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What Is Health?: Allostasis and the Evolution of Human Design
An argument that health is optimal responsiveness and is often best treated at the system level. Medical education centers on the venerable “no-fault” concept of homeostasis, whereby local mechanisms impose constancy by correcting errors, and the brain serves mainly for emergencies. Yet, it turns out that most parameters are not constant; moreover, despite the importance of local mechanisms, the brain is definitely in charge. In this book, the eminent neuroscientist Peter Sterling describes a broader allostasis (coined by Sterling and Joseph Eyer in the 1980s), whereby the brain anticipates needs and efficiently mobilizes supplies to prevent errors. Allostasis evolved early, Sterling explains, to optimize energy efficiency, relying heavily on brain circuits that deliver a brief reward for each positive surprise. Modern life so reduces the opportunities for surprise that we are driven to seek it in bigger burgers, more opioids, and innumerable activities that involve higher carbon emissions. The consequences include addiction, obesity, type 2 diabetes, and climate change. Sterling concludes that solutions must go beyond the merely technical to restore possibilities for daily small rewards and revivify the capacities for egalitarianism that were hard-wired into our nature. Sterling explains that allostasis offers what is not found in any medical principled definitions of health and health as the capacity for adaptive variation and disease as shrinkage of that capacity. Sterling argues that since health is optimal responsiveness , many significant conditions are best treated at the system level.
264 pages, Hardcover
Published February 25, 2020
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Displaying 1 - 14 of 14 reviews
May 16, 2020
Rethinking the foundations
Medicine is a vast enterprise. Even one's own medical training is a vast undertaking. So perhaps it's surprising how little attention is given in that training to the most basic question, "What is health, anyway?" Implicitly the answer is generally taken to be, "Obviously, health is having the same blood pressure etc. as most other people (especially those european males we have studied a lot). Obviously health is having the same physical and mental abilities as most other people." When a patient presents with the "wrong" blood pressure, some "defective" mechanism is sought and ideally a drug to "correct" it is administered. For many situations, like bacterial infection, this model of health has been fantastically successful, but less so for the increasing list of chronic conditions.
Sterling demands that we go back to basics. In his magisterial survey he shows us how sophisticated every living organism is, practically back to the dawn of life, at predicting its future environmental stresses, from the most basic (daily sunrise) to more advanced (predator threat), and then adjusting its physiology to optimize survival in the predicted conditions. In this way we, and every other organism, have greatly enhanced our our own survival, and yet these ancient mechanisms can be fooled by modern life. Chronic stress causes us to constantly prepare for struggle, choosing an elevated target blood pressure until we adapt and get stuck at that target. In ancient times, when that stress came from physical danger, the resulting loss of lifespan was a good tradeoff to make for enhancing short-term survival; today it is not. And drugging one particular biochemical pathway thought to be responsible for this adaptation mechanism is rarely successful, because evolution has given us so many parallel backup pathways to implement this valuable survival mechanism.
Any science looks away from inconvenient facts, so it is startling to see the whole world re-viewed from this new viewpoint. Others have said things similar to the thesis as I have tried to summarize it, but in a fascinating tour, this book marshals an enormous body of knowledge from all levels of biology and medicine. I was especially interested in the discussion of prediction versus error correction at the cellular level in chapter 2.
Medicine is a vast enterprise. Even one's own medical training is a vast undertaking. So perhaps it's surprising how little attention is given in that training to the most basic question, "What is health, anyway?" Implicitly the answer is generally taken to be, "Obviously, health is having the same blood pressure etc. as most other people (especially those european males we have studied a lot). Obviously health is having the same physical and mental abilities as most other people." When a patient presents with the "wrong" blood pressure, some "defective" mechanism is sought and ideally a drug to "correct" it is administered. For many situations, like bacterial infection, this model of health has been fantastically successful, but less so for the increasing list of chronic conditions.
