I'M NOT ON A DIET
Culture, Health and Healing
Our Growing Health Crisis
Growing Trends in Health-Related Diseases
Currently in the United States, we are experiencing a growing health crisis. Unfortunately, the growing health crisis, is not limited to our country, but is spreading worldwide. Many countries around the world face serious issues related to the health of their citizens, as well. With the dramatic rise in health-related diseases, such as cancer, cardiovascular heart disease, obesity, and diabetes, the United States and many other countries will face economic hardships in trying to provide adequate healthcare. Although, innovations in medical technology do help some; many are not able to access healthcare in their communities, many simply cannot afford the healthcare they need to prevent the devastating effects of many chronic diseases, while others do not have any healthcare insurance to help cover the preventative costs of disease. In looking at current health trends in national and international studies, we will look at why many of these chronic diseases need to be addressed and why policies need to be in place to provide preventative measures to combat the growing epidemic.
According to two independent studies released in 2008, by Duke University researchers and the International Agency for Research on Cancer (IARC) reported the dramatic rise in both Type 2 Diabetes and Cancer rates will create a worldwide crisis. Both studies showed that if the trends continue, not only will the United States (U.S.) health care systems, but the world health care systems will face an enormous burden in providing medical care. The security and viability of health care systems worldwide are at risk because of the growing number of people affected with these two diseases and their complications. The American Cancer Society (ACS) 2008 Annual Report, the ACS is also concerned with the growing number of new cancer cases, especially for those 25 million in the U.S. who are underinsured, those 47 million in the U.S. with no health insurance, and those who belong to underserved populations, such as Native Americans. Also, in the American Heart Association (AHA) 2009 report, entitled “Heart Disease and Stroke Statistics—2009 Update,” show that progress has been made in controlling several of the risk factors, such as high blood pressure and high cholesterol, which are associated with heart disease and stroke. Despite the promising decline in the number of deaths, this trend is in danger of being reversed because of the lack of progress made with other risk factors, such as obesity, diabetes, and lack of physical activity.
The study released in early 2008, by Duke University researchers, dealt with the rise of diabetes and the complications associated with this disease among the elderly in the United States. This study looked at all Medicare cases of diabetes among those over the age of 65 from 1994-1995 to 2003-2004. Within this age group, it was found that new cases rose by 23%, while the prevalence of the disease rose by 62% during the same period. In looking further into the data, researchers found that those diagnosed with diabetes, also had related complications, such as heart disease and stroke. Of those diagnosed with diabetes, 90% had at least one diabetes-related complication within six years after the initial diagnosis. Also, approximately half of those still living at the end of the study had a secondary diagnosis of congestive heart failure. Surprisingly, after being diagnosed with diabetes, the death rate for those diagnosed as a diabetic were 8.3% higher than those not diagnosed and treated for the disease.
In their 2008 Annual Report, the ACS found that although the number of cancer cases and cancer deaths decreased for the first time in a decade, several types of cancer actually increased during the same period. The decline in new cancer cases and cancer deaths are found in three of the most common types of cancers in men: lung cancer, colon cancer, and prostate cancer, and in two of the most common cancers found in women: breast cancer and colon cancer, while there was a leveling off of lung cancer death rates for women. While this is good news, there were several types of cancer which had an increase in new cases, which include cancer of the skin, kidney cancer, and thyroid cancer. Although lung cancer in smokers has shown a dramatic decrease, cigarette smokers account for approximately one third of all cancer deaths in the U.S. While lung cancer deaths have actually decreased in men, lung cancer deaths have increased in 13 states among women.
The growing number of new cancer cases is of concern to the ACS, along with the number of those uninsured, underinsured, and those populations underserved. The ACS believes that there are other interrelated issues that create a lack of access to early diagnosis and treatment of cancer. Many of the newer cancer screening tests are not covered adequately or are not covered at all by insurance companies and therefore must be paid out-of-pocket by those requesting the tests. With the rising costs of medical treatments, many of these existing tests are underused. They cite colon cancer as an example of this type of preventative measure. Colon cancer can be detected when approximately 90% of the cases are curable, while only half of those adults 50 years and older get the colon cancer screening done when recommended. Also, the medical system tends to focus on cancer treatment, once the disease is diagnosed, and the amount of monies made available for cancer research is not adequately funded. However, the ACS believes that the focus needs to be placed on the education and prevention of cancer, with more emphasis on eating a healthy diet, maintaining a healthy body weight, and getting more physical activity.
