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This is a 2-part series on finding health. In this post, I will describe two models in which to compare health and how they might be integrated.
Reductionism and Holism: Complimentary Approaches to Understand the Body
A physician may diagnose high blood pressure in an obese patient (BMI > 30) based on vital signs during an office visit. There may be swelling in the extremities. Maybe a person is found to have a high hemoglobin A1c – greater than 6.4 – indicative of diabetes mellitus. They may have bloodwork showing an elevated total cholesterol of 300 with an LDL cholesterol of 150 and an elevated triglyceride of 300.
Does this person now have three conditions – hypertension, diabetes mellitus and hyperlipidemia? They are prescribed medications for each of these diagnoses. These medications induce an effect on the body to reduce blood pressure, treat high cholesterol and reducing blood sugars, but the physiology of the process is not altered.
What if all of these diagnoses were just describing manifestations of one condition: an imbalance in the body’s homeostasis. Would the treatment be different in a patient who has alcohol dependence and is found to have high blood pressure, high triglycerides and stomach pain from alcoholic gastritis, an inflamed irritated stomach from alcohol after drinking 12 beers a day? Would we prescribe a high blood medicine, a triglyceride-lowering medication and an acid blocker to this patient, so that he can continue to drink alcohol but with less complication? Most of the times, these patients are given a Band-Aid in the ER – with some pills to pick up and told to stop drinking and see a doctor.
Are we missing the forest for the trees? Let’s take an forest/tree example:
If you were a botanist and were given a job of determining why a particular type of tree is dying in a forest, you can go about it several ways: 1) you could study the details of the affected trees — the bark, the leaves, the roots and growth characteristics — breaking the tree down and analyzing its parts; 2) you could assess the results of subjecting a tree to various hypothesized causes and determine if a reaction occurs; 3) you could even take an aerial view of the forest, searching for patterns e.g. locations of affected trees and a local river or field, etc. Each method may complement the other, though some understanding could be gained by either alone. An excellent example of identifying patterns is Dr. John Snow’s investigation of the Broad Street cholera outbreak in London in 1854, and instituting control measures to stop an epidemic – even while the miasma theory of infectious diseases had a strong foothold – and clashed with Snow’s conclusions.
Two models can be used in gaining an understanding of the mechanisms of the body: reductionism and holism. Reductionism is breaking the more complex to simpler parts. Holism is looking at multiple systems at interplay with each other. Both methods are useful views of how the body functions, but each have their limitations. If you reduce the complex into its components, you may not be able to factor in how these components interact with each other and with the larger systems. If you look at the multiple systems simultaneously, you may not be able to understand, with a level of detail, the exact signals, only detect what you might be looking for – bias, or make false conclusions of associations – confounding. A hybrid of the two is next to impossible because of our linear, finite reasoning that looks for patterns it is prepared to see. Ultimately, both are useful approaches and more complementary and inter-related rather than oppositional viewpoints.
The scientific method is largely reductionistic, favoring a specific question, such as “Is this medication more beneficial than Placebo, all other things being comparable and random.” This scientific discovery is the foundation of Allopathic Medicine. The largely observational disciplines of Ayurveda and Chinese medicine are holistic in their view on health – looking at the body as homeostatic, where an imbalance in one system may lead to an imbalance in other systems. Neither of these practices applicable for all conditions nor do they need to be mutually exclusive, separate disciplines. Or … are the more ancient disciplines obsolete or inferior to the detail of understanding of Allopathic medicine?
No doubt that the assumption of thousand of years of clinical wisdom ensure their validity is wrong. The miasma therapy goes back to almost 15 centuries and were espoused by Hippocrates and Galen. So too were the four humors which led to practices such as bloodletting. There were times when it was “half-correct”. For instance, it was not the cause of malaria, or “bad air”, but the Anopheles mosquito which transmits Plasmodium species was found outside. Again, these were observational theories that were later disproven. (An interesting concept here is how bias affects perception).
The medical disciplines of functional medicine, integrative medicine, naturopathy and the founding tenets of Osteopathic medicine * (I am an Osteopath!) provide other frameworks on health and wellness. These disciplines emphasize preventive approaches over medications, and have been bolstered by a general shift of the zeitgeist toward the prevention and reversal of chronic diseases, in the spotlight of studies on epigenetics and physiology of aging.
Functional medicine has not been immune from opposition; neither has naturopathy (and the earlier times of osteopathic medicine). The scrutiny generally stems from its poor scientific basis on the use of certain compounds and vitamins. There are also some concerns about the level of training of the practitioners and some of the tenets of the holistic model. Finally, this type of healthcare has a capitalist side to it, which may taint its underlying philosophy — multiple (possibly) unnecessary tests and the selling of supplements and vitamins, most of which haven’t been found to be beneficial or scientifically-based. It is not without its pseudoscience and quackery. This occurs when assumptions fall short or predict patterns that are not true or provide a glimmer of hope to those desperate.
