Why Are Preventable Illnesses Still Killing So Many People?

‘Although many individuals attribute their chronic illness to genetics or a family history of said disease, research shows that the overwhelming majority of the most common chronic illnesses are associated with lifestyle and not genetics.’

It is not like we do not know that cardiovascular disease (CVD) is the most common cause of death and disability in Westernized countries; and it is not like we do not know that the majority of CVD is preventable. Why then are these preventable illnesses still killing so many people?

Similar to the situation with cigarettes, we have known for many years that the standard American diet and the standard American lifestyle increase the risk of CVD. When individuals change their eating habits and get some exercise, the risk and incidence of CVD, most chronic illnesses, and many of the common cancers declines rapidly.

The standard American diet diet and the standard American lifestyle are filled with several risk factors for CVD including high blood pressure, high blood lipids and glucose (sugar), cigarette smoking, sedentary lifestyle, excess stress, not enough quality sleep, mental and behavioral illness, obesity, and more. Although many individuals attribute their chronic illness to genetics or a family history of said disease, research shows that the overwhelming majority of the most common chronic illnesses are associated with lifestyle and not genetics.

Also, the science of epigenetics (how one’s behavior and what he/she is exposed to influences gene function) shows that a healthy lifestyle can essentially turn off bad genes and turn on good genes. For example, the work of Dr Dean Ornish showed that 400 genes that influence prostate cancer are affected by an intensive lifestyle intervention program.

When we start to look at the risk factors for chronic illness and specifically CVD, we see that recently the American Heart Association revised its guidelines for hypertension (high blood pressure) based on these new guidelines, and almost half of Americans are now classified as hypertensive and, therefore, have at least this as a risk factor for CVD, strokes, renal disease, dementia, and more (Figure 1). In past years physicians would be happy when their patients had a blood pressure of <140/90 mm Hg. Now we know that a much lower blood pressure is necessary to avoid complications that include heart attacks, strokes, peripheral vascular disease, dementia, erectile dysfunction, and more.

Figure 1.

Risks for CVD.

When we look at cholesterol and other blood lipids as a risk factor for CVD, why is it that so many people with normal lipids still go on to have complications of CVD? The answer is that lipids alone are not the best test for the evaluation of endothelial dysfunction, which some people have called the other ED!

In addition to the general lipid profile, there are other blood tests that specifically evaluate the function of the endothelium including oxidized LDL (low-density lipoprotein), which reflects damage to the LDL particles. These oxidized LDL particles, especially when they are small in size, get into the endothelial cells lining the blood vessels resulting in endothelial dysfunction and the start of plaque formation. F2 Isoprostane is a blood test that measures oxidation within the endothelial cells. Oxidation is analogous to rusting metal. When the cells rust from within, they cannot function normally. Reactive oxygen species (ROS) form as a result of this oxidation and damage the cells, the DNA, and the mitochondria, which function to produce energy for the cells (Figures 2 and 3).

Figure 2.

Progression of Endothelial Inflammation.

Figure 3.

Vessel wall Inflammation.

The LP-Plac2 blood test (aka the PLAC test) measures inflammation within the arterial wall (Figure 4). This is an early sign of endothelial inflammation and can be detected long before abnormalities are seen in a calcium score test, ultrasound, or catherization. The calcium score test is essentially a CT (computed tomography) scan of the arteries in the heart and represents the body’s attempt to wall off the plaque formation (keeping it localized and less likely to spread). An ultrasound of the heart reveals the pumping ability of the heart; it does not directly tell what is happening inside the arteries. The cardiac catherization is the gold standard to evaluate the stenosis/occlusion of arteries in the heart. Since it is an invasive procedure, there is more risk associated with doing this test.

Figure 4.

Advanced Tests for Endothelial Inflammation.

Davidson MH, Corson MA, Alberts MJ, et al. Consensus panel recommendation for incorporating lipoprotein-associated phospholipase A₂ testing into the cardiovascular risk assessment guidelines. Am J Cardiol. 2008;101(suppl):51F-57F

This is an important distinction since many people have these tests completed to represent late-stage disease, meaning the endothelial damage has been occurring for some time—usually years. If we as health care professionals are to practice preventive medicine, we need to start looking for disease early when we can have a significant positive impact on treating and reversing the disease. The LP-Plac2 test measures the amount of plaque within the arterial wall due to the accumulation of oxidized LDL. The more plaque formation the more arterial dysfunction, stenosis, and impaired blood flow.

