Diapositiva 1

1
Malocclusions and Urolithiasis in the Context
of Evolutionary Medicine Giacinto Libertini
giacinto.libertini_at_tin.it www.r-site.org/ageing
www.programmed-aging.org
2
Preamble
What is Evolutionary Medicine?
3
Evolutionary or Darwinian Medicine 1-6 comes
into being in 1991 1, but there are some known
forerunners 7 (e.g. 8) and others not
generally cited as forerunners 9,10.
1 Williams GC, Nesse RM (1991) The dawn of
Darwinian medicine. Quart. Rev. Biol. 66,
1-22. 2 Nesse RM, Williams GC (1994) Why we get
sick. New York (USA), Times Books. 3 Stearns SC
(ed) (1999) Evolution in health and disease (1st
ed.). Oxford (UK), Oxford University Press. 4
Trevathan WR, Smith EO, McKenna JJ (eds) (1999)
Evolutionary Medicine. New York (USA), Oxford
University Press. 5 Trevathan WR, Smith EO,
McKenna JJ (eds) (2008) Evolutionary Medicine
new perspectives. New York (USA), Oxford
University Press. 6 Stearns SC, Koella JC (eds)
(2008) Evolution in health and disease (2nd ed.).
Oxford (UK), Oxford University Press. 7
Trevathan WR, Smith EO, McKenna JJ (2008)
Introduction and overview of Evolutionary
Medicine. In Trevathan WR, Smith EO, McKenna JJ
(eds) Evolutionary Medicine new perspectives.
New York (USA), Oxford University Press. 8
Eaton SB, Shostak M, Konner M (1988) The
paleolithic prescription a program of diet
exercise and a design for living. New York (USA),
Harper Row. 9 Price WA (1939) Nutrition and
Physical Degeneration. New York London, Paul B.
Hoeber. 10 Libertini G (1983) Ragionamenti
Evoluzionistici. Naples (Italy), Società Editrice
Napoletana English Edition (2011) Evolutionary
Arguments. Crownsville (USA), Azinet Press.
4
Evolutionary Medicine is not an Alternative
Medicine (like homeopathy, iridology, ayurvedic
medicine, naturopathy, traditional Chinese
medicine, energy medicine, etc.) but a Medicine
that is more thoroughly scientific In that it
involves the concepts of Evolutionism.
A medicine that ignored the principles of
chemistry, for example, would be partially
scientific. Similarly, a medicine that
ignores the principles of evolution is partially
scientific.
5
So the contrast is not between
Current Medicine
Alternative Medicines
but between
Evolutionary Medicine (which is a more
thoroughly scientific medicine)
Current Medicine (which in most cases ignores
Evolutionism)
However, the first practical question is
immediate Is this difference only a theoretical
/ verbal nicety? or Has this difference strong
and significant implications for the structure of
medical studies and for health organization?
6
Evolutionary Medicine involves many concepts and
applicative consequences. Here, I develop a
practical application of a simple concept, the
mismatch 1,2, to the genesis of malocclusions
and of urolithiasis.
The concept of mismatch is simple but with huge
implications
If a species is adapted to a certain range of
conditions (including diet, environmental
conditions, interrelations with other living
beings, etc.), called for brevity ecological
niche, any change in the ecological niche
potentially is a source of disfunctions
(diseases), because there is no adaptation to the
new conditions. This is defined as "mismatch.
1 Eaton SB, Shostak M, Konner M (1988) The
paleolithic prescription a program of diet
exercise and a design for living. New York (USA),
Harper Row. 2 Libertini G (2009) Prospects of
a Longer Life Span beyond the Beneficial Effects
of a Healthy Lifestyle, in Bentely JV, Keller MA
(eds) Handbook on Longevity Genetics, Diet
Disease, New York (USA), Nova Science Publishers
Inc.
7
Malocclusions and Urolithiasis in the Context of
Evolutionary Medicine
Step 1 - Epidemiological study of modern
populations For Malocclusions In USA
Noticeable incisor irregularity occurs in the
majority of all racial/ethnic groups, with only
35 of adults having well-aligned mandibular
incisors. Irregularity is severe enough in 15
that both social acceptability and function could
be affected, and major arch expansion or
extraction of some teeth would be required for
correction. 1 In a study on Peruvian children
The prevalence of malocclusions was 85.6
2
1 Proffit WR et al. (1998) Prevalence of
malocclusion and orthodontic treatment need in
the United States estimates from the NHANES III
survey. Int. J. Adult Orthodon. Orthognath. Surg.
13, 97-106. 2 Aliaga-Del Castillo A et al.
(2011) Malocclusions in children and adolescents
from villages and native communities in the
Ucayali Amazon region in Peru Article in
Spanish Rev. Peru Med. Exp. Salud Publica 28,
87-91.
8
Step 1 - (CONTINUED) A study on Tanzanian
children showed that 63.8 per cent of the
subjects had at least one type of anomaly
1. For Urolithiasis The overall probability
of forming stones differs in various parts of the
world 1-5 in Asia, 5-9 in Europe, 13 in North
America, 20 in Saudi Arabia. 2 Among 20- to
74-old United States residents nephrolithiasis
incidence increased from 3.8 in the period
1976-1980 to 5.2 in the period 1988-1994
3. Recent data provide evidence that the
incidence of nephrolithiasis in children is
rising. 4 Pediatric urolithiasis has
increased globally in the last few decades. 5
 
