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March 13th, 2024 
Awake Goy 
For how much longer will health policy ignore multimorbidity, that looming, giant elephant in the room, that propagates and amplifies suffering? For how much longer will the ‘trend’ of increasing diagnoses of multiple health conditions, at younger and younger ages be rendered down by government agencies to better and more efficient services, screening modalities, and drug choices?
Multimorbidity, the presence of many chronic conditions, is the silent shame of health policy.
All too often chronic conditions overlap and accumulate. From cancer, to diabetes, to digestive system diseases, to high blood pressure, to skin conditions in cascades of suffering. Heartbreakingly, these conditions commonly overlap with mental illnesses or disorders. It’s increasingly common for people to be diagnosed with multiple mental conditions, such as having anxiety and depression, or anxiety and schizophrenia.
Calls for equity tend to revolve around medical treatment, even as absurdities and injustices accrue.
Multimorbidity occurs a decade earlier in socioeconomically deprived communities. Doctors are diagnosing multimorbidity at younger and younger ages.
Treatment regimens for people with multiple conditions necessarily entail a polypharmacy approach – the prescribing of multiple medications. One condition may require multiple medications. Thus, with multimorbidity comes increased risk of adverse outcomes and polyiatrogenesis – ‘medical harm caused by medical treatments on multiple fronts simultaneously and in conjunction with one another.’
Side effects, whether short-term or patients’ concerns about long-term harm, are the main reason for non-adherence to prescribed medications.
So ‘equity’ which only implies drug treatment doesn’t involve equity at all.
Poor diets may be foundational to the Western world’s health crisis. But are governments considering this?
The antinomies are piling up.
We are amid a global epidemic of metabolic syndrome. Insulin resistance, obesity, elevated triglyceride levels and low levels of high-density lipoprotein cholesterol, and elevated blood pressure haunt the people queuing up to see doctors.
Research, from individual cases to clinical trials, consistently show that diets containing high levels of ultra-processed foods and carbohydrates amplify inflammation, oxidative stress, and insulin resistance. What researchers and scientists are also identifying, at the cellular level, in clinical and medical practice, and at the global level – is that insulin resistance, inflammation, oxidative stress, and nutrient deficiencies from poor diets not only drive metabolic illness, but mental illnesses, compounding suffering.
There is also ample evidence that the metabolic and mental health epidemic that is driving years lost due to disease, reducing productivity, and creating mayhem in personal lives – may be preventable and reversible.
Doctors generally recognise that poor diets are a problem. Ultra-processed foods are strongly associated with adult and childhood ill health. Ultra-processed foods are
‘formulations of ingredients, mostly of exclusive industrial use, typically created by series of industrial techniques and processes (hence ‘ultra-processed’).’
In the USA young people under age 19 consume on average 67% of their diet, while adults consume around 60% of their diet in ultra-processed food. Ultra-processed food contributes 60% of UK children’s calories; 42% of Australian children’s calories and over half the dietary calories for children and adolescents in Canada. In New Zealand in 2009-2010, ultra-processed foods contributed to the 45% (12 months), 42% (24 months), and 51% (60 months) of energy intake to the diets of children.
All too frequently, doctors are diagnosing both metabolic and mental illnesses.
What may be predictable is that a person is likely to develop insulin resistance, inflammation, oxidative stress, and nutrient deficiencies from chronic exposure to ultra-processed food. How this will manifest in a disease or syndrome condition is reflective of a human equivalent of quantum entanglement.
Cascades, feedback loops, and other interdependencies often leave doctors and patients bouncing from one condition to another, and managing medicine side effects and drug-drug relationships as they go.
In New Zealand it is more common to have multiple conditions than a single condition. The costs of having two NCDs simultaneously is typically superadditive and ‘more so for younger adults.’
This information is outside the ‘work programme’ of the top echelons in the Ministry of Health:
Official Information Act (OIA) requests confirm that the Ministries’ Directors General who are responsible for setting policy and long-term strategy aren’t considering these issues. The problem of multimorbidity and the overlapping, entangled relationship with ultra-processed food is outside of the scope of the work programme of the top directorates in our health agency.
