The current approach to healthcare in the United States isn’t working. As I discuss in the Road of Health course, modern medicine has in ways been a remarkable triumph. (The Road of Health course is free, and other courses are available here.) In the twentieth century, the development of things like antibiotics and vaccines eradicated many diseases that would have killed millions of people. But nowadays we face new problems. Most patients are coming to the doctor not to be treated for tuberculosis or pneumonia, but instead for ongoing treatment of chronic diseases, like atherosclerosis, diabetes, arthritis, obesity, and cancer. In fact, half of all Americans have a chronic disease, and seven of the top ten causes of deaths are chronic illnesses. It therefore appears that our conventional medicine approach is flawed and needs an overhaul… perhaps we need unconventional medicine?
No doubt, part of the reason for this predicament is simply that we are living longer – long enough to develop these conditions. Yet the burden of chronic disease appears to be cascading into younger generations. Diseases that were formerly only found in older people, like type two diabetes, are now being frequently diagnosed in children. It is at the point that public health experts have projected that the steady rise in life expectancy of the past two centuries may be coming to an end.
This is an alarming trend that may be very difficult to reverse.
Why we need unconventional medicine
Unfortunately, chronic disease is a more complicated problem than infectious disease. We can’t eliminate atherosclerosis just by taking a pill or an injection. Conditions like diabetes and heart disease develop gradually over many years and are closely linked to the patient’s diet, environment, genetics, and so on. A 10 to 15 minute doctor’s visit can only do so much. These conditions demand a more complex intervention, with more active participation on the part of the patient and the medical practitioner. The modern medical model, relying upon a battery of pharmaceutical drugs to suppress symptoms, falls hopelessly short of addressing the root causes of these types of illnesses, and we’re all paying the price.
We’ve come a long way, but we can’t solve modern challenges using the methods of last century. We need a new system. And my guest today has a plan for how to make a better approach – an unconventional medicine approach – happen.
On today’s episode of humanOS Radio, I talk with Chris Kresser. Chris is deeply concerned with the dilemma of chronic disease and has spent much of his career dealing with the situation personally as a practitioner. Chris recently launched the Kresser Institute, an organization dedicated to reinventing healthcare and reversing chronic disease by training healthcare practitioners in functional medicine. He just released his book Unconventional Medicine, which lays out the problem in detail and presents his plan to create an unconventional medicine system that works better for both patients and practitioners. To learn more about Chris’s vision, and what you personally can do to help make it a reality, tune in below!
Chris Kresser - 00:06: If you have a rock in your shoe and it's making your foot hurt, the conventional approach would be to give you a diagnosis of foot pain, but actually it would probably have a much more science-y sounding name to it to make it sound official. Then, the prescription would be Ibuprofen or some other analgesic to reduce the pain and certainly, it would help, but in functional medicine, we would take off your shoe and dump out the rock.
Kendall Kendrick - 00:36: HumanOS, learn, master, achieve.
Dan Pardi - 00:45: Chris Kresser, welcome to humanOS Radio.
Chris Kresser - 00:47: Dan Pardi, pleasure to be with you.
00:50: I am honored to have you here. You've had me on your show a few times, and I am excited to have the table switched here, so I get to ask you a bunch of questions.
00:58: Awesome. I hope I don't bring down the real estate values too much as Rob likes to say.
01:05: That's great. Well, you've got a lot going on, my friend including the launch of a new book, "Unconventional Medicine," and I've just been just reading. I'm extraordinarily impressed and today, I can't wait to dig into it because there's some really important topics about how healthcare needs to change in order to continue to serve human health, and I think you've laid out a really beautifully articulate compelling plan. First of all, congratulations and thank you. For our audience, for those that may not be familiar with your work, I'd love it if actually you could start and talk about your personal journey because it clearly is field nothing less in a passion for what you do. If you could start by telling us about how you have gotten to do what you do now.
01:44: Yeah. In some ways, the book is part memoir because what I do now and the lens through which I see the healthcare system both its weaknesses and strengths comes from two experiences. One is my own experience dealing with a complex chronic illness and not being well served by the conventional healthcare system in that, and two is my experience working as a clinician treating people with complex chronic illnesses, which is what I chose to do after I was able to recover from mine. Perhaps it's not a unique perspective but perhaps, somewhat unusual perspective of having been in both chairs or in both sides of the desks so to speak. In my 20s, I sold everything I owned and took off for a year long around the world search trip basically and it was a surf and meditation yoga trip actually, and I was in Indonesia, the island of Sumbawa in a little village surfing a spot called Lakey Peak, and I got extremely ill there with a tropical illness classic symptoms, vomiting, diarrhea, fever, delirium. Don't really remember much what happened for three days.
03:06: Fortunately, I had some Australian guy who was in the village, have some antibiotics in his medical kit and I took them and those brought me back from the brink. The acute symptoms passed but very, very long story short, I spent the next 10 years recovering my health. I ended up after quite a long time of not knowing what was going on figuring out that I had multiple parasite infections. Then, I did the treatment for those and the treatment was as bad or worse than the disease as often can be the case, and I had several years of recovering from both the illness and the treatments for the illness.