In the study released in late 2008, the International Agency for Research on Cancer (IARC) looked into the potential global crisis because of the growing incidence of cancer diagnosis. It was reported that cancer is on its way in the leading cause of death by 2010. One of the findings in this report project that new cancer diagnoses will continue to increase by 1% every year. Another finding showed that smoking and lifestyle factors, such as obesity, will overtake chronic infection as the leading cause of cancer, especially in those populations that are poor and from middle-income countries. It is estimated that approximately 1.3 billion people smoke tobacco worldwide and 12% of cancer cases in low-income countries are attributed to the use of tobacco. Not surprisingly, this figure is expected to rise. In looking at some data from different countries, it was found that in India chewing tobacco is an important cancer risk factor. In Japan, Singapore, and Korea breast cancer rates have doubled or tripled over the last four decades. The IARC report stated that worldwide, by the year 2030 there will be 27 million new cancer cases and 17 million cancer-related deaths each year. Worldwide the rate of cancer cases has doubled between 1975 and 2000, and is expected to doubled again by 2020 and triple by 2030.
Costs in Health-Related Diseases
Every ten years, the Department of Health and Human Services (HHS) produces a report which is much like a prospective census which sets goals in 28 health related areas. Some of the specific areas include weight and diabetes incidence, cholesterol levels, and cancer screenings. This report also tracks how well we are meeting the goals set within the ten year period. The next “Healthy People” report is due in 2010, but the HHS released an interim assessment in 2008. According to this assessment, while 59% of its health objectives have been met or on their way to being met, 20% of their health objectives have retreated from the objectives that were set. Some of these statistics are troubling. For example, this assessment reports that in 2003-2006 only 33% of Americans were at a healthy weight; half the number who should be at their ideal weight and 10% fewer than in 1997. In looking at specific diseases, health officials had hoped to cap the prevalence of diabetes at 25 cases per 1,000 people. But currently this number has more than doubled this goal and has actually risen since 1997.
The United States spends far more on health care than any other developed nation. In the U.S., the total annual healthcare spending per capita is $7,026 and is expected to rise because of the increasing number of chronic diseases. In comparison, for example both France and Canada provides government run healthcare for all its citizens. Both of these countries have a lower annual healthcare spending per capita, at $4,056 and $3,912 respectively, than the U.S. While many may argue that the majority of this expense keeps the U.S. a leader in medical innovation, the U.S. still does not have equality of healthcare for all of its citizens.
The cost of U.S. health care is expected to be one-fifth of our national economy within nine years; is expected to double per person and approximately half the money needed for healthcare in the U.S. is expected to come from public assistance programs, like Medicare. For example, hospital care remains the largest expense, especially among the aging population. For every dollar the U.S. spends, $0.31 goes toward hospital care, $0.21 to physician and clinical care, $0.10 to prescription drugs, $0.09 to nursing home care, which includes home healthcare workers, and $0.07 to administrative costs. The remaining costs go toward dental care and medical equipment both at $0.04, research at $0.02, and all other healthcare costs not listed at $0.12. In the coming years, with the large number of baby boomers set to retire, this issue will become more relevant.
The Commonwealth Fund, a foundation which funds healthcare research, reported in 2005 that Americans paid 16% of our gross domestic product (GDP) for healthcare, for a total of $2 trillion. This makes the U.S. the top spender on healthcare per capita in the world. In comparison, France paid 11.1% of its GDP and Canada paid 10% of its GDP. Although the U.S. spends a record amount of money on healthcare, we do not spend it wisely and with equality to all Americans. According to the Commonwealth Fund 2008 report, 101,000 deaths from 2002-2003 could have been avoided with access to timely and effective healthcare. These deaths were from a variety of illnesses that are deemed preventable, such as influenza, pneumonia, diabetes, and stroke. This foundation also reported that in 2005 half of Americans did not receive recommended preventative healthcare, such as vaccinations, cancer screenings, and routine examinations. It was noted that one of the reasons we rank poorly among industrialized nations in delivering healthcare is because we do not have or provide basic wellness infrastructure. Healthcare providers do not focus on preventative measures, but rather focus on treatment of conditions and diseases after the condition has progressed to a more advanced stage. Although not all of these deaths would have been prevented, many health conditions are preventable. While others can be fixed or treated with more success before they become life threatening. As an industrialized nation, we rank last (19th) in providing quality healthcare to our citizens.
The American Diabetes Association (ADA), in an annual report looked at both the direct and indirect costs of diabetes. Type 2 Diabetes is one of the most disabling of diseases because many people are not aware that they are diabetic until they show symptoms of one of the complications. Type 2 Diabetes can lead to numerous complications, which include heart disease and stroke, eye complications which can lead to blindness, kidney disease and kidney failure, nervous system disease which includes complications related to poor circulation, such as amputations, dental disease with the most common periodontal or gum disease, complications of pregnancy, and sexual dysfunction. Controlling diabetes can reduce the risks of developing complications. According to the Department of Health and Human Services (DHHS), adult onset diabetes has a strong physiological tie to cardiovascular heart (CVD). The DHHS also reported that the majority of those diagnosed with Type 2 Diabetes, die from complications of CVD and not from causes directly associated with blood glucose control.
