“Non-communicable disease”. Let’s retire this phrase. Isn’t it counterproductive to Public Health?

Sitting here on the tail end of another awesome ASLM conference https://www.lifestylemedicine.org.au/conference/program/, I find myself again reacting to public health concept “Communicable disease” (spread by infectious agents) vs “Non-communicable” disease as I find it binary, polarised, disempowering and counterproductive to our efforts to live healthier.

I react because of the possible implications of the latter term. If something is “non-communicable” then we aren’t spreading, encouraging, allowing, promoting this condition are we? The factors causing the epidemic of type 2 diabetes are mainly non communicable, no?

“No” I argue. But do you agree? The way I see it, whenever we promote sweets as a reward for eating healthy food to children, or a Friday beer session as a reward for a hard week’s work, or a G and T as the deserved treat at the end of a stressful day, we are spreading the “you deserve this” meme. We are communicating and transmitting a message. We are trafficking in communicable harmful beliefs, and we are promoting all sorts of “non communicable” conditions.

Furthermore, so many of the conditions have a transmissible component through vertical and horizontal gut microbiome transmission (families share the gut microbiome, mothers pass down their microbiome (gut/skin) during childbirth. We are now well aware of the gut-brain, gut-nerve, gut-joint axes (amongst others) and the importance of a healthy mouth microbiome in preventing cardiovascular disease. We transmit our microbiomes, and we exchange bits of them with our pets.

Add to this the component of epigenetic signalling (which is partially genetically passed down, and partially modulated by the gut-biome) and suddenly we question whether we are really passive in perpetuating society’s chronic diseases.

And don’t get me started on how we transmit ideas that we are individuals with rights, rather than an interconnected colony of humans. The latter idea, intrinsic to the gentler cultures, is a weird concept to us Western Lifestylers.

Suffice it to say, I think we should broaden the term “communicable conditions” and thereby share a bit more responsibility for our part in promoting and transmitting the upstream determinants of lifestyle disease, starting with our language. (Owning up to my hypocrisy here.. I feel very certain about this, and that’s a problem… ). To me this is about more helpful ways of thinking about taking collective responsibility for our health and health inequality.


If we are serious about suicide prevention… what about this conversation?

I find myself constantly despairing about the missed opportunities to change our ways of thinking in order to prevent mental illness and suicide.

I’m worried we are taking a less than optimally effective approach to suicide prevention.

I was reading about Australia’s  “you can talk about suicide” launch.

I found no reference to shame in the document and that concerns me, as shame, I think, isn’t far from self-loathing if it’s not talked about, shared and normalised.

What about “How to have conversations which disclose and normalise the experience of shame, and self shaming internal dialogue?”

I don’t believe we can have an effective conversation about suicide until we are skilled up in having this conversation. 

I think it’s not that hard, but the principles of the conversation are counter-cultural.. let’s start on that project ASAP rather than conversations which assume that depression or anxiety have an internal locus (diagnostic model) with a biochemical basis, on top of causal genetics and experiences and therefore respond to fortification or medication.

The diagnostic model is struggling to achieve great results in primary prevention. It’s had an OK effect on secondary prevention but I strongly believe that looking at the social construction of mental illness might be more fruitful. 

Let’s start the conversation with the question “We all suffer from shame in some form or another. What would I need to do differently so that you and I/we all can talk about our shame and work together against its effects?”

What do you think?

“Mental Illness” and medical students with Anxiety/Depression

So today I heard on the radio that 3 point something percent of medical students are suffering from a severe form or mental illness, which was described as anxiety or depression. A brave young doctor spoke out about her own experience. You can find the information here .

What I want to say about this is simple, and I believe vital.

That we regard “anxiety/depression” as “mental illness” is part of the problem.

Continue reading “Mental Illness” and medical students with Anxiety/Depression

A model of apology- 6 steps.

I wrote this piece about apology many years ago for several friends/acquaintances whose relationships had ended precipitously. While they were male, I don’t necessarily think this is a gendered issue. I’ve toned it down a bit as my original was really preachy!

Dear mystified male,

If you feel misunderstood by and rejected by your ex-wife, your children, or your former friends who have either drifted away, or suddenly and dramatically rejected you, this might be for you. Maybe, none of it was your fault! What if the FAULT THING is a distraction; a huge distraction to prevent you from doing something positive about your plight? Continue reading A model of apology- 6 steps.

Transition through the middle place

Prompted by witnessing a person in the education world flip between “our students are adult learners- it’s their fault if they can’t organise their education schedule” to “don’t burden the poor little things with too many resources- we have to stage their education in developmental steps” I found myself thinking about what construction might lie between these two extremes. What is the middle place? And how quickly do we transition through it without noticing? Continue reading Transition through the middle place

Empowerment. Two disparate views. (published despite my dislike of dichotomies)

View 1. Some people have more power than others. Some have privilege and are blind to the fact that fate has dealt them a good hand, and others not so good. Empowerment is more the responsibility of the blessed who are in a good position to advocate for those who have less ability to do so. Let’s call this responsibility.

