건강과 대안 » 사망률 http://www.chsc.or.kr 연구공동체 Mon, 13 Apr 2026 01:34:28 +0000 ko-KR hourly 1 http://wordpress.org/?v=3.5.2 [경제위기/공공의료] 미국 경제봉쇄로 쿠바인 더 건강해져? http://www.chsc.or.kr/?post_type=reference&p=3908 http://www.chsc.or.kr/?post_type=reference&p=3908#comments Thu, 11 Apr 2013 11:09:07 +0000 건강과대안 http://www.chsc.or.kr/?post_type=reference&p=3908

Population-wide weight loss and regain in relation to diabetes burden and cardiovascular mortality in Cuba 1980-2010: repeated cross sectional surveys and ecological comparison of secular trends


Manuel Franco, Usama Bilal, Pedro Orduñez, Mikhail Benet, Alain Morejón, Benjamín Caballero, Joan F Kennelly, Richard S Cooper


BMJ 2013;346:f1515 (Published 09 April 2013)


http://www.bmj.com/content/346/bmj.f1515

===============

경제봉쇄로 쿠바인 더 건강해져?


주영재 기자 jyj@kyunghyang.com

경향신문 입력 : 2013-04-10 13:53:29ㅣ수정 : 2013-04-10 13:53:29
http://news.khan.co.kr/kh_news/khan_art_view.html?artid=201304101353291&code=970100

쿠바인들이 1990년대 초반 미국의 경제봉쇄와 러시아 지원의 중단으로 석유와 식량 부족에 시달리며 힘든 시기를 겪으며 오히려 심장 질환과 당뇨의 발병률이 낮아졌다는 연구 결과가 나왔다.

쿠바인들은 1991~1995년까지 고난의 시기 동안 당나귀에 의존해 짐을 날랐고, 정부는 석유를 소비하는 차량 대신 중국에서 150만대의 자전거를 수입해야 했다.

가디언에 따르면 미국, 스페인, 쿠바의 대학 연구자들은 이 기간 식사량이 줄고, 자전거를 타거나 걷는 시간이 늘고, 육체 노동이 증가한 것이 건강에 어떤 영향을 미쳤는지를 확인하려고 했다.

쿠바는 무상 의료가 상당한 수준으로 진척된 국가로 “맨발의 의사”들이 광범위한 기초 진료를 행하고 있으며 국민 건강 상태에 대한 자료도 잘 구축되어 있다.

연구자들은 1980~2010년까지 쿠바인들의 몸무게와 심장질환, 뇌졸중, 당뇨로 인한 사망률의 변화를 관찰한 결과를 영국 메디컬저널에 발표했다.

스페인 마드리드의 알카라 대학의 마누엘 프랑코 교수가 이끈 연구진은 쿠바인의 몸무게가 경제봉쇄로 위기에 몰린 1991~1995년 동안 평균 5.5㎏ 감소했음을 알게됐다. 이는 건강에 직접적인 영향을 줘 당뇨로 인한 사망자를 절반까지 줄였으며 심근경색으로 인한 사망률은 3분의 1로 줄었다.

연구진은 “이런 추세는 소비에트 붕괴와 미국의 경제봉쇄로 쿠바 경제가 식량과 대중교통을 확보할 수 있는 능력이 줄어든 것과 관련이 있었다”며 “심각한 식량 및 에너지 부족은 열량 섭취를 줄이면서 동시에 (대중교통 대신 걷거나 자전거를 타면서) 열량 소비를 증가시켰다”고 말했다.

쿠바 경제 위기가 1996년 이후 끝나고 회복기에 들어서자 몸무게는 다시 증가하기 시작했고 신체활동 수준도 미미하지만 감소했다. 쿠바는 2000년부터 안정적인 성장을 지속했으며 2002년에 이르러서는 음식과 음료 소비량이 증가해 위기 이전 수준을 넘었다. 그 결과 2011년 쿠바 인구의 비만률은 1995년에 비해 거의 세배로 증가했다. 당뇨도 1995년부터 증가해 2002년부터 2010년까지 당뇨사망률은 위기 이전 수준의 증가세로 돌아갔다.

월터 윌렛 하버드 공공의료대학의 영양학과장은 이 연구가 “비만과 과체중 감소가 주는 커다란 이점을 보여주는 강력한 증거”라고 평가했다.

논문 저자들은 이같은 결과가 체중 감소가 실질적인 이득을 가져올 수 있다는 것을 보여준다고 주장하고 있다. 프랑코 교수는 “교통 정책이 근본적인 것으로 교통 수단으로 걷기와 자전거 타기를 장려할 필요성이 있다”고 밝혔다.

또한 육체 활동을 증진시키고 건강에 좋지 않은 음료와 음식을 어린이에게 공격적으로 홍보하는 것을 규제하거나 불량 식품에 더 많은 세금을 부과하는 것도 하나의 전략이라고 과학자들은 조언했다.

그럼에도 그는 쿠바의 경제 위기가 현재 경제위기를 겪는 유럽에 건강과 관련한 어떤 유사한 이득을 주지는 않을 것이라고 내다봤다. 인종과 사회적 환경이 유사한 쿠바와 달리 유럽은 훨씬 이질적이기 때문이다.

연구자들은 또한 과학 논문에 어울리지 않게 위기를 초래한 정치에 비난을, 쿠바인들의 대응 방식에 찬사를 보냈다.

이들은 논문에서 “우리는 고난의 기간 동안 극도로 어려운 사회 경제적 도전에 직면한 쿠바 국민들이 용기와 위엄을 잃지 않고 대응한 것에 존경과 찬사를 보낸다”며 “이 비극은 국제 정치에 의한 ‘인재’이며 다시는 어느 나라에서도 되풀이 되어선 안된다”고 썼다.

=======================




Research








Population-wide weight loss and regain in relation to diabetes burden and cardiovascular mortality in Cuba 1980-2010: repeated cross sectional surveys and ecological comparison of secular trends




BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f1515 (Published 9 April 2013)
Cite this as: BMJ 2013;346:f1515
http://www.bmj.com/content/346/bmj.f1515
















      1. Manuel Franco, associate professor1, adjunct associate professor2, visiting researcher3,
      2. Usama Bilal, research assistant1, visiting researcher3,
      3. Pedro Orduñez, regional adviser4, professor5,
      4. Mikhail Benet, professor5,
      5. Alain Morejón, assistant professor5,
      6. Benjamín Caballero, professor6,
      7. Joan F Kennelly, research assistant professor7,
      8. Richard S Cooper, professor and chair8


      Author Affiliations




      1. Correspondence to: M Franco mfranco@uah.es


      • Accepted 11 February 2013


      Abstract


      Objective To evaluate the associations between population-wide loss and gain in weight with diabetes prevalence, incidence, and mortality, as well as cardiovascular and cancer mortality trends, in Cuba over a 30 year interval.


