I have always found the interplay between nature and nurture interesting, and the often very polarizing ways people understand this dynamic is even more fascinating. I will illustrate with a bit of my own experience on the matter.

Nurture Is Supreme (Or So I Thought)

I started my professional life with a very strong bias toward nurture - that is, the belief that most people can achieve good physical and emotional health through making safe, healthy choices on a daily basis. I still remember the first time I got my hands on a book promoting the benefits of healthy eating, exercise, fresh air, stress control and other good habits; it was a paperback entitled NEWSTART. An Austrian physician gave it to a physician friend of mine during a visit to Romania, and since my friend didn't know English, he gave it to me. I read it in one day. It was an amazing experience, it felt like I was having a revelation with every new page I turned.

I was in my first year of medical school at the time, and I felt my calling in life was to educate people on how much better their life could be if they made good lifestyle choices every day. I was 100 percent confident that anybody, anywhere, no matter what their age, gender, and more importantly, genes were could have access to vibrant health by practicing good health habits.

Through a set of circumstances, shortly after finishing medical school, I became employed part-time to lead the health department of my church in Romania. For almost 8 years, I had the privilege of writing articles on health in the official church magazine, of visiting and speaking in local churches about the abundant treasures of health and happiness that could be unlocked with simple, daily lifestyle choices, organizing educational conferences for health professionals in my church, and meeting and dealing with a lot of interesting people, from one end of the spectrum of physical and mental health to another. It was a very intense experience, considering the fact that for most of those eight years I had to finish a 5-year residency program, I was in charge of a weekly one hour health education, live radio program broadcast on Romanian public radio, as well as a similar weekly program broadcast on the church's radio station in the capital city. Toward the end of those eight years I have also been involved in running a church operated medical center in Bucharest.

My days would start very early and end very late. I hardly had any time to eat, and even when I had time, I didn't have many options to choose from. At the time, there were no vegetarian options to eat out in Bucharest. Sometimes I wonder how I kept going, with so little food, and so much to do. I was burning the candle from both ends, and there wasn't much left of me. At the end of that time of my life, I was weighing around 115 lbs (I am about 5'8" tall).

Time For A Change

Fast forward another 15 years. During this time, I moved to the United States, finished a masters program in human nutrition and a residency program in Internal Medicine. We were also blessed with two children. Oh, and I gained over 40 lbs, most of which during the first year or so...

In 2007, I started working as a physician, seeing anywhere between 3,000 and 4,000 patients a year. For the last 7 years I have worked in a rural area in the Pacific NW. A significant number of my patients are Seventh-day Adventists who have been vegetarians for decades, who don't smoke cigarettes or drink alcohol. They exercise, attend church regularly and practice other healthy habits.

It has been a huge privilege for me to be able to see the impact of this healthy lifestyle on a large-scale, yet individual basis. I feel I now have a better understanding of the true, real-life balance between nature and nurture. I will list below some of my insights:

• Long-term adherence to sound lifestyle habits pays off, in most cases. I have many 80, 90 year-old patients that look, move, talk and think 10 or 20 or sometimes more years younger. I thoroughly enjoy spending time with them, it is one of the highlights of my job. I like their positive attitude, I like when they share life-changing stories with me, and I find their whole life inspiring. Every single one of them is a powerful testament to what healthy living can do for you.
• Similarly, at the other end of the lifestyle habits spectrum, I see a very clear pattern of early physical aging, from wrinkled skin to degenerated joints and back discs, to obesity and other chronic conditions such as diabetes, coronary artery disease, high blood pressure (and many others), and brain damage from strokes, vascular dementia, etc. Unfortunately, there is a large percentage of the general population who grew up thinking and learning from those around them that life is not worth living if you don't enjoy the "fun" of smoking, drinking, sexual promiscuity, and a host of other such habits. I sometimes ask such patients why they think they enjoy things that clearly damage their body and/or mind. I haven't been able to get a clear answer so far, except for the occasional admission that it is really hard to give up bad habits. I have also heard some strange answers, such as one from a long-term smoker lady who told me she was absolutely sure people will smoke in heaven...
• But reality is not black and white: in between these poles of the spectrum, there are many patients in whom the interaction between genes and what they decided to do with what they were born with is very intricate and sometimes surprising:
  • I have some (not many, but there are a few) patients who seem to have been born with such a strong constitution that, despite what sometimes amounts to a severe abuse of their body, they are still enjoying reasonable health into their senior years. I have a sweet 80+ year-old lady, for example, who enjoys her eggs and bacon every morning, and whose sole significant exercise is going fishing a few times a month. She still stands tall, has a clear mind, and is clearly enjoying her life.
  • Conversely, I have seen patients who, despite being vegetarian/vegan for years, still have elevated blood lipids. I've seen quite a few of these patients, actually. Most of them suffer from metabolic alterations of their lipid metabolism that cause their blood cholesterol or triglycerides (or both) to remain well above levels considered safe, even when they don't ingest any cholesterol and use very little saturated fat in their diets. Do all of them end up having heart attacks or strokes? Actually no; but I've seen a few that required coronary stents or by-pass procedures, or carotid endarterectomies for clogged arteries.

