The Hacking of the American Mind

by Robert H. Lustig

  Why is this happening? What is the cause of this death spiral? Either we’re so unhappy that we are killing ourselves (see Chapter 11), or we’re under the malicious spell of some external force that is powering this tornado. Are our opioid crisis and our metabolic syndrome crisis related? What is the connection between happiness, health, health care, and life span?

  Happily Ever After

  There’s no question that innate happiness predicts a longer life. A group of American nuns were asked to write an autobiography in their twenties, and their writings were analyzed for content on well-being and positive affect. Those who exhibited contentment lived to an older age than those who did not.14 But was that because those who were happy didn’t find the need to engage in more problematic behavior, e.g., smoking or alcohol (neither of which is forbidden by the Church)? OK, but those are nuns. A more recent and complete assessment of different populations internationally15 suggests that high subjective well-being and life satisfaction predicts longevity irrespective of economic status, although it doesn’t necessarily extend the lives of people who are afflicted with chronic disease.

  Conversely, poor health clearly causes unhappiness. And poor health is a primary predictor of mortality. But does unhappiness cause mortality directly? In the case of suicide, unequivocally yes. And those who are stressed, unhappy, and yearning for contentment often seek a consolation prize in the form of reward, thus breeding a host of lifestyle factors associated with skewed dopamine, such as alcohol, tobacco, and street drugs. So which kills you—the behaviors or the unhappiness? Three recent studies, two from the UK and one from the U.S., start to answer this question.

  First, a British longitudinal study of men and women ages fifty and older16 modeled the role that happiness plays in predicting a long life. Happiness was assessed using a four-point questionnaire (I enjoy what I do; I enjoy the company of others; I look back with a sense of happiness; I feel full of energy). Of note is that this study took into account both depression and the diseases of metabolic syndrome (e.g., heart disease, stroke, diabetes, cancer, impaired mobility, chronic lung disease) in the model, but did not ask about the behaviors that led to these diseases (sedentary activity, bad food, smoking, alcohol, drugs, sleep debt). The results showed that of all those who had specific diseases, you were more likely to survive them if you were happy by a factor of 25 percent.

  However, the conclusion reached in the next study was somewhat different. In the UK Million Women Study,17 post-menopausal women at a median age of fifty-nine years were asked, “How happy are you?” About 40 percent said they were happy most of the time, 44 percent said some of the time, and 17 percent said none of the time. They asked these women to self-rate their own health. The investigators followed this group for ten years. Death rate was definitely associated with poor health assessment at baseline, and poor health was associated with unhappiness. But after adjustment for self-rated health, reward-driven behaviors (smoking and hedonic eating), and treatments with medicines for reward-related diseases (e.g., hypertension, diabetes, and also depression and anxiety), it turned out that these women’s innate unhappiness played no role in their death rate from heart disease, cancer, or any other disease.

  The third U.S.-based study adds yet another piece to the puzzle. A group of adults had fMRIs performed at baseline and then three to four years later, during which time 9 percent of the subjects suffered a heart attack.18 What was different about their brains that could be a predictor? Those who demonstrated the highest activities in the amygdala (the fear center) were the most likely to experience a cardiac event. The amygdala dampens function of your PFC (see Chapter 4), putting you at risk for more self-destructive behaviors.

  What are we to make of these three seemingly different yet related studies? They tell us that unhappiness itself isn’t the killer. Rather, it is likely that our fear and anxiety stoke our unhappiness, which drives us toward unhealthy behaviors (many of which are dopamine driven), and it is these behaviors that increase morbidity, disability, and eventually mortality. These studies don’t answer directionality—which came first, the fear or the unhappiness? Ultimately, it doesn’t matter: behaviors continue to increase the force and the expense of the death spiral. It’s all about how we seek pleasure in the absence of contentment, driving both addiction and depression, and where and how we have run off the rails. It’s the cheap thrills that kill. And the cheap thrills are everywhere. But there’s a silver lining here, because all of these cheap thrills are man-made. And they could be un-made—if we choose to.

  The Tragedy of the Commons

  Health care and social security are finite resources. There’s only so much money in the pipeline. In the past, we’ve just upped the dollars devoted to health care. In 1965, health care amounted to 5 percent of gross domestic product. In 2014, health care took up 17.5 percent of GDP. And by 2022 it is projected to be 19.9 percent. But now we can’t print money fast enough to afford it; the money has dried up. When such finite monetary resources are used indiscriminately by everyone, we suffer from the paradigm known as the “Tragedy of the Commons.” The principle: you have a big field where all the farmers graze their cattle. When there are few cattle, there’s no problem. But when farmers buy more cattle and let them graze to their hearts’ content, soon there’s no grass and no cattle. This is a well-documented principle by which a limited resource that is supposedly available for all is utilized by all and then disappears for all. This is what is happening to social security and health care. And ostensibly, this was the basis for Obamacare.

  Dr. Ezekiel Emanuel, President Obama’s health care advisor and architect of Obamacare, published an article in October 2014 in the Atlantic titled “Why I Want to Die at 75.”19 In it he argues that health care has not extended the time of living but rather has extended the time of dying. While we have increased the length of life, we have not contributed to improving either happiness or productivity.

