Sarah
Boseley, “Hard times behind
fall in heart disease and diabetes in 90s Cuba, says study”, The Guardian 9/04/2013.
The hard
times experienced by the people of Cuba in the early 1990s – when food was short and petrol almost unobtainable
owing to the tightening of the US embargo and loss of Russian support – led to
falling rates of heart disease and diabetes, say doctors.
Researchers
studied the so-called "special period" between 1991 and 1995, when
people resorted to donkeys to transport loads and the government imported 1.5m
bicycles from China, to see whether eating less, walking, cycling and manual
labour made a difference to the health of the population as a whole.
Unusually
for a scientific study, the researchers, from eminent universities in the US as
well as Spain and Cuba, put on record their condemnation of the political activity
that caused the crisis and their admiration of the way the Cuban people coped.
"We would like to acknowledge our great respect and admiration for the
Cuban people who faced extremely difficult social and economic challenges
during the special period – and by making common cause against this tragedy
held up with courage and dignity. This tragedy was 'man made' by international
politics and should never happen again to any population," they write.
Cuba, which
has a much-admired healthcare system based on the "barefoot doctors"
who provide comprehensive primary care, has excellent data on the health of its
people as well as complete and publicly accessible death records. The
researchers, publishing their findings in the British Medical Journal, say they were able to track what happened
to the weight of the population and look at the subsequent death rates from
coronary heart disease, stroke and diabetes from 1980 to 2010, focusing on the
city of Cienfuegos.
Led by Dr
Manuel Franco, associate professor at the University of Alcalá in Madrid, the
team found the population lost an average of 5.5kg (12lb) in weight during the
five years of the economic crisis. That had a real impact on health, cutting deaths
from diabetes by half and from coronary heart disease by a third.
"Marked
and rapid reductions in mortality from diabetes and coronary heart disease were
observed in Cuba after the profound economic crisis of the early 1990s,"
the doctors write. "These trends were associated with the declining
capacity of the Cuban economy to assure food and mass transportation in the
aftermath of the dissolution of the former Soviet Union and the tightening of
the US embargo. Severe shortages of food and gas resulted in a widespread
decline in dietary energy intake and increase in energy expenditure [mainly
through walking and cycling as alternatives to mechanised transportation."
But as the
economic crisis ended in 1996 and Cuba began to become more prosperous again,
the weight started to go back on. From 2000, the economy has had sustained
growth. From 1996, physical activity levels have declined, although only
slightly. But energy intake – the amount of food and drink consumed – had
increased above pre-crisis levels by 2002.
As a result,
write the researchers, "by 2011, the Cuban population has regained enough
weight to almost triple the obesity rates of 1995".
Diabetes
levels had dropped during the five hard years, but from 1995 they began to
surge. With economic recovery, the incidence of the disease peaked in 2004 and
again in 2009. From 2002 to 2010, death rates from diabetes were rising again
every year at the same rate as before the crisis. Deaths from coronary heart
disease and stroke were declining, as they have done elsewhere with better
treatment, but only at the same rate as before 1991.
What this
shows, say the authors, is that interventions to bring down the weight of whole
populations – as opposed to leaving it up to individuals – can have real
benefits. But, they say, "so far, no country or regional population has
successfully reduced the distribution of body mass index or reduced the
prevalence of obesity through public health campaigns or targeted treatment
programmes".
Franco, in a
video explaining
the study, says that one of the lessons from Cuba for governments is that
"transportation policies are fundamental – therefore we should encourage
walking and bicycling as means of transportation. The results also highlight
the need for physical activity and diet changes to happen at the same time,
involving the whole population."
But he
doubts whether the Cuban crisis holds out any hope for a beneficial health
outcome from the current economic crisis afflicting European countries like his
own. Europe is far more heterogeneous than Cuba, which has around 11 million
people mostly of the same racial background and similar social circumstances.
In a
commentary supporting the call for government action, Walter C Willett,
professor and chair department of nutrition at Harvard School of Public Health
in Boston, says the study offers "powerful evidence that a reduction in
overweight and obesity would have major population-wide benefits. To achieve
this is perhaps the major public health and societal challenge of the century.
Medical treatment of people at high risk for disease will have limited impact
on mortality rates if the primary causes of disease are not dealt with, and
reviews agree that solutions will require multi-sectoral approaches."
Potential
strategies include "educational efforts, redesign of built environments to
promote physical activity, changes in food systems, restrictions on aggressive
promotion of unhealthy drinks and foods to children, and economic strategies
such as taxation."
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