In 2017, the United States crossed a grim threshold: Average life expectancy decreased for the third year in a row.^[1] At first glance, the drop in life expectancy looks like a blip. Other developed nations also experienced a decline around 2015, caused partly by severe influenza strains and less effective vaccines.^[2]

However, most other developed countries bounced back with longer life expectancies in 2016. The United States did not. In addition, the 2015 life expectancy decline played out differently in our country. Among Americans, it was concentrated in people younger than 65 years, whereas in other developed countries, it occurred among the elderly. When death occurs in those who are younger, there is a bigger impact on life expectancy measurements overall.^[2]

Even more alarming, the life expectancy decline in the United States fit into a long-term pattern. Back in 1960, Americans had the highest average life expectancy in the world, and it was 2.4 years longer than the average in countries in the Organisation for Economic Co-operation and Development (OECD).^[3] However, in the 1980s, the rest of the developed world caught up. By 1998, the average life expectancy in the United States fell below the OECD average, and in 2012, it reached a plateau. Americans now live an average of 1.5 years less than the OECD average.^[3]

What accounts for the difference? Perhaps the most familiar health statistic separating the United States from the rest of the world is its high rate of obesity. As early as 2005, researchers predicted that if the prevalence of obesity continued to increase, it would begin to affect life expectancy in the first half of this century.^[4]

Obesity-related mortality did indeed increase in 2015 in the United States, but so did most nonobesity-related causes of death. For men in particular, much more of the increase was attributable to "external" causes, defined as accidents, violence, and other environmental factors.^[4]

Deaths of Despair

Researchers have now identified a pattern termed "deaths of despair" that includes drug overdose, alcohol-related deaths, and suicide. The death rates for all of these causes have increased over the past 15 years, with white men aged 45-54 years especially affected.^[4]

Within this deadly constellation, opioid abuse has received the most attention. The easy availability of fentanyl plays an important role, as does the casual attitude many doctors take toward prescribing opioids.

To diminish deaths of despair, we first need policies to combat these causes and offer help to those left out of the American dream.

The equally disturbing spiral in suicide has also prompted headlines, particularly when celebrities such as Anthony Bourdain take their lives. My life has been affected by multiple suicides, and last year I offered my thoughts about what sports physicians can do to stem the tide.

The increase in alcohol abuse hasn't received as much attention, but it is well documented. After Prohibition ended in 1933, the age-adjusted death rate from liver cirrhosis in the United States increased steadily to a peak of 18.1 deaths per 100,000 people in 1973. It then steadily declined for three decades until 2006. However, in that year it began to climb again, reaching 13.2 deaths per 100,000 people in 2015.^[5]

These deaths of despair disproportionately affect white, middle-aged Americans, particularly in rural counties and in regions where manufacturing jobs have disappeared. As a recent editorial in The BMJ pointed out, these economic trends entail a loss of social cohesion, as well as greater social isolation and hardship. They have paralleled trends toward weakening educational performance and a growing gap between the rich and poor.^[3]

Sports physicians can't reverse this trend by themselves. To diminish deaths of despair, we first need policies to combat the causes and offer help to those left out of the American dream. This can include better support for education, broader distribution of economic opportunity, and increased availability of healthcare and mental health resources, particularly in distressed populations. As opinion leaders in our communities, sports physicians must speak out in support of such policies.

Decoding the Genetics of Survival

When I look around me, I see a nation of humans straying off their evolutionary path. Instead of becoming better adapted to our environment, we are doing the opposite. Understanding how this happened is a necessary first step in addressing our patients' health.

For most of the time that life has existed on earth, which is estimated to be at least 3.5 billion years, our ancestors were prey. It wasn't until about 2.6 million years ago that early humans began to develop stone tools and sufficiently large brains to become predators.^[6] They evolved into Homo sapiens between 200,000 and 300,000 years ago, and in just the past 300 years, they adopted an industrial lifestyle with relative abundance of high-energy food and sedentary occupations.^[7]

[W]e must activate the genes of our athletic ancestors.

Most diseases result from an interaction of genes and the environment. We now live in an environment very different than the one from which we evolved, and research in the field of epigenetics shows that our genes are expressing themselves differently as a result.

We have known for a long time that if you exercise more, you are less likely to succumb to the modern predators of heart disease and cancer. What's new is that we are beginning to understand these processes at a molecular level. For example, growing evidence suggests that methylation of DNA resulting from exercise may trigger tumor suppression.^[8,9]

As I discussed in my book The Win Within: Capturing Your Victorious Spirit,^[10] we must activate the genes of our athletic ancestors. Just as our ancestors ran and jumped to win the bounty of an impala for dinner, we now must run and jump to win the bounty of feeling healthier and living longer. We must empower ourselves to understand these systems and how we can manage them.

This is true from the perspective of patients, who must take responsibility for their lifestyle choices, and from the perspective of healthcare providers, who must understand the contribution of patients' genes to their survival. For example, there is a gene called OPRM1 that is associated with postsurgical pain and encodes the opioid and endorphin receptor.^[11] Variations in this gene affect a patient's response to opioid drugs and susceptibility to chronic pain and fibromyalgia, and offer an opportunity for intervention.^[12]

Similarly, the same genetic mutation that causes sickle cell anemia also confers protection against malaria. Understanding this mechanism may lead to new therapies for both conditions.^[13]

The burgeoning field of epigenetics is steadily contributing to these understandings. There are mechanisms for surviving and adapting. We have to figure out what these mechanisms are, and we have stumbled upon a few. It's like coming across an icon on your computer that gives you more memory when you use it.

