300: The Indoor Epidemic: Why Nature Is the Missing Medicine for Burnout, Sleep, and Performance, With John La Puma

What if burnout isn't simply a workload problem?

In this fascinating conversation, Dr. Pelè sits down with physician, chef, regenerative organic farmer, and two-time New York Times bestselling author Dr. John La Puma to explore a surprising idea: many of the health challenges we blame on stress, aging, and burnout may actually be linked to the fact that modern humans spend approximately 93% of their lives indoors.

Drawing from more than 2,000 scientific studies and the research behind his new book, Indoor Epidemic, Dr. La Puma explains how natural light, fresh air, distance, movement, and time in nature directly influence sleep, mood, memory, focus, cardiovascular health, and even leadership performance.

They discuss:

• Why "nature is not a luxury, it's a biological requirement"

• The concept of "digital obesity" and pixel overload

• How morning light impacts deep sleep and brain health

• What healthcare organizations can learn from hospital design research

• Why burnout may actually be a symptom of under-restoration

• The surprising minimum effective dose of nature for better performance

Whether you're a healthcare leader, executive, clinician, or simply someone who spends too much time in front of a screen, this conversation may change the way you think about productivity, wellness, and the environments we create for ourselves and others.

Transcript

Welcome And Meet Dr. LaPuma

Dr. Pelè 0:07

Welcome to the human side of leadership and healthcare. I'm Dr. Pele. On this podcast, we explore how leadership is experienced in real moments, not just defined in theory. Today we're talking about an aspect of healthcare leadership that many organizations overlook entirely. The environments we create for the people who deliver care and for the patients. It is truly my pleasure to welcome Dr. John LaPuma. John is a board-certified internist, professionally trained chef, regenerative organic farmer, TEDx and TED Med speaker, and two-time New York Times best-selling author. And he has a new book, Indoor Epidemic, and we're going to talk all about that today. John, welcome to the show. I'm really glad you're here. Dr.

John La Puma 0:56

Pillet, how great to be with you. Thank you so much. Oh, this is awesome. So, first of all, you're a chef too. I was lucky to be trained, and I worked for Rick Bayless for four years after I graduated from cooking school in Chicago and was on the line from noon to midnight on Fridays, went to clinic on Saturday morning.

Dr. Pelè 1:15

Oh my goodness, you are just all over the place, and it's so amazing. I'm so excited to learn more. And on that note, you know, you spent a career exploring food as medicine, culinary medicine, and now nature as medicine. And we'll talk about your book coming up shortly. But what first led you to become interested in the relationship between some of these environmental things and health?

John La Puma 1:40

I've always been interested in what seems to make a real difference to people personally in their own lives, as much as I've been interested in the medical problems that they have. And I wanted, I think, throughout my career to find ways to bring some of that personal interest into medicine. So my first career was in medical ethics, my second career was in food, and I taught the first culinary medicine class in the country to U.S. medical students with my friend and colleague Mike Roisen, who is the head of the wellness center at the Cleveland Clinic and the founding director. And now we're on to nature as medicine, where I taught the first skills-based nature as medicine course in the U.S. for practicing physicians with the UCLA School of Medicine just last year. And that seems to be what ties it all together to get clinicians in a place that doesn't have any PowerPoints. And the six-hour course that we put them through, that curriculum lowered their blood pressure by 10.3% systolic and 8% diastolic. Wow.

Dr. Pelè 2:56

When did you begin to suspect that some of these

From Culinary Medicine To Nature

Dr. Pelè 3:00

problems, you've mentioned, you know, some of the health things already, that we attribute to stress, burnout, or who knows, aging, might actually be connected to how disconnected we've become from the natural world. When did you arrive there?

John La Puma 3:15

It was, I think, around the time that I bought my own farm. I have a little three-acre place in Santa Barbara that in the Midwest would be known as a big backyard. But here it's an organic farm that we farm regeneratively. And it was an abandoned sand dune at the time, abandoned flower nursery. It was decrepit and lots of old cars and it needed a lot of attention. But I thought I didn't have to really pay attention to it because it looked kind of like an old sand dune with abandoned buildings. So I thought I could go along my merry way and be on TV shows and write books. And I was on a fancy New York TV show and uh after the last book in 2014 or around 2014, and I just for some reason couldn't wait to get back to the farm, even though I wasn't really growing very much then, and I just started to plant things, and I didn't understand why it was so interesting to me, why I was so compelled to try to make something of it. And so I read 2000 studies in the medical literature and put together this idea that uh that is being known as chronomedicine or circadian biology, but actually starts with the idea that we are the first humans to live almost entirely indoors and our biology simply hasn't caught up. And that's what got me started. And with this research, I put together a protocol that I think works for a lot of people in sleep and mood and memory and mood and focus.

