9780241742846 by Smakprov Media AB

Prologue: Bad News on the Bus

The conversation passes in a blur with phrases such as ‘results took longer than usual’, ‘abnormal cells’, ‘possibly cancer’. The nurse is vague when I ask what happens next. ‘Well, you’ll get a letter, probably in the next few weeks, that you’re on the waitlist, and then a letter with your appointment a few weeks after that sometime. It might take a couple months to get you in, possibly six months, I don’t know. We have a large backlog. But keep calling in asking about cancellations and maybe you’ll get it sooner. Sorry.’ She hangs up the phone.

I sit there paralysed by the call. The woman behind me pats my shoulder. I wonder what she must think, overhearing someone getting potentially life-changing bad news on a bus. A bus to work on a freezing Scottish winter’s morning.

In my routine smear test with the National Health Service (NHS) three months earlier, high-risk human papillomavirus was found, and this has caused changes to my cervix. I know there’s a vaccine highly effective at preventing HPV, but I’m too old to be covered by the NHS vaccination programme which targets teenagers. It was only approved in 2006, when I was already twenty-two. If you’re vaccinated before being exposed to HPV, it’s 97 per cent effective at preventing cell changes that could lead to cervical cancer. But that doesn’t help me right now.

When I am lecturing my students about public health, I tell them that more than 95 per cent of cervical cancers are caused by high-risk HPV. Thousands of women are diagnosed each year and more than a quarter die. Famously, TV personality Jade Goody died of cervical cancer at just twenty-seven, and it’s a cancer most frequently diagnosed in women between thirty-five and forty-four. It’s survivable if precancerous cells are treated at an early stage, but my lab results are from months back, and I know the long NHS waiting lists mean it might be months before I see a doctor for further examination and treatment.

I also tell my students that the UK has one of the worst survival outcomes for cancer in Europe and North America because of late diagnosis, delayed treatment, and an overstretched health service. When cervical cancer is diagnosed at an early stage, I tell them, the five-year survival rate is 92 per cent. If it’s diagnosed, and treated, after it has spread throughout nearby tissue and organs, this drops to 59 per cent. Luckily, I’ve been identified by routine screening, but I’m dependent on the overstretched NHS for rapid investigation and, if necessary, treatment.

As I sit on the bus, my mind wanders. What if my dream to move back to the Florida coast never happens? What if I can’t go see my mother again, and I end up dying before her? What if it’s nothing and I’m freaking out for no reason . . . but also what if it is something?

The word cancer feels like a death sentence. The tough paths of chemotherapy, radiation, surgery. I’ve seen it all closely when my dad was sick to the point where you wonder whether living with this kind of pain and treatment is worth it. Could it even be worse than just living and dying with cancer?

My father, who himself was an oncologist, was diagnosed with lymphoma in his early forties. I was twelve. There were two possible conversations at each blood check or screening: a crossroads of good news or bad news, with whatever the doctor said leading you down very different paths.

I remember one of my father’s colleagues saying, ‘Cancer will get you in the end, whether it’s now, or a bit later or a lot later. Treatment can push back the outcome, but it lingers and never really goes away. Even when you’re in remission.’ This is not entirely true, but it was true enough – or scary enough – to stick in my mind.

Before each of my father’s doctor’s appointments, my high school friends would comfort me. ‘Of course it’s going to be good news. Statistics show he’ll be fine.’ And that’s exactly what I am hearing now: the nurse trying to reassure me with statistics about survival rates and treatment.

I am told what I already know. More than 80 per cent of women have HPV at some time in their lives and most HPV resolves on its own. In 95 per cent of cases, the HPV virus causes no symptoms or

health problems, and in the roughly one in twenty women who have abnormal smear results (like me), only about one in 2,000 will have cancer. Pre-cancerous cells can be detected and killed early. Most women go back to living their life, perhaps slightly more conscious about their mortality and the other path their life might have taken.

But statistics didn’t work for my dad. They didn’t work for twentyseven-year-old Jade Goody. Statistics help at a population level, but how relevant are they to me? Will I die too soon?

