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We may have already seen the healthiest generations

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28 February 2022
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"It is hard to be healthy in an unhealthy world." - Maarten Jan Wensink - © Adobe Stock/Rawpixel.com

The joint existence of the Coca Cola Company, PepsiCo, Ben and Jerry's and friends is not compatible with public health. We know that, policy makers know that, and many of the people who routinely consume these companies' products know that. We also know that large shares of the population are increasingly engaged in unhealthy lifestyles, with e-scooters and the likes now being passed off as innovation. Yet we do nothing to interfere, as is our right. However, a similar scenario has played out with global warming, and indeed with global pollution, with devastating consequences.

We know it's wrong but do nothing, then feel increasing unease but still do nothing, until finally producing a scrambled, last-minute response that is expensive, not nearly as effective as it could have been, and politically destabilizing. A similar scenario has played out in the case of the West enabling the rise of China, an un-free country, making itself dependent on China’s cheap and polluting produce, and now asking what situation it got itself into. This essay argues that a similar mechanism is currently underway in public health, buoyed as yet by seemingly limitless increases in life expectancy – a lagging and only partial indicator of population health. And this essay argues that in all these three cases, there are psychological mechanisms at work that prevent us from seeing the problem. Because we do not want to. The essay identifies these mechanisms and makes recommendations - probably in vain.

The observation

According to the World Atlas, among the top-10 soft drink consuming countries, soft drink consumption ranges between 89 and 155 liters per capita per year. These include soft drinks with caloric sweeteners (sugars) as well as non-caloric sweeteners (sugar replacements). Soft drink consumption is particularly staggering in the Americas, but the top-10 countries also include Belgium, Germany, and Norway. The Coca Cola company alone reports selling 1.9 billion products per day; PepsiCo reports approximately half that number. The percentage of these soft drinks that is caloric is hard to establish, but a quick look around in the supermarkets of countries like Denmark or the Netherlands suggests that this percentage remains substantial. And it is uncertain that non-caloric soft drinks are any healthier.

We might ask ourselves which number of soft drinks consumed per person per year could be compatible with public health. If we generously allow one soft drink every second day during the summer and none otherwise, and allow for a long summer, this number would be 50. With an adult world population of approximately 6 billion, this implies 300 billion soft drinks per year, or less than 1 billion per day. Hence, if half the Coca Cola Company's sales were water, the existence of the Coca Cola Company in its current form would be "public health max": the existence of no other company of this kind, however small, could be compatible with public health. But apart from PepsiCo, there exist many other producers of soft drinks, such as supermarkets' own brands, producers of soft drinks with a measure of taste such as San Pellegrino, or East-German anti-capitalist brands like Fritz cola.

If only the poison came in soft drinks alone! The same supermarket that sells soft drinks also sells candy, chocolate, cake, and ice cream, not to speak of the mystifying sugar content of that seemingly innocuous bun. Nestlé, Danone, Mondelez; their business is trouble. Europe is not quite as sullied as the United States, where products as simple as carrots have long lists of ingredients (apparently, a carrot is first bleached, then colored properly orange, sweetened, and finally rubbed in with a cocktail of conservatives), but is not particularly the opposite either.

Unsurprisingly, childhood obesity is a growing problem, 1 in every 3 children in the USA being overweight or obese30595-X/fulltext). At 1 in 6 to 1 in 3 children, Europe is not too far behind (although Eastern-Europe32129-3/fulltext) seems to be an exception), while Latin-America is usually worse in these respects. These daunting numbers seem to arise predominantly from high-caloric consumption, but a lack of exercise is certainly another contributing factor (even though most primary school children do seem to like to move!). This lack of exercise has more than one manifestation. A Dutch governmental report indicated that compared to 2006, in 2016, fewer children were able to play simple games like hopscotch, where one jumps on one leg across a field of numbers. Indeed, 5 out of 8 marked physical ability items showed a deterioration relative to 2006, the other 3 items remaining stable. In the same vein, orthopedists have signaled their concern about what they call iPad necks and Game Boy backs, manifested in the fact that some children not yet in their teens have backs like 70-year-olds. The iPad neck is, to an extent, preventable by letting the children watch on their bellies, which reinforces the musculature of back and neck, but even that does not grow strong cartilage and bones. Playing outside does. In the same vein, walking stairs is vital: up for strong leg muscles, down for strong leg bones. And yet the world is ever more replete with escalators and elevators.

