Unconventional Medicine: Join the Revolution to Reinvent Healthcare, Reverse Chronic Disease, and Create a Practice You Love

CHAPTER FIVE

5. THREE REASONS U.S. HEALTHCARE IS DESTINED TO FAIL

It’s no secret that our healthcare system is in trouble: countless books, media articles, and scientific studies have explored its many shortcomings in detail. They include:

·        Misaligned incentives. In the U.S., we rely on insurance companies to pay for care. However, the goals of insurance companies are not always aligned with patient needs, nor with doctors’ needs. Insurance companies profit when healthcare expenditures grow. Because of this, there’s little motivation for insurance companies to embrace treatments that would ultimately shrink spending on health care. And there’s little incentive for doctors, hospitals, or other providers to prioritize quality, efficiency, and cost-effectiveness in their approach.

·        Big Pharma influence. Like insurance companies, pharmaceutical companies wield enormous influence in the medical industry and are usually motivated by factors other than optimizing care. The incentives to promote a pharmaceutical company’s work and products may be more focused on making money than aligning with patient and doctor needs.

·        Bias in medical research. Two-thirds of medical research is sponsored by pharmaceutical companies, and conflicts of interest, groupthink, and a failure to replicate many findings undermine the credibility of the studies that form the edifice of our current medical paradigm.

·        Broken payment models. Because we rely on insurance companies to pay for care, the treatments offered are not necessarily the most effective or those supported by the most current evidence—they’re simply the treatments that insurance companies have agreed to reimburse. This is not evidence-based medicine, it’s reimbursement-based medicine.

These problems are real, and collectively they’ve brought our current system to its knees. But if you’ve been following the healthcare debate in the news, you might have the impression that if we just make some minor changes here and there, we can get ourselves out of this mess.

That impression is hopelessly misguided.

Making a few small tweaks to our current system and expecting that to work is like rearranging the deck furniture on the Titanic as it inexorably sinks into the ocean. Too little, too late. Why? Because as significant as the problems I’ve described are, there are three much deeper reasons that healthcare in the U.S. (and in many other parts of the world) is doomed to fail:

1.       Our modern diet and lifestyle are out of alignment with our genes and biology.

2.       Our medical paradigm is not well-suited to tackle chronic disease.

3.       Our model for delivering care doesn’t support the interventions that would have the biggest impact on preventing and reversing chronic disease.

Let’s take a closer look at each of these reasons.

#1: Mismatch Between Our Genes and Environment

The evolutionary biologist Theodosius Dobzhansky once said, “Nothing in biology makes sense, except in the light of evolution.”

What does this mean? All living organisms—including human beings—evolved in a specific environment. Our genes and our biology adapted over tens of thousands of generations to allow us to survive and thrive in that environment. But if that environment changes faster than our genes can adapt, mismatch occurs.

Before farms and factories took over, human beings lived most of our history eating a hunter-gatherer diet and living a hunter-gatherer lifestyle. Our ancestors would hardly recognize modern agriculture and manufacturing or the foods they produce. Our genes have not been able to fully adjust to these changes. The result: a discrepancy between our ancestral genes and the modern environment, which has spurred the chronic disease epidemic.

If you visualize the timeline of human history as a football field, you’ll see how quickly our environment has changed. A walk across most of that field—ninety-nine-and-a-half yards out of 100—represents the amount of time we lived as hunter-gatherers. The last half-yard represents the time since agriculture was developed. The Industrial Revolution came along only in the last few inches.

We think the way we live now is normal because it’s all we know. It may be all our parents and, to a lesser extent, our grandparents knew. Yet, it’s not normal. It’s far outside the norm of human evolution and history.

Diet

For most of evolutionary history, humans ate primarily meat and fish, wild fruits and vegetables, nuts and seeds, and some starchy plants and tubers. Nobody ate processed food. Nothing came in a bag or a box. There was no refined sugar, no refined flour, and no industrial seed oil. The only food available was nutrient-dense and whole. Preparation was minimal.

Contrast that with today. The top six foods in the American diet are grain-based desserts, bread, sugar-sweetened beverages, pizza, alcohol, and chicken—primarily fried dishes like chicken nuggets (DIAG 2010). If you put pictures of these two diets next to each other, you’d see a profound difference. We went from a diet that was naturally anti-inflammatory, high in nutrients, and low in calories, to one that is pro-inflammatory, low in nutrients, and high in calories.