1 Mtaya M et al. (2009) Prevalence of
malocclusion and its relationship with
socio-demographic factors, dental caries, and
oral hygiene in 12- to 14-year-old Tanzanian
schoolchildren. Eur. J. Orthod. 31, 467-76. 2
Ramello A et al. (2000) Epidemiology of
nephrolithiasis. J. Nephrol. 13, S45-50. 3
Stamatelou KK et al. (2003) Time trends in
reported prevalence of kidney stones in the
United States 1976-1994. Kidney Int. 63,
1817-23. 4 Sas DJ. (2011) An update on the
changing epidemiology and metabolic risk factors
in pediatric kidney stone disease. Clin. J. Am.
Soc. Nephrol. 6, 2062-8. 5 Sharma AP, Filler
G. (2010) Epidemiology of pediatric urolithiasis.
Indian J. Urol. 26, 516-22.
9
Step 1 (CONTINUED) There has been
considerable increase in the incidence of
idiopathic renal stone in Europe, North America,
Australasia and Japan within the present century
(Grossmann, 1938 Inada et al., 1958 Andersen,
1969 Fig. 4.1) 1  
1 Trowell HC, Burkitt DP (eds) (1981). Western
diseases, their emergence and prevention. Edward
Arnold, USA.
10
Step 2 - Comparison between the frequency of a
disease in modern populations and the frequency
of the same disease in populations in primitive
conditions

• For Malocclusions
• Although previous studies of primitive Eskimos
  have reported practically no malocclusion, 82 per
  cent of the children in this study had
  malocclusions. 1
• It is a matter of great significance that the
  Eskimos who are living in isolated districts and
  on native foods have produced uniformly broad
  dental arches and typical Eskimo facial patterns.
  Even the first generation forsaking that diet and
  using the modern diet, presents large numbers of
  individuals with marked changes in facial and
  dental arch form 2
• from 25 to 75 per cent of individuals in
  various communities in the United States have a
  distinct irregularity in the development of the
  dental arches and facial form In a study of
  1,276 skulls of these ancient Peruvians, I did
  not find a single skull with significant
  deformity of the dental arches. 2 (see fig. on
  the right)

Figure 78 from 2

• 1 Barry FW (1971) Malocclusion in the modern
  Alaskan Eskimo. Amer. J. Orthod. 60, 344-54.
• 2 Price WA (1939) Nutrition and Physical
  Degeneration. New York London, Paul B. Hoeber.

