In a story from ancient Greek philosophy, Hercules faces a choice between two paths: one promising pleasure and ease; the other, hardship and struggle — but also growth and greatness. According to today’s guest, this ancient parable is more relevant than ever.

Dr. Paul Taylor, a psychophysiologist and the author of the new book The Hardiness Effect, returns to the show to argue that comfort has become our default mode — and it’s making us mentally and physically sick. To reclaim health and meaning, we must actively choose the path of arete — a life of effort, engagement, and challenge.

Paul first outlines the four traits that define a psychologically hardy person and how we grow by embracing and even relishing discomfort. We then dive into the physiological side of hardiness. We discuss how intentionally seeking stressors can strengthen both body and mind and some of the practices and protocols that lead to optimal health. We end our conversation with what tackling heroic, Herculean labors looks like today.

Resources Related to the Podcast

• Paul’s previous appearance on the AoM podcast: Episode #941 — How to Avoid Death by Comfort
• AoM Podcast #1,087: Why You Need the Good Stress of Socializing
• AoM Podcast #793: The New Science of Metabolism and Weight Loss with Herman Pontzer
• The Choice of Hercules 
• AoM podcast on the benefits of sunlight
• “Don’t Die: Eat More Small Fish” by Michael Easter
• AoM Article: Nature’s Prescription — The 20-5-3 Rule for Spending Time Outdoors
• Norwegian 4X4 HIIT Protocol
• AoM article on Zone 2 Cardio
• Omega-3 testing

Connect With Paul Taylor

• Paul’s website

Listen to the Podcast! (And don’t forget to leave us a review!)

Listen to the episode on a separate page.

Download this episode.

Subscribe to the podcast in the media player of your choice.

Transcript

Brett McKay:

Brett McKay here and welcome to another edition of the Art of Manliness podcast. In a story from ancient Greek philosophy, Hercules faces a choice between two paths, one, promising pleasure and ease, the other hardship and struggle, but also growth and greatness. According to today’s guest, this ancient parable is more relevant than ever. Dr. Paul Taylor, a psychophysiologist and author of the new book, The Hardiness Effect, returns to the show to argue that comfort has become our default mode. It’s making us mentally and physically sick. To reclaim health and meaning, we must actively choose the path of arete a life of effort, engagement, and challenge. 

Paul first outlines the four traits that define a psychologically hearty person and how we grow by embracing and even relishing discomfort. We then dive into the physiological side of hardiness. We discuss how intentionally seeking stressors can strengthen both body and mind and some of the practices and protocols that lead to optimal health. We enter conversation with what tackling heroic Herculean Labors looks like today. After the show is over, check out our show notes at aom.is/hardiness. All right, Paul Taylor, welcome back to the show.

Paul Taylor:

Thanks for having me, Brett. It’s such an honor to be a returning guest on your bloody awesome show.

Brett McKay:

Well, we had you on a few years ago to talk about your book, Death by Comfort. You got a new book out called The Hardiness Effect, and I love that word, hardiness hardy. People need to use that more. And we’re going to talk about what that is exactly. But I want to talk about how you opened up this book and how it frames what you talk about in the book. You start off The Hardiness Effect with one of my favorite myths from antiquity. It’s the choice of Hercules. For those who aren’t familiar with that myth, can you walk us through it and then explain why did you use this myth as the framework for your book?

Paul Taylor:

Yeah, look, it’s one of my favorite stories as well, Brett, and the myth goes back to Socrates who told the story of a young Hercules and in the Greek version he’s Heracles, but we’ll just go with Hercules. So he was the son of the God, Zeus, and he found himself standing at a literal and a moral crossroads, and two goddesses appeared in front of him. One was Kakia who said her name was happiness, but it was actually vice and the other was Arete, which means virtue. Now, Kakia was beautiful and seductive, and she promised Hercules an easy life, one of luxury, one of comfort and pleasure. Without effort, everything he could possibly want would be handed to him. And then on the other hand, on the other road was Arete. She was pretty plain in appearance, but she had a bit of a natural beauty.

And she told him the truth that her path would be hard. It would demand discipline, courage, and effort, but it was the only one that led to true fulfillment. So Hercules, as we probably know, he chose the Arete path and that choice actually defined him. It leads to the famous 12 labors of Hercules. These were impossible challenges that he had to undertake, that forged his character and ultimately led to Zeus deifying and making him a God because he was impressed with this character. Now, this story, it’s not just mythological, it’s also psychological as well. And it actually inspired Zeno who I know you know Brett was the founder of Stoicism. And today, this represents the choice that we all have between a life of comfort and a life of challenge. And I used it to frame the hardiness effect because I believe that we’re living through our own version of that myth right now, only Kakia has had a makeover. She no longer tempts us with this debauchery, but seduces us with a life of comfort and convenience, the life of, we think about it’s climate controlled homes, processed foods that are engineered to hijack our dopamine systems. We have endless digital entertainment that gives us an illusion of connection, but ultimately delivers loneliness. And this modern life of ease, I think leads to a life of disease. Now it’s really comfort creep on a civilization scale. We’ve now medicalized normal emotional experiences. We’ve created effort for ease and created a society with a default discomfort. And the outcome really is fragility. It’s physical, it’s mental, it’s emotional fragility. And we see that in rates of obesity, chronic disease and mental illness reflecting it. So really the story of Hercules at the crossroads became my metaphor for modern human condition. And every day we choose, do we walk Kakia’s path of ease and decay or Arete’s path of discipline, growth and meaning. And really the hardiness effect is an instructional manual for choosing arete. In the modern world, it’s about building the psychological and physiological capacity to take the hard path because that is the one that leads to the good life.

Brett McKay:

At the beginning of the book, you talk about the consequences of our modern day Kakia path that a lot of westerners are living. And you get into the statistics, obesity, diabetes, mental illness has just been creeping up for the past several decades. And you argue that it’s because just our way of life where we can be sedentary and be isolated and not do hard things is what’s contributing to that?

Paul Taylor:

Absolutely, a hundred percent. If you take an animal out of its natural environment, that animal does not do well. And this is what’s happened to us is that we have slowly over time moved into an environment that is not natural for us. We are not meant to be creatures of comfort. It is actually through challenge, physical and mental challenge that we actually become really human. And when we don’t have those challenges, we actually decay. The body just reacts to the environment.

Brett McKay:

Yeah, I mean, we had Herman Posner on the podcast. He studies metabolism.

Paul Taylor:

Yes.

Brett McKay:

Yeah. One of the big takeaways I got from him is that the human body has to move. You have to move for overall health, and if you don’t, you just get fat. What’s interesting, other primates like gorillas and chimpanzees, they can sit around and eat leaves all day and they don’t get fat because they don’t have to move. But for some reason, humans, you have to move in order to stay metabolically healthy. And our environment, our lives no longer compel us to do that anymore.

Paul Taylor:

That’s right. And actually when you look, our biology is so wired from movement. Hernan is absolutely correct. And what we know is that when we don’t move, not only does it affect us physically, but it also affects us mentally and psychologically. Every time you exercise, I like to tell people there is a neuro symphony going on in your brain. There is this orchestra of neurotransmitters. Everybody knows about endorphins, but when you exercise, we also release dopamine. We release serotonin, release noradrenaline, release endocannabinoids, and cafallons in our brain. And these are all positive neurotransmitters that not only help your brain to function well, but are really important for good mental health. And so I always say to people, if you have a life where you’re not moving very much, and especially if you combine that with eating a crappy diet and not sleeping very well, good luck with your mental health because you are swimming upstream massively. We’re just starving our body of what it actually needs to perform normally, nevermind optimally.

Brett McKay:

So we all face this choice to choose Kakia, but the problem we have today is that it’s not so much a choice. Like Kakia is almost like the default and you have to kind of fight against it. And you have to choose arete intentionally. I mean, maybe you can argue 200 years ago you were kind of forced to choose arete because you had to farm and you had to work hard just to live your life. And kakia was sort of like a luxury. Today it’s the opposite. And you have to intentionally choose arete, and you propose that hardiness is the way to choose the path of arete. And what’s interesting, hardiness, it’s a fun word I think of the hardy boys, kind of these vital young men, you’re full of vigor, but there’s actually a psychological concept. How do researchers define hardiness?

Paul Taylor:

Yeah, look, it’s a bit of a close cousin to resilience and often they’re used interchangeably in the research, but they’re actually not the same. Resilience is more of an outcome. It’s about bouncing back, but it doesn’t tell you how to get there, hardiness actually does. So it was first identified by Dr. Suzanne Kobasa and Dr. Salvato Maddi in the 1970s and really explains why some people thrive under stress while other people crumble. So they did this landmark 12 year study at Illinois Bell and Telephone company, and they were going through a corporate crisis. And they found that over these 12 years, about two thirds of the employees fell apart under pressure, but a third of them didn’t just cope, they actually grew stronger. And they found that these group, they shared three core attitudes, a challenge orientation, a control orientation, and a commitment orientation. So let’s look at each one of those.

Challenge orientation and hardiness is about seeing both change and adversity as opportunities for growth rather than threats. Control is the belief that you control or heavily influence your environment or your destiny. And in psychology we call that an internal locus of control, and it’s also about focusing your energy on what you can control or influence rather than feeling like a victim. And then the last is commitment. This is about being fully engaged in life and living with purpose instead of withdrawing or wandering aimlessly. Now these guys started the research, but other researchers like Paul Bartone, he’s a US Army psychologist and he’s great and he’s a bit of a mentor of mine in this area. He really expanded the research and he found that hardiness actually predicted who passed and who feels basic military training, and then found that hardiness predicted who passed special forces selection course.

And it’s then it’s been shown that hardiness predicts career longevity and high pressure careers such as the military, police and first responders. And so if resilience is about bouncing back, hardiness is about bouncing forward. It’s the process that creates resilience. And the benefits are huge as well as predicting success in high pressure environments, high hardiness scores predict better cardiovascular health, stronger immune systems, lower rates of anxiety and depression. And even kids who are higher in hardiness are much more likely to go to university independent of their socioeconomic status, which is pretty critical. And then in my own PhD research, we ran a six week hardiness intervention and we saw measurable improvements, statistically significant in mental wellbeing, in stress tolerance and hardiness as well as measures of cognitive performance. So we showed that you can learn it, it’s not just a trait you were born with, it’s a set of learnable skills. And I’ve added a fourth C that of connection, which I’m sure we’ll unpack a little bit. But really for me, choosing hardiness, like you said, is today’s version of choosing the path of rite. It’s committing to growth through discomfort both psychological and physiological. And the payoff is a life that’s not just longer but also fuller and more engaged and more meaningful.

Brett McKay:

So what you’ve done in the book, you’ve broken down hardiness to two parts. There’s psychological and physiological hardiness, and it seems like those three C’s you laid out the challenge control commitment. And then the fourth one that you’ve added connection. We’ll talk about that here. That makes up psychological hardiness. Correct?

Paul Taylor:

Correct. That’s right, yes.

Brett McKay:

Well, let’s dig deeper into these different components, these four C’s of psychological hardiness you mentioned. The first one is challenge. This is about seeing adversity as a challenge instead of a stressor. How can seeing stress and adversity in your life as a challenge as opposed to something just to upset you, how does that change your psychology and even your physiology?

Paul Taylor:

Yeah, look, it has a massive effect. It changes how we think, how we act, and even how ourselves behave. So at its core challenge orientation, this is about how we appraise stress. It’s the view we take of it. So when something tough happens, whether it’s you’re in a big project given an argument or some sort of a setback, your brain decides almost instantly is this a threat or is this a challenge? And that split second perception actually dictates both your psychological leaning and your physiological response. So if you view it as a threat, you go into avoidance mode. So you’re motivated to leave, to procrastinate, to run away. It’s the flight part of fight or flight. Whereas if you see as a challenge, it’s what we call approach orientation. In psychology, you actually lean in and then physiologically it’s very, very different. When you see as a threat, your body constricts your blood vessels, cortisol rises, your cognitive flexibility drops, and the chemicals that the major stress hormone is cortisol, and I’ll come back to that in a second.

But when you see something as a challenge, your cardiovascular system actually responds like it does during exercise, your blood flows freely, oxygen delivery improves performance and cognition actually rise. And this is the fight part of the fight or flight. Now, the chemicals involved in your body with a challenge orientation, it is about the hormones, adrenaline and no noradrenaline, which in your side of the ditch, they call it epinephrine and norepinephrine. Now the half-life of those chemicals is about a minute, and that means with about four half-lifes, that chemical’s out of your body. So within five minutes, your body is back to homeostasis. So same me and you both have the same situation. You view it as a challenge, your body is back to homeostasis within five minutes. With me, because I’ve released cortisol, the half-life of cortisol is well over an R. So that means that ours later, even when that challenge or threat is gone, my body is still in a stress field. I still have cortisol going through my bloodstream, attacking my organs and my brain. Now this isn’t just theory. There’s research by numerous psychologists that show that our mindset towards stress literally changes our biology. And people with a challenge orientation, they recover faster from stress, they got lower inflammatory markers and they performed better under pressure. And I recently interviewed professor Jeremy Jameson. He ran a series of experiments with college students before an exam, I think, do you call it the GRE Brett?

Brett McKay:

Yeah. To get into grad school.

Paul Taylor:

Yeah, that’s it. The one to get into grad school. And he told half of them that anxiety was a normal thing and it actually prepared their body to action and could translate into better performance. And the other half the control group, he told no such thing. And then they all did a mock exam. And the people who he primed that anxiety, this challenge orientation, they did better in the mock exam, but they also then did better in the real thing as well. So your perception influences your performance as well. And the stoics understood this. 2000 years ago, Seneca said “A gem cannot be polished without friction, nor a man perfected without trials.” And the idea is that the friction is the forge. Hardiness is about leaning into that friction deliberately. That’s the key thing.

Brett McKay:

Yeah, I think that’s a powerful concept to understand if you see your stress in your life, not as a threat, but as a challenge, there’s so many benefits to that. Any tips that you found? Research backed tips on how you can strengthen your challenge muscle? I mean, I think one you talked about is this idea of acceptance and reprisal.

Paul Taylor:

Yeah, yeah, yeah. So this is really key. It goes back to even the historics who talked about life being hard, the Buddha, the first noble truth of Buddhism is life is suffering. Well, the word is actually dca, which means hard to do. So it’s first of all accepting that life is going to be hard. And then it’s about accepting that you are going to come through challenges in your life. And I tell this to my kids, I say to my kids, life is amazing, but it is also going to be hard at times. And it’s about how you react to that. So first of all, it’s just accepting that life is going to be hard, that occasionally you will get shit sandwiches from the universe and that acceptance puts you into a state where you can then reappraise. This. Reappraisal is training your brain to interpret stress as fuel rather than poison.

I call it stress alchemy. When you feel that surge, the heart rate rising, your tension, instead of saying to yourself, I’m anxious, say I’m energized. That’s the key thing. And this is the psychological framing, and it’s basically the Stoics talked about life being a contest. So it’s about getting yourself up for the contest of life and seeing these things as challenges to actually test and develop you. So that’s really key. And that reappraisal of viewing stuff as a challenge rather than a threat. You can do it not just in the moment when you’re dealing with stress, but also you can look back on it and actually taking time for your listeners to think of times in your life that were really hard or stressful. And then looking back now, how did that benefit you? What was the silver lining that came? So you can do this arete appraisal two ways. One is viewing things as challenges, but then secondly, looking back on the hard stuff and going, Hey, what did I learn from that? How did I actually grow from that? And that’s really key.

Brett McKay:

Alright, let’s talk about that second C, which is control. It’s about having an internal locus of control. What can the stoics and Admiral James Stockdale teach about developing an internal locus of control?

Paul Taylor:

I love that. So I have a copy of Epictetus’s Enchiridion, which roughly translates as a manual for life. And the very first line of this is of things, some are up to us and others are not. This is really about the stoic dichotomy of control and it’s one of the most powerful psychological tools ever developed. Marcus Aurelius, he put it beautifully, you have power over your mind, not outside events. Realize this and you will find strength. And this is really what’s at the heart of the control component. When you’re in control orientation, you don’t waste mental energy on things you can’t change, whether it’s the weather, other people’s opinions, the economy or those sorts of things. You focus on what you can do and what you can influence. And that actually reduces our stress. It takes us out of victim mode and gives us some agency, right?

So the stoic said that we must focus on that which we can control and refuse to invest our energy in that which we can’t control. And a lot of people get into trouble psychologically when they’re investing their energy in stuff they can’t control. They’re in their own heads wishing their past to be different, wishing other people to be different, wishing the universe to orientate around them. These are all things that we can’t control. Now, Stockdale, I love that you mentioned Stockdale. He’s a bit of a personal hero of mine and he is a modern day stoic and he really embodies this control orientation. Now Stockdale, he was shot down over North Vietnam and he spent seven and a half years in the infamous Hanoi Hilton prison camp. And four of those years he was in solitary confinement. He was tortured on 15 separate occasions. But what kept him going was stoicism is specifically Epictetus’s Enchiridion that he had brought that to war with him when he got shot down.

