Human Limits

Exploring performance and health with Michael J. Joyner, M.D.

Photo of Michael J. Joyner, M.D.

Demography, Destiny & Demographic Cliffs

It has been said that “demography is destiny” suggesting that at some level basic facts – like the distribution of the population in different age groups – are key determinants of what happens to a given culture, country or even the world. That having been said, it is well known that the “population is aging” and some have argued that the impact of aging on the world will ultimately be as big as the development of agriculture or the Industrial Revolution. I agree with this assessment and would add that aging is happening much faster and that we can see it coming in comparison the rise of agriculture and industrialization.

 

Countries age for two basic reasons: 1) fewer children being born per woman, and 2) people living longer.   These two factors also operate to determine the total population of a given country and the world as well. The chart below shows world population pyramids starting in 1950 with projects to 2100.

 

worldpop

 

In 1950 the relative number of young people was far greater than older people. The so-called pyramid then gets progressively “squared” by 2010 and beyond.   This chart also projects total world population to be in the 9-10 billion range in 2010, it is currently about 7 billion.

 

China’s 1 Child Cliff

In the 1970s China took some pretty drastic population control measures including a strictly enforced 1 child policy. The rationale was to avoid famines. The policy has “worked” but now China’s population is rapidly aging and in fact the population of China is also projected to decline and population experts in China believe the 1 child policy needs to be reversed. The chart below shows the projections for China. The solid red line is the best estimate for what will happen this century with various high and low projections bracketing it. Subsequent charts for other countries follow the same format.

 

china

 

 

The impact of both an older population with fewer workers for every retiree and less total population is uncharted territory especially for a developing country like China. However, several more advanced countries like Japan and to a lesser extent Germany (and much of the rest of Western Europe) are already headed in this direction or at least headed to stagnating populations with a higher average age and fewer workers per old person.

 

japan

 

In terms of both total population and the ratio of old people to workers, the US is relatively well off compared to China, Japan and most other developed countries. The reasons for this are more babies per woman and immigration.

 

usa

 

Uncharted Territory

Population is a topic that leads to all sorts of discussion and debates:

  • What are the ecological costs of increased population and what is sustainable?
  • How aggressive should specific countries and the world in general be in promoting birth control and lower population growth?
  • If there are fewer workers per old person, how will old age pension systems and medical care be funded? This is a topic in the US, but it is also a topic essentially everywhere. The relative good news for the US also points out one advantage of liberal immigration policies – fewer young people to pay the bills.
  • Should the retirement age be raised?
  • What will the psychology of an older world be like? Young people take chances and roll the dice on all sorts of things while older people tend to be more risk averse and seek “certainty”. Will the aging population lead to less economic growth as a smaller faction of the world decides to “go for it”?

 

Who knows how all of this will play out, but if the phrase “demography is destiny” is a truism, it is likely to be especially true over the next 50 or so years. And, we can see at least some potential demographic cliffs coming.

 

Three Books & Our Messy-Crazy World

If you had any doubts about just how messy-crazy the world is, the terrorist attacks last week in Paris should have convinced you. I have been thinking about how to understand the Paris attacks in specific and the phenomenon of terrorism and political violence in general.   To do this I have started to re-read Eric Hoffer’s classic short book “The True Believer” first published in 1951.

 

In this book Hoffer outlines the causes of fanaticism and how it preys on alienated people with a sense of grievance who are looking for “something bigger than themselves”.   The book was a favorite of Dwight Eisenhower who had seen in World War II exactly what evil unchecked fanaticism can bring. He also saw echoes of it in the Cold War including the way the US and other democracies were responding. As recounted in the New York Times link above, in the late 1950s Ike wrote to a terminally ill WWII veteran seeking “clarity” on the complex national security issues of the Cold War.

