Random Thoughts from a Restless Mind

Some time ago I wrote about creating a way to measure health. Real health. Health that encompasses every aspect of what it means to be alive and well. As a CrossFitter I definitely included Coach Glassman’s Disease -> Health -> Wellness continuum, and I also acknowledged the critical importance of his concept of “Fitness over Time”. As a classically trained physician/scientist there is clearly a place for more traditional metrics like blood pressure, serum lipids and the like, although they may, indeed, be an variable that is ultimately tied to fitness.

Where my thoughts on defining and measuring health seem to depart from most current trends is in the recognition that mental health–emotional wellbeing—is as much a part of being healthy as any other thing we might examine.

Think about it for just a moment. Most of what we would classify as mental illness has as many outward signs that we can see as diabetes and hypertension. Which is to say, none. Yet we—all of us, not just CrossFitters—see nothing but the good in treating diseases like diabetes openly and aggressively. There is no stigma attached to seeking care for your hypertension or your elevated LDL. To the contrary, if someone who loves you discovers you quit measuring your glucose before you bolus your insulin, they are for sure gonna get in your grill.

For whatever reason, mental illnesses are looked at quite differently. No one is asking the person with chronic depression whether she is taking her life-saving medication, for example. We might notice an insulin pump on a friend or family member, but then it’s quickly forgotten. Everyone seems to be very uncomfortable around the young man who has very obvious hand tremors from the life-saving medication he takes for his Bipolar disease. We all seem to be so much more understanding when we have to wait for a response from someone suffering from Parkinson’s Disease than from the young women who has the same symptoms as a side-effect from the medicine that quiets the dangerous thoughts in her head from Schizophrenia.

It’s not even necessary to look only at these kinds of severe mental illnesses when we are examining the importance of mental or emotional wellbeing as an integral part of being healthy. What good does it do to have a 5:00 mile, a 500 lb. deadlift, and a 1:59 “Fran” if it was self-loathing that drove you in the gym to get there? You may be quite accomplished, the envy of your peers, at the peak of whatever life mountain you wished to climb, and yet you cannot feel joy. How is it possible to be healthy without joy? I look at Usain Bolt and what I see is quite possibly the healthiest man alive. My friend Tim, the writer, tells me that Justin Gatlin has nearly everything that Bolt has—youth, fitness, wealth—but the combination of failure to knock off Bolt, and the public disapproval reigned on him as boos from the Rio stands has left him emotionally broken. It’s subtle, but if you look at his face in the blocks of the 100M Final it’s there.

Our complex and conflicted attitudes and feelings about mental illness are especially evident when the topic of suicide comes up. Just typing the word makes me uncomfortable. Even how we describe suicide is fraught with hidden meaning that reflects our discomfort: someone has “committed suicide”. Right? Someone committed an act that we simply cannot fathom, one that leaves the survivors completely without any understanding whatsoever. How could someone DO that? It’s as if every suicide is the same as the suicide of the crooked prison warden in The Shawshank Redemption when he looks out the window and sees his fate arrive in the front seat of a State Trooper’s car.

In reality most of the time it’s simply not like that at all. Nothing about it is simple at all.

The outer walls at the periphery of my world have been breeched by suicide twice in the last couple of weeks. One of them actually does feel a bit like that prison warden. Frankly, I am too conflicted, too aware of the external circumstances and not enough aware of the internal life of the deceased to offer much right now. The other one, however, just stopped me in my tracks when I heard. The loss was profound.It has also introduced to me a new vocabulary that I truly believe provides a starting line from which we can change how we think about not only suicide, but all of mental illness. A friendly acquaintance lost his wife when she was killed by suicide.

We don’t need to know all of the details of the story. Suffice it to say that in the face of a child’s illness she suffered quietly. Too quietly to be noticed. Perhaps she didn’t realize how badly she was suffering, or maybe she was like so many of us and couldn’t bring herself to see her illness for the life-threatening entity that it was. No one will ever know. What is clear, though, is that this was not anything about commitment. Kidney failure may be cause of death in a diabetic, but it is diabetes that kills him. There is no difference here. The cause of death was suicide. Her disease, her depression is what killed this young woman.

