Compression of Morbidity: Vitality to the End
“Live long and prosper.” -Spock
“Live long and drop dead.” -Grok
Got your attention? (Thought so.) Sisson’s gone morbid, you say. Not exactly. Death is on the docket for today but more so the time leading up to death – (for some) a period of morbidity during which we experience major illness and impairment. We live, of course, with the prospect of our own mortality and how it will befall us, but we’re also emotional witnesses to that of our loved ones. I’ve lost many family and friends at this point in my life. Although I believe most had a good life, not many had what any of us would consider a “good death.”
I’d venture to say that most of us have known someone, perhaps even someone very close, who lived their last years with serious disease and debilitation. Perhaps they were in and out of the hospital, caught in continual throes of pain, rendered increasingly immobile and confined by physical weakness, stressed by the financial burden of their ongoing care, juggling medications and treatments whose side effects were almost as unbearable as the conditions they were meant to treat. Those final years may have offered the invaluable chance to be emotionally and cognitively present, to appreciate and reciprocate the love of family and friends, to bring individual and interpersonal business to a peaceful, meaningful closure. Maybe not. Either way, we can’t help but wish our loved ones could have lived out those years with less suffering, less hardship.
On the other hand, we’ve known people who, up until the day they died, lived active, independent lives wholly on their own terms. Old age obliged perhaps a slower rhythm but little constraint. There was a spirited, graceful older lady I knew growing up. Up until her last day, she lived (not far from us) in the house she’d raised her children in – staircases and all. She entertained her dozens of grandchildren and great-grandchildren there. She mowed her own yard. She biked around town every day. She kept one of the most beautiful gardens I’d ever seen and tended dozens of ferns (some thirty years old or more) in her sunny Victorian home. One spring morning while she was dusting a curio, she died of a massive, sudden heart attack. There’d never been evidence of heart disease or any other medical condition. She’d been fit as a fiddle, as they say, until the day when she literally dropped dead in front of that cabinet, duster still in hand. She was 89.
To be sure, it’s a shock when people die that way, but after the reality sinks in, there’s also a sense of gratitude, relief, even fortune that they had the life they wanted – up to the very last moment. Whatever the extent of our own grief, we take comfort in their quick passing. Given the choice, I sincerely hope to follow my old neighbor’s example.
We’d all like to live to a ripe old age. What a trip it must be to turn 100. However, I’d gladly give up those extra years, even decades, if it meant they were to be spent bedridden and miserable. Truth be told, I live the way I live not because I’m shooting for longevity. If I’m lucky enough to enjoy a long life, so be it. Rather, I live my life according to certain principles in order to push illness and markers of aging further and further down the road. Coined by James F. Fries, M.D., there’s a phrase for this: compression of morbidity. It’s the shortening of the period between the “first appearance of aging manifestations and chronic disease symptoms” and the end of life (PDF). In my book, that’s what it’s all about.
While statistics show that we’re generally living longer – some 78 years and 2 months according to the latest figures, the flip side is that other research shows we’re living fewer years disease free and more years with chronic and often debilitating disease. We congratulate ourselves in the developed world on our mortality-related statistics (e.g. life expectancy), but our morbidity picture is increasingly abysmal. As Eileen Crimmins, AARP Chair in Gerontology at the University of Southern California and co-author of the study examining morbidity and life span, observes, “There is substantial evidence that we have done little to date to eliminate or delay disease while we have prevented death from diseases. …At the same time, there have been substantial increases in the incidences of certain chronic diseases, specifically, diabetes.” In a short ten year span, we’ve lost on average a full year of healthy life (slightly more for women) – life without one or more of the major diseases that constitute the most common causes of death in the U.S.: cancer, diabetes, and cardiovascular disease. (I wonder what the picture would look like if you added other common chronic and debilitating conditions like Parkinson’s and Alzheimer’s.)
As this study showed, we also spend less of our life fully mobile. Just ten years ago, the average 20-year-old man would experience 3.8 years of his life with impaired functional mobility – “the ability to walk up ten steps, walk a quarter of a mile, stand or sit for 2 hours, and stand, bend or kneel without using special equipment.” Today that number is 5.8 years. Women fare even worse. Ten years ago, that number was 7.3 years and has since risen to 9.8 years. That’s almost ten years of one’s life without basic mobility. Yes, there’s much more to life than the ability to walk up stairs, but I can’t call this an ideal. We’re not talking about a freak accident here that couldn’t have been helped. This trend represents broad and gradual systemic decline – the kind of impairment that is almost always preventable by effective and consistent lifestyle intervention.