This could have been a book about how I have accepted the possibility of death. Since my father’s diagnosis when I was a teenager, I have thought a lot about life’s deeper meaning: what is it all about? How do we live a meaningful life and find happiness? What ultimately makes people feel fulfilled, and how do we balance daily stress and distractions with the many chapters of our lives? Is there a way to accept our mortality – even when it comes at a time when we don’t expect it?

But no. I don’t want to write about being at peace with dying, because I am not. I like my life. This is not a book about how to die. This is a book about how to live longer. Because while there’s a randomness in life – like the thunderbolts of bad news that strike on your morning commute – we know from scientific studies and decades of public health research not only how to increase life expectancy but also how to maintain quality of life.

My story isn’t unusual – we all have our brushes with death. We tend to take our health for granted until faced with death, or even chronic pain. Fortunately, mine has a happier ending (so far). Taking the nurse’s advice, I kept calling the NHS hotline in case there was an appointment cancellation and managed to have my colposcopy within a few months of my lab results. I was treated at a local hospital by an experienced physician, with a one-year follow-up. My scare wasn’t fatal.

From working in global health, I know quite well that if I lived in Tanzania or Zambia, or even India or Brazil, my story might have had a different ending. Avoiding an early death to cancer had less to do with any individual choices I made during my life, and more to do

with living in a country, in this case Britain, that has free high-quality health care with a cervical cancer screening programme. My thanks to the government in 1948 who created the NHS and the people who voted for these visionary leaders.

I am living longer because of political choices made more than half a century ago. And in this book I will show that, despite a thriving individualistic, self-help economy, your life expectancy is much less about your own choices and is instead tightly linked to where you live and the political choices made by your government.

1. Eternal Life

While searching for the fountain of youth and eternal life in 1513, Spanish explorer Juan Ponce de León discovered Florida. I grew up near a street in Miami that bears his name. More recently, you might have seen headlines about American tech multimillionaire Bryan Johnson who spends £1.6 million a year on an intensive regime designed to reduce his biological age from that of a man in his forties to that of an eighteen-year-old. Part of this plan involves injecting himself with his teenage son’s blood, after studies in mice indicated that younger plasma rejuvenated ageing tissue.

In laboratory experiments, two mice (one old and one young) were stitched together to share a circulatory system. Within five weeks, the blood from the younger mouse had restored muscle and liver cells, and enhanced growth of brain cells, in the older one. On the other hand, young mice who were exposed to older blood suffered reduced growth. The experiments were not without risk, with several mice dying due to tissue rejection.

Bryan, currently forty-six, claims to have reversed his ageing by 5.1 years, with biological tests estimating he has the heart of a thirtyseven-year-old and the lung capacity of an eighteen-year-old. The madcap things he is doing seem to be working for him, but we don’t all have the luxury of that kind of money – or time – to invest in our longevity. Never mind the mass appeal of familial blood transfusions. But while Bryan’s money might help him live longer, he cannot buy immortality – he’ll be lucky to live beyond 120.

Humans haven’t (yet) figured out how not to die. Most people are just trying to figure out how to keep on top of their bills, stay painfree and get by each day. Even so, it’s become a fixation of the rich, such as billionaire Jeff Bezos who has invested in start-up companies looking at cellular rejuvenation, and Google founders Sergey Brin and Larry Page who have launched Calico, a business venture which

tracks mice from birth to death in the hope of understanding markers for ageing-related diseases.

I’m not interested in being immortal, or even being the oldest person alive. My ambitions are more universally achievable. I’d like to live to 100 with – importantly – good health, and I’d like to help others do the same. Research into reversing the biological effects of ageing, including (let’s say creative) studies about mice-blood transfusions, will continue to be well funded and make advances, but bold claims of banishing disease are far-fetched, not to say (at the moment at least) ridiculously expensive. It’s unlikely to affect our own lives or the lives of most people on this planet. It’s caught in a billionaire bubble. If we all want to live longer, most answers can be found in public health research. You might be surprised to know that we in the field of public health already have the knowledge to prevent the majority of premature deaths around the world. This is true of deaths from infectious diseases like cholera, and chronic diseases like heart disease and stroke, as well as from injuries whether violent or unintentional, such as on the roads. In total, it’s estimated that 20–40 per cent of all premature deaths (depending on where you live) are preventable and could be delayed.