Each of us has a very few moments in our lifetimes that forever change us. On the second Tuesday of July in 2006, unbeknownst to me, one of those moments was transpiring in a lonely, dark corner. Joyfully, the moment was a beginning, not an ending. Regardless, once learning of the moment I was changed forever. Now I knew. You cannot see any marks from mental illness, no swollen appendage or insulin pump. But it is there all the same, and it must be acknowledged and accorded the same degree of care as any other disease that may take our loved ones from us. Mental illnesses are real, and they can be deadly. There ought not be any conflict or discomfort in treating them.

We may stop losing so many of our loved ones when start to see emotional wellbeing as part of being healthy.

Health should be defined along the lines of individual human potential. An actionable definition would go something like “the ability to live at the limits of your fullest potential without any encumbrance now or in a foreseeable future”. Fitness as defined by Greg Glassman and CrossFit–work capacity across broad time and modal domains–should therefore be seen as “applied health”. As such, since fitness at any given time is an accurate measurement of one’s functional ability, our variable ‘F’ should have the heaviest weighting in our Health Index.

Let us begin our discussion of Fitness by reviewing and dispelling several myths and misconceptions about the interrelation between health and fitness. First, is it really necessary to review all of the data which now stares us in the face as far as the importance of exercise in health? By the same token, it should be clear to any sentient being that not only is what we eat important (although we must concede that this may differ across populations) but how much?  Simple carbohydrates, manufactured substances meant to cheaply replace real food, harmful (trans-) fats–it doesn’t matter what KIND of nutrition plan you follow, these are all BAD. As I write this I am recovering from surgery and I am not able to exercise. Does anyone believe that I will NOT gain useless weight if I maintain my pre-operative food intake? This part isn’t rocket science, folks. Coach Glassman says it as well as anyone: “Eat [protein] and vegetables, nuts and seeds, some fruit, little starch, and no sugar. Keep intake to levels that will support exercise but not body fat.”

Next up is the canard that fitness is simply being able to do something for a very long time. This view, promulgated and propagated by the likes of Outside Magazine and others, is not only insufficient but has been shown to be false as well. In the last couple of years there have been a number of very important studies showing a degradation of heart function in so-called “Ultra” athletes in any area. Decreased cardiac output and an increase in cardiac arrhythmias such as atrial fibrillation have been shown to be caused by excess endurance training. Endurance as the sole defining characteristic of fitness is as incomplete as would be strength. One need only look at the life expectancy of the strongest humans on record to see that strength in and of itself is not sufficient to produce health.

The question of what constitutes fitness is one that has been answered, at least insofar as health is concerned. It is not enough to be able to run or bike or swim long distances if you cannot also lift heavy things, including your own body. In the same vein one is not truly fit if one can deadlift or squat 3X his or her own bodyweight but cannot run a mile in under 15:00. One must have some measure of BOTH. As such the inescapable conclusion is that Greg Glassman is correct when he says that fitness equals work capacity across broad time and modal domains. You must be able to lift heavy things over a short distance when necessary, but also possess the ability to carry lighter things a longer way for a longer time as well. While I am not naive enough to expect that this will be accepted without spirited debate, when it comes to any measurements of health now available, all arguments to the contrary are not supportable. Glassman has won this battle.

As an aside, this should once and for all put to rest the myth of the “healthy obese”. What good is it to be happy, ‘W’ off the charts, with a stratospheric ‘M’ because all of your bloodwork is perfect, to go with your BP of 120/70, if your joints will cave under pressure decades sooner than they need to? You simply cannot escape the reality that health requires physical fitness.

If fitness can be described as “applied health”, it stands to reason that it will have the greatest contribution to our eventual Health Index. As such it is especially important that our chosen tests meet the criteria outlined in Part 1, that the measurement be as broadly accessible in all ways as possible. In the purest sense we would be able to measure an individual’s “work capacity”, the totality of his or her expression of fitness as measured by many tests covering different loads, distances traveled, and time. In CrossFit we talk of this as the “area under the curve” of a graph that records Power (lbs-ft. per second) on the X axis and Time (in minutes) on the Y. In a perfect world this would be part of every individuals ongoing pursuit of health, but alas, even in the CrossFit world where a very committed everyone records everything, this has proven to be problematic. In designing a series of tests to be applied to the broadest possible swath of humanity this ideal must yield to a more pragmatic approach.