The myeloperoxidase (MPO) test measures inflammation outside the arterial wall (Figure 5). Inflammation inside and outside the arteries stimulates an immune reaction that brings white blood cells and other mediators of inflammation to the area in an attempt to combat the damage. MPO is also a specific marker of plaque vulnerability, meaning its potential to rupture. When plaque ruptures, it allows the release of cholesterol and other harmful substances, which then travel downstream to the smallest artery causing blockage of blood flow resulting in a heart attack (if the blood vessel is within the heart) or a stroke (if the blood vessel is within the brain).

Figure 5.

The “PLac” test.

Brennan ML, Penn MS, Van Lente F, et al. Prognostic value of myeloperoxidase in patients with chest pain. N Engl J Med. 2003;349:1959-1604

Plaque vulnerability is an important piece of information for the physician and the patient since it will dictate the aggressiveness of the treatment. This latter point cannot be overemphasized since the complications of vascular disease are often minimized when the degree of stenosis is not significant. As mentioned above, the cardiac catherization is the gold standard used to measure the percentage of occlusion in an artery, and when the percentage is not high, the action plans may be less than helpful particularly if the patient does not understand how important it is to change their lifestyle. Any percentage of stenosis/occlusion of an artery is not good since it tells the physician and the patient that the individual has caused damage to the largest and one of the most important organs in the body, the endothelium. If the person does not improve the quality of food they eat, do not start an exercise program, do not address the stress in life, and do not improve the quality of their sleep, then the endothelium damage will continue until the occlusion gets to the degree where a heart attack or stroke occurs. Thus, the point is to emphasize to the patient the importance of working to reverse any degree of stenosis.

Another simple test to do is a microalbumin test to measure the amount of albumin protein in the urine. When the arteries in the kidneys are damaged (another example of endothelial dysfunction), they spill more albumin protein into the urine than when the arteries are healthy.

Ridker PM, Danielson E, Fonseca FA, et al. Reduction in C-reactive protein and LDL cholesterol and cardiovascular event rates after initiation of rosuvastatin: a prospective study of the JUPITER trial. Lancet. 2009;373:1175-1182

Hs-CRP, or high sensitivity C-reactive protein, is a simple blood test that is a general measure of inflammation within the body and is a good marker of successful treatment (Figure 6). As the CRP number decreases, it tells the health care provider and the patient that inflammation is decreasing and the individual and the endothelium are getting healthier.

Figure 6.

CRP versus LDL.

The above-mentioned advanced tests beyond the traditional lipid panel gives more detailed and specific information about what is happening within and around the arteries. These tests add to the list of risk factors that should be itemized for the patient and the health care provider. Even when an individual does not have a specific diagnosis, if they have many risk factors, this becomes a problem list that should be worked on to help the individual become and stay healthier.

Diabetes and prediabetes represent conditions of elevated glucose and abnormal insulin function. When glucose in the circulation is elevated above the normal level, the glucose molecules attach to proteins in the body creating a distortion of the proteins and, therefore, dysfunction of the proteins. This is one mechanism thought to be related to the cause of dementia, which is now being called type 3 diabetes. These changes (protein dysfunction) also occur in the prediabetic state. This is one reason health care providers should be as diligent with prediabetic patients as they are with their diabetic patients. Over time, the same complications occur in both groups. Therefore, it is incumbent upon the health care provider to impress upon the patient the seriousness of this disease. With aggressive lifestyle change, both diabetes and prediabetes can be effectively managed, and we know from many clinical studies that intensive lifestyle change programs bring about the same or better clinical results than many of the first-line medications for diabetes and other chronic illnesses.

Diabetes, CVD, obesity, metabolic syndrome, and a host of other chronic illnesses are to a large extent lifestyle-related illnesses. They are not in most cases genetic/inherited and certainly are not related to advancing age. As such, the public needs (as do many health care providers) to be aware that these illnesses are largely preventable!

Knowler WC, Barrett-Connor E, Fowler SE, et al; Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346:393-403

With this background, then why are so many people still dying of preventable illnesses? Is this related to social determinants of health (ie, food insecurity, financial problems, excess stress, inadequate social support, addictions, transportation issues, and unemployment), or is it just that life is too stressful and many folks are unable to make health a priority?

The solution to this problem is not impeded by the cause. By this I mean we can largely avoid these preventable chronic illnesses regardless of the cause (lifestyle or social determinants of health). Since life and lifestyle contributed to the problem in the first place, we know that life and lifestyle changes can help solve these problems. Starting with the standard American lifestyle, the health care provider and the patient can work on a plan to improve nutrition, increase exercise time, deal with excess stress, develop a healthy sleeping plan, support mental and behavioral health, and help the individual understand their purpose in life (Figure 7).

Figure 7.

Exercise and All-Cause Mortality.

What is the evidence that lifestyle treats and prevents chronic illnesses such as hypertension, diabetes, heart disease, obesity, as well as many common cancers?