He talks about this in a number of his books as he ejected out of his aircraft and he was coming down to land, he could see the Vietcong coming in to capture him. And he said to himself, I’m now leaving my world, the world of technology and I’m entering into the world of Epictetus. And he knew that he couldn’t control his captors or his circumstances or the torture, but he could control how he responded to it. So Stockdale famously, he took control of his mind. He maintained leadership over the other prisoners because he was the senior officer in there and created meaning within chaos. And it was that focusing on what he can control that was really central to his success in there and him helping his other fellow prisoners to get through. Now, studies in both military and organizational settings show that people who have a strong internal locus of control, they experience less anxiety, they perform better under pressure and they recover faster from trauma. And so it’s proactive rather than reactive. And you can actually train yourself into this way as well. You can develop your control muscle if you like.

Brett McKay:

Yeah. How do you do that?

Paul Taylor:

Well, it’s basically changing your narrative. So say you got pissed off about something, a lot of people will go, they made me angry or this ruined my day, or I had no choice in this. All of those things are handing away control. It’s actually about self-awareness is really the first thing. And reframing that in your head from they made me angry too. I chose to feel angry. I decided to let that affect me. Now that can be a bit uncomfortable at first and a bit awkward, but it really is incredibly I empowering because what you’re actually training yourself to do is to realize that you have a choice about how you react to things. That’s really key. And I think that another second practice is the stoic idea of visualizing your day. Now this might seem a bit pessimistic, but it’s actually really helpful. It’s basically the stoic excuse to Marcus really famously would do this.

He would think about all the things that could possibly go wrong, the bad people he would meet and what he would actually do for that. So it’s about mental rehearsal so that when the bad stuff happens, you’re actually ready to do that. And then it’s about doing little small daily acts is about making your bed properly, finishing your workout even when you don’t want to. Choosing the healthy thing rather than the unhealthy thing and then reflecting on it and going, Hey, I made a conscious choice. There are around control. Every little action just builds that muscle bit by bit.

Brett McKay:

Alright, so the third C is commitment. What is it about commitment that makes us more hearty?

Paul Taylor:

Yeah, so it’s interesting, there’s a number of different elements to commitment, but they all interact with each other. So it’s really about being fully engaged in life. And I am increasingly concerned about modern society, and I know you are Brett as well. I listened to your podcast that there’s an increasing amount of people who are spending an increasing amount of their spare time within the confines of four walls with their heads buried in a bloody screen, either scrolling on social media or watching crappy tv. These people are what I call passive consumers of life. And it’s the polar opposite to high hardiness commitment, high hardy, committed people are fully engaged in life, whether it’s their work, their relationships, their health or their learning. They’re people. You know these people because they’re curious, they bring positive energy, they derive their meaning from participation, not from results.

And I really think that this commitment, it’s a bit of an antidote to apathy. So in our culture it’s really easy to live that passive life of scrolling, multitasking, of numbing yourself with drugs and alcohol. But when you’re committed, you’re really present. And the stoics really talked about this as well, and Seneca said, it’s not that we have a short time to live, but that we waste a lot of it. And this is about whether or not you are fully engaged. Now, linked to that in commitment to orientation is a sense of meaning and purpose. And in Viktor Frankl’s book, Man’s Search for Meaning, which I read as a 17-year-old that had a pretty profound effect on my life. And he showed that those who survived the concentration camps, they weren’t the strongest or the smartest, but they were the people who were committed to a purpose that was bigger than themselves. And the hardiness research actually echoes that. Salvador Maddie found that people who were high in commitment, they kept deeply engaged in their work and their relationships under stress. They handle stress far better than people with low commitment and they actually experience a lot less burnout.

Brett McKay:

So what are some things we can do to develop our commitment muscle?

Paul Taylor:

So one is about really clarifying your values. And I think part of the problem in modern society is the decline of religion. Now, I’m not religious at all, I’m more of a spiritual person, but I think what religion does was it gave people a sense of shared values and meaning. And when that’s missing, if you don’t deliberately find it, people can end up in an existential vacuum. So it’s really about getting clear on your values, the stuff that is meaningful to you, and then it’s about creating systems around because motivation that will get you started. So this gets into another part of commitment to orientation, which is about being committed to your health. It’s not just about having goals, but it’s about having processes that will actually help you to get to the person that you want to be and ideally linking them to your values.

And then I like to get people to do what I call a tombstone statement, which is what would you like to be written on your tombstone that would sum up your contribution to society or your little corner of the universe? It’s kind of a morbid thing, thinking of how would I be thought of when I’m dead? But that is the thing that uncovers that deeper sense of meaning and purpose. So getting clear on your values and on your purpose in life and then trying to live intentionally using those values as a compass. These are the things that really help to drive that commitment orientation.

Brett McKay:

Alright, so you added a fourth C to these three Cs of psychological hardiness. That’s connection. What is it about connecting with others that makes us more psychologically hearty?

Paul Taylor:

Well, look, Brett, the human brain is essentially a social organ. And we need that social connection. We know that when somebody is lonely, it is as bad for their health as smoking 20 cigarettes a day. It takes 10 to 12 years off your life and it’s hugely, hugely important. We talked about Stockdale in the Hanoi Hilton. The thing that got these guys through when they were put in solitary confinement was they created this thing called the tap code where they could tap out the letters of the alphabet on the walls and the pipes and they created all this shorthand and the tap code was the glue that held these guys together. When you connect with somebody else, you release oxytocin and vasopressin in your brains. Now they’re the hormones of love, trust, and social bonding, but they are also the most potent anti-stress chemicals that human beings produce.

And decades of research on military veterans as well as people who’ve been through trauma shows that those who are socially connected, who have people that they can lean into, they suffer much less PTSD and suicide than people who don’t have those social connections. And it’s because we are evolved to survive and thrive in tribes. And social support is one of the most powerful buffers against stress that we have. I mean Paul Barone showed this on PTSD and also there’s a researcher, she showed the people with strong social relationships, they’ve got a 50% lower risk of premature death than people who don’t have those relationships. So connection for me is hugely, hugely important. And that’s part of today’s massive problem of Kaia is that we are massively digitally connected, more connected than we’ve ever been, but we are really disconnected when it comes from to face to face perspective.

Brett McKay:

Yeah, we had Derek Thompson on the podcast a while back ago. He wrote an article for The Atlantic about how it’s basically there’s no loneliness epidemic because people aren’t really feeling lonely because we have all of this technology that can basically, we don’t feel like we’re lonely and so we don’t feel like we have the need to reach out to people, but we’re still seeing the ill effects of not actually connecting with other people.

Paul Taylor:

When you do face to face interactions, it is very, very different to online interactions. And he makes a good point that we don’t actually notice it because we still think that we are connected. But there is nothing that replaces that face-to-face interaction. And other research has shown that it is about catching up with people in person. It’s about having good friends that you will see at least once a month. That is one of the real key things here.

Brett McKay:

So it takes intention. You have to be intentional about this because everyone’s schedule’s crazy. You’re not just going to run into your friends like maybe you would’ve done a century ago. You have to plan for it, you have to choose it.

Paul Taylor:

You absolutely do. You’re a hundred percent right Brett. And it’s not about waiting for other people to organize something, it’s about being the connector in your little corner of the universe. Taking that on board I think is really key.

Brett McKay:

Alright, so that’s psychological hardiness. So there’s the four Cs challenge orientation, have an internal locus of control commitments to being engaged, have a higher purpose that you’re going for and then connecting with others that can give you psychological hardiness. Let’s talk about physiological hardiness. And we had you on last time talking about your book Death by Comfort. And one of the things we talked about in that podcast was how hormesis can be the antidote to the damage that all this comfort is causing to us physiologically. For those who aren’t familiar with hormesis, what is it?

Paul Taylor:

So hormesis is basically it’s summed up by the words of Frederick Nietzsche, that which does not kill us, and I’m sure all your listeners can finish the sentence makes us stronger. And this goes back, it actually goes back to biology like core biology. Edward Calabresi first noticed in his PhD research he was giving pesticides to plants to try to kill him and seeing what was the smallest dose that would actually kill them. And he found that at small doses, the plants actually flourished when they were given small doses of poison. And that led him to a whole heap of research and other researchers that they enjoined in. That shows that when we are exposed to small intermittent doses of stress, we actually get stronger, more robust at a cellular level. So when your body is presented with stressors, something called the cell danger response kicks off.

And that is the cells actually responding to stress by upregulating protective pathways. I describe them in the book, there’s things like NRF two and HIF one, but these drive our antioxidant defenses, they make our mitochondria stronger and they drive cellular cleanup processes like autophagy. And it’s basically your sales saying, Hey, we’re under a bit of pressure here. We need to get fitter, we need to train for this eventuality. And so for me, physiological hardiness and psychological hardiness or physiological hormesis and psychological hardiness, they’re like two sides to the same coin. The hardy mind reframes stress as a challenge and the body uses stress as medicine. So we actually, because of exposure to small amounts of stressors, and think of the obvious ones like exercise, cold exposure, heat exposure, all three of these activate these stress response pathways and not just in humans, in fruit flies, in worms, in cats, in dogs, in rodents, all primates all respond to those stressors and fasting as well with an upregulation of these stress response genes that in humans switch on at least 300 protective mechanisms.

So the goal here is not to avoid stress, but it’s to dose it deliberately. So there’s a hermetic curve. If you don’t do anything, it’s bad for you. You start to do some of these stressors, it’s good for you, a bit more is better, but there is an optimal point where it starts to become too much after that. And so this is about dosing it deliberately and intermittently. And the ancient stoics, they did it with cold baths and fasting, and this is about stress inoculation, it’s about nature’s physiological hardiness because of exposure to stress and appropriate recovery. That’s the key thing. And it actually keeps us biologically young and adaptable.

Brett McKay:

So in the book, in the section about physiological hardiness, physiological robustness, you provide different forms of hormetic stress, stress that can be medicine for individuals. One of the most potent ones is exercise. And in that section you recommend that people focus on two markers of fitness, VO2 max and strength. Why those two?

Paul Taylor:

Yeah, look, they are really critical. Just before I dive into that, two legendary exercise physiologists released a paper, I think it was 2013, exercise prevents and or treats 26 common chronic diseases. That is just crazy. You imagine if the pharmaceutical industry produced a pill that would simultaneously reduce your risk of 26 chronic chronic diseases and that the reason is that it releases all of these mykines, which are signaling molecules. But to answer your question now, so your VO2 max, that’s your maximum oxygen uptake, how much oxygen you can take in and use, and it’s the gold standard measure of cardio respiratory fitness. And lots of your listeners will have heard of it. And if they have an apple watcher or Garmin or whoop band or an oil ring, it’ll actually estimate their VO2 max and then you can look up tables online to see where you are.

What we now know is that your VO2 max is the single biggest predictor of how long you’re going to live way above everything else. So there was a massive 2018 study I talk about in my book from the Cleveland Clinic that followed over 120,000 people who’d all done stress testing on their heart and had their VO2 max measured and they followed these guys, they were in their fifties or their sixties at the start and they followed them for 15 years and a bunch died and a bunch obviously didn’t. And then they went back and looked at the data 15 years ago around their VO2 max and they found that VO2 max was associated with dramatically lower all cause mortality and there was no upper limit that meant that the fitter people got the longer they actually lived. And it was way more predictive of future death and having heart disease or diabetes or high blood pressure, any of those things.

So it is about training for your VO2 max. So how do you do it? Well, first of all is a bit of a base of zone two training, and your listeners may have heard of this. It’s 60 to 70% of your max heart rate. Basically you can talk but you can’t sing. Now that’s a base, but you can’t just do zone two and hope to improve your VO2 max. That will really help your mitochondria. The best way to build your VO2 max is the Norwegian four by four protocol. So this is basically you do four minutes of all art exercise, you can pick any piece of equipment, a rower, a step or a treadmill, whatever, or you can just be out running and you go as hard as you can for four minutes to the point that at the end of those four minutes, your heart rate should be 95% of your maximum. That is like I’m almost dying. And then you recover for three minutes. You just sort of turn your legs over for three minutes and you do that four times. That’s the four by four protocol. That is the single best way to re your VO2 max. And you only need to do that once a month. That’s key. And then I think, did you ask about the second one, which was about strength

Brett McKay:

Training? Yeah, strength, yeah, strength training.

Paul Taylor:

Yeah. Look, I know you’re a big fan of strength training and the second biggest predictive of how long you’re going to live is your muscle strength. And it appears in the research to be muscle strength, not your muscle mass. Stronger people live longer and they stay independent for longer. And it’s because our muscles aren’t just for movement. I mentioned it earlier, they are endocrine organs. Your muscle is an endocrine organ that secretes these molecules called myokines that reduce our inflammation, improve our brain health, and improve the health of all of our different organs. So really it is about using that muscle. And we know that becoming stronger is protective against sarcopenia. That’s that loss of muscle and bone as you age. And that if you become sarcopenic in old age, it actually dramatically increases your risk of pretty much every chronic disease. So I’m a big fan that everybody who’s listening to this podcast should be lifting heavy.

I don’t care what sex they are, what age they are. In fact, the older they are, the more important it is to lift heavy. And a good program if people don’t do it would be just full body strength training sessions. Ideally three of those a week focusing on compound movements, the big lifts that use multi joints, things like squats, deadlifts, presses, pull-ups. Plus also I think it’s really important to add in single leg work like Bulgarian split squats or lunges because that stability is really, really important, especially as we age and especially if you get over 50 as well as single leg work, do some balanced stuff as well because what we now know is if you’re in your sixties and you fall over and break a hip or a pelvis, you got a 50% chance of being dead within the next five years. So the takeaway here is simple. You need to train your body to be hard to kill. Cardio makes you harder to kill from the inside out and strength makes you harder to kill from the outside in and together is this physical foundation of hardiness. I think we need to do both.

Brett McKay:

Awesome. So yeah, strength train three times a week and then get in some zone two cardio and then a HIIT workout. 

Paul Taylor:

Get comfortable with being uncomfortable with the Norwegian four by four and you can just look it up. It’s not pleasant, but it’s useful.

Brett McKay:

I do it once a week. Yeah. So another hormetic stress you talk about is light. How is light a stressor?

Paul Taylor:

So light is both, as I said, it’s a hermetic stressor so you don’t get any of it and it’s really bad for you. You get some, it’s good, you get more, it’s better. But there is an optimal point and everybody knows with sunlight that you could get too much sun and that can cause skin cancer. But what most people don’t realize is that if you have low vitamin D or even suboptimal vitamin D, which according to different agencies, between 70 and 80% of us globally have suboptimal vitamin D, if you have suboptimal vitamin D, it increases your risk of pretty much every cancer other than skin cancer. Now, if I take a step back and talk about light in general, we now know that light is a signal to our body and it triggers adaptation. So morning sunlight sets your shahinian rhythm, it boosts your serotonin, it anchors your sleep wake cycle and without it your hormones drift, your sleep quality tanks and even your metabolism suffers.

So as I said, low vitamin D levels, they’re not just linked to increased risk of cancer, there is a significant increased risk of cardiovascular disease, a massive increased risk of depression. And actually they’re finding increasing vitamin D acts like an antidepressant. People with low vitamin D have immune dysfunction as well. So I’m all about outcomes. So it’s about getting your blood tested and you want your level to be, if you’re in the states, 40 to 60 nanograms per deciliter, that’s what you use. Over here we use nanomoles per liter. So it’s between a hundred and 150 MLEs per liter, or if you live in the states, 40 to 60 nanograms per deciliter. Now the other thing is you’ve got to look at your skin tone. If your skin is darker or you live further from the equator, you’re going to need to get more sun exposure than people with light skin or who live closer to the equator.

And then when we get to red and near infrared light, that’s when things get really spooky. I mean, Einstein talked about quantum physics as spooky action at a distance and we now know that light has quantum effects on our cells. It’s just ridiculous. But rather than do a deep dive into that, I want to talk about how we use this therapeutically. So red light and near infrared, their wavelengths are between 620 and about 1,050 or more. So red light, which is that sort of 620 to 700 ish, that has a massive effect on your skin. It’s great for healing, it’s great for inflammation, it’s great for eczema and even childhood acne and even in adults, it has really good effects on our skin. It’s good for wound healing, it’s good for burns. They now treating burns victims with red lights straight away and then near infrared lights, which has a slightly longer wave of length, kind of 820 to 1,015 nanometers that actually penetrates through your skin and actually interacts with your mitochondria and triggers the activation of an enzyme called cytochrome sea oxidase.

That’s really important for the electron transport chain, and I don’t want to get too geeky in the physiology, but basically near infrared light stimulates your mitochondria to produce more a TP, the cellular energy, and that’s the fuel for everything in your body. And we know that having good efficient mitochondria protects you against a whole he of physical diseases. So really this is about driving this cellular agents of energy, your mitochondria through that near infrared light. And then as I said, the red light’s good for your skin, but also sunlight is also therapy as well. And then the darkness is really, really important as well for those circadian rhythms. When you change your sleep wake cycle, basically you mess with your circadian rhythms and you mess with your biology. Most people don’t realize, Brett, that your hormones run off circadian rhythms and lots of your cells do too. So when you mess with your sleep cycles, you’re actually messing with your biology.