Turning Down Harvard

In my day job as a public health professor at the University of Edinburgh, my colleagues and I try to figure out what makes people die too soon and then advise governments on how to implement policies to support people living long and healthy lives. When my dad became sick, I saw intimately how ill health affects daily life, and learned the important lesson that health is true wealth. We don’t think about pain or our body much when we’re healthy and going about our routine. But once we get sick or injured, it consumes our entire life. I remember thinking at sixteen: ‘We can put men on the Moon, we can talk to people instantly across the world, why can’t we solve something as basic as keeping people healthier longer? Why aren’t more people working on this problem?’

My personal interest in health and wellbeing transformed into a professional career, including an offer of a full scholarship to Harvard Law School. When I was about to confirm my dorm in Boston, I decided that I wasn’t yet done with research and academic life in Oxford. I wanted to understand public health first-hand, starting with infectious disease and malnutrition in the villages of Tamil Nadu and the slums of New Delhi.

My friends and family were in shock when I told them this decision: ‘You’re turning down Harvard to collect data in rural India? Your parents left India to bring you to America and give you a better life, and now you’re going back to study poverty? What kind of career and security will you have going for a PhD?’

Twenty years later and I stand by this decision: it opened the world of research, data analysis and collection, and academia to me. The Japanese would refer to this as ikigai, or life purpose and meaning: find something you love, that you’re good at, and that the world needs. You’ll be the only person to know what your ikigai is, and it might be a totally different path to your peers or family. But it’s your life to make the most of and to find happiness within.

Where Are You From? No, Where Are You Really From?

I’m now a dual British-American citizen of Indian heritage. All three countries are fascinating in their own way, and in how they’ve attempted to address (or ignore) major health challenges. Britain and America are countries with a similar language and a completely different culture. Americans are enthusiastic, optimistic, with a ‘can do’ attitude. The British are more realistic, with a ‘but you can’t’ attitude.

If you say you’re okay at something and you’re American, you’ve probably done it once or twice. If you say the same and you’re British, you’ve probably been to the Olympics or won the Nobel Prize. If an American person says your idea is interesting, it means they want to hear more. If a British person says the same, it means they think it’s bonkers and are trying to change the topic.

The US and UK are both highly unequal countries with an

ever-growing political divide between the left (dismissed by the right as ‘woke’ and ‘elitist’) and the right (labelled by the left as ‘fascist’ and ‘establishment’). Over the past two decades, the rich have become richer and the poor have become poorer. America has the world’s largest number of billionaires, up from 607 in 2019 to 735 in 2023. At the same time, the child poverty rate has stayed around 16 per cent across the country – around 11.6 million kids.

The same story could be told about Britain, where the poorest quintile (bottom 20 per cent) of households have seen their income reduced, while the richest fifth’s income increased. During the pandemic, a record number of billionaires were created in the UK (171 in total). Meanwhile, child poverty hovers around 30 per cent. These are children living in unheated homes in households struggling with food bills, and who miss out on play, activities and growing up with security.

India is one of the most unequal countries on the planet: the bottom 50 per cent in India own only 6 per cent of the total wealth, while the top 1 per cent own 33 per cent. I found it astonishing to visit Delhi and compare the glistening supermalls full of luxury brands and eyewatering price-tags (often higher than in London or Miami) with the slums sprawling out across the road. On one side opulence and showy wealth, on the other malnourished children playing halfdressed on the street.

I try to share this knowledge with younger generations in my university lectures. I’m competing for students’ attention with the person sitting next to them, with their phone, with their urge to make up for sleep lost to a night partying, so the lecture has to be engaging. I guess I’m doing the same thing with you: you could be watching the latest Netflix series instead of reading this book.

Life Expectancy Is Going Down

In my role as an expert in global public health, government officials often come to me and ask, ‘How should we prepare for the next pandemic?’ My response is that the top lesson for all countries must be

that preparing for pandemics means investing in broader health and wellbeing. Not during a crisis, or in hospitals, but right now in communities, schools and homes.

