, I might have to change my tune. We'll see. We'll see how it shakes out. But I have a fun little activity for us before we get started. Okay, a quiz for you. Because as you may know by now, botulinum toxin is the single most toxic thing in the entire planet. Gram for gram. So it is incredibly, incredibly toxic. So of course we should inject inject it into our faces.

Emily: [00:00:55] What could go wrong? What good plan.

Perry: [00:00:57] My, my quiz for you is for you to [00:01:00] tell me how much more toxic is Botox than a couple of things. Okay, so so. So here we go. Take your take your best guess. So we're going to start with arsenic. How many more times more toxic is Botox than arsenic? Gram for gram.

Emily: [00:01:16] Ten.

Perry: [00:01:18] That's a good guess. But the answer is actually it is 15 million times more toxic than arsenic. Okay, what about.

Emily: [00:01:24] Was off by a few orders of magnitude? Not close, but now I'm prepared.

Perry: [00:01:29] All right, you're ready. Cyanide. That's. That's pretty bad.

Emily: [00:01:32] 10 million.

Perry: [00:01:33] Okay. All right. I think you're getting you're getting it now. It's it's only 6 million times more toxic than than cyanide. What about sarin gas? Notorious, uh, wharf, a chemical warfare agent.

Emily: [00:01:48] I'm going to go with 50. I feel like this one's bad.

Perry: [00:01:51] 50. It's bad. It's bad. Uh, sarin is bad. Was that the one from the rock? I think it might have been. Oh, no, that was like V or whatever, but, um. Botulinum toxin [00:02:00] is 100,000 times more toxic. Gram for gram.

Emily: [00:02:03] Again, I overcorrected.

Perry: [00:02:05] Than sarin gas. Um, uranium. Radioactive uranium.

Emily: [00:02:12] This is like if you ate it, like if I ate the uranium.

Perry: [00:02:15] Or I injected you with uranium again.

Emily: [00:02:19] Uh, 3000.

Perry: [00:02:20] Okay. Botox is 200 million times more toxic than uranium. Last one. Tetanus toxin.

Emily: [00:02:28] Tetanus 6 billion.

Perry: [00:02:32] Only twice as toxic. So you.

Emily: [00:02:35] Are ridiculous.

Perry: [00:02:37] Tetanus toxin is actually incredibly toxic and also comes from Clostridium genus of bacteria. So those bacteria know what they're doing when it comes to killing humans. This is just the tip of the iceberg of the interesting stuff that Botox can do that we need to talk about today.

Emily: [00:02:53] I'm very excited for this episode because of course we are going to get to your face. But I think the basic. I am just [00:03:00] so interested in the question of how we got from. This is the most toxic substance known to man, to like. Let's inject it into various parts of our body and see how that goes. Like what? What could go wrong?

Perry: [00:03:13] Isn't science awesome?

Emily: [00:03:18] I'm Emily Oster. I'm an economist and a data expert.

Perry: [00:03:21] And I'm Perry Wilson. I'm a medical doctor.

Emily: [00:03:23] It is Thursday, October 8th, 2026. And this is Wellness, Actually.

Perry: [00:03:28] Because you're getting a staggering amount of health and wellness information nowadays from every source imaginable. And some of it is awesome.

Emily: [00:03:36] And some of it is, well, actually bullshit. Fortunately, we're both people who know how to read studies, how to parse the data, and can tell you what's worth thinking about and what you can safely ignore.

Perry: [00:03:50] But before we dig in a note that this podcast is for educational purposes and should not be construed as medical advice. We don't know your unique situation, so talk to your doctor for personal health decisions. [00:04:00]

Emily: [00:04:01] This week we're asking what's the deal with Botox? Perry and I will give the official smash or pass, and we'll get to your question of the week. But first, let's do the health news roundup after the break. And now for the health news of the week. Perry. It's Nobel Prize week. Uh, we are recording this on Monday. And the Nobel Prize in Physiology and Medicine was just announced. Um, this is always very exciting. Uh, they always give it for something that is difficult to understand. Uh, do your, do your doctor's story about who won it this time and whether this was the person you had in the voting pool.

Perry: [00:04:50] I always love Nobel Prize week. It's very exciting. I love learning about these these people. So Nobel Prize in Physiology or Medicine, awarded to Karl Deisseroth, Peter Hegemann and George [00:05:00] Nagel for their work on light gated ion channels and optogenetics. Need I say, I think we all know about optogenetics. And so.

Emily: [00:05:08] Moving on.

Perry: [00:05:09] Um, this is super cool actually. So these guys discovered channels on nerve cells that open and let ions in in response to wavelengths of light, as opposed to like things binding them, which is typically when you think of a channel in a cell, it's like some something binds to the channel like a key, and the channel opens and lets in calcium or something else. And that's how signaling happens. But these channels responded to light, which is just really neat. Um, but they not only discovered that, they realized that they had really cool applications. So where they took that was cloning those proteins, putting them in viruses that could then genetically get those proteins to be expressed in cells that don't normally express light gated ion channels, specifically nerve cells in certain clusters of nerves. The practical upshot of which [00:06:00] is when you do that now, you can activate nerve cells and clusters of nerve cells by shining laser beams at them, as opposed to trying to bathe them in a chemical or something like that. And this is a really huge advance because light is really precise, right? You can shine it for a split second and let the channel open for a fraction of a second, and then boom, it's closed again, which you can't do with chemical ligands to receptors. And it allowed them to begin to understand the really complex web of connections that form the basis of all of our brains. And now we've got mice that have these proteins expressed in their brains. And I put a picture on Twitter of this. You can see like little mouse with a little laser drilled into into its head, which they can like turn off and on with radio waves. Okay. It's not that's, you know, the poor mice, but we are learning a ton about how the brain works from this line of fascinating research. So big congratulations to them.

Emily: [00:06:57] Incredibly cool. Yeah. The economics [00:07:00] Nobel Prize. It's actually not a regular Nobel Prize, but it's on Friday. So. Or no, next Monday. So the economists are all getting very excited.

Perry: [00:07:08] I'd like to think that you're in contention, Emily.

Emily: [00:07:10] Yeah. I think my I'm like maybe 25, 30% chance. So, you know, fingers crossed. I'll let you guys know next week if I'm the winner.

Perry: [00:07:19] Absolutely, absolutely. Um, we said we wanted to do more good news for health news of the week. But you know what? Forget that Nobel Prize is all we're going to give you folks the next news item that I wanted to talk to you, Emily, about is the plague. Um, we're recording this on Monday, October 5th, and this is sort of breaking news. So I think we might get some developments over the next few days. But seeing a lot of chatter now that there has been an outbreak of plague from a lab in Russia. Uh, sounds to me like the start of a very scary movie. Emily, what's going on?