      Design Repeated cross sectional surveys and ecological comparison of secular trends.


      Setting Cuba and the province of Cienfuegos, from 1980 to 2010.


      Participants Measurements in Cienfuegos included a representative sample of 1657, 1351, 1667, and 1492 adults in 1991, 1995, 2001, and 2010, respectively. National surveys included a representative sample of 14 304, 22 851, and 8031 participants in 1995, 2001, and 2010, respectively.


      Main outcome measures Changes in smoking, daily energy intake, physical activity, and body weight were tracked from 1980 to 2010 using national and regional surveys. Data for diabetes prevalence and incidence were obtained from national population based registries. Mortality trends were modelled using national vital statistics.


      Results Rapid declines in diabetes and heart disease accompanied an average population-wide loss of 5.5 kg in weight, driven by an economic crisis in the mid-1990s. A rebound in population weight followed in 1995 (33.5% prevalence of overweight and obesity) and exceeded pre-crisis levels by 2010 (52.9% prevalence). The population-wide increase in weight was immediately followed by a 116% increase in diabetes prevalence and 140% increase in diabetes incidence. Six years into the weight rebound phase, diabetes mortality increased by 49% (from 9.3 deaths per 10 000 people in 2002 to 13.9 deaths per 10 000 people in 2010). A deceleration in the rate of decline in mortality from coronary heart disease was also observed.


      Conclusions In relation to the Cuban experience in 1980-2010, there is an association at the population level between weight reduction and death from diabetes and cardiovascular disease; the opposite effect on the diabetes and cardiovascular burden was seen on population-wide weight gain.



      Introduction


      It was recognised early in the course of the global epidemic of type 2 diabetes that variation in the prevalence of the disease among populations could be explained largely by relative weight.1 This observation is supported by survey research from virtually every country in the World Health Organization database.2 Despite predictions on the effect of the obesity and diabetes epidemics on life expectancy,3 it is unclear to what extent they can alter the downward trend of cardiovascular diseases prevalence observed in many countries.4 Furthermore, lack of adequate data for public health precludes the empirical assessment of comparable trends across the developing world. Most cohort studies have suggested a “U” shaped association between body mass index and mortality, with the lowest point in the index range of 24 to 29.5 6 Therefore, key unknown factors are the net health impact of a given downward shift in the distribution of body mass index in a population, and the time lag between changes in body mass index and in the prevalence of non-communicable disease.7





      Video abstract

      Video


      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.8 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).


      The largest effect of this economic crisis occurred over a period of about five years (1991-95, the so called “special period”), resulting in an average weight loss of 4-5 kg across the adult population.8 This economic crisis was not a full disruption of previous routines of daily life, but was actually characterised by its slow process of economic decline. During these years, the whole population continued to meet responsibilities in relation to work, school, and other social aspects, and the Ministry of Public Health maintained its regular surveillance system activities.9 10


      Since then, the Cuban economy has shown a modest but constant recovery, especially after the year 2000.11 12 In fact, surveys have shown that the prevalence of obesity has now exceeded pre-crisis levels.13 The table⇓ shows basic sociodemographic and economic information on Cuba before, during, and after the economic crisis.




      View this table:


      Basic sociodemographic and economic information on Cuba at various stages of economic crisis12



      To advance the prevention of non-communicable diseases, population-wide data remain crucial. Comparing disease rates over time, in relation to changes in risk factor levels in the population, indicates the extent to which disease can be prevented and what the most important risk factors are at the population level.14 The population preventive approach articulated by Geoffrey Rose in his seminal paper,15 is of importance when preventing and controlling non-communicable diseases, particularly cardiovascular diseases. The current study exemplifies a unique situation where population-wide body weight changed considerably, as a result of the combined and sustained effect of reduced energy intake and elevated physical activity. This scenario allowed us to assess its effect on diabetes and cardiovascular disease.16


      Our objective was to examine the effect of population-wide changes in body weight—over a full cycle of weight loss and regain—on diabetes incidence, prevalence, and mortality in Cuba, from 1980 to 2010. We also assessed the effects of this weight change cycle on rates of death from cardiovascular disease, cancer, all causes.



      Methods


      To study the population-wide changes in body weight over time, we used four cross sectional surveys in the city of Cienfuegos, on the southern coast of Cuba. These surveys are part of the Project of Cienfuegos, an initiative designed to study the risk factors for non-communicable diseases in Cuba.


      To obtain all available data from government and published sources on mortality, physical activity, energy intake, and smoking in Cuba between 1980 and 2011, we did a systematic search. We used the following databases: Medline, Spanish Bibliographic Index in Health Sciences (IBECS), and the Scientific Library Online (BVS-SciELO Cuba), which includes most Cuban journals. Web appendix 1 details the 12 references included.



      Height, weight or overweight, and obesity


      The four cross sectional surveys measured height and weight, on the basis of stratified probability samples from the urban population aged 15-74 years. The surveys included 1657, 1351, 1667, and 1492 adults for the years 1991, 1995, 2001, and 2011, respectively. The age distribution of the population in Cienfuegos is similar to the general Cuban population (web appendix 2). We used the following categories for body mass index: underweight (<18.5), normal weight (18.5-<25), overweight (25-<30), and obesity (≥30). All participants in the four surveys signed the informed consent. The ethics committee of the University of Medical Sciences, Cienfuegos, approved protocols.



      Physical activity


      Measures of self reported physical activity were available from representative samples of the population in Havana in 1987, 1988, and 1994 and from the national surveys on risk factors and chronic diseases (conducted nationally in 1995, 2001, and 2010, respectively). In these surveys, participants were designated as physically active if they engaged in regular physical activity, defined as 30 minutes of moderate or intense activity on at least five days per week.



      Energy intake


      The Food and Agriculture Organization of the United Nations provides disappearance data on energy intake per capita, by dividing total calories available for human consumption by the total population consuming the food supply during the reference period.



