The pressure on the NHS and social care has reached breaking point. If the burden of disease is not reduced in the next few years, then the NHS will fail together with the Government that is in power at the time.
The U.K. is an affluent country and our health, as indicated by falling age specific mortality rates, has improved over the last hundred years. We are living longer but the proportion of time we spend with ill health appears to be rising. Too many have chronic diseases that prevent them from continuing employment in their 50s and 60s. In addition, disease in the young is on the increase.
Increasing longevity is indicative of the health of the elderly, of those born between the 1920s and the 1950s. They appear to be doing relatively well. But those born since the 1960s are getting progressively less well. There has been an increase in diseases which were uncommon in the 1950s. These include asthma, eczema, hay fever, autism, type 1 diabetes mellitus, acne, anorexia nervosa, chronic fatigue syndrome, irritable bowel syndrome, anxiety neurosis, autoimmune disease, falling sperm count, inflammatory bowel disease, cancer in the under-50s and obesity and type 2 diabetes mellitus.
What the medical profession must do is identify the cause, or causes, of this deterioration in health. What the Government must do is invest in primary prevention to reduce the burden of disease. There is, however, a problem. While those Left of centre in the political spectrum are keen to intervene in the lifestyle and diet of the population, and are happy to tax and ban, those on the Right are not.
I think this problem stems from the oldest idea in medicine, which is best expressed as a haiku:
Sin causes disease,
Piety for prevention,
Penance is the cure.
Nobody, Left or Right, would support this concept explicitly; but it is planted in the sub-conscious of us all and always emerges when disease is discussed. Surely obesity is due to too much food and too little exercise, isn’t that gluttony and sloth? Avoiding obesity means a life of self-denial. Treating obesity requires punishing diets and exercise. Sin also means that somebody, or some organisation is to blame. When it comes to prevention, we have this uneasy feeling that the things we enjoy will be bad for us and we will have to give them up. Only the things we dislike will emerge as healthy. Prevention based on these principles will only appeal to puritans.
Well, I can state with confidence that sin is not the cause of disease, and piety and penance have no role in prevention; indeed, the opposite. Our ancestors have all, every one, negotiated the treacherous journey from birth to reproduction maintaining their health on the way. Evolution ensures that we will seek and enjoy those actions which are healthy and avoid those that are not; and our instincts are the guide. So do not deny yourself that second glass of wine or turn January dry.
The U.K. bio-bank is a treasure trove of information. Hundreds of thousands of citizens have given tissue samples and information to epidemiologists. A recent publication from the bio-bank identified seven lifestyle factors that are associated with good mental health. These are never smoke, moderate alcohol consumption, a good night’s sleep, exercise, not sedentary, social contact and a healthy diet. These are associations; if your lifestyle fits with these seven factors then you will have low levels of inflammation and you will tend to be healthy. Low levels of inflammation also mean a reduced likelihood of neurodegeneration (senile dementia), atherosclerosis (strokes and heart disease) and cancer. The only surprise in the lifestyle factors, perhaps, is that it is moderate alcohol consumption that is associated with good health; but that fits with our instincts. Healthy people like to exercise, not a punishing schedule, but a walk in the countryside. They like to socialise, we all crave a good night’s sleep, and it’s only those who are ill who prefer to be sedentary. We all know that smoking is bad for you and so is pollution.
There is even a great deal of agreement on a healthy diet. We should eat more fruit and vegetables, consume more full cream milk and yogurt, increase white meat relative to red meat, and purchase less calorie dense ultra-processed food. A Mediterranean diet with plenty of milk and yogurt or perhaps a more traditional diet as consumed in the U.K. between 1920 and 1950.
Most of what is stated above is not too contentious apart from increased consumption of full cream milk and yogurt. But, in my opinion, this is the most important point I have to make. It gets rather technical from now on, but hold on it is worth it. Disease in the young and the middle aged is increasing and is caused by inflammation. There are a relatively small number of bacteria (millions not trillions) growing within the superficial tissues of our body. They cause low grade inflammation and contribute, but are not the sole cause, of most disease. These bacteria (the mucosal tissue microbiota) are pathogens (they cause disease). On the surface of our skin, and in the lumina of the multiple ducts within our body there are trillions of bacteria (the mucosal luminal microbiota). They derive their energy from body secretions and form a protective layer that prevents the pathogenic bacteria getting into our tissues. If the composition of the mucosal luminal microbiota (the trillions) is sub-optimal more pathogenic bacteria get into our tissues causing more inflammation and more disease.
Milk has evolved over millions of years in mammals. It contains all the bacteria that are required to line the superficial surfaces of the infant and form an optimal luminal microbiota. But our increasingly affluent and hygienic lifestyle with an increasingly sterile diet means that the optimal luminal microbiota cannot be maintained. We need to drink cow’s milk and eat yogurt after weaning.
In the 1960s the medical profession decided that cow’s milk was bad. They thought it contained too much saturated fat and was contributing to heart disease. They overturned several thousand years of belief that milk was healthy. It was a bad mistake on the part of the medical profession and since the 1960s consumption of liquid milk has fallen and disease in the young has risen.
My concept of primary prevention is not about legislation and taxation. It is advice to the general population about lifestyle and diet which is based on evidence. In my opinion there is evidence to support the statements above but not everyone will agree. Insofar as there is disagreement, then, that is a reason for urgent research to define the role of the mucosal tissue microbiota in disease. The Government must ensure that this research is undertaken.
In the meantime, I will continue to drink at least a pint of full cream milk each day and consume 150gms of yogurt (full fat, live, no added sugar) last thing at night.
Dr. James A. Morris is a retired consultant pathologist.
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