Sterling demands that we go back to basics. In his magisterial survey he shows us how sophisticated every living organism is, practically back to the dawn of life, at predicting its future environmental stresses, from the most basic (daily sunrise) to more advanced (predator threat), and then adjusting its physiology to optimize survival in the predicted conditions. In this way we, and every other organism, have greatly enhanced our our own survival, and yet these ancient mechanisms can be fooled by modern life. Chronic stress causes us to constantly prepare for struggle, choosing an elevated target blood pressure until we adapt and get stuck at that target. In ancient times, when that stress came from physical danger, the resulting loss of lifespan was a good tradeoff to make for enhancing short-term survival; today it is not. And drugging one particular biochemical pathway thought to be responsible for this adaptation mechanism is rarely successful, because evolution has given us so many parallel backup pathways to implement this valuable survival mechanism.
Any science looks away from inconvenient facts, so it is startling to see the whole world re-viewed from this new viewpoint. Others have said things similar to the thesis as I have tried to summarize it, but in a fascinating tour, this book marshals an enormous body of knowledge from all levels of biology and medicine. I was especially interested in the discussion of prediction versus error correction at the cellular level in chapter 2.
July 7, 2021
What Is Health? is a cogently argued book that traces the epidemic of Western lifestyle diseases to us sabotaging our ancient neurological reward circuits. See my full review at https://inquisitivebiologist.com/2021...
May 11, 2020
I’m not a scientist. I didn’t even take biology in high school because I didn’t want to cut up the animals. This very special book fills in a lot of gaps for me and provides a fascinating perspective on what “health” really means and how we approach it in our modern culture.
I’ve been hearing a lot recently about “deaths of despair,” but this author, Peter Sterling, has explored the topic with an original and provocative approach. He begins with a “quick” history of human evolution, then turns his attention to the question: What is health?
You first have to read through some science to get to his insights. But Sterling manages to cover three billion years of human evolution in 100 pages or so without insulting the scholar or crushing the amateur. An intelligent lay reader can skim these chapters, extracting just enough to create context for the provocative theories that follow. And it isn’t a slog, thanks to Sterling’s engaging writing style. I had no idea that science could be so entertaining. For example:
• Describing a marine worm that resembles our earliest human ancestor: “Exuberantly bilateral, Platynereis resembles a cuddly refugee from Sesame Street. So, what do we share with it besides a pretty face?”
• Presenting evidence of our simian origins (and perhaps suggesting we are hardwired for porno proclivities?): “A male macaque will work for an opportunity to view an image of a female perineum.”
Sterling suggests that Earth’s poor health and humans’ poor health have the same cause: excessive consumption. The problem is not any philosophical attitude or political system, he says. Instead, as we humans have moved from foraging to farming to modern life, we have fewer opportunities to use our natural gifts. “What became of the quirky communities where every brain was different and everyone had something to offer?” In these places, “sacred practices” such as music, storytelling, and rites of passage kept us feeling connected. “We’re still wired to live like that,” he says. “But now multitudes are confined to punch a ticket, scan an item, or sit in cubicles and stare at screens. These activities are unrewarding, and so we despair.”
Sterling explains “reward” in physiological terms: Small, positive surprises (say, catching a big fish or finishing a 5K) prompt the release of a feel-good brain chemical called dopamine. But modern life does not lend itself to regular, natural pulses of dopamine. So many people seek these rewards from alcohol, drugs, rich food, hyperactivity, acquiring possessions. Those things can produce big jolts of dopamine. But the brain adapts, the next dose is less effective, and more and more is required for the same high.
So what we have now are epidemics of obesity and hypertension and diabetes and depression. We have an opioid crisis. And the problem, says Sterling, is that modern medicine wants to treat these problems with pharmaceuticals instead of addressing the underlying issue: the stress of modern life, with its lack of natural positive rewards. Sterling believes a more rational approach would be to develop new avenues to restore meaning and challenge to daily life and ends with some reflections on what that might look like.
I’ve been hearing a lot recently about “deaths of despair,” but this author, Peter Sterling, has explored the topic with an original and provocative approach. He begins with a “quick” history of human evolution, then turns his attention to the question: What is health?
You first have to read through some science to get to his insights. But Sterling manages to cover three billion years of human evolution in 100 pages or so without insulting the scholar or crushing the amateur. An intelligent lay reader can skim these chapters, extracting just enough to create context for the provocative theories that follow. And it isn’t a slog, thanks to Sterling’s engaging writing style. I had no idea that science could be so entertaining. For example:
• Describing a marine worm that resembles our earliest human ancestor: “Exuberantly bilateral, Platynereis resembles a cuddly refugee from Sesame Street. So, what do we share with it besides a pretty face?”
