Why an article on longevity in this newsletter? Whereas we may all have a personal interest in increasing longevity, there is probably also agreement that a significant prolongation of human life in our society creates more problems than it solves. In a modern revival of “The Twilight Zone” some months ago there was an episode in which Death took a vacation. Havoc ensued quickly. The emergency room doc who had to deal with the fallout came to realize how merciful death can be. By the end of the show, however, he was cut down as well. Having embraced death, it in turn embraced him. It is understandable to want a personal exemption. Woody Allen once allowed that he did not actually mind death. “I just don’t want to be there when it happens.” But this piece is about life, not death. It is certainly in everyone’s interest that our functional capacities be maintained as well as possible as we age. And better health is probably correlated with longer life expectancy. Also, we observe that even in the absence of a policy objective, longevity is quite simply increasing. It is worth looking at the particulars of this development.
An article in Scientific American a few months ago compelled a revision of the standard view that mankind is endowed with a fairly well-defined life span, although life expectancy could fall well short of that in different cultures and communities for many reasons. The standard view was that as causes of premature death were gradually managed, more people would simply bump up against that natural life span. But this life span is quite clearly increasing gradually in a number of developed countries. We are encountering no hard limits. The marginal death rate is declining across the age range.
A second stimulus for this piece came from the recent speculation about the possible retirement of one or more Supreme Court justices. Despite their advanced age, all of them have decided to continue. This is not just true of the present court, as it happens. Throughout our nation’s brief history, most Supreme Court justices lived to a ripe old age, and died while still serving. No “65 and out” for these people. This reflects the historical life span argument: old age was then what it is now. What skewed the life expectancy early on was early childhood death, and death in connection with childbirth, warfare, or pestilence. Still, this history merits the question, how did these men manage to maintain their mental skills to such advanced age? Britain just lost its oldest World War I veteran at the age of 108, mentally alert to the end.
A third stimulus for this issue was raised in an earlier newsletter, written in Germany. What accounts for the greater life expectancy in nations that appear to be violating the rules of good health with respect to smoking, alcohol consumption, fat consumption, sugars and carbs. What gives these folks special dispensation? The French diet is said to be as bad as the English one, but their cardiac mortality is much lower. Other examples could be cited.
A fourth and final stimulus was the recent proposal to fabricate an omnibus pill to reduce cardiac mortality. By combining various magical ingredients that target specific cardiac risk factors, and assuming that individual benefits are additive, a risk reduction by 80% was thought to be achievable.
Whereas I have raised a scientific question, I am not going to claim to answer it scientifically. Rather, I will indulge in some educated speculation. And I welcome your feedback. I would like to identify key themes that jointly could explain both where we are and where we might be going.
An article in a German newspaper pointed out that traffic lights were being timed on the basis of pedestrian walking speeds. These were clocked at roughly 1.47 meters/second (>4.8 feet per second!). Not only does this seem rather fast, but it was observed that larger cities lie on the upper end of the range, as do northern cities. Here we have our first clue. The pace of life is faster in our modern urban societies, and carries with it considerably greater stress. Could adverse stress response be a key determinant of life expectancies, now that we are no longer undone by childhood infections?
Another article observed that the cardiac health in German women was declining over the years and was about to match that of men. Smoking had something to do with that, of course, but it was postulated that the decline in physical activity among women from generation to generation was the real culprit. Women had seen a significant decline in physical labor. They no longer washed clothes by hand, etc. The traditional German Hausfrau certainly had been a whirlwind of domestic busywork fifty years ago, and no one would yearn for a return to those days. But physical inactivity could be a contributing factor as well in this relative decline in health among women. Also, women entering the workforce were seeing a different kind of stress than they traditionally had to live with.
And now it is time to flog the American diet, both for what it delivers and for what it fails to deliver. We clearly have an epidemic of obesity in this country, and things are getting worse. When looked at from this vantage point, obesity is the fastest growing cause of disease and death in the US, and has even been fingered as the dominant cause of premature mortality when its role in disease is properly taken into account. Ours is probably also the country most fervently devoted to dieting. The case can be made that dieting (taken collectively) is actually counter-productive, i.e. that diets can even be an active agency of weight-gain. This can be understood if one looks at dieting as a particular challenge to what we know to be a self-regulatory system. And the system counters the change. It will have learned a lesson of deprivation, and sooner or later, it will have its way in compensation. So conventional dieting is, among other things, an attempt to fool Mother Nature— in the colloquial idiom—and not a very good one.
