The Amish Health Paradox – Genetics, Lifestyle and Community

LANCASTER COUNTY, PA, UNITED STATES – The Amish are often described as a community living apart from many of the health challenges of modern society. Their physically active lifestyle, strong family networks and distinctive approach to healthcare have attracted considerable interest from physicians and researchers. Yet the Amish health story is more complicated than the idea that traditional life automatically produces better health. Genetic isolation has contributed to a concentration of rare inherited diseases, while changes in occupation, diet and lifestyle are gradually reshaping some Amish communities.

I recently had the opportunity to speak with Dr. Steven M. Nolt, a Professor of History and Anabaptist Studies at the Elizabethtown College in Pennsylvania, who has studied Amish communities for decades and has published extensively on Amish history and society. I was grateful for the opportunity to discuss several questions with him to better understand how the Amish approach health, illness and healthcare. One point became particularly clear during our conversation: there is no simple division between genetic and environmental influences. “Every disease or health condition involves a different combination of genetics and environment,” Dr. Nolt explained.

This is particularly important because the Amish are not one genetically uniform population. Different communities have different histories and founding families and their genetic characteristics can vary considerably. At the same time, their large families, multiple generations living in close proximity and detailed genealogies have made some Amish communities unusually valuable for genetic research.

Since the 1960s, researchers have identified numerous hereditary disorders among the Amish. The geneticist Victor McKusick of Johns Hopkins University was among the pioneers of this research. Ellis-van Creveld syndrome, characterized by short stature, an extra digit on each hand and, in some cases, congenital heart abnormalities, is particularly prevalent among the Lancaster County Amish. Other reported disorders include cartilage-hair hypoplasia, pyruvate kinase anemia, hemophilia B and phenylketonuria.

One of the clearest examples of the relationship between genetic research and community medicine is glutaric aciduria type I. In a 1991 study, Dr. Holmes Morton and colleagues reported the disorder in 14 children from seven Old Order Amish families. The researchers found that early diagnosis and treatment could help prevent or limit severe neurological damage.

The Amish experience is also interesting because genetic vulnerability exists alongside relatively low rates of some common chronic diseases. In the Amish Family Diabetes Study, researchers examined 953 adults from 45 multigenerational families and found that diabetes occurred approximately half as frequently as among Caucasian participants in the Third National Health and Nutrition Examination Survey.

Physical activity may be one factor, but it would be too simplistic to attribute this difference to exercise alone. Farming, gardening, household work and other forms of manual labor remain important in many Amish communities. Yet Dr. Nolt cautioned that Amish communities vary considerably and that Lancaster County should not automatically be treated as representative of Amish communities across the United States.

The Amish way of life is also changing. Dr. Nolt noted that since at least the 1980s there has been a decline in farming in many settlements and an increase in non-farm occupations, including construction and factory work. In Lancaster County, he estimated that about one-third of Amish families are still farming. These changes can provide more regular income and discretionary time, but they can also create greater opportunities to eat in restaurants or purchase commercially prepared and processed foods. Family gardens, however, remain common.

Perhaps the most revealing part of our conversation was how health itself may be understood within Amish culture. Based on his observations, Dr. Nolt said an Amish person might think of being healthy primarily as being able to go about one’s life and work without significant impairment. In this sense, health is closely connected to one’s ability to do what is necessary each day. This perspective may contribute to a more practical and sometimes reactive approach to healthcare, in which the immediate question is whether a person can continue doing what needs to be done rather than identifying every possible future health risk.

This perspective also helps explain what Dr. Nolt describes as Amish “medical pluralism.” Amish families may use physicians alongside chiropractors, dietary supplements, midwives and traditional remedies. It is not necessarily an either-or choice. Different forms of healthcare may be used according to the circumstances.

For healthcare professionals, Dr. Nolt believes that trust and cultural humility are essential. Amish patients may be more willing to communicate openly when healthcare providers understand their community, establish personal relationships and ask about other forms of treatment without judgment. Researchers have similarly built trust by responding to health problems that Amish families themselves considered important, working with trusted people within the community and providing something in return.

The Amish health experience therefore offers a lesson that extends beyond genetics. Their communities demonstrate how genes, occupation, diet, family, culture and relationships can interact to shape health. For physicians and public-health professionals, understanding those relationships may be just as important as understanding the diseases themselves.

Perhaps the most important lesson is that the Amish should not be viewed either as a genetically isolated population burdened by rare diseases or as a model of perfect traditional health. Their experience is more complicated and more instructive. It shows that health is shaped by the interaction of biology, behavior, environment and community, and that effective healthcare may depend not only on what medicine can offer, but also on whether it understands the people it is trying to serve.

References

Hsueh, W.-C., Mitchell, B. D., Aburomia, R., Pollin, T., Sakul, H., Ehm, M. G., Michelsen, B. K., Wagner, M. J., St. Jean, P. L., Knowler, W. C., Burns, D. K., Bell, C. J., & Shuldiner, A. R. (2000). Diabetes in the Old Order Amish: Characterization and heritability analysis of the Amish Family Diabetes Study. Diabetes Care, 23(5), 595–601. https://doi.org/10.2337/diacare.23.5.595

McKusick, V. A. (Ed.). (1978). Medical genetic studies of the Amish: Selected papers. Johns Hopkins University Press.

Morton, D. H., Bennett, M. J., Seargeant, L. E., Nichter, C. A., & Kelley, R. I. (1991). Glutaric aciduria type I: A common cause of episodic encephalopathy and spastic paralysis in the Amish of Lancaster County, Pennsylvania. American Journal of Medical Genetics, 41(1), 89–95. https://doi.org/10.1002/ajmg.1320410122

Morton, D. H., Morton, C. S., Strauss, K. A., Robinson, D. L., Puffenberger, E. G., Hendrickson, C., & Kelley, R. I. (2003). Pediatric medicine and the genetic disorders of the Amish and Mennonite people of Pennsylvania. American Journal of Medical Genetics Part C: Seminars in Medical Genetics, 121C(1), 5–17. https://doi.org/10.1002/ajmg.c.20002

Nolt, S. M. (2016). A history of the Amish (3rd ed.). Good Books