03:45: During that time, I started out by going to my doctor and saw probably no fewer than 30 doctors over the course of the first few years. First in California, and then in some other states around the US. Then, I eventually flew to Australia to see a tropical disease specialist that had a lot of experience working with people who had infections in Indonesia since Australia is so much closer and has a lot more experience dealing with that kind of things. I flew halfway back across the world and all of the conventional doctors that I saw almost without exception were caring. They wanted to help me and they did their best to help me, but it became clear overtime that the conventional healthcare system was not set up to deal with their chronic complex multi-system illness that I was suffering from.
04:43: There are a lot of reasons for this, which I'm sure we can get into. Overtime, I started to threw my own exploration and then my journey outside of the conventional system, find answers to my problems. Eventually decided as people around me started to see my recovery, and they saw how low I had been brought by the illness and then, how much I was able to recover, they started to ask me questions, "How did you do that? How did that work? I've got this problem, can you help?" Then, I realized, "Well, this is perhaps one of those things in like where every challenges is an opportunity," and I was never really planning a career in healthcare. I wasn't a kid that thought I would be a doctor when I grew up or a healthcare practitioner, but as I went through that experience, I began to see that what I have learned in that process could be really helpful for other people and I had become pretty passionate about it.
05:44: I decided to go back to school and formalize that. Then over the last 10 years, have been working with patients. My typical patient is not necessarily someone who went through quite the same experience that I did, but they're people that have been underserved by the conventional healthcare system and feel like they haven't been able to find answers anywhere else and are looking for a different approach. I've spent the last 10 years working with patients like that, so that gave me the perspective of being in the clinician role. Out of all that experience came the book.
06:19: Right. When people have whatever they're dealing with completely resolved, you don't continue to look for solutions, but there are so many unsatisfied sick as I call them, where whatever the therapy was that was provided by the conventional medicine system just doesn't completely help somebody feel the way that they way, which is fully resolved or completely better. As long as it stays a persistent issue, then people will hunt down. They're going to have that motivation to keep finding a solution. Clearly, you found that a lot of people were in that role and in that position. In that process for you, I know that you also discovered the ancestral health methodology. Looking at pre-modern lifestyle patterns as a way to provide directive for how we might be healthy today and perhaps you could tell us a little bit about your journey there as well because it's a fundamental part to what you do and it's obviously a really important part to the benefit you provide.
07:10: Absolutely. Yeah. I was actually always pretty interested in food. I was an athlete in high school, a basketball player. Dan, you and I have bonded on that note.
07:20: Our high school basketball coach, he was an assistant coach at USC. We had like a college level kind of program where I would come to school with like a cooler full of food, like home made food that I made myself before school. At that time, it was all about wheat bread and pasta, salad, and carb loading, that was the thing, but I was super interested in it from a very early age. When I got sick, what I have been doing before wasn't working. I began to explore a lot of different options and at that time, again it was much more about low fat and vegetarianism and even veganism, so I explored all of those. I have actually at one point, became a macrobiotic vegan and I was even apprenticing with a macrobiotic chef in San Diego. I tried just about every diet philosophy that I was aware of and none of it really did the trick.
08:16: In some cases, I improve in some ways. Then, I was in a bookstore in Victoria, British Columbia and I saw a book called "Nourishing Traditions" which is written by Sally Fallon who is a modern current day advocate of the dietary philosophies of Weston Price, who is a dentist who back in the 1920s and 30s, traveled around the world and studied the diets of traditional ... Not an exclusively hundred data, but traditional cultures who had largely maintain their traditional diet and lifestyle because as a dentist, he was interested in why tooth decay was so ramped up and prevalent in industrialize world, but seem to be almost non-existent in traditional societies, and he published a landmark text, I think it's "Nutrition and Physical Degeneration."
09:13: He has these amazing photos in the book, pictures of people teeth in the industrialized world side by side with pictures of teeth and not just teeth, but their face, their jaw structure, their palette and you see people from the traditional world, their dental palette is wide. They have got this broad arch, beautiful wide circular round faces and straight teeth and in the west, people have ... Like me, this very narrow faces like a receding jaw, overbites, tooth decay, and I was fascinated. I found it really compelling and he had also even pictures of people that were living a traditional diet lifestyle, but then he switched to a modern process and refined food.
10:00: Within one generation, he has pictures of them side by side. You can see like their kids, they look like western people. I found it to be really compelling, and I started to adapt the dietary principles that he had summarized from all of these people. They included really nutrient dense foods, Argan, meat and fish, egg yolks, sea vegetables, pasture-raised, full fat, fermented dairy products and some of those cultures he studied did consume grains and legumes, but they went to pretty great lengths to prepare them in such a way that would break down some of the nutrient inhibitors that can be present in grains and legumes to make the nutrients in them more value available and make them more assimilable.