Moving the scope to mental health, the picture is not brighter. Explaining to your daughter that Barbie is not what girls look like is one thing; to counterweight Instagram videos where your children are incessantly battered with the most depraved beauty ideals is another. Faces that are no longer recognizable as human beings are revered on Instagram. In Colombia it is now normal for a girl to ask her parents for new breasts when she turns 16. Many a teenager across the world now spends her time exercising the buttocks in pants that push everything to where it apparently belongs while filming herself, posting the result on Instagram, TikTok, or YouTube. Hungry for likes, vulnerable to distress if these likes do not come.

It does not get much better when teenagers grow up, because strive for academic achievement, already well on the way at school, only intensifies when the time comes to go to college (alongside the focus on the buttocks). Since everybody now excels (apparently), good grades are no longer good enough to get into a prestigious college, and the completion of a regular college is no longer good enough to be allowed to, say, run a bank or country. Once in a prestigious college, teenagers often have become accustomed, indeed addicted to striving and selection, which now move to the level of competing for entrance to the most prestigious sorority, book club, or sports association. This troubling interpretation of meritocracy, with endless focus on achievement and singularity, is described in Sandel’s The Tyranny of Merit. A particularly pungent implication of this exaggerated meritocracy on mental well being, Sandel argues, is that those who do not make it to the top are not only less well off, but also morally responsible for their failure. Meanwhile, everybody is President and CEO of their own company, even though that ‘company’ is often just them and the house cat. LinkedIn profiles suggest that one is a "serial entrepreneur" (my start-ups have gone wrong) or "reacher for the sky" (I don't know what I want). Certain corners of the dating market, I am told, are not much better: since everybody is now searching for perfection in their partner, which is obviously impossible to come by because perfection is judged against the distribution of potential partners that exist, disappointment means rates of divorce and loneliness are up – big.

Back to physical health. A typical (median, to be exact) young Danish male (assessed for possible conscription) is now only borderline able to impregnate a woman. This because median sperm concentration in ejaculate, an important measure of fertility, is now around 45 million sperm per ml, while below 40 million per ml there is a reduced chance of achieving pregnancy within a given menstrual cycle. Staying on the reproduction track, a growing number of prospective fathers now take prescription drugs during the development of fertilizing sperm. Diabetes drugs, both insulins and oral treatments, are among the fastest risers, as are antidepressant, anti-acids (for the stomach), and cholesterol pills. While most of these drugs may be entirely safe, the knowledge gap here is substantial. Diabetes is associated with reduced fertility. A study showed that type II diabetes in 2016 affected 2 percent of 40-year-old males in Denmark, while 20 years before, diabetes was virtually non-existent in this age group. Some of this may be due to more intensive testing, but most observers believe that most of this increase is real. For example, family doctors observe that patients are now more often obese than 20 years ago.

Some believe that current fertility problems are partly the result of the approximately 100,000 products made from fossil sources. While this hypothesis remains to be investigated, that the spread of chemical compounds across the world environment is unchecked, is certain. In, say, a lake, one can find numerous chemicals of concern, most of which are human made, including common drugs like metformin (a diabetes drug). While many of these compounds will be innocent to health and fertility, some will not be, and for most of these compounds it is unknown what they do in interaction: compounds A and B may be innocent individually, but may not be innocent when occurring together. Observations such as these have recently triggered a panel of scientists to call for a UN oversight body on chemical pollutants.

Moving to the microbial front, the risk of increasing antibiotics resistance has been pointed out for a while, with no solution in sight. Many antibiotics are so widespread that bacteria have learned to survive in their presence. For example, bacteria, which are just cells, may learn to pump antibiotics out, prevent antibiotics from coming in, or change the cellular pathways which the antibiotics were meant to disturb. This means that antibiotics no longer work.