View 2. It’s all to do with choices and perception of choice. Disempowered people have more power than they realise. We can assist them to embrace their power, but we shouldn’t give handouts, as this will impede their empowerment. Let’s call this “blame the victim”.

I just saw red when I clicked on this link in from a mailing list I get sent to me. Empowerment. It’s from a chartered psychologist in the UK called Peter Honey.  It outraged me and took me a while to calm down. It’s worth a read to see how cruel some ideas can be. I’m not criticising his intentions here, just wondering whether he has critically examined his assumptions, which I would say aren’t particularly uncommon. The harm I believe can be more when such views are delivered by a “guru” as I saw him described on the web. It’s no wonder the disempowered often end up anxious or depressed after they encounter these oppressive views.

While this view has a tiny bit of merit in some circumstances (I think there are some people whose survival skills fuel their disempowerment and it becomes hard to break the cycle), I believe it does so much harm. You see the effects of pushing this as a truth in the news on a regular basis. Only today in Ballarat were victims of past child abuse pointing out to the Church that supporting George Pell in preference to advocating for them was making them feel blamed for the consequences of the abuse. Why not take this assertion at face value?

I believe we need to really question some constructions of “empowerment” and its compatriots, for example “resilience”. There are some people who have been so oppressed that they become “doppressed” and their lack of resilience is because of the ongoing and persistent labelling (“not taking responsibility” for example.) Let’s not blame them for their suffering.


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And here’s a nice view from today as I walked the dog. Aware of my privilege to be able to do so.

Rethinking medicine- the microbiome, diet and disease

Ok. This is my third post and it’s really the first one that has anything to do with the URL “unorthodocs” which I derived from being a doctor and finding my ideas really on the “fringe”. This has been the case for most, if not all, of my career. As a GP I found myself admiring people with so called “borderline personality disorder” when my peers were in a different frame of mind. I became interested in narrative therapy as a very respectful way of dealing with suffering rather than the diagnostic model which believed in chemical deficiencies, ideas of “normal” and “abnormal” and pharmaceutical supplementation. (I’m not dead against this, obviously, but against the overuse of this model, especially when it doesn’t help). In the 1990s I became interested in what we thought then was “food sensitivity” despite much scoffing by some of my peers.

Anyhow, times have changed. The stuff that was scorned is suddenly OK again. Colonic enemas, once quackery, are being reappraised as we contemplate faecal transplants for some conditions now that we have a new of understanding  of disease.

The new model is complex. It can’t really be simplified. But here goes (forgive any oversimplification- but it’s not possible to do this simplistically- we really stuffed up previously with oversimplifying eg: “Saturated fat is bad for you”, “cholesterol causes hardening of the arteries” etc.)

We all come with a genetic makeup. Some genes protect us from disease. Some predispose us- there’s a lot of luck here, but diversity is important for survival, so we are not made as clones. This is not new thinking- I’ll get to the new stuff soon.

We also come with a microbiome: that’s bugs in us and on us. (In fact they are mainly “on us” as the gut is technically part of the exterior world, and that’s where the most bacteriae reside).

Our microbiome is unique to each of us. It depends on our early exposure (Caesarean section anyone? Would you like a five-fold increased risk of food allergy with that?). If you are born by vaginal delivery you get a microbiome very much based on your mother’s gut microbiome rather than her skin microbiome. That’s probably good.

Our microbiome is then modified by our lifestyle- predominantly our diet, but also by exercise, antibiotic exposure and other medications that we previously didn’t realise also kill some bugs and favour others.

Our microbiome directly or indirectly alters our metabolism, our desires, food preferences and cravings. (Google “neuropods” if you are interested!). We westerners eat an excess of food. It can also create inflammation in the body, directly starting off processes that underly much of our troublesome diseases.

A healthy diet for you may not be so for me. We have different genes, and they might even be because we are descended from different cultures or geographical areas. We’ve adapted differently. Then add in what might be our uniquely healthy microbiome. Our optimal internal bacterial community will differ depending on whether we are descended from populations whose staple is maize, wheat, rice, millet or others. And it will move and change dynamically with our diet.

The microbiome and disease.

There is lots being written about the microbiome. A lot of it is not new, but a lot is. Rather than write a huge essay, here is a start-

There are some bacteria that are appearing as culprits in the generation of dementia, depression, diabetes, infertility, inflammatory bowel disease. These diseases may be more related than we think. They all involve inflammation. Firmicutes species (some types only) Proteobacteriae and Clostridium difficile seem to appear in the police lineup with suspicious regularity. Currently we have a few suspects, and a lot of crimes. Matching them up will require supercomputing, not conventional research trials.