10:45: Then at some point, I cut out the grains and legumes because I found in even preparing them well, I couldn't tolerate them probably because of all the damage that have been done to my gut, and I ended up on what I later learned was referred to as a paleo diet, but I had no idea at that time. I didn't know anything about the paleo diet, and that was a big turning point for me. It made a huge difference in my own health. Then overtime as I began to explore further and then as I started to work with patients, I saw how potent not just the diet is, but the whole lens for looking at ... Using as a way to guide our own choices around how we eat, how we move, how we sleep, how we experience, how we relate to other people's social support, play, pleasure and things that are really, I would say, as important to our experience of being human as a food that we eat.
11:42: Yeah. When I think about diets and you hear something like, let's say the DASH diet, when you think about a diet that is dissociated from some other sort of guidance that will help you live in a manner that is orchestrating, like some principle that is orchestrating your behaviors across many different things, even beyond diet, like the ancestral methodologies do, how did our ancestors live before the advents in modernity? Then, all of a sudden, I think we can start to capitalize on, like you said, the myriad of other opportunities that there are to aid our health in a positive way. You've been one of the largest contributors by far to promoting ancestral methodologies. Now, this has become a part of your practice, you say?
12:26: Absolutely. It's one part of the three-part ADAPT framework that I talk about in the book because I think if we look at why the conventional healthcare system has failed, I lay out a few reasons in the book, but one of them was that there is a profound mismatch between our genes and thus, our biology and physiology and the modern diet lifestyle that we are exposed to today. What's interesting to me is diet ... What I just said is that's a fundamental concept in the field of evolutionary biology. It's well established and not controversial at all that all organisms are adapted to survive and thrive in a particular environment and if you change the environment faster than the organism can adapt, there's going to be trouble.
13:11: We can use examples all the way up to food chain. There are hydrothermal bacteria that live near these vents deep in the ocean where there's no light. It's completely dark, and they're on of the few organisms in the planet that can survive any absence of photosynthesis and they can process chemicals that would be toxic to just about any other organism. That's an example of how environment shapes biology. If you take that hydrothermal bacteria and drop it into a shallow ocean exposed to light, it will die but it's also true for cats. You think of cats, we know that they're true carnivores. In the wild, they only eat animal products. They don't eat grains. They don't even eat vegetables. They just eat animal products. When you feed a cat kibble, their health suffers because biologically, physiologically, they have a digestive tract that is optimized for only digesting animal products.
14:10: It's interesting to me as this is actually pretty well recognized in the veterinary and zoology communities now, and even in the consumer pet world. If you go into a pet score, all of the premium pet foods say, "Meat only. Raw. Meat only diet." It's ironic to me that many people now are feeding their pets a more species appropriate genetically aligned diet than they're feeding themselves.
14:37: Right. Whoa, whoa, whoa. Are you suggesting possibly that these principles [inaudible 00:14:41] humans do?
14:42: Yeah. That's the crazy thing is everyone recognizes this with every other organism on the planet. Even in zoos now, John Durant talked about this in his book where back in the 70s and 80s, or maybe in the 90s, a lot of animals in captivity were living shorter life spans than would be expected. Typically, animals in captivity live longer life spans because they don't get killed by predators. They're not subject to some of the stressors that you would find in a natural environment, but that wasn't happening. They start to look into it and someone probably an evolutionary biologist or a scientist thought, "Hey, maybe it's because we're feeding them stuff that they would never eat in their natural environment. Maybe we should go back to feeding them a species appropriate diet," and they did and sure enough, all of these animals from elephants to apes to tigers started getting healthier.
15:35: We recognize this for every other organism on the planet except for human beings. I think fortunately that's starting to change. I'm seeing articles now even on the popular media that are referencing the species appropriate ancestral diet lifestyle. I don't know if you've seen the series on the Tsimane in the New York Times over the past few months. This is a hunter-gatherers consistence farming population in Bolivia and these quite well known anthropologist, Gurven and I'm not sure if Kaplan was on these studies too, they've worked together in the past, but they went down there and they wanted to find out what the incidents of heart disease was in this population, who is one of the few populations that has largely maintained their traditional lifestyle. They've had contact with the west and they do have some western ways, but they've largely retained their traditional diet lifestyle.
16:26: They eat primarily meat and fish, fruits and vegetables, nuts and seeds and some starches like plantains, a little bit of rice and corn. They walk in average of 17,000 steps a day. That's about eight miles. They live in close knit tribal social groups. They are not exposed to a lot of our official light at night and they're not sitting for long periods. They're living pretty close to their traditional lifestyle. This research has found that the incidents of heart disease in the Tsimane is 80% lower than that in the US, and nine in 10 Tsimane ages 40 to 94 had completely clean arteries on CT scans. No evidence of heart disease at all.
17:11: We've all heard the argument, "Oh, hunter-gatherers don't get a heart disease or other chronic disease because they don't live long enough to acquire them." But as I just said, there were adults up to 94 years of age in the study and they also found that the average Tsimane, 80-year-old Tsimane person had the vascular age of an American in his or her mid-50s. This is powerful evidence, and that there's something we're doing in the industrialized world that is contributing to this risk of chronic disease and it's not just purely genetic, which was kind of, I think the idea for so long.
