Two years ago, during a routine physical, my doctor told me I was developing diabetes. My fasting blood sugar levels were rising and also becoming erratic. After my doctor prescribed a course of medication, I asked him whether losing weight and exercising would bring my blood sugar levels into a normal range. “Probably,” my doctor said.
I decided to try intermittent fasting. I didn’t think I’d be able to fast 16 hours a day. But I have done it for 515 consecutive days, and I have reduced my blood sugar and weight to sustainably healthy levels.
Many Americans are not so lucky. U.S. health outcomes consistently rank poorly among high-income countries. Among Economic Cooperation and Development (OECD) nations, for example, the U.S. has the lowest longevity from birth, along with the highest rates of maternal and infant mortality and death from treatable disease. The U.S. has twice the obesity rate over the OECD average and among the highest suicide rates.
Paradoxically, the U.S. spends nearly twice as much on healthcare as any other high-income country. In other words, the U.S. spends more on healthcare and gets less.
Healthcare experts explain the contradiction in a multitude of ways, but the root cause is largely outside medicine. Some of the most powerful determinants of healthspan—living healthy for longer—are social. Income, education, social connection, job stress and social status all factor into a patient’s access to quality care. Inequities implicit in those factors are, in turn, mirrored in healthcare statistics. The result is that good healthcare in the U.S. is simply out of reach for many people.
I am fortunate enough to be one of the exceptions. I collaborate with two leading healthspan researchers—Leroy Hood at Phenome Health in Seattle and Eric Verdin, CEO of the Buck Institute for Research on Aging—who both recommend intermittent fasting as a way to help extend healthspan. I am also educated, and I have sufficient income and a supportive community.
Social determinants of good health like these must be addressed to improve healthspan for everyone. That’s possible. Just as there are communities suffering across the U.S., there are communities that are thriving. Decision-makers have access to the science and the data that reveals what separates the two. What’s lacking is a commitment to policies that prioritize population health, and the will to enlist the public and private sectors to build a new society focused on the health of all individuals.
Simple question, difficult answers
The Jesuits have a concept for living: cura personalis, or “care for the person.” It implies a dedication to promoting human dignity and care for the mind, body and spirit of the whole person. In secular terms, this concept translates to Whole Person Health Care, which, according to the National Center for Complementary and Integrative Health (NCCIH), considers “multiple factors that promote either health or disease” and empowers individuals, families, communities and populations to improve their health. Whole Person Health Care embraces multiple dimensions of wellness, including physical, emotional, spiritual and social.
Understanding how an individual lives can offer clues, drawn from population data, about how that person might age. The first telling question is: Where does that individual live? Data from a county or even a zip code contains a multitude of healthspan information.
The goal is to bring impoverished areas closer to the level of wealthy ones, such as Marin County, California, a suburb of San Francisco. Marin County ranked as the state’s healthiest county, as measured by the 2024 County Health Rankings & Roadmaps, a report put out by researchers at the Population Health Institute at the University of Wisconsin–Madison. It scores highly in quality of life, clinical care and other social and economic factors. According to U.S. News and World Report, Marin County ranks fifth among counties nationally in terms of median household income.
The story is far different in Fresno County, which is located in the Central Valley, where the economy is mostly agricultural. The average resident of Fresno County can expect to live eight years less than residents of Marin County. It has twice the burden of premature deaths. Twice as many residents are physically inactive, smoking rates dwarf Marin County and 50 percent more residents are obese. Twenty-seven percent of residents live in poverty, versus eight percent in Marin County.
In Fresno County, zooming in further offers a more complex picture. Researchers at two institutes at Fresno State University—the Joint Center for Political and Economic Studies and the Central Valley Health Policy Institute—analyzed data from a national repository called PLACES that makes localized health-related data, including chronic disease burden, available to counties across the country. PLACES—a collaboration of the Centers for Disease Control and Prevention, the Robert Wood Johnson Foundation and the CDC Foundation—aims to help local health departments and jurisdictions understand health disparities in their area and better plan public-health interventions.
Similar health disparities by region, county and even neighborhood are common across the U.S. Without data, and without the willingness to use it to guide policy and healthcare recommendations, such problems will remain invisible. Bridging the gap between wealthy and resource-deprived counties will require new policies at the federal, state and community levels geared to building a healthy population. These policies must be data-driven and consider the social determinants of health, chief among them where a person lives and what resources they have access to.