Brett McKay:

How do you get red light near infrared light?

Paul Taylor:

Yeah, so you can get panels and masks and things like that. So they’re all available commercially and there’s a range of expense based on the size of them and the par and all of that sort of stuff. I get mine direct from China from a factor, it’s called red L led and it’s a lot cheaper and they will make a lot of the ones that American brands put their brand on and doubled the price from it. But I have a red and near infrared light panel and I used it. I had open heart surgery at the start of this year. I found I was born with a dodgy aortic valve and I think that red light and near infrared massively helped my recovery.

Brett McKay:

So another stressor you recommend is nature. Typically we think of nature’s, oh, it’s relaxing to be out in nature. How is nature a stressor?

Paul Taylor:

Well, it’s this balance of stress and recovery that’s really key and nature definitely falls up more on the recovery side. Now there are obviously there’s a bunch of challenges out in nature, temperature, variation, terrain, microbes, all of these things that can stimulate adaptation and they strengthen our immune and our nervous system. So we actually know that when you spend time in nature, if you go walk through the forest, you actually pick up some of the microbiome from the forest, even walking beside the sea. You’ll pick up some of the microbiome in the sea and it actually is good for us. There’s stimulation of it, but then spending time in nature can be hugely relaxing as well and can give us profound recovery. The Japanese, they call it shin Yoku or forest bathing as some people may have found. And when I was researching the book, I couldn’t believe how many research studies, there were studies around forest bathing and study after studies showing that spanning even 20 minutes in nature, lowers your cortisol, lowers your blood pressure, lowers your heart rate, and actually improves immune cell activity.

And then we have the microbiome connection that I talked about. So when you or your kids, they play in the dirt or the garden or you walk barefoot, you’re actually exposed to the microbes in the soil and they interact with the microbes in your skin and even in your gut. And that helps us to regulate inflammation and immune function. So we know that kids who live on farms, adults who live on farms have got much more diverse microbiomes than people who live in cities. This is linked to something called the hygiene hypothesis, that basically our obsession with cleaning and disinfecting everything has actually weakened our immune systems and increased rates of autoimmune disorders and allergies. And an interesting little tidbit for your listeners, Brett, I live in Melbourne in Australia that has the highest rate of allergies anywhere in the world. And you know what they’ve linked it to.

Melbourne also has the highest rate of cesarean section birth anywhere in the world. And what we now know is that being born cesarean section completely changes the immune system, mostly through the gut microbiome. Having a natural birth actually triggers the activation of the immune system. So that time in nature is hugely important. And then there’s this whole idea of grounding or earthing, which I used to think was woo woo. But again, looking into the research, there’s actually a lot of physics behind it that basically when your feet or your body is in contact with the earth’s surfaces, the electrons on the earth, they have biological effects. Now the research is pretty early, but it’s very, very interesting. And there is evidence increasing, evidence of improved sleep, reduced inflammation from grounding our earthing and probably it’s due to changes in our autonomic nervous system and stress as well. So just getting out, spending some time walking, getting your feet, your bare feet on the surfaces of the earth, grass, sand, rock, whatever, actually reconnects us to the world and resets our electric charge. It’s pretty bonkers, but it is real.

Brett McKay:

And one prescription you give people to get more time outdoors is following the nature pyramid. We’ve written about this on the website, it’s really cool. So it’s the 20-5-3 rule. So you want to get 20 minutes in green space three times a week, five hours in a semi wild environment once a month and then three days completely off grid annually. So that’s like a camp out or something. And that’ll give you enough nature that you need for overall health and wellbeing.

Paul Taylor:

Yeah, I love that. I love the stuff that’s just simple that people can go, yeah, you know what, I can do that. And I tell you what, if you do that 20-5-3 prescription, you will notice a significant effect.

Brett McKay:

Going back to that balance between stress and recovery, you talk in the book about nutrition and you focus on a few things that are essential for health and strength. You talk about avoiding ultra processed foods, which is something we discussed the last time you’re on the show. You talk about protein, how essential protein is people should aim to get at least 0.7 grams per pound of body weight. It’s often better to get more, get a gram per pound of body weight. And then you talk about the importance of omega fatty acids. What are omega threes and why are they so important for hearty health?

Paul Taylor:

They’re essential and they are structural fats for your brain and they’re also very potent anti-inflammatories for your body. And I really encourage people to get their omega index tested. You can do this at omega quant QAN t.com. I’ve got no association with these guys whatsoever. They just do brilliant testing. So they’ll give you an omega index or an omega score. It’s the amount of omega threes and percentage of those fats in your rare blood cells. And what we now know is that if people with a score of 8%, they live about five years longer than those who score around 5%. Like you show me some one thing in nutrition that can extend lifespan by five years. I don’t think there’s anything other than omega fatty acids. And what we now know is that the Japanese, on average, their omega index is about 8%, Americans is about 5%, and the Japanese live five years longer than the Americans.

So we really need to increase our omega index and we can get there if you eat lots of fish. That’s why the Japanese have it, particularly fatty fish, salmon, sardines, anchovies. But a lot of people will have to be supplemented. If you’re not eating fish three or four times a week or more, you really got to supplement and about two grams of high quality fish oil or if you’re plant-based algal oil, the stuff algae, the stuff that the fish feed on, that is actually a really good way to reach your omega fatty acids as well. And I think as well as minimizing ultra processed foods, they are the two most powerful nutritional interventions you can do.

Brett McKay:

Yeah, something I’ve been doing lately for the past couple months is I’ve started eating anchovies and sardines. As a kid I was like, that’s gross. That’s what grandpas eat. But then Michael Easter, he had an article on a substack about you need to eat more small fish. I was like, okay. So I went to Whole Foods and bought some cans of sardines and anchovies and they’re not bad. They taste like tuna fish, anchovies a little salty, but I try to get two to three of those a week and it’s easy and it’s cheap. It’s not that expensive.

Paul Taylor:

Yeah, that’s right. And I’m a fan of eating anchovies, and I think it’s useful to explain to people why small fish, small fish don’t live as long the big fish, particularly big fish like tuna, you’ll find that they tend to have more heavy metals in them, more mercury, because they eat lots of small fish. So having the small fish like sardines and anchovies is a really good way to do it.

Brett McKay:

So you wrap up the book by revisiting the Myth of Hercules, and you frame your recommendations using Hercules’ mythical 12 labors, and they’re kind of a summary of the principles we discussed. So let’s end there. What are the Herculean labors a modern person should undertake to live a life of arete?

Paul Taylor:

Yeah, look, the first one I think is overarching and it’s actually forging the hardiness mindset. This is that actually choosing to see change and adversity as opportunity for growth just as Hercules did then it’s embrace life’s challenges. And I love this idea that stoics talked about life as a contest. The Olympic games are upon us, and I think we need to view life as a contest and actually get into the contest with passion and view all of these challenges as little tests of your character and wake up every day and go, you know what? I’m ready for the contest. I think that’s really key. Then it’s focus on the stuff that you can control. Don’t invest your energy in the stuff. You can’t get committed to life. Be fully engaged in life. I get people to look at their screen time and if you are spending three Rs or four hours of your life on screens extrapolated over your lifetime, that’s like 10 to 15 years of your life with your head buried in a screen.

So it’s, for me, it’s about choosing to engage fully in life. And then the other say about connection, having meaningful face-to-face interactions with friends. And then the rest of it is really about that physiological hardiness is actually engaging in these deliberate stressors of exercise, of heat, of cold exposure, of nourishing your body when you’re eating, of exposing yourself to beneficial light and then making sure that you recover. But the key for me, Brett, I think the last thing that I’d like to impart to your listeners is that recently scientists have roughly estimated our chances of ever having being born, and they reckon it’s about one in 400 trillion. And if you think about it, all of your ancestors way back to your homo Habilis, homoerectus ancestors, they all had to survive in order for you to be alive. Somebody probably survived the plague in England, one of your ancestors, somebody probably survived just World War I or World War II. But this is the thing is waking up every day and going, I have won the greatest lottery ever. I’ve had a one in 400 trillion chance of being alive. Let’s not waste it and let’s embrace the contest. I think that’s the key thing.

Brett McKay:

Well, Paul this has been a great conversation. Where can people go to learn more about the book and your work?

Paul Taylor:

So the best place to go would be my website, which is paultaylor.biz. You can get the book there. You can also get the book on Amazon and also my podcast, which is the Hardiness podcast. I think if you’re interested in this, there’s going to be a big deep dive on hardiness in that podcast.

Brett McKay:

Fantastic. Well, Paul Taylor, thanks for your time. It’s been a pleasure.

Paul Taylor:

Thank you for having me on again, Brett, and love your work. Absolutely love it.

Brett McKay:

Thank you so much. My guest was Dr. Paul Taylor. He’s the author of the book, The Hardiness Effect. It’s available on amazon.com and bookstores everywhere. You can find more information about his work at his website, paultaylor.biz. Also, check out our show notes at aom.is/hardiness where you’ll find links and resources to delve deeper into this topic. 

Well, that wraps up another edition of the AoM podcast. Make sure check out our website at artofmanliness.com. Find our podcast archives and check out our new newsletter. It’s called Dying Breed. You sign up at dyingbreed.net. It’s a great way to support the show directly. As always, thank you for the continued support. Until next time, it is Brett McKay reminding you to not only listen to the podcast, but to put what you’ve heard into action. 

This article was originally published on The Art of Manliness.

An important part of manhood has always been about having the competence to be effective in the world — having the breadth of skills, the savoir-faire, to handle any situation you find yourself in. With that in mind, each Sunday we’ll be republishing one of the illustrated guides from our archives, so you can hone your manly know-how week by week.

Your snoz is full of blood vessels, and nosebleeds happen when they incur some kind of damage. That damage can come from vigorous nose picking or blowing, outright injury (as in taking a punch to the face), or, very frequently, from exposure to dry air (whether via the outdoor climate or indoor heating). Nosebleeds are particularly common in children ages 2-10, but can occur at any age.

We don’t often see our blood outside of our bodies, so that when a nosebleed occurs, it can feel a little alarming. But unless nosebleeds are extraordinarily heavy, accompanied by other symptoms like high blood pressure and trouble breathing, last longer than a half hour, and/or happen more than twice a week, they’re almost certainly harmless. They’re just messy and annoying, so that you want to stop your own, or your kid’s, as soon as possible, by following the instructions above.

To prevent future nosebleeds, it helps to keep the nasal membranes moist by putting a humidifier in your home/office, using a saline spray 2X a day, and/or applying Vaseline inside the nostrils. More frequently occurring nosebleeds may need to be addressed through cauterization.

Illustration by Ted Slampyak

This article was originally published on The Art of Manliness.

An important part of manhood has always been about having the competence to be effective in the world — having the breadth of skills, the savoir-faire, to handle any situation you find yourself in. With that in mind, each Sunday we’ll be republishing one of the illustrated guides from our archives, so you can hone your manly know-how week by week.

If you’re physically active, you’ve likely rolled an ankle now and again. Ankle sprains come in two types: an eversion, in which the ankle rolls outwards, and an inversion (by far the most common type), where your ankle rolls inwards. Either kind of sprain results in the painful stretching or tearing of ligaments. When you sprain an ankle, you should immediately ice it, compress it, and elevate it to reduce swelling and inflammation.

But when can you start walking or even running again after you’ve sprained an ankle? The answer varies depending on who you ask. Many physical therapists and sports doctors recommend that you don’t resume physical activity until your ankle no longer hurts when you take a step. Depending on the severity of the sprain, that could take weeks.

Other physical therapists and sports doctors suggest that movement may in fact speed the healing process, and that walking and even running can resume less than 24 hours after a sprain so long as the ankle is given support through proper taping. Taping limits the range of motion of your ankle, which reduces the chances of it spraining again, which allows you to continue to engage in physical activity while it heals. Taping also compresses the injured area, which helps reduce swelling and inflammation.

Sprains are rated as mild, moderate, or severe. With a mild sprain, the ligament has just been stretched. Your ankle feels stable when you put weight on it and just feels a little sore and stiff. With a moderate sprain, the ligament has torn a bit. Your ankle doesn’t feel entirely stable when you put weight on it, you can’t move it very much, and it’s swollen. With a severe sprain, the ligament has been completely torn. You can’t put any weight on it, can’t move it, and it hurts a ton. Taping an ankle to resume physical activity immediately after a sprain should only be reserved for mild to moderate sprains. For severe sprains, you need to stay off your ankle for a few weeks so that the torn ligament can heal. 

This article was originally published on The Art of Manliness.

Modern medicine has given us incredible tools to peer inside the body and spot disease earlier than ever before. But with that power comes a problem: the more we look, the more we find — and not everything we find needs fixing.

My guest today, neurologist Dr. Suzanne O’Sullivan, argues that our culture of over-diagnosis is leaving many people more anxious, more medicalized, and sometimes less healthy. In her book The Age of Diagnosis: How Our Obsession with Medical Labels Is Making Us Sicker, she explains how screening tests, shifting definitions of “normal,” and the rise of mental health labels can turn ordinary struggles or idiosyncrasies into problems in need of treatment. We dig into everything from cancer and diabetes to Lyme disease and ADHD and discuss how diagnosis really works, why screening can sometimes harm as much as it helps, and how to know when a label is and isn’t useful.

Listen to the Podcast! (And don’t forget to leave us a review!)

Listen to the episode on a separate page.

Download this episode.

Subscribe to the podcast in the media player of your choice.

Transcript Coming Soon

Brett McKay: Brett McKay here and welcome to another edition of The Art of Manliness podcast. Modern medicine has given us incredible tools to appear inside the body and spot disease earlier than ever before. But with that power comes a problem. The more we look, the more we find. And not everything we find needs fixing.

My guest today, neurologist, Dr. Suzanne O’Sullivan, argues that her culture of overdiagnosis is leaving many people more anxious, more medicalized, and sometimes less healthy. In her book, The Age of Diagnosis, How Obsession With Medical Labels is Making Us Sicker, she explains how screening tests are shifting definitions of normal and the rise of mental health labels can turn ordinary struggles and idiosyncrasies into problems in need of treatment.

We dig into everything from cancer and diabetes to Lyme disease and discuss how diagnosis really works, why screening can sometimes harm as much as it helps, and how to know when a label is and isn’t useful after the show’s over. Check out our show notes at AoM.is/diagnosis.

All right, Suzanne O’Sullivan, welcome to the show. 

Suzanne O’Sullivan: Thanks for having me. 

Brett McKay: So you are a neurologist and you’ve got a book out called The Age of Diagnosis, how Our obsession with medical labels is making us sicker and you’re making the case that in the past few decades we’ve developed this culture in the West where you have patients who are actively seeking.

Medical diagnoses for things they might not have thought about addressing a few decades ago. And this might actually be doing us more harm than good. And so in your book, you talk about over-diagnosis. What do you mean by over-diagnosis and why is it a problem? 

Suzanne O’Sullivan: Yeah, so I think the definition of over-diagnosis is crucial here because I think a lot of people, if they hear over-diagnosis, their mind immediately goes to this idea that, oh, there’s nothing wrong with that person.

They’ve been diagnosed and, and they’re complaining about nothing. But that’s really not what over-diagnosis is. Over-diagnosis could mean that someone is really suffering and they definitely have a problem. But that medicalizing, that problem is doing more harm than good. So if I give you a couple of examples, it can happen in different ways.

So one way that over diagnosis occurs is over detection. So now we’ve got all these amazing tests we can do. We have MRI scans, we have blood tests that weren’t available decades ago. The consequence of those tests is that we can pick up diseases and abnormalities at earlier and earlier stages. And when we do that, we usually treat everything that we find, but not everything that we find was inevitably going to cause a medical problem in the long run.

So not everything we find actually needs to be treated. So that’s kind of over-diagnosis by over detection, treating things that are there but did not necessarily need to be treated and wouldn’t have caused health problems if left alone. And the second way that we get over diagnosis is through over medicalization.

So that’s where you begin applying medical labels to things that may really just be ordinary types of suffering. So that may be giving mental health labels, for example. To people who are genuinely suffering. But it may be that that suffering is better addressed through examinations of life, such as, you know, changing your work circumstances or changing your relationship rather than referring to that suffering by a medical label.

So it’s really sort of, overdiagnosis doesn’t mean that a person doesn’t have a problem, but it’s asking the question whether referring to that problem as medical, is that really the right thing to do? And I also want to, I, my. Terrible talker, and you may often need to interrupt me, but at the, at the outset you said that we are seeking this out.

I have to say that that’s not my perception. I think it’s a kind of a collusion between scientists and doctors and the public. We’ve got tests and we want to do them, and we want to find diseases at earlier, earlier stages. We are calling people forward to be medicalized, but people are equally coming forward quite willingly and allowing that to happen to them.

Brett McKay: Yeah that was one of the big takeaways that I got from your book was that one of the reasons why this overdiagnosis is happening is that we just have these tests that are available to us that weren’t available decades ago. And I think what it’s done, and you talk about this in the book. Is that it’s really maybe distorted the lay person’s idea of how a diagnosis is supposed to work.

