This piece continues from the previous installment of Stones in the Body: More Frightening Than Cancer (Yoon Jong-won). The body, figures, and citations follow the manuscript as written.
The Meaning of the Scene Order
Why does the judgment of order matter? Because even with the same code, the cause is different.
For example, let us think about D-PH (physical-stimulus deficiency). It is a state in which there is no stimulus to the bone because the person does not move. But why does the person not move?
First case: the person does not move because they have no drive due to depression. Even when they open their eyes in the morning, they have no strength to get up. Everything feels meaningless. Exercise? They have no capacity to bother with such a thing. In this case D-PH is first order. Because the problem of the mind is the fundamental cause.
Second case: the person does not move because they have no exercise habit. They put off exercise with the excuse of being busy, the excuse of it being a bother. They are not especially depressed and not sick either, but they simply do not exercise. In this case D-PH is second order. Because lifestyle is the cause.
Third case: the person cannot move because a fracture has put them in a cast. Even if they want to move, it is physically impossible. In this case D-PH is third order. Because an acute event is the cause.
It is the same D-PH, but the treatment strategy is completely different.
If it is first order, treating the depression comes first. Antidepressants, counseling, cognitive behavioral therapy. Only when the mind recovers does the drive to exercise arise.
If it is second order, correcting the exercise habit comes first. Making an exercise plan, finding an exercise partner, starting from small goals. Changing the behavior is enough.
If it is third order, rehabilitation treatment comes first. Physical therapy, gradual exercise, use of assistive devices. Recovery of bodily function comes first.
If the cause is different, the prescription must be different too. Telling a depressed person to "just exercise" has no effect. Giving antidepressants to a person whose problem is habit is meaningless. Telling a person in a cast to go to the gym is absurd.
The judgment of order is the starting point of treatment.
First Order (the Fundamental Trigger): the Layer That Topples the Living Engine
First order is the problem of the mind and the rhythm.
The human body has basic engines. The sleep engine, the appetite engine, the activity engine, the respiration engine. These engines run while riding their rhythms. Sleeping at night and waking in the day, eating when hungry and stopping when full, being active and resting, breathing in and breathing out. This rhythm is life.
First-order factors topple these engines.
Think about chronic stress. When stress persists, the person cannot sleep. Even when lying down at night, thoughts follow one after another, and at dawn they wake and stare at the ceiling. The sleep engine collapses.
When the person cannot sleep, the appetite changes. Some people lose their appetite and go hungry. Some people relieve stress through binge eating. In particular they seek sweet food, salty food, greasy food. The appetite engine collapses.
When the appetite changes, the weight changes. If they starve they grow thin, if they binge they gain. Either way it is a burden on the body.
When the person cannot sleep and the appetite changes, the amount of activity also decreases. Being tired, they do not want to move. They cannot bring themselves to exercise. They lie on the sofa and look at their phone. The activity engine collapses.
When the amount of activity decreases, sleep comes even less. One must be active during the day to be tired at night and sleep, but if one does not move during the day, one is not tired at night either. It is a vicious cycle.
This is the characteristic of first order. When first order collapses, second order automatically worsens. When the mind collapses, the habit collapses. Even if one tries to fix the habit, if the mind does not support it, it does not last.
Let us look at the representative factors of first order.
Chronic stress. Workplace stress, family stress, economic stress, relationship stress. Modern people swim in a sea of stress.
Anxiety. The future is uncertain, health is uncertain, the children are uncertain, old age is uncertain. Anxiety tenses the body, and tension raises cortisol.
Depression. There is no drive, no joy, no hope. Depression shifts all the engines into low gear.
Social isolation. The person lives alone. There is no one to talk to. They are lonely. Loneliness is more fatal than one might think.
Trauma. Past wounds dominate the present. Memories of abuse, accident, loss keep rising up. The body still thinks it is inside that danger of that time.
Collapse of the sleep rhythm. Day and night are reversed, there is sleep apnea, there is insomnia. When one cannot sleep, everything collapses.
First order is not visible to the eye. It does not come out as a number like blood pressure. It is not caught by a test like blood sugar. That is why it is easy to ignore. "It is just stress." "I am a bit tired, that is all." "When you get older, everyone is like that." So it is passed over.
