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Let's pause for a moment and look back at what we've seen in the preceding lectures they've tried to develop a rather rich view of patient informed by a variety of evolutionary perspectives I'm going to recast some take-home points in different words to try to get across what I think are the most important insights here the first is that patients are mosaics of parts that have very different ages some of the very oldest parts of our bodies like our intermedia metabolism are very precise very efficient, and they have been shaped by billions of selective events they are also very hard to change and some of the most recent responses have not yet had time to adapt and that they are mounted they can produce maladaptive mismatches we've seen some of those with things like the hygiene hypothesis and the microbiome patients who have different ethnicities different geographical origins have genes that experience different histories of exposure to disease and to diet they vary in ability to resist disease and to metabolize drugs that is why we need to have good genetic information if we can afford it so that we can personalize medicine humans have only very recently evolved altricial young that is young that are helpless at birth young short interior intervals and menopause these conditions are not yet as precise or as elegantly designed as ancient traits simply because they have been shaped by many fewer selective events you can think of the number of selective events as being something like how course the sandpaper is if there have been billions of events it's very fine sandpaper that's practically down to lens grinding compound in terms of how smooth and beautiful it can make something but if they're just a few events it's either very coarse sandpaper or it's more like a hammer and a chisel, and you get a very rough shaping of the adaptation a fourth point is that patients not only have an evolutionary history they have a developmental history, and they react to diet exercise and disease with plastic responses among their most important experiences are the ones that happen very early in life things that happen when they are in uteri during childbirth and just after childbirth that is when things like the difference between c-sections and vaginal delivery and breastfeeding and formula feeding and the use of antibiotics or not can make a big difference to the microbiome and then to the risk of 80 PS and autoimmune disease later in life another point that we encounter repeatedly in evolutionary medicine is that patients are bundles of trade-offs these trade-offs between traits were assembled by evolution out of whatever variation there was that happened to be good to use at the time, and it had side effects, so those side effects have accumulated over evolutionary history if there's a trade-off than a change in one trade is going to be linked changes in other traits it's going to be linked genetically developmentally, and physiologically it's almost...
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