 

“Eisenhower also recommended a short book — “The True Believer” by Eric Hoffer, a self-educated itinerant longshoreman who earned the nickname “the stevedore philosopher.” “Faith in a holy cause,” Hoffer wrote, “is to a considerable extent a substitute for the lost faith in ourselves.”

 

Though Eisenhower was criticized for lacking an intellectual framework or even an interest in ideas, he was drawn to Hoffer’s insights. He explained to Biggs (the terminally veteran) that Hoffer “points out that dictatorial systems make one contribution to their people which leads them to tend to support such systems — freedom from the necessity of informing themselves and making up their own minds concerning these tremendous complex and difficult questions.” The authoritarian follower, Eisenhower suggested, desired nothing more than insulation from the pressures of a free society.

 

Substitute “religious fanatic” a few places in the excerpt above and what Ike said in the late 50s is perhaps even truer today.

 

If you only read one book all year read “The True Believer”.

 

Book #2

If you want to understand the limits of our metric driven world and the efforts of economist, managers, and others to turn everything about humanity into some sort of measurable “science experiment” with a business angle, then read “Small is Beautiful” by E.F. Schumacher published in the early 1970s.   Schumacher points out that the human costs of economies of scale, bigger is better, growth is good, and all of the related activity needs to be considered skeptically along with ever more and more “return on investment” thinking.  As things have “grown” and become more globalized and hyper connected since the book was first published in the early 70s, Schumacher’s ideas and observations seem almost prophetic.

 

Does every human activity have a value that can be monetized, measured and managed? It sure seems that way……

 

Book #3, Man’s Search for Meaning

So in a world where it is easy to get either alienated and/or become essentially a cog in some sort of industrialized or commoditized activity, is there a way out?   The short answer is yes and one of the best resources to think about how to do this comes from the death camp survivor and psychiatrist Viktor Frankl. His book “Man’s Search for Meaning” was written in 1946 as he recovered from the Holocaust. He points out that in life there is no happiness without the pursuit of something beyond the self. One of his best observations is:

 

“Between stimulus and response, there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.”

 

To me this is a clear response to the industrialization and the increasing application of management theory to all human activities. We must choose to be more than organisms on some sort of stimulus response curve subject to manipulation

 

Connecting the Big 3

At some level the observation by Frankl above connects the major themes of these three great books. Themes of alienation and dehumanization run throughout the “True Believer” and “Small is Beautiful”. Some humans give up and essentially surrender. Unfortunately some of us are lured by mass movements and political or religious ideologies and surrender in a different way as we pursue “a purpose”.   I guess in the final analysis, the hard thing to do is choose your own responses to this crazy world.

Don’t surrender your choices too easily to outside forces that seek to manipulate them for their own gain.

 

 

Remarkable Old People: Share Your Story!

Over the Holidays I bumped into a colleague who told me about her 95 year old father (a retired pharmacist) who is still physically active and living independently. He walks two miles per day, and plays golf (he shot his age at 91, but is now “only” doing 9 holes). He is also active in his church and community. The other interesting thing is that “Dad” had a hard time retiring and for many years pinch hit in pharmacies in the upper Midwest that were short staffed. My colleague also mentioned in follow-up e-mails that her Dad lost his mother in childbirth, was a WW2 veteran who got off the farm and into the pharmacy via the GI Bill, and he also quit smoking back in the 1960s.

 

Did He “Know” Lester Breslow?

The graphic below is one I use in talks on healthy aging and “who makes it to 90”. It highlights the key principles on this topic that were discovered by the pioneering epidemiologist Lester Breslow. When I heard the story of my colleague’s father what Breslow discovered certainly seems to ring true for “Dad”.

 

lester

 

Circumstances & How You Respond

The other thing that hit me about “Dad” in specific and that also seems to apply to many healthy agers is how resolute and resilient they have been over the years. Somehow they all seem to understand — or maybe have learned — that you can’t always control the circumstances you find yourself in but you can control how you respond. At some level this may be a learnable life skill and the Holocaust survivor and famed psychiatrist Viktor Frankl felt that resilience can be learned. He noted:

 

“Forces beyond your control can take away everything you possess except one thing, your freedom to choose how you will respond to the situation.”