Emily: [00:07:56] So this is the same plague from medieval times. [00:08:00] It killed a very large number of people in over a long period from, you know. Well, you know, 300 A.D. probably before that, through kind of the 1600s. So I think one thing to note before I get into what happened is that we do have antibiotic treatment for the plague. So the plague. Yeah. It's a bacteria now treatable. Uh, if you start treatment early. I actually have a friend who got the plague a number of years ago. Really? Um.

Perry: [00:08:29] Yeah, from an armadillo. Perhaps that's the in the US.

Emily: [00:08:32] That's. I'm not sure if there was an armadillo involved. Right. So what is, what is going on now is that there is a lab worker in Russia, um, in it's Russia who has died after a lab accident which released a dangerous Infection, a pneumonia of unknown etiology. They haven't said that. It's the plague. We know this lab studied the plague. It seems like it's very likely it was the plague. They've quarantined about [00:09:00] 200 people. There are several hospitals under quarantine. It's very difficult to know exactly what is going on, because Russia has not been extremely forthcoming about what what is going on and how many people are ill and what was going on inside this this lab. So as you said, I think we will know more about this. Um, certainly it is very scary. It is also, again, in contrast to Covid, we do have a lot of research on how to address the plague. So hopefully this will be something we don't need to discuss. Again. We'll just go.

Perry: [00:09:42] To, um, you're going to see some scary stuff online. Uh, you know, as, as, as you might expect with this kind of thing, this lab is not a Russian government lab, as far as we know, but that doesn't necessarily mean the government isn't involved. And of course, the Soviet Union had a pretty significant biological warfare [00:10:00] research program that may or may not continue to exist. I did see some things on the Twitter suggesting that the course of this disease she was exposed on September 25th, died October 1st or second is like, oh, that's so fast. This is not actually plague. It's like super plague or, you know, it's some biological weapon. Um, that's not true. Uh, pneumonic plague, which is the long form of the disease, which is almost certainly what someone would have acquired in this scenario, because I don't think they're getting bitten by fleas, which would cause the bubonic plague. That is, it's very fulminant like, like it really is like you get infected and then six days later you could be dead. So this doesn't to me, this doesn't read as like, oh, brand new super flu, super plague thing. Um, but obviously we'll keep our, keep our tabs on it.

Emily: [00:10:47] Okay in the not great news, but more ridiculous. Uh. There is a new abstract that I saw suggesting that GLP one lead to detached fingernails, that [00:11:00] they make your fingernails detached.

Perry: [00:11:02] Now, this creeps me out. Is this like a this is body horror? What was that movie that we talked about before? Where, um, where Demi Moore. Oh, yeah.

Emily: [00:11:11] Where? Demi. Yeah. So first of all, I just want to say I lose toe nails all the time. I'm really not thinking that losing your fingers and toenails is like a super big deal. I have barely any.

Perry: [00:11:21] That's a Tuesday for Emily.

Emily: [00:11:23] I'm not concerned.

Perry: [00:11:24] Yeah. Okay. For endurance athletes, when.

Emily: [00:11:28] I first I will say, when I first read this headline, I thought, well, that seems plausible in the sense that, you know, people like lose. I thought this was like a mild, tiny effect. And I could see, you know, people sometimes lose more hair when they lose a lot of weight. I can imagine that, you know, fast growing cells like your fingernails could be somehow affected by this, but the size of the effects in this abstract, which provides no additional detail, are so ridiculous that it seems impossible.

Perry: [00:11:58] It totally. I cannot [00:12:00] believe the amount of credulous reporting across totally that is happening about this. It's like if you put GLP one in the title of your abstract, like don't like you're, you're going, you're going viral, guys. It's it's wild. So okay, so again, this is not peer reviewed. We don't have the whole paper. We can't review the methods. But what the abstract says is they compared 600 GLP one users versus 1500 people who had diabetes and obesity, but weren't using a GLP one GLP one. And they found that they had the people that were using it had a four times higher fingernail problems. We have no idea how they were assessing this, by the way, like whether it's like coding in the chart or the direct survey, not in the abstract. Um, and again, okay, I'm like you, Emily. I'm like, okay, four times, you know, I'm sure the baseline rate is low four times something very low maybe, you know. Yeah. Nutritional stuff like iron. Zinc. I don't know, maybe we'll figure it out. Okay. And then you read further and it says, um. The multinational study found that 39% of GLP one users reported nail detachment, [00:13:00] compared with 9% of controls, while two thirds experienced at least one nail disorder. 40% of GLP one users have their fingernails.

Emily: [00:13:09] That is, one in like 1 in 6 people in America is on these. Like, if this were true, America would be littered with like fingernails that have just were falling off everywhere.

Perry: [00:13:20] Yeah, it's just I, this is something I like. This is just a sanity check. It's like when, when, whenever we do research in our lab, our clinical research lab, and I've got trainees and stuff and they get a result. I'm like, okay, the first thing isn't to be like, oh, what does this mean? You know, the first thing is just to look at the actual numbers and be like, is this possible? And it is not like, look around you.

Emily: [00:13:45] I tell my students, I'm like, I'm just like, they'll show me something. I'll be like, data doesn't look like that. So come back to me with because that's not how data looks like. That's just like I can tell that's wrong.

Perry: [00:13:56] I can guarantee you that there are more people with frozen foreheads [00:14:00] from Botox than there are with their fingernails falling off. And I've been checking that, too. I'm looking at your fingernails.

Emily: [00:14:06] I start thinking like, is the GLP people are going on GLP ones and are they like running more? And is that. But I still think it couldn't possibly be because you.

Perry: [00:14:12] Can't get to 40%.

Emily: [00:14:13] And it's, it's fingernails. Yeah. So anyway, don't worry about your fingernails people on GLP ones.

Perry: [00:14:22] All right. Uh, let's let's talk Botox. I'm excited.

Emily: [00:14:27] Let's talk Botox.

Perry: [00:14:29] Emily, would you inject not your face you'd inject. Not your face.

Emily: [00:14:34] Oh, I mean, I got a flu shot this weekend. Yeah. Like I'll I'll put. Yes, I would if there was Botox was helpful for something I would consider I would I would use it. Yes, of course I like medical care. I just, uh, I don't, I don't know, even though I'm like my, my whole job now is like to have my face on Instagram. Mhm. I just can't, I can't get exercised.

Perry: [00:14:57] I think you do have you, you do have nice skin though. [00:15:00] I will, I will say that you must have used a lot of um like SPF when you were younger.

Emily: [00:15:04] I one time got such a bad sunburn on my face that I had like, large blisters.

Perry: [00:15:09] Oh, yeah. That's not.