According to the ADA, the annual per capita costs of treating a person with diabetes is $11,744 and one of every five healthcare dollars is spent on caring for a person with diabetes. In 2007 the Center for Disease Control (CDC) reported 8% of Americans or 23.6 million are diabetic, of which 17.9 million are diagnosed diabetics and 5.7 million are undiagnosed. A staggering 57 million are pre-diabetic and likely to become diabetic unless they make life changes. In 2007, 1.6 million new cases were diagnosed for adults 20 years and older. With the numbers increasing, the amount we spend on the treatment of diabetes will continue to rise, as well.
Also, in 2007 the ADA report indicated the total annual economic cost for diabetes in the U.S. was approximately $174 billion. In their report, it stated that medical expenditures totaled $116 billion, of which $27 billion for direct diabetes care, $58 billion for treatment of diabetes-related chronic complications, and $31 billion for excess general medical costs. The remaining $58 billion was spent on indirect costs, of which $26.9 billion represents the value of lost productivity because of premature death-related diabetes. The indirect costs represent other issues, such as diabetes-related unemployment disability, reduced work performance, lost productivity because of early mortality, and increased absenteeism. Unfortunately, the actual cost of this disease cannot be fully calculated because this does not measure pain and suffering, care provided by non-paid caregivers (who are usually family members that must quit their paying jobs to care for a loved one), and the cost of extreme and excessive medical treatment in conjunction with undiagnosed diabetes.
Causes of “Lifestyle” Diseases
Many researchers and health professionals disagree as to some of the direct causes, such as diet, exercise, family history. For example, some researchers believe we may have “genes” that can cause a higher chance to develop certain diseases despite precautions one takes. Recently, researchers from the University of Texas, Southwestern Medical Center found what they believe to be a gene that is linked to serious liver disease, which may lead to the development of other liver diseases, such as cirrhosis and liver failure. This disease, known as Nonalcoholic Fatty Liver Disease (NAFLD), is the most common liver disease in the United States and Europe. Approximately a third of all Americans have fatty livers, a predisposition linked to their ancestry, and may develop NAFLD. Researchers discovered a gene related to liver fat, but with unknown function, called PNPLA3. One variant of this gene does not allow it to function or to function poorly. This gene variant is found in approximately 49% of Hispanics, 23% of European-Americans, and only 17% of African-Americans in the study. While another variant of this same gene links it to lower risk of liver fat. This healthier gene variant was found more often in African-Americans, than in Americans of any other ancestry in the study. Although this research does not conclusively prove that those with fatty liver will develop more serious liver diseases, this gene variant does show an increased susceptibility of diseases of the liver and liver injury.
Another example of a gene that may cause obesity and diabetes is with the Pima Indians in southern Arizona. According to National Institute for Health (NIH), they were initially using the “thrifty gene” theory to help explain why Pima Indians were overweight. This gene was supposed to help the body store fat and then use it in times of famine. Unfortunately, as the Pima Indians adopted a Western lifestyle, which included less physical activity and a diet higher in fat, and with greater access to high calorie foods, this gene started to work against them. In 1993, the NIH, after studying the Pima Indian genetic code, identified a gene that they believe may contribute to insulin resistance and higher rates of diabetes. This gene, called FABP2, produces an intestinal fatty acid binding protein. This protein then produces two amino acids. One of the amino acids, threonine, appears to absorb more fatty acids from fat in a meal. The researchers believe this ultimately leads to higher amounts of fats and fatty acids in the blood and this is what leads to insulin resistance. While the researchers have found these two amino acids may lead to insulin resistance, they have also found a possible third solution to insulin resistance. In the Pima population, there is an enzyme, called protein phosphatase 1, which also appears to cause insulin resistance. Research is still ongoing as to which of the three is most important in fighting insulin resistance among the Pima.