New Zealand’s Ministry of Health’s top deputy directors general might be earning a quarter of a million dollars each, but they are ignorant of the relationship of dietary nutrition and mental health. Nor are they seemingly aware of the extent of multimorbidity and the overlap between metabolic and mental illnesses.
Neither the Public Health Agency Deputy Director-General – Dr Andrew Old, nor the Deputy Director-General Evidence, Research and Innovation, Dean Rutherford, nor the Deputy Director-General of Strategy Policy and Legislation, Maree Roberts, nor the Clinical, Community and Mental Health Deputy Director-General Robyn Shearer have been briefed on these relationships.
If they’re not being briefed, policy won’t be developed to address dietary nutrition. Diet will be lower-order.
The OIA request revealed that New Zealand’s Ministry of Health ‘does not widely use the metabolic syndrome classification.’ When I asked ‘How do you classify, or what term do you use to classify the cluster of symptoms characterised by central obesity, dyslipidemia, hypertension, and insulin resistance?’, they responded:
‘The conditions referred to are considered either on their own or as part of a broader cardiovascular disease risk calculation.’
This is interesting. What if governments should be calculating insulin resistance first, in order to then calculate a broader cardiovascular risk? What if insulin resistance, inflammation, and oxidative stress are appearing at younger and younger ages, and ultra-processed food is the major driver?
Pre-diabetes and Type 2 diabetes are driven by too much blood glucose. Type 1 diabetics can’t make insulin, while Type 2 diabetics can’t make enough to compensate for their dietary intake of carbohydrates. One of insulin’s (many) jobs is to tuck away that blood glucose into cells (as fat) but when there are too many dietary carbohydrates pumping up blood glucose, the body can’t keep up. New Zealand practitioners use the HbA1c blood test, which measures the average blood glucose level over the past 2-3 months. In New Zealand, doctors diagnose pre-diabetes if HbA1c levels are 41-49 nmol/mol, and diabetes at levels of 50 nmol/mol and above.
Type 2 diabetes management guidelines recommend that sugar intake should be reduced, while people should aim for consistent carbohydrates across the day. The New Zealand government does not recommend paleo or low-carbohydrate diets.
If you have diabetes you are twice as likely to have heart disease or a stroke, and at a younger age. Prediabetes, which apparently 20% of Kiwis have, is also high-risk due to, as the Ministry of Health states: ‘increased risk of macrovascular complications and early death.’
The question might become – should we be looking at insulin levels, to more sensitively gauge risk at an early stage?
Without more sensitive screens at younger ages these opportunities to repivot to avoid chronic disease are likely to be missed. Currently, Ministry of Health policies are unlikely to justify the funding of tests for insulin resistance by using three simple blood tests: fasting insulin, fasting lipids (cholesterol and triglycerides), and fasting glucose – to estimate where children, young people, and adults stand on the insulin resistance spectrum when other diagnoses pop up.
Yet insulin plays a powerful role in brain health.
Insulin supports neurotransmitter function and brain energy, directly impacting mood and behaviours. Insulin resistance might arrive before mental illness. Harvard-based psychiatrist Chris Palmer recounts in the book Brain Energy, a large 15,000-participant study of young people from age 0-24:
‘Children who had persistently high insulin levels (a sign of insulin resistance) beginning at age nine were five times more likely to be at risk for psychosis, meaning they were showing at least some worrisome signs, and they were three times for likely to already be diagnosed with bipolar disorder or schizophrenia by the time they turned twenty-four. This study clearly demonstrated that insulin resistance comes first, then psychosis.’
Psychiatrist Georgia Ede suggests that high blood glucose and high insulin levels act like a ‘deadly one-two punch’ for the brain, triggering waves of inflammation and oxidative stress. The blood-brain barrier becomes increasingly resistant to chronic high insulin levels. Even though the body might have higher blood insulin, the same may not be true for the brain. As Ede maintains, ‘cells deprived of adequate insulin ‘sputter and struggle to maintain normal operations.’
Looking at the relationship between brain health and high blood glucose and high insulin simply might not be on the programme for strategists looking at long-term planning.
Nor are Directors General in a position to assess the role of food addiction. Ultra-processed food has addictive qualities designed into the product formulations. Food addiction is increasingly recognised as pervasive and difficult to manage as any substance addiction.