Emily: [00:15:10] Good. Yeah. Okay, let's talk about Botox, guys. Let's discuss it. Let's start with how we know about this toxic substance and where it comes from. Perry, tell me about sausages.

Perry: [00:15:23] Yeah, it all starts with sausages, as I think most medical stories do. Um, uh, let me take you back to Germany, where in the 1820s. And, um, a physician named Justinus Kerner documents a wave of deaths. Uh, that a little bit of old school epidemiology determined was related to badly made blood sausage. The Latin word for sausage or casing, I guess, is is botulus. And so botulism is literally sausage ism. Like that's the disease. It's a sausage disease. That's what they got. The disease [00:16:00] was the same type of botulism that we get today. It was characterized by a paralysis. And really interestingly, Kerner himself suspected that there was some poison. Obviously, they didn't have the technology at the time to figure out like what the poison was or how it worked or anything like that. But he actually thought that, you know, someday we might be able to use this poison, which paralyzes people and kills them for overactive muscles and nerves. Um, which I just think is kind of like he's a clever guy, just a little bit ahead of his time.

Emily: [00:16:31] Yeah. So this, this was a single batch of badly made blood sausage or a whole badly made blood sausage company.

Perry: [00:16:39] This particular one apparently was, you know, from one one place. You know, one geographic location. But the disease had been certainly existed before that. And but it was just this guy who kind of put the pieces together and was able to tie it. You know, remember back in the 1820s, people are dropping dead of foodborne illnesses like similar to [00:17:00] rates we see today. No. Just kidding. We're much better today, but we're on the rise.

Emily: [00:17:05] So what? What is this? It is a rod shaped anaerobic bacteria. Bacteria? Um, it is killed by oxygen. Uh, lives in soil. There's spores kind of everywhere. And they actually survive boiling. Um, the, the spores are not toxic, but when they like wake up and start to grow, that is when you generate, uh, that is when you generate the toxin.

Perry: [00:17:31] Right. I think of the bacteria called Clostridium botulinum. There's a Clostridium tetani, which makes the tetanus toxin. So they're sort of related toxin forming bacteria. And it's everywhere. It's like in the soil, like it's all over your surfaces. You're touching some right now. It's everywhere, but it's in the spore form. And I think if spore like seeds, like they just are inert, and then they need to be in proper environment to sprout and produce live bacteria that produce the toxin, and that environment [00:18:00] is hard to come by because, as you said, they're anaerobes. Oxygen actually kills them. And our our world is full of oxygen. And that's nice unless we put them in like a can that has other bacteria that will eat up all the oxygen. And then when that's gone, the botulism can take over. And that's how you get from botulism, from improperly canned food, which is, you know, the main source of infection in adults at least. But Emily, this feels like your area. I'm sure you're familiar with the risks of botulism in babies and honey.

Emily: [00:18:39] Yeah. So. So this is this is a very common piece of advice that parents are given. Do not give your baby honey before the age of one because it the infant gut flora is not able to process the spores in the way that adults are. So for adults, you have botulism in [00:19:00] in the spores, in honey, in your gut processes them and it's fine. The infant gut is less advanced. And so there is concern about these spores in honey. I will say that, uh, link is much more tenuous than many people think. So this was a sort of when in in infants are generally more susceptible. Infantile botulism is one of the more common. It is one of the more common risk groups for. For botulism and honey is a. Like was a suspected cause, but in fact it. The sort of follow up on that has not been real compelling. Like, you know, don't give your what I sort of tell people is like, it's perfectly reasonable to not give your baby honey when people freak out because their mother in law gave their kid a half a graham cracker, it's like actually first botulism extremely rare. And second, like it doesn't just not it's not like every graham cracker can contains it.

Perry: [00:19:54] Yeah. There are a couple hundred cases of infant botulism in the US per year. So we are talking [00:20:00] very rare. But you know, you've got other options than honey. Certainly I did try to figure out like, what's so special? Like I eat honey. Like why? You know what, what makes what makes infants so uniquely.

Emily: [00:20:10] Infants are uniquely susceptible to consuming these spores. It is not. It's just that these that honey has these. This is like a, it's like, this is a source of botulism spores because of, I don't know, I guess probably the same reason honey can like live in Egyptian tombs for, for a long time or whatever. Uh, and infants are. So you also see, for example, botulism. There was a number of cases in the last year from formula. So it can grow in in formula. And again, if adults drank that formula, no problem. Infant consumption of formula more complicated.

Perry: [00:20:43] And we, we have um, a little our acid in our stomachs a little bit stronger than infants. And we, and we have some competing gut bacteria that the infants might not have, which, uh, which also makes them a little bit more susceptible. Um, you know, the roots of disease are essentially [00:21:00] that, right? It's worth really thinking about botulism, the disease as a poisoning as opposed to an infection, because that's really what it is. It's the toxin. And, but it's a pretty scary syndrome, a poisoning syndrome, right?

Emily: [00:21:15] Yes.

Perry: [00:21:15] I don't want to like get to horror show here, but the.

Emily: [00:21:19] Descending symmetric flaccid paralysis.

Perry: [00:21:23] Yeah. So what that means is it paralyzes you from the head down. You are wide awake when this happens. There's. Because it's not like an infectious. It's not like fever and sepsis, and your blood pressure's dropping and you're delirious. It's just like you are slowly going paralyzed. You are wide awake. And when the paralysis hits the nerves that innervate your diaphragm, you stop breathing. And, you know, in 1820s, that's how you would die. Sort of wide awake, suffocating. Nowadays, we can put you on a ventilator. Um, [00:22:00] but you're typically on a ventilator until the botulinum toxin wears off. And for anyone who has used Botox, you know that that does not happen overnight. People are on the vent for months until they can breathe on their own. Again, not a great disease.

Emily: [00:22:17] It's not a great disease. It's it's bad. Uh, I will say, you know, the and again, I think for, for parents of infants, it is very rare for babies to die of botulism. Like very rare. It does require a period of treatment for these reasons. But this is treatable in the sense of like, not that they give you something, but that you I mean, there's an antitoxin, but that you still need a fair amount of time in eventually over babies and adults, it's caught in time typically do recover.

