🏇🏽The 4 horsemen of chronic disease and how to prevent them
This was the front page of the Post-Courier newspaper earlier this month:
Reading the headline and its article, it made me think about the concept of the “4 horsemen” of chronic disease. Peter Attia MD describes the 4 horsemen in his book “Outlive: The Science and Art of Longevity”. He talks about the major health killers that prevent us from living long and fulfilling lives. Let’s explore the concept of the 4 horsemen of chronic disease and how to prevent them.
What are the 4 horsemen of chronic disease?
The 4 horsemen refers to the harbingers of the biblical apocalypse, representing the end of the world. In the bible, they represent conquest, famine, war and death. In medicine, Dr Peter Attia refers to the 4 horsemen as the major “health“ killers. They are: Cardiovascular disease, metabolic disease, cancer and neurodegenerative disease. The 4 horsemen are lifestyle diseases that account for 80% of deaths in people over the age of 50 who don’t smoke. But, they are starting to creep into the younger age groups. Here is a breakdown of each of the 4 horsemen:
1. Cardiovascular disease
This encompasses diseases likely hypertension (high blood pressure), coronary artery disease, acute myocardial infarcts (heart attacks), atherosclerosis and strokes etc. These group of disease accounts for the most deaths in the Asia-Pacific and the world.
2. Metabolic disease
Metabolic diseases are the conditions that prevent your body’s ability to properly use the energy from food, which causes imbalance of chemicals and hormones in the body. Obesity and diabetes mellitus are the most common metabolic conditions in the world and are increasing with incidence. It’s interesting to note that being overweight/obese or diabetic significantly increases your risk of developing the other 3 horsemen.
3. Cancer
Cancer is the proliferation of abnormal cells. Basically, when there are more “bad“ cells in the body than good cells. Common cancers are breast cancer, lung cancer, mouth cancer and liver cancer.
4. Neurodegenerative disease
These group of diseases cause death in neurons (nerve cells), leading to loss of coordination, brain cognition (impaired ability to think) and memory loss. This includes dementia, the most common being Alzheimer’s disease (the “forgetting” disease), Parkinson’s disease (the “stuttering, shaking” disease) and Lou Gehrig’s disease (ALS - Amyotrophic Lateral Sclerosis).
One of the reasons these 4 horsemen are particularly debilitating and annoying is that they are costly to treat and their continuous management can be a burden, in terms of time and money. For example, diabetic patients need to come to the hospital regularly, wait in line to attend their diabetic clinic, wait in line to get their resupply of medications and constantly have to monitor their blood sugar levels, spending money on a glucometer (device to check your blood sugar) and its glucose strips. And if the hospital or health centre runs out of their medications, they have to buy them pay out of pocket at pharmacies around the city. The same goes for hypertensive patients and their meds, buying a BP machine to constantly monitor their blood pressure. Now, since these chronic diseases, once acquired are usually lifelong, imagine doing all of these things for the rest of your life. Yeah, no. I’d rather keep healthy now then spend a lot of time and money trying to manage dealing with these diseases for the rest of my life.
My observations
During my stint in the emergency department from late 2020 - early 2022, patients would be rushed in to the ED due to sudden collapse from strokes, hyperglycaemia/hypoglycaemia (very high/very low blood sugar levels from diabetes), slurred speech and excruciating chest pains from heart attacks. Since joining radiology from March 2022, I’ve seen a lot of preventable, non-communicable disease from the ultrasound and CT scans that I’ve done. These include:
From ultrasound scan: Fatty liver disease, liver cancer, gallstones, kidney stones, chronic kidney disease (the kidneys start to malfunction).
From CT scans: Strokes - haemorrhagic type (bleeding in the brain) and ischaemic type (reduced blood supply to part of the brain due to blockage), atherosclerosis (arteries become blocked due to calcium and plaque), dementia.
Cancers: Oral cancer (from chewing betelnut), lung cancers (mostly from smoking), oesophageal and liver cancers (mostly from smoking and alcohol) and others.