Many researchers agree that our Western lifestyle, in relation to diet and exercise, may have a direct link to some “preventable” diseases, such as heart disease and Type 2 Diabetes, also known as adult onset diabetes. Type 2 Diabetes traditionally did not develop until a person was in their mid-50s. But, this trend is changing, mostly in part to the growing number of overweight and obesity rates. Overweight people are those whose body mass index (BMI) is 25 or greater; while obese people have a BMI of 30 or greater. Obesity is broken down into two categories—obese and extreme or morbidly obese, which has a BMI of 40 or greater. For woman, it is normal to have approximately 25% of body fat and for men to have approximately 17% of body fat. However, being overweight or obese can cause unnecessary stress and strain on your body, can increase a person’s resistance to insulin and susceptibility to infections, increase the risk for coronary heart disease and stroke, Type 2 Diabetes, high blood pressure, and kidney disease, as well as other serious health problems which can result in premature deaths.
According to a report by the World Health Organization (WHO), the rates of obesity have risen in every age group in the United States. The report concludes that between 1980 and 2004, the prevalence of obesity in the U.S. has doubled among adults and rose by 17% among children. Overall, approximately 67% of Americans are overweight or obese. African-American women, at 52%, have the highest rates of obesity in the U.S.; while African-American men and white-Americans of both sexes have an approximate 31% obesity rate. In looking at how Americans eat and exercise, 96% stated they could not remember the last time they ate a salad and approximately 40% do not exercise. The lesson is that Americans eat more calories than they burn off by exercising.
The WHO also reported the number of smokers in the U.S. has declined to a record low of 19.8% of our population. This has led to a trend in lower lung cancer cases and deaths. Although this is good news, the WHO also reports 39.5% of adult Americans do not exercise and 29.5% of adult Americans get some exercise. The lack of exercise is directly linked to income, in that more than half of all people living in poverty do not exercise regularly; and poor Latinos are the least likely to exercise. While the average weight of women and children has appeared to stabilize, the rate of obesity among men has continued to rise. Part of this healthier trend for women and children is due to aggressive health-related programs introduced in schools, hospitals, community groups, and churches.
Many researchers believe that Type 2 Diabetes reflects lifestyle issues and is, therefore, a lifestyle disease. In particular, these lifestyle issues reflect an imbalance between calories ingested and calories exerted by physical activity and exercise. A recent article published in Pediatrics showed that more children are eating “fast” foods, which are higher in calories and fats and are less likely to eat balanced meals, which include fresh fruits and vegetables. Also, children and adults are less likely to engage in physical activities and exercise, including the simple task of walking. In another study, there was a direct correlation between the number of hours of television a child watched on a daily basis and the prevalence of obesity. Therefore, the more television was watched, the less exercise and physical activity the child engaged in. According to a report by the National Council of La Raza (NCLR), it was noted that there are three main risk factors for becoming overweight; the first being—genetics, the second being—diminished physical activity, and the third being—greater reliance on high-calorie, high-fat foods associated with poverty and food insecurity.
Unfortunately, this disturbing trend is not limited to the youth of the U.S., but is rapidly becoming a global problem. Recently, Time Magazine reported in a series of articles related to obesity in our children and the growing trend around the world. What they found was that as more people adapt the “American, western-style” of eating, more children are experiencing higher rates of obesity. According to a second Time Magazine article, “Obesity Goes Global,” the U.S. leads the way for industrialized countries with 37% of American children age 5 through 17 that are overweight or obese, as compared to 20% of European children and 10% of Chinese children. Health ministers fear that obese children will become obese adults. This will eventually lead to higher rates of chronic and debilitating diseases, such as heart disease, hypertension, diabetes, and cancer. According to a Hungarian doctor, 9% of obese children and adolescents have a pre-morbid condition known as “metabolic syndrome.” This syndrome, which has elevated of LDL “bad” cholesterol level and elevated blood “sugar” levels, is the precursor to Type 2 Diabetes or adult onset diabetes. Health officials in China believe that if the trends continue, the rate of diabetes among their children and adolescents will double in the next ten years.
In studies by several European organizations, it was found that obesity and growing health problems associated with obesity are not limited to the United States. Because the age-old Mediterranean diet, which included fresh fish, fruits and vegetables, pasta and olive oil, is losing out to the American-style of eating, an increasing number of European adults and children are becoming overweight and obese at an alarming rate. According to doctors at the Rome Federation of Pediatrics, they believe that many Europeans, in general, have lost the healthy eating habits of sitting down with the whole family and eating healthier prepared meals. Many more European adult and children are eating outside of the home, which means more “fast” foods and packaged snack foods. These processed foods are higher in saturated fats, higher in processed sugars, and higher in calories. It was also noted that many more children and adolescents are less physically active, with many physical activity in schools limited, and are spending an average of four to five hours a day on front of a television or on a computer. This “Americanized” style of diet and of lifestyle choices are believed to be the main causes of their country’s overweight and obesity problems.