17:48: Right. I'll do a bit of a summary here to catch us up to where we are now. You had this personal tragedy of very serious health issue as you were traveling around the world. You had to visit over 30 doctors to try to find resolution and you still were not finding resolution, but along that process, you learned a lot and you started to develop some ideas and tools that helped you begin to improve your own situation and in doing so, you started to get questions from people in your surroundings that had noticed your recovery and wanted to see if you could help them as well.
18:20: That made you pursue something professionally, and along the way, you discovered the work of Nourishing Traditions and you discovered the idea of ancestral diets, and how people used to live before this rapid change in the modern lifestyle that is now normal and that led also to looking into paleo and now, there's a bunch of examples that are increasingly populating the literature about how these ideas that natural living communities are indeed healthy if they do survive past childhood mortality, and you've been implementing this into your practice with great success.
18:53: Excellent summary, my man.
18:54: Yeah. Thank you. All of these has led to, I think, fuel this passion that you have of helping people and you are now wanting to then take this the next step, which is to help more people experience the benefits of these things that you know can be extraordinarily useful. This leads to your new book, "Unconventional Medicine." Maybe we'll take a step to the side now for a moment, and this is about functional medicine, and why don't we start by talking a little bit about the differences between conventional medicine and functional medicine? With conventional medicine, you gave a great analogy about the rock in the shoe. If you could tell us a little bit about that.
19:34: Sure. I will just even take bigger step back and say there's really three elements of what I'm talking about in the book, and they're all in the context of a solution to the chronic disease epidemic. One is the ancestral diet and lifestyle, which we just talked about. The second is functional medicine, which we're about to pop into, but the third is equally important, I think. I've only come to realize this in the last few years, and that's the importance of a collaborative practice model and we can go more into that. By that, I mean including health coaches, nutritionist and other allied providers that can support patients in making the most important changes that are going to lead to lasting improvements in health and that's diet, lifestyle and behavior change.
20:20: Knowing you and what your interest are, I know that you agree with that and I imagine that will be an interesting discussion, but let me address your question about functional medicine.
20:30: Yeah. The analogy I use in the book and I often use and I'm talking to people about it is if you have a rock in your shoe and it's making your foot hurt, the conventional approach would be to give you a diagnosis of foot pain but actually it would probably have a much more science-y sounding name to it to make it sound official. Then, the prescription would be Ibuprofen or some other analgesic to reduce the pain. Certainly, it would reduce the pain. It would help, but in functional medicine, we would take off your shoe and dump out the rock.
21:02: That's the promise of functional medicine. Conventional medicine is largely based on managing disease after it has occurred and suppressing symptoms with drugs and sometimes surgery, and the reason for that is that our medical model evolved during a time when acute problems like infection, trauma and emergencies were the biggest challenges that we face. Back in 1800, the top three causes of death were typhoid tuberculosis and pneumonia, right? All acute infectious diseases. Other reasons that people go see the doctor were like a broken bone or an appendicitis, or gallbladder attack, also acute problems. It was pretty straightforward. It wasn't always successful, but doctor would set a cast. Set the bone in a cast or take out the appendix or gallbladder, and then once antibiotics were invented, we're prescribing antibiotic for the infection and it was one problem, one doctor, one treatment.
22:01: But today, that's not the healthcare landscape that we're facing. Seven of 10 deaths are now caused by chronic disease. Chronic disease accounts for 86% of our total healthcare dollar spent and 99% of Medicare dollars, so we're living in a totally different landscape and what we're trying to do is apply a medical paradigm that evolved in a completely different healthcare landscape to our current landscape, and that's like fitting a square peg in a round hole. It's just not working because unlike acute problems, chronic diseases are complex. They're difficult to manage and they often last a lifetime. They don't lend themselves to that one treatment, one problem, one doctor, one treatment model.
22:48: Chronic diseases usually require multiple doctors. In our system at least, you often see a different doctor for every different part of the body, right? Then, multiple treatments that last for a lifetime. Our symptom suppression sick care disease management system, which actually does a fantastic job with acute problems. Look, if I get hit by a bus, I want to be taken to the hospital, not a functional medicine doctor. At least not right away, maybe after a while. Antibiotics, absolutely revolutionized the treatment of infections. Vaccines have reduced the burden of acute infectious disease, sanitation and both on a societal scale and antisepsis, surgical operating room have saved countless numbers of lives where the medical technologies we've developed now is starting to be able to restore sight to the blind and reattach limbs and potentially even fight cancer with nanorobots in our lifetime, it's incredible. It's not about giving that up.
23:54: We still need doctors who can do colonoscopies and endoscopies and who can remove cancerous tumors, and who can operate within their scope of practice and do what they're trained to do, but I think we can all agree that that's not enough because those strategies or those tools and that methodology is not effective for chronic disease because the primary driver of chronic disease is diet, lifestyle and behavior.
24:22: Right. It's not one infectious agent that you can identify, remove from the body or suppress with a drug?
24:29: It's not at all.
24:30: It's how you live.