One of the best researchers in this area is Dr Dean Ornish, who has shown that intensive lifestyle intervention positively influences hundreds of genes related to prostate cancer. His program incorporates healthy eating with active living, meditation, and yoga and has significant impact on the development of CVD such that many insurance programs now pay for this prevention program.

Dr Caldwell Esselstyn has also contributed a tremendous amount of clinical information to the world of CVD. He has shown by using cardiac catherization studies that CVD can indeed be effectively treated and even reversed! His program is a strict plant-based program with no animal products and no oil. This intensive program has proven that CVD can be reversed and is now used by hundreds, if not thousands, of individuals.

Another program that treats, reverses, and prevents chronic disease is the Complete Health Improvement Program (CHIP). This is a 9-week in-classroom program facilitated by an instructor who teaches the participants how to shop, cook, and enjoy plant-based meals. The participants have homework assignments including restocking their pantry and kitchen. The participants are asked to eliminate all junk food and to keep only healthy food in the home so this becomes the easy choice. The program also emphasizes increased physical activity and stress reduction.

Realize the number of choices we make daily and understand how many of these choices affect our health in the short term and long term. When we choose to stop at a fast food restaurant, when we choose to smoke a cigarette, when we choose to stay up late and not get enough sleep, all these choices negatively affect health in the present and in the future if such behaviors continue. Conversely, when we choose to stop for a salad and a veggie burger, when we stop smoking, and make quality sleep a habit, we positively influence present and future health.

As a practicing internist for 25 years and as a specialist in preventive health care, I have seen firsthand the power of what is known as lifestyle medicine as well as able to compare this to traditional health care methods. The latter type of health care is delivered via prescription medications and surgical procedures. As I have critically evaluated and compared preventive health care and traditional medical care, I have been amazed at how effective preventive health care is. Rather than take a heartburn medication, individuals do better after they stop eating the offending foods. Rather than take high cholesterol medications, individuals (without previous evidence of CVD) do better after they start on a healthy low-fat diet and exercise. For those with diabetes, I have witnessed the amazing results from the CHIP program and have seen many individuals decrease and even stop many of their medication as their diabetes markers come into the normal range.

When I relay this information in public presentations as well as to medical professionals, I often see that people are surprised by these findings, and I wonder how this can occur. This information has been accumulating for decades; unfortunately, it has not been disseminated as well as the propaganda people hear from the meat and dairy industry. The clinical evidence is clear—animal protein increases the risk and incidence of most of the chronic illnesses and many cancers. Dairy makes the bones weaker not stronger as the television commercials tell the public. All a person needs to do is to start reading some of the clinical reports that are on the website www.nutritionfacts.org as well as listen to the video blogs from Dr Michael Greger, who is one of the most knowledgeable physicians in the area of plant-based research. This information is supported by the work of many others including Dr Joel Fuhrman, Dr Joel Kahn, Dr T. Colin Campbell, Dr Garth Davis, Dr Scott Stoll, and dozens of others who have devoted their professional careers to helping health care providers and the public understand the role of nutrition in good health.

Once we understand this and know what is stated above is grounded in evidence-based, scientifically validated research, and not opinion or philosophy, what we do next is most important. As health care providers, we are all responsible for understanding the current clinical evidence. With this information we should be educating our patients on the benefits of healthy living, plant-based eating, and intensive lifestyle interventions. I believe we, as health care providers, are also responsible for being role models for healthy living. We cannot just tell our patients what to do—we have to believe this enough to live our lives in the same fashion. In this way we talk the talk and walk the walk. When we do this, the results are tremendous!

We transform our clinical work from a sick care system to a true health care system. In the United States, we have a sick care system. We essentially wait for people to become sick and then we try to cure them rather than focusing on keeping healthy people healthy in the first place. Included in my public presentations, I often show the YouTube video, Make Health Last, which shows how most people in America spend the last 10 years of their lives—in sickness and not in wellness. Most people get old and die after a long bout with a chronic illness or cancer. Most Americans do not live the last years of their lives in wellness. In contrast, many live in the Blue Zones of the world where there are more centenarians than any other place on the planet. The reason for this is the people who live in the Blue Zones (Sardinia, Ikaria, Okinawa, Loma Linda, and Costa Rica) eat healthy food daily, they are regularly active, they sleep well, manage their stress, and live with purpose. They have great social support and do not worry about who is going to take care of them as they age because family and friends are all around for support. When you watch this video, most people say, “I want to live like that!”

Certainly, that is how we should structure our lives. Again, it is all about choices. We can choose to be healthy or we can choose to live a life that leads us down the road to sickness, chronic disease, disability, and early death. Lifestyle either creates a problem or creates a solution! Each day the choice is ours—so how are you going to live?