Take Japan, which has one of the healthiest populations in the world. Its life expectancy is the highest of high-income countries at 84.4 years. Its ‘preventable’ mortality, at 130 per 100,000, is far below the high-income average of 199 per 100,000. This is with over a quarter of its population over the age of sixty-five. Only 27 per cent of its population has a body mass index (BMI) over 25 (seen as a metric for being overweight/obese), making it the lowest of the high-income countries. Perhaps it’s not surprising, then, that Japan had one of the world’s lowest COVID-19 death rates (246 per million people) without implementing lockdowns or government mandates.

A similar story can be told about Denmark if we compare the country to its European neighbours. Life expectancy is high at 81.6, and 70 per cent of Danes say that they’re in good health. Obesity rates are around 16 per cent of adults, with physical activity levels around the European average.

Just contrast this with Scotland, where life expectancy is 76.6 years for men and 80.8 for women. This is the lowest life expectancy at birth of any Western European country. Scotland also has high inequality, with those in deprived areas such as Inverclyde and North Ayrshire dying younger and spending more than a third of life in poor health.

Obesity is a major problem, with roughly 70 per cent of men and 64 per cent of women categorized as being an unhealthy weight. This has led to media articles under headlines such as ‘How Scotland became Europe’s unhealthiest country’, which focus not only on the poor diet, but also binge drinking, drug overdoses and wider deprivation.

Unsurprisingly, the COVID-19 death rate in Scotland was eyewateringly high (2,315 deaths per million people), even with a cautious pandemic approach focused on containment. In a comparison of England and Scotland, Scotland had higher per capita deaths recorded in January 2023, despite lower estimated overall infections. Basically, the likelihood of someone dying was higher if they got COVID-19 in Scotland.

In contrast, Denmark experienced 3.5 times fewer COVID-19 deaths relative to its population size than the European average at 440 per million. Policy responses were central to this, including strong containment and early access to widespread testing, but the government implemented these in a healthy and compliant population.

The take-away is that if your population was healthier going into the pandemic, as in Japan or Denmark, you could manage a wave of infections better than if you had poor underlying health such as in Scotland. Countries with healthier populations (defined as a lower burden of disability and deaths given their population size) had fewer hospitalizations per capita and fewer deaths per infection. This of course leads to the question: why are Japan and Denmark healthier than Scotland? More on that soon.

Unfortunately, general population health is not improving in most countries, certainly not the United Kingdom or the United States. Quite the contrary. Key measures of progress in public health are going backwards. Since 2020, most countries, including Spain, England, Italy, Belgium and the Netherlands, have seen reductions in life expectancy and reversals in progress on reducing mortality. Oxford researchers have highlighted that most life expectancy reductions were attributable to direct and indirect COVID-19 deaths. For example, in Britain the pandemic reduced life expectancy by half a year, and in the United States by 2.33 years.

But, We All Want to Live Longer

While life expectancy stagnates, or even goes backwards at a population level, our individual desire to live longer is stronger than ever. We can talk all we want about ‘accepting death’ and ‘being at peace with mortality’, but like me, when most people are faced with their own mortality, or the death of somebody they love, above all they want everything to be done to live longer. This is a key trait of being human.

It is one of the reasons why such a huge amount of money is spent

on end-of-life care, where we try to prolong someone’s life by a month, a week, even a day. In the US in one year (2019), $365 billion, or 10 per cent of all health care spending, was spent in the last six months of someone’s life. Greg Eastwood, a leading expert in this area and a professor at Upstate Medical University, has confirmed what we all might expect to be true: money is often a secondary consideration for a family dealing with the potential death of a loved one. Whatever their financial situation, families will spend anything for more time together.

Having been in this position, I can understand it. More than anything, I wanted my father to live. I wanted him to see me graduate high school and university. To meet his future grandchildren. I wanted to watch him get older and enjoy his retirement. I wanted him to be there to give advice when life gets rocky. To make sure my mother wasn’t lonely and help her raise me and my four siblings.