But there are problems in the standard American fare that we should be aware of. I am intrigued with an emerging model that pins much of our malaise on insulin. The numerous findings of extended life spans with food deprivation among animal species can be completely accounted for by the reduction in insulin exposure. Our bodies clearly react badly to chronic overexposure to their own insulin. Our conventional diet, in turn, challenges our body’s insulin regulatory system, and eventually that system “blows its fuses.” Insulin levels are no longer well-managed; insulin resistance develops; and medical consequences eventually follow. The typical American diet is heavy on substances that are high in “glycemic index,” i.e. they are readily convertible to sugars that quickly burden the insulin regulatory system. Significantly, we have here another aspect of the failure of self-regulation.
Other dietary offenders could be listed, and the list might even be long. It is enough for present purposes to highlight the dominant issue, and insulin probably ranks at the top. As for the flip-side of the dietary coin, the dietary essentials that we are not getting, perhaps the most significant is the Omega-3 fatty acids that are a major constituent of neuronal cell walls. Intriguingly, we see omega-3 supplementation helping with conditions such as Bipolar Disorder and depression, and that has to get our attention.
When Albert Einstein died, scientists thought it important to get a look at his brain. How silly of them. It would be hard to tell his dead brain from any other. (Of course even absent any scientific interest, it was Einstein’s brain, and thus deserving of a book being written about its journey in a jar from East Coast to West in the back of a car, in the custody of a devoted disciple.) Significantly, however, it was found upon inspection to have been in a good state of health. Einstein had happy glial cells, and that probably was important. There must be the nutritional support for what the brain needs to do, and in the current state of affairs, for whatever reason, we don’t get the necessary omega-3 fatty acids out of our typical diet. Other deficiencies could be cited as well, but this one will serve as standard-bearer for this category of ills.
Another major category limiting our life expectancy is the field of medicine itself. An article in JAMA a couple of years ago demonstrated with hard numbers that medicine was the third largest cause of death in this country, behind cancer and heart disease. 250,000 deaths annually were attributed to medical errors (Journal American Medical Association Jul 26, 2000, 284(4), 483-5) When the author of the article, Dr. Barbara Starfield (of the Johns Hopkins School of Hygiene and Public Health), was asked privately whether she actually believed these numbers, she said no. When all is said and done, medicine probably ranks first as a cause of death, in her view. Now a lot of this probably concerns slightly premature deaths among the elderly, so that little may be lost here in terms of useful years of life.
What was being assessed here are discrete, countable events: surgical errors, obvious misdiagnoses, wrong medications given, fatal dosages administered, inappropriate drug combinations, and death due to infections that ought to have been managed, etc. The author reasonably surmises that what is actually reported in this regard is only a fraction of the mischief that occurs in the real world. Additionally, there are major medical disasters that nevertheless do not terminate in the premature death of the patient. So when morbidity rather than mortality is assessed, the story gets much worse.
But there may be a more systemic issue that is not even on the radar screen of even this forward-thinking, courageous doc. As we know, the target of much of medicine is symptomatic relief. Many of these symptoms should be seen as an alert to our sentient selves that something is amiss. If the symptom is simply silenced, perhaps this allows the underlying pathology to deteriorate further. What may start out as being within the compass of a self-regulation-based remedy may end up as essentially intractable. The escalation and compounding of such medical non-solutions may in fact just be pasting over a general decline of health that ultimately leads to premature morbidity and death.
The problem, in short, is that we apply tactical solutions rather than strategic ones to the problem of chronic illness. The doc does what he can to have the patient walk out feeling better than when he or she came in. The likelihood that the problem will be fundamentally addressed may be reduced by these interventions rather than enhanced.
When I recall past “discoveries” of societies with very old members, the examples that come readily to mind are a community in Georgia (in the former Soviet Union) and a community high in the Andes, in both of which the elderly were valued members of the society. Record-keeping was poor, so these folks may have embellished their ages (since age was considered virtuous). But still, these folks were old, and they obviously did not have access to modern health care. Finally, there is the example right here in the US that when we see newspaper references to the oldest folks now alive, they are likely to be rural Southern blacks. They probably never got to see the inside of the Mayo Clinic.
