Which is more important to you — living as long as possible in any condition or being physically healthy and mentally happy for a slightly shorter time?
Most everyone will quickly come to the same conclusion as epidemiologist S. Jay Olshansky, PhD, expressed in a Journal of the American Medical Association 2018 article. Extending vitality is the goal for this century much the way extending life expectancy was for the last century. The positive but rather unforeseen consequences are profound.
Life expectancy across the world has increased dramatically since 1900, primarily due to better sanitation, making the point that one’s environment is the best predictor for overall health. In 1900, about 22 percent of the population died before age 10 from infectious diseases. Clean water and sewer systems shifted survival so that 96 percent of infants born today will live to age 50, and 84 percent will live to 65 or older. Maximum life expectancy across the world has leveled off because most of the easy “wins” have been accomplished. Changing lifestyles for everyone from youth to the elderly will be the next major opportunity, shifting from infirmity and misery to health and happiness.
Social determinants of health, recently rediscovered and currently the rage, are the cause of about 80 percent of all illnesses. Just describing SDOH — housing, food, transportation, safety and healthcare — doesn’t change their consequences much as weighing yourself doesn’t cause weight control. Cures for lagging SDOH must be evidenced-based and broadly, not just individually, effective.
Predicting life expectancy has been an attractive distraction and not nearly as important as maximizing healthy and functional “health span.” Epidemiologists use quality-adjusted life years as a metric to measure for both quality and quantity of life with one QUAL equal to one healthy year of life. If people are encouraged to stay well from youth through adulthood to old age by avoiding tobacco, maintaining appropriate body weight, eating fruits/vegetables and moving naturally (walking or exercising) four or five times per week, QUALs for whole populations will accrue. Concerningly, only 8 percent of the population meets these four modest attributes, according to “Healthy lifestyle and life expectancy free of cancer, cardiovascular disease, and type 2 diabetes: prospective cohort study,” in the British Medical Journal.
What should be the focus for prudent healthcare systems, responsible businesses and sensible governments? If they joined public health departments, typically under-resourced but committed to improving SDOH, community aging would change, not only adding life span but also more importantly, health span.
Holding our nation back is the current perverse payment system that rewards five beneficiaries (physician/non-physician providers, healthcare systems, pharmaceutical industry, device manufacturers and insurers) with a fee-for-service mentality, reinforcing an economic advantage of sickness as opposed to mandating an ethical benefit of prevention.
Upton Sinclair’s quote, “It is difficult to get a man to understand something when his salary depends on his not understanding it,” is applicable. Most would ultimately thrive and feel better about themselves professionally by preventing rather than profiting from illness.
As the payment system evolves from fee-for-service to total value or capitation, keeping people healthy will be the goal. Healthy people will have a longer “middle age” in which they can continue to contribute to society. Delaying onset or even completely avoiding certain diseases — diabetes, cardiovascular conditions, even some forms of cancer — will add QUALs, extending fruitful years while decreasing a prolonged, minimally functional, care-driven last phase of life. Productivity will increase in two ways. First, people will want to stay useful and engaged. Traditionally, this desire is manifested by a satisfying career. The second gain is freeing up care givers who are already in short supply.
Treating, or better yet avoiding, disease is possible, occurring in many healthcare systems that own their own medical insurance company. The incentive is clear cut. When a company both provides care and pays for it, decreasing the burden of illness is logical and beneficial.
As people become healthier, they will need fewer resources for traditional treatment. These excess assets can be redirected to prevention, thus creating a virtuous cycle for improvement. For example, home environments will change with increased independent housing and decreased assisted living (or skilled nursing).
Of course, these changes will take time while the current, maturing cohort is still caught up in diseases of modern society — diabetes, heart disease, cancer — as well as diseases of despair — alcoholism, drug addiction, mental illness. By starting prevention at youth in an environment designed for both active living and appropriate interaction, vibrant middle age will cut into frail old age.
Early pockets of success are sprouting across the nation. Receptive regions are transforming into active communities by developing: (1) complete streets including walking paths, bike lanes and attractive scenery; (2) food markets featuring fruits and vegetables, as well as restaurants with healthy choices; (3) thriving faith-based organizations; and (4) societies and clubs with active members. All of these add years of healthy and happy life, also known as QUALs.
Objective cures for SDOH within regions have been developed and implemented successfully in more than 50 communities across North America. For example, Southwest Florida’s Collier County metropolitan statistical area added 0.6 years of life expectancy over the past five years. This positive result, due in large measure to the Blue Zones Project, is in contradistinction to the rest of the nation which lost 0.2 years from 2015 to 2017. A slight rebound of 0.1 year in 2018 was due to fewer opioid deaths and a lower cancer death rate according to the CDC’s most recent information. Additionally, Southwest Florida’s cardiac mortality declined 8.1 percent during the same time period.
The Blue Zones Project is based on nine principles — moving naturally, having purpose, downshifting, consuming a plant-slant diet, eating until 80 percent full, having wine at five, putting family first, belonging to a right tribe, and participating in a faith based organization — gleaned from five locales around the world where more people live to age 100. This formalized program, currently changing communities across North America, encourages people, places, and policy to adopt healthy behavior. As metrics document happier, healthier and more productive lives, the result is better, longer health spans.
Allen S. Weiss, MD, is CMO of the Blue Zones Project. He is the former president and CEO of the NCH Healthcare System in Naples, Fla., and practiced rheumatology, internal medicine and geriatrics for 23 years.
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