Call me callous (or not), but I think we’re shockingly blasé about the constraints people are routinely living with at the end of their lives. We’re physical beings, of course. I understand that bodies don’t last forever. Nonetheless, the fact that we’re losing so much ground in only a decade’s time should constitute a five-alarm fire.
For those who suffer in their final days or years, I’m grateful for the interventions of modern palliative medicine. Yet, it’s an uneasy contract. Do we accept the limitations, pain, and suffering of chronic disease more as a society when we have a “fix” to treat it? No one I know who’s dealt with a long decline has many good things to say about the treatments that spared them the worst of their suffering. They’re grateful, but they still traverse a long, hard road. These measures are better than the immediate alternative to be sure, but the commonality of their circumstances still begs a bigger question, I think.
For my part, I’m not going gently down that path of decrepitude. There’s no sense of surrender here. I’m not master of the universe, but I do have quite a bit to say about my own fate. I live every day of my Primal life as an affirmation of wholehearted, all-out living. Thriving, as it were. I’ll make my peace with my life and loved ones each day rather than wait until some compromised 13th hour. I’ll embrace every particle of discipline and self-respect to live a life that I know will support my well-being and independence today and in my later years. Let me live with the primal spirit of my ancestor kin and meet death (when it comes) with a vigor and vitality that confound the statistics and conventional resignation of our time. That, in my mind, would be the best resolution for a Primal life – and a good death.
Thoughts? Responses? Let me know what you think, and thanks for reading today, everyone.
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Posted By: Mark Sisson
Word.
I play racquetball with a 90 year-old man who’s been married 70 years! He has a wonderful upbeat attitude that makes him a pleasure to be around. He can’t move like he used to but he’s up for the game!
I’m sorry, but isn’t anyone seeing how arrogant and insensitive this post is? As an occupational therapist, I work people with disabilities from birth to death. (Two positions- one with children birth-three and one at a skilled nursing facility.) I have been following the diet, am interested in living a balanced healthy life. However, to insist that it’s better to be dead than disabled is ableist, ageist, and naive. Persons with disabilities can and do live meaningful, productive lives. Get over yourself Mark.
I agree of course that people with disabilities can have great lives. Plenty of people enjoy themselves regardless of age and physical limitations. I have several physically disabled relatives myself.
But I would still say that decisions about one’s personal standards for what constitutes a sufficiently high quality of life are just that, personal.
It’s an individual thing. I don’t think I’ve seen anyone here speaking for anyone but themselves on that front, although I have seen (quite reasonable) sympathy for relatives and friends in bad shape.
People will also revise their attitudes based on their experiences once they get to the point of disability. For example, initially Christopher Reeve thought perhaps it would be better if they “let him go”, but changed his mind.
I do think it’s important that we all focus on making the most of our situation rather than giving up too easily when we do start showing signs of age, though.
I agree with the gist of Mark’s post — but that’s just for myself. I’ve always been averse to traditional medicine and do well with alternatives, but not everyone goes for that.
Both my parents are in their 80s and experiencing disabilities, they’re being treated in a rehab center. I would never want to go through what they’re going through. Yet — I think this is what they want. My mother strongly desired hip replacement surgery and was willing to go through the physical therapy afterward to have a better quality of life. No one talked her into it, something deep in her wanted the chance for improvement. My father has also had numerous health issues but only recently began a cognitive decline: up until a few months ago he was sharp, interested in the world, enjoying his grandchildren. Yes he suffered a lot, but he had a will to live and go on.
I don’t know what the answer is, all I can think recently is that if someone has a will to live it’s important to respect that and help them as much as possible (I think this is distinct from the issue of prolonging people’s suffering through life support when they’re barely hanging on).
There are mysteries here, who knows why someone still wants to be alive even if they’re not “optimal.” It’s not what I envision for myself, but clearly the will to live and enjoy life is deep-rooted and stronger than judgments of whether it’s worth it. I especially think that people need to be treated with dignity no matter how poorly they seem to be doing, we need to respect the life force within them that keeps them going.
What a great post!! I live my life like a do (primally) despite the eye rollings of my husband and others, because I believe it will help me live a BETTER life. Not necessarily longer. But healthier. And surely active until the very end. Or, at least that is my goal.