One of the frustrating aspects of this for me has been the almost daily encounters with a certain type of patients who are very convinced that they can treat/cure/reverse absolutely any disease with lifestyle or supplements. I strive to explain to such patients what should otherwise be obvious, in my opinion: there are conditions caused or aggravated by a bad diet, lack of exercise, poor coping skills, smoking, alcohol, etc. We usually call these non-communicable diseases: obesity, coronary artery disease, diabetes, high blood pressure, and so on. The beauty of lifestyle intervention in these conditions is not only the fact that a serious effort can render dramatic results both on the short and long-term, but that the same lifestyle changes work for all of them!

There are, however, a number of health issues that are not as responsive to lifestyle changes as those listed above. Think about the common cold, cholera, HIV infection and hundreds of other infectious diseases; also, think about seizures, cerebral palsy, and many congenital defects or conditions (spina bifida, schizophrenia, etc.).

There are some conditions that are in-between: while a strong commitment to a healthy lifestyle can go a long way to help, it usually doesn't provide a cure for them. I've seen, for example, patients with rheumatoid arthritis or lupus experience improvement of symptoms when they gave up animal foods, but cures are hard to witness.

Last but no least, I try to help my patients understand that there is a significant difference between the impact of lifestyle changes on prevention vs. cure. A healthy diet rich in fruits, vegetables, whole grains and nuts, together with regular exercise and avoiding smoking can go a long way to prevent cancer, as at least two thirds of all cancers are attributable, in good part, to poor diets, rich in meat and animal products, and smoking. But once cancer develops, it is not realistic to expect that making these healthy changes will cure it. While painting and taking care of your car on a regular basis can go a long way to prevent rusting, a paint job done after rust has destroyed the metal would not do much good.

A Conclusion of Sorts

It wasn't too long after I started seeing patients that I had to put to rest the idea that all, or even most of us are born with fairly equal abilities. By far, the most surprising lesson I have learned as a physician has to do with how powerful genes are. Some patients seem to have been born with bodies or minds so vulnerable, that in spite of their best efforts, are still plagued by all kinds of ailments. I owe a lot of eye-opening moments to this group. I have learned to expect and respect what nature throws at us. But even in these cases, a positive outlook/attitude can go a long way to make things better.

I remember a couple in their late 70s who went through a lot of challenges health-wise. They told me once a true story of how the husband, who had issues with balance, fell one evening next to his bed, and couldn't get up. His wife was in the room, but because she was hard of hearing, she didn't hear the thud caused by his body hitting the floor, nor his pleas for help. She was in her wheelchair, reading a book, facing the opposite side of the room. Desperate to get help, he found a hair brush on the floor, close to where he had fallen, and he hurled it at her. He said he was nervous about doing that, but had no choice. I asked him it he was afraid it would hurt her, but he said no, he was nervous he would miss her :-). Fortunately, he didn't miss, and he didn't hurt her either. She became aware of what had happened to him and was able to call for help.

As I sat there in the exam room, listening to them taking turns in telling this tragic-comic story, and laughing heartily in the process, I had an epiphany: these were two very happy people, who were able to use good humor and a positive attitude to transcend what were some very obvious and severe health issues. In the end, it is much more important how we deal with what we have (or not have), rather than what we are given in life. Or, as a church sign in our town put it recently, we should not allow the things we cannot do keep us from doing the things we CAN do.

Dr. Gily Ionescu MD, MS.