24:31: Yeah. It's how you live, and Dale Bredesen who is an amazing physician, who has studied Alzheimer's for his entire career, I just want to tell his story because I think it's a really good example of this. He started out on the bench, as a bench scientist just studying the mechanism of Alzheimer's, and in that world, the idea was if they could just identify the one mechanism and then come up with the one drug that could target that mechanism, they could cure or at least treat Alzheimer's successfully, right? After 25 years of drug development, there's not been a single drug that even slows the progression of Alzheimer's much less reverses it. Dale, Dr. Bredesen came to realize over many, many years that that approach was failing because it was the wrong goal.
25:23: Like all chronic diseases, Alzheimer's is multi-factorial. They'll never find a single mechanism because there's more than one mechanism and they'll never find a single drug, they can reverse it because it's caused by the same diet, lifestyle and behavioral issues that are driving every other chronic disease, and he has a great saying that he says, "We don't need a silver bullet, we need silver buckshot."
25:47: I like that. I think once you experience that epiphany of going from thinking about the body in that manner to realizing, like you said, how multi-factorial life is and our health is in relation to the world and how we're living, then it becomes incredibly obvious and important to realize that we need more support about for how we are living. Now, there might be specific issues that you're trying to address that have now advanced because of one reason or another and let's talk a little more deeply about how functional medicine's approach can actually help solve things where the conventional medicine would fail.
26:22: Right. Let's use the irritable bowel syndrome as an example. This is now the second leading cause of people missing work. It's epidemic. I think almost everybody knows somebody who's affected by it, and while it's not life threatening, it's debilitating. It can really wreck somebody's life and the conventional approach to irritable bowel syndrome, well just starting from the name of it. This is like we're talking foot pain and coming up with a fancy name for that diagnosis. That's essentially what IBS is. You go to the doctor, you say, "Oh, doctor. I've got pain in my gut and I've got gas and bloating and diarrhea and constipation." They say, "Okay. Well, I've got a message for you. You've got irritable bowel syndrome." You're like, "Wait. I just told you that. It's not any new information." It's just a description of the symptoms. It's what's known as the diagnosis of exclusion, which means they test for other things like inflammatory bowel disease or diverticulitis, and they rule all those out.
27:20: Then, you're left with irritable bowel syndrome, which essentially means your gut is irritated and we don't know why. But then because of that, the treatments are all based on symptom suppression, so they will prescribe analgesics for the pain. They'll prescribe promotility drugs if you have constipation, or the antidiarrheals if you have diarrhea and they might, in some cases, they prescribe antidepressants both to deal with the psychological comorbidities and because there's some cognition at least of the connection between the gut and the brain and the nervous system. The gut being the extension of the nervous system where you're going to distinct nervous system in some people's opinion, but none of that is oriented toward investigating why that bowel's irritable in the first place.
28:09: Then, addressing those causes which would allow for actually curing the condition, or at least significantly ameliorating without unnecessary use of drugs for the rest of the patient's life. Now, let's contrast that with the functional medicine approach. We start out in a totally different way. We don't just accept the diagnosis of irritable bowel syndrome. We say, "Okay. Well, that's a description of the symptoms and what's happening," but we want to answer the question why? Why is this patient's bowel irritable? If you go into the scientific literature, you will find hundreds, if not, thousands of papers that identify what core pathologies that underlie irritable bowel syndrome. These range from things like a disrupted gut microbiome, which of course has gotten a lot of attention in the media lately.
29:06: There are many, many studies which correlate changes in the microbiome with irritable bowel syndrome. You can find correlations with SIBO, or small intestine bacterial overgrowth. A condition where bacterial that should stay in the colon trans locates to the small intestine and proliferates there. They're a strong connection between SIBO and IBS. You can find connections between helicobacter pylori and other gut pathogens and infections, and IBS. You can find connections between non-celiac gluten sensitivity or other food intolerances and IBS. You can find links between HPA access dysfunction or cortisol dysregulation and IBS. You can find links between mercury toxicity or toxicity of other metals like arsenic and cadmium and lead and IBS. The list goes on and on.
30:02: These are peer reviewed papers published in prestigious journals. We're not talking about internet, blog post and wacky internet theories. We're talking about legitimate peer reviewed research that's been published for years, in some cases, decades. For whatever reason, that research is not making it into the primary care setting and the approach to chronic disease in a primary care setting. The reason that I argue in my book is that it's a problem with the paradigm. Our current paradigm does not accommodate or emphasize the importance of addressing the root cause of disease, in part because of how it evolved, which we already talked about, but also in part because of our healthcare delivery system and the limitations of that system to accommodate an approach that truly would be root cause based.
30:54: Right. Well, one of the reasons is that because there's so many different possibilities of what is causing it, not even to say that there could be multiple things that are actually contributing, you'd have to have a lot of time. You'd have to have more time than the conventional meta-system would allow to try to discover what that is, but wouldn't that make a lot more sense than keeping somebody in the system for the rest of their life decades just trying to suppress the symptoms?
31:16: I think you know my answer, but yeah. Let's break that down a little bit. I'm pretty shocked by this. I knew it was short, but when I read through the research for this book, I learned that the average primary care visit is 10 to 12 minutes where some newer doctor's spending as low as eight minutes with a patient.