11

• Step 2 (CONTINUED)
• Seminole Indians using native (left, fig. 24) and
  modernized (right, fig. 25) foods. Note the
  change in facial and dental arch form in the
  children of this modernized group. 1

• 1 Price WA (1939) Nutrition and Physical
  Degeneration. New York London, Paul B. Hoeber.

12

• Step 2 (CONTINUED)
• Another important source of information
  regarding the Aborigines of Australia was
  provided by a study of the skeletal material and
  skulls in the museums at Sydney and Canberra,
  particularly the former. I do not know the number
  of skulls that are available there for study, but
  it is very large. I examined many and found them
  remarkably uniform in design and quality. The
  dental arches were splendidly formed. 1
• Note the marked difference in facial and dental
  arch form of the two Samoan primitives above and
  the two modernized below. The face bones are
  underdeveloped below causing a marked
  constriction of the arches with crowding of the
  teeth. Comment to fig. 36 (on the right) from
  1.

• 1 Price WA (1939) Nutrition and Physical
  Degeneration. New York London, Paul B. Hoeber.

13

• Step 2 - (CONTINUED)
• Price, in his irreproducible work, documented
  in many parts of the world (in people now
  completely modernized, but in 1939 divided into
  groups living in primitive conditions and others
  with more or less advanced degree of
  civilization) very different rates of tooth decay
  depending on the degree of diet modernization. In
  populations living with a natural diet, the set
  of teeth was well-formed, the bones of the face
  well developed, and the teeth practically free
  from caries. By contrast, in populations with
  modernized diets, the set of teeth was
  disordered, the face underdeveloped and tooth
  decay widespread, and all these alterations were
  proportional to the degree of diet modifications.
  1

Figures 17 (left) and 19 (right) from 1

• 1 Price WA (1939) Nutrition and Physical
  Degeneration. New York London, Paul B. Hoeber.

14

• Step 2 - (CONTINUED)
• ...
• For Urolithiasis
• Renal stone is rare among persons living in poor
  or primitive socio-economic circumstances and is
  very rare in African Bantu living under tribal
  conditions (Modlin, 1969) 1
• To summarize, from being virtually unknown in
  historical times, renal stone has become
  significant as a common morbid condition in the
  affluent, westernized countries within the last
  80 years whilst remaining rare in communities
  where the people live in primitive and poor
  conditions. 1

Epidemiological data strongly contrast the
possible hypothesis that the high frequencies of
malocclusions and urolithiasis suffered by modern
populations are caused by a recent (in
evolutionary terms) relaxation of natural
selection pressures. On the contrary, they
indicate that these diseases are largely due to
alterations of the ecological niche to which our
species is adapted, that is presumable phenomena
of mismatch.

• 1 Trowell HC, Burkitt DP (eds) (1981). Western
  diseases, their emergence and prevention. Edward
  Arnold, USA.

15

• Step 3 - Hypotheses on the possible changes in
  the ecological niche underlying the disease and
  on possible pathogenetical mechanisms
• Price, in his fundamental work 1, not
  surprisingly called Nutrition and Physical
  Degeneration, attributes the high frequency of
  malocclusions (and of other dental diseases) to
  changes in diet and lifestyle compared with the
  habits of primitive societies.
• A critical factor emphasized by Price is the
  amount of dietary vitamin D and of sun exposure
  for the formation of additional vitamin D.
  According to Price, an insufficient intake and
  absorption of dietary calcium in the early years
  of life determines, among other things,
  insufficient development of facial bones and an
  improper development of the set of teeth.
• Konner and Eaton 2 reported that prior to 1990
  the recommended daily intake of vitamin D was 400
  IU and that of calcium 800 mg. In 2010, this
  advice had become 1000 IU of vitamin D and 1000
  mg of calcium. But the estimate for the ancestral
  population was over 4000 IU of vitamin D (also by
  sunlight) and 1500 mg of calcium. It is clear
  that with regard to ancestral conditions there is
  a strongly reduced intake of dietary calcium and
  a considerable deficiency of vitamin D, a poorly
  understood problem even in scientific circles.