Getting to 100 as a Collective Endeavour

Getting to 100, or past 100, has largely been seen as an individual enterprise. Beyond the strange methods of billionaires, walk into any bookshop and you’ll find a huge body of literature telling you all the things you can do to improve your life expectancy, from the superfoods to eat, to how much sleep you should be getting, to the optimal amount of exercise at each age, as well as the ideal level of hydration.

Tied to this, the concept of ‘blue zones’ went global in 2008: that is, places in the world where people live longer than anywhere else and have lower rates of chronic disease. Dan Buettner and Michel Poulain, who coined the term, looked at the behaviours of people living within these zones (such as the Italian island of Sardinia and Ikaria in Greece), examining their diet, exercise routine, sleep patterns and religious or spiritual community links. Based on this, they suggest changes we could all be making at an individual level to live longer, such as moving to a largely plant-based diet and sleeping seven to nine hours per night.

If you want to live longer, yes, you need to make healthy choices

throughout your life, and this book will cover those choices in the chapters around diet and physical activity. But the society in which you live also plays a huge role. Notably, these so-called blue zones are not areas where individuals each optimize their lives to live longer, but instead these are places where healthy lives are normalized by government and culture. I suspect that hardly anyone in these areas has read a self-help book.

I find the rampant individualism regarding health frustrating and the advice over healthy habits devoid of context. If we want to live longer, we’ve got to push beyond the superficial layer of individual advice to tackle the deeper issues of public health policy and government action that affect us on a societal level. The UK isn’t fatter than Japan because it is a country filled with people who choose to be overweight – that kind of logic is not only naive, but it stigmatizes overweight people when, as we will see later, the finger might better be pointed elsewhere.

In search of longevity, you could expose yourself to sunlight first thing every morning or take an ice bath, but if the air you are breathing is not clean, the water you are drinking is dirty, the roads you walk or drive on are unsafe, or many people you meet in the street carry military-grade weapons . . well, your gratitude journal isn’t going to do much. We have been focusing on the wrong thing: namely, we have been focusing on ourselves.

This book, rooted in public health, is about living to 100, but I’m more interested in making this a collective enterprise as a society. This means looking at government policies that promote long lives. I will take you through nine of the most important risk factors affecting healthy life expectancy in all countries, and as you will see, most of them are dependent on the government in charge and the policies they adopt. The nine risk factors I’ve chosen are: physical activity, diet, smoking, mental health, gun violence, safe roads and transport, clean water, clean air, and access to quality health care.

No country has it all figured out, but on every single one of the nine health challenges I cover, there are positive examples of policy impact. On every single issue, one place or another has worked out a solution. This book will spin from one part of the world to another,

to illustrate that we can learn across governments and cultures. Policy experiments are happening all the time, and instead of reinventing the wheel, countries can borrow ideas and see how best to adapt them to their own national context.

You might wonder why you should read this book if it’s about our limited individual agency. You might think that it sounds disempowering. Perhaps you just want simple tips to be a bit healthier. I will provide these tips on health issues like smoking or physical activity, where you can indeed affect your life in a big way by things you do individually.

But on other issues such as clean air and water or access to quality medical care, you do still have the power to affect your life. In these cases, we must demand that our governments implement better policies. We must elect leaders who propose and enact concrete action. You have the power through your vote. My aim with this book is to show you that we know what works in solving the major health challenges, to give you the ‘key asks’ of leaders and to show how these have worked, not in theory but in practice, somewhere in the world. We know how to prevent millions of unnecessary early deaths around the world, both in developing countries and closer to home.

The growing literature on ‘how to be healthy’ puts such heavy responsibility for a healthy life on each of us that when someone becomes ill, often there is stigma attached. But there should be no blame involved. I know from experience the questions that come from others when sharing bad health news. ‘Did you smoke?’ ‘Have you been too stressed?’

While this correlation is useful at a population level – we call these risk factors – this approach can unfairly allocate blame at an individual level for circumstances outside our individual control. Is it someone’s fault that they’re born into a city with high levels of air pollution, live somewhere with limited green space, or grow up in a neighbourhood with high levels of gun violence?