31:34: The average amount of time that a patient gets to speak before being interrupted by the doctor is 12 seconds.
31:40: That was so sad.
31:42: Sad. Let me be clear that I don't blame individual doctors for that. If you're a doctor and you have eight or 10 minutes to do what you need to do with the patient, you feel totally stressed out and a sense of urgency and it's really difficult to just let that unfold in an organic way because you very well might not get everything done what you need to get done. None of this is about individual doctors. As I've said before, I've had almost exclusively a good experience with every doctor that I've ever seen. There is much victims of the system as patients are. These very, very brief appointment times do not allow for the kind of investigation that needs to happen to determine the root cause much less than to remedy that through a detailed discussion about diet, lifestyle and behavior change. Then also, doing the necessary testing and investigation to identify those root cause mechanisms that are driving the disease and the symptoms.
32:43: Right. We don't even have enough time to help.
32:46: One in two Americans now has a chronic disease and one in four have multiple chronic diseases. A lot of patients that are seeking care have not just one, but multiple chronic diseases. Imagine a patient is coming into the office with multiple chronic diseases taking multiple medications and presenting with new symptoms that are unfamiliar to the doctor. It's absolutely impossible. I can tell you as a clinician myself who has now worked with hundreds of patients over 10 years, it's absolutely impossible to get to the bottom of what's going on in 10 minutes in that kind of situation. There's barely enough time to say hello and maybe write a prescription.
33:26: It's even inadequate for that. My whole initial process with the patient if you add up all the times spent is really more like two and a half hours, and not all at once but that happens over a series of a few weeks and then, my shortest follow up appointment is 30 minutes. Even then, I've often thought of not even offering 30-minute appointments, and just offering 45 because this 30 often feels too short. Now, I can hear a lot of people's saying, "Well, that's ridiculous. How could we afford to have two-hour appointment and serve 45-minute appointments. There's just not enough doctors and it's a scale problem, and we're never going to be able to do that." Well, I think that's a valid point and I want to address that. The first thing is there's no way to pay for a healthcare system in its current form without significantly reducing the burden of chronic disease.
34:22: The reason healthcare debate ACA versus ACHA and all of this, yes, it's important to talk about health insurance and who should get it and to having that discussion, but it's even more important to realize that health insurance is not the same thing as healthcare. Health insurance is a method of paying for healthcare. It's a really important distinction to make, and what I'm saying here is that there is no method of paying from healthcare. I don't care who's paying for it. Government, individual, businesses, anybody, no payer will be able to afford the cost associated with the explosion in chronic disease that we're seeing. Let me just give a really simple example of this. The estimated cost of treating one patient with type two diabetes is $14,000 a year.
35:13: Now, the age of diagnosis is dropping more and more as you know, Dan. Even kids are being diagnosed with type two diabetes at age eight, but let's just be generous and say take a hypothetical person who is diagnosed with type two diabetes at age 40, and then let's say that they live until age 85 because one of the amazing things about our system is its ability to keep people alive for a long time even when almost by any other way of looking at it, they shouldn't be. I don't think it's outside unreasonable to assume that a four-year old diagnosed with type two diabetes in this age could live another 45 years, and that's what we're seeing with life expectancy. If you multiple 45 times 14,000, you get $630,000. That's just the direct cost to treat one patient with one disease, but of course that patient won't just have type two diabetes. As they get older, they'll develop heart disease. They'll develop other comorbidities that require treatment.
36:13: I think we could conservatively say that one patient can cost the healthcare system a million dollars over the 45-year period. Now, the most recent statistics from the CDC, which I'm sure you saw tell us that 100 million Americans now have either diabetes or pre-diabetes, and 88% of people with pre-diabetes don't know that they have it and it takes only five years on average for some of pre-diabetes to progress to type two diabetes without treatment. In a very scarily short period of time, we could have tens of millions of Americans without diabetes and then you multiply that out by a million dollars of treatment over the course of their lifetime, that is a number that has so many zeroes after it. I don't even know what it is. Is that a Google? I don't know.
37:07: I'm not a mathematician, but I do know that it's a number that's way too big for our healthcare system to sustain regardless of who's paying for care. If you think this through, you reached the natural conclusion that the only chance we have of not going bankrupt as a country and falling apart, and that's really what the stake here. It's not just about individual quality of life or even our health. It's about our survival as a nation. The only way to address it is to prevent and reverse disease. That's it. There's no other chance.
37:42: Again, in complete agreement with you. It's just sad to me when I go to different conferences and tap in to different communities, and still people in the mainstream system, again, which by the way, I completely agree that the advancement that has come out and that continues to come out are no less than remarkable and wonderful. It's just not a complete solution for what the problem is. Only 4% of spending goes towards prevention, where that is really what's going to solve things. I think one of the worries was how that it's so difficult to change people's behavior, but that's what's needed and there will be people that will be very difficult to affect, and yet it's not impossible and we need to be creating systems and putting in more resources to figure out just like you said, how to prevent and reverse chronic disease because it is the only chance that we have at solving this massive problem that is now here.