What, then, should we measure, and how? Let us first propose a couple of general characteristics of the tasks in our test and then see what fits the bill. We should test an individual’s ability to move from one place to another under their own power–running is a fundamental human trait and should be part of our evaluation. Likewise, the ability to pick something up off the ground is a pretty basic, everyday movement and would qualify as our test of strength. Lastly, in the U.S. we have a storied heritage from the 1960’s, The Presidential Council Fitness Challenge (PCFC), in which candidates are tested on their ability to perform calisthenic exercises for both speed and endurance. It would be fitting to include something that evokes this historical element.

Once again I anticipate a vigorous debate about the particular elements we include. I’ll go first. We can reward both speed and endurance by starting with a timed run in which the result is distance traveled. The most common example of this comes from athletic programs and the military: a 12:00 timed run for distance. We live in the U.S.; the unit is yards. Pick up something heavy? Sure sounds like a deadlift to me. Any deadlift you wish, standard or sumo, will do. My bias is that a lifting belt is just fine, but except in very special circumstances (e.g. one-armed subject) I would say that straps to help you grip the bar are not a good idea, especially for the very inexperienced subject.

After giving considerable thought to the exercises and format in the original PCFC I think we should simplify the test while at the same time bringing it into the modern fitness world. In the PCFC one sought a maximum number of reps in 2:00 of pull-ups, 2:00 of sit-ups, and 2:00 of push-ups. What exactly are we testing with sit-ups that reflects true fitness? I would favor swapping out sit-ups for air squats. With a nod to CrossFit and Greg Glassman’s outsized contributions to this discussion, let’s use the format made famous by the CrossFit WOD “Cindy” with a small adjustment. To test our subject’s ability to perform bodyweight movements and move quickly, repeats of the triplet of 5 pull-ups, 10 push-ups, and 15 air squats in 6:00, counting as our result the total number of repitions achieved.

There you have it. A definition of “Health” and “Healthy”. The introduction of the three variables that go into the measurement of “Health”: traditional medical values ‘M’, emotional well-being ‘W’, and Fitness ‘F’. Next I will address how we will value each of these measures, and then ultimately how they will be combined to give us a meaningful, actionable health measurement ‘H’.

2016 is an Olympic year. We will hear stories, as we do in every Olympic cycle, of the extraordinary physical accomplishments of Olympians in sports which require otherworldly amounts of what we in the CrossFit world would consider “Fitness”. Strength, speed, and agility. Uncanny feats of coordination and accuracy, some performed over distances and times that are so far beyond the reach of the average human as to defy credulity. Many of these athletes, certainly the ones we will meet through the intercession of NBC, will match our expectations of the happiness that must certainly accompany such outsized achievements. Mary Lou Retton, anyone? Indeed, what we will see on our screens will fairly scream “Healthy”.

But there will be others, too. And for all of their physical fitness, expressed so dramatically for our viewing pleasure and patriotic zeal, the lack of emotional health will make it obvious to anyone that they are not healthy. Bruce Jenner, anyone?

Remember our proposed definition of “Healthy”: Able to perform in all ways at the farthest limits of one’s potential capabilities. Health is therefore the state in which no infirmity is, or can in the future, impede this ability to fulfill a potential. It takes but a moment to think of how mental illnesses such as depression, bi-polar disease, and schizophrenia can be hidden from view when examining only physical metrics. There are examples all around us. The woman who partners with a 1400 pound horse in the rigorous, physical tasks required to compete in the three-part test that is eventing, so poised and accomplished in the arena, who retreats to solitude outside the barn because she is incapable of overcoming her anxiety around people. The outdoorsman who in his manic phase performs feats of strength and endurance others can only marvel at, and then plunges into the depths of depression from which he cannot see the noon-day sun. Much more prosaic and much more common is the individual who continually increases his or her fitness by any and all measurements due to a deeply held sense of low self-worth, perhaps even self-loathing, pursuing an unreachable ideal and always falling short.