 

Please Share Your Story

I personally find stories like the one above to be incredibly interesting and inspiring. If you have one, please share it in the comments section and in a future post I will highlight the key messages and insights.

 

Thanks and remember the words of John Wooden:

“Do not permit what you cannot do interfere with what you can do.”

 

 

 

New Year’s 2015: Drinking Charts to Ponder

Who can think about New Year’s without thinking about drinking. The chart below is about 15 years old but still considered accurate and shows the relationship between drinking and the risk of cardiovascular disease. It shows that moderate alcohol consumption (essentially 1-2 standard drinks per day) is generally protective.

 

 

chart1

 

 

While moderate drinking is generally good for you, it is important to remember that binge drinking (4 drinks for women 5 for men) is bad news, and it is common.

 

chart2

 

The highlights of the bad news according to the CDC include:

 

  1. Motor vehicle crashes. Every day, 32 people in the United States die in motor vehicle crashes that involve an alcohol-impaired driver.

 

  1. Intimate partner violence. About 2 of 3 incidents of intimate partner violence are associated with alcohol.

 

  1. Risky sexual behaviors. Excessive drinking increases risky sexual behaviors, including unprotected sex and sex with multiple partners, which can result in HIV infection, other sexually transmitted diseases, and unplanned pregnancy.

 

  1. Fetal alcohol spectrum disorders. Any alcohol use by a pregnant woman can cause harm to a developing fetus, resulting in physical, behavioral, and learning problems later in life.

 

  1. Chronic conditions. Over time, excessive drinking can lead to alcohol dependence, liver disease, high blood pressure, heart attack, stroke, and certain kinds of cancer.

 

Summary

The data above and resources in the links speak for themselves. Enjoy New Year’s and every other social occasion that includes alcohol but remember that alcohol is perhaps the most dangerous drug and needs to be used judiciously.

 

chart3

 

 

Aging: The Political Elite & Airline Pilots

The reemergence of former Vice President Dick Cheney in the CIA torture debate raises or re-raises all sorts of questions. One question that is not getting much attention is the health and age of key decision makers like Supreme Court Justices and high ranking elected officials.   I bring this up because Cheney has a long standing history of cardiac disease including at least four major open heart surgeries (two bypasses, an artificial heart and finally a heart transplant).   I also bring it up in the context of commercial airline pilots who are forced to retire at age 65 and prior to that are limited from working if they have significant medical problems. Additionally, depending on their age, they have to pass yearly or twice yearly physical exams to continue flying.

 

The Supremes

Currently, five of nine members of the Supreme Court are over 65 and would be ineligible for a commercial airline pilots licence based on age alone.   Justice Samuel Alito is knocking on the door and will be 65 on April 1st, 2015.

 

The Senate and House

The US Senate is an “old” organization with 40 of 100 members over 65. Harry Reid is 75 and Mitch McConnel is 72. I have no idea about the health status of Mitch McConnel, but Reid suffered strokes in 2013 and 2005. John Boehner is 65 and Nancy Pelosi is 74.

 

2016?

If Hillary Clinton were to be elected president in 2016 she will be 69, and she has a history of a venous blood clot in her brain. Vice President Joe Biden just turned 72 and has had brain surgery and also atrial fibrillation. Mitt Romney is 67, and at least as of 2011 was very rigorous about his diet and exercise regimen, but again as fit as he appears to be — he can run for president but can’t fly a commercial airline.

 

Does it Matter?