1 Price WA (1939) Nutrition and Physical
Degeneration. New York London, Paul B.
Hoeber. 2 Konner M, Eaton SB (2010) Paleolithic
Nutrition Twenty-Five Years Later. Nutr. Clin.
Pract. 25, 594-602.
16
Step 3 (CONTINUED) But if malocclusions are
largely caused by reduced intake of dietary
calcium and by reduced intake and production of
vitamin D, these factors could seem to cause a
reduced frequency of urolithiasis, a thing that
is clearly contradicted by data from modernized
population. However, it has been shown that
urolithiasis frequency is inversely related to
dietary calcium intake 1-3, even though
supplemental calcium may increase the risk
2. Dietary calcium reduces oxalate absorption
and the urinary excretion of oxalate and this
lowers the risk of kidney stones of calcium
oxalate, the prevalent type of stones 1. This
may be due to increased binding of oxalate by
calcium in the gastrointestinal tract
1. Other factors correlated with a lower
frequency of urolithiasis are potassium intake
1 and fluid intake 1. The intake of fiber
and plant foods reduces urinary calcium excretion
and thus the frequency of the stones, while
carbohydrate intake has the opposite effect
3. A higher protein intake is associated with a
moderate increase of urolithiasis risk 1.
1 Curhan GC et al. (1993) A Prospective Study
of Dietary Calcium and Other Nutrients and the
Risk of Symptomatic Kidney Stones. New Engl. J.
Medic. 328, 833-8. 2 Curhan GC et al. (1997)
Comparison of dietary calcium with supplemental
calcium and other nutrients as factors affecting
the risk for kidney stones in women. Ann.
Intern. Med. 126, 497-504. 3 Heller, HJ (1999)
The role of calcium in the prevention of kidney
stones. J. Am. Coll. Nutr. 18, 373S-378S.
17
Step 3 (CONTINUED) It is essential to compare
the ancestral diet with that of contemporary
Western populations 1.In the table, the
factors in the modern diet that increase
urolithiasis risk are highlighted in pink, while
those having the opposite effect are highlighted
in green. It is not shown in the table the
reduced intake of calcium in modern diets that is
strongly correlated with urolithiasis frequency.
Ancestral (Hunter-Gatherer) Contemporary Western
Total energy intake More Less
Caloric density Very low High
Dietary bulk More Less
Total carbohydrate intake Less More
Added sugars/refined carbohydrates Very little Much more
Glycemic load Relatively low High
Fruits and vegetables Twice as much Half as much
Antioxidant capacity Higher Lower
Fiber More Less
Solubleinsoluble Roughly 11 lt1 insoluble
Protein intake More N.B. lean, from game Less N.B. fat, from breeding
Total fat intake Roughly equal
Serum cholesterol-raising fat Less More
Total polyunsaturated fat More Less
?-6?-3 Roughly equal Far more ?-6
Long-chain essential fatty acids More Less
Cholesterol intake Equal or more Equal or less
Micronutrient intake More Less
Sodiumpotassium lt 1 gt1
Acid base impact Alkaline or acidic Acidic
Milk products Mothers milk only High, lifelong
Cereal grains Minimal Substantial
Free water intake More Less
1 Konner M, Eaton SB (2010) Paleolithic
Nutrition Twenty-Five Years Later. Nutr. Clin.
Pract. 25, 594-602.
18
Step 4 - Study of the mechanisms linking the
alteration of the ecological niche to the
pathogenesis of the disease For
malocclusions The proper development of facial
bones and set of teeth is optimal when the values
??of dietary calcium and of vitamin D absorption
and production are those to which our species is
adapted. Modernized alimentation has severely
altered these factors, and perhaps others that
are more or less important to a correct
development. The details of these alterations and
the mechanisms by which the correct development
is compromised require further information and
explanations, but the correlation between
alterations in diet and lifestyle and the correct
development of facial bones and set of teeth are
clear and well documented for a long time past
1.
1 Price WA (1939) Nutrition and Physical
Degeneration. New York London, Paul B. Hoeber.
19