To keep people healthy into old age, an effective social safety net is a must.
Mark Smith/Salzmanart.com
A true safety net
Another factor that contributes to the healthspan gap is how the U.S. supports its elderly. Many are simply not prepared for the financial burden of living longer. Despite the existence of Social Security and Medicare, many are in danger of outliving their savings. About half of those over the age of 65 live in households that rely on Social Security payments for at least 50 percent of their family income; for a quarter of them, Social Security benefits make up at least 90 percent of their family income.
With the future of entitlements uncertain, most Americans will need to become economically active longer. This will involve putting in place workforce initiatives like those of the AARP Foundation, which include Digital Skills Ready@50+, which helps people retrain for new types of work, and the Senior Community Service Employment Program, which helps unemployed people over 55, including low-income people, hunt for work. The reality is that aging is the greatest risk factor for most chronic diseases, and along with aging for most people comes a reduction in income. For many workers in the gig economy, it is not possible to earn enough money to support a healthy life, no matter how hard they work.
In the creation of a support structure for people of all ages, the role of community must also be considered. Recent research has shown that social health and community have an outsized impact on healthspan. As a result, the World Health Organization (WHO) has issued a call to make social connection a global health priority. U.S. Surgeon General Vivek H. Murthy’s report, Our Epidemic of Loneliness and Isolation, puts the number of adults experiencing loneliness in the U.S. at one in two. It is associated with a greater risk of cardiovascular disease, dementia, stroke, depression, anxiety and premature death. “Loneliness is far more than just a bad feeling—it harms both individual and societal health,” the report says.
Conditions of housing and the environment also have an impact on healthy aging. This includes larger environmental influences such as air and water quality, safety and access to nutritious and affordable food, but also access to green spaces and cultural opportunities. Initiatives such as community gardens, which are popular in parts of Europe and the U.S., can help people connect to the living world, forge new friendships and provide a sense of awareness that personal wellness and environmental wellness are intertwined.
Efforts are underway in the U.S. to “regreen” cities. One of the pioneers is the Bezos Earth Fund, whose aim is that “living in a city should not have to mean living without nature. Green spaces such as parks, community gardens, nature trails, and tree canopies along city blocks are vital to the health and well-being of all Americans. And as extreme weather events and record-breaking temperatures become more frequent, urban green spaces play an ever more crucial role in climate resilience for all communities.”
A generational goal
Since healthspan is so heavily influenced by social factors, improving it will take a commitment to true social change. That does not come quickly. The U.S. needs a long-term strategy to bring its healthcare provision into alignment with those of other wealthy nations, to succeed where we’ve failed before.
Based on successful efforts in the U.S. and abroad, we now know how. The solutions include changing the healthcare focus from treating chronic disease to preventing it. Leroy Hood’s vision of P4 Medicine offers a promising path; it uses data and science to predict a person’s future health and steer them to implement measures that prevent chronic disease.
We need a system that is organized and paid for by a single payer, and it needs to offer healthcare to everyone, regardless of ability to pay. A non-profit foundation could be both the payer and provider, something Kaiser Permanente (KP) already does in California. Governments can as well, as they do in many other developed countries, including U.K., Canada and Japan. In the U.S., state-level legislation is being piloted based on this thinking. For example, a California law that went into effect in 2023 would create a waiver to federal law that would allocate Medicare and Medicaid funds to a state-level single-payer system financed by state and federal funds.
Public education is essential. Examples include the Live Longer Better campaign in the U.K., led by Sir Muir Gray of Oxford, which aims to reduce risk and extend people’s healthspans in measurable ways by increasing their physical, cognitive and emotional activity. Shifting the food system is also essential. It should be based on nutritional science and supported by policies like that proposed by Robert H. Lustig, a San Francisco–based physician and chief science officer of Eat Real, a nonprofit that aims to provide nutritious and subsidized meals in U.S. schools. Affordable housing is a must, along with initiatives like Finland’s Housing First plan, which has almost completely eliminated homelessness in the country by creating group homes that provide unhoused people with small apartments, addiction treatment and other care. Without a home or shelter it is close to impossible to live a long and healthy life.
As the above examples suggest, science is only half the answer. This challenge is as much moral, political and economic as it is scientific.
It is fair to ask: Who is increased healthspan for? The best answer is, for all people. By improving healthspans for all individuals we will be able to create a more equitable and just society.
Explore the emerging science of healthspan in other stories in this special report.