Perry: [00:22:51] Yeah. I want I wanted to touch on the mechanism here of like, why does it cause paralysis? Because it explains why it lasts so long and also why the antitoxin isn't [00:23:00] like, I mean, it's great, but it doesn't help as much as you might expect. So I think what you need to know is that this is all happening at the junction between a nerve and a muscle. So a nerve tells a muscle to contract. That's how everything works. And the way it does that is the nerve terminal releases acetylcholine onto a receptor on the muscle, the acetylcholine binds and the muscle contracts. The botulinum toxin gets into the end of the nerve cell, and it binds a very specific protein that it destroys, it cleaves that protein. And that's a protein that's necessary to allow the release of acetylcholine from nerve cells. So it's essentially it blocks the signal from nerve cells. So all of a sudden the muscle is not being told to contract anymore. And it just goes flaccid because that's what happens to a muscle when it's not being told to contract anymore. This binding and damage to the protein is essentially irreversible. The way that the muscle starts contracting again is a new nerve terminal grows. [00:24:00] Like you actually have to wait for the nerve to grow a new little new little process out to the muscle. And nerve cells don't grow that fast, right? Like they're, they're very, they last a long time. They're very slow growing cells. So it can take months. That's why Botox injections and botulinum, the disease takes so long. The antitoxin can bind toxin in the blood before it gets into the nerves. So it can kind of stop the spread. But the paralysis that has happened, has happened, and you have to wait for it to come back.

Emily: [00:24:34] Okay, so I will say this. This disease is very scary. It sounds very scary. It takes a long time to treat. However, there are a couple like I want to emphasize again, there's a couple of hundred cases of this in the US every year. They are mostly in infants. So this is not something that is commonly affecting most.

Perry: [00:24:56] People unless someone decides to try to kill us. All right. [00:25:00]

Emily: [00:25:00] Because that is a potentially very good bioweapon due to its incredibly lethalness.

Perry: [00:25:07] It is it's a, it's a, it's a great and it's a bioweapon, kind of a name that actually would behave more like a chemical weapon because again, it's the toxin is more of a poison than anything else. It's not like it's not like this bacteria spreads from person to person. And, you know, I never told, I don't know if I've told you this before, but my senior thesis back in college was about like, uh, using bioweapons, particularly anthrax as like a, as a modified chemical agent. And that was like right before 2001. And, and when that anthrax thing happened in like my thesis advisor got questioned by the CIA or FBI or something. Like it was a whole thing. So anyway, I find this stuff really fascinating and it's absolutely terrifying as a bioweapon because of the potency of this thing, right? Botulinum toxin is the most toxic substance, period. [00:26:00] Full stop. It is the thing. Back of the envelope math. If you had £4 of Botox, you would kill. You could kill everyone on earth with that. If you could aerosolize it appropriately and get them to breathe it in.

Emily: [00:26:14] Please tell me it is not that easy to Aerosolize.

Perry: [00:26:17] I well, I can tell you that, uh, the Shinrikyo cult tried to weaponize it and failed. Um, which is, which is good. So it must be a little hard. They switched to sarin gas, you know, just just old fashioned sarin gas, as, you know, much less toxic. Um, but Iraq actually produced around 19,000l of concentrated toxin, which was appropriately sized for bombs and missiles. I don't believe there's any evidence that it was used in warfare, but geez, this would be bad. This would be bad.

Emily: [00:26:50] Okay, so that's great. Uh, let's pause on that. And we're going to move next to talking about why [00:27:00] we want to inject this into our face and elsewhere. Uh, but first, let's take a quick break.

Perry: [00:27:10] We're back. We've talked about the scariest toxin known to man, the most toxic substance in the world, um, in the universe, as far as we know, at this point in time. Uh, so let's talk about where we can stick it in our bodies and what good it will be. Um, so I think the, the first thing, you know, the unofficial slogan of wellness, actually the dose makes the poison. There's perhaps no better place than botulinum toxin to talk about this because the dose are so small. Um, so Emily, walk me through, you know, if you go into an to an office and you're going to get some Botox, they'll get out a little vial of Botox, which typically the typical vial has 100 units in it. So what are we talking like? What are we what are we talking? What's in that vial? And can it kill everyone on earth or not?

Emily: [00:28:00] Right. [00:28:00] So a 100 unit vial has 0.73 nanograms of toxin. Um, so a nanogram is one millionth of a gram, I believe. So do teeny weeny little bit. But if you're looking for a lethal IV dose, if you were going to sort of give someone an IV of this in the hopes of killing them, you would need about one nanogram per kilogram. So for someone who's like a 70kg adult, you'd basically need to inject them with 100 vials of toxin, like right into their veins. If you are fixing the little teeny lines on, on your forehead, uh, you would typically use about 20 units and they would be injected into the muscle and not a vein. So it would be a tiny, tiny, tiny, tiny fraction of what you would need to kill somebody.

Perry: [00:28:57] The units of Botox have [00:29:00] an interesting story. You might assume that the units are just like some measure of the weight or the volume or something like that. But no one unit is defined as the amount of Botox that you would need to inject into the belly of a mouse to kill a mouse. So when you're getting 20 units in your forehead, uh, that's enough to kill 20 mice. If you injected it into their into their bellies.

Emily: [00:29:24] But like the other unofficial slogan of this podcast, could be like, wow. We don't treat mice great.

Perry: [00:29:29] We do not treat mice great, but we appreciate their sacrifice.

Emily: [00:29:34] So so you're the amount that you're getting is very is very small. But actually the, the sort of reason that this botulism might work really does connect back to the reasons that it is also potentially very, very dangerous. So the toxin kind of stays where you put it. It's not reversible. It paralyzes [00:30:00] muscles. And it, it wears off in about three months. So if you've got a lot of that, you know, eating sausage, you're dead. Uh, but if you get a little bit of it in a syringe, in the muscles in your face or somewhere else, it actually is a sort of dose, temporary on off switch for one tiny muscle. And that is what makes this such a useful medication. And that's why this guy Kerner was basically right when he speculated in 1820 that, you know, one day we might use his sausage poison for something good.

Perry: [00:30:36] Yeah, super smart guy. And it took 150 years for us to actually, um, you know, profit from that observation. Um, we're in the 1970s now, and, uh, an ophthalmologist named Alan Scott wanted a non-surgical fix for strabismus, which is the medical term for crossed eyes and thought, you know, there's probably a muscle that's kind of pulling [00:31:00] this eye out of alignment. And if we could paralyze that muscle, then we don't have to do surgery. And he came up with the idea of using purified botulinum toxin to do it. He sold that. Uh, he tested that. He showed it worked. He sold the technology to Allergan, reportedly for very little money. Um, Um, and, uh, we're very sorry, Alan Scott, because I think he'd be really, really rich. Um, if he had, uh, recognized what he had in his hands there. It took a while to go through FDA and get approved and whatnot, but it was approved in 1989 for two indications. Strabismus, crossed eyes and blepharospasm, which is a involuntary twitching of the eyelid. Uh, so two things that kind of make a lot of sense, both ophthalmologic and, you know, that was how it all got started, but it didn't take long, obviously, for people to say, oh, wait, if we have an on off switch for a muscle, [00:32:00] what other muscles in the body might be firing too much? Like what other things could we turn off? And it turns out there's an awful lot.