The only objective way to deal with Facebook, Instagram and the likes is to ignore them. Many people are not able to do so, and believe much of what they see, with devastating consequences for their mental wellbeing.

Maarten Jan Wensink

The interpretation

The above represents a staggering amount of evidence that not all is well in our chemical, pharmacological, social, mental, and physical living spaces. So what? There have always been problems and there always will be, and this is no less true for the health sphere. Some problems of the past have indeed been resolved, and this has fueled a remarkable rise in life expectancy over the last century or more. Living conditions in Europe have increased dramatically, including standards of housing and work safety. The same can be said for healthcare overall. In many European countries, tobacco-related mortality is finally declining, although worldwide it is still on the rise.

In the past, people were generally able to understand that they weren’t James Bond, so why would the unreal lives of others presented on Instagram have such a devastating effect on mental health? And yes, there is more obesity and diabetes than ever before, but if people are content with taking a couple of pills every day, and if with those pills they can live almost as long as their healthy counterparts, then what is the problem? It is difficult to address all aspects of health and weigh these against each other. The evidence presented above, while troubling, is not a systematic overview of a complex phenomenon. So why should this time be different from the past?

Three reasons, actually. First, everybody knows that they are not actually James Bond because James Bond is a distant, theoretical, clearly made-up personality that nobody has ever met (not least because a real James Bond would not survive a single movie). But modern technology – Instagram – removes this distance, and rather comes as close to you as it can get. You may have met me, and you could have been me, but my Facebook profile is still a lie. If you are not aware of the fact that my Facebook posts are a selection of my life, that give very little, if any, insight into how my life really is, you may feel depressed about why my life is so perfect, while yours is not. The same goes for the retouched pictures that you may find on my Instagram (actually I haven’t got one): you will recognize me, but at the same time what you are seeing is not really me. Something similar goes for personalized media: In the Netherlands, there have always been strongly separated pillars of society, all with their own media. But at least the newspaper you opened said so, calling itself “liberal” or “reformed”. Also, everybody who opened the liberal or reformed newspaper would open the same paper. This is no longer the case. The dangers to democracy have been pointed out – but have the same dangers been pointed out in the case of mental health?

The latter point deserves development. The most widely accepted definitions of knowledge hold that the minimum requirement for a belief to classify as knowledge must be that the belief tracks with the truth: if the truth were different, the belief would be different as well. A saying has it that even a broken clock is right twice a day. This, however, is not really so (which is of course the crux of the saying) because to be right, the hands of the clock would have to be different had the hour of the day been different, which isn’t the case. Such tracking of information with truth is equally broken in the world of Facebook and Instagram: The life that I present as my life on media like Facebook and Instagram tracks in no way with my actual real life. Rather, the presentation is largely independent of reality. Interestingly, propaganda could be defined in much the same way: government reports that would not be different had reality been different, even if some of the things in them happen to be true, are propaganda. Similarly, personalized media that confirm me in my opinions do so irrespective of whether my opinions make any sense at all. So rather than living in information abundance, as is sometimes claimed, we live in information void. The only objective way to deal with Facebook, Instagram and the likes is to ignore them. Many people are not able to do so, and believe much of what they see, with devastating consequences for their mental wellbeing. These effects, massively understudied, are highly worrying.

Second, an important part of current optimism about public health derives from a seemingly ever-rising life expectancy. People who have proposed theoretical limits to human life expectancy have always been wrong, sometimes even at the time of making their prediction, not being fully aware of the data. This pattern of “broken limits to life expectancy”, along with the longevity risk that keeps pension insurers awake at night, has understandably led to a tendency to expect further increases in life expectancy. And indeed there may well be no biological limit to human life expectancy. A different question, however, is whether life expectancy will continue to rise in the 21st century.