• Presenting evidence of our simian origins (and perhaps suggesting we are hardwired for porno proclivities?): “A male macaque will work for an opportunity to view an image of a female perineum.”
Sterling suggests that Earth’s poor health and humans’ poor health have the same cause: excessive consumption. The problem is not any philosophical attitude or political system, he says. Instead, as we humans have moved from foraging to farming to modern life, we have fewer opportunities to use our natural gifts. “What became of the quirky communities where every brain was different and everyone had something to offer?” In these places, “sacred practices” such as music, storytelling, and rites of passage kept us feeling connected. “We’re still wired to live like that,” he says. “But now multitudes are confined to punch a ticket, scan an item, or sit in cubicles and stare at screens. These activities are unrewarding, and so we despair.”
Sterling explains “reward” in physiological terms: Small, positive surprises (say, catching a big fish or finishing a 5K) prompt the release of a feel-good brain chemical called dopamine. But modern life does not lend itself to regular, natural pulses of dopamine. So many people seek these rewards from alcohol, drugs, rich food, hyperactivity, acquiring possessions. Those things can produce big jolts of dopamine. But the brain adapts, the next dose is less effective, and more and more is required for the same high.
So what we have now are epidemics of obesity and hypertension and diabetes and depression. We have an opioid crisis. And the problem, says Sterling, is that modern medicine wants to treat these problems with pharmaceuticals instead of addressing the underlying issue: the stress of modern life, with its lack of natural positive rewards. Sterling believes a more rational approach would be to develop new avenues to restore meaning and challenge to daily life and ends with some reflections on what that might look like.
July 21, 2022
This enthralling, accessible book explores the nature of human health from the most microscopic to the most cosmic, developing a fascinating and persuasive unified account of the intertwined mechanisms and dynamics that underlie how the "health of modern sapiens is challenged by the prevalence of chronic illness." Eschewing technical language and academic loftiness for an accommodating and economical prose style that will be easy to digest by anyone with a college degree, Sterling retraces the key moments in the evolution of human health over the past billion years, revealing that fundamental self-management process of human health is not homeostasis, but alleostasis: "Whereas homeostasis tends to define 'health' as a list of 'appropriate' lab values and 'disease' as 'inappropriate' values, allostasis defines health as the capacity for adaptive variation and disease as a shrinkage or compression of that capacity." Allostasis is designed to maximize possibilities while homeostasis is about aiming for a fixed target. The fundamental reality of allostasis suggests that there can be many principled approaches to promoting health--and that most of these approaches start at the topmost level, at the level of the system: the human community. Sterling points out that modern medicine is laser focused on the micro-level--particularly on medications, but the chronic, ubiquitous nature of modern unhealth demands systemic changes, which Sterling outlines. Filled with wisdom, scholarship, and the voice and passion of a man who was willing to live on a farm in Panama for 15 years in order to learn about the health of foragers and indigenous agriculturists, WHAT IS HEALTH is a convincing and inspiring dose of clarity on how we should live in these turbulent, high-tech times in order to allow our body and brain's natural capacity for health to flourish.
July 23, 2021
A brilliant book -- the science in the first half makes this harder to understand, initially, than books like Sapiens and Guns, Germs, and Steel, but in the end the point becomes very clear and it's powerfully, resonantly argued.
"The allostasis model defines health as the capacity to respond optimally to fluctuations in demand."
Which seems pretty simple actually (he has gone into some depth). But it has a host of interesting, radical implications, mostly along the lines that many of the things we treat pharmacologically, like chronic diseases and mental 'illness,' are in fact bodies behaving as they are programmed to do, in response to circumstances that are pushing them beyond their limit. What we need to do is to change the circumstances; to find ways to allow people to live more meaningful lives -- not make up for the lack of meaning with excessive consumption, nor treat our societal ill health by drugging people.
"The allostasis model defines health as the capacity to respond optimally to fluctuations in demand."
Which seems pretty simple actually (he has gone into some depth). But it has a host of interesting, radical implications, mostly along the lines that many of the things we treat pharmacologically, like chronic diseases and mental 'illness,' are in fact bodies behaving as they are programmed to do, in response to circumstances that are pushing them beyond their limit. What we need to do is to change the circumstances; to find ways to allow people to live more meaningful lives -- not make up for the lack of meaning with excessive consumption, nor treat our societal ill health by drugging people.