Emily: [00:32:09] And once, of course, once something is FDA approved for this, then it becomes much easier to sort of start experimenting and using it for different things in a kind of off label way. And it has turned out there's a. Pretty large number of of uses which I think are worth running through a bit. And then yes, we will talk about your face. Um, so it started with the strabismus and can you, how do you say this word.

Perry: [00:32:34] Blepharospasm. Blepharospasm. Blepharospasm.

Emily: [00:32:38] This is also been used for spasticity after strokes. It's been used some in cerebral palsy. It is used often in excessive sweating. So people who have excessive underarm sweating can get Botox injections in their underarm, which actually sounds really painful, but I think is but is very effective at reducing [00:33:00] excessive sweating.

Perry: [00:33:02] And that's because sweat glands also are signaled with acetylcholine. So it's it's the same mechanism.

Emily: [00:33:08] Signaling but it's not a muscle. Yeah. And overactive bladder. Spasmodic dysphonia which is a vocal issue. It's actually the vocal issue that RFK has. So you know, there are many different places where muscles are firing when they shouldn't, and this is just a way to turn them off. Uh, the big one, though, I want to talk about is migraine because this is the, the indication that I think is the most probably the most common medical use. A lot of people struggle with migraine and where we have reasonably good data.

Perry: [00:33:44] Right? And it's not one that you would necessarily think of because, you know, migraine is a very complex syndrome. Um, there's clear like brain stuff going on with migraine, you know, functional MRI shows these like spreading [00:34:00] depressions of migraine syndromes and things like that. So it's not like, oh, this is clearly a muscle thing. Nevertheless, we've got, you know, reasonable randomized controlled trial data to suggest that Botox works for at least for chronic migraine. Um, these are trials called the preempt trials, which were funded by the pharmaceutical companies, but Preempt enrolled 1384 adults and randomized them to Botox versus placebo injections. Emily, I'm sure you'll have a comment on that. But before we get there, so the doctors injected seven like pre-specified sites in the head and neck. They also injected they had the option to inject sites based on the patient's pain. So if they described like, oh, you know, my migraines hurt right here or some, you know, right in my upper forehead, they, they did have the ability to sort of follow the pain. And the primary outcome here was headache days per month, at 24 weeks in the major trials combining all the data, the Botox [00:35:00] group had 8.4 fewer headache days per month. The placebo group had 6.6 fewer headache days per month. So that's the difference. There is about 1.8 headache days a month, so that's statistically significant, although maybe it's not as. Like 8.4 sounds great. Like I definitely want 8.4 fewer days, but 1.8 fewer days on the margins compared to placebo maybe. Doesn't sound as impressive. What do you think?

Emily: [00:35:27] Yeah, I mean, I think this is a this is a really interesting trial. You know, it is an example of a trial where I find the the placebo effect quite impressive. I mean, that's a that's really very large placebo effect, not inconsistent with some of the places we most commonly see placebo effects, which is when we're talking about pain, when we're talking about things where there's a sort of perception aspect. Um, this is there's also an issue with this trial, which is that it's basically impossible to blind it. So yes, [00:36:00] they were doing injections of saline, but as anyone who has had Botox will tell you, like you can tell if your face is moving or not moving. And so there's, you know, if anything sort of 1.8 feels like an overstatement of the actual treatment effect. But on the other hand, I've always looked. So it's like, okay, so it's it's 1.8 over placebo, but it is 8.4 in the sense that when you get this, you are getting both the placebo effect and the real effect, right? And so, and I'm not sure that people would get as much placebo effect if you didn't tell them that they were getting the placebo effect. So, um, so I don't really know, like from a decision standpoint, this is potentially quite like quite large if you are a person struggling with migraine.

Perry: [00:36:46] Yeah, yeah. And I mean, for what it's worth, it is it's entered into common practice. Like, like headache clinics all around the country are injecting Botox for this. Um, I don't, I don't know that I could say it's 100% [00:37:00] standard of care, but it's quite common.

Emily: [00:37:02] It's pretty.

Perry: [00:37:02] Common. Yeah, yeah. I did find some weird uses for weird uses for Botox. Uh, some experimental uses. One that is sort of interesting is to prevent atrial fibrillation after cardiac surgery. There are some CT surgeons who are injecting Botox in the epicardial fat pads around the heart. The idea being kind of calmed down the nerves there, and maybe they don't angry up the heart after surgery. Atrial fibrillation. Abnormal heart rhythm after surgery can be a problem. The results on this are mixed up, and I also found some small trials on using Botox for premature ejaculation.

Emily: [00:37:41] Because if you. As soon as you have a medication, the question is how can we improve the penis? Like just like get let's get focused, guys. Okay, we're not focused enough on men's sexual pleasure. Just as a society, we are not focused enough. Let's get focused.

Perry: [00:37:55] Thank you. Emily, you're very brave for for saying that. Um, I [00:38:00] think sticking needles into your penis is a natural cure for premature ejaculation. I don't know, I'm not actually sure what the timing of the needles is here. I think if you time it right, you're going to be just fine. Hold on, honey.

Emily: [00:38:16] Moving on.

Perry: [00:38:17] Okay. Okay.

Emily: [00:38:20] What about depression? Depression.

Perry: [00:38:25] Depression is an interesting use here. I cards on the table. I believe this could work.

Emily: [00:38:31] So. Okay, the hypothesis for why this. There's, like, a hypothesis for why this might work for depression, which is, uh, which is facial feedback. The idea is like, if you can't frown, maybe you feel less sad. And actually there is, although in some ways that sounds totally ridiculous. Uh, actually, there is a fair amount of evidence in psychology that, like you in sort of social psychology that like forcing yourself to smile makes you happier. So there's like a, there's [00:39:00] like a sort of feedback because there's like a feedback loop there. And so it's not as totally ridiculous as it seems. There are some small RCTs. The effects here to me read much too large for to be real.

Perry: [00:39:17] Talk to me. What effects are you talking about?

Emily: [00:39:19] So the sort of pooled analysis of RCTs, which ends up being about 150 to 160 people, total found of 4,054% response rate versus only 10% on placebo. You know, again, difficult to blind. And then in some of the larger follow ups, it's much smaller. So there's kind of like this feels like we could really afford to have a much larger trial to try to, to nail it down. I don't know, but you're more optimistic.

