STEWARDING: MENTAL & METABOLIC HEALTH

WHAT'S THE PROBLEM?: MULTIMORBIDITY.

Multimorbidity is the norm in New Zealand, but our policies and public discussions do not highlight the extent to which multiple conditions – multimorbidity – are diagnosed in the New Zealand population. Increasing numbers of children and young people are diagnosed with multiple conditions at younger and younger ages. This is environmental - which includes diet. Genetic risk factors are often amplified by environmental factors, and dietary insufficiency and the wrong kind of diet, play a big part driving more and more people having multiple health conditions at younger and younger ages and driving polypharmacy - the prescribing of multiple medications at younger and younger ages.

Most people with mental illness also suffer various forms of metabolic illnesses. [1][2]
Most people with mental illness are diagnosed with more than mental disorders,[1][2]
People with metabolic disorders commonly have more than one chronic illness.[1][2][3]
More New Zealanders now live with multimorbidity than with a single long-term condition.[4]
Multimorbidity is increasingly diagnosed in children and young people.[3][5][6][7]
Multimorbidity is often associated with socio-economic status.[3][4]
Health system costs accelerate with multimorbid patients, they are ‘super-additive’.[9]

What is metabolism? From the Greek metabolikos ‘changeable’; and metabole ‘a change, changing a transition’; German metabolisch (1839), French métabolisme. (ref.)

Metabolism is the process of turning food into energy or building blocks for growing and maintaining cells, as well as the appropriate and efficient management of waste products. Metabolism is how our cells work.[2]

What is a metabolic disorder? Metabolic disorders are frequently seen in people with metabolic syndrome[10], which comprises insulin resistance, obesity, elevated triglyceride levels and low levels of high-density lipoprotein cholesterol, and elevated blood pressure. But metabolic disorders are involved in complex pathways and feedback loops across body systems. Patterns and relationships between hormones, the brain, the gastrointestinal system, kidneys and lever; as well as problems with joints and bone health, autoimmunity, nerves and sensory conditions evolve from and revolve around metabolism, which of course arises and is driven by the quality of dietary nutrition. The aetiology of a given condition can be very different, evidence that common chronic and mental illnesses are accompanied by oxidative stress, inflammation and insulin resistance driven by diet - is growing stronger and stronger.

In the clinic doctors are faced with problems that immediately distress their patient. A wide range of practical, professional, cultural, social and economic factors result in doctors prescribing to address the immediate problem of the patient.

But. If the dilemma of multimorbidity is built into how doctors diagnose and treat patients, there may be room to shift policy, especially if the cost of long-term multimorbidity, patient suffering, and patient choice is factored into policy.

But doctors have different experiences, different case studies to work from.

WHAT IS MISINFORMATION? - WHEN MULTIMORBID CONDITIONS ARE THE 'NORM'?

Yet there is no first-line treatment to support doctors in using dietary and nutritional approaches to reverse and/or mitigate many chronic conditions, even though there is enormous evidence that diet and nutrition can and do make a big difference in improving health outcomes.

Currently there is little support for New Zealand doctors in changing practices and recommendations to support non-pharmaceutical drug treatment approaches which include dietary and nutritional. Some doctors are proactive while other doctors are conservative, as doctor training downplays the role of nutrition.

Some doctors are in a better 'place' to work to alleviate and reverse long term conditions. Some medical doctors may have 10-20 years of research into metabolism, dietary nutrition and patient care, and be motivated to guide a patient through a personal care regime which might alleviate or reverse a patient’s suffering. But many doctors may not consider they have the skill to do this. Their medical education does not equip them to believe in, or recognise the extent to which, multiple co-existing conditions may be alleviated or reversed by nutritional and dietary changes.

It is important, given such context, to have a public discussion about doctor-patient relationships, trust, and recognise the importance of the Hippocratic oath to first do no harm.

Questions can be asked - if patients were to understand that diet may be an underlying driver of multiple conditions, and a change in diet and improvement in micronutrient status might alleviate suffering - would patients be more likely to change? Economically, if wrap-around services, such as health coaching, were provided in clinics to support dietary change, would less harm occur to patients from worsening conditions that accompany many diseases (such as Type 2 diabetes) and the ever-present problem of drug side-effects?

Without wrap-around support (including health coaching) many doctors will be unwilling to adopt a nutritional approach that has potential to alleviate multiple conditions, to reduce symptoms, lower prescribing and therefore lessen side effects. But these doctors are also faced with the hopelessness felt by their patients in dealing with chronic conditions, and the vigilance required for dealing with adverse effects. Drug non-compliance is associated with adverse effects suffered by patients.

Doctors do not have nutritional training, and they do not want to risk going outside treatment guidelines. As PSGRNZ have identified, current nutrient recommendations are based on mitigating deficiency, not in driving optimum health status. Yet if doctors exceeded current nutritional guidelines, and they were reported to the Medical Council of New Zealand, no matter the evidence in the scientific literature, they risk losing their medical license, and being unable to practice.