  The data would argue that our paradigm of life (or death) extension seems to have reached its zenith. Newer research argues that this is the first generation to live shorter lives than its parents.20 In Chapter 11 we noted that life span has started to decline. While the percentages might not seem like much, it’s the slippery slope. Expect further life span reductions in the future, despite spending over one-fifth of our GDP on health care.

  Worse yet, Obamacare was predicated on a false premise—that the healthy people would pay for the sick people, and that access to a doctor would keep them out of the ER. The idea was that we could add 32 million sick people to the insurance rolls, and we would pay for this by providing “preventative services”—that is, by having access to a doctor, and by treating symptoms with medicines (e.g., treating high cholesterol with statins, high blood pressure with angiotensin converting enzyme [ACE] inhibitors, diabetes with oral hypoglycemic agents), you would stay out of the emergency room, where the costs are fifty times higher. Sounds good, but there’s a catch. There are no services to prevent chronic metabolic disease that can be provided by the health care system. There’s only treatment. We doctors can keep these people alive, but we can’t stop people from getting heart disease or diabetes or fatty liver disease or kidney disease with pills, just like we can’t stop people from getting obese. And these treatments cost health care big bucks. Just look at how the rates of these diseases have continued to climb over the past twenty years, despite our full knowledge of the obesity epidemic. And once you’ve had your heart attack or stroke or once you’re in chronic kidney failure, you’re nothing but a liability. You’re just another head of cattle grazing on the commons. Why do you think three of the biggest health insurers (United, Aetna, Humana) opted out of Obamacare: at a 15 percent profit cap, they couldn’t keep up with all the sick people with diabetes. Yet we could all save money on chronic metabolic diseases if we could actually prevent them.

  Health Care Is Sick Care

  Health care has been sucking at the teat of
the federal government for decades. Everyone wants their share. Doctors, lawyers, and insurers were natural-born enemies. After all, we doctors wasted the insurance company’s profit on health care and its delivery. We demanded all modes of exorbitant therapy for our patients, including treatments that might prolong a patient’s life for a few months. Never was this truer than in the good old heydays of health insurance. Big Medicine relied on Big Treatment to generate Big Bucks. Treating chronic diseases, especially those with no cure, is expensive, and the markup is huge. The government negotiated with the American Medical Association (AMA) to provide fee-for-service. Procedures became the cash cow, and the premiums reflected it. The doctors drove the bus, the insurance company charged higher rates, the employers anted up, and the patients came to expect the magic of modern medicine. No talk of prevention. The results of prevention don’t happen within one political cycle. Prevention requires a cultural shift, and that is political suicide, especially when there’s money to be made. Prevention puts responsibility not just on the individual but on society as a whole, including government. Prevention may sound good on a bumper sticker, but it doesn’t make any money for doctors, for hospitals, for insurers, or for politicians for that matter. Prevention is a zero-sum game.

  The costs associated with procedure-driven health care made doctors the bad guys through the last half of the twentieth century. We doctors lost our credibility with Congress. This was the impetus for expansion of HMOs: to try to control doctors and, in turn, control costs. Except 43 percent of health care was spent on administration by the insurance companies. So who really wasted the money? But hey, just raise the premiums. Keep those profits rolling in. And the lawyers were happy to tap into all that largesse. Malpractice suits generated awards that topped $69 million a pop. At one point, almost 60 percent of all doctors had been sued for malpractice at least one time in their careers. All paid out of the insurers’ profits. And so it was.

  But the Tragedy of the Commons means that the party’s over and the grazing land has gone fallow. Academic medicine, Medicaid, Medicare—they’re all on life support. And the bankruptcies are not due to physicians’ salaries, which have decreased relative to inflation, or in-patient costs, nursing costs, or infrastructure expenditures. It’s due to chronic metabolic disease. These diseases aren’t killing us outright; instead they’re sucking us dry. And if you think that other people getting sick is their problem and not yours, chew on this: 65 percent of all health care expenditures are paid out of government dollars. That means your taxes.21 You’re paying twice—more for your own insurance premium, and more for everyone else too.

  One question around which the 2016 election revolved is whether Obamacare worked. Well, as of 2016, 20 million people who were previously denied or could not afford it were able to obtain health insurance. Insurance company profits were capped at 15 percent. Any extra money that the insurance company took in had to be returned to its subscribers. So that should reduce corporate profits, right? Not necessarily.22 The large insurance plans have cut administrative costs to make the 85 percent minimum loss ration (MLR), but they hiked both premiums and deductibles, so that it became harder to use the health care you got. This resulted in the big insurers making even more money and doling out bigger executive bonuses.23 Those three major insurers abandoned the state exchanges altogether, thus squeezing the rest. Because with 15 percent profit, they can’t make money using the casino model anymore. The best way to make money now is to save it; that is, nobody get sick so there’s no payout (or make the premium so high that nobody uses it). And Trumpcare will continue to ignore the elephant in the room: more of the populace is sick, and getting sicker. And they won’t get better until there’s a substantive change in the food supply. Trumpcare’s answer? Deny 24 million people health insurance.