We have been living with my in-laws while we close on our house (having moved across several states), and my in-laws are the ‘typical’ older folks (and seriously, they’re not that old – 65 and 63) who take a ton of meds and hobble around and sit and complain about diabetes and bad genes and what we (the kids) have to look forward to when we get old. It is appalling and so SO depressing!! I NEVER want to live like that. And their lifestyle – full of carbs, starch, sugar, no activity, and 8 hours of nightly TV watching after dinner (just to name a few things) are what I think has led to this demise.
At least I have to hope that there IS hope. And the Primal Blueprint has given me hope so now living primally is the only way I can feel like I’m living the best life I can. And I’m so much happier and healthier for it!!
Wow. Awesome post. I’ve been hoping someone would cover this in greater detail.
I remember reading awhile back (not sure where) that hunter-gatherers that are lucky enough to escape child mortality, accidents, and infectious diseases to make it to old age generally have a very compressed morbidity at the end of their lives, generally just a few days on average.
This reminded me of a quote from On the Road by Jack Kerouac
“I shambled after as I’ve been doing all my life after people who interest me, because the only people for me are the mad ones, the ones who are mad to live, mad to talk, mad to be saved, desirous of everything at the same time, the ones that never yawn or say a commonplace thing, but burn, burn, burn like fabulous yellow roman candles exploding like spiders across the stars and in the middle you see the blue centerlight pop and everybody goes ‘Awww!’”
At the ripe young age of 63.5 years I discovered MDA via a local radio interview with Mark in Charleston, WV. My Doc was ready to put me on insulin due to my progressive Type II diabetes. I have regained my health and my life over these past 6 months. Lost 50+ lbs. Eliminated 2 oral diabetic Rx’s plus my cholesterol meds and 1/2 of my blood pressure meds (still working on the other half.) More energy, lots of compliments from those that know me and greatly motivated to dig in a little deeper. Couldn’t do even one pushup when I started and only a few squats. Recently took a 13 mile hike by myself in the woods during a snowfall and it was exhilirating. Let’s roll, time is wasting. Thanks for your work Mark and all of you who offer such great posts.
there’s no gurantee for any of this stuff. Your DNA may have already determined your future. Live the best life you can and don’t let the experts tell you what you should be doing. I like the Scott Tinley philosophy.(fUCK IT THIS IS WHAT I LIKE TO DO) Cheers
Ha ha I like it too! With the women in my family they seem to have the longevity gene..I enjoyed many years with great grandmothers on my mother’s side, they were in their 90′s when they passed on. I lost one grandmother in the last few years in her 80′s a long and painful path due to MS. One of my grandmothers still cuts her own lawn, has a boyfriend, and travels. I am going to be 38. These women are an inspiration, they worked hard, raised families, stayed active and some even enjoyed themselves!
My English Bulldog Koko just died a few weeks ago, during her afternoon nap. She was fine and happy in the morning, we ran out to do a few errands, when we came back, she was snuggled in her bed by the front door with her chewy bone under her chin, dead. Peacefully, in her sleep. RIP Kokomo Kissabull Aguiar, that’s how I want to go….
i think modern medicine does not prolong life.
it just lengthens (the process of dying)
regards,
I’m another reader who could not agree more with you.
I work as a medical transcriptionist. I don’t agree with a lot of what conventional medicine does, but it’s how I make my living.
I have transcribed lots and lots and lots of reports for people who spend the last years, even decades, of their lives in some form of nursing home, very debilitated, and often going back-and-forth between the nursing home and the emergency room.
Frequently these people cannot walk, can’t talk, and can’t recognize their loved ones anymore. The light’s on (just barely), but you’d be hard put to say that anyone’s really home.
Oh, yeah, and one of the hospitals for which I transcribe is a teaching hospital, and they’re still teaching them the garbage about the cholesterol theory of heart disease.
No doubt some of the patients are even more demented because of statin drugs, but we won’t even get into that right now.
Anyway, I really enjoy your blog. I am also impressed by the respectful way in which you interect with your readers.
once again so timely–i was happy to ride my mtn bike up a very steep grade tonight as I usually don’t get up that thing without stopping until about 6 weeks deeper into the spring riding season and I was talking with another rider up there about how many more springs would I be able to do this? he said he’d seen a guy who looked to be about 60 heading up this hill. i’m 49 this spring. i wanna ride that steep section as long as I can and climb lotsa crags and then settle into yoga, gardening and biking around town and then go out like that old lady, oh yeah!
My father turns 72 this year. He has spent all of his life doing 50 laps of an olympic sized swimming pool each day, going for long walks, riding a push bike, and runs a marathon once a week. He has only just started to complain that his legs are starting to feel stiff and sore after one of his runs.