Because I think now with these tests, we think, well, you just take a test. You do the MRI, you do the blood test, maybe answer a few diagnostic questions, and then the doctor gives you this definitive diagnosis. But you argue with any medical diagnosis, there’s. An interpretive element to it. It’s not just this objective test.

Can you explain what people misunderstand about how diagnoses are actually made? 

Suzanne O’Sullivan: Yeah, so I mean, a diagnosis is much more of of a clinical process, so that means that you have a complaint, it’s a pain, or it’s a lump, or something along those lines. And through the doctor listening to the story of what happened to you and examining you, they form a theory about what the diagnosis might be and then the test.

And I think people often think the test is then done to make the diagnosis, but really the test is done in order to help with. The clinical diagnosis a doctor has already made. Now, the important distinction here is that tests are meaningless without that first part of the stage. And I think MRI scans are a great example of this.

So I have to always remind people that MRI scans only came into regular clinical use in the 1990s. So. We’ve really only been using them in clinics for actually a relatively short amount of time, and the early MRI scanners weren’t very strong. So the new scanners have only been around for 10 or 20 years.

Before we had an MRI scan, it wasn’t possible to look. Inside a healthy person safely. We didn’t know what the inside of a healthy body looked like. ’cause you wouldn’t do a CT scan, a CAT scan, which is the predecessor really well still in use. But you wouldn’t do a CAT scan on a healthy person because it comes with a big dose of radiation.

So you only did CAT scans if you really needed to. The consequence of that is we didn’t really know what the inside of the healthy body looked like until we began doing regular MRI scans, and we’d never seen the inside of the healthy body in high definition until we got the MRI scan. Another thing I remind people then is look at how different we are on the outside.

Most of us have two eyes, two ears. You know, we, we are basically the same, and yet we are completely different on the outside. We are also different on the inside. So we suddenly have this technology that allows us look at the inside of the healthy body as we never could before, and we’re suddenly finding all these differences that we quite frankly just didn’t realize were there because we’d never looked at the inside of a healthy body before.

So in the same way that some of us have big noses and some of us have small noses and some of us have birthmarks and you know, other kind of outward differences. We also have inner differences that really don’t matter in any way to our health. The minute you do a test, be it an MRI scan or a blood test or, or almost any test, you begin finding all these irregularities by the time you get into your fifties.

About 50% of people have an abnormality on their MRI scan. So what I’m trying to point out is that these tests will pick up loads of little things that doctors call incidental omas. So just incidental findings that don’t matter to a person’s health. So the thing you find on the scan is not making a diagnosis, it is being taken in the context of the story you told your doctor and what your doctor found when examining you.

And then the doctor dismisses or places emphasis on what they found in the test based on that story, the test. Produce red herrings all the time, and this is the case for almost every type of test. So doctors are constantly filtering through those red herrings based on the quality of the story that they got from you.

So it’s not really a case of that you go to your doctor and they ultimately do the test to make the diagnosis. They’ll make the diagnosis clinically, and then they’ll use the test to help them. So it’s a real art, but the story is still really central to diagnosis. 

Brett McKay: Have you noticed that younger doctors who have gone to medical school where these tests existed, they rely more on the tests than maybe an older doctor who didn’t have these tests when they were coming of age?

Suzanne O’Sullivan: Yeah, I absolutely have noticed that actually, and it is a concern. You know, I’m sort of, unfortunately, I hate to have to admit to it. I’m getting into the older doctor territory now. You know, I’m in my fifties and I qualified as a doctor in 1991, so I qualified just before we had a real kind of technological explosion.

And I think doctors of my era understand the clinical art and its importance a little bit more. Not in all younger doctors, but recently qualified doctors have all these incredibly high tech tests at their fingertips, and I’m not sure that they’ve learned the art of using them as well as they could always.

Of course, there’s many. Excellent doctors, but also there are doctors dependent on technology when I think really technology is a kind of an aid rather than something you should be dependent on. 

Brett McKay: Yeah, I noticed this. So I had a general practitioner for a long time. He was an older guy in his sixties, and at the physical we do blood work, the typical thing.

And sometimes he’d say, well, here’s this thing. It’s a little. Out of the normal range, but uh, it’s not a big deal. And he’d ask a few questions, are you experiencing any of the issues? I’d say no. And he’d say, okay, we’ll just keep an eye on it, but you’re fine. Well, he retired and then I got this new general practitioner when she was younger.

She was younger than I was. That’s a weird moment whenever your doctor’s younger than you. And I went in to meet her and she’s like, well, while you’re here, let’s just do some blood work. And I’m like, okay, whatever. Sure. And we did it, and there was some stuff that came back abnormal, not super out of the range.

And she said, okay, we gotta do more tests. I’m worried about this. And I’m like, wait a minute, I don’t. I don’t think there’s a problem. I’m not experiencing any things. She’s like, no, we have to do it. And for a while there I was kind of spooked. I thought, oh my gosh, maybe something’s really wrong with me. I don’t know.

But it was interesting. I saw that difference between a younger doctor. And the older doctor, maybe that’s just a situation where as she gets more experience, she won’t be so test happy. 

Suzanne O’Sullivan: Yeah, I think that probably is the case. You know, I think medicine is still really one of those careers where maturity makes a really big difference to how you practice.

You learn from, you know, what you see regularly and you will become a little bit less trigger happy with tests. But your story really, it illustrates the exact problem is if you do enough tests, you’ll find irregularities, especially as we get older. If I do blood tests in people in their sixties, I’ll rarely find that I get a hundred percent normal tests back.

There’ll be lots of little irregularities and that can really send a person down a rabbit hole, you know, ’cause you have a test to check the test and then that test shows something. And I’ve seen quite a lot of people going down that sort of medical rabbit hole that led nowhere. And a lot of us would shrug it off.

You know, most of us would just say, Hey, you know, it’s, you know, you’re a little bit worried, but it’s probably nothing. But it can take over some people’s lives. It can be very anxiety provoking. It can also have a lot of practical impacts on people in terms of insurance and things like that. So we, we do need to be, I think sometimes people don’t know what a good doctor looks like.

And I would say to people that good doctor isn’t the doctor who, when you go to them every time you tell them you have a pain or an ache somewhere, they do a test. That to me, isn’t the good doctor. The good doctor is the one who listens to you and understands when to do tests and when not to do tests.

If they do tests every time, then that’s a situation that concerns me. 

Brett McKay: One of the arguments you make in the book is that doctors should only give a diagnosis whenever it would be useful. What makes a diagnosis useful or not. 

Suzanne O’Sullivan: So again, you know, we’re doing all these tests and we’re constantly turning up irregularities, and it’s really part of the clinical acumen of a doctor to know how to communicate.

That to their patient and, and, um, what a patient can understand. So I, I think I use the example in the book. We can do a lot of genetic tests now and people with children who have learning problems can have quite extensive genetic tests done that sometimes show up. These things that we call variants of uncertain significance.

So again, we’re, we’re talking about a test here that’s only been around for 20 years and is turning up results that we don’t understand. And in the world of genetics, if you get a result you don’t understand, you call it a variant of uncertain significance. Now imagine you had a a two year-old child who’s struggling a little bit.

You get genetic tests and you’re hoping, those genetic tests will either tell you, you know, this is the problem, or there is no problem, and instead you get that middling answer, oh, your child has a variant of uncertain significance. Now nobody knows what that means. Could be absolutely nothing, could be something.

The question that I’m really asking is if that test result. Tells you nothing. Is it information that I need to pass on to you? I don’t think there’s a right answer to this question, by the way, because I think it depends on the doctor and the patient and their interaction. But if it’s possible that this test result that I got back that I don’t understand at all, and that might be meaningless and that I can’t really explain to you because it’s clinical significance is unknown.

If I pass that on to you and you spend the next 20 years. Terrified for your child’s health. Have I really done you a favor? Or if I withhold that information, am I being paternalistic and withholding information? You might want to know. So I think there’s a real delicate balance in medicine about what information you share and what you don’t share.

Because our job is not to find lots of irregularities that we don’t understand and then scare the living daylights out of our patients, which is becoming increasingly easy with all the tests we have available to us. 

Brett McKay: So in the book you talk about different areas where we’re seeing over-diagnosis happen.

Let’s talk about over-diagnosis in cancer. So I think all of us have probably seen reports that cancer rates are increasing, particularly among young people. Do we know if cancer rates are actually increasing or is that we’re just catching more cancer because we’re doing more screening? 

Suzanne O’Sullivan: Yeah, I think there’s pretty good evidence that cancer rates are increasing.

So if I make the distinction between symptomatic cancer, so symptomatic cancer is something you found a lump where there’s blood or there’s pain, you know, so you have a symptom that draws your attention to the cancer. And then the second type of cancer I’m gonna talk about is cancer found on screening.

And that’s where you are 100% healthy. You’ve been called forward for screening, and someone has. Found something that you didn’t know was there. So the first kind of cancer, symptomatic cancer that is increasing, you know, there is evidence that people under the age of 50, younger people than ever before are getting cancer.

So I do think there’s a real increase in cancer rates. Maybe it’s related to lifestyle, diet, obesity, et cetera. But we also have a problem of. Overdiagnosis in this group of screened cancer. So this is where people are being called forward and having mammography or blood tests to try and detect cancer that they haven’t detected because they’re perfectly well.

This type of cancer is subject to huge overdiagnosis, which I think it might be a little confusing to people, but we’re back into that sort of territory of. The inside of the healthy body is riddled with little irregularities. And until we got the technology to find them, we didn’t know that people lived out their lives with these super early looking cancer cells that never grow and never cause health problems.

So if you do autopsies and lots of people who died for other reasons, you find little. Abnormal cells that would be technically considered to be cancerous, but they never grew enough to cause health problems. The problem is when you do screening, you find these irregularities. They were always there. They were there in previous generations.

We didn’t know they were there in previous generations because we never looked at at them. We started screening and say the 1970s. Pre 1970s, we didn’t know that people lived out their lives with little abnormal cells that never go into anything dangerous. Post screening. We’re now finding these things, but we cannot tell the difference between an abnormal cell that will become malignant, life-threatening cancer, and an abnormal cell.

The won’t become malignant life-threatening cancer. And the consequence of that is we kind of have a tendency to treat all of them as equal when they’re not really equal. So a lot of people who are treated for cancer and screening probably would’ve been perfectly fine if we never treated them. I hasten to say, I don’t want to put people off from screening with this conversation.

You know, if they’re screening programs, it’s reasonable for people to present themselves for that, for that, but they need to know. About the uncertainties of the results so they can have a good conversation with their doctor about what they do if they got a positive result. So for example, if I have breast cancer screening and I was found to have an abnormal cell, I wouldn’t necessarily automatically say, well, I want, you know, all bells and whistles, cancers.

Tests and treatment, I might say, well, if it’s a very small localized abnormal cell and I know about these things, perhaps can we just do another scan in two months time and another scan two months time after that and see if it’s growing. So there are different ways of addressing these abnormalities when they’re found, and that’s what I want people to take away from this.

Brett McKay: Yeah. So a watch and wait. 

Suzanne O’Sullivan: Exactly. A watchful waiting. 

Brett McKay: What’s interesting though, with all this, and this is kind of counterintuitive ’cause I, I had a hard time wrapping my head around this, is that overall mortality rates for cancer are down. And so people would think, well that’s because, you know, we’re just catching this stuff earlier.

So the early screenings work, but that’s not entirely what’s going on. So what is going on? 

Suzanne O’Sullivan: Well, it’s a little bit a mixture of things and it is kind of a hard thing to wrap your head around. Certainly people are surviving from, say, symptomatic cancer, so cancers that unequivocally need to be treated.

People are surviving better because cancer treatments are better. You know, there used to be no treatment for melanoma. Now there is a treatment, so, you know, treatments for cancer are getting better. However, we also have these sort of really, um, kind of difficult to interpret cancer survival statistics from people who are getting.

Diagnosed with cancer from screening. So just imagine that you screen a thousand people for, for cancer, and let’s say a hundred of those were destined to get symptomatic cancer at some point in their lives, but you over diagnose 300 people and you treat all of those 300 people for cancer. Well, 200 of of those 300 were never going to get symptomatic cancer in the first place.

But if you now look at how successfully you treated those people, the results will look really optimistic. They were never gonna get cancer, therefore they didn’t get cancer and therefore they didn’t die of cancer, but they were never going to. Anyway, my hope I’m making sense here because it’s, yeah. It’s, you know, if you over-diagnose people with cancer and you treat too many people for cancer, you will make cancer survival statistics look a lot better than they actually are.

And that’s why a more useful way sometimes at looking at how successfully we’re treating cancers that are found on screening is to look at what we call all, all cause mortality. So you can look at one of two things. Did they die of cancer? One would hope if you’re overdiagnosed in cancer, that the answer to that question would be no.

So let’s look instead at this thing called all cause mortality. So deaths for any reason. And there was a really sobering study published, I think it was in the Journal of the American Medical Association in 2023 in which they looked at all cause mortality. People who’d been diagnosed with cancer and screening for a whole bunch of cancers like colon, prostate, breast, and they found that they had not prolonged any lives in most of the groups through cancer screening and the colon cancer group.

They had prolonged life by three months, but in the other groups like prostate and breast, people did not live any longer courtesy of their screening and cancer diagnosis. And the reason for that is if you’re over diagnosing, so you screen people. You save somebody’s life for sure. So you found somebody who had cancer that was gonna grow.

You found it, you treated it, you saved that life. But probably there are 10 or 20 other people who you treated who never needed to be treated, and now you have negatively impacted the health of those 20 people. So you’ve saved one person’s life, but you have. Affected the health negatively of 20 or 30 other people who might die of complications of treatment, for example.

So you’re saving some lives, but you are having a very negative impact on others. So it’s a kind of zero sum game, you know? Yes, some people are safe, but other people are given unnecessary treatment that is dangerous to them. 

Brett McKay: Yeah, cancer treatment is rough. 

Suzanne O’Sullivan: Yeah. You know, people always relate very strongly to the life that was saved in these questions because we all know people with cancer and we know people who’ve died of cancer, and it’s a very frightening thing.

I don’t think we think long or hard enough about the people who got the unnecessary treatment because. Radiotherapy, chemotherapy operations. These are really enormous things physically, but also the psychological impact of being told you have cancer is absolutely enormous. And then we’ve got the kind of financial impact in terms of insurance or jobs or applying for mortgages going forward.

So there’s, we’ve got a very kind of strong focus on saving that one life. And I think we have an unnecessarily kind of blase attitude to that overdiagnosed group. 

Brett McKay: One area in cancer where you see a lot of over-diagnosis due to screening. There’s a lot of debate around it. Is prostate cancer, why is prostate cancer so prone to over-diagnosis?

Suzanne O’Sullivan: Yeah. I mean, you know, so. Prostate cancer. It’s because the type of screening they do for prostate cancer at the moment. Now this will change and people are working on improving this, but at the moment the most common type of screening is just to measure a blood test for prostatic specific antigen. So this is sort of a, a blood test that if it is elevated, it doesn’t mean you definitely have prostate cancer, but it means that you could potentially have prostate cancer.

The problem with that test is it’s just completely unreliable. You know, I draw people’s attention to the fact that there is no national screening program for prostate cancer in the US or in the uk or in most countries in the world. And that’s because this particular test has such a reputation for over-diagnosis.

You know, studies are really different on these statistics. To give people a rough idea. If you screen a thousand men for prostate cancer using PSA, you will likely save one life, but you will probably find an elevated prostate in about 240 or 250 people. That’s a lot of men who are now kind of gonna go on a diag.

They won’t all be diagnosed with prostate cancer, but they will all be started on a kind of diagnostic odyssey of do they don’t? They have prostate cancer and tests and screening. A small number of them will have biopsies and. Small number of them will be told that they do have prostate cancer. But most of those never needed to know that because as men get older, a huge number of them develop cancerous cells in the prostate that never progress.

So there was an interesting study done in Detroit where the autopsies were done on people who had died in accidents and things unrelated in any way to the prostate. And they found that 45% of men in their fifties have abnormal cells in the prostate and 60% of men in in their. Might have that. Statistics might be slightly low actually, of men in their sixties have abnormal cells in the prostate.

So as men get older, they all get abnormal or a large number, get abnormal cells in the prostate. Once you start screening for that, using prostate specific antigen, you’ll over diagnose lots and lots of men. So the unreliability of the test is the reason we don’t do this now. I think the solution to this.

Is to screen the right people. So there are men who are at higher risk of prostate cancer than other people. People with family history of prostate cancer, for example. Um, black men are more likely to have prostate cancer, so you can still do screening. But screening is more meaningful if it’s done in people who are at high risk.

Whereas if it’s done in people with low risk, it can produce very unpredictable results. And also, if a person is really concerned about their health, they may still wish to discuss getting a PSA test with their doctor, but it’s important they know before they have that test done. How. Uncertain. The interpretation of the results will be know yourself in a sense.

You know, are you the kind of person who if they get that abnormal result back, will struggle to live with that knowledge? Or are you the sort of person who can enter a watchful waiting program and not worry too much? So it’s all about knowledge, so you know what to ask, and knowing whether you can handle the information that you get back.