Perry: [00:39:48] I don't know, I sort of agree like the, the physiologic feedback of depression and anxiety, I think is very real. Like we have reasonable data, for example, in anxiety that taking beta blockers, which just kind of like reduce your heart rate [00:40:00] and stuff makes people feel a little bit better. And it's like, they're not anti-anxiety med. They don't do anything in the brain, but they just like, if you don't feel your heart racing as much, you just kind of it breaks some cycles. And so I sort of believe it. If it's harder to frown or, you know, it's harder to make that face, maybe you feel better. And I mean, Emily, I just want to speak out again for men here. Like when we tell you, hey, you know, you should smile more. Uh, that is just a therapeutic bit of advice. Um, you know.

Emily: [00:40:30] That's just like your, your concern about our mental health.

Perry: [00:40:33] I just want you to be happy. You'd be, you know. Great. Um, so smile more ladies. Okay. That's a joke. All right. Um, let's remember facial feedback. We'll come back to it. But all of that was here's a muscle that's like doing something that we don't want it to do. Now it's time to move on to the muscles that are doing what they are supposed to do, which is to move your face [00:41:00] around. We don't like it. We don't like that. So let's talk about the face and M did you see how we sort of figured out that like, ooh, this, this, this might work for wrinkles.

Emily: [00:41:13] Yeah. It's like many. So this story is like many of these kinds of things in, in medicine where it's basically a side effect. So they're treating there's an ophthalmologist, Jean Carruthers. She's treating people for blepharospasm and people noticed, hey, like my frown lines look better. Uh, her husband conveniently a dermatologist. And they're.

Perry: [00:41:36] Doing.

Emily: [00:41:36] All right. They published this result. And, uh, you fast forward ten years. The FDA approved this for the. I didn't know this was what they were called, but these are globular lines, which I believe lines right between your between your eyebrows, which, uh, I'm, I now learned are called the angry elevens.

Perry: [00:41:57] Mhm. You didn't know. Yeah, I love that. Yeah. So I [00:42:00] can do it. Your skin is so much better.

Emily: [00:42:01] No, no, no, I have them. It's just you're not you're not zoomed in enough. Okay. But people are really like, this was this is a really successful venture. You know, this is a $13 billion market. I will say this is by far the most common question I get from people in my work in pregnancy and parenting, which is, can I get Botox while I'm breastfeeding? People are like, it wears off after three months. I got it before I got pregnant. It's been nine months. My dermatologist wouldn't shoot this in my face while I was pregnant. Now I'm breastfeeding. I'm like desperate. I just pushed the baby out. Like, can I get the Botox person in the delivery room to fix shit on my face right now?

Perry: [00:42:43] What do you tell them?

Emily: [00:42:45] Yeah, it's fine. I mean, so, so it doesn't we actually have some pretty good evidence on on breastfeeding. It doesn't pass at high rates into or really at all into the breast milk. So it's, it's fine to get it. I first I tell them your face looks great and I don't think you need to do this. And then I explain [00:43:00] that it's fine to do it. And then um, yeah.

Perry: [00:43:02] That's, that's very nice. Yeah. I mean, I think biologically that all makes sense. I will say I wouldn't be surprised. Doctors get real skittish around pregnancy and breastfeeding, so.

Emily: [00:43:12] They won't do it. Actually, there's pretty good evidence it would be fine also in pregnancy because when people get botulism poisoning during pregnancy, it doesn't affect the fetus. Uh, but, uh, but no one will do this during pregnancy.

Perry: [00:43:24] Yeah. They just we're a little too risk averse for that. Um, sorry. Okay, so going through Botox for the face, you know, the use here is for dynamic wrinkles, right? It only works for the lines and creases that change when your muscles move around. And you can see what those are. But of course we all have lines and wrinkles that just stay. Not we all. I have lines and wrinkles that stay no matter what, that are just due to skin aging won't work for that. But but there are plenty of other cosmetic products like fillers and things that you can inject into those to fill them out. And maybe we should do a whole episode on the other stuff you can inject [00:44:00] into your face. But Botox, we're talking about dynamic lines and wrinkles. Boy, there are a bunch of brands out there. Um, I know this is really expanded. I listed for em. Have you come across these have people asked you about these.

Emily: [00:44:13] People just like this? Botox is like Kleenex. Botox is the major brand. People refer to everything as Botox. There's dysport, there's zimovane, there's daxxify, there's all this different stuff. When people ask about it or talk about it, they just talk about Botox. But like the details of these things have slightly different units. They maybe some of them might last longer. You know, it's all the same basic idea.

Perry: [00:44:38] Yeah, yeah. And I will say I, I dug in like, um, you know, daxxify is supposed to like last longer and, and, and I think Dysport is the one they market as starting quicker because Botox actually doesn't work right away. It takes a few days to a week to, to sort of kick in and paralyze the muscle. Actually, the data is not terribly supportive of that. Like, I think this is a lot of branding and marketing [00:45:00] and they all kind of work similarly. So, you know, whatever.

Emily: [00:45:04] You tell somebody, this works faster and you get the placebo effect for a couple of days, and then it really does work. And so it's like, whatever.

Perry: [00:45:10] Yeah. So let's look at some pictures. Uh, and we'll put this in YouTube for those of you who are watching the video, but Emily, I'll ask you to describe this because I did find one really famous. So when we asked, like, does Botox work? You know, most of wellness actually is like, ooh, this weird health trend or wellness trend? Like, is it real? Like, does it actually work? But okay, Botox for wrinkles works. Yeah. It does. It does work. There's not much controversy here. You can see it all around you, especially if you're of a certain age. So the question really here isn't efficacy. But the question surrounding that. And one of the big questions is, is there such a thing as preventative Botox? Emily, you're an economist. Do you think there's an economic motivation to for people to argue for preventative Botox? Just asking. [00:46:00]

Emily: [00:46:00] Do.

Perry: [00:46:00] I do.

Emily: [00:46:01] Baby Botox? Yes. I mean, look, one of the problems with something like Botox is you're limited to a time period in which people have wrinkles and also still care about how they look. So that's actually like, you know, of course everyone cares about how they look, but like at some point it just is like, okay, most people are going to be like, you know what? I'm going to age, age gracefully. So let's say, you know, you start maybe it's like people from 45 to like 55, you know, that's, that's not that long. But if only you could push that, like, could we get a 17 year old and be like, hey, get your Botox in before.

Perry: [00:46:34] It's.

Emily: [00:46:34] A problem, you know, and then you've got them. And then you tell them what's great about preventative Botox from a marketing standpoint is you get people in and then you tell them, if you stop doing it, then it it gets worse. Now you're like sucked in, which I think is just a totally also totally made up.

Perry: [00:46:49] That seems BS to me. Yeah.

Emily: [00:46:51] Um, but they really, this has pushed like younger and younger and younger.

Perry: [00:46:54] Um, totally.

Emily: [00:46:56] And for, you know, because of capitalism.