      Smoking


      National use of cigarettes per capita was calculated as the total number of cigarettes sold per year divided by the population aged 15 years and over. The prevalence of smoking was obtained from the national surveys on risk factors and chronic diseases conducted in 1995, 2001, and 2010, and other national studies previously conducted. We defined smoking as self reported current use of cigarettes or cigars (or both).17



      Diabetes prevalence and incidence


      In the Cuban national health system, the primary care doctor-nurse team is responsible for collecting health data for all residents in the neighbourhood of their catchment area (about 1500 individuals per team). One of the team activities organised by the health system is continuous assessment and risk evaluation (CARE, or Dispensarización in Spanish).18 19 All households are visited at least once a year for a comprehensive health evaluation of the family, while patients with chronic diseases receive a visit at least once every three to six months. These health examinations covered 61.2% (n=595 1088) of the population in 1979,20 75.9% (n=7 918 647) in 1989,20 and 98.2% (n=11 038 820) in 2009.21 We obtained data for diabetes prevalence and incidence from the CARE registries, spanning the time period of 1980-2009.20 21 These registries allow the monitoring of chronic disease trends, such as diabetes incidence or prevalence.



      Mortality


      We obtained annual, age adjusted rates of mortality per 100 000 people from the Cuban Ministry of Public Health. ICD-10 (international classification of diseases, 10th revision) codes were used for death from type 2 diabetes (E10-E14), coronary heart disease (I20-I25), stroke (I60-I69), cancer (C00-C97), and all causes for the period of 1980-2010. We used data from 1980 to examine possible trends unrelated to the economic crisis during the special period in 1991-95. The 1981 Cuban population census was used for age adjustment. Vital records in Cuba are essentially complete. Postmortem examinations in some hospitals include up to 85% of people coded as dying from cardiovascular disease, which provided considerable confidence in an accurate designation of the cause of death.22



      Statistical analysis


      To illustrate the distributions of body mass index in the four surveys from Cienfuegos (in 1991, 1995, 2001, and 2011), we used Stata SE version 12.1 to generate density plots through the Gaussian kernel function. To analyse changes in prevalence and mortality, joinpoint regression analysis was conducted using software developed by the Surveillance Research Program of the United States National Cancer Institute.23 This regression model allows identification of significant changes in linear trend slopes. The estimated annual change (%) was then computed for each mortality trend by fitting a regression line to the natural logarithm of the rates within each period or phase.


      We did not use this procedure to analyse diabetes incidence, owing to missing data from the years during the crisis. Because incidence estimates are inherently unstable, we enhanced visual presentation by constructing moving averages for each year with available data, using the incidence data from the previous, current, and following year.



      Results



      Risk factor trends


      From its lowest point in the mid-1990s, average daily intake of energy per capita increased monotonically, reaching pre-crisis levels in 2002 and levelling off in 2005 (fig 1⇓). On the other hand, physical activity had a slight downward trend after the mid-1990s, remaining stable from 2001, with more than half of the population being physically active. Although 80% of the population was classified as active in surveys conducted during the special period in 1991-95, this proportion fell steadily in the last decade, and is currently at 55% (fig 1). These population-wide changes in energy intake and physical activity were accompanied by large changes in body weight over this entire interval (figs 2⇓ and 3⇓).




      View larger version:



      Fig 1 Physical activity, dietary energy intake, and smoking in Cuba, 1980-2010. Red shaded area=period of economic crisis; blue shaded area=period of economic recovery. Physical activity data recorded in 1987, 1988, and 1994 obtained from Havana surveys; data recorded in 1995, 2001, and 2010 come from national surveys. *1 kcal=0.00418 MJ





      View larger version:



      Fig 2 Distributions of body mass index as recorded by national surveys conducted in Cienfuegos in 1991, 1995, 2001, and 2010





      View larger version:



      Fig 3 Prevalence of obesity and diabetes, incidence, and mortality in Cuba, 1980-2010. Red shaded area=period of economic crisis; blue shaded area=period of economic recovery. Diabetes prevalence increased by 2.93% per year from 1980 to 1997, and 6.27% per year from 1997 to 2010. Diabetes mortality increased by 5.85% per year from 1980 to 1989, but fell by 0.68% per year from 1989 to 1996 and 13.95% per year from 1996 to 2002, before increasing by 3.31% per year from 2002 to 2010



      Smoking prevalence (fig 1) slowly decreased during the 1980s and 1990s (42% in 1984, 37% in 1995), before declining more rapidly in the 2000s (32% in 2001, 24% in 2010). The number of cigarettes consumed per capita decreased during and shortly after the crisis. In 1990, 1934 cigarettes per capita were consumed (fig 1). This number changed to 1572, 1196, and 1449 cigarettes per capita in 1993, 1997, and 1999, respectively. Cigarette consumption has since remained stable.


      Figure 2 depicts the distribution of body mass index from the Cienfuegos surveys of 1991, 1995, 2001, and 2010 with kernel density plots of each year’s measurements. During the special period of 1991-95, there was a weight loss of 5.5 kg across the entire range of body mass index (that is, not only among obese people), with a mean reduction in body mass index of 1.5 units. After a period of economic recovery and stability, an increase in body mass index of 2.6 units was observed from 1995 to 2010; weight regain also occurred across the entire population, irrespective of body mass index. These distribution shifts in body mass index were consistent across surveys. The proportion of the population in the normal weight category decreased from 56.4% at the end of the special period in 1995 to 42.1% in 2010. At the same time, proportions in the overweight and obesity categories increased by 19.4%, from 33.5% in 1995 to 52.9% in 2010 (web appendix 3).



      Diabetes trends



      Diabetes prevalence and incidence


      Joinpoint regression analyses showed two different phases of diabetes prevalence (fig 3). The first phase had a slow and stable increase from 1980 (1.5 per 100 people) to 1997 (1.9 per 100 people), a total increase of 26.6% (2.9% per year). In the second phase, diabetes prevalence increased from 1.9 per 100 people in 1997 to 4.1 per 100 people in 2009 and 2010, a total increase of 115.8% (6.3% per year).


      Incidence of diabetes fluctuated widely (fig 3). For the decade before the crisis, incidence was stable, between 1980 (1.5 per 1000 people) and 1989 (1.8 per 1000 people). The only data point in the middle of the economic crisis showed a decrease in diabetes incidence, falling to 1.2 per 1000 people in 1992. For the years immediately after the crisis, incidence was lower than pre-crisis levels (1 per 1000 people in 1996 and 1997 v 1.4 per 1000 people in 1999). Sharp increases were observed from 2000 onwards, peaking in 2002 (2.2 per 1000 people) and 2009 (2.4 per 1000 people). Thus, overall diabetes incidence decreased by 53% from its peak in the pre-crisis years (1986) to its lowest point after the crisis (1996 and 1997). Subsequently, incidence rose by 140% from 1996 to 2009.