When researchers investigated the state of health in some Southern nursing homes, they found that life expectancy was considerably greater in the nursing home populated by blacks. The best explanation for this heightened life expectancy among elderly Southern blacks is medical neglect. These people had not been smothered by long-term medical attentions into progressive dependency.
This is obviously a hypothesis at this point, and other factors clearly matter as well—greater connectivity to family among Southern blacks; the sample of elderly blacks is selective—consisting of those who successfully surmounted earlier deprivations. In this regard, I am reminded of a study on fruit flies reported in Science many years ago, in which those flies that survived a particular challenge exhibited a depressed marginal death rate subsequently, and long out-lived their normal kin. A kind of selection had been at work. So this happy circumstance of successfully aging blacks should not be taken to indicate that their prior circumstances were benign. The very opposite is the case, as we shall see.
Some years ago I became aware of a sociological study on health issues among blacks. The findings were stunning. There was one variable that explained more of the morbidity among blacks than all of the usual culprits combined: obesity, smoking, drinking, drug use, etc. This factor was socio-economic status. Just as we have come to view chronic pain as a disease process in and of itself, so one might call low socio-economic status a disease vector in its own right along with viruses, etc. And in this case, poor medical care is a detriment, because this now includes deficiencies in pre-natal care, etc., as opposed to the management of chronic illness and disability in old age.
There is probably a key underlying factor here that goes beyond such specifics as the availability of health care. I suspect that it is the pervasive effect of unmanageable, unrelieved stress in the life of the poor, particularly when these live in the context of a general prosperity. This adverse stress response is observable in secular trends upward in depression and in depressive syndromes, among other things. We now have more than one hundred years of data showing progressive increases in the incidence of depression. Anti-depressants are now the second largest category of prescribed drugs (after analgesics).
A World Health Organization study a few years evaluating the “Global Burden of Disease” placed depression fourth in terms of its overall health impact (not just death rate). They assessed this impact in terms of DALY units, where DALY refers to Disability Adjusted Life Years. Thus, a 50% disability for ten years would be the equivalent of a foreshortening of life by five. The WHO projected that within a decade or so depression would even rank second or first. If one lumps all of mental illness together, it already ranks first in terms of health impact.
Now if one looks more closely, matters are even worse. The top three health concerns are lower respiratory infections, diarrhea, and perinatal disorders, those early childhood conditions that are still prevalent in most of the developing world and would weigh most heavily when measured in terms of years of life lost. These are also effectively logistical problems, since they are simply a matter of delivering basic public health services around the world. This means that for our purposes (i.e., readily remediable childhood diseases aside), depression already ranks number one in terms of its health impact. (In passing, it should also be noted that cancer did not rank within the top ten health impacts around the world.)
Sleep is another issue that needs to be mentioned. According to William Dement, who has studied the subject, “Healthy sleep has been empirically proven to be the single most important determinant in predicting longevity, more influential than diet, exercise, or heredity, but our modern culture has become an alarming study in sleep deprivation and ignorance.” (William C. Dement, M.D., Ph.D., Science News, 160 (25), p. 391 (2002)) Sleep is therefore another factor that apparently has a lot of explanatory power.
So let’s “connect the dots” as best we can. My hypothesis for the relative shortcomings in American life expectancies and life spans vis-Ã -vis the best available practice (Japan, as well as some of the Scandinavian and Mediterranean countries) is firstly that our medical approach to chronic illness is detrimental in terms of its net influence. Secondly, our conventional diet is not in our interest, both in terms of what it delivers, and what it fails to deliver. Third, our society imposes intolerable stresses on individuals and families, particularly on the underclass. And, finally, our modern society is in a collective state of chronic sleep debt. Among the elderly, the problem of poor sleep hygiene is compounded by sleep disregulations that in turn are poorly managed medically.
Now if truth be told, the evidence for the first two hypotheses is not that strong, and the third is speculative on my part. The US has been ranked 12th out of 13 countries in terms of male life expectancy at age 15, but we actually catch up by age 80, where we rank 3rd. Perhaps it would be better to say that our considerable medical expenditures don’t seem to be giving us much advantage in terms of longevity. The bad balances the good. And with respect to diet, we in the US are clearly not the worst offenders, as already pointed out. We actually rank fifth best in terms of smoking, alcohol, and the consumption of animal fats. All the more reason then to look for the evidence in lifestyle factors such as the stress response to account for the fact that we rank tenth (out of thirteen countries examined) in terms of age-adjusted life expectancy.