A truly universal measurement of health must include some element of emotional well-being. Let’s call it “W”. You could certainly call it the “Happiness Factor”, and some undoubtedly will. I imagine criticism directed toward this to take the form of “Happy Face” mockery. No matter. Well-Being is a better term for this part of our equation because it encompasses more than whether or not you are happy, whatever happy may mean to you, when you are measured. Are you content with your circumstances at the moment? Do you have the ability to persevere under duress?  What is the state of your relationships? A recent study of Harvard men carried out over decades found that both happiness and longevity were tied quite closely to the quantity and quality of your relationships with family and friends. Where are you in your pursuit of your goals, your dreams, and how do you feel about that? How much stress do you perceive in your life and how are you managing that? All of these make up what one might think of when we consider Well-Being.

How, then, should we go about measuring ‘W’? Remember, all of our tests should meet the dual imperatives of being accessible to pretty much everyone, and as inexpensive as possible. We could certainly use something like the classic anesthesia “smily face” pain scale, relabeling the figures, but this feels too simplistic and too momentary to be truly applicable. Our measurement should require a bit more thought than that. I have to admit here to countless hours of internet crawling trying to find a validated test of emotional well-being that has a track record in a heterogenous group that mirrors our population; most have been utilized in very specialized populations (e.g. soldiers) with a very specific research interest. Those that might apply must typically be purchased.

John Pinto is a well-regarded consultant in the world of my day job, ophthalmology. He has long had a list of clients that spans the gamut of pretty much every measurement you could think of in a group of doctors. Men and women. Young and old. Fantastically successful doctors and those that could only be described as spectacular (if unexpected) failures. As part of his quest to better understand his clients in order to better serve them, John used a questionnaire that measured emotional well-being. He found that external measurements of success such as volume of surgeries, income, and professional acclaim did not always coincide with his clients sense of success, their emotional valuation of their professional lives. These were certainly variables that mattered, but his happiest clients were not always his wealthiest, and his least happy not always those who had less. The assessment he used is the best one that I’ve been able to find, notwithstanding the fact that it is not free.

(http://psychcorp.pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid=PAg511 ).

I am not wedded to the Psychcorp assessment and would happily review any alternatives. Especially if they are free! As is the case with ‘M’, our traditional health metrics like blood pressure and serum lipids, I expect a vigorous debate as to the relative weight of ‘W’ in our final Health Index. My bias is that ‘W’ is a current factor with a greater impact on health, and it should have a correspondingly greater weight in our formula. Let me start the “bidding” with double; however the final formula shakes out ‘W’ should have twice the value of ‘M’.

Mental health is an inextricable part of health. It must be included in any serious definition and measurement of health. Our variable is “Well-Being” or ‘W’.

“Eating healthy is too expensive.” How often have you heard some version of that phrase. Whether it be Zone, Paleo, Whole 30, or just “stay out of the middle of the grocery store”, this is uttered with some degree of exasperation and oppression with a kind of mind-numbing, self-fulfilling frequency. There is an overarching sense of deprivation here, a feeling that it’s just impossible to find the money to eat lean protein or fresh fruits and vegetables.

How so? Per the folks at Whole Foods, regularly skewered for being too expensive (seriously, they sell fancy potatoes), on average we in America spend 7% of our disposable personal income–that’s SEVEN–on food. 50 years ago that number was 16%. We now spend less than 1/2 of our after-tax income on food compared with what we spent 50 years ago.

And eating well is too expensive.

If we dig deeper into that stat alone we see that modern food production has decreased the cost of food relative to both income and inflation. The cost of producing food of all kinds has risen much more slowly than income. Why? Partly because junk carb-laden food is cheap. High-fructose corn syrup costs a fraction of grain sugar. Corn-fed protein with or without pharmaceuticals is grown faster and cheaper than grass-fed. Stuff like that. Less expensive to produce/incomes risen over 50 years at a greater rate across the entire spectrum, top to bottom.

How then is it too expensive to eat a more healthy diet. We have 9% of our after-tax income to play with, right? Even I can do that math. Is some other necessity (shelter, transportation, medical care, etc) eating that up? What are we doing with that 9% that we can’t find some of it to eat better? Ah, Grasshopper, now we begin to see. It’s a ‘Nando thing, it’s superficial. It’s not how healthy you are, it’s how you look, or feel, or something like that.

