We are dangerously close in the United States to spending 20% of our GNP on healthcare – this year it will top $3.2 trillion or ~$10,000 per person. Yet we lag behind virtually all other Western democracies in nearly every health biomarker, including longevity, where we rank an astonishing 34th, despite being the wealthiest country in the world, and despite having a healthcare system that is generally regarded – at least at its best – as perhaps the most advanced, even if its coverage is highly uneven demographically. How and why are we getting such poor results in relationship to such a staggering amount of money here in the US? In my opinion, it comes from a perverse set of upside-down priorities, in which we will spend $100,000 in relationship to an advanced disease of aging at or close to end of life, but we won’t spend a fraction of that to prevent or meaningfully delay that illness – in other words, we really don’t have a healthcare system we have a disease-care system. And we don’t prioritize ‘primary prevention’ but rather secondary prevention. Primary prevention means fundamental lifestyle change that prevents risk biomarkers from emerging, while ‘secondary prevention’ means chasing those biomarkers, and an emphasis on conventional interventions such as statins and beta blockers.
Everyone is familiar with the aphorism that an ounce of prevention is worth a pound of cure, but in relationship to the diseases of aging (cardiovascular disease, type II diabetes, cancer and Alzheimer’s disease being the Big Four) that are breaking the back of the healthcare system, the real ratio might be that 1 ounce of prevention is worth 500 pounds of cure. Not simply from the standpoint of medical economics, but from the standpoint of reducing the enormous suffering associated with virtually any disease of aging as it advances, due to their universally punitive impact on quality of life. Although there a current emphasis on reinvigorating prevention and primary care, less than 5% of our healthcare dollar goes there. I believe we have been literally brainwashed into embracing this upside-down system, with much of this supplied by powerful vested interests committed to protecting their share of a $3.2 trillion pie.
In my judgment, most of these consequences stem from an uncritical acceptance of the central ‘meme’ of our civilization – that our technology, can and will solve virtually any problem, a notion that justifies the increasingly expensive applications of technology to problems that simply don’t have hi-tech solutions. We have little critical distance from this ‘meme’. Hasn’t technology and our genius for it been the key to our success . . . the unambiguous pathway to our total dominance on planet Earth and its literal transformation by our technology? Putting aside how that transformation now threatens us with the greatest crisis in our history as a species (in relationship to climate change), don’t science and technology still offer the best hope for conquering human diseases? This is clearly what the medical industrial complex would want all of us to believe. Like the other more famous complex, the military-industrial complex, it functions as a powerful and distorting set of vested interests. We are bombarded every day on TV by messages to the effect that first-line drugs are our best defense against the diseases of aging. But these notions blind us to how various technologies, particularly our sedentary tech-assisted living and our technology-driven agricultural diet, are a very large part of the problem.
Won’t science and technology eventually provide simple cures for these conditions? The notion of a simple cure in relationship to all of the diseases of aging seems increasingly elusive, as they have no single or simple cause, but rather emerge from a host of age-related processes and mechanisms that are deeply interactive. And the current costs associated with these diseases are simply staggering. We currently spend $300+ billion a year in relationship to both direct and indirect costs for Alzheimer’s disease, even more than that in relationship to heart disease and stroke, and roughly $150 billion a year in relationship to cancers. Alzheimer’s disease is posed to explode, and without a fundamental treatment breakthrough, its costs may crest $1 trillion a year by the year 2040-2050. This past year we spent $300 billion on prescription drugs in the US – that’s almost $1000 for every man woman and child in the US! The fraction of these diseases that are deterministically created by our genes is probably under 1-2%. Instead, the vast majority of these conditions and their manifestations as we age emerge from complex interactions between genes and environment, and where the enormous preponderance of any form of reversible contribution is entirely emerging from lifestyle issues, even if a future medical technology might allow amelioration of the more risk-prone gene products and effects. In other words, Western lifestyles, interacting with various polymorphisms and other minimally understood genetic vulnerabilities may determine who gets Alzheimer’s disease, who gets heart disease, and who gets cancer. Differential genetic vulnerability may explain why some people can smoke and live until their middle to late 80s, while other people who smoke die of a heart attack in their 40s. But that complexity aside, research suggests that the bulk of the trouble that we can address in a meaningful way is mostly emerging from our lifestyles and not from our genes, as modification of those risk-prone polymorphisms is well beyond us. And such an approach may even reflect a mis-emphasis, in terms of our perpetual gravitation to the most high-tech solution possible.