Little influences our health more than the foods we consume. The modern diet is a prescription for obesity, metabolic problems, and all kinds of other chronic diseases.

Lifestyle

The mismatch between our evolutionary history and our modern environment goes beyond diet. Consider our exposure to light. If you think about the evolution of humans—indeed, all organisms—you’ll see that life evolved in the natural twenty-four-hour light-dark cycle on this planet. We’ve long used candles and fire to light up the night, but only in the past 100 years have we had the capacity to be exposed to bright, artificial light at times when the sun wasn’t shining.

While there’s no doubt artificial lighting has been a boon from a cultural perspective—it lets us stay up late to create art, literature, and music, for example—it has had a disastrous effect on our health. We take advantage of expanded daytime to do more activities at night, but doing so disrupts our circadian rhythm. Every cell in our body is regulated by the natural light-dark cycle. When we change that cycle, our bodies suffer.

Here’s how it works: When we wake up in the morning, sunlight hits our eyeballs and our cortisol levels rise, telling us it’s time to get up. When the sun sets and darkness falls, on the other hand, our melatonin levels rise, telling us it’s time to go to sleep.

What happens when someone lies in bed at night with their iPad before going to sleep? The iPad emits blue light, which is like the spectrum of sunlight. When blue light hits the body, it sends a “time to wake-up” message. That not only interferes with sleep but has been shown to deregulate metabolism, promote weight gain, and cause cancer (Chepesiuk 2009). Changes to the circadian rhythm mediated by light exposure can have profound effects onhealth.

Flight personnel, for example, have long been known to have higher risk of cancer and other diseases, probably due to the circadian disruptions that come from flying across time zones and working at odd hours. By being awake when they should be asleep and asleep when they should be awake, they have upset their body’s healthy rhythms. The same happens with people who work night or alternating shifts: they have higher rates of obesity, diabetes, metabolic problems, and cancer (Blask et al. 2009).

Artificial light seems like a benign environmental change, but when you understand it through an evolutionary framework, you begin to see its problems. Then, when you look at the research, you find that yes, in fact, this difference between our ancestral and current environments is significantly harming our health.

One of the most valuable aspects of the evolutionary framework is that it helps us ask questions about our environment we might not otherwise ask. Light is a good example. If we understand that our environment has changed faster than our genes can adapt, we can look at our modern environment and identify the ways it differs from the historic one. We can then investigate and study these differences to see if they have caused problems. If we find they have, this exploration can give us ideas on how to make changes.

For instance, people might decide not to use electronic devices in bed before sleep. They might avoid shift work, or at least advocate for regular, rather than alternating, shifts. They could plan to get some exposure to bright sunlight in the morning before work. Just a week of camping, for instance, can reset the circadian rhythm (Wright et al. 2013). Thinking about it this way reveals a whole realm of possibilities, not just in terms of diagnosing a problem, but solving it.

Behavior

We’ve known for a long time that exercise is important. That’s not a news flash. What might be more surprising is the recent research indicating that going to the gym isn’t an adequate solution. If we look at exercise from an evolutionary perspective, we see that our ancestors moved all the time. They walked an average of 10,000 steps a day (Cordain and Friel 2005). They didn’t sit for long periods and they stood more than half the day. In between, they chased prey, ran from predators, and built things.

This non-exercise physical activity may be more important than the regimented workouts we’re familiar with today. If you work at a desk but go to the gym three or four times a week, you’ll meet the conventional guidelines for exercise, but you’ll still be at increased risk of disease because of all that sitting. Even marathon runners in training who spend most of the rest of their time sitting have an increased risk of death and disease (Möhlenkamp et al. 2008).

People who walk or are active doing gardening, chores, or manual labor in addition to exercise have a much brighter outlook than those who just exercise. If someone is inactive, it’s more important for them to reduce the amount of time they’re sitting than it is for them to start a workout routine. The important change for them is to move from being completely sedentary to increasing their non-exercise physical activity.