To think about this, it is necessary to clarify how a life expectancy calculation is worked out. I have previously compared it to the prediction of transit time calculated by travel assistance software like Google Maps. Such predictions are typically based on traffic conditions as they exist at the moment of prediction. Departing from Odense to Bolzano, there may be a traffic jam near Leipzig, causing delays on my route. These delays show up in my summary measure, estimated transit time. But when I pass Leipzig, the bottleneck may have dissolved, so the estimate is off. Similarly, life expectancy is a summary measure of current mortality conditions: life expectancy in 2021 assumes that someone lives their entire life under the mortality conditions as they exist in 2021; nobody does that, but it gives a nice summary measure of current conditions. Yet when I turn 60 (in 2044), mortality conditions may be markedly different from now.

There are two ways, then, in which the picture of rising life expectancy may be beginning to crack. The first is the inequality perspective, which by now has made its way into mainstream knowledge: the rise in population life expectancy is increasingly carried by select subgroups of populations, usually the rich and educated. This awareness is part of a broader realization that apart from averages, variability around the average matters too. The second one is related, but more subtle. Above it was mentioned that in Denmark, 2 percent of males aged 40 now have diabetes, versus 0 percent 20 years ago. This means that by 2036, for the first time in history, 2 percent of males aged 60 will have had diabetes for 20 years. By 2056, for the first time in history, 2 percent of males aged 80 will have had diabetes for 40 years. Will these be as healthy as the current octogenarians? Will they even be alive?

Third, to deal with problems, problems need to be recognized first. Yet, important shifts in perceptions of what is normal are now hiding existing problems. I have already alluded to the shifting perspective on reproductive health: It is now normal to have a low sperm count, which is therefore no longer low. It is now normal to have long waiting time to pregnancy, which is therefore no longer long. Similarly, family doctors may consider slightly elevated cholesterol levels to be normal for two reasons. First, with rampant obesity and unhealthy dietary habits, most people have somewhat elevated cholesterol, making it normal. Second, an economic argument: we cannot pay for everybody’s cholesterol pill. But that does not make borderline cholesterol healthy.

Normal values are also determined by clear problem levels. If it were normal to be depressed, then we would presumably still consider being depressed a problem, as depression is a clear, unwanted outcome. But for risk factors that have no immediately perceptible outcome, perceptions of normality are easily bent. Like most other such bodies, such as the WHO, the Dutch Hartstichting (Heart Association) recommend at least 2.5 hours of "moderately intense" exercise per week - such as walking or swimming at low speed (the important thing being to get off the couch). On top of that, they recommend muscle or bone reinforcing activities, such as running or dancing twice a week. For children, they recommend moving at least one hour per day. All this is clearly better than nothing, and presumably such guidelines are partially targeted at people who need encouragement, so that setting too high a target could be counterproductive. Be that as it may, there is a risk that people who see such guidelines, and who meet those guidelines, think that they are healthy. They are not. The WHO and others have adjusted their recommendations to our way of life, and it is obviously much healthier to practice moderately intense exercise for 2.5 hours per day rather than per week (i.e. the 10,000 paces a day), while for healthy children it is hard to think what else they should be doing if not moving about, school, and piano lessons exempted. This may strike the reader as excessive, but again, what is excessive, depends on the norm.

The human race will allocate ever larger shares of the economy to products that make people sick (sugar, television, consumerism), and a correspondingly larger share to products that make people better again (diabetes drugs, new knees) or that make them able to live their lives unhealthily (elevators, personal robots). Until it no longer works.

Maarten Jan Wensink

The perspective

I drive a 2002 1.2 Honda Jazz hatchback. According to the owner’s manual, it gets 18.8 kilometers out of a liter of gas, and experience is that indeed it does. Nowadays this is still good mileage. So what happened with 20 years of technology innovation? They went up in smoke: cars are now larger and have more features, so mileage has hardly improved. Similarly, the same period has witnessed explosive growth in terrace heating, open-air heated pools, and air travel, not to mention unprecedented consumerism. This is not very intelligent if at the same time one wishes to reduce dependence on oil and gas from dictatorships and other unpleasant countries, and is testimony to a lackluster, decadent Europe that is now brutally wakened from its slumber by the Russian invasion of Ukraine. All along, extensive lip service has been paid to climate and environment. The mainstream policy maker has not perceived these observations as incongruent: a now unfindable Dutch governmental study published just pre-COVID envisioned 3 percent sustainable yearly growth in passenger numbers for KLM, the Dutch national airways while becoming climate neutral.