Recent surges in protocols and guidelines for medical doctors reduce flexibility and narrow treatment choices for doctors. Treatment can involve pharmaceutical and biologic drugs, or non-drug modalities. However, funding and research to explore non-drug modalities to alleviate or reverse metabolic and mental illness is rare in New Zealand. Similarly, medical doctors are not trained in dietary nutrition or nutritional medicine, and regulatory and licensing bodies do not encourage such activity.

Therefore medical doctors (known as general practitioners, or GPs in New Zealand) in New Zealand are unlikely to voluntarily prescribe non-drug modalities to any meaningful extent.

Western nations and regions have pivoted in the past 5 years to focus intensively on the problem of misinformation. New Zealand’s disinformation project states that

Disinformation is false or modified information knowingly and deliberately shared to cause harm or achieve a broader aim.

Misinformation is information that is false or misleading, though not created or shared with the direct intention of causing harm.

When it comes to human and environmental health, there is enormous difference in the capacity for a human, or an ecosystem to tolerate insults from environmental exposures - which include inadequate diets which are nutritionally insufficient and often inflammatory.

The point where technology/pollution - and - biology meets - is fundamentally complex, nuanced and uncertain.

If we zero into humans – what evidence is required to steward health – to maintain health homeostasis? What science and information should guide parents? From preconception, to pregnancy, infancy, childhood and adolescence?

Diet has always been ground zero for health. There is an enormous body of evidence in the scientific literature that reveals how the acceleration in chronic illness and mental illness can now be firmly tied to modern diets. There is an enormous quantity of evidence revealing that ultraprocessed food, and refined carbohydrates sit at the base – that they represent the foundation of the metabolic and mental health epidemic that is in front of us.

However, governments are not funding public health research to translate that evidence into policy. Most science funding is diverted to research that will produce innovations. Government agencies and elected members – from local councils all the way up to government Ministers, are dependent on being informed by the Ministry of Health, when it comes to government policy.

Unfortunately there is no division inside the Ministry of Health that reviews the latest evidence in the scientific literature, to ensure that policy decisions correctly reflect the latest evidence. There is no scientific agency outside the Ministry of Health that has flexibility and the capacity to undertake long term monitoring and research in nutrition, diet and health that is outside the narrow parameters of science policy. Despite excellent research being undertaken, it is frequently short term. Problematically, there is no resourcing for those scientists to meaningfully feed-back that information to either the Ministry of Health or to Members of Parliament and government Ministers.

When the information contradicts the established policy of the Ministry of Health – achieving such feedback is even more difficult.

When it comes to complex health conditions, and alleviating and reversing metabolic or mental illness, based on different patient capacity – from socio-economic, to cultural, to social, and taking into account capacity for change, what is sound, evidence-based information and what is misinformation?

REFERENCES

[1] Ede G (2024) Change Your Diet, Change Your Mind, Hodder & Stoughton.

[2] Palmer C. (2022) Brain Energy. Benbella Books Inc.

[3] McLean G, Gunn J, Wyke S, Guthrie B, Watt GC, Blane DN, Mercer SW. The influence of socioeconomic deprivation on multimorbidity at different ages: a cross-sectional study. Br J Gen Pract. 2014 Jul;64(624):e440-7. doi: 10.3399/bjgp14X680545. PMID: 24982497; PMCID: PMC4073730.

[4] Blakely, T., Kvizhinadze, G., Atkinson, J., & Dieleman, J. (2019). Health system costs for individual and comorbid noncommunicable diseases: An analysis of publicly funded health events from New Zealand. PLOS Medicine, e1002716

[5] Schiøtz ML, Stockmarr A, Høst D, Glümer C, Frølich A. Social disparities in the prevalence of multimorbidity. A register-based population study. BMC Public Health 2017;17:422. doi:10.1186/s12889-017-4314-8 pmid:28486983

[6] Dunbar P, Hall M, Gay JC, et al. Hospital readmission of adolescents and young adults with complex chronic disease. JAMA Netw Open 2019;2:e197613. doi:10.1001/jamanetworkopen.2019.7613 pmid:31339547

[7] Perro M & Adams V (2017. What’s Making our Children Sick? Chelsea Green Publishing.

[8] Ferro MA, Qureshi S, Van Lieshout RJ, et al. Prevalence and Correlates of Physical-mental Multimorbidity in Outpatient Children From a Pediatric Hospital in Canada. The Canadian Journal of Psychiatry. 2022;67(8):626-637. doi:10.1177/07067437221074430

[9] Millar, E., Dowell, A., Lawrenson, R., Mangin, D., & Sarfati, D. (2018). Clinical guidelines: what happens when people have multiple conditions. NZMJ, 73-81.

[10] Huang PL (2009)A comprehensive definition for metabolic syndrome. Disease Models & Mechanisms 2, 231-237 (2009) doi:10.1242/dmm.001180

MISINFORMED ABOUT MULTIMORBIDITY

WHAT'S THE PROBLEM?: MULTIMORBIDITY.

WHAT IS MISINFORMATION? - WHEN MULTIMORBID CONDITIONS ARE THE 'NORM'?

REFERENCES

Information

Providing scientific & medical information & analysis in the service of the public's right to be independently informed on issues relating to human & environmental health.