Some stuff might be more expensive; it probably really is more expensive to put a roof over your head in Manhattan nowadays, both the Island and the Beach. The seemingly obvious culprits are actually false targets (eg. healthcare which for this audience represents only a tiny % of new cost compared with 50 years ago because of insurance, govt. programs, etc.). Nope, it’s how we CHOOSE to spend that freed-up 9% .

Think about that household in the 1960’s or even the 70’s. Average of 6 people under that roof. One car. One TV. One radio. Once purchased all data was free. A pair of shoes and a pair of boots. Sneaks if you were a jock. You didn’t get your hair done if you were a guy, you got a haircut. You didn’t get your acrylics touched up every 2 weeks; if you wanted long nails you grew ’em. Stuff like that.

Fast forward to today and think about the stuff you’ve acquired, stuff you are convinced you can’t live without, stuff that costs money, cash that you choose to spend every single day. The ratio of drivers to cars in a household is seldom less than 1.5/1. The ratio of phones to people over the age of 10 is seldom less than 1/1, often more than 1/1 if you add in a landline upstairs, downstairs, and in every bathroom.  It’s not enough to have a cellphone, or even a cellphone with an unlimited text plan, nope, it’s gotta be a SMARTphone that will let you post your thoughts on today’s weather in Bimini to FB. Right now, from anywhere. If you don’t have Netflix available on each of the 4 flat-screen TV’s in the house you are considered a Luddite.

Listen, I certainly am not saying that all that stuff isn’t great, that it’s not a ton of fun and really convenient (as I type on one of the Apple products that literally litter our household, through my WiFi network, in front of my LightBright lamp, in the bathroom), or anything like that. What I most certainly AM saying, though, is that people who whine about how hard it is to afford to eat better almost always do so via a FB post from their iPhone 5 while sitting in the salon having their hair done, hungover from too much Bellevedere they consumed last night while noshing on Doritos smothered in Cheez-Wiz.

9 %. The stark reality is that we have let our things become more important than ourselves. We are choosing Apples alright, just not the ones we find in the outer aisle of Whole Foods.

I have been pretty generous in sharing my thoughts about some of the ills of our American Healthcare system, especially with regard to the barriers erected between physicians and patients. The attempt to “reform” medical care via a top-down, bureaucratic solution to what may or may not ail our system is ridiculous on its face. We are to believe that our Federal Government can handle something as complex as healthcare, a segment of the economy representing ~20% of GDP? A Federal government that has proven so adept at managing other major segments of our economy like, oh, energy policy?

The “baby with the bathwater” approach in the halls of our Capitol and the editorial offices of our leading media outlets (WSJ excepted) is about as wrong-headed as you can get.  What we need is an AMERICAN solution to the challenges that we presently face with the economics of healthcare in the U.S., using our present system as the foundation. We need a solution that emphasizes the strengths of our markets, with government providing oversight to establish a playing field that is as level as possible.

Not surprisingly, I have some thoughts!

1) Malpractice tort reform. See my thoughts in “Tort Reform = Healthcare Reform”. Effective reform will dramatically reduce the scourge of defensive medicine with its attendant costs and risks to patients. We all do it, and we do it when we don’t get paid to do it. Defensive medicine represents 15-25% of all medical costs in the U.S. That’s 15-25% of $2.5 Trillion. Do the math.

2) Tax Reform #1: Remove the tax deduction for employer-offered health insurance. Provide a 100% TAX CREDIT to the lowest 60% of wage earners for the purchase of health insurance. Provide a progressive TAX DEDUCTION for the upper 40% of wage earners. Level the playing field by removing the penalty for not working for a company that can deduct your insurance premiums.

Tax Reform #2: Remove the tax deduction for advertising as a business expense for Hospitals. If we are concerned about unnecessary increased utilization of medical resources why are we allowing advertising by hospitals? Seriously, why are we subsidizing the Ohio State Medical Center when it advertises for business in Cleveland. Ohio State is in Columbus, 2.5 hours away.

For that matter, remove the tax-exempt status of any hospital or  provider that advertises. How is it appropriate to allow a hospital system to advertise to increase revenue, deduct that advertising as an expense, and still be not-for-profit? If it looks like a business, acts like a business, and sounds like a business, tax it like a business.