Anyway, it’s not just the microbiome that’s new on the block in our understanding of disease. There’s a few people around challenging the orthodoxy in our understandings. And their ideas are looking plausible. Some are greatly more plausible than what we doctors thought was fact:

Diabetes and insulin

What if we are wrong about diabetes? What if insulin is as much the problem as it is the solution? What if diabetes is an adaptation to overnutrition? (ie- get so sick you have to stop overeating, and spill glucose into the urine to avoid it being driven into overloaded and inflamed fat cells) If overloaded reserves are the cause of organ damage, treating with insulin may be harmful. Maybe we should be advising increased fat intake and reduced carbohydrate intake (a reliable way of reducing total calories) thereby reducing the need for insulin (see the Ted talk by Peter Attia, or the work of David Lustig, Jimmy Moore’s podcasts, or David Gillespie’s books here, and read them all discerningly- no commentator is perfect.)


Still on diet here… what if cravings are mediated by the bacteria, and it’s not just as simple as willpower? What if we are blaming people for a neuropsychoimmunological response that is beyond their control, just like we blamed people for TB before we understood it was caused by a bacteria? (I read an article making this connection, but I can’t find it to make the attribution here)

At medical school we were told about dopamine and cravings. We were told what parts of the brain were involved. We were told about addiction, but we didn’t know about the microbiome and how it might be calling the shots here. We were told that the vagus nerve (brain to gut) was a superhighway with 2/3 of its traffic going from gut to brain, but not why.. no-one really knew.

But back to medicine. We have a number of epidemics currently. Two of the most serious are metabolic syndrome (“diabesity”, “fatflammation”, “carbohydrate-storage-disease” call it what you will) and the second is abuse including domestic violence and sexual abuse. Both have solutions but require paradigm shift. I’ll talk about abuse in another blog.

Suggestion – Change our food guidelines.

I think we should abandon our reductionist dietary guidelines that confuse us by dissecting food down in some semblance of  a scientific experiment. We could stop doing trials that distract us from the obvious, and stop trying to control variables that can’t be factored out and ultimately leave studies wide open to criticism. Instead we could adopt sensible National Food Guidelines like Brazil’s. Or just to keep is simple, we could avoid any “food” that doesn’t rot or wasn’t in existence before the industrial revolution- they are most likely not a real food.. more likely a  “food like substance”. We should, as Katz found when he compared all diets, eat food, as close to nature as possible with a predominance of fruit, nuts, vegetables and fibre. We should eat just enough to satisfy hunger.

Meat is problematic. Apart from the ethical issues, it’s pretty hard to find meat that isn’t based on grain-fed animals or fish. Grain isn’t great for animals or many humans, but grass fed meat is expensive, less available, and we can’t make enough to feed the world.

I think we should ignore consensus derived guidelines and stick to evidence based recommendations, or if there are none, regress to traditional pre-1900 diets appropriate to our genetics.

Warning- if you are diabetic, always discuss dietary change with your medical team. The following isn’t medical advice.. your doctor is the place for that. I do advise looking at the following ideas and discussing with your trusted doctor.

Hopefully people can find an up-to-date doctor. When this post was written, many doctors hadn’t heard of the microbiome, but now many are familiar. If you have cravings and are not diabetic, have a look into the evidence about withdrawal from sugars and processed carbs (including bread) . It seems likely that healthy fats, nuts and fermented products can assist by reducing the number and power of the bad carb-dependent bacteriae that feed the cravings. Carb withdrawal is becoming pretty popular. Even for type 2 diabetics, who of course will need all dietary changes supervised as insulin is likely start becoming more effective if you start reversing the diabetes. This can lead to hypoglycaemic attacks (hypos) which can be extremely dangerous if medication isn’t adjusted accordingly.

There’s a lot of exciting research being performed and new strategies are emerging to prevent or treat diseases when previously we could only despair our therapeutic impotence. The drug companies are also excited. See this article in Nature. I prefer to be excited about lifestyle and dietary change without popping pills, but each to his/her own. The microbiome will be/ (is, 2019) big, and people aren’t even talking yet about the virome (your average spinach leaf is teeming with viruses which can kill bacteria called phages, and it seems they attack the bacteria that cause us harm). It will take decades to nail the virome and make it into pills, so in the meantime, let’s just stick to green leafy vegetables like grandpa and grandma said.


Let’s not be resilient together.

So welcome to my new blog. It’s going to be a bit random because previous attempts caused me to obsess too much trying to get it right. So this is the first post, and for some strange reason I wanted to start with a little rave about resilience.

Just sayin’ – I’m not a big fan of resilience. I think it’s too often used as an excuse for treating people badly, and it’s over-revered. Everyone has a breaking point, and maybe the world would be a better place if we concentrated more on reducing the stresses on people than telling them they need to be more resilient. By pointing the finger we forget that those of us with power or privilege can be a little softer.

You see the extremes of the strength-worshippers in some of our leaders who pride themselves on their ability to resist bending in response to pressure, even to their own and our detriment (2014 budget anyone?)

So let’s be gentle and fragile together. I work in health care, but at the moment it’s more like health scare- it can often be a daunting place. Maybe if we didn’t believe so much in resilience we would acknowledge our own fragility and we might provide a whole lot more emotional support for patients, and for all those working in health care including our nurses and doctors.

Hmm.. I just re-read this post and realised there’s a risk this blog could be a bit preachy. Better not let that get out of hand!

That’s enough for now, so ‘bye.