Dr. Pelè 4:48

You mentioned um, you know, this idea in the book, in the book Indoor Epidemic, which, by the way, I love that title. You know, you're sort of playing, playing with some things there. I love that. Um, you you mentioned the idea that just as you said now, we humans spend a lot of time indoors. We're the first version of humans that are spending this much time. I think you say approximately 93% of our lives are indoors. Can you kind of map out for us why that matters biologically? Like, why is that a problem?

John La Puma 5:22

It's because when you're indoors, you don't have any natural inputs. And nature isn't a luxury, it's a biological requirement. It's often the cheapest intervention in the building. And like outdoors isn't exercise, it's input, it's regulation. Uh, I write a chapter in the book on forest bathing, which really ought to be called neuroendocrine optimization. It's a we light and air and movement and distance all have physical biological effects on your metabolism, on your brain, on your muscles, on your vision, on your uh cardiovascular system, and yet we treat them like we can just operate solely 14 hours a day in front of a device. And what's happened is that um people are getting burned out on pixels, burned out, period. But part of that is that people aren't burned out, they're simply indoors too much, surrounded by pixels too much. Like too much sugar burns out your metabolism, too many pixels burn out your brain. People, so your best people aren't disengaged, they're under-restored. And that under-restoration is because they don't have the natural inputs that they need of light, air, and distance in a quantifiable, measurable, prescribable way.

Dr. Pelè 6:52

I love the way you uh sort of paint that picture. In fact, I love the words forest bathing. That's a cool one. You're you're you're you're pretty good at bringing these uh concepts together that people understand and may, you know, may understand better with uh an analogy. And I have one for you that I enjoyed from your book. You say digital obesity is a problem. And you've sort of touched on that right now a little bit with the pixels uh conversation. But what do you mean by digital obesity exactly?

John La Puma 7:20

I mean just the saturation we have of being on a phone, a tablet, a screen, a television, a monitor. You know, we go to we wake up and we look up at our phone, we go to bed as a wind down, looking at screens at night. And that is too many pixels for our brain to process. We without any kind of restoration, without any kind of reset. Um, and that's resulted in people not just being exhausted and anxious and foggy and lonely in ways their biology can name even when they cannot, but this is an indoor saturation. Interestingly, a small, repeatable, prescribable dose of 17 minutes a day, 17 minutes is the minimum effective dose. You need to be outdoors intentionally in a blue or green space, or both of them, to begin to shift mood and memory and focus and your physiology, cortisol level, insulin level, and blood pressure.

Dr. Pelè 8:28

I grew up in

Why Indoor Life Breaks Biology

Dr. Pelè 8:30

Africa when I was very little. Of course, where I grew up, hey, we had nature everywhere. So, what I'm hearing you say is that your message is different from those people who say, hey, you're burning out on technology, stop using technology. You're saying stop using technology and go outside. Because the going outside and the getting involved in nature is actually the added benefit here. Is that what I'm hearing?