      Diabetes mortality


      Joinpoint regression analysis of diabetes mortality showed four different phases (fig 3). The first phase, from 1980 to 1989 (pre-crisis years), was characterised by an increase of 60% (5.9% per year). The second phase from 1990 to 1996 overlapped with the special period in 1991-95, during which diabetes mortality stabilised (0.7% decrease per year). However, from 1996 to 2002, we recorded a decrease in diabetes mortality of 50% (13.95% per year). Finally, from 2002 onwards, mortality rose by 49% (3.31% per year; from 9.3 deaths per 10 000 people in 2002 to 13.9 deaths per 10 000 people in 2010), returning to pre-crisis rates.



      Mortality trends



      Coronary disease mortality


      Mortality from coronary heart disease evolved in three phases (fig 4⇓). From 1980 to 1996, mortality fell consistently (reduction of 8.8%, 0.5% per year). After the crisis in 1996-2002, mortality decreased sharply by 34.4% (6.5% per year). After 2002, the rate of decline slowed to 7.4% (1.4% per year), similar to pre-crisis rates.




      View larger version:



      Fig 4 Obesity prevalence and coronary heart disease, cancer and stroke mortality in Cuba (1980-2010). Red shaded area=period of economic crisis; blue shaded area=period of economic recovery; CHD=coronary heart disease. CHD mortality decreased by 0.50% per year from 1980 to 1996, 6.48% per year from 1996 to 2002, and 1.42% per year from 2002 to 2010. Cancer mortality decreased by 0.12% per year from 1980 to 1996, but increased by 0.47% per year from 1996 to 2010. Stroke mortality fell by 0.39% per year from 1980 to 2000, 5.03% per year from 2000 to 2004, and 0.01% per year from 2004 to 2010




      Stroke mortality


      Mortality from stroke mirrored the pattern of mortality from coronary heart disease, with a modest decrease of 6.9% lasting from 1980 to 2000 (0.4% per year) and a sharp fall between 2000 and 2004 of 13.6% (5.3% per year). From 2004 to 2010, mortality fell by 1.3% (0.01% per year, similar to pre-crisis rates).



      Cancer mortality


      Cancer mortality followed a distinctly different pattern to that observed in coronary heart disease, stroke, and diabetes, with two distinct phases (fig 4). From 1980 to 1996, a slight decrease of 2.4% in cancer mortality was observed (0.1% per year), which reverted to a slight increase of 5.4% in 1996-2010 (0.5% per year).



      All cause mortality


      Mortality from all causes, as expected, was highly influenced by trends in coronary heart disease and stroke, showing three different phases (data not shown). A prolonged decrease in mortality of 1.7% from 1980 to 1996 (0.1% per year) was followed a sharp decline of 10.5% from 1996 to 2002 (2.9% per year). From 2002 to 2010, there has been a modest decrease of 2% (0.7% per year).



      Discussion


      During the deepest period of the economic crisis in Cuba, lasting from 1991 to 1995, food was scarce and access to gas was greatly reduced, virtually eliminating motorised transport and causing the industrial and agricultural sectors to shift to manual intensive labour. This combination of food shortages and unavoidable increases in physical activity put the entire population in a negative energy balance, resulting in a population-wide weight loss of 4-5 kg.8 The decline in food availability was associated with a neuropathy outbreak in the adult population in 1993.24 25 The Cuban economy started recovering in 1996 with a sustained growth phase from 2000 onwards. Since 1996, physical activity has slightly declined. By 2002, energy intake had increased above pre-crisis levels.


      As a result of the above trends, by 2011, the Cuban population has regained enough weight to almost triple the obesity rates of 1995. This U shaped, population-wide pattern in body weight is historically unique because of several factors: the initial weight loss occurred in a population that had been well nourished previously, lasted for five years, and affected people at all initial levels of body mass index.


      Diabetes trends could have been substantially influenced by these population-wide changes in body weight. Diabetes prevalence surged from 1997 onwards, as weight started to rebound. Diabetes incidence decreased during the crisis, reaching its lowest point in 1996. The largest economic recovery saw diabetes incidence peaking in 2004 and 2009.


      Five years after the start of the economic crisis in 1996, an abrupt downward trend was observed in mortality from diabetes, coronary heart disease, stroke, and all causes. This period lasted an additional six years, during which energy intake status gradually recovered and physical activity levels were progressively reduced; in 2002, mortality rates returned to the pre-crisis pattern. A particularly dramatic shift in diabetes mortality was observed: from 2002 to 2010, the annual increase in diabetes mortality was similar to that before the crisis. Moreover, declining rates of coronary heart disease and stroke slowed to annual decreasing rates similar to those before the crisis.



      Comparison with other studies


      The effect of high risk, preventive approaches on diabetes or cardiovascular mortality has been extensively studied and has reported conflicting and non-conclusive results. For example, the Look AHEAD clinical trial,26 aimed at reducing cardiovascular risk associated with diabetes through weight reduction and exercise, has been prematurely terminated for lack of an effect on cardiovascular mortality. Other high risk approaches, such as the prevention and control of diabetes through massive screenings, has recently shown no improvements in diabetes, cardiovascular, or all cause mortality.27 Overall, it seems that high risk preventive approaches have either not produced a beneficial effect on cardiovascular mortality or diabetes control and mortality, or have been unsuccessful in reducing risk to a sufficient degree to warrant a conclusion.


      The complementary pathway to disease prevention, the population approach, has received scant attention in the literature. To our knowledge, the effect of population-wide weight regain on diabetes and cardiovascular mortality has not been previously studied. Research on population-wide interventions has so far only studied modelling studies28 or small scale interventions.14


      Research on weight cycling, described in obese individuals undergoing repeated attempts at weight loss followed by weight regain, has reported conflicting results: either an increase29 30 31 32 or no association with general mortality.33 Specifically, no association between weight cycling and diabetes incidence has been recorded.34 35 Since individual weight cycling usually refers to multiple weight changes over an extended period, those results might have limited relevance for the population experience of a single cycle of weight gain, loss, and regain that we report here.


      As shown in our results, smoking levels were affected by the crisis. The number of cigarettes smoked per capita in Cuba decreased in the crisis years, only to slightly recover afterwards and remain stable thereafter. Smoking prevalence has continuously decreased during the past 15 years in Cuba. The role of tobacco in the development and control of diabetes has been recently studied; both active and passive smoking are associated with increased incidence.36 This association is dose dependent37; therefore, the decrease in smoking in Cuba during the crisis may have contributed to the decline in diabetes incidence in those years. The effects of decreasing smoking rates should drive down the rates of diabetes incidence and mortality in the long term. In this case, the observed decline in smoking rates during and after the crisis should cause a decrease in diabetes mortality in the last decade of our study. The increase in diabetes mortality from year 2002 seems to rule out smoking as a major confounding factor in the observed trends, although it could be masking the true size of the effect of changes in dietary and physical activity on diabetes mortality. This consideration is analogous for coronary heart disease and stroke, which should fall as smoking prevalence declines.