38:27: It's interesting. It's almost in parallel to climate change where we're seeing such clear signs of the now and we have these large systems that are set up that take a very long time to create and when there's such a shift that there's such a push back, people still want to try to solve the problem from within the system that exists because there's such an infrastructure there, but I think often times we see that the solutions did not come from within the system, they come from outside of it. Luckily, in reading your book, we're seeing real growth of dysfunctional medicine idea which is again, finding the rock in the shoe and I'd love to talk about your approach to this because your ADAPT framework, which really articulates in a beautiful way, not only the realities of how to then structure care support for an individual, but where that all falls in the process? Tell us a little bit more about the allied care network that you think is going to help somebody make the change that we'd now at least agreed upon is an absolute certainty and necessity?
39:24: Right. Again, if you think the problems through in the way that we've been talking about on the call and then you accept, "Okay. Diet, lifestyle and behavior is the primary driver of modern chronic disease and the only chance we have of addressing modern chronic disease is to prevent and reverse it rather than just manage it." The natural conclusion from there is that we need to have a method of delivering care that supports the interventions that we'll have the biggest impact on preventing and reversing chronic disease, right? It seems pretty logical to me at least.
40:01: Then, you look at our system and you ask the question, "Does our system support those interventions?" The answer is unequivocally, "No." We know, and you and I both like to geek out on this kind of research, we know that information is not enough to promote change. We're not suffering from an information problem or a lack of information problem. People know that the choices they're making are not the ones that are more conducive to health, and yet they go on making them. Is that because they're lazy or weak or there's something wrong with them? No. There are several reasons for that. One is that people largely just don't know how to change. I don't know about you, Dan, but I never received any instruction on behavior change in school at any level. Not in grade school or a high school or college, or even when I studies integrative medicine. None of that. Change is very hard because we're often working against hard wired biological mechanisms that were designed to help us survive in an ancestral environment, but actually work against us when it comes to certain types of behavior change.
41:06: An example of that would be we evolved in an environment of food scarcity where we were programmed to seek out highly rewarding calorie dense foods because that would help us survive periods of famine and food scarcity, but today when there's a 7/11 on every corner and a Costco on every town, those same mechanisms that helped us survive in our natural environment have largely precipitated the obesity epidemic today. That's one reason. Another reason is the environment itself is full of things that unfortunately play right into that hard wired programming and make it difficult for us to make good choices, and an example of that would be if you go out to eat at a restaurant, the portions are often enormous and that hard wired programming again in that situation works against us because we tend to just eat what's available because that would have helped us survive. That's the bad news.
42:03: The good news is if you understand all of these influences, you can work to solve those challenges. For one, we can do a much better job of educating both patients and also care providers on behavior change and there's tons of evidence that you are very well versed in down about how to promote successful and lasting behavior change, but doctors don't know that. Even nurses and physician assistants aren't trained in that way, and even if they were, they would not have the time to implement those strategies with their patients. We need longer appointments and we need a different approach but even more than that, we need a whole new class or group of healthcare providers, which we already have that's already happening. Health coaches and nutritionist and other what I call allied providers, people who are not necessarily licensed clinicians like doctors or nurse practitioners or physician assistants, but they are explicitly trained to support people in making successful diet, lifestyle and behavior change.
43:10: If we do that and then we create an infrastructure that supports that kind of interaction with patients where you have these allied providers who are trained in these very specific areas working hand in hand with licensed clinicians that are maximizing their scope of practice, able to order the diagnostic test and perform procedures and do everything than a doctor, a licensed clinician can do, that's where it starts to get really interesting. Again, to use an example, imagine a patient who's just diagnosed with pre-diabetes and in the conventional system, they might get like a very brief discussion about diet, eat a healthier diet, here's the diabetic association guidelines to follow, you should make sure you're exercising and the patient's going to leave that office and 99 out of 100 patients are not going to do anything about that because again, information is not enough. Maybe they're busy. Maybe they know they want to change their diet, but they just haven't been able to do that successfully and they would like to start exercising more but they're tired at the end of the day and they don't do it.
44:17: That's as far as that will go, but if that person's prepared with the health coach who was trained in motivational interviewing, in strengths based coaching, in positive psychology, in building trust and rapport, that coach could help that person to use motivational interviewing to help that patient tie their deeper goals and values to those diet and lifestyle changes. Maybe the patient is a grandma and wants to see her grandchildren grow up and wants to remain active and be able to play with them, that's one of the things that motivational interviewing can do. It can tie those deeper goals and values to the change that the patient wants to make, so they can find their own intrinsic motivation to make that change. Maybe that coach is trained in strengths based coaching or positive psychology, so they know how to identify strengths in the patient and capitalize on them instead of trying to fix what's broken.