What’s interesting is that these conditions are becoming more frequent, especially in the younger age groups. For example, most stroke cases I would see were between the ages of 50-70 years. Now, patients between ages 25-40 are coming in with strokes. There are about 2-3 patients during on-calls that come in for a CT scan to confirm the type of stroke they have.
The majority of the diseases that us doctors and healthcare workers see are made up of at least 1 of these 4 horsemen.
My personal experience
To be honest, up until around June last year (2024), I wasn’t that concerned about my diet. I thought that since I had been slim all my life (I’m turning 32 this year), had a fast metabolism and exercised about once a week that I could get away with eating more junk food than most others. I would eat fried chicken and chips almost every weekend with friends and drink a lot of soft drinks to go with it. Then I noticed that people close to me and people around my age started having health problems; stroke, gallstones, kidney stones etc. After witnessing these events, I realised that I was lucky that I didn’t experience any major health scares like that but I knew that I had to change my lifestyle:
I stopped drinking soft drinks and almost exclusively drink water,
I only eat fast food about once every 2 months,
I started exercising more frequently now, about 3-4 times a week,
and I’ve been monitoring my weight and body mass index (BMI) every week since June last year.
It wasn’t easy to make the change, and yes, I have had my slumps, bad days and go off-track. But once I started, I started feeling so much better - I have more energy throughout the day, I sleep better and feel happier overall.
What can we do about the 4 horsemen of chronic disease?
To be blunt: we need to change our lifestyles. It’s something we all know we have to do but we don’t do it.
Here are some changes that will reduce your risk of developing one of these 4 annoying horsemen:
Firstly, before anything else like changing your diet and exercising more, you need to come up with why you want to be healthier in the first place. Is it so that you can see your children grow up or see your grandchildren? There’s no reason to lead a long, healthier life if you just want to watch more TV or social media. Find a reason that’s so important to you so that you are more likely stick to your goals especially when things get difficult.
Have a healthier diet, exercise more and stop bad habits. Stuff we already know. You don’t need to research the most optimal diet, the optimal exercise regimen, take all kinds of weird health supplements or count calories for every meal you take. It’s not a lack of information, it’s a lack of execution. You already have some idea of what you should be doing;
Eat more fruits and vegetables; more traditional, garden food,
Eat less junk food,
Move your body more often,
Drink more water,
Don’t drink a lot of alcohol
Don’t smoke and don’t do drugs.
Again, we already know this stuff. But we need to implement these practices into our lives.
Take responsibility of your body and your health. Be proactive and execute on taking better care of your health. How often have you said “I had a hard day or week, I deserve this,“ when it comes to bingeing on food or alcohol? The thing is, your body does not understand context. If you consume a lot of sugar because you had a hard week, your body isn’t going to say “it’s okay, I won’t make him diabetic because this was a hard week for him, I’ll go easy on him,“ and then stop you from being diabetic. Your body only processes what you put into it, without context. You need to be conscious about what you are putting into your body and how you are treating your body. Also, most people focus on exercise alone to be healthy but ignore their diet. Exercise alone isn’t enough. Exercise and diet go together like a married couple.
Allow yourself to have a cheat day. But, you need to be strict with yourself about it. Decide in advance which days will be your cheat days where you can be more liberal with your diet within reason. For example, last week I attended a cultural street-food food festival with my wife. It was my cheat day to enjoy myself but I gave myself these two clear conditions so that I do not overindulge:
I will not stuff myself with food. Meaning, I cannot eat until I can barely breathe/walk or I become sick afterwards.
I must stay within my budget and not dip into my savings account to pay for anything.
We really ended up enjoying the food, stayed within budget and had a really good time. So, come up with your own mini-conditions for your cheat days so that you don’t overindulge and feel worse afterwards, which is what most people do.
As a medical professional, seriously, I urge you to take care of your body. We are seeing increasing cases of non-communicable diseases as I’ve mentioned above and it is very scary. Don’t treat your body like crap and then expect healthcare workers to “fix“ it with pills. Do your part and start with the basics of controlling your diet and exercising more. Please don’t become a statistic.