On this morbid, but inherently positive, post I’d like to add my favourite poem by Dylvan Thomas: Do Not Go Gentlie Into That Good Night
http://www.bigeye.com/donotgo.htm
Good ol Mark, tough as nails!
This year I will be luckily enough to help celebrate the 100th birthday of an amazing lady who still lives alone in her own home, cares for herself and still has all her wits about her. She is Amazing.
On the other hand, my uncle developed Alzeheimers in his 50′s and has spent nearly 20 years in a secure unit for late stage Alzheimers patients. He is gone, simply a body housing the mind of a newborn baby. He only lives because he has a swallow reflex and they continue to feed him. The doctors say he could live for many more years (If living is what you call it).
My point….. Is that I guess you just never know what you are going to get in life.
Im really looking forward to that Party!
Great post, thanks.
Since starting to live primally last summer, I keep noticing how much time people around me spend talking about their illnesses and those of folks they know. It’s so depressing! More and more, I stay out of the conversation and just think about something else, something life affirming – like the nice, juicy steak I’ll cook for dinner with a tomato salad sideplate, or walking the dog in the New Forest. Also, when anyone asks me, I tell them, “I’m growing younger!” and that is my belief. Living primally is fun and makes me feel good! Grok on!
Three years ago, at age 47, I could barely move, locked in a body wracked with rheumatoid arthritis. Then the celiac diagnosis. Tried the standard near western pseudo gluten free route and stopped getting worse.. not better, but no worse after a nearly daily decline that had me preparing for the inevitable. Switched to paleo and within forty eight hours went from a morning gel time of two or more hours to being able to literally hit the ground running. I still have a long row to hoe as to healing and recovery but now I have another few days to move in a positive direction.
I read a quote the other day. “I do not eat really healthy to make myself live longer….I eat healthy to have quality of life while I am here on the planet.”
I found this to be so profound. There are consequences to our choices. I used to always see that as such a heavy handed negative. Now I see the consequences as one of the most positive as to the impact it can have on our quality of life. Now, if I can only get my loved ones to pay more attention.
My grandparents have been going through this for several years now. It’s taken a harsh toll on my mother to have to care for them and watch them suffer for nearly a decade. And they’re no happier for it. They can’t have anything they want, and every day is another set of humiliations. I don’t want to touch any nerves here, but on top of all that, I can’t even imagine how much of other people’s money has been wasted in prolonging my grandparents’ suffering.
I spoke with my mother yesterday about it. We both said that we would never follow them down this road, but maybe that’s easier to say when you’re healthy and not staring death in the face.
Absolutely agree. I’ve seen both sides up close in my family. The cost of my mother’s thirty year slow dying with Type2 diabetes, both emotionally and financially is a very unpleasant picture. When my grok-like dad dies, now 90, it will have been having enjoyed a physically active, healthy life, and next to nothing in insurance and related health costs. While it may seem callous to reduce this to $$, the fact is we are each paying for health costs related to obesity and poor diet generally. But the bottom line is my mother did not enjoy those years of decline, and that is really a terrible testament to any life.
I’ve seen both sides in my family. Most immediatly, my mother spent 30 years declining due to obesity caused T2 diabetes; years she did not enjoy life, nor have the energy to do much with here children and grandchildren. The costs were great physically, mentally, financially. My Grok-like dad, 90 now, has rarely had a sick day, remains active, and enjoys life fully. He volunteers at a nursing home where most of the people are younger than he by ten or more years. When he dies, it will have cost the insurance he carries, almost nothing. It may seem callous to reduce this to $$, but we all pay for the diet and obesity related
health problems. But the saddest part is that life is only half lived when illness dominates.
Sorry for the duplication, my computer wigged out and I thought it didn’t post.
As a primal Crossfitter I am hoping to be the tough old gramma who is still around to do Wod’s with my grandkids!
I lost my dad when I was 17 and I am determined to be around for a very long time for my kids and show them that life is meant to be LIVED!
love the comments by everyone, Grok on!
I”m in my late 20′s been diagnosed with renal failure 4 years ago. Yes 4 years ago it was a death sentence, but after 1 year on dialysis and a lot of muscle loss, I started researching food and exercise. I’m not 100% primal more the 80-20 rule. And it works for me. I’ve also started Kettlebell this year and saw my strength go up. I sometimes forget I have renal failure since I”m healthier then before renal failure where I ran, and ate “healthy”.