But how many children and young people have insulin resistance and are showing markers for inflammation and oxidative stress – in the body and in the brain? To what extent do young people have both insulin resistance and depression resistance or ADHD or bipolar disorder?
This kind of thinking is completely outside the work programme. But insulin levels, inflammation, and oxidative stress may not only be driving chronic illness – but driving the global mental health tsunami.
Metabolic disorders are involved in complex pathways and feedback loops across body systems, and doctors learn this at medical school. Patterns and relationships between hormones, the brain, the gastrointestinal system, kidneys, and liver; as well as problems with joints and bone health, autoimmunity, nerves, and sensory conditions evolve from and revolve around metabolic health.
Nutrition and diet are downplayed in medical school. What doctors don’t learn so much – the cognitive dissonance that they must accept throughout their training – is that metabolic health is commonly (except for some instances) shaped by the quality of dietary nutrition. The aetiology of a given condition can be very different, while the evidence that common chronic and mental illnesses are accompanied by oxidative stress, inflammation, and insulin resistance are primarily driven by diet – is growing stronger and stronger.
But without recognising the overlapping relationships, policy to support healthy diets will remain limp.
What we witness are notions of equity that support pharmaceutical delivery – not health delivery.
What also inevitably happens is that ‘equity’ focuses on medical treatment. When the Ministry of Health prefers to atomise the different conditions or associate them with heart disease – they become single conditions to treat with single drugs. They’re lots of small problems, not one big problem, and insulin resistance is downplayed.
But just as insulin resistance, inflammation, and oxidative stress send cascading impacts across body systems, systemic ignorance sends cascading effects across government departments tasked with ‘improving, promoting, and protecting health.’
It’s an injustice. The literature solidly points to lower socio-economic status driving much poorer diets and increased exposures to ultra-processed food, but the treatments exclusively involve drugs and therapy.
Briefings to Incoming Ministers with the election of new Governments show how ignorance cascades across responsible authorities.
Health New Zealand, Te Whatu Ora’s November 2023 Briefing to the new government outlined the agency’s obligations. However, the ‘health’ targets are medical, and the agency’s focus is on infrastructure, staff, and servicing. The promotion of health, and health equity, which can only be addressed by addressing the determinants of health, is not addressed.
The Māori Health Authority and Health New Zealand Joint Briefing to the Incoming Minister for Mental Health does not address the role of diet and nutrition as a driver of mental illness and disorder in New Zealand. The issue of multimorbidity, the related problem of commensurate metabolic illness, and diet as a driver is outside scope. When the Briefing states that it is important to address the ‘social, cultural, environmental and economic determinants of mental health,’ without any sound policy footing, real movement to address diet will not happen, or will only happen ad hoc.
The Mental Health and Wellbeing Commission, Te Hiringa Mahara’s November 2023 Briefing to Incoming Ministers that went to the Ministers for Health and Mental Health might use the term ‘well-being’ over 120 times – but was silent on the related and overlapping drivers of mental illness which include metabolic or multimorbidity, nutrition, or diet.
Five years earlier, He Ara Ora, New Zealand’s 2018 Mental Health and Addiction enquiry had recognised that tāngata whaiora, people seeking wellness, or service users, also tend to have multiple health conditions. The enquiry recommended that a whole of government approach to well-being, prevention, and social determinants was required. Vague nods were made to diet and nutrition, but this was not sufficiently emphasised as to be a priority.
He Ara Ora was followed by 2020 Long-term pathway to mental well-being viewed nutrition as being one of a range of factors. No policy framework strategically prioritised diet, nutrition, and healthy food. No governmental obligation or commitment was built into policy to improve access to healthy food or nutrition education.
Understanding the science, the relationships, and the drivers of the global epidemic, is ‘outside the work programmes’ of New Zealand’s Ministry of Health and outside the scope of all the related authorities. There is an extraordinary amount of data in the scientific literature, so many case studies, cohort studies, and clinical trials. Popular books are being written, however government agencies remain ignorant.
In the meantime, doctors must deal with the suffering in front of them without an adequate toolkit.
Doctors and pharmacists are faced with a Hobson’s choice of managing multiple chronic conditions and complex drug cocktails, in patients at younger and younger ages. Ultimately, they are treating a patient whom they recognise will only become sicker, cost the health system more, and suffer more.