The self-regulation remedy has something essential to contribute to all four of these major themes. Our approach to chronic disability should clearly have a significant self-regulation component. This is true in particular for cardiac care, where the proposed magic omnibus pill could be largely replaced, or at least augmented, with self-regulation based remedies. The same goes for our approach to eating disorders, to developing insulin resistance, and to hypoglycemia and diabetes. Self-regulation strategies can support our ability to tolerate stress, and to either avoid tailspins into depression, or to aid in recovery therefrom. And finally, self-regulation strategies may be the best means of addressing chronic sleep disregulation in the elderly. Collectively, this would suggest a major shift of attention and resources to what we might call “The Self-Regulation Solution.”
But health is not merely the absence of disease. On the positive side, what keeps Supreme Court justices in their seats and aging conductors on their podiums is the fact that they have a certain amount of autonomy in their lives, and they are in a position to have a significant positive influence through everything that they do. Their life satisfactions may indeed rise almost to the level of an addiction. And removing them from their status may be akin to taking the driver’s license away from the elderly.
Obviously not everyone can be so plentifully rewarded in his or her life’s work. But all of us get to touch other lives, and ultimately it is a matter of personal or spiritual orientation whether that provides sufficient life fulfillment. A recent study indicated a thirty to forty percent increase in marginal life expectancy among the elderly who were engaged in service to others. Here again, self-regulation approaches can be helpful in allowing persons to access their own internal resources, to encounter their own soul. If one cannot go with Luther (“salvation through grace”), one can go with Calvin (“salvation through good works”).
It is difficult to really get one’s arms around this topic, but I have the suspicion that ultimately a lot of the answer regarding longevity lies in this less quantifiable, more personal or even spiritual realm. The elderly rural blacks are more tied to family and church. They lived more centered and less frenetic lives. As for the rest of us, the economic uncertainties that are supposed to be so good for our society are stressing out the whole family system. The extended family of earlier days is currently only available by e-mail. In this regard, both Japan and the European countries are more traditional. The existence of viable safety nets means that families are not driven to extremes by overwhelming economic stresses.
The other good fortune experienced by most Supreme Court justices is that they have continuing access to a well-functioning brain. Here again we are able to help with self-regulation-based approaches. What is not clear at the moment is the extent to which a well-functioning brain contributes in turn to improved longevity. Improved self-regulation entails improved immune system functioning, improved sleep, improved energy levels, etc. One is likely to also get improved life expectancy in the bargain.
When the field of medicine does acknowledge lifestyle factors in health, it is usually by way of a general admonition to be attentive to “diet and exercise.” This is surely done with little expectation that behavioral change will actually ensue. We would now make it a triumvirate: “Diet, exercise, and self-regulation practice.” Self-regulation practice has something to offer for nearly all of the above major categories that impinge on mortality among the aged: the stress response; sleep regulation; dietary tolerance and appetite regulation; mood regulation; staving off mental illness on the downside and supporting the quality of brain function on the upside; reduction in need for invasive medical care; and finally the spiritual realm, where self-regulation can help with the quality of our relationships and put us in touch with our deepest yearnings and our most essential selves.
Space is too limited to also cover the implications of diet, although it is easy enough to recommend some general prescriptions such as moving down the food chain and closer to the prehistoric, paleolithic diet for which evolution prepared us. Significantly, this matter of diet is also largely under our personal control. The same goes for physical exercise. In addition to various general benefits to health and to mental function, exercise also has specific benefit against depression, and against insulin resistance. The same can be said for improved sleep hygiene. It is entirely under our personal control, and it promises specific benefits against depression and other ills. This points to a synergistic effect among all the elements mentioned—diet, exercise, sleep hygiene, self-regulation practice, and devotion to a cause larger than self. It is therefore apparent that when it comes to taking care of the life that we hold so dear, matters are largely up to us, leaving medicine to take care of the occasional medical emergency that mankind has learned to handle well.
Now as I survey what I have written, a slight demurrer is in order. The spoils in this life do not seem to go systematically to the prudent person who carefully constructs his list of dietary supplements, calibrates risks, and regularly consults medical professionals. The oldest documented person, a French woman who died at the age of 122, smoked and drank to the end. While we may not be able to banish disease and disability, we can have mastery over them. The best prescription: to wallow with delight in the life that we are given, and to love with abandon.
“Yesterday is history; tomorrow is a mystery; today is a gift.”