But first order is the deepest root. If first order is not solved, second-order correction does not last. Even if you tell a person whose mind has collapsed to "exercise," "eat well," "quit smoking," if they have no drive they cannot even begin. Even if they begin, they cannot keep it up.
First order "amplifies the gate over the long term." It does not open all at once, but slowly over a long time, and yet deeply, it opens.
Second Order (the Habit Trigger): the Layer That Widens the Gate Every Day
Second order is the problem of lifestyle.
Not exercising yesterday does not make a disease appear today. Overeating yesterday does not bring diabetes today. Smoking yesterday does not create lung cancer today.
But when this piles up for 1 year, 5 years, 10 years, 20 years, it becomes different. Second-order factors are small pressures repeated every day. Each single day seems like nothing much. But when it piles up every day, it becomes a mountain.
Think about a drop of water. A single drop of water cannot pierce a rock. But when a drop of water falls on the same spot tens of thousands, hundreds of thousands of times, a hole is bored in the rock. Second-order factors are the drop of water. One drop is nothing, but if it keeps falling, it pierces.
The characteristic of second order is that there is no awareness of it. Because it progresses slowly, one does not feel the change. Yesterday and today look the same. Today and tomorrow look the same. But if you compare today with 10 years ago, it is completely different.
10 years ago you ran up the stairs, now you take the elevator. 10 years ago you worked all night and were fine the next day, now if you work overtime it drags on for 3 days. 10 years ago your clothing size was M, now even XL is tight. 10 years ago you were "normal" on your checkup, now you get the labels "caution," "borderline," "slightly high."
This is the fearfulness of second order. It progresses invisibly. Until one day, suddenly, a disease name is attached.
Let us look at the representative factors of second order.
Lack of exercise. The person does not move. They commute by car, work sitting down, go home by car, eat dinner sitting down, and lie down watching TV until they fall asleep.
Sedentary living. It is different from lack of exercise. Even if you go to the gym three times a week, if you spend the rest of the time sitting, it is sedentary living. 1 hour of exercise a day, 15 hours of sitting a day. 1 hour cannot beat 15 hours.
Overeating. The person eats even when the stomach is full. Because it is a waste to leave what is on the plate, because the dessert looks tasty, because they are stressed, because they are bored.
Unbalanced eating. They eat only meat and not vegetables. They eat only sweet things and not bitter things. Nutrition tilts to one side.
High-salt diet. They eat salty. They drink the broth to the last drop, they love salted seafood, and they do not leave even the ramen broth.
High-sugar diet. They eat sweet. Two spoons of sugar in the coffee, cake for dessert, snacks for a treat, cola instead of a beverage.
Smoking. They smoke cigarettes. A pack a day, or half a pack, or a few sticks. The amount is not the problem. That they smoke every day is the problem.
Drinking. They drink alcohol. A drink with every meal, or heavy drinking every weekend, or drinking until drunk at every company dinner. The liver is overworked a little every day.
Lack of sleep. They do not sleep enough. Because there is a lot to do, because the drama is interesting, because the game does not end. They stay up all night and are drowsy during the day.
Second order "widens the gate every day." By 1mm a day, invisibly, but surely, it widens the gate.
Third Order (the Acute Trigger): the Layer That Pushes Through the Gate in One Stroke
Third order is an acute event. It comes without warning. It happens suddenly one day. One was fine until yesterday, and today one is different.
The characteristic of third order is shock. The body is shaken all at once. There is no time to adapt. There is no room to prepare.
Let us look at the representative factors of third order.
Falls and fractures. The person falls. On the stairs, in the bathroom, on the icy road, at the threshold. A bone breaks. The wrist, the hip joint, the spine. Like Mr. Jeong-mo.
Acute infection. The person gets infected. Pneumonia, urinary tract infection, sepsis. The fever rises, and the immune reaction explodes. Surgery. The person goes onto the operating table. Whether a planned surgery or an emergency surgery. They are anesthetized, opened with a knife, sutured, and taken to the recovery room. Hospitalization. The person is admitted to the hospital. They lie in the bed. They receive IV fluids, eat hospital food, and go back and forth to the ward.
Traffic accident. A car crashes. Or the person is hit by a car. Bones break, organs are damaged, blood flows. Acute hemorrhage. A lot of blood is lost. Through an accident, through surgery, through internal bleeding. The blood volume decreases, and oxygen does not reach the tissue.