In the lead-up to the Glasgow summit held in early November 2021, there was talk of making hard choices this time. Examples of such hard choices were putting absolute and unnegotiable limits on the amount of fossil resources that could be extracted from the Earth’s surface. The logic of such limits is compelling: no matter how you measure, oil that is not pumped, cannot be set fire to and therefore cannot contribute to climate change (could we put a similar limit on the sugar industry?!). But to call this a hard choice is laughable. While remaining significant, the lobbying power of big oil has declined, simply because other industries have grown faster. And from the perspective of publicity, targeting big oil as the root of all evil is appealing. Real hard choices could be the following. Strict limits on the number of business and non-business flights, say one flight per person per year. Hefty taxation of flights, starting with jet fuel, which is currently tax exempt. A legal ban on terrace heaters. 1-Liter three-cylinder engines in all private cars (constructing a car that gets 30 kilometers out of a liter of gas is tremendously easy – this is how you do it). Forced closure of shops that sell any goods not expected to endure a very long time. Forbidding the existence of Facebook data centers, as invading your privacy costs a tremendous amount of energy and serves no one but Facebook (any green energy that is used in a data center, is not used to replace fossil fuels elsewhere). Except from some here-and-there measures on for example disposable drinking straws coming from the European Union, no actually hard choices have been made.

Why? Because postponing to deal with problems is human. Because we hope that time may bring solutions. Because belief in human liberty is a tranquilizing reason not to intervene (even though future intervention may be a whole lot tougher). A similar mechanism has played out with the rise of China, now a serious competitor to the democratic world. In this case, the tranquilizer that we took was a convenient belief in “convergence”: with law-like necessity, countries that are “behind” will become Western, converging both economically and politically. Neither of these things are true, but cheap imports from China were too convenient, so dealing with the reality was sidelined. And allegedly we have been controlling big tech for years now, but the combined net profits of Microsoft, Google, Facebook, and Amazon now equal the GDP of Austria, a country of 9 million. How is that possible if they are supposedly being controlled? The hard fact is that as long as such profits are made, public health and democracy are not safe. Similarly, we now hold public information campaigns about healthy living, and we fund scientific research into healthy aging. Supporting science is commendable, but one look at the sugar books of Nestlé and Danone can tell us exactly how healthy aging is going: not very well. Penny wise, pound foolish?

So, what to expect? Past experience suggests that, appealing to things like the right of individual choice, the human race will allocate ever larger shares of the economy to products that make people sick (sugar, television, consumerism), and a correspondingly larger share to products that make people better again (diabetes drugs, new knees) or that make them able to live their lives unhealthily (elevators, personal robots). Until it no longer works. A small, highly select group will escape this scenario and live healthier, longer lives.

At my department, we study why some people are healthier than others, and live longer lives. A summary answer is delivered yearly in the form of the Christmas gift. Naturally, I throw most of it away.© Maarten Jan Wensink

What the individual can do about this

Including casting their vote with care and voicing concerns to policy makers, there are many things that individuals can do to improve this situation. For mental health, ignoring the existence of Instagram and Facebook is a good start. Another is to deny the existence of cookies, cake, and candy: whether or not you are going to take a piece of your colleague’s birthday cake should not be a choice you make each time. Rather, you should have your polite refusal ready. And unless you suffer from a chronic disease that gives you specific dietary prescriptions, which you should always follow, getting up from the dinner table (and later going to bed) slightly hungry will markedly improve your metabolism, the way you feel, and your athletic record. Yet, as the birthday cake example shows, it is hard to be healthy in an unhealthy world. Some type of collective action should exist.

Getting up from the dinner table (and later going to bed) slightly hungry will markedly improve your metabolism, the way you feel, and your athletic record.

Maarten Jan Wensink

A role for regions?