Brett McKay: Yeah, I got an example of someone who had a deleterious outcome because of a PSA test. So he is in his fifties. Got the PSA, it was elevated and the doctor’s like, I’d like to do a biopsy. And for those who don’t know biopsies, they basically stick a needle through your rectum to your prostate and then extract some tissue.

And he’s like, I don’t want to, no, I don’t. I don’t think so. I don’t think I have prostate. I’m healthy. I don’t have a history of it. And the I said, no, you need to do it. And so he, he did it and he ended up getting sepsis from the biopsy. And he was in the hospital for a few weeks and he didn’t end up having prostate cancer.

There was nothing there. 

Suzanne O’Sullivan: Well that’s, that’s it. Precisely. I mean, you know, you will save the occasional life through this type of screening, but you will send a lot of people on this very, very unpleasant road of tests. So they’re working obviously very hard on, on proving this screening. And in the future I hope that things will be better, but at the moment, there is no national screening program for a reason, and that’s worth thinking about.

Brett McKay: We’re gonna take a quick break for your word from our sponsors and now back to the show. You mentioned colon cancer and there’s been more of a push in the past decade or so to get a colonoscopy, but I think the recommendation for the age to get your first one has been lowered. It used to be 50, now it’s 45, at least here in America. 

Suzanne O’Sullivan: Yeah. We don’t have colonoscopy as a standard screening tool in most countries. It’s usually testing for blood in your feces, and if there’s blood there, then that potentially is symptomatic cancer, but it could also be hemorrhoids. So that’s the usual type of screening that it wouldn’t be to go straight to colonoscopy because colonoscopies, you know that that’s an unpleasant test that comes with risks of things like perforation.

You don’t want to. Leap into that unless you have a family history. Again, we’re we’re, we’re always back to this sort of, these things need to be made. These decisions need to be made in the context of risk. It’s like, what’s your clinical story? What’s your story? What’s your background? If you’ve got a family history of colon cancer, then you’re in a high risk group, and then certainly colonoscopy is something you’d wanna consider.

But if you’re someone who’s very healthy with a very healthy diet, who is asymptomatic. Then that may be not something you want to consider. 

Brett McKay: Yeah, that’s something I’ve interesting. I’ve noticed America tends to be screening happy, like we love our tests and not so much in Europe. 

Suzanne O’Sullivan: Yeah. Well, do you know what we do fair bit of screening as well, but I, I think you’re, you’re right, we’re not quite as, I think it’s how to, a certain degree is how our health services differ.

You know, we, in the National Health Service in a way. I, I consider myself to be protected by the NHS from Overdiagnosis because, you know, there’s no, you can’t have a test on demand. We’re much less likely to have whole body MRI scans or to have MRI scans if you have no, or minimal symptoms and a. I’m quite happy with that term of events because the more tests you have, the more likely you are to find these incidental things.

And I think that once really sobering, um, study was in the New England Journal, I’ve forgotten the date of it now, but a very, very recent in the twenties roughly. And they looked at cancer diagnosis in high income countries like the US for example. Versus low income countries. And what they found was that, yeah, people live longer in high income countries.

Well that’s not surprising. You know, you, you don’t only have better healthcare, you also have better lifestyles, et cetera. But they found something else that is worrying. They found that much more people were being diagnosed with cancer in the high income countries than in the low income countries. But the cancer survival rates for those cancers were actually quite similar.

So. It seemed like a lot of people in high income countries, by virtue of having more tests and more high quality tests are being diagnosed with cancer potentially unnecessarily. No extra lives were saved by all the extra cancers being diagnosed. The paper estimated that, you know, for every cancer diagnosis, through all of this availability of technology, 10 probably weren’t necessary.

So, you know, I know that the NHS has a great deal of problems. It is. Needs to be a a lot better funded than it is, but there is something to be said for the lack of financial dealings between patient and doctor. You know, a patient comes to see me. The diagnosis is dependent on nothing but the story that they tell me.

I have no, they’re not my customer. I don’t need them to come back to me to be paid and so forth. And there’s something in this kind of financial transaction between patient and doctor that is, is potentially harmful. And I don’t think people always realize that. 

Brett McKay: Another area you talked about where there could be.

Overdiagnosis going on is diabetes. I mean that’s because the diagnostic boundaries have shifted in the past, I think, decade. What was that change and how has that led to overdiagnosis? 

Suzanne O’Sullivan: Yeah, so this is a trend in medicine in multiple different areas of medicine. So, you know, there’s lots of medical problems, which the diagnosis isn’t based on there being an abnormality.

It’s. Based on drawing a line between normal and abnormal, like what level of blood sugar are we willing to accept as normal? What level of blood pressure are we willing to accept as normal? And we’ve had this assumption in medicine that if we kind of keep moving, that if we can detect more and more people with borderline diabetes or borderline hypertension.

Or borderline obesity, borderline mental health problems, that we will help more people and therefore we keep adjusting the line between normal and abnormal to diagnose more and more people. So I think it was in about 2003, we had created this condition called pre-diabetes. So this isn’t diabetes. This is a kind of borderline state between being perfectly healthy and potentially going on to develop diabetes.

In 2003, they made this slight adjustment. To the measure that would allow a diagnosis of pre-diabetes and then a fasting blood glucose. You fast, you have your blood sugar taken. And on one day in 2003, if you had a measure of 6.1 millimoles per liter of fasting blood glucose, you were healthy. But then they adjusted that and said, no, 5.6 will be the new cutoff.

So it’s just a small change, you know, one day. 6.1 is normal. The next day, 5.6 is normal, but the result of that is that if the changes in the way that pre-diabetes was diagnosed was applied to everybody in the world, this small adjustment along with some other changes in how the diagnosis made would mean that half of Chinese adults would be pre-diabetic and a third of us adults would be pre-diabetic.

So. You are sitting at home minding your own business essentially, and you feel you’re perfectly healthy. And meanwhile, somewhere in the background, a committee is convening and deciding, you know what, what counts as normal glucose? And on a Monday they change it and suddenly you are. No longer healthy.

Now you are a patient, and this is done with very good intention. It’s because, well now we’ve recognized loads of more people with pre-diabetes, we can stop people getting diabetes. The problem is that it’s not working. The rates of diabetes are rising all the time. Even though for 20 years we’ve had escalating diagnoses of pre-diabetes, and this is really the absolute definition of overdiagnosis, is you identify more and more and more patients.

But you’re not actually making people healthier. And it may be that they’re not following the advice that they were given, for example, but what is clear is that this kind of growing, um, group of people with pre-diabetes is, is not benefiting them to know that. 

Brett McKay: Yeah. And it’s essentially about pre-diabetes.

It’s in this weird gray area ’cause it’s not officially a diagnosis, but then people treat it like a diagnosis. They think of themselves as a patient. Well, I have pre-diabetes and I have to do certain things to make sure I don’t get full-blown diabetes. 

Suzanne O’Sullivan: Yeah, that’s it. It’s not actually a disease, pre-diabetes.

It’s like a pre disease state, but it sounds very much like a diagnosis and in one sense it could be a great thing. So it depends really on your mindset and your lifestyle and how you respond to news. You know, if I was told that I had pre-diabetes, then perhaps I would respond by improving my diet and exercising a bit more and trying to lose some weight.

And, you know, it could have a really positive impact on me. It could be a really good. Thing for my long-term health, but somebody else might respond differently to that. If you take a healthy person and tell them, you know, now because of this blood test, I consider you a patient. That can have a very negative impact on other people.

It can affect, if you turn a person into a patient, they can start behaving like a patient. They begin noticing things about their body. You know, being told that you’re unhealthy turns your attention inwards to your body. And then you start noticing little things and worrying about symptoms you didn’t worry about before.

You know, in a sense, the creation of pre-diabetes, we created it to protect people’s long-term health, but we’ve underestimated the impact of the news that you have pre-diabetes on a person, how that might affect their kind of self-concept and how it might affect how they feel about their body and so forth.

Brett McKay: Yeah, it threw me for a loop for a while, so I remember I had some blood work done. My fasting glucose was high. It was like 102, and I was like, oh my gosh. I got pre-diabetes and I even went out and I bought a glucose monitor, started measuring my glucose every day, and I’m like, I don’t know what I’m supposed to do.

’cause I exercise, I eat right, I don’t drink. I’m doing everything. I’m not overweight. And I remember I finally talked to a doctor, I was like, what do I do? I have pre-diabetes. And they’re like, well, let’s check your insulin, your fasting insulin looks good. So you don’t look like you’re on the road to diabetes.

Maybe your glucose just runs a little high. In the morning and that’s your normal. 

Suzanne O’Sullivan: Yeah. Well that’s it. You know, again, I kind of remind people of how different we are on the outside and you know, these sort of differences exist on the inside too, and it doesn’t have to be an abnormality. And in a sense you made the important point there, which is you are otherwise a very healthy person.

You know, these things have to be taken in context. If I was told I had pre-diabetes and I was also a smoker. You know, my father had heart disease and my mother had a stroke and I’ve also got borderline high blood pressure. Well then these are issues that need to be addressed. But if you’re otherwise a very healthy person with a borderline blood test abnormality, then you don’t necessarily have to be so worried about it.

So we need to take these things in context and, and not be terrified of every abnormal result. 

Brett McKay: You mentioned high blood pressure, uh, has undergone. Uh, a change similar to diabetes and how we define it? 

Suzanne O’Sullivan: Yeah, I mean, you know, uh, so there’s this thing sort of borderline hypertension, which I guess is the same as pre-diabetes.

You know, you, your blood pressure’s kind of in that border area. You’re not really hypertensive, but you could spill over into that region. The level of blood pressure required to have borderline hypertension just keeps shifting and. In the US Now, borderline hypertension is a measure of 130 over 80. Now, when I was in medical school in the 1980s, 130 over 80, you’d be delighted with that blood pressure.

That’s perfectly normal blood pressure. Whereas now if if it’s a little bit higher than that, you potentially. Could be offered. Well, you’ll definitely be offered lifestyle changes, but you could also be offered drug treatment for that, something which would’ve been considered completely normal two or three decades ago.

In Europe, we use a slightly more generous cutoff, more around 140 over 80, or 140 over 90, because these are arbitrary cutoffs. No one knows where normal blood pressure begins and ends. So committees of experts get together and make arbitrary cutoffs. And when they do that, when the change was made to decide that blood pressure should now be normal, up to 130 over 80 and abnormal above that, that immediately made a third of American adults a borderline hypertensive, which is just astonishing statistics.

Can it really be true that a third of adults in the US are borderline hypertensive? The purpose is good. The purpose is prevent heart disease, prevent strokes. But how many people with borderline hypertension do you have to treat to prevent a stroke? Well, that could be, if I treat every single person I meet with borderline hypertension, I might prevent.

You know, one stroke per per a thousand people, but I might treat 150 people who never needed to be treated. So you always, with these adjustments, you’re always saving somebody, but you are equally, you can be guaranteed. You’re overtreating a great deal. Many people. More people. So you’re probably, you know, per life save you’re probably overtreating a hundred and 150 people.

But that’s, you know, that’s okay if it’s just a little kind of reminder to be healthy. You know, if you are the person who goes to your doctor and they say you’ve got borderline hypertension, and then you go home and your lifestyle is suddenly transformed by the news, well then that’s been great for you.

And I don’t object to that. But you could be the person whose life is taken over by concern about your blood pressure or who goes on tablets and gets side effects that makes you sick when you weren’t sick before, or whose health insurance goes so high that you can no longer afford it. So we have to think both sides of it.

Brett McKay: Another area you talk about where there’s a lot of over-diagnosis is Lyme disease. Why is Lyme disease so hard to diagnose and why is it vulnerable to over-diagnosis? 

Suzanne O’Sullivan: You know what, uh, the first thing I’d say is I don’t think Lyme disease is hard to diagnose. Lyme disease is very well defined clinical criteria and you know, no test is a hundred percent reliable, of course, but pretty reliable.

Two stage blood testing, there’s two stages of blood testing you have to make the diagnosis. So actually, I’d say diagnosing Lyme disease. Is relatively straightforward. The reason it’s so overdiagnosed is twofold. One, because Lyme disease causes a huge array of symptoms, many of which are symptoms that any one of us could, you know, have probably experienced at some point in our lives, like fatigue, joint aches, and pains.

Just these kind of non-specific symptoms that are part of loads and loads of different medical problems, including psychiatric problems, but also physical problems and also aging. So these are super common symptoms, so that makes Lyme disease very available to overdiagnosis. If you go to your doctor tired and they can’t think of any other explanation.

Well, Lyme disease is one that can be provided if you are desperate for an explanation. That’s one reason I think it’s overdiagnosed. It’s in a world where people are suffering and want answers, it’s an answer. The other reason it’s overdiagnosed is because the tests are misused. Really. You know, as I’ve said before, tests need to be taken in a context.

The tests for Lyme disease have lots of reasons. You can have a positive test but not have Lyme disease. So if you spent your whole life, you grew up. Living beside a forest in Connecticut where there’s loads of Lyme disease, chances are that in childhood you’re exposed to Lyme disease and developed immunity.

And later in life, if you have a blood test, you can test positive for Lyme but not have Lyme disease. Or maybe if you’re sick in some other way, you’ll get a false positive on the test. So the tests are easily misinterpreted and you’ve got a disease that has symptoms that overlap with so many other things.

And you’ve got a society that needs explanations when they’re not feeling well, and if explanations aren’t readily available, then Lyme disease. Will account for quite a wide range of symptoms. Then you also have an element of corruption added in here. You know, if you have a diagnosis that is available to give to people who are desperate for an explanation and you work in as a private doctor in, in this area, then over diagnosing is very, very simple because of the uncertainties in the blood tests.

Brett McKay: Yeah, I thought it was interesting you talk about, there’s a surprisingly large number of people who have been diagnosed with Lyme disease in Australia, but Lyme disease, the bacteria that causes Lyme disease doesn’t exist in Australia. 

Suzanne O’Sullivan: Yeah, I mean, this really speaks to the problem, so, you know, e exactly that.

I mean the, the type of the climate in Australia, the type of ticks that carry the bacteria that cause Lyme disease, they can’t survive in Australia because of the climate, and therefore nobody has ever found the bacteria in any ticks that. In Australia, and yet there’s something like a half a million people in Australia who believe they contracted Lyme disease in Australia, which is fundamentally impossible.

And yet people are getting these diagnosis. But you know, there’s similar. Very high misdiagnosis rates in the us. So a specialist Lyme disease clinic reviewed the diagnosis of a, a large thousands, I think it was 5,000 people who had a diagnosis of Lyme disease. Went to this specialist Lyme Disease Clinic, and they determined that 85% of the people who thought they had Lyme disease did not have Lyme disease.

So this is a diagnosis that is overused at an enormous rate. It’s estimated that about 60,000 people test positive in a, in a proper lab that is making the diagnosis correctly in the US 60,000 people per year. And yet something in the region of half a million people are being treated for Lyme disease.

So the number of people being overdiagnosis is very high. And I think that’s because it’s an available explanation for symptoms that people struggle to explain. And I think it’s also because there is a problem with people. Essentially giving out slightly over exuberant diagnosis for monetary reasons.

Brett McKay: What do you think is going on with these people who, you know, they get the diagnosis of Lyme disease, but maybe they don’t have it? Like they do the test and they don’t, there’s like, okay, you don’t, there’s no way you could have Lyme disease, but they’re obviously suffering. You know, they’ve got the fatigue, the joint pain, brain fog.

Similar thing happened with people after COVID and they’re like, I got, you know, this whole idea of long COVID, they’re obviously suffering. So what do you think’s going on? 

Suzanne O’Sullivan: Yeah, I think, I mean, that’s a super important point to emphasize, which you just did, which is to say that someone has been misdiagnosed doesn’t mean they’re not suffering.

But yes, so there’s, at any one point in time, there’s a lot of people who are suffering with non-specific symptoms like headaches, difficulty sleeping, joint pains, tiredness, and those people will be given a diagnosis that sort of makes sense at a. Particular point in time, and as you said, during a COVID pandemic, if you have that collection of symptoms, you’ll be, could be told you have COVID or long COVID.

You know, if you live beside a forest filled with Lyme disease or in a period when Lyme disease is common, you be given Lyme diseases that diagnose for the exact same symptoms. What is going on with these people? Well, there’s a variety. People are probably just hard to diagnose. They have something that we have not yet fully understood, like an autoimmune condition that we don’t yet fully understand.

But I would suspect that the largest proportion of these people probably have what I would refer to as psychosomatic symptoms. So I’m a neurologist. This would be something I would see very often. So a lot of people in response to stresses or anxiety or difficult lives or unhealthy lives, develop non-specific symptoms.

So we’ve all had this experience. You know, if you’re stressed, you get a headache, or if you are. Just very tired or not looking after yourself, you’re more likely to pick up colds and flus, or you get aches and pains. So our bodies are very vulnerable to developing physical symptoms in response to psychological stressors, and very common symptoms in that context are things like tiredness and aches and pains.