Third order itself is in many cases unavoidable. A fall happens even when one is careful. An infection catches you when it catches you, no matter how much you wash your hands. A traffic accident befalls you when the other party is careless even if you are careful.
The problem is when third order strikes "a body whose reserve capacity has been exhausted."
When a young and healthy person falls, they get up. Even if a bone breaks, it knits. Even if muscle is lost, they build it back. Because they have reserve capacity.
But when the gate has already been widened by first order (chronic stress) and second order (lack of exercise, nutritional imbalance), and third order (a fall) comes, it is different. The bones are already weakened. The muscles are already lost. The recovery power is already lowered. The same shock arrives far greater.
For a young person a cold is an illness that heals with a few days of rest. But for an elderly person a cold can go to pneumonia, and pneumonia threatens life. It is a difference of reserve capacity.
First order and second order "widen the gate," and third order "pushes through the widened gate."
Third order "suddenly pushes through" the gate. Without warning, all at once, by force.
The three layers are connected to one another. First order summons second order, and second order makes one vulnerable to third order.
Let us follow the flow.
There is a person who receives chronic stress (first order). The pressure from work and personal relationships is severe. At night the person cannot sleep. The sleep rhythm collapses.
Because the person cannot sleep, they are tired. Because they are tired, they cannot bring themselves to exercise. They come to not exercise (second order). When tired, sweet food is craved.
Chocolate, cake, carbonated drinks. It is the instinct to replenish energy through sugar. The eating habits worsen (second order). When tired, one wants to unwind with alcohol. A drink after work, two on the weekend. The amount of drinking increases (second order).
Because the stress persists, the inflammatory reaction does not easily turn off.
In people in their 30s to 50s, the gums swell acutely and micro-bleeding increases. When the inflammatory signal lasts long, calcium begins to leak out of the alveolar bone. The bone density of the alveolar bone gradually falls, and the "foundation work" that supports the teeth weakens.
One day the person chews food. It is a very small shock. In the old days it would have held, but because the alveolar bone is sparse like micro-osteoporosis, it cannot absorb that shock. The alveolar bone collapses microscopically (third order), and a small bone fragment produced in that process enters the gum tissue and creates a foreign-body reaction, making the inflammation grow larger.
The larger the inflammation grows, the more the bone efflux accelerates, and the weaker the bone becomes, the more easily it crumbles even under a small shock, and this vicious cycle repeats; in the end the support that held the tooth cannot bear it, and this leads to tooth loss.
In the case of the elderly, because they do not exercise, their muscle strength declines. The leg muscles weaken. The sense of balance grows dull. Because their eating habits are bad, their nutritional state becomes poor. Calcium intake is insufficient. Vitamin D is insufficient. The bones weaken.
One day the person goes down the stairs. They lose their balance. In the old days it would have held, but because there is no strength in the legs, they cannot hold. They fall (third order). Because the bones have weakened, even a light fall becomes a fracture.
First order (stress) induced second order (lack of exercise, eating habits), and second order made one vulnerable to third order (a fall). It is a chain reaction. Why does this matter? Because it tells you where the link to be cut is. To truly prevent third order, you must prevent second order. You must exercise to build muscle strength, maintain the sense of balance, and take care of nutrition to make the bones strong. Then even if you fall you can hold, and even if you fall you do not break. But to prevent second order, you must prevent first order.
You must manage stress, protect sleep, and take care of the health of the mind. Only when the mind is healthy does the drive to exercise arise, and the drive to eat good food arise. In the end, first order is the key. If you miss first order, second order collapses, and if second order collapses, you become vulnerable to third order.
