The Lucky Years: How to Thrive in the Brave New World of Health (20 page)

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It’s one thing to talk about sequencing genes and tumors, deleting our diseases, and learning about the human microbiome. But it’s clearly another to bring the lessons of these technologies home to our everyday lives. So with that in mind, let me help you measure and interpret your own data. But before doing so, I want to give you a primer question to consider that will help you contextualize your life:

What are your personal health goals?

You’ve obviously picked up this book for a reason. So it helps to have a clear sense of your personal health goals as you proceed. And I hope they are loftier and more precise than just “I want to lose weight,” or “I want to feel and look better.” Aim higher with things like “I want to be able to play with my kids and grandkids when I’m older,” or “I want to optimize my life today using the best medicine has to offer so I can reach my health goals now and in the future,” or “I want to free myself from chronic anxiety and fear of the future so I can perform better at work and be more present and happy at home.”

Now let’s get personal.

Observe, record, tabulate, communicate. Use your five senses. Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone you can become expert.

—Sir William Osler

These data represent the hope for health prevention studies.

H
ow long do you think you will live? How long do you
want
to live? How old are you biologically today, and how long will you live strong and happily, unencumbered by an illness or chronic condition?

The numbers in the chart above are real, and troubling to me. I can hardly stand the fact that many of my patients probably could have prevented their suffering from cancer or other life-altering diseases had they done a few things differently earlier in life. Kept their weight under
control. Managed stress better. Quit smoking sooner. Made physical activity a regular habit. Been more attuned to what their bodies were telling them and acted accordingly. Stopped procrastinating on important tests and early-detection screenings.

Most of the data we have on file are observational. Scientists look at a large group of people—some of whom practiced one behavior and others another—and then they study the outcomes, attempting to make the groups equal with respect to other variables, with men and women of roughly the same age in each group, who share similar lifestyles in terms of their diet and exercise habits. These large, randomized controlled trials are the best resource we have to identify behaviors that can alter our risk for disease. The problem is that it is very hard to dictate behavior to a group of people and expect them to be compliant for years and then study an outcome that has a very long lag time, meaning time until the desired effect is seen. Few, if any, scientists want to stake their efforts and career on an experiment that won’t yield a result for a decade or more. Which is why we need to discover shorter-term endpoints. For example, if we have a simple blood test for inflammation of the arteries, which leads to heart disease, we could have someone change a behavior and see how it affected that variable in the short term.

When HIV was spreading and patients had long been panicking by the late 1980s and early 1990s, scientists were developing drugs with the hope that they would change long-term outcomes of the disease. Traditional trials would have taken years to see such an effect, though, and no one had the luxury of time amid the epidemic. A clever group of lab scientists developed a blood test that counted first how many of the CD4 T cells were present in the patient. HIV targets these cells, and they plummet when the virus is active, leading to AIDS. Later a more accurate test was developed that counted how many copies of the virus are in the bloodstream. These are called surrogate markers, and in 1992 the FDA actually adopted new regulations (after much lobbying by the HIV patient advocates) designed to speed approval of important new treatments using these surrogate markers. The new regulation became
known as the Accelerated Approval provisions. The FDA for the first time articulated an explicit requirement for drug approval based on the effect of a drug on a surrogate marker, and not just a clinical outcome. The key portion of the regulation reads as follows:

The United States Food and Drug Administration (FDA) may grant marketing approval for a new drug product on the basis of adequate and well-controlled clinical trials establishing that the drug product has an effect on a surrogate endpoint that is reasonably likely, based on epidemiologic, therapeutic, pathophysiologic, or other evidence, to predict clinical benefit, or on the basis of an effect on a clinical endpoint other than survival or irreversible morbidity.
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This new legislation set the bar for developing drugs for a surrogate marker, and the number of HIV drugs in development exploded. The progress and excitement over these new drugs were palpable at the time. I remember being in the “Osler 8” medical ward at Hopkins, the place for patients who have infectious diseases (and most of the patients at this time had AIDS). The daily talk on rounds was about new data on these new drugs. Everyone, patients included, would discuss the new drugs and their progress in the clinic. I get excited when I think about what could happen if we developed validated surrogate markers for other diseases. There would be a dramatic increase in the development of drugs that could potentially delay or prevent diseases.