There are plenty of examples of blame making matters worse. For instance, in many countries of the world, an HIV diagnosis comes with stigma and exclusion through its (incorrect) depiction as a ‘gay disease’, and its link to sexual relations that are often taboo in many

cultures. This came to the forefront also during COVID, when people hid their positive test results because the next question was, ‘What did you do to get infected?’

It’s not just infectious disease. Even with cancer there’s a psychological human need to link something bad happening with a cause. ‘Why? What did you do?’ Getting my own health news sent me down this spiral too. I’ve tried very hard to do what I can to live longer based on what I’ve learned, including exercising regularly, eating a balanced diet, not smoking, and managing chronic stress. Bad health news wasn’t supposed to happen to people like me. Hadn’t I done everything ‘right’? In the end, it wasn’t my personal choices that mattered, it was that I was fortunate to live in a country with free access to quality medical care.

Of course, there’s a randomness to life that we have to accept in terms of who lives and who dies: the ‘shit happens’ perspective. Sometimes we’re just in the wrong place at the wrong time. We can’t all live to be 100. But we can all be more likely to live to 100 if we take a public health approach instead of an individualistic one. Here’s how.

2. Exercise: Just Do It

I exercise whenever I can. It’s my default ‘non-work’ activity. Partly because I enjoy it, and partly because I think that exercise is the most effective intervention to stay disease- and pain-free. I often find myself hiding from friends how much time I spend in the gym each week, out of fear of judgement. People talk about Netflix binges without much shame. What about fitness binges? Some people go to cafes or bars when they want to get away from the walls of their home. The gym for me always had that attraction: a place to see other people without directly engaging with anyone. A place to escape the outside world, especially the Scottish winter.

In late 2020 when gyms were shut due to the pandemic, but outdoor exercise was permitted, I attended a daily boot camp in the park. One evening, the instructor didn’t show, so I called the boot camp owner and offered to run the class. I had been attending religiously for weeks and knew the drill. While appreciative of my enthusiasm, she declined, saying I didn’t have professional personal training certification and wouldn’t be covered by the company’s insurance.

Two years later, I qualified as a personal trainer, a way to combine my lifelong interest in staying fit and healthy with my professional career in global public health. Most of the others studying alongside me were in their late teens or early twenties. I was probably the oldest person on the course.

Often my colleagues in public health combine their research work with a clinical career: three days a week in research, and two days working in a GP clinic or in a hospital. This means they see patients coming in with various medical conditions, while also doing research about what is making their patients sick, the diseases and their risk factors.

But my interest (and why I went into public health) is in how we can prevent someone becoming sick in the first place. It feels almost

too late by the time they show up in a medical clinic because they’re already ill, often from conditions that could have been prevented with earlier intervention.

My interest in fitness goes back to my dad’s childhood in India. He loved sports and played tennis, cricket and basketball while in school and college. His free time back then in Chennai, and as a young dad in Miami, was spent doing some form of sport. My earliest memories are watching him play doubles tennis in our local park, while I bounced a ball back and forth with my older sister, Divya, at the side of the court. We then got into our beat-up silver Toyota van and went for a special meal at Hardee’s, a fast-food takeaway of American hashbrowns, donuts and coffee (for the adults). These childhood experiences made exercise seem fun and social. What else would you do on a Sunday morning?

My parents didn’t want my siblings or me to fall into traditional gender roles, or to think of ourselves as foreign or different. I was never stuck at home having to cook or clean. I didn’t have to conform to traditional Indian ‘girl’ roles. They wanted us out of the house being active, whether it was on sports teams, wearing whatever we were comfortable in (even if that meant exposing our arms and legs), or studying hard at school and becoming women who would be equal to and just as strong as any man. They didn’t talk about gender equality, but they imprinted it in each of us in the way we were raised. I never felt any less or different being an immigrant child or being a girl. I still feel that way: I don’t think about my skin colour or gender actively. It’s only when it’s raised by others that I notice it. Skin colour is probably the least interesting aspect of someone. We’re all the same species who started in Africa before migrating to various parts of the world. Our skin colour evolved to fit the UV light wherever we ended up: pigmentation is a balance of the skin absorbing enough vitamin D without becoming damaged from the sun. With this logic and my darker skin, it makes no evolutionary sense that I’ve ended up in Scotland.