      Strengths and limitations of study


      Our study presents the first observation of a population-wide event of this magnitude and its subsequent effects on public health. Population-wide shifts in other risk factors, such as cholesterol and blood pressure, have been described in large scale prevention interventions, for example, the North Karelia and FINRISK studies.38 In the Cuban experience, the changes in population-wide body weight were adaptive responses to dietary energy availability and energy expenditure; therefore, it is not possible to separate these two effects on mortality patterns.


      Other unique effects of this experience should also be considered. Problems with food production in Cuba led to the creation and expansion of urban agriculture, allowing citizens to buy fresh produce directly from farmers. Large public health campaigns in schools and communities are currently in place using community gardening as an effort to improve nutrition education and diet quality.39 During the crisis, the Cuban government acquired and distributed more than one million bicycles, which contributed to the population-wide increase in physical activity.39 These unique features of the Cuban experience make it to that degree non-comparable with other examples of economic crises. For example, previous research on the health consequences of the Great Depression in the US showed that banking suspensions (as a proxy for large scale economic decline) was not followed by a decrease in mortality.40


      As noted previously, controversy persists over the net benefit of generalised weight loss in modern populations.41 As articulated by Geoffrey Rose,15 a key element of a prevention strategy for diseases in populations with near universal exposure to the causal risk factor is a downward shift in the overall mean. The data presented here confirm this theory. The Cuban experience shows that within a relatively short period, modest weight loss in the whole population can have a profound effect on the overall burden of diabetes. In Cuba, weight loss also had a major effect on trends in cardiovascular diseases and all cause mortality. Although obesity is an important risk factor for cancer,42 only modest changes in cancer mortality were observed.


      Our study has some important limitations. We had no data on diabetes incidence for most crisis years, and rates in the subsequent years showed wide fluctuations. Data for diabetes mortality were available for the whole study period, but might not have adequately represented the health burden of diabetes. Death certificates are subject to misclassification bias, although the parallel trends in cardiovascular and all cause mortality rule out substantial shifts away from diabetes to major illnesses that occurred at the same time—the most common of which would have been vascular in cause. The cyclic pattern of the observed trends makes a bias less likely, owing to widespread changes in coding of death certificates. Estimating dietary intake from food disappearance data has known limitations, but data from available dietary surveys for the years before, during, and after the special period were consistent with food disappearance data from the Food and Agriculture Organization.8



      Conclusions and policy implications


      We found that a population-wide loss of 4-5 kg in weight in a relatively healthy population was accompanied by diabetes mortality falling by half and mortality from coronary heart disease falling by a third. Furthermore, a rebound in body weight was associated with an increased diabetes incidence and mortality, and a deceleration of the decline in mortality from coronary heart disease. 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.16 The latest reports in the US have documented a plateau in the epidemic curve of obesity in adults,43 children, and adolescents,44 but the public health effects of these changes have not yet been reported. It is therefore not possible to compare the Cuba findings with other populations. Therefore, the generalisability of our findings is uncertain. Nonetheless, these data are a notable illustration of the potential health benefits of reversing the global obesity epidemic.




      What is already known on this topic




      • The health effects of population-wide changes in body weight on a well nourished population with a functioning universal health system is unknown



      • Large reductions in diabetes and cardiovascular mortality were noted after the population-wide weight loss in Cuba, during the economic crisis of the early 1990s



      What this study adds




      • Body weight regain in the Cuban population was associated with an increase in diabetes prevalence, incidence, and mortality, as well as a deceleration in the previously declining rates of cardiovascular death



      • Small losses in body weight and prevention of body weight gain across the population could be a critical strategy in the prevention of non-communicable diseases



      Notes


      Cite this as: BMJ 2013;346:f1515



      Footnotes




      • 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.



      • Contributors: MF and RC contributed to the original design. PO, MB, and AM organised and conducted data collection. UB conducted the statistical analyses. MF, UB, and RC carried on the systematic literature research. MF, UB, PO, BC, JFK, and RC were active in the interpretation of results. The manuscript was drafted by MF, UB, JFK, and RC, and reviewed by all authors. All authors have approved the final report. All authors had full access to the data in the study and take responsibility for its integrity and the accuracy of the data analysis. MF is the guarantor for this study.



      • Funding: No funding sources had any role in the decision to submit this manuscript or in its writing.



      • Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work.



      • Ethical approval: The ethics committee of the University of Medical Sciences, Cienfuegos, approved protocols.



      • Data sharing: No additional data available.



      This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/3.0/.



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      ==================

      Economic Hard Times in Cuba Reduces Rates Of Heart Disease And Diabetes

      Medical News Today Article Date: 10 Apr 2013 – 11:00 PDT
      http://www.medicalnewstoday.com/articles/258930.php

      During the 1990s in Cuba, food was sparse and gasoline was nearly unavailable because of the US embargo and loss of Russian support; one of the positive consequences of that situation was a reduction in rates of diabetes and heart disease.

      The “special period” (as it became known) was between 1991 and 1995 and consisted of people using donkeys to move loads, as well as the government importing 1.5 million bicycles from China for modes of transportation. The current study, published in BMJ, aimed to determine whether eating less, cycling, walking, and manual labor contributed to the health of the nation as a whole. In other words, might a change in whole nation’s dietary intake plus increased physical activity caused by transportation policies impact on the incidence of type 2 diabetes and cardiovascular disease?

      The shortage of food and fuel in Cuba produced a reduction in dietary energy intake and a large increase in physical activity. These changes produced a population-wide weight loss of 4-5kg (8-11 lbs.) Significant decreases in death rates from coronary heart disease and diabetes were seen shortly after.

      A team of investigators from Cuba, Spain, and the U.S. analyzed..:


      • ..link between diabetes prevalence and population-wide body changes
      • ..incidence and death rates from type 2 diabetes and cardiovascular disease
      • ..cancer and all-causes
      Cuba is a nation with a long history of public health and cardiovascular research, which provided the data needed from primary chronic disease registries, cardiovascular studies, and national health surveys. The Cuban population has seen economic and social changes directly associated with physical activity and food intake from 1980 to 2010.

      The data used for the analysis included participants between the ages of 15 and 74 years and information on:

      • height
      • weight
      • energy intake
      • smoking
      • physical activity

      Dramatic Drop in Rates Seen Just From This Instance

      Changes in physical activity and energy intake went hand-in-hand with changes in body weight. For example, between 1991 and 1995 there was a 5kg reduction on average, while between 1195 and 2010 a weight rebound was seen of 9kg.