Perry: [00:46:59] Perry yeah, [00:47:00] because of capitalism. Um, there's a famous identical twin study that gets trotted out whenever they talk about preventative Botox. This is from the Archives of Facial Plastic Surgery in 2006. M I'm going to show you a picture and I think I did it the right way. So I, I hid the, um, I hid. I hid who got what here. But if you look at these pictures, you can see, uh, two identical twins. Ones on the left, ones on the right. One had 13 years of regular Botox, one did not. Um. And talk to me. Which one do you think is which?

Emily: [00:47:30] I think the one on the right is the one with the Botox, like on my right. So that's DEN and f. I think she's the Botox one, am I right?

Perry: [00:47:40] Yep. You got it right. Um, for those of you just listening to this, um, uh, these are the, I love a good identical twin study. Obviously it's n of two. The argument made by the researchers and marketers about this is like, oh, look like 13 years of Botox. And doesn't she look great? Actually, they're both very pretty. And but that said, you know, this [00:48:00] is not randomized, like just because you're identical twins doesn't mean you're behaving in exactly the same way. And in fact, if one identical twin is committed to getting Botox for 13 years, you might expect that she engages in other behaviors that might be different from her identical twins, such as, you know, wearing more sun protection or moisturizing more or any number of, you know, skin health promoting things. Right. So I don't see why this is such compelling evidence.

Emily: [00:48:26] This doesn't tell you whether you need to do Botox for 13 years. This just tells you that Botox prevents like a like we don't know if what if she did it for six months. Right, right, right. Right before these pictures. Like, I don't know, you know, this isn't whatever.

Perry: [00:48:39] Yeah. I don't think you need Botox before you have wrinkles. I just it works fine with when you have wrinkles.

Emily: [00:48:45] There's all kinds of other weird stuff. Like people like to inject it in their neck, um, to like make it longer.

Perry: [00:48:51] Oh, I have a picture of that longer.

Emily: [00:48:53] How would that even work for you?

Perry: [00:48:55] Okay, this is trapezius Botox. So your trapezius [00:49:00] is the sort of strong like if you shrug your shoulders, that's the muscle you feel contracting that brings your shoulders up towards your neck. And, you know, if you really work out that muscle group, it can hypertrophy and you get kind of like a triangle shape going down from your neck to your shoulders. I think in men, you know, many men are kind of actually going for this, but women might feel Emily's like, Emily's checking right now.

Emily: [00:49:23] I have trapezius. Like I have that right now.

Perry: [00:49:26] Well, if you did and you didn't like it, you could inject your trapezius to paralyze at least parts of them. And that would sort of smooth out the line there and I'll put up the picture. M what do you think of this before?

Emily: [00:49:40] Definitely. You can see this person has a smoother shoulder after this.

Perry: [00:49:46] Does it matter? Like um aesthetically I don't care. Do you? You're women are more critical than men about how women look.

Emily: [00:49:54] I don't I, I.

Perry: [00:49:55] Like what do you think?

Emily: [00:49:56] I can barely tell that this like if I saw this person. In [00:50:00] reality, there is literally no chance that I would be able to notice this difference.

Perry: [00:50:06] Yeah, I mean, but to be fair, you know, a lot of these things are for the person themselves, right? Like, like if you feel more confident, if you, if you feel prettier, you'll like, be prettier or more handsome or whoever's doing this, right. Like there is that part of it. And I appreciate that. Um, the newest like sort of off target Botox thing that I saw online was, um, was jawline slimming. I'll put up another picture here of a before and after. Do you want to describe.

Emily: [00:50:38] I cannot tell this.

Perry: [00:50:39] You're not sure who's, who's who or who's the same person.

Emily: [00:50:43] These two are identical twins. Is the.

Perry: [00:50:45] Same person. Same person before and after. Sorry.

Emily: [00:50:46] Yeah, she looks literally the same. It's like she added earrings in one picture.

Perry: [00:50:51] The power of hoop earrings. Um, the the idea, at least here. Um, well, I'll tell you what they what they did. You're injecting the [00:51:00] masseter muscle, which is, um, gonna help squeeze your, your jaw when you're, when you're chewing. And so the, the bigger your master gets, it might make your jaw look a little more square and less pointy. Can I prompt your brain to see that in this.

Emily: [00:51:16] The one in the with the earrings is the is after.

Perry: [00:51:19] Yeah. That's right, that's right. So they're sort of slackening this muscle here to give a slightly more, I don't know, maybe more delicate appearance to the lower face. I think this one is very subtle. Um and I will say that there has been some evidence of um, actually like thinning of the jawbone itself secondary to this because like muscles that the muscles that attach to bones and like move things that are important. And I think I might put the trapezius muscles here to like, generally like you want them, like they're doing something, they're doing something that are, that are pretty good for you. Like the muscles in our face are important for facial expression, you know, chewing.

Emily: [00:51:56] Is so I want to get into that because I think it is worth talking about some of the risks and potential downsides [00:52:00] of.

Perry: [00:52:00] Okay, yeah, yeah, yeah. What are the risks? Yeah, talk to me.

Emily: [00:52:02] So there's a sort of basic risk associated with injecting things into yourself. Bruising, infection. Um, you can get asymmetry if it's done poorly. Um, and so, and of course it will fade, but like over a period of months. So if you, if somebody like overdoes one side of your face and then it's like droopy, you got to wait three months for that to be, uh, for that to be fixed.

Perry: [00:52:26] This stuff is incredibly potent, right? Like, so if you inject it slightly wrong, you know, and all of a sudden, like you have half a droopy eyelid for, for, for three months, because I don't want to go an episode without a Star Trek reference. I'm going to put up a picture of what is known as Spock Brow. This is what happens when you're, you know, you're paralyzing the muscles above the eyebrows. And in general, when you're injecting the forehead, the people who are doing this are trying to maintain your ability to lift your eyebrows because you. It's nice to kind of express surprise if they don't. And one gets [00:53:00] paralyzed, but the other can still go up. You get this. Look for those of you on video. This is the Spock Brow look, which I think is cool, but some people think it's a side effect. Some people don't like that.

Emily: [00:53:12] So there's also some evidence that this same kind of mechanism, the sort of like almost like frozen face mechanism might actually make you worse at reading emotions on other people. So part of how we, we recognize emotions is by kind of mimicking the faces around us. So if someone looks sad, it causes us to kind of our face to get more sad and then to like echo that sadness or happiness and people who use Botox a lot, actually, there's a little bit of evidence that they rate other they're like rate other faces differently and maybe have more trouble recognizing emotions like a little bit of neuroimaging for that. So, I mean, I don't know that this is like very strong, uh, evidence, [00:54:00] but I think it's interesting.