I actually see people with much more extreme versions of this with seizures, paralysis, blindness, and so forth. I think a great, many of these people have psychosomatic symptoms, but we live in a society that. Looks down on psychosomatic symptoms. So you know, if somebody is very sick, if they’re bed bound because they feel so bad, they literally can’t get outta bed.

And you learn that the problem has a more of a psychological cause than a physical cause that’s looked down on, you know, we don’t have a lot of respect for that. And that pushes people into the need to find an explanation that society is more understanding of. And usually that’s a physical disease. So I think there’s a lot of people who have an array of physical symptoms that probably arise out of psychological distress, but which are diagnosed as a disease because that’s the culture we live in.

You know, psychological suffering is not respected to the same degree as physical disease. 

Brett McKay: And you talk about once someone gets a di, like a medical, a biological. Diagnosis for what could be psychosomatic. It causes the nocebo effect where you start paying more attention to your body and thinking, oh, this is actually, this shows that I have this thing.

And it just sort of creates this vicious cycle downwards. 

Suzanne O’Sullivan: Yeah, I mean, this is the problem with all the medical labels we’ve been talking about. This is the problem for the people with hypertension, the people with pre-diabetes, the people with cancer, et cetera, is that once you’re given a medical diagnosis, it, it can have, you know, it’s, everyone’s familiar with the placebo effect, which is if you given a tablet and you believe it will work, it can alleviate your symptoms.

The exact same happens in the opposite direction, referred to as the no sibu effect. So this is where you know, if you believe something will make you sick, it can make you sick. I always say to people, listen, there is examples of this in everyday life everywhere. You know, if you were about to sit down to your dinner in a restaurant and you turned around and you saw the chef. 

Coughing into the food, which immediately changes your experience of your body following what you’ve just eaten. You know, um, if you eat something and then you suspect it was unhygienic after the fact, you can start feeling sick. This is the most normal thing in the world. So imagine now that somebody has told you that you have a disease and that it causes, you know, X number of symptoms.

You immediately kind of look at your body and beginning examining yourself for those symptoms. And I guarantee you, especially as you get older, your body is awash with things to be found. If you pay enough attention, you know that aching knee that you know, it only lasted a day. Normally you’d dismiss it, but you’ve just been told you have Lyme disease, so now you.

Place a lot of emphasis on that aching knee, whereas you might not have worried about it yesterday or you know, some little mole on your skin suddenly gets heightened in your perspective through anxious tension. This is the problem with medical labeling, is it reinforces not in everyone, but in a percentage of people, it can reinforce symptoms.

By turning anxious attention to your body and really worrying less about your health is sometimes the answer. 

Brett McKay: There’s been an increase in mental health diagnoses in the past few decades. Are there actually rising rates of mental health issues or are we diagnosing people that maybe don’t need a diagnosis?

Suzanne O’Sullivan: Yeah, so it’s such a super hard question answer in the sense that it’s so hard to untangle. In in one sense, there does seem to be evidence that suggests that particularly in the group of adolescents to young adults, say age 16 to 24, there does appear to be more mental health issues in this group, for example, more than any other, and that means they’re more likely to go to the doctor with symptoms and also that they have more mental health symptoms.

But does that mean that there is more mental health illness in this group because that can be explained in so many ways. It could be that we’ve got all these awareness campaigns going now, often targeted at young people and awareness campaigns in schools that bring people’s attention to mental health problems.

So are they going to their doctor because they’ve been. Given express instruction to examine themselves for problems, and they’re finding things we wouldn’t have found before because we didn’t think that way. Are they more symptomatic because of the anxious attention that they’re paying to their moods, or are they genuinely more symptomatic?

So I think it’s really hard to untangle. To what degree is the fact that young people have more mental health problems there because we have created that through awareness campaigns, through telling people to worry about small changes in mood, or is it a real increase in mental health problems. But I think whatever.

Conclusion you come to on that you have to say that there is an over-diagnosis of conditions like ADHD, and autism. Now, again, I emphasize that when I talk about over-diagnosis, I’m not saying this person isn’t suffering and you should ignore them and tell them to snap out of it. That’s not my attitude.

I’m saying that. Adolescents sometimes have struggles, and by over-diagnosis, I mean medicalizing those struggles by referring to them through labels of ADHD and autism might be harmful to them. The reason I say there’s over-diagnosis is very hard to spot over-diagnose an individual. So let’s say you’ve got a 16-year-old and they’ve been told they have a DHD, and they’re validated by the diagnosis and they feel better.

Is that over-diagnosis or isn’t it? You can’t really tell. You can tell by looking at the population. So we’ve been making mental health diagnosis at escalating rates since the 1990s. We’ve been telling young people they have ADHD and autism at escalating rates since the 1990s. Now, the purpose of seeking out those young people and giving them those labels is that the problem should be recognized.

They should get support, and then they should be happier, healthier. Better adjusted adults, but what do we see downstream? We’ve got way more teenagers getting diagnosis of ADHD and autism, but we also have way more young adults who now have mental health problems like depression and anxiety, and that’s the very definition of over-diagnosis.

It’s not to say that original group who were told they had autism and ADHD didn’t have a problem at all. But it seems to me that framing the problem through these lenses of autism and ADHD has not resulted in healthier and happier adults, and we really need to rethink what we’re doing. You know, my real fear is that you take an adolescent and you tell them that their communication problems are.

Abnormal and due to a brain chemistry abnormality or that their sort of attentional difficulties are not because they’re a teenager and teenagers have attentional difficulties, but because they have a dopamine and abnormality in their brain, then you potentially make that problem so concrete that a child can’t overcome it.

Adolescence is a time of change. You should have the opportunity to mature out of your difficulties or to work on things, and I’m afraid that because we tend to make a diagnosis and then accommodate them, we’re not giving children the chance to make the changes that we all made. 

Brett McKay: People get really touchy about this, particularly around ADHD and autism.

Uh, I know it can get very heated, the debates about it. Why do you think that is? 

Suzanne O’Sullivan: Yeah, I think it’s mostly because people kind of understand this conversation to mean that. Their difficulties are being dismissed as irrelevant or they don’t have struggles, and that’s certainly not how I feel about it. I think that adolescents in particular is a real time of difficulty, but also people who are getting diagnosis in older age, I believe the difficulties are real.

But I don’t think medicalizing the difficulties with these labels is the right thing to do. So I wouldn’t wish in any way for anyone to feel that. I’m saying we should go back to the old days where everyone was told to snap out of it or you know, I was in school in the eighties, you know, nobody in my class of 120 was recognized as having a special learning need.

There must have been someone, you know, so we had an underdiagnosis problem. I’m not suggesting we should go back there, but I’m suggesting that we should think about how we are helping struggling people and ask if it’s the right kind of help, you know, is it really optimal? I still think we should. If someone has a problem, then they need to be able to voice it and then their problem needs to be acknowledged, but is then attaching a medical label, the right way to go about things.

And I know that it can make people feel validated and I don’t want to take that away from people. But I think that a diagnosis needs to come with something more than validation. It needs really to lead to something more positive. Unfortunately, when you’re validated by a diagnosis, it can just make the symptoms worse because in order to.

Remain validated and remain part of this new tribe that you belong to. Courtesy of your diagnosis, you have to continue to not be well. Getting well means you lose your tribe and you potentially lose your diagnosis. So how do you get well in those circumstances, I think we’re better to frame our difficulties in terms of, you know, what in my life can be changed to make me feel better.

Rather than framing them through internal chemistry. 

Brett McKay: And in the case of ADHD, I mean, one of the things you do to treat it is, you know, prescribe Ritalin or Adderall, which, I mean, those are schedule one substances, like those can be highly addictive substances. And it’s like, well maybe you don’t need to get on that if you don’t need it.

Suzanne O’Sullivan: You know, it’s interesting how, how badly we learned from the past. You know, we had a whole benzodiazepine crisis in the eighties. You know, it seemed to be a drug that did amazing things for people, but then people got highly addicted to it. And then we had an opioid crisis, you know, for a while everyone thought opioids were the best thing ever, you know?

And look, look where that led us. We are not very good at learning from the difficulties of the past. You know, I’d be very loath to take a medication that is fundamentally a stimulant, which isn’t amphetamine-like drug unless I knew I had to take it. Now, that’s not to say that I don’t think there’s a role for medication.

There will always be people who have extreme disability. There always are hyperactive children who are so hyperactive. They really cannot. Engage in education and they may need something to help them through a difficult period. So I’m not a kind of, never say never, but this wide prescribing of stimulant drug seems really ill-advised to me.

Brett McKay: So what do you think the right balance is between diagnosing too much and not diagnosing enough? Like what do you want readers to take away from your book the next time they’re dealing with a health concern? 

Suzanne O’Sullivan: Yeah, so I think what’s really important is first of all, you know that you have choices very often, and I think that’s something people don’t really realize.

Uh, most medical. Situations are not urgent. So we have occasional emergencies, but most things you go to your doctor with, you can get a test result and you can think about it. So I think that we should be creating a system of more slow medicine where you get test results back and then you consider all the variables.

Are you a high risk? Person, what else in your life might put you at risk of this particular disease so that you can decide whether you need to react urgently or whether you may be someone who doesn’t have to worry and can go down a more watchful waiting pathway? I think it’s very useful for people to understand the uncertainties in test results ’cause it, it might feel like the best thing in a certain circumstance to have that blood test or to have the scan. You know, a lot of neurologists wouldn’t have a brain scan as it happens, and I think it’s useful for people to know that, that sometimes the scan that you have to relieve your anxiety can actually cause more anxiety.

I really want people to just do a balancing exercise when it comes to diagnosis. Ask themselves before they get that. Mental health diagnosis or ADHD or autism diagnosis. If I get this diagnosis, what will I get? What will it bring me that is positive? And if I get this diagnosis, what are the potential negative impacts of that diagnosis?

And you really need to be sure that what you get is substantially greater than what you lose through a diagnosis. 

Brett McKay: Well, Suzanne O’Sullivan, this has been a great conversation. Where can people go to learn more about the book and your work? 

Suzanne O’Sullivan: Well, I hope everybody will buy the book, which is called The Age of Diagnosis, How Our Obsession With Medicine is Making Us Sicker.

You know, I feel like sometimes when I talk about this subject, people might think I’m an outlier doctor that you know, who is this doctor coming along and saying all of these kind of slightly scary things. But actually everything I’m talking about is widely discussed within medicine. We’re just not having a good enough public conversation yet.

Brett McKay: Well, Suzanne O’Sullivan, thanks. Your time has been a pleasure. 

Suzanne O’Sullivan: Thank you for having me. 

Brett McKay: My guest there is Dr. Suzanne O’Sullivan. She’s the author of the book, the Age of Diagnosis. It’s available on amazon.com at bookstores everywhere. Check out our show notes at AoM.is/diagnosis where you can find links to resources and we delve deeper into this topic.

Well that wraps up another edition of the AoM podcast. Make sure to check out our website at artofmanliness.com to find the podcast archives. And while you’re there, sign up for a newsletter. We have a daily and weekly option. They’re both free. It’s the best way to stay on top of what’s going on at AoM. And if you haven’t done so, I’d appreciate it if you take one minute to review the show on your podcast app or Spotify, it helps out a lot. And if you’ve done that already, thank you. Please consider sharing the show with a friend or family member if you think you’ve gotten something out of it. As always, thanks for the continuous support. Until next time this is Brett McKay. Put what you’ve heard into action.

This article was originally published on The Art of Manliness.

I didn’t think about my blood pressure in my 20s and 30s. I only noted it when it got checked during urgent care visits. I always thought it was something I’d worry about when AARP sent me a welcome letter.

While I’m not quite ready for senior discounts, I’ve entered middle age and have become more interested in preventive health.

One health metric I’ve started to track regularly is my blood pressure, which I measure once a week.

Why?

Well, blood pressure is a key indicator of long-term health, and it’s worth monitoring when you’re younger and not just when you’re officially elderly.

High blood pressure, or hypertension, often has no symptoms. It’s a silent killer. Left unchecked, it damages your arteries and organs until it announces itself with a heart attack, stroke, or kidney disease.

Based on the stats, nearly half of you reading this article have high blood pressure.

That’s the bad news.

The good news is that there’s a lot you can do to keep your blood pressure healthy with straightforward lifestyle changes. If you need medical backup, modern treatments are effective and widely available.

In today’s article, I’ll cover blood pressure, its health importance, what raises it, and practical steps to keep it in check.

What Is Blood Pressure?

Think of blood pressure as the force your blood exerts against your artery walls every time your heart pumps. When your heart beats, it creates a surge of pressure called systolic pressure — the top number on a blood pressure reading. When your heart relaxes between beats, the pressure drops; that’s diastolic pressure, the bottom number.

So if you’re 120/80, the 120 is how hard the blood is pushing during a heartbeat, and the 80 is the pressure while your heart rests.

The American Heart Association defines a healthy adult blood pressure as below 120/80. Here’s the full list of blood pressure benchmarks and diagnoses:

• Normal: <120/80 
• Elevated: 120–129/ <80
• High blood pressure (Hypertension, Stage 1): 130–139/80–89
• High blood pressure (Hypertension, Stage 2): ≥140/≥90
• Hypertensive crisis (medical emergency): >180/ >120

If your systolic stays in the 120s, you’re not hypertensive but “elevated.” It’s like a diagnosis of prediabetes.

A systolic above 130 means a hypertension diagnosis.

The 120 vs. 140 Debate

For years, 140/90 was the hypertension diagnosis line. In 2017, the American Heart Association and American College of Cardiology lowered it to 130/80, labeling anything above 120/80 as “elevated.”

The change was controversial. Overnight, millions of people who’d been told their blood pressure was “fine” were suddenly borderline hypertensive. Critics said it over-medicalized healthy individuals in their 20s–40s, making more of them eligible for drugs.

Supporters countered that risk doesn’t suddenly appear at 140/90; it rises gradually. Lowering the threshold aimed to encourage earlier awareness and lifestyle changes, not just more prescriptions.

Different groups still disagree: European societies and the World Health Organization continue to use 140/90 as the benchmark for diagnosing high blood pressure.

Think of blood pressure as a continuum. Lower is better over time. If your blood pressure is slightly elevated, don’t panic, but don’t ignore it either. Take it as a nudge to tighten your habits.

Why Healthy Blood Pressure Matters

High blood pressure has earned the nickname “the silent killer” for a reason. You usually feel fine, until you don’t. Here’s what uncontrolled hypertension does behind the scenes:

• Heart disease and heart attacks. Chronically high blood pressure stiffens arteries and forces your heart to overwork. Heart disease is the number one killer of men in America, and high blood pressure is a main culprit.
• Stroke. Hypertension weakens brain blood vessels, leading to clots or ruptures — strokes that leave you debilitated or dead.
• Kidney damage. Your kidneys rely on tiny blood vessels to filter waste. High pressure scars them over time, leading to kidney disease or failure.
• Sexual health. High blood pressure is bad for your boners. Erectile dysfunction not only impacts your sex life but is also linked to hypertension and can serve as an early warning sign of cardiovascular trouble.

Common Causes of High Blood Pressure

Hypertension usually stems from a mix of genetics, aging, and lifestyle. Some factors can’t be controlled; others can be. Here are the main factors for men:

• Age. Arteries naturally stiffen with age, and plaque builds up. Expect blood pressure to rise in your 30s and 40s if you’re not proactive.
• Being male. Men get hit earlier than women. After menopause, women catch up, but until then, men lead in hypertension rates.
• Family history. If your parents had high blood pressure, you’re more likely to develop it too.
• Diet. Too much sodium (from processed and restaurant foods) and not enough potassium (from fruits and veggies) is a recipe for high blood pressure.
• Inactivity. Sedentary lifestyles weaken hearts and stiffen arteries.
• Excess weight. The heavier you are, especially around the middle, the harder your heart has to pump.
• Alcohol. Occasional drinks don’t have a big impact, but consistent heavy drinking raises blood pressure.
• Nicotine. Whether from cigarettes or Zyn, nicotine raises blood pressure by stimulating adrenaline release, which increases heart rate and constricts blood vessels.
• Stress. Chronic stress keeps your system revved up, nudging blood pressure higher.
• Poor sleep (and sleep apnea). Less than 7 hours a night — or untreated sleep apnea — can keep your pressure elevated.