In the case of Dick Cheney there has been speculation dating from the middle 2000s that his medical condition(s) might have led to cognitive issues and clouded his judgement. There are also long standing concerns about the health of Franklin Roosevelt in the waning years of World War 2. He had a history of severe hypertension and other problems that almost certainly limited his ability to function late in the war.   Woodrow Wilson had a debilitating stroke in office that was largely covered up. Then there is the case of William Howard Taft who weighed over 300 pounds, was likely diabetic and clearly hypertensive with systolic blood pressures over 200. Taft also had sleep apnea.   After his presidency he served as Chief Justice of the Supreme Court and more or less acknowledged that he was having cognitive issues before he resigned and then died shortly thereafter at age 72. While we are at it, let’s not forget JFK, who was much younger but a medical train wreck.

 

Age Limits?

I am an advocate of healthy aging and believe that there should be no hard age limits for most jobs. However, I do believe that the health, especially the cognitive health of older decision makers needs to be evaluated and that those who show evidence of impairment should not be eligible for service. The other issue here is ongoing testing and evaluation of those already in office. Ronald Reagan was confused and rambling in one of his debates with Walter Mondale in 1984. Was it an early sign of his cognitive decline? A key elected leader or judge can make decisions that affect thousands of people in major ways with far more lives at risk than a full airplane. The president can embark on most military interventions with limited oversight. And don’t forget, there is a co-pilot on the plane.

 

 

A Holiday Gift For Your Athlete

I get a lot of questions about exercise equipment. What is the best exercise? How to workout on the road? What “should my kid be doing to improve” etc.   There is one simple answer to this question and it is also an ideal gift for almost anyone with fitness or athletic goals regardless of age who does not have too many orthopedic limitations. So what is the answer?

 

Get a Jump Rope and use it!

Jumping rope (or skipping rope) is outstanding for general conditioning. It can be used to generate an aerobic workout and you can things like minute on minute off intervals skipping rope. Skipping rope also develops footwork and balance. For younger athletes these are skills that carry over to almost all sports. For middle aged and older people these skills are critical to ward off things like frailty and falls.   Jump ropes are also cheap, portable, and don’t require a lot of space. The video clip below shows some classic footage of boxers jumping rope. Note especially the foot work and wild routine of the great Sugar Ray Robinson.   Later in the video you can see Bernard Hopkins who keeps fighting at age 50.

 

 

click for video

What kind of rope?

I have a 40 year old Everlast leather jump rope with ball bearings that my mother got me sometime in the early 1970s. This is the type of rope the boxers use and it has stood the test of time. It is also a beautiful piece of functional industrial design. But almost any rope will do.

 

jumprope

 

 

No barriers

The specifics of skipping rope aside it is important to remember that you don’t need much if any equipment or space to develop an outstanding and effective whole body exercise routine. Skipping rope along with some simple calisthenics is free, can be done almost anywhere, and requires minimal equipment. The key requirements are simply self-discipline and motivation.

 

Football (soccer) Learning: 4 on 4 Beats 5 on 5!

David Epstein the author of the Sports Gene circulated this note to his e-mail posse:

“Mike, I’d totally read you blogging your thoughts about this: http://www.ministry-of-football.com/research-measuring-learning/.

The link is about optimizing skills acquisition and learning in football/soccer. The take home message is that for indoor versions of the game played by primary school kids there more learning goes on with 4 on 4 vs. 5 on 5 games. In other words more touches per player, more and better passing, and more periods of continuous play.

 

My Response: This is so Triangle!

David, this is so triangle offense. All old school basketball coaches break the game down into 2 on 2 and 3 on 3s. If you also look at fast break drills and other traditional b-ball drills they are all 3 on 2 with a trailer. The whole point of all of this is to; 1) generate spacing, 2) that passes are faster than running or dribbling, and 3) to “feel” the pressure from the defense and generate a mismatch.

This is why the Spurs win, why John Wooden said later in his life that the women’s game was better than the men’s, and why Pop hired Becky Hammon etc.

I have the Wooden/Sharman book of b-ball drills I picked up someplace and it is all in there.

This is also classic Soviet ice hockey and Herb Brooks as well.