Why do we continue the behaviors that are obviously causing us so much trouble? Our behavioral patterns are hard-wired for a specific environment. That environment has changed, but our behavioral patterns have not. For example, we’re programmed to seek out calorie-dense, highly rewarding foods. Eating potato chips is rewarding: it makes us want to eat more. Eating a plain baked potato will satisfy hunger, but it’s not as rewarding.

We’re wired to seek rewarding foods because in the past obtaining them would have given us an advantage. These foods have a lot of calories; they prevent us from starving. Starvation was historically the problem for humans, not obesity. Our brains are programmed to help us survive in an environment of food scarcity. Our cravings and desires are set up for that kind of environment.

For instance, there’s a hunter-gatherer population in Paraguay, the Aché, that illustrates how strong this programming is. Certain people in the tribe climb extremely high trees, risking their lives, and getting stung by hundreds of bees, just to get honey. When they do get it, people will consume up to a liter of honey at a time. They have no concept of what’s healthy or not healthy. They’re acting purely out of their evolutionary programming when it comes to food. If you’re living in a situation where food scarcity is a problem, it makes sense to use every calorie-dense source of food you can.

What happens when there’s a 7-Eleven on every corner selling Big Gulps and jumbo bags of potato chips? We still eat it all, as if it were scarce. Yet we live in a food-abundant environment today. The same behavioral patterns that helped us survive in a natural environment now make it very likely we’re going to become overweight and develop metabolic problems and other chronic diseases.

The mismatch between our evolutionary inheritance and our modern environment lies at the root of chronic disease. This mismatch is causing a massive health crisis in America and the West that our current health systems are ill-equipped to manage.

To address this, we need to adopt diet and lifestyle behaviors that are species-appropriate, acknowledging the ways humans have evolved to survive in an environment very different from the one we live in today. If our current diet and lifestyle are totally at odds with our natural history, we must make different choices to bring ourselves back into alignment. Choosing a diet that is more closely aligned with our genome and epigenome acknowledges that, although our ancestral diet varied according to what was available, there were some common characteristics: There was no processed food. People ate some combination of meat, fish, wild fruit and vegetables, nuts and seeds, and starchy plants, no matter where they lived. They weren’t eating Ding Dongs, Cheez Doodles, and Big Gulps.

We’ll discuss how to realign our diet, behavior, and lifestyle with our genes in more detail in Chapter Nine.

#2: The Wrong Medical Paradigm for Chronic Disease

Our current medical paradigm is based more on managing disease and suppressing symptoms than it is on preventing and reversing disease, or promoting health.

Conventional medicine is structured to address trauma, acute infection, and end-of-life care, not to keep people healthy. Imagine a linear spectrum, where death sits on the far right and perfect health on the far left. Conventional medicine intervenes at the right end of the spectrum. The closer a patient gets to death, the less chance a clinician has of restoring that patient to health. Yet, that’s precisely where we spend our greatest resources. Heroic interventions can prevent death, but don’t necessarily promote health.

The spectrum of chronic disease

Don’t get me wrong: modern medicine is incredibly effective in acute and trauma care. If I get hit by a bus, I want to be taken to a hospital! Fantastic advances in medicine have turned what was previously limited to the realm of science fiction into reality: we can restore sight to the blind, re-attach limbs, and even clone human stem cells. We absolutely need oncology surgeons who can remove cancerous tumors and gastroenterologists who know how to perform a colonoscopy. But I think we can all agree that conventional medicine does not excel at preventing or reversing chronic disease, which is the biggest challenge we face today.

One reason for this is that there has been a fundamental change in the healthcare landscape throughout the past century. Our healthcare paradigm evolved during a time when the top three causes of death were all acute, infectious diseases: typhoid, tuberculosis, and pneumonia. In 1900, you might have visited a doctor for an accident or injury, a gallbladder attack or appendicitis, or an infection—not because you had an autoimmune condition, allergies, orasthma.

Top causes of death in the U.S., by year

Treatment for these issues was relatively simple: the doctor removes the gallbladder or appendix, sets the broken bone in a cast, or gives the patient medicine for an infection. One problem, one doctor, one treatment.

Early in the twentieth century, antibiotics revolutionized the treatment of infections. Previously unimaginable cures became common. If a patient had an infection, she took an antibiotic and shortly thereafter was cured. Cause and effect seemed clear. The “one disease, one treatment” mentality was applied to other medical procedures as well, such as surgery.