Managing Blood Pressure: Lifestyle Strategies

The encouraging news about blood pressure is that lifestyle changes can have a huge effect on it, often enough to avoid or delay medication. Here are the big levers you can pull to keep your blood pressure in check:

1. Dial in your diet. Cut back on processed food and salt; eat more vegetables, fruits, lean proteins, and healthy fats.
2. Lift weights. While strength training spikes blood pressure during sets, it lowers it over time by improving heart function and blood vessel health.
3. Get in Zone 2 cardio. Aerobic exercise is a powerful lever for lowering blood pressure. Zone 2 cardio strengthens your heart, improves vascular flexibility, and trains your body to use oxygen more efficiently. Aim for 150 minutes a week through walking, cycling, rowing, or jogging.
4. Hit the HIIT. High-Intensity Interval Training (HIIT) can also help; short bursts of near-max effort followed by recovery periods give you big cardiovascular benefits in less time. I’m a fan of the assault bike for HIIT.
5. Lose weight if needed. Even just a reduction of 5–10% of your weight can improve blood pressure.
6. Limit alcohol. No more than two drinks a day. Less is better.
7. Quit smoking and Zyn-ing. Every cigarette and nicotine pouch tightens your arteries, spiking blood pressure. Quitting will relax them and reduce blood pressure.
8. Manage stress. Exercise, meditation, hobbies, prayer, time outdoors — whatever keeps you from running in the red zone all the time.
9. Get good sleep. Aim for 7–9 hours. If you snore, check for sleep apnea.
10. Deep breathing. Slow, controlled nose breathing activates the parasympathetic nervous system, lowering heart rate and blood pressure. Even 5–10 minutes a day of box or diaphragmatic breathing can help.
11. Catch some rays. Moderate sunlight exposure helps your body release nitric oxide stored in the skin, which relaxes blood vessels and lowers blood pressure. Research suggests people who spend more time outdoors have fewer heart problems than those who stay indoors. Aim for regular, sensible sun exposure.
12. Cut back on caffeine (if you’re sensitive). Coffee affects people differently. For some men, it barely moves the needle; for others, it can spike blood pressure for hours. If you notice big jumps after an energy drink or espresso, scale back.
13. Stay hydrated. Staying hydrated helps your kidneys balance sodium and maintain blood volume, supporting healthy blood pressure. Dehydration makes your heart work harder and can spike stress hormones.
14. Spend time in nature. Japanese research on shinrin-yoku (forest bathing) shows that being in green, natural environments lowers stress hormones and blood pressure. Follow the 20-5-3 nature prescription!
15. Check your numbers. Regularly track your blood pressure. Aim for once a week. See below on how to do it.

How to Take Your Blood Pressure at Home

To keep your blood pressure in check, monitor it regularly. At-home, automatic arm-cuff monitors are inexpensive and reliable.

I check my blood pressure once a week on Sundays.

Measuring at home can give you a more accurate reading than at the doctor’s office. A lot of people have “white coat syndrome,” where they get nervous at the doctor’s office and their blood pressure spikes, making it appear they have high blood pressure when they don’t.

Technique matters for blood pressure measurements. A sloppy reading can skew your numbers. Here are the best practices:

• Use an upper-arm cuff. Wrist and finger devices aren’t as accurate.
• Check at the same time. Mornings are best, before caffeine or workouts.
• Sit quietly beforehand. Rest for 5 minutes before taking a reading.
• Posture matters. Back supported, feet flat, arm resting at heart level. I keep my arm on the couch armrest to achieve the arm level height.
• Don’t talk during the measurement. Even chatting can bump your numbers.
• Take two or three readings. Do them a minute apart, then average them.
• Log your results. A written record (or the machine’s memory) shows trends better than one-off numbers.
• Avoid common mistakes. Don’t measure over clothing, after coffee, or right after exercise.

When Lifestyle Isn’t Enough to Lower Blood Pressure

Sometimes, despite doing everything right, your blood pressure stays high. Genetics and age can be stubborn. That’s when medication comes in.

There are several meds out there that lower blood pressure. The most common are thiazide diuretics and ACE inhibitors (like lisinopril).

If your blood pressure remains high despite lifestyle changes, talk to your doctor about medication.

Conclusion

Blood pressure is a scorecard of how hard your heart is working and how healthy your arteries are. Keep your numbers in check, and you’ll drastically reduce your risk of heart attacks, strokes, kidney disease, and even erectile dysfunction. Ignore it, and the silent killer may come calling.

So check your blood pressure. Make the changes you need to make: eat smarter, move more, stress less. If you need meds, take them.

Your heart and overall health will thank you for the effort.

This article was originally published on The Art of Manliness.

When you think of the microbiome, you probably think of your gut. But bacteria live all over your body. And they’re incredibly numerous; you play host to about as many microbes — a hundred trillion of them — as you do human cells.

As my guest will explain, these microbial ecosystems are not only ubiquitous but hugely influential for your health — impacting everything from your weight and mood to your risk of developing many diseases.

Dr. Brett Finlay is a microbiologist and the co-author of The Microbiome Master Key. Today on the show, Brett explains what the microbiome is, how modern life — including our overemphasis on hygiene — has damaged it, and how the quality of your microbiome is connected to nine of the top ten leading causes of death, as well as everything from depression to Parkinson’s. Brett also shares how we can boost the health of our microbiome, including whether probiotic supplements are effective, how something as simple as flossing your teeth can cut your risk of Alzheimer’s by 50%, and why you might want to let your dog lick you in the face.

Resources Related to the Podcast

This article was originally published on The Art of Manliness.

We all need sleep to maintain our physical and mental health and perform our best.

So it’s unsurprising that there’s no shortage of content out there about how to improve your sleep.

Unfortunately, so much of it repeats the same things you’ve heard a million times before: keep a consistent sleep/wake schedule, stop drinking caffeine later in the day, keep your room cold and dark, etc.

Those fundamentals matter — and if you’re not doing them yet, they’re worth implementing. But if you’ve already got the basics down and are looking for some lesser-known strategies to enhance your sleep, we’ve got you covered below.

What follows are 45 fresher, research-backed tips for improving your sleep, drawn from Trick Yourself to Sleep: 222 Ways to Fall and Stay Asleep from the Science of Slumber by Kim Jones. Chances are, you’ll find at least a few that will help you fall asleep faster, stay asleep longer, and wake up feeling more rested.

Daytime Activities That Can Improve Sleep

While we typically think of what affects sleep largely in terms of what happens at night while in bed, the foundation of good sleep is built during your waking hours.  

1. Process Information and Emotions in the Light of Day

There’s plenty of evidence that stress is a major saboteur of sleep. When your head hits the pillow full of anxious thoughts, drifting off can feel impossible. Additionally, since sleep is the time the brain organizes the day’s information, processes emotions, and works through problems, it stands to reason — though this is just a personal theory rather than a scientifically proven fact — that going to bed with a big backlog of unprocessed inputs forces the brain to work harder overnight, leading to less restful slumber.

To avoid this kind of evening overload, get a jumpstart on your cognitive processing during the day. Don’t wait until your head’s on the pillow to start sorting things out. As you go about your day, take short breaks — five minutes every hour or so — for daydreaming, reflecting, and journaling. Use these pauses to process emotions, mull over dilemmas, and defuse stress.

2. Meditate

Another way to avoid an evening overload of sleep-disrupting stress is to meditate during the day. While we typically think of the mind-calming benefits of meditation in relation to our waking hours, by preventing a build-up of anxiety, the practice also makes it easier to wind down and sleep more soundly at night. Just 20 minutes of daily mindfulness meditation has been shown to improve sleep quality in people with insomnia.

3. Work by a Window

Exposure to natural daylight helps calibrate your circadian rhythm and boosts mood-regulating neurotransmitters, both of which support better sleep. If you’re stuck in an office all day, even sitting near a window can make a difference — research shows that people who do sleep 46 minutes longer each night than those working in windowless spaces. If a window seat isn’t an option, eat lunch outside or use breaks to get more sunlight exposure.

4. Move as Much as Possible Throughout the Day

Physical activity is a well-known aid to sleep, but is seriously underrated. The more you move, the more “sleep pressure” builds up — a drive, fueled by the accumulation of adenosine, that makes it easier to fall asleep and stay asleep at night.

Dedicated exercise is clutch here, of course, but even small bits of activity help build sleep pressure too. So rather than seeing physical activity as an all-or-nothing proposition, look for ways to incorporate movement naturally throughout your day: stand during phone calls, take brief walking breaks every 30 minutes, periodically do a quick set of squats while watching a movie, etc.

5. Exercise Outside When You Can

Research shows that outdoor exercise — even just 30 minutes of walking — helps people fall asleep faster and sleep more soundly than the same amount of indoor activity. Natural light exposure combined with fresh air and physical exertion creates a powerful sleep-promoting combination.

6. Challenge Your Brain

It’s not just physical exercise that builds sleep pressure; mental exertion does as well. Fill your day with reading complex material, learning new skills, solving puzzles, and having meaty conversations, and you’ll sleep better at night.

7. Seek Novel Experiences

You can give your brain the kind of cognitive challenge that builds sleep pressure simply from encountering sheer novelty. When researchers in one study exposed participants to new and stimulating environments, they fell asleep faster and enjoyed more deep sleep than on routine days. If you’ve ever visited a museum, you’ve experienced this phenomenon firsthand; you probably felt surprisingly fatigued, and it wasn’t just from walking around — it was also from your brain taking in so many novel stimuli.

You don’t have to visit a major attraction to score this effect. Even small changes help: take a different route home from work, explore a new neighborhood, or visit an unfamiliar store.

8. Create Microtransitions Between Work and Home

Research has found that people who mentally carry work stress home sleep worse and wake more frequently. To prevent the grind from following you through the front door, build in a “microtransition” — an intentional ritual that helps you shift out of work mode and into domestic life.

Hit the gym on the way home, take a few minutes to meditate in the driveway, or change clothes as soon as you walk inside your abode. Check out this article/podcast for more tips on creating an effective microtransition.

9. Prioritize In-Person Socializing

Perhaps it’s because of the mental-fatigue-inducing cognitive processing involved in having conversations or simply all the feel-good neurochemicals that are released when we connect with others, but face-to-face social interaction is associated with better sleep onset and maintenance. So meet up with friends and loved ones whenever you can to slumber more soundly.

10. Stay On Top of Your To-Do List

Research shows that procrastinators are up to three times more likely to experience sleep problems. Leaving tasks unfinished creates cognitive loose ends that your brain continues processing during the night, while completing even small tasks provides a sense of closure that allows your mind to rest easy.

11. Take a Sundown Stroll

You’ve probably heard that getting morning light regulates your circadian rhythm and improves sleep. But taking a walk when daylight is fading helps too. Researchers have discovered that an evening walk, particularly at dusk, significantly improves sleep quality in insomnia sufferers. Walking at sundown helps synchronize your body clock as natural light fades, preparing your system for sleep.

12. Cultivate Purpose

According to research, people with a strong sense of life purpose enjoy significantly better sleep quality, perhaps because having this sense of direction reduces stress and boosts the kind of psychological resilience that carries over into slumber. To increase your sense of purpose, spend time in reflection, engage in activities that align with your values, and set meaningful goals.

Nutrition and Eating Habits

What you eat — and when you eat it — can have a surprisingly strong effect on how well you sleep.

13. Skip Spicy Foods in the Evening

Research shows that eating spicy foods close to bedtime can negatively affect sleep by raising core body temperature, which interferes with the body’s natural cooling process needed for sleep onset. Capsaicin, the compound responsible for heat in chili peppers, triggers thermogenesis, making it harder to fall asleep and leading to more nighttime awakenings. To avoid these effects, it’s best to enjoy spicy meals earlier in the day.

14. Limit Saturated Fats

High saturated fat consumption is associated with lighter, less restorative sleep and more nighttime awakenings. Focus your diet on heart-healthy unsaturated fats from nuts, seeds, avocados, and olive oil instead of the saturated fats found in processed foods and fried items.

15. Implement a Dinner Curfew

Eating too close to bedtime redirects blood flow to your digestive system rather than allowing your core temperature to drop for sleep. Consider adopting time-restricted eating — confining meals to a 10-hour window (such as 9 AM to 7 PM) — which studies show improves sleep quality and prevents middle-of-the-night digestive disturbances.

16. Boost Your Fiber Intake

Research shows that people who consume low-fiber diets take longer to fall asleep and experience less deep sleep. Prebiotic fiber, which is found in foods like garlic, onions, leeks, and artichokes, seems to be particularly beneficial. In one study, subjects on a prebiotic-rich diet spent more time in restorative non-REM sleep and showed resilience to stress-related sleep disruption.

17. Eat Walnuts as an Evening Snack

Walnuts naturally contain melatonin — the hormone that regulates sleep-wake cycles — as well as magnesium and healthy fats, which can aid in relaxation and overall sleep quality. A study found that eating walnuts increased circulating melatonin levels in the body. Eating a small handful of them a few hours before bedtime can help prepare your body for sleep.

18. Make Sure You’re Getting Adequate Potassium

Potassium can improve sleep by reducing nighttime awakenings and helping muscles relax. This effect is especially notable in people with low dietary potassium intake. To boost your levels (though you don’t want to go too high with potassium), consume food sources with significant amounts of the mineral like sweet potatoes, white beans, bananas, and avocados, or take a supplement.  

19. Stay Hydrated

Mild dehydration is a common cause of nighttime awakening, whether from a dry throat or your body stirring to seek water. Maintain consistent hydration throughout the day, tapering off in the evening to minimize bathroom trips. The right balance will keep you comfortable through the night without interruptions.

Creating a Sleep-Friendly Environment

The state of your bedroom can go a long way in promoting a good night’s sleep.

20. Wash Your Sheets Weekly

According to the National Sleep Foundation, 73% of people report sleeping more comfortably on clean sheets. Beyond the psychological comfort, regular washing removes accumulated sweat, oils, skin cells, and dust mites that can disrupt sleep. Once-a-week washing is the sweet spot for most sleepers.

21. Declutter Your Bedroom

One study found that people sleeping in cluttered rooms took longer to fall asleep and experienced worse sleep quality. Beyond the practical annoyance of navigating a messy space, visual clutter stimulates your brain and can raise cortisol levels. Your bedroom should be a sanctuary, not a reminder of unfinished business.

22. Get a Bigger Bed

If you share a bed, size matters. The average person moves 60-70 times per night, providing plenty of opportunities to disrupt their partner. The Sleep Council recommends this test to see if your bed is sufficiently large: lie side by side with your partner, arms behind your heads and elbows out — if they touch, your bed is too narrow. Get the largest bed that your budget and room size will allow.

23. Sleep Scandinavian Style

As Dr. Wendy Troxel explained on the podcast, if sleeping in the same bed with your partner disrupts your sleep, it’s perfectly fine, and can actually be beneficial, to get separate beds. But if you’d rather not physically part, take a cue from Scandinavians and try using two single duvets instead of fighting over one shared covering. This approach eliminates the nightly tug-of-war and allows each person to select their preferred warmth level, significantly reducing sleep disruptions from temperature differences and blanket stealing.

If you’d like the top sheet + comforter set up, another option for separating bedding while staying physically close is to get two full or twin-size mattresses/beds, each with their own bedding set, and put them close together.

24. Get an Air Filter

Research indicates that people living in high pollution areas are up to 60% more likely to sleep poorly. If outdoor air quality is a concern, consider using an air purifier in your bedroom. Focus on HEPA filters that remove particulate matter and VOCs, which have been most strongly linked to sleep disruption.

25. Hide the Time

When sleep expert Dr. Merijn Van De Laar came on the podcast, his number one tip for better sleep was not watching the time, noting that “We know from research that if you watch the time, then it takes up to 20 minutes longer to fall asleep again.” Clock-watching during sleepless periods only increases stress about lost sleep and how you’ll function tomorrow. So keep your smartphone in another room, take off your watch before bed, and turn your clock away from view.  

26. Ditch Your Sleep Tracker

While it may seem counterintuitive, ditching a sleep tracker can actually improve sleep — at least for some people.

Those with insomnia often get more rest than they think, and seeing that confirmed by a tracker can ease anxiety and promote better sleep. But for others, tracking creates more stress, triggering what’s known as “orthosomnia” — a fixation on perfect sleep metrics that paradoxically worsens sleep quality. Trackers can also lead to a “nocebo” effect, where you feel tired simply because the data told you that you should.

If your tracker helps you build better habits, great — but if it causes stress or contradicts how you actually feel, it may be time to trust your body over your device.

Bedtime Preparations

From how you spend the hour or two before bed to what you do once you’re in it, certain activities and rituals are especially effective at helping you wind down and prepare your mind and body for restful sleep.

27. Sip, Instead of Chug, Your Last Fluids

If you regularly wake up at night to urinate, try stopping fluid intake about 10 hours after waking. When you do have your last drink of the day, sip it slowly rather than chugging it.

As the day goes on, your body becomes less efficient at processing fluids. Drinking a large amount quickly can spike urine production, and not all of it is eliminated right away; the excess can linger and continue filling your bladder hours later, potentially waking you up while you sleep.

In contrast, drinking slowly allows your bladder to handle liquids in smaller, more manageable amounts — reducing the chance of a backlog that carries into the night.

28. Do the Double Void

If you still find yourself waking up to pee at night despite cutting off fluids hours before bed, try the “double void” technique. First, use the bathroom as usual, then wait about 30 seconds and try again. Alternatively, go once before brushing your teeth and again right before getting into bed. This simple practice helps ensure your bladder is fully emptied, reducing the chances of a nighttime wake-up call.

29. Rock Yourself to Sleep

It’s not just babies who are soothed by gentle rocking. Adults are too. A study showed that adults who napped in a rocking bed fell asleep faster and enjoyed deeper sleep than when the bed remained stationary. The rocking motion helps synchronize brain waves into patterns associated with quality sleep. Rocking beds are actually available on the market, but a more practical implementation of this idea is to sit in a rocking chair to relax for a few minutes before you lie down in a standard stationary bed.