Currently there is little support for New Zealand medical doctors (known as general practitioners, or GPs) in changing practices and recommendations to support non-pharmaceutical drug treatment approaches. Their medical education does not equip them to recognise the extent to which multiple co-existing conditions may be alleviated or reversed. Doctors are paid to prescribe, to inject, and to screen, not to ameliorate or reverse disease and lessen prescribing. The prescribing of nutrients is discouraged and as doctors do not have nutritional training, they hesitate to prescribe nutrients.
Many do not want to risk going outside treatment guidelines. Recent surges in protocols and guidelines for medical doctors reduce flexibility and narrow treatment choices for doctors. If they were to be reported to the Medical Council of New Zealand, they would risk losing their medical license. They would then be unable to practice.
Inevitably, without Ministry of Health leadership, medical doctors in New Zealand are unlikely to voluntarily prescribe non-drug modalities such as nutritional options to any meaningful extent, for fear of being reported.
Yet some doctors are proactive, such as Dr Glen Davies in Taupo, New Zealand. Some doctors are in a better ‘place’ to work to alleviate and reverse long-term conditions. They may be later in their career, with 10-20 years of research into metabolism, dietary nutrition, and patient care, and motivated to guide a patient through a personal care regime which might alleviate or reverse a patient’s suffering.
Barriers include resourcing. Doctors aren’t paid for reversing disease and taking patients off medications.
Doctors witness daily the hopelessness felt by their patients in dealing with chronic conditions in their short 15-minute consultations, and the vigilance required for dealing with adverse drug effects. Drug non-compliance is associated with adverse effects suffered by patients. Yet without wrap-around support changing treatments, even if it has potential to alleviate multiple conditions, to reduce symptoms, lower prescribing and therefore lessen side effects, is just too uncertain.
They saw what happened to disobedient doctors during Covid-19.
Given such context, what are we to do?
Have open public discussions about doctor-patient relationships and trust. Inform and overlay such conversations by drawing attention to the foundational Hippocratic Oath made by doctors, 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 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? Would education and wrap-around services in early childhood and youth delay or prevent the onset of multimorbid diagnoses?
Is it more ethical to give young people a choice of treatment? Could doctors prescribe dietary changes and multinutrients and support change with wrap-around support when children and young people are first diagnosed with a mental health condition – from the clinic, to school, to after school? If that doesn’t work, then prescribe pharmaceutical drugs.
Should children and young people be educated to appreciate the extent to which their consumption of ultra-processed food likely drives their metabolic and mental health conditions? Not just in a blithe ‘eat healthy’ fashion that patently avoids discussing addiction. Through deeper policy mechanisms, including cooking classes and nutritional biology by the implementation of nourishing, low-carbohydrate cooked school lunches.
With officials uninformed, it’s easy to see why funding for Green Prescriptions that would support dietary changes have sputtered out. It’s easy to understand why neither the Ministry of Health nor Pharmac have proactively sourced multi-nutrient treatments that improve resilience to stress and trauma for low-income young people. Why there’s no discussion on a lower side-effect risk for multinutrient treatments. Why are there no policies in the education curriculum diving into the relationship between ultra-processed food and mental and physical health? It’s not in the work programme.
There’s another surfacing dilemma.
Currently, if doctors tell their patients that there is very good evidence that their disease or syndrome could be reversed, and this information is not held as factual information by New Zealand’s Ministry of Health – do doctors risk being accused of spreading misinformation?
Government agencies have pivoted in the past 5 years to focus intensively on the problem of dis- and 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.
Unfortunately, as we see, 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 autonomous, long-term monitoring and research in nutrition, diet, and health. There is no independent, autonomous, public health research facility with sufficient long-term funding to translate dietary and nutritional evidence into policy, particularly if it contradicted current policy positions.
Despite excellent research being undertaken, it is highly controlled, ad hoc, and frequently short-term. Problematically, there is no resourcing for those scientists to meaningfully feedback that information to either the Ministry of Health or to Members of Parliament and government Ministers.
Dietary guidelines can become locked in, and contradictions can fail to be chewed over. Without the capacity to address errors, information can become outdated and misleading. 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.
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?
In the impasse, who can we trust?
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