45:14: Maybe they have also trained in behavior change and so, they know about a principle that we can call "Shrink the change," where instead of telling the patient to exercise for five times a week, 45 minutes in the gym, that they just start by going out and buying a pair of shoes for exercise. Then maybe the first time they take a walk around the block and then maybe the next week, they do 10 minutes or 20 minutes of walking. All of this stuff can make ... That's where the rubber really meets the road, and that makes the difference between in this patient, actually reversing the pre-diabetes and going back to having normal blood sugar and potentially saving the healthcare system a million dollars over the next 45 years at least, or doing nothing and progressing in five years to type two diabetes and then ending up on Metformin and then eventually having beta-cell failure and taking insulin, and then developing peripheral neuropathy, and maybe becoming disabled because of lower leg problems and everyone knows what that looks like eventually.
46:22: I've struggled with how to communicate this, because I think when you put it that way like just on an individual level in one person's life, it becomes really clear and I hope it's also clear that even though that might be a little more expensive upfront where even if we subsidize the health coach for that patient and gave them the support they needed to figure out how to eat better, and then maybe even subsidize the gym membership, imagine that, it might spend a little more upfront, but think of what we've been saying over the lifetime of that patient.
46:50: Yeah. What I like about your book is that it's going to captivate a lot of doctors that are unsatisfied in the system to make a transition. At the time when I finished my master's degree, I was interested in going into medicine. I was taking gross anatomy with the medical students at Florida State, and I thought to myself I would really like to contribute in this way. At that time, I went and I interviewed a medical student, residents, people doing their internship, doctors at a new practice and one that have been in their practice for a long time and except for the medical student, everyone advised that I pick a different path.
47:25: I'm laughing because you and I are so much alike in some ways. That is exactly what happened to me. When I decided to go back and formalize my training, I did exactly the same thing. I interviewed doctors and people in the medical profession, 15 different doctors in the San Diego area and 13 out of 15 told me that they wouldn't do it again.
47:47: Yeah. Gosh. The doctor that I see now, as a personal anecdote, is wonderful and he works hard to try to make more time for your visit. He's been really struggling and grappling to try to create a practice that allows him to help people in the way that he wants to, and he's going to a concierge medical practice and has a technologically advanced office, but still hearing you articulate the system to help an individual, I know it's going to resonate with a lot of doctors and I think again, instead of having the system change from within, a more compelling option is going to be provided that you are really laying the groundwork floor here and we're just going to see a migration towards it. Overtime, there will be more and more case studies and evidence and data that backup the approach, which will obviously yield results.
48:34: It's also clear about what needs to happen and we also meet people like yourself to write out extraordinarily convincing thesis about, "This is how to do it. Here's an approach," and to compel people both as a patient if you read this book, or an individual who cares about their health, you can then say, "Okay. This is where I actually want to seek health professionals to help me." Then if you are a doctor, or an allied health professional, you also know, "Hey, there's a light over here that's shining that I can go to and take part in the system that resonates." Again, I applaud you for putting these altogether. I think that when you really are digging down to say, "What would you do if you had to help an individual and what are all the different steps that you would do? Then, how do you scale that up?"
49:15: I think that bottom up approach is really what's needed because it resonates all the way down to that person who's dealing with the specific issue. Thank you for all of this work that you've done and I keep seeing overtime as we've known each other, these layers are adding into how you are magnifying your contribution and it's really impressive and I know that in years to come, it's going to have a massive impact and even beyond with the big impact that's already happening.
49:40: Thank you, Dan. I appreciate that. It's always great to talk with you because we share so much of this perspective in common, and I know the work you do and I have the same goals and we're just approaching it from a slightly different backgrounds and perspectives, and I'm looking forward to collaborating with you because bringing this altogether in the way that leverages, not only the understanding of all the concepts that we've talked about today but the modern technology that's available to us to support lasting behavioral change, which is really where you're focused is exciting to me, and I think it's going to be a big part of the solution.
50:17: It's why humanOS, I described it as a personal health mastery application and in thinking about behavior change you brought up earlier, when we were taught about behavior and when we were younger, or even throughout the career, you got to teach yourself. What I've realized is that health is something that we have a very casual relationship with. You go to your doctor occasionally. This should be something that is fundamental to our education from when we are very young and that accompanies that education all the way into adulthood, so that you actually are masterful at taking care of your self and not outsourcing it entirely as the responsibilities of others. It's great that you have people that are even more dedicated to these subjects that can help you along the way. We need that. It's not about being incredibly independent, but we also need to help people become really good at taking care of their own health as well.
51:06: I agree 100%, and it can start really early. I sprinkled little tidbits of behavior change principles to my interactions with Sylvia, my six-year old daughter. I imagine you do that too.
51:19: Cool. Well, thanks so much for having me on this show. It's always a pleasure to speak with you and look forward to collaborating more on ending chronic disease.
51:28: Yeah. Likewise, Chris. Thanks for taking the time to come on and look forward to having you on again in the future to talk about other great work that you're doing.
51:35: Cool. For anyone who is interested in the book, it's on Amazon, Paperback, Kindle and audio book formats. That's the easiest place to get it.
51:47: Great. Great. I'll put a link to that in the show notes as well.
51:50: Thanks again, Dan. I appreciate it.
51:51: Have a great one, Chris. Thank you.
Kendall Kendrick - 51:55: Thanks for listening, and come visit us soon at humanOS.me.