30. Soak Your Hands in Warm Water

You may have heard that taking a warm bath about 90 minutes before bed can improve sleep. The heat draws blood to the skin’s surface, and when you step out, the dilated blood vessels help dissipate core body heat. This drop in core temperature signals the body to produce melatonin and promotes sleepiness.

If you don’t have the time or patience for the rigmarole of a full bath, soaking your hands in warm water for at least five minutes can induce a similar effect. The palms contain specialized blood vessels that are especially effective at radiating heat, aiding in core temperature cooling.

31. Mindfully Do the Dishes

Sleep is improved by having a wind-down routine — knocking off from all mentally or physically taxing tasks at least an hour before bedtime.

But if you must complete one last chore before bed, make it hand-washing dishes. A study found that participants who focused on the sensory experience of dishwashing — like the warmth of the water and the smell of the soap — experienced a 27% reduction in anxiety. This calming effect can help ease the transition into sleep.

32. Read a Physical Book

Reading before bed is a well-known wind-down habit, but its effectiveness is often underrated.

One study found that just six minutes of reading reduced stress levels by 68% — more than listening to music, drinking tea, or playing video games — by lowering heart rate and relaxing muscle tension. Less stress translates into an easier time falling asleep.

Physical books, with their unlit pages, may be especially calming, offering distance from both the temptation to check social media and the cortisol-spiking content it so often delivers.

33. Write a To-Do List

It’s not just completing to-dos during the day that aids sleep, but preparing to tackle future tasks as well. Researchers found that people who spent five minutes writing down upcoming tasks fell asleep approximately ten minutes faster than those who merely documented completed tasks. The more detailed the to-do list, the quicker participants nodded off. This “cognitive offloading” helps free your mind from the responsibility of remembering everything overnight.

34. Address Worries Constructively

Research supports the idea that writing down your worries before bed can help improve sleep. This practice is particularly effective when you write down worries and potential solutions. People who document both their concerns and possible next steps experience less “pre-sleep cognitive arousal” than those who only list their worries, making it easier to fall asleep.

Schedule a 15-minute “worry session” in the early evening (around 6 PM) to document problems and brainstorm concrete next steps, and this will head off bedtime rumination.

35. Warm Your Neck

Studies have found that warming the back of your neck to about 104°F (40°C) before bed improves both sleep onset and quality. This specific warming helps reduce sympathetic nervous system activity (which creates alertness) while increasing parasympathetic activity (which promotes relaxation). A warm compress or heated neck wrap (plug-in and microwavable options are available) can do the trick.

36. Release Jaw Tension

When you clench your jaw, it sends signals to your brain that you’re under stress, reinforcing anxiety that can make it harder to fall asleep. Instead, aim for a relaxed, slack jaw — like a trout’s. When your mouth is at ease, your brain takes it as a cue to relax the rest of your body, too.

If you’re struggling to release jaw tension, try this: place your thumb under your chin and slowly open your mouth while applying gentle resistance. Hold for a few seconds, then relax. Repeat 5–10 times. You can also massage your temples in small circles with your fingertips to relax the temporalis muscles, which play a key role in jaw movement.

37. Sheathe Your Feet

When you warm your feet, it dilates blood vessels and helps release heat from your core — a key signal your body uses to initiate sleep. Cold feet not only block this process but can also simply be uncomfortable and keep you awake. Research shows that people who wear socks to bed fall asleep faster, sleep longer — by an average of 32 minutes — and wake up less during the night compared to barefoot sleepers. If your feet tend to run cold, try wearing socks to bed or placing a hot water bottle at your feet.

38. Practice Gratitude

You’ve probably heard that regularly writing down what you’re grateful for can boost both physical and mental health — from lowering blood pressure to lifting your mood. But gratitude has sleep benefits, too: by shifting you into a more positive frame of mind, it can help you fall asleep faster and stay asleep longer. Each night, try jotting down five good things from your day — whether it’s a thoughtful gesture from a colleague or simply snagging a great parking spot.

39. Relax Your Tongue

Your tongue holds more tension than you might think — you may be pressing it against the roof of your mouth right now without realizing it. Like a clenched jaw, a tense tongue can send subtle signals of stress through the body, making it harder to fall asleep.

To release this hidden tension, press your tongue firmly against the roof of your mouth, then let it drop completely as you allow your jaw to hang slightly open. Keep both the front and back of your tongue relaxed, letting it rest heavily in your mouth. This simple act of release can become an effective cue for full-body relaxation.

40. Apply Gentle Warmth to Your Abdomen

Research shows that gently warming the skin — especially around the abdomen — increases neuronal activity in brain regions that regulate sleep. Try placing a warm (not hot) water bottle against your stomach. The key is subtle warming, just slightly above skin temperature, as too much heat will disrupt sleep.

41. Let Your Thoughts (Even If Negative) Come and Go

Thinking stressful or worry-inducing thoughts as you lie in bed can create mental arousal that makes it harder to fall asleep. Paradoxically, actively trying to fight these thoughts can actually backfire — making them more persistent and sleep more elusive; research has shown that people instructed to suppress specific thoughts before bed took longer to fall asleep than those allowed to let their thoughts flow naturally.

Instead of resisting unwanted thoughts, try acknowledging them without judgment, then gently shift your focus to your breath, positive reflections, or calming visualizations.

42. Try Sleep Restriction Therapy

Counterintuitively, spending less time in bed can improve sleep quality. If you’re lying awake for hours, track your actual sleep time and initially restrict your time in bed to just that amount (but no less than five hours). For example, if you average six hours of actual sleep but need to rise at 6 AM, don’t go to bed until midnight. As your sleep efficiency improves, gradually move your bedtime earlier in 15-minute increments.

During the Night

Even if you successfully fall asleep, it’s normal to wake up during the night, and these tips can help you return to sleep more easily.

43. Embrace Stillness When You Wake

If you wake during the night, resist the urge to toss and turn. Movement signals your body to increase alertness and can trigger adrenaline production. Instead, calmly maintain stillness while taking slow breaths, focusing on the sensation of the sheets against your skin or the coolness of air on your face. This mindful stillness often allows sleep to return naturally.

44. Apply Acupressure at Heart 7

Traditional Chinese medicine — and some emerging research — suggests that massaging the Heart 7 acupressure point (also known as the “Spirit Gate”) may help relieve anxiety-induced insomnia. To find it, look at the crease on your wrist directly below the gap between your ring and pinky fingers; you’ll feel a small hollow beside the tendon on the outer edge of your wrist. Using your thumb, gently press and massage this point in a circular motion for about a minute on each wrist. This simple technique may help you fall asleep more easily — and return to sleep if you wake up during the night.

45. Keep Your Eyes Half-Shut During Middle-of-the-Night Bathroom Trips

When nature calls in the middle of the night, avoid turning on bright lights — even brief exposure can suppress melatonin and make it harder to fall back asleep. Before bed, clear a path to the bathroom that’s easy to navigate in the dark, or use a dim nightlight if needed. If your trip to the loo will inevitably expose you to some light, try to keep your eyes partially closed to minimize the impact. The less stimulation your brain receives, the easier it will be to drift back to sleep.

This article was originally published on The Art of Manliness.

An important part of manhood has always been about having the competence to be effective in the world — having the breadth of skills, the savoir-faire, to handle any situation you find yourself in. With that in mind, each Sunday we’ll be republishing one of the illustrated guides from our archives, so you can hone your manly know-how week by week.

If you were a kid in the 1950s and you got socked during a playground fight, chances are the remedy for your ensuing black eye would involve a nice T-bone steak. Before ice packs were widely available, chilled meat was the go-to household remedy for treating a black eye because it offered a way to cool the area and decrease swelling without applying raw ice. Nowadays, we’ve got more tools and a bit more knowledge at our disposal when it comes to the treatment of shiners.

Black eyes happen when there is trauma to the area. The color comes from bleeding that occurs under the skin near the eye. In most cases, black eyes aren’t serious. But, they can signal a more significant injury. If you have double vision, blood showing in the white part of your eyeball, vomiting, or dizziness, you should see a doctor right away. Black eyes can be signs of more severe injuries, like skull fractures. But, for commonplace black eyes, here’s what to do to get them healed up as quickly as possible.

Like this illustrated guide? Then you’re going to love our book The Illustrated Art of Manliness! Pick up a copy on Amazon.

This article was originally published on The Art of Manliness.

Flu and cold cases are at all-time highs this year. I got the flu two years ago. Never felt sicker in my life. It was awful.

Kate got it too, and felt nigh near to death’s door at times, but she seemed to recover faster than I did and wasn’t moaning and groaning as much as I was. She was in bed for a couple days and then was back to work. Meanwhile, I was holed up in our bonus room upstairs for a week, alternating between Tylenol and Advil to manage the fever and body aches.

Kate has always teased me about being overdramatic about my symptoms whenever I get sick.

But, truth be told, I don’t think I’m exaggerating. I genuinely feel damned awful when I come down with something, and all I want to do is moan and lay in the “sick hole” upstairs for days.

Other couples have noticed a discrepancy between how men and women experience sickness — with men seeming to have more severe symptoms while women can power through the sniffles without missing a beat. So much so that we’ve named how men experience sickness as the “man cold” or the “man flu.”

But is the man cold actually a thing?

Do Men Get Sicker Than Women?

Many people have noticed that guys seem to feel sicker and feel sicker longer than women do when they get the flu or cold. And there are clinical studies that bear these observations out.

According to one study about the differences between men and women when they get the flu, women report more flu symptoms than men, meaning that while a guy might just have a fever and body aches when he gets sick, a woman might have both those symptoms plus cough, headache, runny nose, etc. But men are two times more likely to be hospitalized when they get the flu, which suggests that of the symptoms they do experience, they experience them more severely.

You saw this pattern with COVID-19 during the pandemic. Around the world, severe cases of COVID were predominantly among men, with men’s mortality rates 1.6 times higher than women’s. (It’s worth noting that some of this difference may be due to men generally having poorer health and being more likely to delay seeking medical care when COVID symptoms worsened.)

Surveys have suggested that men take about 1.5-1.7 days longer to recover from the flu than women. But other studies have shown that men recover faster from the flu than women. 

So, based on some studies, men do experience more severe symptoms, for longer. Man flu/cold might be a thing. 

But why would there be sex differences between how men and women experience sickness?

Blame the Man Cold on Testosterone and (Low) Estrogen

It all comes down to sex hormones. At least, that’s what the research suggests.

Testosterone, which men typically have 10-20X more of than women, can be a double-edged sword. While it increases muscle mass and puts hair on your chest, it also suppresses inflammatory cytokines like IL-6, potentially prolonging recovery from the flu by delaying viral clearance.

Testosterone also gives men a larger hypothalamus region, which, among other things, regulates body temperature. Scientists theorize that this enlarged hypothalamus could explain why men often report higher fevers during infections. And because fever drives some of the unpleasant symptoms of the flu or a cold, like chills and body aches, more severe fevers mean a more severe sickness.

Estrogen also plays a role in immune function. It seems to boost it. While men have estrogen, they don’t have anywhere near the same amount as women. Women’s elevated estrogen levels seem to enhance antiviral responses by boosting interferon-γ production, which slows down viral replication in illnesses like the flu. The retardation of viral replication can take the edge off of symptoms in women. What’s interesting is that this female hormonal advantage diminishes after menopause, when estrogen levels go down in women. Postmenopausal women have an immune response that aligns more closely with men’s.

Other studies show that women have additional immunity advantages over men, like stronger innate (first-line defense) and adaptive (targeted) immune responses. This can help clear infections faster.

So, men’s high testosterone makes them more prone to getting sicker longer, while elevated estrogen in women helps blunt the severity of symptoms and helps them recover faster.

Scientists hypothesize that these hormonal differences between men and women are evolutionary in origin and represent a “reproduction-immunity trade-off.” Females evolved to have less testosterone but stronger immunity to protect offspring during pregnancy and breastfeeding; men evolved to have more testosterone, giving them weaker immunity to disease but greater strength and drive for the tasks of hunting and fighting.

Is Man Flu Just in Your Head?

While many scientists think that man flu is real and biologically rooted, others argue it’s psychosomatic. In other words, man flu is all in your head, man.

A study from the University of Glasgow suggests that men are less in touch with their biofeedback signals (which helps in understanding how one’s body feels), which could result in reporting that their symptoms are more severe than they truly are.

Another study suggests that men and women objectively experience the same severity and duration of flu and cold symptoms, but men subjectively rate some of them as more severe and longer-lasting. The study examined how the sexes experienced the common cold and found that while men and women experienced physical symptoms (like nose and ear issues) similarly, men reported emotion-based symptoms, such as mood changes and psychological distress, as being more severe. The researchers of this study concluded that the man cold is just in dudes’ heads.

Why would men subjectively experience more severe cold symptoms? Some researchers theorize that because men are conditioned to be stoic, tough, and productive, and to power through things, when they do experience a sickness, they see it as an opportunity to take a break from these expectations; they amplify the severity of their symptoms to elicit sympathy, get taken care of for once, and justify taking off work.

I’m not sure I buy that, but that’s the argument.

Perhaps it’s the case that, since women historically were responsible for the lion’s share of childcare, which creates urgent obligations (kids still need to be fed and diapered even when their parents are sick), it’s more ingrained in women to bounce back and make sure the family is tended to. Is that difference rooted in evolutionary biology, cultural expectations, or a mixture of both? There’s no conclusive evidence to know.

How to Treat the Man Flu/Cold

Personally, I think the man flu/cold is a thing — an actual biological phenomenon. It’s been interesting to watch how my son Gus’ experience of sickness has changed as he’s moved from boyhood to teenagehood. As a boy, he’d get sick and be down for a day or two. Now that he’s 14, and has testosterone coursing through his veins, he experiences sickness like I do. He feels like garbage, and he’s out for longer. He just wants to go up to the bonus room and be by himself to wallow and moan and groan. Whenever either of us gets a bad cold or flu, we just tell the family, “Well, I’m off to the sick hole. See you when I feel better.”

You treat the man version of the cold or flu just as you would its female counterpart; do the stuff your mom told you to do when you were a kid:

• Drink plenty of fluids. Water is best, but you gotta get some ginger ale in there. It’s a miracle elixir.
• Keep your eating light. Soups and saltine crackers are clutch.
• Avoid caffeinated drinks.
• Get plenty of sleep and rest.
• Alternate between Tylenol and Advil to manage pain and fever.
• Watch The Price is Right and The Young and the Restless.

Most colds and flu bouts take about 4-7 days to clear. You could experience lingering fatigue for up to two weeks.

When you feel the first symptoms of sickness, take an at-home test to see if you’ve got the flu, cold, or COVID. If it’s the flu, get a prescription for xofluza. Taking it within 48 hours of your first flu symptoms can reduce their severity and duration.

While whether the man flu is an actual physiological thing or just in guys’ heads is up for debate, doctors all agree that we shouldn’t label men as whiny when they get sick because it could delay men getting the care they need to get better, which could result in worse outcomes — including death. Be sure to go see a doctor if:

• Your fever reaches 104 degrees Fahrenheit or higher or is above 100 for over three days.
• You have difficulty breathing or chest pain.
• Your symptoms get worse after an initial improvement.
• Your symptoms last longer than three weeks without improvement.

Trying to tough out a sickness and continue your normal routine isn’t wise; it will just prolong the sickness and delay your recovery. In keeping your sickness lingering on for longer, you’ll actually lose more productivity in the long run than just completely taking time off and letting yourself heal up. It’s in your best interest, and in the best interest of your family, who wants to see you bounce back as quickly as possible, to hit your rest and recovery hard. At the same time, your household may be hurting without your help, so don’t wallow unnecessarily, and once you’re ready, get back in the saddle.

This article was originally published on The Art of Manliness.

For several decades, people’s reported sleep quality has declined. This, despite the fact that specially optimized sheets, mattresses, and sleep trackers have emerged during that time, and despite the fact that the amount of time people are sleeping hasn’t decreased for over fifty years.

In other words, people aren’t sleeping less than they used to, but are less happy about their sleep than ever before.

My guest would say that to improve our experience of sleep, we’d be better off looking past the reams of modern advice out there and back in time — way, way back in time.

Today on the show, Dr. Merijn van de Laar, a recovering insomniac, sleep therapist, and the author of How to Sleep Like a Caveman: Ancient Wisdom for a Better Night’s Rest, will tell us how learning about our prehistoric ancestors’ sleep can help us relax about our own. He explains that the behaviors we think of as sleep problems are actually normal, natural, and even adaptive. We talk about why hunter-gatherers actually sleep less than we think we need to, how their natural wake periods during the night might explain our own sleep patterns, the methods they use to get better sleep, and why our modern efforts to optimize sleep could be making it worse. Merijn shares when it’s okay to use a smartphone before bed, the myth that you have to get eight hours of sleep a night, how to intentionally use sleep deprivation to improve your sleep, and more.

Resources Related to the Podcast

This article was originally published on The Art of Manliness.