Applying a reductionist model to understand multiple systems has its shortcomings – the body does not reduce into systems easily. (I am an infectious diseases specialist and have seen this first hand). For instance, recent medications used for inflammatory or rheumatologic conditions (use of monoclonal antibodies) may produce an intended effect in calming the inflammation of Crohn’s disease only to lead to reactivation tuberculosis. We can sometimes only truly understand a medication when it is tried on the body as a whole.
A holistic model may have its greatest impact in understanding how perturbations in health affect the body as a whole. When someone becomes obese and reaches a threshold, their blood pressure increases – the heart requires greater force to overcome tissue pressure – the lung pressures increase as the lungs expand less and as sleep apnea worsens – the pancreas increases the secretion of insulin because its function is reduced in adipose tissue. Leptin – a hormone that signals satiety is over-produced in the fatty tissue and a leptin resistance occurs in the brain. The interactions and mechanisms of the body defy our linear logic.
Yet one amazing thing happens when someone shifts toward a whole food diet – with increased fat, decreased carbohydrate content and plenty of leafy vegetables that seems to defy reason and make perfect sense at the same time…
The person begins to have less cravings signaled in the brain, less mood swings, better fasting glucoses – insulin levels reduce, glucagon triggers movement of triacyclglycerols or “ketone bodies” to circulate in our blood reducing body fat. As the weight is lost, the insulin resistance, cholesterol imbalance, fluid retention and sleep issues disintegrate — the imbalance is correct and the body is becoming balanced again!
It is important to understand that innovation often precedes complete understanding. The body is what it is – nothing changes but the way we interact with it to understand. Perhaps an integrative, holistic approach to health – as attractive as it sounds – will only be readily accepted when more sophisticated tools and computer models can be used to provide greater scientific support.
Ultimately, think of a future model that defines the body in its parts AND the whole. The innovations of fractal geometry help to describe these phenomena in natural structures and applies to the body (this will be a subject to another post). The definition of a fractal is an iterative structure that displays self-similarity. It is difficult to imagine that are venous, arterial and nervous structures extend to include every millimeter of our body. Any disease process may originate at these crossroads and cause system-wide malfunction or disease. A smoker inhales from cigarettes and the tar and nicotine as well as thousands of other carcinogens gets absorbed into the blood in the alveoli and travels throughout the body. The liver metabolizes it but vascular are exposed to these particles and become inflamed. This changes lead to atherosclerosis. The heart is affected by and adjusts to these changes as well as the other organs including our brains.
Just think of all the potential entry points of disease – the skin, the gastrointestinal system, the lungs — they interestingly relate to how our body incorporates environmental exposures – including the food we eat! In the background of most health problems that are seen in the clinic there is an environmental exposure linked to BEHAVIOR.
Health and Wellness: The parable of the three blind men and the elephant
One metaphor to explain our limitations to understanding health and wellness is the elephant and blind men parable:
A group of blind men heard that a strange animal, called an elephant, had been brought to the town, but none of them were aware of its shape and form. Out of curiosity, they said: “We must inspect and know it by touch, of which we are capable”. So, they sought it out, and when they found it they groped about it. In the case of the first person, whose hand landed on the trunk, said “This being is like a thick snake”. For another one whose hand reached its ear, it seemed like a kind of fan. As for another person, whose hand was upon its leg, said, the elephant is a pillar like a tree-trunk. The blind man who placed his hand upon its side said the elephant, “is a wall”. Another who felt its tail, described it as a rope. The last felt its tusk, stating the elephant is that which is hard, smooth and like a spear.Wickepedia “Blind men and the elephant”
The same holds true for how we have traditionally looked at health. Someone has a high blood pressure — start a medication if it is too high. Someone has fluid retention — give them a diuretic. Someone has diabetes — give them a diabetic medication or if they are more severe, give them insulin. In adding medications the false pretense of solving a problem is implied — that the condition will improve to reduce the risk. A person may construe that as “keep calm and carry on”. The behavior continues that was fueling the problem.
In the above conditions, obesity is the common link that wasn’t even thoroughly addressed in most medical schools during a time that saw an epidemic increase in obesity. The dogma of “eat less and exercise more” was commonplace. Meanwhile, the food industry removed the fat from food and marketed sugary foods as “low-fat”. Nutella (candy spread) became “part of a complete breakfast”. Missing in all of this was a true understanding of how the body builds adipose tissue through excess sugar and how obesity is largely preventable – and much more difficult to treat when present.
What is health and wellness?