  There is one good thing that did result from Obamacare that will likely remain, perhaps an unintended consequence. Before Obamacare, insurance was based on the casino model. It was pay-to-play, and the insurance company, like the casino, set the payout. Under the casino model, the insurance company wanted you to get sick. More people getting sick was their excuse to raise the premiums and make more money. There was no impetus for prevention because there was no money in prevention. And decades ago, Big Business wasn’t necessarily happy when people got sick, but it wasn’t crying either as CEOs could replace older employees, who garnered high salaries and pensions, with younger ones to whom they could pay lower salaries and who had never heard of pensions. But as the premiums grew, Big Business realized that insurance costs were cutting into their economic productivity, because they are spending $2,751 per annum per employee for obesity-related diseases, whether the employee is obese or not.24 Nonetheless, because of the cap, for the first time in history, insurance companies actually want you to be healthy. So they are all paying for preventative care now. Now they want their payout to go down, and a healthy workforce is the only way to reduce those costs.

  Stayin’ Alive

  But what if we had healthy ninety-year-olds instead of sick seventy-five-year-olds? My wife’s grandmother lived on her own farm in rural Minnesota till the ripe old age of 101, growing her own food, gardening, limiting her TV, and not seeing a doctor. Her family’s single regret in her life was that when she hit 100, the Today Show’s Willard Scott didn’t mention her. What if we all consumed minimal health care resources in our old age because we were the epitome of health? What if we prevented the national exposure that drives economic, social, and medical devolution all at once? And what if we could be happy at the same time? In Zeke Emanuel’s Atlantic article, he never even addressed the biggest issue in this entire debacle: diet. Could we turn this around? Could we save lives and money? We could, if we would just reduce the most ubiquitous dietary item that is driving it upward: the cheapest of thrills—sugar.

  While there are likely many environmental factors involved in metabolic syndrome, the one we have causation for is sugar.25 Disability-adjusted life years, or DALYs, are a way of determining the health and economic burden of a particular exposure or behavior. One study26 looked at the effects of sugar-sweetened beverages on DALYs worldwide. What was interesting about this analysis was the breakdown by age group. Despite having the highest general disease rates, the over-sixty-fives were virtually untouched by sugar-sweetened beverages. Conversely, it was the twenty- to forty-four-year-old age group that showed massive increases in DALYs due to sugar-sweetened beverages. In other words, drinking sodas, juices, and sports drinks doesn’t just hurt you when you’re older. It hurts you now, when you’re supposed to be at top earning potential, when you’re supposed to be paying into the system.

  In America, it’s no better. The Supplemental Nutrition Assistance Program (SNAP), also known as food stamps, is a $75 billion program that covers 15 percent of adult Americans and 33 percent of children. What do these people buy? Sugared beverages are number two, and some other form of sugar-containing food are numbers four, five, ten, eleven, and twelve; amounting to 27 percent of all expenditures.27 Why should we care what they buy with our taxpayer money? Because people who get their food on the SNAP program are 50 percent more likely to die of heart disease or diabetes than SNAP-eligible people who don’t participate, and three times more likely than those who are SNAP ineligible.28

  My UCSF global health team looked at what would happen to the death spiral if we just cut back a little on our cheapest thrill, sugar.29 From our research on metabolic syndrome, we identified the development of liver fat as the single most important risk factor for developing the various diseases of metabolic syndrome. We then modeled how disease prevalence would change, and how much money could be recouped, if the United States engaged in a campaign to reduce our added-sugar consumption, first by 20 percent (the amount that is targeted by sugar-sweetened beverage taxes, such as the one in Philadelphia), and then by 50 percent (which would bring us to the 10 percent added-sugar limit recommended by the new USDA dietary guidelines).
The model was carried out going forward for twenty years, from 2015 to 2035. The results were astonishing. For instance, at a 20 percent reduction in added-sugar consumption, cases of heart disease and diabetes in the U.S. would decrease by 0.1 percent and 0.2 percent, with health care savings of $10 billion, while a more restrictive 50 percent reduction in added sugar consumption would reduce heart disease and diabetes by 0.3 percent and 1.2 percent, with combined health care savings of $32 billion per year. Over a twenty-year year period, we’re talking about a half trillion dollars saved. Such a move would be a boon for both health and health care. And what is driving increased sugar consumption? It isn’t a slam-dunk, but in most people dopamine plays an outsized role.

  Redrawing the Lines of Engagement

  Politics makes strange bedfellows. Natural-born enemies aren’t such enemies anymore. It used to be the doctors against the lawyers, the doctors against the insurers. But now we’re all on the same side for the first time. It’s all the people who stand to lose—the doctors, the lawyers, the insurers, and those big businesses that have to pay the health care tab—against those who want to maintain the status quo—the food industry, the drug industry, the White House, and Congress. All of a sudden we have some very rich partners with a lot of clout. Now we just have to figure out how to harness it.