December 24, 2020
What we guessed but did not want to admit
Peter Sterling gives us an engaging and scientifically fascinating history of our evolution to a healthy, surviving, adaptable indeed dominating species. He then encourages us to follow what took us here, i.e., a life style fit to the demands of our internal and external environment rather than relying on medications that attempt, but so often fail, to provide a stable and satisfying physical and mental equipoise.
Peter Sterling gives us an engaging and scientifically fascinating history of our evolution to a healthy, surviving, adaptable indeed dominating species. He then encourages us to follow what took us here, i.e., a life style fit to the demands of our internal and external environment rather than relying on medications that attempt, but so often fail, to provide a stable and satisfying physical and mental equipoise.
September 4, 2022
This book is absolutely genious! Definitely one of the best books I've read this year. I haven't seen such scientific and eloquent critique of the medical paradigm anywhere else. The main idea is that medical treatment - like a broken leg or cancer - is because some bodily mechanism or function isn't working anymore and treatment makes it work. However, if the illness is due to the brain predicting a certain environment and adapts to it, eg increasing blood pressure in a chronical unsafe environment, no medicine is really going to work. You can try one but the brain will compensate to keep its setting. The brain has many pathways to regulate the body (eg increase blood pressure) and will use them. When the first medicine doesn't work, you have to use another. After a while average blood pressure decreases to a healthy average level, but at the cost of decreasing variability (it can't go up or down fast to respond to environmental demands) so you're still sick - handicapped - but in a more invisible way.
In Sterlings view, much of modern illnesses are "illness of despair" like diabetes from eating too much, in turn from feeling insecure, isolated, unsafe etc. The brain responds to an extreme environment (ie one we weren't trained on evolutionary like cheap refined sugar) by adapting, setting new expectations/predictions like it use to and the result is diabetes, high blood pressure etc. They're not a result of your body not working, it's a result of your body working perfectly normal in an "alien" environment our brain hasn't been trained on. The remedy is to change environment (like paid vacation or psychoterapy I assume) and so change the brains setting.
Even if the ideas turn out not to be true, they are fascinating to think about and will help ask relevant questions. There are actually a few question marks about this book. One is that natural human life span is alleged to be 70 years (otherwise the intergenerational energy budget needed for a big brain won't work). I thought average stone age life span was 30-40? There's not much evidence in the book about 70 year life span. Also, the arguments about what is wrong with Western schools and upbringing are shaky. Sterling says there based on current hunter-gatherer cultures and his own obserations in Panama. This is not very convincing scientifically but still valuable ideas to investigate (like the argument about less bullying in age mixed child groups). Also hunter-gatherer culture and agriculture are treated quite monolithical. I thing the book would benefit if Sterling had been able to read The Dawn of Everything (not possible, I know).
Anyway, I highly recommend this book!
In Sterlings view, much of modern illnesses are "illness of despair" like diabetes from eating too much, in turn from feeling insecure, isolated, unsafe etc. The brain responds to an extreme environment (ie one we weren't trained on evolutionary like cheap refined sugar) by adapting, setting new expectations/predictions like it use to and the result is diabetes, high blood pressure etc. They're not a result of your body not working, it's a result of your body working perfectly normal in an "alien" environment our brain hasn't been trained on. The remedy is to change environment (like paid vacation or psychoterapy I assume) and so change the brains setting.
Even if the ideas turn out not to be true, they are fascinating to think about and will help ask relevant questions. There are actually a few question marks about this book. One is that natural human life span is alleged to be 70 years (otherwise the intergenerational energy budget needed for a big brain won't work). I thought average stone age life span was 30-40? There's not much evidence in the book about 70 year life span. Also, the arguments about what is wrong with Western schools and upbringing are shaky. Sterling says there based on current hunter-gatherer cultures and his own obserations in Panama. This is not very convincing scientifically but still valuable ideas to investigate (like the argument about less bullying in age mixed child groups). Also hunter-gatherer culture and agriculture are treated quite monolithical. I thing the book would benefit if Sterling had been able to read The Dawn of Everything (not possible, I know).