According to the Organization of Economic and Cultural Development (OECD) study, data from 1999-2001 showed the United Kingdom has the second highest percentage of obese adults at 22%, while Spain has 13%, Finland has 11%, Denmark has 10%, and Sweden, France, and Italy all having 9%, as compared to the United States at 31%. In another study on obesity, the International Obesity Task Force (IOTF), which is a number of London-based consumer groups which work in collaboration with the World Health Organization, found disturbing numbers of obesity for European children age 6 to 13 years. The IOTF reported Italy had the highest percentage of obese children at 36%, with Spain not that far behind at 30%, while the United Kingdom has 22%, Denmark, France, and Sweden all having 18%, and Finland has13%, as compared to the U.S. at 15%.
Because of the alarming rate these numbers are growing, many countries are beginning to institute measures in order to combat the medical consequences and long-term costs that are associated with obesity. Sweden has negotiated voluntary restrictions on television advertising aimed at children for “junk” foods, such as snacks and soft drinks; while England is pushing for a ban on this type of advertising during preschool television programs. Italy is looking at several ways to fight their obesity problems; by negotiating with restaurants to reduce the size of portions and by making Friday a day of fasting.
According to a report by The National Institute of Public Health (NIPH), in Mexico two of every three people are either overweight or obese, and many of those die of Type 2 Diabetes or diabetes-related complications. Mexico is now considered to be the “second fattest” country in the world, behind the United States. Over the years, several studies by the Mexican government have shown a rise in the number in the rates of obesity and diabetes; in which the percentage of Mexican women considered to be obese spiking 160% between 1988 and 1999. In 2000, approximately 60% of Mexican men and 64% of Mexican women were considered overweight or obese. As of 2008, a recent study showed that 66% of Mexican men and 71% of Mexican women were obese. A 2002 government study in Mexico City, reported that 30% of Mexican elementary-age school children and 45% of adolescents were overweight or obese.
In the poorest rural areas of Mexico malnutrition is a major concern, with 10 to 12% of the population suffering from malnutrition. However, even in these poor communities, obesity is becoming a growing problem. Many of the poor are turning to the growing availability of the cheap and convenient industrialized processed foods, which in most cases are devoid of nutrients and are calorie dense. In 2000, it was found that among Mexican families of the less wealthy, their children had an increased body weight of 40% and one quarter of the children age five to 11 years were overweight.
With globalization and modernity, the citizens of Mexico are adopting the lifestyle habits of their neighbors to the north—the United States. The traditional healthy diet of Mexicans, which included corn and beans along with fresh fruits and vegetables and the sparingly use of meat and dairy products, is now being replaced by prepared processed foods, made from white flour, saturated fats, and processed sugars. The pinto and black beans, which are nutrient dense foods, are being replaced with processed pasta soups and other microwavable foods. Even the traditional corn tortilla is being replaced with a white flour tortilla and cheap white bread. But Mexico does not import all of its fast foods, as there is an infinite variety of home grown junk food. Although numerous stores and street stands may sell fresh fruits and juices, many sell cookies, snacks, potato chips, and candy. One of the problems Mexico faces is that approximately 80% of schools do not have access to drinking water. Therefore, it is easier for the schools to provide soft drinks. Currently, Mexico comes in second to the U.S. in the amount of soft drinks consumed, with the amount of soft drinks consumed over the last 14 years rising by 60%. The eating habits of Mexicans has totally transformed from healthier traditional foods to convenient processed foods and to the growing number of American “fast” food chains that have spread over the last ten years.
Unfortunately, Mexico also recognizes the other American lifestyle habit that has contributed to their growing obesity problem—a decline in physical activity. Along with modernity, there is no longer the opportunity to burn off the calories that the body takes in. Because of technical advances, the lack of manual labor can be easily seen in the larger cities, and these advances are making their way to the smaller rural communities. Mexico also recognizes that because of technological advances, the lack of health and physical activity in schools has been reduced over the years. In the 2002 study, it was found in elementary schools approximately 32% of children in South Mexico City exercise and 60% of these children are not considered overweight or obese. Mexico recognizes there are not enough physical education programs in the school systems. In 2008, the Mexican Health Secretary began a program with the goal of increasing physical activity among elementary-aged children.
The spike in obesity rates is believed to be the main cause of the rising numbers of those being diagnosed with diabetes, which is estimated to be at approximately 11%. According to the Health Ministry in Mexico, diabetes is now the leading cause of death among Mexican adults. In addition, the diabetes-related diseases can lead to health problems that shorten the life span of Mexicans; with approximately 70,000 dying of diabetes each year. This places a tremendous strain on Mexico’s health care system, and currently Mexico is spending the majority of its health care budget on diabetes and diabetes-related diseases.