The Elephant

So we've been touching different parts of this thing; now let's step back and really see what we're looking at. When clinicians ask patients across all of the major diseases what is actually ruining their quality of life, two of the top three complaints across all diseases were fatigue and depression, with pain being the third in over half of the diseases.

And sure, people feel worse when they’re sick, but as we’ve established, these symptoms appear years before the official diagnosis is detectable. And then there’s the data on what predicts patient mortality and disease progression. What they find is that these trunk symptoms are actually more predictive than the actual biomarkers that medicine routinely measures and uses to define disease. In heart disease they measure something called ejection fraction to predict mortality risk, but they’ve found it’s actually better predicted by looking at the patient reported symptoms instead. Every 5-point improvement on their quality of life survey correlated with 7-10% lower cardiovascular death. In MS there’s a phenomenon called the "clinical-radiological paradox" which refers to the fact that the lesion load, the defining disease marker, is poorly correlated with disability progression overall. Depression in diabetic patients increases mortality risk by 32% across nearly half a million patients studied. Sleep disruption adds another 14-34%. This shows up across all the major diseases.

And finally, when you you look at the prevalence of these trunk symptoms, the SAME symptoms, the ones determining quality of life AND predicting death rates and progression, you will see that they are all there, in all of them:

It becomes clear that this is one disease showing up across all humans, with variable downstream DAMAGE. Just like you would see in any ecosystem where there was upstream disruption.

It seems that the reason we have missed this might just be that we’ve normalized these symptoms as part of being human. Nobody would look at a pacing, self-harming, lethargic cheetah and say "well, it’s just really hard to be a cheetah." They’d say the cheetah’s conditions are wrong. But we look at a species where half the population can't sleep, can't digest properly, is in chronic pain, and is mentally struggling, and we write poetry about it. And the fact that this contradiction even needs to be pointed out is itself evidence of how deep the normalization goes. We've so thoroughly accepted collective dysfunction as a baseline that saying "humans shouldn't be this sick" sounds radical rather than obvious. And the reason this feels normal is because we have been systematically dismantling our social structure for all of recorded human history, so we don’t have a clear template for humans in optimal conditions.

Social structure collapse

So let’s look back at how this has progressed throughout our recorded human history, and what the chronic illness rates have looked like as it did.

A study done in 1988 compiled diabetes prevalence data from 11 populations of hunter-gatherers, subsistence farmers and pastoralists, and found the rate of diabetes to be from 0-2% of the population. They also documented that diabetes was rare in American Indians before 1940 and hypertension was unknown in East Africans before 1930. Then in 2018 Pontzer looked at the Tsimane, a Bolivian forager-horticulture society who had the lowest prevalence of coronary artery disease ever recorded. He also compared the fact that over 60% of US adults over 60 have clinically significant hypertension while less than 30% of hunter-gatherers and subsistence farmers over 60 show even mild hypertension.

We started noticing this happening, our chronic disease rates rising, in the 1960s. And this is when diet started being pointed to and blamed for health outcomes. This era blamed fat and cholesterol, as we talked about in chapter four with Ansel Keys. This is also when we had largely moved to the suburbs, and televisions started becoming popular. At this point only about 2% of children had documented chronic disease. Then in the 1980s, TV use exploded, we started moving further toward dual income households, and children’s disease had risen to 2-5%. Adults with major chronic diseases rose 40-150% depending on the source you’re looking at. This is when low fat diets became a government policy, and the food industry started replacing fat with sugar. In the 1990s TV use has hit its stride, dual income is the norm rather than the exception, and we started blaming carbs in addition to fat. This era sees children's chronic disease rates at 13-31% and adults with 50% having at least one chronic disease.

Then comes the 2000s, and along with it comes the internet and early social media. This is when the primary dietary villains are sugar and carbs, with gluten starting to enter the conversation as well. And then finally we enter modern day conditions. Everything that came before it, plus smart phones. And the childhood disease rates are now 27-40+%, and adults are showing 51-76% with at least one chronic disease, with 26-51% having multiple.

The further we get away from what our social systems biologically expect, the sicker we get societally. We moved from farms to factories, from single earner households to double. We added TVs and left our front porches. And finally we added cell phones, which reduced social interaction even when we are in public. And our best guess as to why we’re declining has always been food, but as you can see, every era identified their own dietary villain: fat, trans fat, cholesterol, carbs, sugar, gluten, processed food, ultra processed food, seed oils; with millions of people changing their diets to conform with the trends of the time, and the disease rates just kept going up. In children and adults. If diet were the answer, something would have shifted.

Social proof

We looked at ACEs data already, showing that childhood dysfunction predicts disease better than what medicine is routinely measuring. But what about social deficit in adulthood? There is one thing that clearly shows how important this is in adulthood as well, and that is the rate at which we see people dying in direct response to the death of their spouse. We have collapsed our social world so completely that for many adults the majority of their daily social world consists of one single person. And when that person dies, we see precipitous decline.

In 2013 the Harvard School of Public Health did a study showing that when one spouse dies the surviving spouse is 66% more likely to die within the first three months. And a major meta analysis that included this study, combining 15 studies covering over 2 million participants found that the widowhood effect, as they called it, was NOT different for those younger than 65 as compared to those over 65. This analysis found 41% increased risk still up to 6 months, and 14% after 6 months. The effect is still there over time but less the longer you survive as you are able to shore up your social network more widely.

Waite at the University of Chicago and Hughes at Johns Hopkins did a study on divorce, and found that divorced people are 20% more likely to develop chronic health conditions like heart disease, cancer, diabetes, and digestive and metabolic problems. And that even if they remarried they are STILL 12% more likely to have these issues. They also found that death rates for divorced men is three and a half times greater than for married men, and that heart attack risk for women increases 24% after one divorce and after 2 or more it increases to 77% risk.

And finally researchers at the university of Ohio studied spouses of people with depression over decades and found that the spouse of the depressed person has increased risk across an almost absurd range of conditions: asthma, allergies, peptic ulcer disease, hypertension, diabetes, metabolic syndrome, arthritis, cancer, and cognitive decline. Showing that in this world where many people have one primary person in their life, when that person can’t coregulate with you, that lack of coregulation can lead to disease.

Whether the social disruption is acute from death or divorce, or chronic from a partner that can’t coregulate with you, the outcome is the same across all of them: disease. These all look at what it looks like when adults lose their primary coregulator. Which again illustrates just how impactful getting our social need bean counter fed is.

Predictable progression

Pathostasis has a very predictable progression throughout the lifetime. But like with the widow data above we also often see big stressful events triggering quicker and more precipitous decline. This progression of course varies some but the path it takes when you look at the societal data goes in this general order:

Behavioral/mood symptoms → coping behaviors (addiction and disorders like eating disorders) → trunk symptoms → metabolic dysfunction (diabetes/weight gain) → organ disease.

We call the metabolic dysfunction stage expressions risk factors before disease onset, and the trunk symptoms get recognized as prodromal after diagnosis, but the whole chain is a predictable cascade playing out throughout our species. It was always one disease. It progresses like one disease. Until you’re so far downstream that the damage itself causes big enough symptoms like in Alzheimer’s that it starts to maybe look like it is something else. This is just what it looks like when you’re looking at one thing, and it was only missed because we set up our medical model to look at named endpoints. The downstream damage varies but the things determining mortality and quality of life largely do not.

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So now that we know what we’re looking at, let’s look at what we can do about it.