The disconnect between our current environment and the one from which our minds evolved helps explain the constellation of mortality related to despair— depression, suicide, and substance abuse—that seems to be driving the recent decline in American life expectancy.

Empowering Patients to Reverse This Trend

How can sports physicians address this moral crisis? It comes back to the principle of empowering people to discover that the secrets are within them.

It's not as simple as being kind and motivating to all our patients. For some, it's their genetic lot that they are chemically depressed from a neurotransmitter deficiency, and they need to be treated pharmaceutically. Yet there are countless others who have problems with positivism and hopelessness because they are surrounded by negative images and frustrations. We can help them through inspiration, education, communication, and mindfulness, and by encouraging them to embark on spiritual journeys.

To achieve this type of leadership, we must start with our own self-assessment and self-awareness, continue by building empathy and social skills, and finally arrive at a diagnosis leading to treatment. Even when our patients are in the most dire circumstances, positivism and motivation can help them.

Claudius Galen (130-210 CE) was a botanist, surgeon, and perhaps the world's first team doctor because his athletes were the gladiators in the Roman Colosseum. He also wrote the first book on the philosophy of medicine. He felt that humans were not meant to have too much pleasure, which he referred to as licentiousness, because we were meant to be workers and adapters and not just sit in the Roman baths putting food in our mouths. Rome had reached the height of its power right before his birth, and it was already beginning its long, slow decline.^[14]

Those writings echo in our own time, with automation and outsourcing making meaningful work scarcer and the gap between rich and poor becoming wider.

For me, the Kennedys expressed the true concept of empowerment. "Some men see things as they are, and ask why," said Robert F. Kennedy. "I dream of things that never were, and ask why not."

"Ask not what your country can do for you," said John F. Kennedy. "Ask what you can do for your country."

Along with Martin Luther King Jr, who dreamed his famous dream, these men gave the people a reason to believe. They stepped forward at a time when the world was sinking into the Cold War, and when the civil rights movement was getting underway. Today, we are lacking leaders who can unite us in this powerful way, whether it be President Donald Trump or Speaker of the US House of Representatives Nancy Pelosi. None of today's leaders are truly inspirational, and I think this is another important reason for the deaths of despair that are driving down our life expectancy.

It's not just a matter of getting up and doing something for your country; it's a question of how you see yourself contributing to the larger human population. Humans are only successful when working as a team. Biologists have great terms for this phenomenon: mutualism, commensalism, and symbiosis. When you take humans and put them together as a TEAM, Together Everyone Achieves More. The problem is when people are excluded. That's what brings on depression, and that's when we succumb to human diseases such as depression and alcoholism.

I believe that sports physicians can play a key role in getting the health of our country back on track. No one understands the relationship of motivation and health better than those in our profession. In these times, we face a crisis in both. Although none of us can fill the gap left by our political leaders, we can make a difference every day by raising the spirits of our patients, our teams, and our communities. Let's step forward to help everyone regain the sense of purpose that will lead to better exercise, nutrition, and self-care.

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References

1. Dyer O. US life expectancy falls for third year in a row. BMJ. 2018;363:k5118. Source
2. Ho JY, Hendi AS. Recent trends in life expectancy across high income countries: retrospective observational study. BMJ. 2018;362:k3622. Source
3. Woolf SH, Aron L. Failing health of the United States. BMJ. 2018;360:k496. Source
4. Acciai F, Firebaugh G. Why did life expectancy decline in the United States in 2015? A gender-specific analysis. Soc Sci Med. 2017;190:174-180. Source
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6. Smithsonian National Museum of Natural History. Human Origins Initiative. Source
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9. Gillman AS, Gardiner CK, Koljack CE, Bryan AD. Body mass index, diet, and exercise: testing possible linkages to breast cancer risk via DNA methylation. Breast Cancer Res Treat. 2018;168:241-248. Source
10. Mandelbaum B. The Win Within: Capturing Your Victorious Spirit. Austin, TX: Greenleaf Book Group Press; 2014.
11. Hwang IC, Park JY, Myung SK, Ahn HY, Fukuda K, Liao Q. OPRM1 A118G gene variant and postoperative opioid requirement: a systematic review and meta-analysis. Anesthesiology. 2014;121:825-834. Source
12. Goldenberg DL. Genetic factors in fibromyalgia and chronic widespread pain. Practical Pain Management. Updated October 13, 2016. Source
13. Ferreira A, Marguti I, Bechmann I, et al. Sickle hemoglobin confers tolerance to Plasmodium infection. Cell. 2011;145:398-409. Source
14. Hankinson RJ. Partitioning the soul: Galen on the anatomy of the psychic functions and mental illness. In: Corcilius K, Perler D, eds. Partitioning the Soul: Debates From Plato to Leibniz. Boston, MA: Walter de Gruyter GmbH; 2014:85-106.

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