• Step 4 (CONTINUED)
• For urolithiasis
• There is hypercalciuria in 95 of patients with
  nephrolithiasis 1.
• The mechanism by which hypercalciuria causes an
  increased risk of renal stones is known 2.
• There are foods that reduce calcium absorption,
  and therefore the urinary calcium - K, PO4,
  fiber, Alkali Load alias fruits and vegetables -
  and others that have the opposite effect
  supplemental Ca, Na, Mg, Carbohydrates, Acid Load
  alias animal flesh - and the mechanisms that
  cause these effects are quite known 2.
• But an increase in dietary calcium reduces
  oxalate absorption and oxalate excretion in the
  urine and thus reduces the frequency with which
  they form calcium oxalate stones, the most common
  type of calculations 3.

1 Levy FL et al. (1995) Ambulatory evaluation
of nephrolithiasis an update of a 1980 protocol.
Am. J. Med. 98, 50-9. 2 Heller, HJ (1999) The
role of calcium in the prevention of kidney
stones. J. Am. Coll. Nutr. 18, 373S-378S. 3
Curhan GC et al. (1993) A Prospective Study of
Dietary Calcium and Other Nutrients and the Risk
of Symptomatic Kidney Stones. New Engl. J. Medic.
328, 833-8.
20
Step 5 - Possible restoration of the normal,
alias primeval, conditions or possible
compensatory conditions

• It is clear that Paleolithic diet and lifestyle
  are optimal to prevent malocclusions and
  urolithiasis, but it is also true that the return
  to ancestral conditions of life is not feasible.
• More realistically, it is certainly useful to
  correct as much as possible those changes in diet
  and lifestyle that to a greater extent show to
  increase disease frequencies.
• Available data suggest the following indications
• - to increase the intake of dietary calcium,
  potassium and vitamin D to the levels estimated
  for the Paleolithic
• to increase the exposure to sunlight, so as to
  increase the production of vitamin D
• to increase the intake of foods and elements
  that reduce oxalate absorption and calcium
  absorption (and therefore urinary calcium K,
  PO4, fiber, Alkali Load alias fruits and
  vegetables)
• - to increase the intake of plain water
• to reduce the intake of the foods and elements
  that increase oxalate absorption and calcium
  absorption (and therefore urinary calcium
  supplemental Ca, Na, Mg, Carbohydrates, Acid Load
  alias animal flesh).