      The incidence of smoking fell during the 1980s and 1990s and decreased even more quickly in the 2000s.

      The prevalence of diabetes continued to rise from 1997 as the population started to gain weight. It then decreased during the weight loss period, followed by another increase until it peaked in the weight regain years.

      A sudden downward cycle in deaths from diabetes was seen five years after the beginning of the weight loss period, in 1996. This went on for about six years during which energy consumption status slowly recovered and physical activity levels decreased. In 2002, death rates went back to pre-crisis figures and a significant increase in diabetes deaths was seen.

      Stroke and coronary heart disease death rates slowly dropped from 1980 to 1996 with a bigger decrease occurring after the weight-loss phase. During the weight regain phase, these declines stopped.

      The investigators concluded that the “Cuban experienced in 1980-2010″ showed that within a short period, noteworthy weight loss in the whole population can greatly affect the overall burden of deaths from diabetes and cardiovascular disease.

      They point out that findings show that a 5kg population-wide weight loss “would reduce diabetes mortality by half and CHD mortality by a third”, however, these findings are an unusual circumstance from this one experience. On the other hand, they do provide a “notable illustration of the potential health benefits of reversing the global obesity epidemic”.

      Previous research has shown that there is a link between diabetes and heart disease. Diabetics are more likely to develop hardened arteries than non-diabetics.

      A separate study demonstrated the association between sitting for long periods and developing heart disease and diabetes. Even for people who are physically active, sitting for long periods could raise the risk for both conditions.

      Written by Kelly Fitzgerald

      .

      ]]>       http://www.chsc.or.kr/?post_type=reference&p=3908/feed 0       [식품] 어류 섭취, 수명 연장 효과(?) http://www.chsc.or.kr/?post_type=reference&p=3864 http://www.chsc.or.kr/?post_type=reference&p=3864#comments Tue, 02 Apr 2013 14:06:34 +0000 건강과대안 http://www.chsc.or.kr/?post_type=reference&p=3864 내과학회보(Annals of Internal Medicine) 최신호에 하버드대 보건대학원(Harvard School of
      Public Health) 연구팀이 오메가-3 지방산을 섭취한 그룹은 전반적인 사망률 27%, 심장질환
      위험도 35%가 각각 낮아져 결과적으로 수명이 연장되는 것을 확인했다는 논문을 
      발표했다는 AFP 뉴스입니다.

      그런데 이러한 뉴스는 항상 유의해서 연구 결과를 해석해야 합니다.

      하버드팀의 연구는 16년 동안 65세 이상 미국인 2700명을 대상으로  한 역학연구인데…
      일단 샘플 수가 많지 않고… 사망률과 심장질환 위험도가 줄어든 원인과 오메가-3 지방산과의
      명확한 인과관계가 과학적으로 규명된 것은 아닙니다.

      예를 들면 내과학회보(Annals of Internal Medicine)에 발표된 article 중에서 오마가-3 지방산
      보충제(영양제)를 투여한 결과 심혈관계 질환이 전혀 감소되지 않았다는 내용들이
      꽤 있습니다.

      ===========================


      Eating fish linked to longer life: US study


      April 1, 2013 (AFP)




      WASHINGTON, April 1, 2013 (AFP) – People age 65 and older who eat fish may live an average of two years longer than people who do not consume the omega-3 fatty acids found mainly in seafood, a US study suggested on Monday.


      People with higher levels of omega-3 fatty acids also had an overall risk of dying that was 27 percent lower, and a risk of dying from heart disease that was 35 percent lower than counterparts who had lower blood levels, said the study.


      The research was led by scientists at the Harvard School of Public Health and was published in the Annals of Internal Medicine.


      While other studies have demonstrated a link between omega-3 fatty acids and lower risk of heart disease, this research examined records of older people to determine any link between fish-eating and death risk.


      Researchers scanned 16 years of data on about 2,700 US adults aged 65 or older. Those considered for the study were not taking fish oil supplements, to eliminate any confusion over the use of supplements or dietary differences.


      Those with the highest blood levels of omega-3 fatty acids found mainly in fish like salmon, tuna, halibut, sardines, herring and mackerel, had the lowest risk of dying from any cause, and lived an average of 2.2 years longer than those with low levels.


      Researchers identified docosahexaenoic acid (DHA) as most strongly related to lower risk of coronary heart disease death.


      Eicosapentaenoic acid (EPA) was strongly linked to lower risk of nonfatal heart attack, and docosapentaenoic acid (DPA) was most strongly associated with lower risk of dying from a stroke.


      The findings persisted after researchers adjusted for demographic, lifestyle and diet factors.


      “Our findings support the importance of adequate blood omega-3 levels for cardiovascular health, and suggest that later in life these benefits could actually extend the years of remaining life,” said lead author Dariush Mozaffarian, associate professor in the Department of Epidemiology at Harvard School of Public Health.


      “The biggest bang-for-your-buck is for going from no intake to modest intake, or about two servings of fatty fish per week,” said Mozaffarian.

      =======================

      출처 : http://annals.org/



      ACP Journal Club   |   18 December 2012



      Review: Omega-3 polyunsaturated fatty acid supplements do not reduce major cardiovascular events in adults
      Donald A. Smith, MD, MPH, FACP, FNLA


      Annals of Internal Medicine, Dec 2012; 157 (12); JC6-5. doi: 10.7326/0003-4819-157-12-201212180-02005

      PDF PDF



      ACP Journal Club   |   21 August 2012



      Review: Omega-3 fatty acid supplements provide no protective benefit in cardiovascular disease
      Sharif A. Halim, MD, L. Kristin Newby, MD, MHS


      Annals of Internal Medicine, Aug 2012; 157 (4); JC2-3. doi: 10.7326/0003-4819-157-4-201208210-02003

      PDF PDF



      ACP Journal Club   |   17 May 2011



      Prescription omega-3 fatty acids did not prevent recurrent, symptomatic, paroxysmal or persistent atrial fibrillation
      Brian Olshansky, MD


      Annals of Internal Medicine, May 2011; 154 (10); JC5-9.