Surgery seemed efficient—if the appendix was going to burst, surgical removal would fix the problem in one fell swoop—and was widely celebrated. Surgeons made amazing discoveries and began saving lives with their new techniques. People who once had no hope could now survive, if they had access to the right surgeon. Surgeons were treated like gods.

Today, the healthcare landscape has changed dramatically. Seven of the top ten causes of death are chronic diseases (NCCDPHP 2016). Unlike acute problems, chronic diseases are difficult to manage, expensive to treat, and usually last a lifetime. They don’t lend themselves to the “one problem, one doctor, one treatment” model that worked well in the past. Today’s patient has multiple problems, sees multiple doctors, and requires multiple treatments that go on for years if not decades.

Another reason that conventional medicine hasn’t been successful is that it focuses on suppressing symptoms rather than addressing the underlying cause of disease. Imagine you get a rock stuck in your shoe, and it makes your foot hurt. If you look for help in the current medical system, you may get a description of foot discomfort along with directions to the nearest drugstore for some extra-strength ibuprofen. Sure, ibuprofen would help to reduce the pain. But wouldn’t it be better just to take off your shoe and dump out the rock?

For example, patients regularly arrive in doctors’ offices with myriad health issues related to diet, such as obesity and/or diabetes. After meeting with a doctor, they’ll walk out with prescriptions for insulin and drugs that lower blood sugar. While these drugs might be crucial to maintaining a diabetic’s health, they won’t ultimately solve the patient’s chronic disease. A Type II diabetic requires a lifestyle change: patients need to remove unhealthy processed foods and refined sugars from their diet. Most doctors know and advise this, but our current medical system doesn’t support patients to make the lifestyle changes required for long-term solutions. The result? Patients continue to live with chronic disease, and doctors continue to prescribe them medication for symptom management.

But perhaps we’re not being fair. In the examples listed above, it’s likely that a skilled conventional medical practitioner would identify the rock in the shoe. It’s possible that a persuasive doctor would adequately convince a patient to initiate a lifestyle change, and conceivable that a motivated patient would go home and diligently apply those changes. That is, of course, if the issue is as simple as identifying just one rock.

In most cases, there’s more than one rock. The first pebble might be a patient’s poor diet. The next comes from sleep deprivation, a result of going to bed at 3:00 a.m. and only getting five hours of sleep at night. Another rock is born from sitting at a desk for eight hours a day and failing to do any exercise. A patient who has accumulated several rocks like this needs medical advice that considers the whole picture, not merely the acute presentingsymptoms.

Some rocks are nearly invisible. Perhaps a patient, Yolanda, is dealing with a disease like irritable bowel syndrome (IBS). Typically, Yolanda would go to the doctor and leave with a handful of medications, all of which simply suppress symptoms without addressing the cause of her problem. Yet, there are often mechanisms or pathologies at work that require further exploration. Yolanda might have something called SIBO, or small intestinal bacterial overgrowth, which involves inappropriate growth of bacteria in the small intestine. Maybe she has an undiagnosed food intolerance, or an undetected parasite infection. She might have a gut-brain axis problem caused by an autonomic nervous system issue, like sleep loss or stress. An array of mechanisms may be driving the condition, and, unfortunately, they often remain undiscovered—or at least go unaddressed.

In a ten-minute appointment, there simply isn’t time to thoroughly investigate all the possible causes of a patient’s chronic illness. Instead, doctors describe the symptoms and prescribe the drugs, and that’s the treatment. If that doesn’t solve the issue, the patient usually gets referred to a specialist, who, as we’ve seen, examines one area of the body in isolation. If the chronic issue persists, the patient is sent to another specialist, who examines another area of the body, and then another specialist, ad nauseum. Unfortunately, it’s rare for those specialists to communicate with one another; our current medical system isn’t set up to accommodate that kind of collaboration. Primary care doctors are supposed to unify the various discoveries, but their overwhelming caseloads often make it impossible.

What would it be like, instead, if doctors were empowered to approach illness like a detective approaches a case? After considering the patient’s host of symptoms, this doctor asks, “What might be causing those symptoms? Let’s do some thorough testing to determine what some of the causes might be. Once we identify those causes, we’ll start removing them and see if you still have those problems. We won’t rule out using drugs if necessary, but we’re going to focus our energy on identifying the root causes of your symptoms and addressing them all.” This is how Functional Medicine operates.