 

David’s Response

See! Ha…I knew it. You should just post this…….

 

Obesity and Bargaining

A couple of weeks ago I floated the idea that for many problems facing the world a sort of collective grieving process is going on. In this post I want to pick up on that theme again as it applies to obesity. In general, for obesity I believe we have mostly moved beyond denial and are now “bargaining” about what to do about obesity both as individuals and society as a whole.

 

Costs of Obesity

Last week the big consulting firm McKinsey released a report on the global costs and consequences of obesity and what to do about it. Incredibly the report put the global costs of obesity at about 2 trillion dollars per year. This is about equal to the global costs of smoking and also the global costs of “armed violence, war and terrorism”. The report concluded that no single action is likely to solve the problem but that a range of policy options might work. The chart below is an example of what various anti-obesity interventions might do to obesity related years of life lost in Britain. My guess is that similar calculations would also apply to the U.S. and most countries where obesity is a serious problem. Of note I see at least three things missing from this chart:

 

  1. Taxes on high calorie foods or sugar sweetened beverages
  2. Higher insurance premiums for obese individuals
  3. Re-engineering the built environment

 

tippingscales

 

Denial Not Gone

At the same time the McKinsey report was coming out, the U.S. CDC was being pressured to take down a website called “lean works” that included an obesity “cost calculator”. The concern was that such a tool might lead to workplace discrimination against obese individuals. So, perhaps denial that obesity is a problem and that something needs to be done about it is not totally gone.

 

Who Stays Lean?

Last month I was giving a talk in Denmark about what to do about physical inactivity and obesity. The talk was to a group of health care professionals who were uniformly lean and fit. Being Danes, many ride their bikes to work. So, at some level I was preaching to the converted. What occurred to me as well during the talk was that I was also talking to a group of highly educated people who all had a suite of behavioral characteristics that let them control their current behavior to prevent a future undesired outcome. In other words these people all had a sense of delayed gratification and conscientiousness. These traits likely permitted them to adopt and adhere to “healthy” lifestyles and remain lean in an obesogenic world. From what I can tell only a modest fraction of the population has a high level of these behavioral traits and skills. So what do we do in a world where so many people have so much trouble with what might be described as “self-control” and personal responsibility?

 

Beyond Personal Responsibility?

This brings me to the built environment and other big picture interventions to address the obesity and inactivity problem. The next chart shows how the battle against infectious disease was largely “won”. A lot of this had to do with things like sewers and clean water supplies. In other words, basic sanitation and civil engineering vs. medical care or medical interventions made a big difference.

 

crudedeath

 

 

When big, dirty and disease ridden cities were being re-engineered and rebuilt in the 1800s and early 1900s, no one was telling the general public that clean water was their “personal responsibility”.  Instead slums were cleared and sewers and water works were built and things like cholera epidemics stopped. That having been said, I wonder how many people in today’s world would consistently boil their own water over days, months, and years in the absence of reliable clean water supplies. My guess is that over time only the most conscientious people would do it. At some level our current world is just as toxic and maybe larger scale interventions are needed.

 

Going Far Enough?

I applaud the McKinsey report, but does it go far enough? My guess is that many of the food policy recommendations will likely work if they can ever be implemented in a comprehensive way. However, I also have serious doubts about whether that can be done. I also believe (as cigarette taxes have shown) that humans are price sensitive and that economic tools have to be part of the solution to the obesity problem. There also probably needs to be a serious discussion about how car “unfriendly” the world needs to be if we really want to make a dent in the inactivity element of the obesity epidemic.  It is hard to imagine that our physical world might be redesigned in a way similar to what happened in cities 150 years ago, but perhaps it will happen. There are innovative proposals on the table in London to promote more bikes and fewer cars.

 

None of this will be easy, but the partial success of the anti-smoking movement in some countries shows that over time it is possible to change bad societal habits, but it takes more than simple personal responsibility.   So let the bargaining begin!