      PDF PDF



      Summaries for Patients   |   2 August 2011



      Omega-3 Fatty Acids and Congestive Heart Failure in Older Adults   FREE


      Annals of Internal Medicine, Aug 2011; 155 (3); I-29. doi: 10.7326/0003-4819-155-3-201108020-00001

      PDF PDF



      ACP Journal Club   |   18 September 2012



      Daily n-3 fatty acid supplements did not reduce CV events in high-risk patients with dysglycemia
      Ellis Lader, MD


      Annals of Internal Medicine, Sep 2012; 157 (6); JC3-11. doi: 10.7326/0003-4819-157-6-201209180-02011

      PDF PDF



      Article   |   1 May 1988



      Adverse Metabolic Effect of Omega-3 Fatty Acids in Non-Insulin-Dependent Diabetes Mellitus
      HARRY GLAUBER, M.D., PENNY WALLACE, R.N., M.S.N., KAY GRIVER, R.D., GINGER BRECHTEL, R.N.


      Annals of Internal Medicine, May 1988; 108 (5); 663-668. doi: 10.7326/0003-4819-108-5-663

      PDF PDF



      Perspective   |   1 December 1987



      Prophylaxis of Atherosclerosis with Marine Omega-3 Fatty Acids: A Comprehensive Strategy
      CLEMENS VON SCHACKY, M. D.

      ]]>       http://www.chsc.or.kr/?post_type=reference&p=3864/feed 0       [담배] Smoking & Tobacco Use (미국 질병관리본부) http://www.chsc.or.kr/?post_type=reference&p=3843 http://www.chsc.or.kr/?post_type=reference&p=3843#comments Mon, 25 Mar 2013 11:59:46 +0000 건강과대안 http://www.chsc.or.kr/?post_type=reference&p=3843

      Smoking & Tobacco Use



      http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/

      Fast Facts


      Morbidity and Mortality


      Tobacco use leads to disease and disability.



      • Smoking causes cancer, heart disease, stroke, and lung diseases (including emphysema, bronchitis, and chronic airway obstruction).1
      • For every person who dies from a smoking-related disease, 20 more people suffer with at least one serious illness from smoking.2


       


      Tobacco use is the leading preventable cause of death.



      • Worldwide, tobacco use causes more than 5 million deaths per year, and current trends show that tobacco use will cause more than 8 million deaths annually by 2030.3
      • In the United States, smoking is responsible for about one in five deaths annually (i.e., about 443,000 deaths per year, and an estimated 49,000 of these smoking-related deaths are the result of secondhand smoke exposure).1
      • On average, smokers die 13 to 14 years earlier than nonsmokers.4

      Costs and Expenditures


      The cigarette industry spends billions each year on advertising and promotions.5



      • $8.05 billion total spent in 2010
      • $22 million spent a day in 2010


       


      Tobacco use costs the United States billions of dollars each year.



      • Cigarette smoking costs more than $193 billion (i.e., $97 billion in lost productivity plus $96 billion in health care expenditures).1
      • Secondhand smoke costs more than $10 billion (i.e., health care expenditures, morbidity, and mortality).6


       


      State spending on tobacco control does not meet CDC-recommended levels.7,8



      • Collectively, states have billions of dollars available to them—from tobacco excise taxes and tobacco industry legal settlements—for preventing and controlling tobacco use. States currently use a very small percentage of these funds for tobacco control programs.
      • In 2013, states will collect $25.7 billion from tobacco taxes and legal settlements, but states are spending less than 2% of the $25.7 billion on tobacco control programs.
      • Investing only about 15% (i.e., $3.7 billion) of the $25.7 billion would fund every state tobacco control program at CDC-recommended levels.



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        New data highlight increases in hypertension, diabetes incidence


        News release


        16 MAY 2012 | GENEVA – The World health statistics 2012 report, released today, puts the spotlight on the growing problem of the noncommunicable diseases burden.


        One in three adults worldwide, according to the report, has raised blood pressure – a condition that causes around half of all deaths from stroke and heart disease. One in 10 adults has diabetes.


        “This report is further evidence of the dramatic increase in the conditions that trigger heart disease and other chronic illnesses, particularly in low- and middle-income countries,” says Dr Margaret Chan, Director-General of WHO. “In some African countries, as much as half the adult population has high blood pressure.”


        For the first time, the World Health Organization’s annual statistics report includes information from 194 countries on the percentage of men and women with raised blood pressure and blood glucose levels.


        In high-income countries, widespread diagnosis and treatment with low-cost medication have significantly reduced mean blood pressure across populations – and this has contributed to a reduction in deaths from heart disease. In Africa, however, more than 40% (and up to 50%) of adults in many countries are estimated to have high blood pressure. Most of these people remain undiagnosed, although many of these cases could be treated with low-cost medications, which would significantly reduce the risk of death and disability from heart disease and stroke.


        Also included for the first time in the World health statistics 2012 are data on people with raised blood glucose levels. While the global average prevalence is around 10%, up to one third of populations in some Pacific Island countries have this condition. Left untreated, diabetes can lead to cardiovascular disease, blindness and kidney failure.


        Obesity another major issue


        “In every region of the world, obesity doubled between 1980 and 2008,” says Dr Ties Boerma, Director of the Department of Health Statistics and Information Systems at WHO. “Today, half a billion people (12% of the world’s population) are considered obese.”


        The highest obesity levels are in the WHO Region of the Americas (26% of adults) and the lowest in the WHO South-East Asia Region (3% obese). In all parts of the world, women are more likely to be obese than men, and thus at greater risk of diabetes, cardiovascular disease and some cancers.


        Noncommunicable diseases currently cause almost two thirds of all deaths worldwide. Global concern about the rise in numbers of deaths from heart and lung disease, diabetes and cancer prompted the United Nations to hold a high-level meeting on noncommunicable diseases in New York in September 2011.


        The World Health Assembly, to be held in Geneva from 21 to 26 May 2012, will review progress made since that meeting and agree on next steps. Work is currently under way to develop a global monitoring framework and a set of voluntary targets for prevention and control of these diseases.


        Published annually by WHO, the World health statistics is the most comprehensive publication of health-related global statistics available. It contains data from 194 countries on a range of mortality, disease and health system indicators including life expectancy, illnesses and deaths from a range of diseases, health services and treatments, financial investment in health, as well as risk factors and behaviours that affect health.


        Some key trends in this year’s report are:


        Maternal mortality: In 20 years, the number of maternal deaths has decreased from more than 540 000 deaths in 1990 to less than 290 000 in 2010 – a decline of 47%. One third of these maternal deaths occur in just two countries – India with 20% of the global total and Nigeria with 14%.


        10 year trends for causes of child death: Data from the years 2000 to 2010 show how public health advancements have helped save children’s lives in the past decade. The world has made significant progress, having reduced the number of child deaths from almost 10 million children aged less than 5 years in 2000 to 7.6 million annual deaths in 2010. Declines in numbers of deaths from diarrhoeal disease and measles have been particularly striking.