We can start with the World Health Organization’s definition in the beginning. We can all agree that health is certainly more than not having a “dis-ease”. It is a state of greatest ease, or well-being. Think of what it would be like to have all of your organs, tissues, joints and senses performing at tip-top function. I am sure many of you are probably thinking about a time in your life when you were closer to this state – and much younger! Although health is that optimal state, the body is anything but a static system.
Think of all of the structures of the body — when the liver can release its glycogen stores into the blood stream in between meals and adipose tissues diminish during a lengthier period of fasting and enters the bloodstream as triacylglycerol or “ketone bodies”. It is a state when all levels are functioning at maximal efficiency – as needed for increased capacity or energy-conserving during resting times.
On a system level:
>The heart smoothly receives the blood in coalescing veins from the body and propels it forward to the lungs. On the left side, the oxygenated blood returns to be propelled forward to the brain and the rest of the body, free from any significant resistance. The size of the heart and pressures in the receiving lung and system allow the blood to flow efficiently and are not too high, to cause the heart to have to grow and increase pressures. The heart is functionally prepared for any increase in aerobic stress.
>The brain is functioning in a focused manner, receiving oxygen-fresh, nutrient-rich blood to fuel it. The brain receives signals from the senses and every part of the body to allow signals to flow to and from it, so that performance is optimal. Neurotransmitters are not over-triggered and are at a stable level, as one is free of excessive anxiety and other distractions. Any external perturbation is processed and a response is applied to maintain a calm, steady state.
>The lungs are not faced with any resistance mechanically, easily expanding to allow for the maximal intake of air. Oxygen transfers into the alveolar sacs with ease, as there is no trapping of air from scarring (as a result of smoking, pollution or other contaminant) or from spasm (asthma). The blood flows freely to and from the lungs without any significant resistance.
>The kidneys are optimally filtering the blood, retaining salt if needed or removing it along with balancing the amount of water needed for the blood volume. All of the harmful ingredients are being secreted out into the urine. The kidneys are producing an optimal amount of erythropoietin to activate the bone marrow to produce enough red cells.
>The GI system: The esophagus is functioning well with normal motion and acid production in the stomach stays there to assist in digesting the food as it churns it. The small intestines absorb all of the nutrients from the food and traffic them to the portal circulation to be metabolized in the liver. The pancreas is secreting an ideal amount insulin and enzymes as the food is fiber-rich, vitamin rich, and mostly plant-based, free of inflammation-provoking substances (e.g. concentrated sugars, salt and saturated fats). In the liver, the glucose is being metabolized by insulin and fats and amino acids are being prepared to be used by all of the cells in the body. Sugar is packaged into glycogen in the liver to be slowly released in the blood between meals by a glucagon signal. Triglycerides and fatty acids are produced at a safe level to be transmitted to the rest of the body.
>The Neurotransmitter and Endocrine systems: The body responds with an appropriate release of hormones including those used for the autonomic systems (epinephrine, norepinephrine), for motivation (dopamine) and positive behaviors and a state of joy (serotonin, norepinephrine). Cortisol secretion is at an optimized, basal rate, not driven to excess production, as the brain is able to adapt to any real or perceived stressor. The sex hormones persist in a normal level, not blunted by sleep issues, like sleep apnea, diabetes or alcohol.
>The Integumentary System: Skin is smooth and producing oils and anti-microbial peptides to an appropriate amount to prevent folliculitis. The skin cells are free of injury caused by sunburn or wounds that can lead to a risk of skin cancer. Muscle mass is preserved and functioning to allow one to complete needed tasks, to prevent falls and protect the joints. Tendonous insertions are free of significant scarring damage and calcium. The joints are well preserved and can handle tension when needed.
>The Immune system: white blood cells (neutrophils) are signaled in the small intestines to neutralize harmful pathogens in the Peyer’s patches and other centers. Other white cells, macrophages, circulate around the blood and vascular tissue to control inflammation and capture pathogens. Other immune mechanisms such as skin antimicrobial peptides, complement, and other proteins in the natural immune system are serving as the initial defense in the skin, tissues and blood. B cells are producing antibodies that are turned on when bacterial invaders trigger the humoral immune system. A person may develop an infection but is at a lower likelihood of more severe disease or complication. There are no triggers that could result in inflammation and auto-immune conditions.
>On a molecular level: Proteins are being translated from messenger RNA in cells in an optimal formation to fulfill the needs of each tissue type. Telomere lengths are being relatively conserved (not shortened) as chromosomes are read and proteins are encoded. Autophagy is optimally functioning to clear proteins, organelles and lipids.
Now combine all of these systems into a dynamic, flowing process and picture what it might be to have a fully functioning body, free of any impedance. That is health and wellness.
“The doctor of the future will give no medicine, but will instruct his patients in care of the human frame, in diet, and in the cause and prevention of disease.” – Thomas Edison