It frustrates me when dialysis patients a few years old or younger then me, come to treatment and complain why me. I haven’t asked why me in over 3 years. And I don’t take all the normal drugs that renal patients have. I have normal blood pressure and I feel great. I try to talk to patients about exercise as a start, but it falls on deaf ears.
I know something related to renal failure will be my end, but I’m enjoying the ride. And people have lived high quality lives for 30+ years on dialysis.
If you do get some disease learn to manage it and you can still live a high quality life, it will only bring you down if you let it and don’t educate yourself.
My grandmother died at 93 a few weeks ago–she experienced that slow, long decline into morbidity and immobility that you describe. She lost all of her faculties one by one, starting with her physical vitality, then her immune system, and finally her mind. She was in and out of the hospital constantly for 2 years, and by the end she had had so many small strokes and serious infections that we’re not sure she remembered who her son (my dad) was, and was unable to speak. We are quite sure, however, that she was miserable and in pain. That was pretty obvious.
She wasn’t Grandma anymore for a long time. She was a shrunken wisp of her formal self. I can say that it was a relief when she finally died. There was a picture of her at her funeral that was taken when I was younger (she was perhaps 75, 80 at the most), and I cried my eyes out when I looked at it, because I was so sad and angry that the memories I have of her from the last several years weren’t really her. That old woman with lively eyes and a sarcastic smile, who used to bake Christmas cookies with me every year, who lived through the Depression and saved everything to the point of obsession, who took care of me when I was small and walked herself to church 6 days a week, every week of her adult life, died a long time ago. Her body just didn’t know when to stop breathing.
I sincerely hope I have the wherewithal to end my own life if I am ever in a situation similar, before I am too weakened to do it. But the best thing to hope for is that death comes swiftly and unexpectedly for me, and I never have to go through the kind of death my grandmother didn’t deserve.
I’m with Carly on this one. Aged 26 I experienced an injury to my spinal cord. I’ve had my backside cleaned by others, remained immobile for many months (unable to move from the neck down), and in 24/7 excruciating pain. Should I have come home with my shield or on it?
I’m 47 now and still in 24/7 pain, unable to walk unassisted and all the other health implications that come with spinal cord injury. Sometimes when I read MDA I do so with a shield of armour to protect me from the oh so macho approach to living.
Even with all my neurological health problems I still have a zest for life. Perhaps this is why many hang on with their meds… because life isn’t just for those who are physically fit.
It’s true; everyone has to decide how much ‘decrepitude’ they’ll tolerate. Sadly, some of us have to face that choice through no fault of their own from a very early age. I’m grateful for big pharma, the medical profession and the paleo/primal way. Hell! I’m thankful I can feed myself.
When I turned 40 I started getting what I called “Old-guy-itis” and I realized that I wasn’t necessarily getting old, I was just out of shape. But getting in shape again had to be different than when I was 20 and could just start running every day and call it good. I got really inspired by Cross-fit, and loved that whole functional fitness idea. The main challenge for me was restoring flexibility and elasticity of my joints, ligaments, and building strength for my whole body. I love PBF and appreciate how you have such holistic approach to being alive. Thanks Mark!
My grandfather used to say he was going to get shot by a 21 year old jealous husband when he was 95. He was a dynamo till 89. Almost no pills his whole life.
Oh, if only my sweet husband had lived long enough to read these posts! We tried so hard to live a “healthy” lifestyle (according to USDA guidelines). How wrong we were. I’ve been Paleo for two months and am feeling great! I am no longer depressed, my joints don’t ache anymore, my acid reflux is gone and I’ve dropped 14 pounds from my 5 foot frame. I’m never hungry since I eat all I want of nutritious, tasty proteins and vegetables. The most difficult part of this lifestyle is not irritating the hell out of your friends who don’t yet understand! “-)
“Is life so dear, or peace so sweet, as to be purchased at the price of chains and slavery? Forbid it, Almighty God! I know not what course others may take; but as for me, give me liberty or give me death!”
In Japanese sword fighting Kendo you have to be at least 46 before you can attempt to achieve the highest level 8th Dan. See here these fantastic athletes compete
http://www.youtube.com/watch?v=ylpdy0XEOfw.
Some are in their 70′s and 80′s
Or see the 10th dan master Mochida Moriji Hanshi her in action at age 76.
http://www.youtube.com/watch?v=_XHSZ-sLG3I
These old guys move so fast. Sometimes a fight lasts 1 second and you have to see it in slow motion to see what happened. Functional fitness and vitality to the end!!