Perry: [00:54:02] I mean, I again, I, I think it's fascinating that like we mimic people and we, we empathize with them through our own bodies. Like that's kind of neat. If it's true, it's, it's, that's interesting to me. I mean, the flip side of it is also true, which is like in your relationships, right? Like if I'm really upset about something and my partner has a bunch of Botox and can't make the like, I'm sympathizing with you face like, could that potentially, um, you know, just like be bad for the relationship? I don't know, maybe.

Emily: [00:54:36] Maybe it's like now Botox is ruining your relationship, but fixing your square jaw problem.

Perry: [00:54:42] At least you're.

Emily: [00:54:43] At least your jaw.

Perry: [00:54:44] And your premature ejaculation is fixed. Okay. Um, so.

Emily: [00:54:50] So the other thing to say is that like, you know, you should get if you were going to be doing Botox. And I know you are because everyone does seemingly, uh, one [00:55:00] wants to be careful about where you do this. So people, there's a lot of like random, unlicensed, counterfeit Botox in your house. Somebody comes to your book book club to do your Botox. Like there are some case reports of people having serious reactions, including quite serious reactions after things that are counterfeit or in some other way problematic. So you do want to be kind of like a little a little careful.

Perry: [00:55:27] Yeah. I mean, this is, in case we haven't mentioned it, the most toxic substance on earth. Like you, you want people who know what they're doing. You want things to be stored in proper places. You don't want them to be buying them from shady labs and shady countries and things like that. So, you know, be a little careful. You probably don't want to look for the best deal out there on Botox. That's that's not necessarily the right pathway.

Emily: [00:55:51] All right. Are you smash or pass on Botox?

Perry: [00:55:54] Botox, I. I am a smash. I mean, I think great uses from [00:56:00] the medical uses we talked about. Sure. Good. Useful. Lots of cases for facial aesthetics and stuff, I think. Yeah. Makes you feel better about yourself. I got no problem with it. How about you, Emily? Smash or pass?

Emily: [00:56:12] Yeah, I am a I'm a smash. I mean, I think I think this is a very interesting space medically because it does feel to me like there are, you know, are probably a lot of other things that we could do with this that might be interesting and useful for different medical problems. So yeah, and it's like the science here is very cool. So I'm a smash even though I'm, I'm not a user.

Perry: [00:56:35] All right, that's it for Botox. Your mailbag. Question of the week after the break.

Mailbag: [00:56:45] Hi, Perry and Emily, I have a question. What's the deal with the Covid vaccine. Should healthy adults and children get a vaccine every year? What are the risks and benefits? Thanks. [00:57:00] I love your podcast.

Perry: [00:57:02] Okay, we are in vaccine season, Emily, and this is a question I think very appropriately about the Covid vaccine. So I'm getting this question a lot. I'm sure you're getting this question a lot. What are we doing about Covid vaccines this year?

Emily: [00:57:16] So I think what I have, what I have told.

Emily: [00:57:18] People based on my read of the evidence, is everyone should get a flu vaccine. I realize that's not the topic of this question, but that everyone should get a flu vaccine and that people over 65 should also get a Covid vaccine. And for for sort of healthy adults and children, the Covid vaccine is a little more dealer's choice. I would not recommend it to, uh, to adolescent boys because of some of the small pericarditis, myocarditis risks. And I think for for healthy adults and kids, the risks of Covid are quite small. You might slightly reduce your chance of getting it by getting the vaccine, but it's relatively mild. [00:58:00] But I don't think everybody sees this the same way. I'm curious what you do.

Perry: [00:58:05] Yeah. I mean, um, I see this actually at this point quite similar to the flu vaccine, um, both in terms of efficacy and risk. Actually, I think, uh, you know, the major reason I get a flu vaccine. Well, I'm a health care provider, so I have to, but I would anyway, even if I, even if I wasn't, is because having the flu sucks. Like I'm not going to die of influenza. You know, I don't have comorbidities, but it just sucks and it takes me out of the game for, you know, real flu is bad and so is real Covid. And so I feel very similarly, which is that basically everyone should get a Covid and a flu vaccine this time of year because the disease having the diseases suck and are unproductive. And of course, yes, in some small number of people, they can be quite serious. I also agree that the signal of myocarditis in adolescent boys and young men bears extra consideration that we don't have [00:59:00] for the flu vaccine. So I'm a I'm I'm a more ambivalent about that. And I wish we had some more data. You know, that being said, there's a non-zero rate of myocarditis from Covid infection as well. Honestly, the mechanisms are probably the same. We don't know fully, but it's probably across antibody reaction to the spike protein, which you can get from infection or from the vaccine. And so I sort of let it be dealer's choice for healthy young men. But otherwise I would get both.

Emily: [00:59:28] Yeah, I think let me just I will say just one more thing about why I see these a bit differently is that I think that the, the age profile of flu is very different than the age profile of Covid. Flu is, is very bad in both kids and in older adults, which is why I think the flu vaccine is quite important for kids, whereas Covid is really just, mean always a little higher risk. Everything's a little higher risk in babies. But like, you know, kids sort of school age kids, Covid risks are very, very low and it really increases a lot. The age profile is really, really sharp for, for older people. And the other thing is that the, [01:00:00] the sort of side effect profile of the vaccine is lighter for flu than, than for Covid. So many people have a sort of stronger mRNA vaccine. But I think certainly if people said like, I like to get like, great, get, get them. And you can certainly the other thing is you can get them at the same time. So people are asking like, can I go and get these at the same time? Is that a problem? Absolutely not. If you're going to get both of them, don't waste your time. Just get them at the same time. I had my flu vaccine yesterday.

Perry: [01:00:24] Excellent. All right.

Perry: [01:00:28] That's it for us today. Stick with us next week when we'll ask what's the deal with intermittent fasting.

Emily: [01:00:37] Wellness, Actually is produced in association with iHeart media. Our senior producer is Tamar Avishai, our executive producer at iHeart is Jennifer Bassett. Our theme music is by Eric Deutsch, and our content is for educational purposes only.

Perry: [01:00:52] If you like the show, help other people find us. Leave a rating and review on Apple Podcasts or your podcatcher of choice and help us spread the word [01:01:00] about the show. You can follow us on Instagram at Wellness Pod. And don't forget, we want to hear from you. Head over to wellness.fm and leave us a question for our mailbag or suggest a topic for a future show.

Emily: [01:01:13] We'll let the influencers have the last word.

SATC: [01:01:15] Samantha didn't need a man to make her feel positive, but she did need a man to inject her forehead. Every so often.

SATC: [01:01:21] We like to warn our patients that some people find it difficult to register emotion on their faces after the injections, so you might have to say, I am so angry.