John La Puma 8:55

Stop using technology all of the time and go outside at the right time with the right timing for the minimum amount of time minimally, and 43 minutes a day optimally to improve performance, improve productivity, improve presenteeism. Bigger problems, I think, are extant in businesses because of presenteism rather than absenteeism. Because when people are at work, they're not truly engaged. You know, and we try to solve this with like wellness webinars. A 70-minute outdoor dose at the right time with of light movement and air is a reinforceable daily behavior. A wellness webinar is not. So you can't medicate your way out of an indoor life, and I think there were staff as proof of this. Um, we've medicalized what is partly an environmental deficiency. Our biology is deficient of the outdoor inputs our it needs to run. And for example, you know, 10 minutes of morning light at the right time, in the right place, can do what a sleep medication often cannot. And some sleep medications actually take away deep sleep, which 10 minutes of morning light uh gives you. And deep sleep is the non-REM uh time of sleep in which you rebuild bone, you repair muscle, you consolidate memory, and you brain clean. The lymphatic system runs then, which is a brain cleaning system discovered in 2013, Nobel given 2017, where your brain shrinks by 40% during deep sleep, and your spinal fluid in your brain washes over it and takes out the toxins of the day, beta amyloid and tau proteins, which accumulate during the day and accumulate during Alzheimer's disease. If you don't brain clean, you don't get rid of those. You don't take out the trash. You need deep sleep to get the lymphatic system to run. It only runs in the first half of the sleep night. And you need to set morning light, have morning light at the right time with the right intensity, without sunglasses or through a window, to get that deep sleep. So there are a lot of pharmaceutical equivalents, interestingly. Um, bright outdoor light has been tested in a randomized control trial, an hour of bright outdoor light versus an initial dose of Prozac and found to be equivalent in depressive symptoms. Um, forest bathing, which we were talking about earlier, which by the way is not taking a bath naked in a forest, it's being surrounded by trees and cycling through your senses and simply noticing what's around you. Your senses, by the way, touch, listen, see, smell, taste. But if you cycle those a minute each, two minutes each while you're in the company of trees, things really change. You begin to see things you didn't see at initially because you were so occupied by what was at uh what was there what there was to do. So uh these are the kinds of things that I teach and that I describe that I read 2,000 studies to put together. It's really powerful medicine, especially about sleep, focus, mood, memory, and cardiovascular disease.

Dr. Pelè 12:38

Your book is probably applicable to humans outside of healthcare. Oh, yeah. And we'll we'll we'll get to that. But healthcare workers specifically, I mean, they spend enormous amounts of time indoors, under artificial lighting, often irregular hours. My my wife is uh is uh an ER doctor, ER physician, so I know this uh very well. But and of course I know they're they're very vulnerable to the challenges you're describing. How might healthcare organizations think differently about these environments? Are you suggesting that they actually create new architectural footprints and and uh ways of building? Is that part of where you're going with this?

John La Puma 13:23

Some of the initial studies of that were done that I reviewed for the book are powerful in, in fact, hospital architecture and and hospital design and clinic design. Uh in 1984, Roger Ulrich, a landscape architect, did a study that identified people on either side of a hospital hallway, some half of whom it all had a gallbladder operation, half of whom had the view of a window and greenery at that window, and half of whom had a window viewing a brick wall. The greenery view used 22% less opiates, fewer pain medications overall, left the hospital eight-tenths of a day early. It actually changed hospital architecture. Uh, it's been cited 6,000 times in science, in the journal Science. Um, but we don't need to redesign hospitals, although many of them could probably use it. We just need to know that your best people aren't lazy. They're running on a circadian system that has not seen real morning in months. And um that morning light that they haven't seen

Digital Obesity And The Outdoor Dose

John La Puma 14:30

in months is um uh makes their whole biology shift. Uh, 50% of our genes are run by their circadian rhythm, by your body clock. And they run optimally when your body clock is set. So we need to build into healthcare and other performance and productivity-oriented businesses ways for workers to get some respite, to be able to clear their brain and not be penalized for it, like they're not working. Um, you know, a lot of people have anxiety that looks like burnout. The low hum of dread on the floor is not a personality problem, it's your brain, the default mode network in your brain stuck on. So what we need to do is be able to give people a neurologic reset. And that uh 2 p.m. brain fog that people get, um, that's that's part of this burnout. It also can be part of having too many people in a room and the carbon dioxide levels rise. If you push past uh thousand parts per million, your cognitive function drops by about 15%. And some of the most progressive companies have CO2 meters inside of conference rooms. So there's a lot we could do inside of buildings, but actually, even better, we can give people the structure to allow them to reset their brain in hospital gardens, in hospital parks, in a hospital greenery as part of their workday, because they need that to not be overwhelmed, not just by the stress of care, but by the stress of screens and the overwhelming dim light of screens, which is actually part of the cause of myopia or nearsightedness.

Dr. Pelè 16:16

One of the things I uh really enjoyed when I researched you a little bit, uh, and by the way, I already told you that I was born in Africa and grew up there, was you know, the article about some of your work and you know the African context, you know, just the whole nature as medicine. I wonder what what um maybe you could tell us a story about that. Just uh let us know about that Africa trip and and what you learned from that.