For the last few decades we have tried to address growing public health concerns through a neo-liberal model of self-regulation, circumspect law making after extensive consultation with the companies that were the prospective subjects of such regulation, and own responsibility. It has not worked. One reason is that once they grow very profitable, large companies can afford to pay the brightest minds to circumvent laws, to target advertising, to design new products and so on. Hence, they stay very profitable, earn money that can be further used for lobbying activities, and so on. The brightest minds in the world are engaged with the question of how to make you click on a (website’s) link. And a next one, and a next one, and a next one; not particularly humankind’s/our finest hour. Like the sugar companies, big tech earns much of their money making you sick. Another reason is that own choice does not exist. Shops makes the choice for you, by letting you wait in the queue while being surrounded by candy.

National governments could introduce laws that, say, ban commercials for soft drinks, sweets, chocolate, ice cream, and so forth, or introduce a sugar tax. National governments could forbid Instagram, tracking cookies (including tracking cookies in the disguise of legitimate interest), personalized advertising, and personalized websites. National governments could forbid the employment of fashion models who are unhealthily thin, as France famously did in 2015, following Italy, Spain, and Israel. But national governments sometimes miss the immediacy of local governments, and sometimes seem to feel that making laws that actually make life better is not something that a government can do, and certainly not without extensive consultation with lobbying clubs beforehand. Careful lawmaking, this is called. Local governments, meanwhile, may be more effective in addressing problems that require affinity with local culture and custom because they are closer to the living space of their population. They see problems clearer, and are ready to act.

To the region or the city, then, befalls the task of confronting the problems that national governments leave unaddressed. There are various points at which to start. For example, schools and institutes of higher education, often a regional responsibility, could make children more aware of the addictive nature of Facebook, TikTok, and Instagram. These same schools could set up proper canteens with healthy food, where possible funded through taxation – some things are too important to be left to parents. Water, clean, healthy water, should come through publicly owned tubes into every house. And local governments, often responsible for the physical infrastructure on which the daily social life takes place, could make these spaces smoke free, ad free, and inviting to practice physical exercise of various degrees of intensity.

Regions and cities are smaller agents than national governments, but they also have flexibilities that national governments do not possess. For example, the similarities between local entities of different countries may sometimes exceed that which exists between local entities within a single country, as is often the case across the complex language zones among the Alpine countries. Thus, cities and regions can form networks, as they already do, sharing experience on works, and on what their policy priorities are.

Local governments also have a clear competitive interest in picking up challenges not (yet) recognized by national governments. We have seen from the climate crisis that once the ball starts rolling, there are often advantages to gain from having a head start. Another competitive advantage could be the possession of a healthy population, although presumably in the market of video gaming that does not get you very far. The most important advantage to gain, however, would simply be a good life for its citizens, who make up a resilient, sustainable, and happy population.

About the Stiftung Südtiroler Sparkasse Global Fellowship

Each year, two Stiftung Südtiroler Sparkasse Global Fellowships are awarded. The Fellows are offered the opportunity to work closely with the interdisciplinary team at the Center for Advanced Studies on topics of both global and glocal relevance, linking personal experiences and research and chosen geopolitical areas with the Center’s expertise.

The Global Fellowships are funded by the Stiftung Südtiroler Sparkasse / Fondazione Cassa di Risparmio di Bolzano.

Maarten Jan Wensink

Maarten Jan Wensink holds a PhD in Medicine and a PhD in Philosophy from Leiden University in the Netherlands. He worked as a PhD student and eventually Post Doc researcher at the Max Planck Institute for Demographic Research in Rostock, Germany before taking up a position as Assistant Professor at the Max Planck Odense Center at the University of Southern Denmark. Since February 2021, Maarten is Associate Professor at the University of Southern Denmark at the Department of Epidemiology, Biostatistics and Biodemography. His current projects include the statistical and epidemiological analysis of paternal medication use in the months preceding conception and potential effects on offspring, as well as theoretical work on population dynamics and aging. He teaches courses on biostatistics and epidemiology. Maarten Jan Wensink is a Stiftung Südtiroler Sparkasse Global Fellow 2021 at the Center for Advanced Studies at Eurac Research.

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Citation

https://doi.org/10.57708/b112262798
Wensink, M. J. We may have already seen the healthiest generations. https://doi.org/10.57708/B112262798

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