My dad was unique for an Indian father. In general, for cultural reasons, brown women don’t engage in enough physical activity. Not only in Britain, but globally, South Asian women are the group that

exercises the least. If you’re told from childhood that exercise is for boys, that muscles look manly, and that being outside could be dangerous, then of course you avoid it. You’re not encouraged to be in sport, and there are few role models. I’ve lost track of the number of times that I’ve been asked at the gym in Oxford or Edinburgh which tanning studio I used because my colour was so uniform. It was easier to believe that I’d spent hours on sunbeds, than that a brown woman would be dead-lifting weights or doing heavy squats.

When I’ve done literary festival events, the chair will often ask how I’ve merged two such opposing careers as a professor and a personal trainer. Frank Skinner, during a Sky Arts recording at the Hay Festival, pointed out that personal trainers are people who wear tight Lycra, have fake tans and go to Ibiza. Social media hasn’t helped this view of personal fitness trainers. Instagram and TikTok posts often link exercise to the already-fit who wear branded spandex (sponsored by expensive clothes companies) with Jennifer Lopez curves and men with six-packs who look like they could be in a Marvel movie.

The rise of fitness social media accounts that focus on what a ‘beach body’ looks like – whether that’s visible abdominal muscles or a thigh gap – can put people off exercise completely. The bar is so high that it simply feels unattainable to most. It’s also questionable that aesthetic goals relate to optimal health.

For most women, achieving visible abs requires an extremely low body fat percentage (less than 17 per cent, below the 20–23 per cent healthy range), which is often linked to irregular menstruation, brittle nails, feeling faint and disrupted hormone production. The only time I had visible abs was when I was running cross-country as a teen in Miami and not eating enough calories to cover my training and races. My body was literally starving and at an unhealthily low weight. My period stopped for several months, and during the school day I felt faint and had to sit down often. I felt much stronger after changing my diet and exercise schedule to increase my body fat (which meant covering up that previously visible muscle).

Over a decade later, in 2012, the Victoria’s Secret fashion show aired with several models walking in lingerie showing off thigh gaps. This became a social media trend, with young women posting photos

of themselves with their feet together and indicating if they had a gap between their thighs. The goal was to show that your thighs were so thin that they didn’t visibly touch in a short skirt or dress, part of the ‘thinspiration’ online community. Those whose thighs touched labelled themselves as ‘fat’ and charted their journey to lose weight and achieve the gap.

That same year, 2012, a major study from Denmark was published which had tracked the body measurements and health outcomes of 2,816 men and women over 12.5 years. They found that people with big thighs had a lower risk of heart disease and early death compared to those with thin thighs. Progressively thinner thighs were linked to progressively higher health risks.

Why is this the case? The researchers suggested that thinner thighs lack muscle, and leg muscle is linked to regular exercise, lifting weights and an active lifestyle. Aside from genetic factors which give people a certain body type, the only way to achieve thin thighs is to reduce not only body fat to an unhealthily low level, but muscle too. In addition to the rampant misinformation on social media, there’s also constant product promotion, often sponsored by clothes or supplement companies. It’s typical advertising: an influencer is paid to share posts showing you something that if only you had, you might be happier, such as a trendy new sports bra, a protein supplement or a laxative drink. The influencer, usually projecting the image of a certain body or lifestyle across their feed, and building their follower base on this narrative, makes you think you’d be just as happy as they look in their posts if you had this product. It’s commercialized FOMO.

The main difference now from previous advertising is that it’s 24/7, fed directly through mobile phones to teens without parental oversight and built on algorithms that target specific interests or demographics. For example, if you look at a few posts around ‘thigh gap’, the algorithm will continue to feed you more and more of this content in an addictive way. Or if the phones around you are looking at ‘thigh gap’ (such as in your school classroom), then the algorithm will assume you’re in the same social setting and feed you that content, hoping it will trigger your interest too.