John La Puma 16:43

Um my trip was amazing because it showed me that other cultures really take what we have as very special and use Circanian biology naturally. You know, I'm not advocating going back to waking up when the sun rises and going to sleep when the sun falls and having 12 hours in bed and going back to a sort of more prehistoric kind of existence, or one that in this country was 200 years ago. I think I'm all in favor of cognitive work. I love technology. I have two different trackers on right now, uh, and we are speaking on screens. But I think that what that showed me is that having that basic rhythm does allow people to have a modicum of joy and a modicum of not just sync with the elements, but the ability to use the elements as medicine. And one thing that we don't name often is isolation. And isolation carries a mortality risk of 15 cigarettes a day, and when you stay inside as much as healthcare workers do, or most office workers for that matter, and it's 93% of the time, 86% in buildings and 7% in vehicles, what happens is that you are isolated. And indoor work culture kind of manufactures it. It's silent charting time, it's to eat at the desk lunches, it's parking garage to elevator to cubicle days. And that's not just abnormal, and not just abnormal since COVID. It's abnormal for our biology. It disrupts our sleep, which is, by the way, the easiest thing to fix that I cover in the book. It disrupts our memory so that we think we're losing track of things, and it's simply that we're overwhelmed and haven't given ourselves a restore break. It actually elevates blood pressure. Half of people, 40% of people go to sleep with a lamp or a TV on, and that increases risk for heart attack by 50% and stroke by 30%, with a huge JAMA study published just late last year. We can fix a lot of these things, but first we have to name the problem. I think shared outdoor time, even 10 minutes, is the most underused cultural intervention that we have. And the question we ask least in medicine of patients is where do you spend your time? If you ask that of a patient, you might be surprised what they say. Almost no one says, I intentionally go out and work in my garden or walk in a forest or go to a meadow or go to the pool or go to watch a river run. And yet those activities have biological meaning that improve blood pressure and immunity and cardiovascular system, mood, memory, anxiety, depression. It's remarkable. The data is all there.

Dr. Pelè 19:57

You know, one of the themes of this podcast is that leadership is revealed sometimes under pressure. And, you know, you are no stranger to the fact that all this sleep deprivation that healthcare providers go through and you know, the chronic indoor working and things like that are affecting them in terms of emotional regulation or resilience and different things like that. If a healthcare leader wants to improve their performance or team performance, how would they think differently differently uh based on your approach to what they do, the environments they create? What can healthcare people that may be listening do next, given what what you're talking about?

John La Puma 20:41

They can model the behavior, for one. Um leaders who hold a meeting walking outside are not being soft. They're prescribing a neurological reset. They're practicing, they're walking the talk, literally. Uh leaders who have a lunch outside are

Healthcare Design And Leader Reset Habits

John La Puma 21:00

using the environment, the rich microbial environment of outdoors, and outdoor air is almost always cleaner than indoor air. And outdoor light is always 25 to 50 times brighter than indoor light. And bright light is what you need during the day to reinforce cortisol rhythm to show that you're awake and to get the best performance from people. Leaders can um can uh model this as Edelman PR did. Edelman PR is the largest PR company in the in the country, and perhaps in the world. And when I gave a talk there in March, they changed their policy to walking Wednesdays in their New York offices, just their New York offices, um, and had everybody go out at Wednesday and walk together to A meet other people, B, go to lunch, C get away from the break, the overwhelming of pixels and D to improve creativity. Because the data show from Stanford and from Cornell that you get better creative idea generation while walking and while engaging in non-pixel activities than in pixel activities. And so leaders need to view this not as a soft thing or burned out as a character flaw. It's not. It's a pixel overwhelm that needs a neurological reset that is prescribable. And uh I like this example from Edelman PR, which, you know, is no stranger to serious financial work and very large accounts with the company, with the world's biggest companies, saying, listen, we care about our workers enough to give them the time that they need to reset their brains. Because we want the best work from them, and that's they should have that. But people can't give that without being restored. And the signal that quiets anxiety is sky, horizon, water. Your eyes need distance like your lungs need oxygen. You have what I tell people to do in the morning is to go out and get 10 minutes of bright morning light without sunglasses, not through a window, through a step out of a doorway, you don't have a doorway, go to a threshold, don't have a threshold, go to a fire escape. And look in the distance. You can't see the sky. See the furthest rooftop you can. And look as far as you can. Most people spend most of their time not looking more than 20 feet in front of them. And your biology is paying the price.

Dr. Pelè 23:47

You also mentioned uh in your book uh kind of a focus on the impact of all of these issues we've been discussing on children, adolescents, families. What concerns you about children, for example, for the next generation growing up indoors?