[Table 6-2] Definitions and Examples by Order
| Order | Definition | Representative Factors | Characteristic | Action on the Gate |
|---|---|---|---|---|
| First order | Collapses the rhythm of sleep, appetite, activity level, and respiration, automatically worsening second order | Chronic stress, anxiety, depression, isolation, trauma, collapse of sleep rhythm | Not visible to the eye but the deepest root | "Amplifies the gate over the long term" |
| Second order | Small pressures repeated every day accumulate slowly and surely | Lack of exercise, overeating, unbalanced eating, smoking, drinking, sedentary living | A chronic path that progresses without awareness | "Widens the gate every day" |
| Third order | An acute event that shakes the body all at once | Traffic accident, fall, fracture, infection, surgery, hemorrhage | A decisive blow struck on an already weakened body | "Suddenly pushes through the gate" |
| Stage | Type | Representative Factors | Core Message | Worsening Result |
| First order | Mind/rhythm | Chronic stress, anxiety, depression, sleep disorder, isolation | "When the mind collapses, the living engine shuts off" | Lowered drive, accumulated fatigue, collapse of rhythm |
| ↓ | ||||
| Second order | Habit | Lack of exercise, overeating, unbalanced eating, smoking, drinking, sedentary living | "The daily choice changes the body" | Declined muscle strength, nutritional imbalance, reduced reserve capacity |
| ↓ | ||||
| Third order | Acute event | Fall, fracture, infection, surgery, accident | "The final shock struck on a weakened body" | Passing the DIAH four gates |
| ↓ | ||||
| Result | BCO | Bone calcium efflux |
[Table 6-3] Criteria for Judging the Order
| Judging Question | Corresponding Order | Example |
|---|---|---|
| Is a problem of the mind/stress/rhythm the fundamental cause? | First order | Not exercising because depressed, not sleeping because anxious, binge eating from stress |
| Is it the result of lifestyle accumulated every day? | Second order | Habitually not exercising, long-standing smoking, high-salt eating habits |
| Is an acute event/trauma/medical intervention the cause? | Third order | Immobility after a traffic accident, bed rest after surgery, debility after pneumonia |
First-Order Factors: the Mind Opens the DIAH Funnel
First-order factors are not visible to the eye. You cannot measure them with a blood pressure cuff, you cannot catch them with a blood test, and you cannot photograph them with an X-ray. But they are the deepest root. When the mind and the rhythm collapse, second order and third order automatically follow.
1. Chronic Stress
When one says that stress affects the bones, some people are puzzled. Stress is a mental thing, and bone is a physical thing, so how are they connected?
The connecting link is cortisol.
Cortisol is the stress hormone. When you receive stress, the hypothalamus of the brain sends a signal. The pituitary gland receives that signal and secretes ACTH. When ACTH reaches the adrenal gland, the adrenal gland secretes cortisol. This is called the HPA axis (the hypothalamic-pituitary-adrenal axis).
Cortisol is originally a good hormone. In a crisis situation it shifts the body into combat mode. It raises blood sugar to supply energy, suppresses inflammation, and heightens concentration. To flee or fight when you meet a tiger, you need cortisol.
The problem is that the stress of modern people is not a tiger. With a tiger, once you flee it is over. But your workplace boss, economic pressure, and human-relationship conflict cannot be fled. The stress does not end. Cortisol stays high continuously.
Chronically raised cortisol has a direct effect on the bones.
First, cortisol suppresses osteoblasts. Osteoblasts are the cells that make bone. Think of them as the construction workers of the bone. When cortisol is high, the construction workers cannot do their work. They cannot make new bone.
Second, cortisol prolongs the lifespan of osteoclasts. Osteoclasts are the cells that dissolve bone. Think of them as the demolition workers of the bone. Originally osteoclasts die after working for a set period. But when cortisol is high, the osteoclasts live longer. The demolition workers work longer. More bone is dissolved.
The side that makes bone is suppressed, and the side that dissolves bone is activated. The result is obvious. Calcium leaks out of the bones. Cortisol also blocks calcium absorption in the intestine. No matter how much calcium you eat, it is not absorbed.
Cortisol also increases calcium excretion in the kidney. It reduces the calcium coming in and increases the calcium going out.
This is the mechanism of the I-ST (stress-type inflammation) code. Chronic stress collapses the cortisol rhythm, and this creates an inflammatory environment. When cortisol is chronically high, immune regulation collapses. A short-term rise in cortisol suppresses inflammation, but a long-term rise in cortisol rather disrupts the immune system. A low-grade chronic inflammation persists.
Stress is dissolving the bones.
2. Anxiety and Depression
There are several research findings that the bone density of people with anxiety disorder or depression is low. Why is that?
The mechanism is complex.
First, it is autonomic-nervous imbalance. When you are anxious, the sympathetic nervous system is overactivated. The heart beats fast, the hands sweat, and a state of tension persists. When the sympathetic nervous system is overactivated, cortisol rises. It is the same path as chronic stress.