Anyway, I highly recommend this book!
February 19, 2022
A profound and beautifully written book
It is a joy and relief to read a meaty science book that is unburdened by jargon. What Is Health is beautifully unfussy and unstuffy, and may also be the best book about health I’ve read – in maybe forever. We are all dimly aware of how complex our bodies are. Thirty trillion cells figuring out a way through life, while also figuring out cooperative coexistence. But the implications of our body as a complex system, as an adaptive complex system, are not appreciated or understood. Peter Sterling, along with Joseph Eyer, pioneered the concept of allostasis, where the brain and body anticipate needs and help make things happen proactively. What Is Health makes the case for this decisively and evocatively.
Why does this perspective matter? We are in a world inundated with medical and clinical data, and it keeps on piling up. The right foundational perspective, and a few guiding principles, can help us stay afloat and make sense of it. Consider one example from the book where the author recalls Pavlov’s famous experiment with his salivating dogs. Neuroscience textbooks bin this into what’s called classical conditioning – how a behavioral response can be learned through association. There’s another equally imporant story that’s left untold. This is yet another case of a complex system predicting a need and proactively preparing for it. “[F]ood captured with effort and risk should be processed efficiently. As the gut moves complex macromolecules along the tract with a rhythm set by its intrinsic neural network, they must be broken down promptly or be lost. Consequently, the brain prepares each region of the digestive system from mouth through small intestine for what it is about to receive. This was Pavlov’s insight: an animal predicting food secretes digestive enzymes *before* the food arrives.”
The book goes on to discuss how the human design that’s been so wonderfully pieced together now faces peril in the information-saturated modern world. “We are drug-addicted, obese, and compulsively gambling and shopping. We are sleep-deprived, anxious, fearful, and depressed.” How this is tied to vicarious pleasures, which sever the intimate multi-billion year link between the body and the mind, is thought-provoking.
There’s much else here that is startling, memorable, and wonderfully quotable.
It is a joy and relief to read a meaty science book that is unburdened by jargon. What Is Health is beautifully unfussy and unstuffy, and may also be the best book about health I’ve read – in maybe forever. We are all dimly aware of how complex our bodies are. Thirty trillion cells figuring out a way through life, while also figuring out cooperative coexistence. But the implications of our body as a complex system, as an adaptive complex system, are not appreciated or understood. Peter Sterling, along with Joseph Eyer, pioneered the concept of allostasis, where the brain and body anticipate needs and help make things happen proactively. What Is Health makes the case for this decisively and evocatively.
Why does this perspective matter? We are in a world inundated with medical and clinical data, and it keeps on piling up. The right foundational perspective, and a few guiding principles, can help us stay afloat and make sense of it. Consider one example from the book where the author recalls Pavlov’s famous experiment with his salivating dogs. Neuroscience textbooks bin this into what’s called classical conditioning – how a behavioral response can be learned through association. There’s another equally imporant story that’s left untold. This is yet another case of a complex system predicting a need and proactively preparing for it. “[F]ood captured with effort and risk should be processed efficiently. As the gut moves complex macromolecules along the tract with a rhythm set by its intrinsic neural network, they must be broken down promptly or be lost. Consequently, the brain prepares each region of the digestive system from mouth through small intestine for what it is about to receive. This was Pavlov’s insight: an animal predicting food secretes digestive enzymes *before* the food arrives.”
The book goes on to discuss how the human design that’s been so wonderfully pieced together now faces peril in the information-saturated modern world. “We are drug-addicted, obese, and compulsively gambling and shopping. We are sleep-deprived, anxious, fearful, and depressed.” How this is tied to vicarious pleasures, which sever the intimate multi-billion year link between the body and the mind, is thought-provoking.
There’s much else here that is startling, memorable, and wonderfully quotable.