What we have discovered piecemeal in an enormous volume of biomedical research about the so-called ‘healthy lifestyle’ can be summarized in an astonishingly few bullet points:
- regular aerobic exercise at least 4-5 times a week for at least 30 min. a day, and more is probably better;
- a diet characterized by a primary consumption of fruits and vegetables, a relative absence of heavily processed foods and processed carbohydrates, refined sugars (sugars not coming from fruits and vegetables in other words), and a major reduction if not elimination of most dairy products – a basic dietary pattern roughly corresponding to a Paleolithic or a modified Mediterranean diet (which allows grains and dairy products while a Paleolithic diet would not);
- a good night’s sleep of at least eight hours (and somewhat more if younger or exercising heavily);
- protein sources in meat, fish, and poultry uncontaminated by antibiotics, other industrial toxins, and raised in their native environments and on their native diets, where the omega-3/omega-6 ratio approaches 1 to 1 or at most 1 to 2;
- enough sun (or vitamin D supplementation) to generate reasonable vitamin D levels (although what constitutes a reasonable level is still hotly debated);
- and last but certainly not least, an absence of social isolation, with good social support, social and intellectual engagement in those contexts, and stimulating peer groups.
While there might be debate about a specific dietary element or component here or there, this broad picture is generally congruent across many studies. While these things all sound quite achievable, given that less than 15% of the US population is exercising regularly, and less than 15% eat adequate amounts of fruits and vegetables every day, while social isolation is rampant in our country, and that eating wisely is more expensive than eating poorly, one suspects that the percentage of individuals in the US actually hitting all these targets may be under 5%. And the fortunate few that do are likely well-educated upper and upper middle class. The fact that we don’t even know what percentage of us are hitting all these desirable targets speaks to the fragmented and systematically mis-informed nature of our research into the most critical variables effecting our health. As our healthcare system faces a potential tsunami of age-related disease in the baby boomer generation, which threatens to swamp the system in the coming two decades, we seem to have no concept of the real problem.
A very interesting and rarely asked question is “what might unite all these lifestyle factors as a common denominator”? This unifying context explains what I mean by the title ‘health in an evolutionary perspective’. A surprisingly high percentage of physicians trained and inculcated in the thinking of the biomedical industrial complex cannot give an answer to this scientifically fascinating and strategically critical question. Unambiguously, the answer is that these characteristics of healthy lifestyles are all shared characteristics of our ancient pre-agricultural environment as hunter-gatherers. Many medical students, post docs and even senior colleagues would give me a quizzical look when I would talk about an evolutionary perspective on health – as though modern medicine has essentially forgotten Darwin’s seminal insight about the fit between organism and environment. As hunter gatherers, we were phenomenally fit, in large part from chasing our dinner. The males often times covered ~ 25 km a day, while the females (who were typically carrying both the smaller children and the food preparation equipment) may have covered ~ 16 km a day. So we were fitter aerobically than all but the fittest athletes in the current day. We had no TV, Internet, or even electricity, all these distracting wonders that we now take for granted were thousands of years in the future, so when the sun went down, so did we, and since we were no doubt quite exhausted from chasing our dinner, we probably slept at least 8-9 hours a night, and very soundly, given the evidence of a critical relationship between aerobic exercise and slow wave sleep. We ate every conceivable type of edible plant, had fiber intake > 30 g/d, perhaps as high as 50-100 g per day, were outdoors in the sun for many hours, and we were virtually never socially isolated. If we fell out of our tribe, in all probability, we were likely soon dead, as survival alone without the support of the group would have been hugely challenging. We had at most minimal grains in our diet, no other agricultural products of any kind, no dairy, and our only sweets were honey, fruits and their juices.