3) Insurance Reform #1: Reverse all of the for-profit conversions of previously not-for-profit health insurance companies. Who was the genius who thought THIS was a good idea? I don’t remember insurance premium increases that were quite so massive when all of the Blue Cross/Blue Shield plans were not-for-profit, do you? And while there were $Million execs in the non-profits I don’t recall any $10, $20, or $100 Million execs. Removing the need to answer to the stock market will create companies that will compete quite nicely with the for-profit companies without the horror of a government run system. Let the equivalent of NGO’s compete with the United Healthcares of the world.

Insurance Reform #2: Remove state-level coverage mandates and create a minimum federal set of mandates for comprehensive insurance policies. A REAL minimum. REAL medically necessary items. This is the brilliance of Sweden’s system. No Viagra or artificial  insemination coverage. Allow cross-state competition for the business. Real competition always drives prices lower.

Insurance Reform #3: Do whatever it takes to encourage the purchase of  high-deductible catastrophic health insurance for all. Real insurance that covers real medical disasters like car accidents or cancers that strike young adults.

Insurance Reform #4: Allow insurance companies (Medicare and Medicaid included) to discriminate IN FAVOR OF people who make healthy lifestyle choices (eg. no nicotine, no DUI, etc.). We are all so afraid of the stick that we refuse to allow any use of the Carrot.

4) Freedom of Speech/Restraint of Trade Reform #1: Abolish, once again, direct-to-consumer pharmaceutical advertising. There was a quantum leap in the utilization of all sorts of medications immediately following the 1997 rulings that allowed DTC pharmaceutical marketing. If it is so obvious that our ever-increasing levels of spending on medical care is a threat to the very existence of our fair Union, then DTC drug marketing is a version of yelling “FIRE” in a crowded theater.

Freedom of Speech/Restraint of Trade Reform #2: Begin a return to the professionalism of yesterday by prohibiting all forms of advertising by, or for, physicians. The AMA gets a lot of criticism, most of it well-deserved in my opinion, but the court and FTC rulings that prohibited the AMA from censoring physicians who advertised was a seminal event in the de-professionalism of doctoring and medicine. Doctors and other medical advertising was, is, and always will be wrong. While we’re at it, do the same thing for lawyers and the practice of law.

5) Public Health. Finally, and most importantly, go to the true root of whatever “Crisis” we may have here in the United States, be it a “Healthcare Crisis” or a “Healthcare Finance Crisis” or what have you. We as a people are not healthy; certainly not as healthy as we ought to be. We are not healthy because of some wrong-headed previous Public Health decisions (simple-carbohydrate based diets, abolition of school phys-ed programs, tort-fearing closures of playgrounds, etc.). We are not healthy because our ability to treat the diseases that result  from poor lifestyle choices (cigarette smoking, alcohol abuse, preventable accidents, etc.) is SO GOOD that we are able to keep more and  more unhealthy people alive longer and longer, paying ever more to do so along the way.

This is where true leadership can make a difference. Remember JFK and the President’s Council on Fitness? I do. 8 pull-ups in the fifth grade for me. Sweden identified saturated fats from whole-milk products as a significant cause of heart diesease in the 70′s; a full court Public Health press for low-fat dairy brought about a dramatic decrease in cardiac deaths in the 80′s. Polio, measles, smallpox and whooping cough were once the leading killers of children in the U.S. but are now historical footnotes due to Public Health initiatives.

We lead the world in per capita alcohol related accidents and deaths, losing young lives by the thousands each year (is it just me or does it seem we have MORE alcohol-related problems in our youth since raising the drinking age?) We have ever more increasing numbers of truly obese citizens who go on to suffer the diseases caused by that obesity, and we pay ever more for their diabetes, hypertension, strokes and heart attacks. These lifestyle choices are root causes for our increased expenditures on Healthcare, much more so than all of the targets of Beltway demagoguery like insurance company expense ratios and pharmaceutical company profit margins. A solution to this issue, more than all of numbers 1 through 4 combined or any other proposal yet floated, is the true crux of the solution to any “Crisis” we may be facing. Everything else is only there to buy time. Time to get healthy.

It’s a Presidential Election year in the United States. There are no votes to be had in making Americans healthier. Nothing but hard work on every side of the equation. Who will stand up and do the hard work? Who will lead?

Who will have the guts to not only say that the Emperor is naked,  but also drunk and fat and puffing away our economy.