It’s smart advertising for companies (and influencers) looking to make money, but it can often have detrimental physical and mental health consequences for those consuming these posts. For example, Khloé Kardashian used her Instagram account with 309 million followers to promote Flat Tummy shakes, claiming they help with weight loss and getting a flat stomach before beach holiday season. The company Flat Tummy Co. claims, without evidence or research, that drinking their product is three times more effective than diet and exercise alone.

How do they work? Each shake contains roughly 140 calories and is supposed to replace one to two meals per day. One of the ingredients, magnesium oxide, is often used as a laxative for those struggling with constipation, while others like inulin (a plant-based fibre) don’t digest completely and sit in the colon where they ferment and produce gas. Basically they make you flatulent and give you the runs. If anyone does lose weight on them, it’s likely because of the laxative effect (which isn’t great for overall health) or because of the replacement of proper meals with a lower-calorie option, creating a calorie deficit.

These shakes aren’t approved by the US Food and Drug Administration and have side effects such as cramping, stomach pains, diarrhoea and even liver damage. After experts pointed out that her posts were false advertising and even dangerous to health, Khloé deleted them. But by that point, her millions of followers had been exposed to them.

The focus on aesthetics (do I have a ‘beach body’?) distracts from the real purpose of our body and the functionality of fitness, exercise and nutrition: do I feel strong and healthy within my body, and can I do what I want to do with it? Just being a certain size or shape doesn’t mean someone is ‘healthy’. It can be intimidating for those who might just want to move more, and get a bit fitter, without wanting to conform to a certain ideal of what ‘fitness’ is on social media. My motto is ‘form follows function’: if your body does what you want it to do and you feel strong, then the way you look will follow that.

Social media posts and photos are also misleading: images are largely filtered and photoshopped. I’ve seen this myself. Grazia

Pakistan asked me to do a cover shoot, and I showed up in baggy jeans, a hoodie and messy hair in a bun. The Grazia team did my makeup, hair and outfits. The final photos are beautiful art, but they don’t look like me, even on my best day. I intentionally posted the Grazia photos next to makeup-free selfies to show how much work goes into making someone appear Instagrammable. It’s not real, and it can be off-putting to those who just want to exist in the world as a normal human being with flaws, bumps and wrinkles.

Yes, I’m a Personal Trainer

Here are some things I’ve learned both from my career as a professor and from working individually with those wanting to become fitter. The reality is that despite the proliferation of new fitness fads and endless columns dedicated to new tricks and tips, my advice sounds much more like what you’d hear from your doctor.

First, basic physical measurements are a quick way to assess health status (and no, thigh gap is not one of them). For example, BMI or body mass index (a measurement of weight for height squared) is a crude measure of whether someone is overweight, underweight, or within a healthy weight range.

Internationally, overweight is classified as a BMI between 25 and 30, and obese is 30–40. But BMI is a flawed measure and not great at assessing someone’s health status, as I’ll talk about more in the next chapter. If someone comes to me wanting to know how ‘healthy’ they are, BMI is one of the measurements but there are other key things to look for too.

I always take physical measurements of body fat percentage (given the links between body fat and metabolic disease), of waist circumference (given the links between abdominal fat deposits and metabolic disease), and of blood pressure (given the links between high blood pressure and chronic disease).

Body fat percentage is the amount of your total body weight that’s made up of fat, and it should be between 20 and 30 per cent for women and 14 and 24 per cent for men. Waist circumference is taken by running

9780241742846

How Not to Die (Too Soon)

The Lies We’ve Been Sold and the Policies That Can Save Us

Devi Sridhar

Sunday Times bestselling author

How Not to Die (Too Soon)

How Not to Die (Too Soon)

The Lies We’ve Been Sold and the Policies That Can Save Us

Devi Sri D har

VIKING

Prologue: Bad News on the Bus

1. Eternal Life

Turning Down Harvard

Where Are You From? No, Where Are You Really From?

Life Expectancy Is Going Down

But, We All Want to Live Longer

Getting to 100 as a Collective Endeavour

2.

Exercise: Just Do It

Yes, I’m a Personal Trainer