21
Step 6 - Analysis of the results achieved and
ideation and proposal of further improvements
Afterwards, it will be indispensable to evaluate
the results obtained with different types of diet
more or less suited to these principles. Useful
indications will be obtained from these results,
which obviously in their application will be
influenced by economic factors, dietary customs,
and individual choices. At the same time, it is
essential to continue the deepening of the study
of ancestral conditions of life to which our body
is better adapted.
If these guidelines were not followed, the
populations will gradually adapt to the new
conditions of life with known evolutionary
mechanisms, but it is good to point out that this
choice is ethically unacceptable as it would
result in countless cases of illness and death
before, over many generations, a good adaptation
will be reached.
22
First Objection Before applying these measures of
prevention on a large scale, observation of
controlled groups in order to confirm their
validity is necessary. But this objection would
be generated by a contradiction of current
Medicine. In fact, if a new drug is proposed, we
rightly expect a series of experiments, in
several stages, before its use is authorized.
Meanwhile, the NON-use of the drug is considered
to be due and NOT subject to preventive
experimentation.
On the contrary, in the case of a new habit of
life, alias a change of the ecological niche, the
new habit is introduced and accepted WITHOUT any
trial that demonstrates its safety. Now, If a new
NOT tested habit of life is suspected of causing
illness, the indication to stop this habit of
life is rightful and proper. Why, before its
suspension, should we demonstrate its harmfulness
and the benefits resulting from its suspension?
23
Such an absurd principle has been used for
decades to extend the use of smoke without that
smokers were at least warned of the deadly risks
they were running. Again a new habit (smoking)
was introduced without any evidence that proved
its safety and for decades it was claimed that
its harm should be proved before taking action
against it.
After many scientific tests (while the slaughter
continued)
24
Any change of the ecological niche to which a
species is adapted must be considered potentially
harmful until the contrary is proved. In the
case of a new drug, this principle is
observed! Precautionary principle
But for other modifications of the ecological
niche, no precaution is taken. It is presumed
irrationally and stupidly, because of
non-scientific evaluations that a modification
must not be considered harmful until the
experience proves the contrary! Imprudence
Principle
25
The correct scientific logic would be to take
steps against a change in the ecological niche on
the sole grounds of the suspicion that this
change is bad and BEFORE the sure demonstration
in irreproachable scientific terms.
Afterwards, the results in populations (or
fractions of populations), which pursue - to a
greater or lesser extent - the restoration of
more physiological (alias natural) conditions
must be compared both to confirm the expected
results and for evaluating other possible
measures. But one should not expect the results
of test samples before applying the aforesaid
preventive actions on a large scale.
26

• Second Objection
• Malocclusions and urolithiasis should be
  attributed to the combination
• of environmental and genetic factors.
• This is a misleading way of describing the case.
• Certainly, when an individual is exposed to an
  ecological niche to which its genes are not
  adapted, in the diseases that are caused by the
  altered ecological niche, his genes, which are
  more or less resistant to the onset of diseases,
  come into play.
• But, we cannot and should not consider the genes
  that are less resistant to the diseases as
  pathological they are entirely normal genes that
  in new conditions, to which the species is not
  adapted, have responses that are more or less
  effective against the onset of pathological
  changes.
• For example, our species is certainly not adapted
  to smoking.
• If, in smokers, some suffer respiratory failure,
  others chronic bronchitis and others cancer, it
  is not correct to say that those who develop
  these diseases have bad genes that somehow must
  be corrected, or for which it is necessary to
  develop opportune treatments.
• The logic says that we must avoid the alteration
  of the ecological niche and thus prevent the
  development of diseases that result from it.
• It should be noted that in some cases
  malocclusions or urolithiasis are actually due to
  genetic alterations. In these cases any
  preventive measure is not able to prevent the
  diseases. But, if we refer to data from the study
  of populations living under primitive conditions,
  the incidence of such cases is rare. Therefore,
  the attribution of responsibility to genetic
  factors should not be an excuse to diminish or
  avoid to address the most attention and efforts
  on prevention.

27
Conclusion

• Malocclusions and urolithiasis involve
  significant costs and causes sufferings, reduced
  quality of life and even death.
• Current Medicine is directed to pursue means of
  correction that are increasingly sophisticated
  and refined.
• But the best goal would certainly be to minimize
  new cases of malocclusions and urolithiasis,
  reserving the cures to exceptional cases.
• This would limit the degradation of quality of
  life, a lot of suffering, and - last but
  something to be reckoned with - rising costs.
• This is possible with the correct application of
  trivial principles of Evolutionary Medicine.

28
Conclusion
Modern doctors, largely unaware even of the most
basic principles of Evolutionism, do not know
these possibilities. At the same time,
evolutionary biologists are unaware of the
extreme importance of these possibilities for a
rational organization of a health system that
should primarily prevent diseases. It is
therefore essential the integration of the
knowledge of Evolutionism in the active body of
current Medicine, transforming it in Evolutionary
Medicine.
29
Thanks for your attention
This presentation is on my personal pages too
www.r-site.org/ageing (e-mail
giacinto.libertini_at_tin.it)