Second, it is a drop in neurotransmitters. In depression, serotonin decreases. But serotonin does not regulate only mood. It also participates in bone metabolism. Serotonin made in the intestine suppresses bone formation, and serotonin made in the brain promotes bone formation. When brain serotonin decreases in depression, the promotion of bone formation weakens.
Third, it is the behavioral effect. This may perhaps be the greatest effect.
A depressed person has a reduced amount of activity. It is hard to get up in the morning. Nothing is fun no matter what they do. Exercise? They have no capacity to bother with such a thing. They just want to lie down. This opens D-PH (physical-stimulus deficiency).
A depressed person has worsened eating habits. They have no drive to set out a proper meal. They make do with instant food, or do not eat at all. Nutrition becomes deficient. This opens D-NT (nutritional deficiency).
A depressed person withdraws socially. They do not want to meet people. When the phone rings they do not answer. They stay only at home. They do not see sunlight. Vitamin D becomes deficient. This too opens D-NT.
Anxiety and depression open D-LF (life-input deficiency) and I-ST (stress-type inflammation) at the same time. When the mind collapses, living collapses, and when living collapses, the gate opens.
3. Collapse of the Sleep Rhythm
Sleep is not just a time to rest. While sleeping, the body is repaired.
Growth hormone is secreted. Growth hormone is not something only children need. It is essential for adults too. It restores tissue, maintains muscle, and participates in bone metabolism. Growth hormone is secreted mainly during deep sleep (slow-wave sleep). When you cannot sleep, the secretion of growth hormone decreases.
Melatonin is secreted. Melatonin is known as the sleep hormone, but it also has a powerful antioxidant action. There is also research that melatonin protects the bones. When you sleep with the light on at night, or live with day and night reversed, the secretion of melatonin decreases.
The cortisol rhythm recovers. Normally cortisol is high in the morning and low in the evening. It gives you the strength to get up in the morning and lets you fall asleep in the evening. When the sleep rhythm is broken, the cortisol rhythm is broken too. When cortisol is high in the evening, sleep does not come. When sleep does not come, the cortisol rhythm is broken further. It is a vicious cycle.
Sleep apnea is especially dangerous.
When you have sleep apnea, this happens every night. You fall asleep. The muscles relax. The muscles that supported the airway also relax. The airway narrows or is blocked. Even when you try to breathe, air does not come in. The oxygen saturation drops. The brain detects the danger. You wake slightly from sleep. As the muscles tense, the airway opens. You gasp for breath. You fall asleep again. And then it is blocked again.
In this process the body experiences an emergency every time. The sympathetic nervous system is overactivated. Adrenaline is secreted. Blood pressure surges. The heart beats fast. This repeats dozens, hundreds of times all night.
Sleep apnea opens H-RS (respiratory-type hypoxia) and I-ST (stress-type inflammation) at the same time. The repeated nighttime hypoxia damages tissue and induces inflammation. Sympathetic overactivation raises cortisol and sustains chronic inflammation.
As we saw in the case of Mr. Park, a single sleep apnea opens several gates at the same time.
4. Social Isolation and Trauma
Loneliness is more fatal than one might think.
There is a meta-analysis that studied the effect of social isolation on health. As a result of the Holt-Lunstad research team synthesizing 148 studies, the health risk of social isolation was equivalent to smoking 15 cigarettes a day. It was higher than the risk of obesity. It was higher than not exercising.
Why is that?
Isolated people have high inflammatory markers. Inflammatory indices such as CRP (C-reactive protein) and IL-6 (interleukin-6) rise. When there is no social connection, the body recognizes it as a "threat state." A chronic low-grade inflammation persists.
Isolated people have low immunity. They are vulnerable to infection, and their immune-surveillance function against cancer also declines.
Isolated people have low stress-recovery power. Even when something hard happens, there is no one to share it with. They suffer alone in silence. The stress is not relieved and piles up.
Trauma too is a first-order factor.
When you have post-traumatic stress disorder (PTSD), the HPA axis is chronically overactivated. Even though the past danger has passed, the body still thinks it is inside the danger. The state of alert does not relax. Cortisol stays high continuously.
Childhood abuse, the experience of an accident, the experience of war, the experience of a disaster. Such trauma affects the health of decades later. The wound of the mind appears as the wound of the body.