John La Puma 24:04

You know, we've seen a rise in antidepressants in teenagers of 69% over the last six years. Kids are um the my the epidemic of myopia in kids, nearsightedness in kids, 40% in California, 90% in Singapore, and that's because of dim indoor light. It's not just a screen problem where your eyes focus on something this close, like here's my phone, this this close, so that the eye physically elongates. It's that it's retinal dopamine not being power being released minimally when you're indoors, but maximally when you're outside. So the eye physically elongates during and causes myopia because kids are on devices so close, and because light indoors is so dim relative to light outdoors. And that's a fixable problem, and actually it's a fixable, dangerous problem because nearsightedness, about 5% of myopia, turns into high myopia, which is corneal damage and retinal damage, and other eye damage in your 30s and 40s that can be irreversible. So when parents tell kids to go out and play, it's not punishment. When I was a kid, going outside and we were told to go outside and play and not come back until after dinner, and or until dinner rather. And that you know seems romantic and old, but it was it was safer, many people think back then. What a lot of people don't realize is that kids don't have the social skills that they used to because they're not meeting kids outside to play. And uh anybody who's constantly on a device has that same inability to connect. It's now kind of hip for young people to meet at a bar. They think it's so OG. And and I guess it is, but it's also how you connect with other people. Isolation and loneliness has the mortality risk of 15 cigarettes a day. But nature is social. You meet people when you're outdoors, and that's a good thing. It's a good thing for longevity, um, it's a good thing for your telomeres, it's a good thing for oxytocin release. When you walk with someone, you're releasing oxytocin and it actually feels better. And outdoor exercise is about 20% less perceived exertion than the same exercise indoors. There's a lot here that leaders can take advantage of in helping workers who want to do the best job that they can, but are not lazy. They're running

Kids Indoors, Loneliness, And Hope

John La Puma 26:50

on a circadian system that's not seen real morning light in months. And the fix is 17 minutes minimum effective dose daily.

Dr. Pelè 26:59

You uh have made the case that I think healthcare is trying to solve burnout while ignoring one of the biggest problems or root causes of burnout. That's right. But I I wonder, I wonder what your what gives you the most optimism? You know, for example, do you think nature-based medicine, like what you propose, becomes mainstream soon, you know, in the next decade or something? What makes you feel optimistic here?

John La Puma 27:24

When I taught the first class in culinary medicine with my friend Mike Royzen at the Cleveland Clinic at SUNY Upstate in 2003, it was the first class to medical students in the country. It's now taught in about 80% of medical schools. I think nature-based medicine is in the same direction. I think uh the we taught the first skills-based CME in nature-based medicine with UCLA last year at my farm for six hours. Um there have been a number of other CME courses in nature's medicine before this. Uh, Harvard is teaching an elective in forest bathing. There there will be, there are already signs that these ideas are going to be adopted. But the real underlying structure is that of chronobiology and understanding chronomedicine, which also affects when vaccines are most effective, when medications are most effective, when uh interventions, other medical interventions, surgeries are most effective. Um, chronomedicine is broad, and in an indoor epidemic attempts to identify the piece that indoor confinement is rendering us helpless with until we change our circadian rhythm and get the reinforcement from the outdoors that we need to improve performance, improve productivity, improve happiness and medical problems such as anxiety and depression and high blood pressure. So, what I like is that this is already being adopted in some medical settings. And when people read the book and try what I suggest for sleep, for example, and and tell me or write to me or call me and say, hey, that really worked, I go, that's amazing. I'm so glad for you. Yeah. But and and you know, it's not a it's not like you have to throw away all your sleeping pills, although I think you ought to try it before you try sleeping pills, um, because some of them take away deep sleep, and having morning light at the right time without sunglasses, not through a window, gives you deep sleep. Uh then um that's just powerful. I love it when people say that. And and all there are 250 ways to do this in the book. I wrote the book kind of as a workbook, so people would have a lot of things to do when they're going outside. So just try one and see if it works. It doesn't, try another. There are lots of choices.

Dr. Pelè 30:00

Dr. John, you have made the case for my favorite uh saying, which is there's a difference between knowing and doing. Right? Uh we can provide all this information, but until people actually go out, try these things, do these things, they're not going to see the results. And I think that's uh that's a powerful message. But first I want to tell you that I truly appreciate this over overall message. I think uh we completely neglect it. I know that I'm inside way too much, uh, even though I have my background from Africa. So it really connected with me. Your the message in your book is powerful. Thank you so much.

John La Puma 30:37

It's very kind of you, Dr. Pillet.

Dr. Pelè 30:39

All right,