In 1993, we updated our understanding and definition of the leading causes of death in the United States. Almost 20 years later, it's time to update the way we express love in the United States. Kindly remain calm, and fully dressed, and I'll tell you what I mean in both cases.
Regarding leading causes of death, prior to 1993, the only established way to delineate them was to look at diseases listed on death certificates. The most common entry was heart disease; the second most common was cancer; the third was stroke, and so on. So prior to 1993, heart disease was the leading cause of death in the U.S. And it still is.
In that year, two leading epidemiologists, William Foege and J. Michael McGinnis, published a seminal paper in the Journal of the American Medical Association entitled "Actual Causes of Death in the United States." The particular interest of the authors was premature death—and what we might need to know to do something about it.
Their analysis led them to what they called "root" causes. Diseases weren't really causes, they reasoned; they were effects. And the salient question for public health was: effects of what? What was causing the diseases that were, in turn, causing premature deaths? And, since the leading causes of premature death were chronic conditions, the question could be expanded: What was causing the diseases that were taking both years from life, and life from years?
The answer they famously disclosed was a list of 10 factors we overwhelmingly have the capacity to control in our daily lives. We will spare ourselves attention to the entire list, but note the first three factors, which accounted for fully 80 percent of the toll: tobacco use, poor diet, and lack of physical activity. The leading causes of premature death and chronic disease in 1993 were wayward use of fingers (to hold cigarettes), bad use of forks (to bring junk foods to the mouth), and relative non-use of feet (lack of physical activity).
That feet, forks, and fingers are the master levers of medical destiny has been a theme in the medical literature ever since. Ten years after the McGinnis and Foege paper, scientists at the Centers for Disease Control and Prevention, led by Ali Mokdad, reanalyzed the issue of root causes and reached much the same conclusions, reporting them again in JAMA All that had changed over the span of a decade was that the gap between tobacco use as the No. 1 cause of premature death and the combination of bad use of feet and forks as No. 2 had narrowed—for one good reason, and one bad. The good reason was our societal progress toward curtailing tobacco use. The bad was deteriorating use of feet and forks alike, and worsening epidemics of obesity and diabetes to show for it.
A 2010 paper in the Archives of Internal Medicine, reporting results of a study of some 5,000 citizens of the United Kingdom followed for 20 years, reaffirmed the findings of McGinnis and Foege yet again; as did a 2011 study, reporting results from a U.S. cohort in the journal Cancer Epidemiology Biomarkers & Prevention.
And so, emphatically, persuasively, and repeatedly, the definition of leading causes of death has been updated. It is not diseases, it is the factors, mostly behaviors and choices we control, that underlie diseases. It is the root causes that matter, because we can—in principle, at least—do something about them.
And doing something about them is what brings us back to love—and the need to update it as well.
We have, for as long as any of us can remember, shown one another love with treats, foods, and feasts. Parents love their children with French fries, and ice cream. Mothers—Jewish, Italian, and probably all others as well—lavish love in the form of copious servings of food there is no hope of finishing, with a side of guilt about not eating it all. There are starving kids in China, you know! (In fact, there are, but overall, China is succumbing to epidemic obesity as it modernizes. I'm not sure whose mothers, in particular, are causally implicated, but I do suspect my own has been in on it!)
Families gather for holidays in a spirit of love, and they sit, and eat. Grandparents love grandchildren by slipping them candies when Mom and Dad are looking away. Men woo women (and, perhaps, these days vice versa) by wining and dining.
In an age of epidemic obesity and diabetes, we are in other words, loving one another to death.
It all rests on good intentions, of course, and good cultural bedrock, too. Throughout most of human history, calories were relatively scarce and hard to get and physical activity was unavoidable. It was called survival—gym membership was not necessary—and everybody did it every day. That context gave rise to the very notion of a holiday as a time for resting weary muscles, and filling empty bellies. The idea that muscles would never be weary and bellies never empty had not yet occurred to anyone.
It was in that context that food was equated with currency, and success. And so we spoke of being bread winners; bringing home the bacon; making dough.
It was in that context that an all-you-can-eat buffet was seen as the quintessential bargain. We should, if our vision is clear, see it now as a chance to get fat at no extra charge and then spend a fortune to lose the weight that we gained for free. Wake up and smell the meal-replacement shakes, people—that's not much of a bargain!
Such seeming digressions of common sense are, in fact, cultural anachronisms: ways of thinking and acting that once made sense, and no longer do; aspects of culture needing to be…updated.
Don't get me wrong. I like a holiday feast as much as the next guy. I still like wining and dining with my wife. Fine food and fine wine are, well, fine. And my kids like ice cream.
But the consequences of our excesses are anything but fine. Epidemic obesity is not fine. Widespread type 2 diabetes in children is not fine. Premature deaths from heart attacks, cancer, strokes, and diabetes that could be avoided eight times in 10 simply with better use of feet, forks, and fingers—are not fine.
Nor is it fine that when some of us try to amend our ways and get to health, others put obstacles in the path. I saw a patient just last week who is working hard both to lose weight and find health. She recounted how almost everyone in her life—male friends, female friends, older friends, younger friends, church friends, family—were trying daily to talk her out of her new commitments. Everyone had reasons why one slice of birthday cake, one tub of buttered popcorn, one more serving of this, that, or both couldn't do any harm.
But of course, they add up to do enormous harm. We have known since 1993 at least that they add up to constitute one of the leading causes of chronic disease and premature death in modern society.
We should not love one another any less than ever. We should not show love any less emphatically. But given a choice between love that helps you stay fit and vital—or love that accelerates your visit by ambulance ride to the local coronary care unit—which would you prefer?
In unity there is strength. It is easier to eat well when we support and encourage each other to do so, rather than indulging ourselves in anachronistic love that bears striking resemblance to sabotage. It is easier to be physically active when some of the love we get from others involves an invitation to do so in a way that is sociable and appealing, be it a walk, hike, bike ride, game of tennis or softball, dance class, or…whatever.
The lifestyle factors that conspire against our health are themselves much aided and abetted by traditional, and obsolete, expressions of love.
We should be able to wear our hearts on our sleeves, without helping one another to wind up needing stents in our hearts. We should be able to love one another, without loving one another, literally, to premature death or states of chronic morbidity.
Love is, as it ever was, good. But it's time—past time—to update the love!
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David L. Katz, MD, MPH, FACPM, FACP, is a specialist in internal medicine and preventive medicine, with particular expertise in nutrition, weight management, and chronic-disease prevention. He is the founding director of Yale University's Prevention Research Center, and principal inventor of the NuVal nutrition guidance system. Katz was named editor-in-chief of Childhood Obesity in 2011, and is president-elect of the American College of Lifestyle Medicine.