The last item on the list – social connection – looks larger and larger in relationship to every single major disease and disorder afflicting our health and swamping our healthcare systems, particularly the syndrome of depression, but also is a major risk factor in relationship to every other disease of aging. Indeed depression – which is now the single most expensive condition in Western societies if you add the cost of treatment to the cost of lost productivity – appears to be potently activated by protracted separation distress in its many forms, rather than any version of a simple ‘chemical imbalance’ as big Pharma might have us believe. And yet how many physicians and healthcare providers – outside of psychotherapists – actually take the time to meaningfully inquire into the state of the patient’s social world, and find out whether they have good social support and viable attachments?
Here’s an even more disturbing question to ponder: how many healthcare contacts actually examine in any meaningful detail all of these critical four major areas (diet, exercise, sleep, and social support)? I would wager that well under 1% of clinical contacts between patients and the various health care disciplines deal with even just two of the four lifestyle dimensions. We have been systematically blinded to this, the real ‘Big Picture’ of health – that health can’t mean relying on high technology but on reducing this chronic and destructive mismatch between our genes and our modern environment, by aligning lifestyles with the lifestyles of ancient humans with whom we share 99.99% of our genome. We are asking that genome to function in an alien, almost unrecognizable, environment. As one of my residents, fully steeped in the myths of the medical industrial complex, wondered “what does Darwin have to do with health or healthcare?” The gene-environment fit (or mismatch) has everything to do with our health, but almost nothing to do with our healthcare system. Is it any wonder therefore why our healthcare system is failing and failing so badly?
Dr Watt’s Bio:
Dr. Douglas Watt was trained in psychology and neuropsychology at Harvard College and Boston College, completing his PhD studies in 1985 after getting a BA in 1972 at Harvard and a Master’s Degree in Psychology at Northeastern in 1976. His dissertation addressed commonalities as well as differences in the presentation of severe character pathology in hospitalized inpatients. After completion of his doctorate, he did his postdoctoral internship year at Human Resource Institute, specializing in projective psychological and neurocognitive assessment of hospitalized in-patients. Over the past 30 years of clinical practice, he has served as Director of Clinical Psychology/Clinical Neuropsychology in two local Boston teaching hospitals. He was on the faculty of the Boston University School of Medicine for 15 years, and was also a faculty member at the Boston Graduate School of Psychoanalysis and Institute for the Study of Violence for four years, where he has taught doctoral level courses on affective neuroscience and its implications for the clinical mental health sciences. He also has had a community teaching faculty appointment at Harvard Medical School, teaching a yearly course for postdoctoral fellows in neuropsychology, neurologists, psychiatrists, and neuropsychologists in clinical neuroscience, neuroanatomy, and neurodegenerative disorders from 2007 until June of 2013, when he finished his part time appointment at Cambridge City Hospital.
He has published roughly 70 peer-reviewed articles, book reviews and contributed book chapters, including three contributed chapters (with co-authors) on Alzheimer’s disease, confusional states, and frontal system dementias to the recently released Springer reference series in Neuropsychology, edited by Noggle and Dean. He has presented over 100 times to local, national, and international groups on clinical syndromes in neuropsychiatry and neuropsychology, and on topics in cognitive and affective neuroscience. He has co-authored with Jaak Panksepp a lengthy target article on the neurobiology of depression, emphasizing its conserved evolutionary basis and its primary relationship to separation distress, social defeat, and other aspects of social stress. He is currently writing and co-editing a book with Dr. Panksepp on the neurobiology and psychology of empathy to be completed in 2015.
In his spare time (what little of that there might be given this deplorable excess of interests), he is passionate about photography, coaching and teaching tennis, and travelling with his wife.