We’ll talk more about Functional Medicine in Chapter Eight.

#3: A Healthcare Model That Doesn’t Support Preventing and Reversing Disease

“The wise physician treats disease before it occurs,” according to the Traditional Medicine proverb from the Huangdi Neijing, an ancient medical text. Unfortunately, there’s simply no framework for that in current practice. The interventions we need to address the chronic disease epidemic require investing our resources in promoting health, which is just the opposite of what we are doing today.

At one time, it seemed that genetics would hold the key to solving chronic disease. Recent studies, however, have found that 84 percent of the risk of chronic disease is not genetic, but environmental and behavioral (Rappaport 2016). Our genes do play a role in determining which diseases we’re predisposed to developing, but the choices we make about diet, physical activity, sleep, stress management, and other lifestyle factors are far more important determinants of our health.

It’s tempting to think that we can solve this problem simply by better educating people about the changes they need to make. But lack of information is not the issue. Most people know that eating poorly, not exercising, not getting enough sleep, and engaging in other unhealthy lifestyle habits is not good for them. Yet they continue these behaviors anyway, or they chase quick fixes that don’t last for more than a few weeks.

What about doctors? Shouldn’t they be the ones to lead this change? We simply don’t have enough of them to address the problem. The most recent statistics suggest that we’ll have a shortage of 52,000 primary care physicians by the year 2025 (Petterson et al. 2012). But even if we didn’t have a shortage of doctors, most of them have neither the training nor the time necessary to support people in making lasting behavioral changes. We could start training doctors and other healthcare providers in this area, but that still wouldn’t solve the problem. Our “sickcare” system is not set up to deliver this type of care.

The average visit with a primary care provider (PCP) in the U.S. lasts for just ten to twelve minutes (Yawn et al. 2003), with newer doctors spending as little as eight minutes with patients (Chen 2013). It is impossible to deliver high-quality care in eight to twelve minutes when a patient has multiple chronic health problems, is taking several medications, and presents with new symptoms. Such brief appointments leave little to no time to dig into the important diet, lifestyle, and behavioral issues that are causing the patient’s symptoms. And with an average of 2,500 patients per provider, it’s difficult for PCPs to develop the kind of relationship with patients that would support meaningful changes.

Even if a provider makes a suggestion about diet or lifestyle change, will it be successful? It is now widely accepted that knowledge is not enough to change behavior. Yet doctors are trained in the “expert model” of simply telling people what to do, and expecting them to do it. That might work well when someone is facing a serious, acute health crisis (like an appendicitis), but it fails miserably when it comes to long-term behavior changes like losing weight, managing stress, or adopting an exercise routine (Elfhaq and Rossner 2005). Doctors aren’t trained to work collaboratively with their patients. This is painfully reflected by the fact that patients get to speak for only twelve seconds on average before being interrupted with advice from their physician (Rhoades et al. 2001).

If we continue to schedule short appointments with doctors, we also need to arrange lengthier visits with health coaches or other allied providers who can work more intensively with patients.

Imagine the healthcare population as a pyramid. The top 5 percent of the pyramid—those experiencing acute or emergency problems that require intensive care, often in a hospital or specialized outpatient setting—are often best served by conventional medical intervention. They need the kind of acute intervention conventional medicine excels at.

The Healthcare Population Pyramid

The next 25 percent of patients in the middle of the pyramid—those dealing with significant chronic health challenges—will likely require the ongoing support of licensed clinicians practicing Functional Medicine (with or without a conventional physician, depending on the scope of practice of the Functional Medicine provider and the specific health challenge).

The 70 percent of patients at the foundation of the healthcare pyramid—those with less severe chronic health problems—can often be adequately served by allied providers (such as nurse practitioners or physician assistants, nutritionists, and health coaches) focusing on diet, lifestyle, and behavior change, with occasional visits to a licensed Functional Medicine clinician. These people could join those at the higher levels of the pyramid at any time if they don’t address their diet and lifestyle, which is exactly what happens in today’s conventional medical paradigm.

We’ll talk more about a new practice model that better supports key interventions for preventing and reversing chronic disease in Chapter Ten.



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