January 21, 2024
В нейронауці є книга Principles of Neural Design яка міняє уявлення про мозок, навіть в науковців зі стажем. Кілька днів тому дочитав книгу одного з її авторів, більш на широку публіку, What is Health? (Peter Sterling). Одна з тих книжок, що формує світогляд на роки. Більшість книги про еволюцію життя від одноклітинних організмів до людини, написано складно, але дуже цікаво. Чому температура 36.6 оптимальна і чому теплокровність вигідніша? Чому люди живуть десь 70 років, а мавпи до 40-50? Чому розмір та форма еритроцита саме такі як є? І багато інших прикладів як природа віднайшла оптимальні інженерні рішення і при чому тут здоров'я. Але під кінець є розділ "Що пішло не так?", який підважує ідею просвітництва та прогресу (про що писав С. Пінкер в книзі "Просвітництво сьогодні"). Той спосіб життя в ліберальних демократіях, і найбільше в США, не відповідає нашій природі, ламається система підкріплення, змінюється поведінка. І це все веде до страшної статистики про сотні тисяч смертей під передозування опіоїдами в рік, не кажучи вже про ожиріння, гіпертензію, діабет, серцево-судинні захворювання, депресію, самогубство …
Автор пише чому так сталося і пропонує деякі рішення.
Але основна в мене думка виникла, що нам не можна будувати в Україні ліберальну демократію за західним зразком. Потрібно взяти звідти все найкраще, але не повторювати помилок. Так щоб наш спосіб життя більше відповідав нашій природі. І не треба чекати закінчення війни, наша статистика хвороб думаю не набагато краща. Треба вже зараз думати які зміни потрібні і як їх втілити.
Автор пише чому так сталося і пропонує деякі рішення.
Але основна в мене думка виникла, що нам не можна будувати в Україні ліберальну демократію за західним зразком. Потрібно взяти звідти все найкраще, але не повторювати помилок. Так щоб наш спосіб життя більше відповідав нашій природі. І не треба чекати закінчення війни, наша статистика хвороб думаю не набагато краща. Треба вже зараз думати які зміни потрібні і як їх втілити.
December 25, 2025
Some familiar material, explained in greater detail.
Some critiques:
This book contains some of the most un-enlightening figures I have ever encountered. The author seems committed to providing full detail of every biological system. While this is laudable in a way, it detracts from the clarity of his thesis and creates a bloated, overwhelming impression without serving any elucidating purpose.
I also have to wonder whether the author's insight in distinguishing between homeostasis (regulation to maintain some appropriate level of performance) and allostatis (regulation supported by predictive algorithms) is really novel, since all effective control systems do, in fact, include predictive sub-algorithms.
Some critiques:
This book contains some of the most un-enlightening figures I have ever encountered. The author seems committed to providing full detail of every biological system. While this is laudable in a way, it detracts from the clarity of his thesis and creates a bloated, overwhelming impression without serving any elucidating purpose.
I also have to wonder whether the author's insight in distinguishing between homeostasis (regulation to maintain some appropriate level of performance) and allostatis (regulation supported by predictive algorithms) is really novel, since all effective control systems do, in fact, include predictive sub-algorithms.
August 23, 2025
I picked up this book after reading “How Emotions are Made”. I wanted to understand that author’s idea of a “body budget”. I realized it was a governing principle / concept that is at the root of emotions and feeling, and is intricately linked with prediction and prediction error.
This book delivered.
The first part is somewhat technical, but therein lie some fundamental concepts.
The end becomes more anthropological.
Good read!
This book delivered.
The first part is somewhat technical, but therein lie some fundamental concepts.
The end becomes more anthropological.
Good read!
January 12, 2025
One of the most educational and enlightening books I’ve ever read.
Peter Sterling has figured out something that most have not. I recommend this book to everyone, not just medical professionals.
Peter Sterling has figured out something that most have not. I recommend this book to everyone, not just medical professionals.
April 25, 2023
Entender la Alostasis y su fenomeno social y cultural, una introducción a la etica en neurociencias
March 20, 2025
If there was a category for “re read,” often, this book would fit that category for me. My copy is underlined and notated with both the back and front open pages filled with scribbled notes. Peter achieved what he notes early in the book, credible accessible science and medical writing. And more, he presented himself; he is part of the message of compassion and clarity and creativity and thoughtful analysis of complexity. I was captured by the book from the very beginning for so many reasons - perhaps for the same reasons that some people will dismiss it out of hand. Peter combines activism and a complex understanding of the sacred with compelling science and actionable health policy, thereby alienating vast swashes of potential readers. If you are one that admires all of this, or can tolerate parts to get to the rest, read it. I’ll be reading alongside you.
Displaying 1 - 14 of 14 reviews