Although we’ve made huge strides in prolonging our life spans, we haven’t yet necessarily done so well at staving off diseases that come with age—especially the chronic ones such as diabetes, heart disease, stroke, and cancer. So we’re living longer, yes, but suffering through illnesses that can be debilitating and enormously diminishing to one’s quality of life. In the United States alone, the number of people with chronic conditions is projected to increase steadily for the next thirty years. My hope is that we can curb this trend in the Lucky Years.

Today, these are the ten leading causes of death in the United States:

• heart disease

• cancer

• chronic lower-respiratory diseases (emphysema and chronic bronchitis)

• stroke

• unintentional injuries (accidents)

• Alzheimer’s disease

• diabetes

• influenza and pneumonia

• kidney disease

• suicide

Infectious diseases such as tuberculosis, pneumonia, and diarrheal disease were the leading causes of death worldwide at the dawn of the twentieth century. By the beginning of the twenty-first century, in most of the developed world, death from communicable illnesses had been replaced by death from chronic illnesses that weren’t necessarily blamed on a germ. Of all the causes of death in the United States, the leading top ten account for nearly 75 percent of all deaths, and the top three killers—heart disease, cancer, and lower-respiratory diseases—cause over 50 percent of all deaths.

Multimorbidity is the most common chronic condition today. This refers to the coexistence of multiple chronic diseases or conditions. Only 17 percent of people who have heart disease, for example, suffer from only that condition. The majority (almost 3 in 4) of individuals aged sixty-five years and older suffer from several chronic conditions, as do 1 in 4 adults younger than sixty-five years who receive health care. Adults with multiple chronic conditions are the chief users of health care services and account for the vast majority of health care spending.
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In all honesty, I don’t know what true health is, particularly on an individual basis. For person A, health can be living totally free of illness and disability. For person B, however, perhaps health means managing a condition well and enjoying life to the fullest despite some disability. While we can certainly try to measure health in a variety of ways—weight, cholesterol, blood sugar, blood cell count, hormone levels, markers of inflammation, how you look, and how well you sleep, for example—none of those figures or generalizations will tell the whole picture. And they won’t reveal how many years and days you might have left on this planet.

There has been a rise in noncommunicable disease in low- and middle-income countries, due to advances in the treatment and prevention of communicable diseases. At the same time, there was a decrease in noncommunicable disease in the higher-income countries.

Such a challenge is partly why I encourage you to view your total health as a complex network of processes that cannot be explained by looking at any one pathway or focal point. Health is in perpetual flux. You need to adapt to changes as you age, a message I’ve been driving home since the beginning. As I also noted earlier, in science-speak we say that humans are “emergent systems”—we are constantly changing, developing, and evolving. The body is an incredible self-regulating machine. You don’t need to do much to support its health and optimal wellness. In the last hour, for instance, about one billion cells were replaced in your body without your having to think about it. Our goal should be not only to maximize our life spans, but also to delay the onset of chronic diseases so we can make the last years or decades of life as fulfilling as possible.

There are too many deaths from noncommunicable diseases in U.S. priority countries (the forty-nine countries in which the United States devoted five million dollars or more in aid for health in 2013). Noncommunicable disease accounted for 28 percent of the premature (under age sixty) deaths in these countries. That rate was 3.5 times greater than premature deaths from HIV/AIDS and 1.6 times as many premature deaths as malaria, tuberculosis (TB), and HIV/AIDS combined. The gray line represents what would happen if this trend followed the trends in high income countries.

Of all the lessons I like to give when I present to a large audience, the top three are: (1) record your body’s features; (2) measure yourself; and (3) automate your life. What exactly do I mean by these recommendations? To start with, I’ll talk about one of the biggest hurdles we all face in making our lives better: honesty.

The death rate from noncommunicable disease in low- and middle-income countries is growing at a disconcerting pace, especially among the poorest populations. This is an epidemic.