        Death registration: Only 34 countries (representing 15% of the world’s population) produce high-quality cause-of-death data. In low and middle-income countries, less than 10% of deaths are registered. For more information, please contact:


        Fadéla Chaib


        WHO Communications Officer and Spokesperson


        Telephone: +41 22 791 32 28


        Mobile: +41 79 475 55 56


        E-mail: chaibf@who.int

        2012년 5월 16일 발간된 2012년 세계보건통계(World Health statistics) 보고서는 전 세계적으로  비감염성질환(non-communicable diseases)의 가 증가하고 있음을 나타내고 있다. 2008년 전 세계 5천 7백만명의 사망자 중에서 비감염성질환으로 인한 사망은 3천 6백만명(63%)으로 추정된다. 인구  집단의 성장과 평균수명의 연장은 노인인구의 숫자를 증가시키고 이로 인해 비감염성질환으로의 사망이 늘어나고 있다.
          보고서에 의하면 전 세계 성인의 1/3이 뇌졸중 및 심장질환의 원인이 되는 고혈압에 해당되며, 성인 10명 중 1명은 당뇨병을 앓고 있다. WHO 사무총장 마가렛 찬(Margaret Chan)은 이번 보고서가 특히 저소득 국가들에서 심장질환 및 만성질환을 유발하는 위험요인에 큰 증가가 있음을 나타내는 근거라고 언급하며, 일부 아프리카 국가들의 경우 성인인구의 절반 이상이 고혈압을 앓고 있다고 밝혔다.
          혈압의 증가는 뇌졸중으로 인한 사망의 약 51%, 심장질환으로 인한 사망의 약 45%의 원인이 되는 높은 위험요인이다. 이는 2004년 기준 7백 5십만명의 사망에 직접적인 원인이 되었으며 전 세계 총  사망원인의 12.8%를 차지한다.
          고소득 국가들에서 광범위한 진단 및 치료는 인구집단의 혈압을 감소시키고, 이는 심장질환 사망   감소에 기여하였다. 그러나 아프리카 지역의 많은 국가들에서 성인의 40% 이상이 고혈압으로 추정되며 이러한 수치는 증가추세에 있다(Figure 1). 이러한 사례 중 다수가 저비용으로 치료가능 하지만, 이들 중 대다수는 진단조차 받지 못하고 있는 상태이며 이는 심장질환 및 뇌졸중으로 인한 사망 및 장애   위험에 큰 영향을 끼친다.
                         
          당뇨병의 경우, 전 세계 평균 유병률이 약 10%인 반면에 태평양 섬 국가들에서는 인구의 1/3이 당뇨병에 해당한다. 이들을 치료하지 않은 채로 방치한다면 당뇨병은 심혈관질환, 실명, 신장질환을 유발할 수 있다. 전 세계적으로 2백 8십만명이 매년 과체중 또는 비만의 결과로 사망한다. 과체중 또는 비만은 심장질환 및 뇌졸중, 제2형 당뇨병 및 다른 암들의 위험을 증가시킨다.
          1980년에서 2008년간 전 세계의 비만 유병률(BMI ≥30kg/㎡)은 거의 두 배 가량 증가하였다(Figure 2).
                         
          2008년 전 세계 남성의 10%, 여성의 14%가 비만(약 5억명)으로 나타났으며 이는 1980년 남성 5%, 여성 8%에 비교하여 크게 증가한 수치이다.
          가장 높은 비만수치는 WHO 아메리카 지역(성인의 26%)이었으며 가장 낮은 지역은 WHO 동남아시아 지역(성인의 3%)으로 나타났다. 전 세계 모든 지역에서 여성이 남성에 비해 비만 가능성이 높았으며, 당뇨병, 심혈관질환 및 일부 암에서도 위험이 높은 것으로 나타났다. 비감염성질환은 현재 사망원인의 2/3을 차지하고 있으며, 전 세계는 현재 심폐질환, 당뇨병, 암 등으로 인한 사망자수 증가에 우려하고 있다.
          세계보건통계는 194개 회원국으로부터 사망률, 기대수명을 포함한 보건지표들과 건강에 영향을 주는 위험요인과 행동뿐만 아니라 질병의 사망과 이환, 보건 서비스 및 치료, 보건관련 재정적 투자 등을 모두 포함하고 있다. 올해 세계보건통계에서 나타난 몇 가지 주요 추세는 다음과 같다.

        ■ 모성 사망률 : 20년 동안 모성사망자 수는 1990년 54만명에서 2010년 29만명 이하로 약 47%   감소하였다. 이러한 모성사망의 1/3은 주로 두 국가에서 발생하고 있는데 인도는 숫자의 20%, 나이지리아는 14%를 차지한다.
        ■ 아동사망 원인의 10년 추이 : 2000년에서 2010년의 자료를 보면 지난 10년간 공중보건의 발전이 아동의 생명을 구하는데 도움이 되고 있음을 보여준다. 2000년 5세 이하 어린이 사망자 수가 약 1천만명에서 2010년 연간 사망자수 7백 6십만명으로 감소하는 큰 발전을 이루었다. 특히 설사관련 질환과 홍역으로 인한 사망자수의 감소가 특히 눈에 띈다.
        ■ 사망 등록: 전 세계 34개국(전체 인구의 15%)에서 질 높은 사망원인 자료를 생산하고 있으며, 저소득 국가에서는 전체 사망의 10% 이하만 등록되고 있다.

        ]]>         http://www.chsc.or.kr/?post_type=reference&p=3653/feed 0         [경제위기] IMF ‘구제’금융,결핵 발생-사망률 14~16% 급증(김승섭) http://www.chsc.or.kr/?post_type=reference&p=1822 http://www.chsc.or.kr/?post_type=reference&p=1822#comments Tue, 02 Mar 2010 15:01:31 +0000 건강과대안 http://www.chsc.or.kr/?post_type=reference&p=1822
















        IMF ‘구제’금융?…정말로 사람잡는다
        결핵 발생-사망률 14~16% 급증…다른 곳서 돈 빌린 나라 감소

        출처 : 레디앙 2010년 03월 02일 (화) 09:03:03
        http://www.redian.org/news/articleView.html?idxno=17476

        1998년을 다들 기억하시는지요. 저는 아직도 그 때의 기억이 또렷합니다. 그 해 겨울, 20년 넘게 다니시던 직장에서 아버지께서 명예퇴직이라는 이름으로 명예롭지 못하게 퇴직을 당하시고 , 어머니와 함께 생계를 위해 무엇을 할 수 있을가를 함께 고민하며 여기저기 알아보려 다니던 겨울이 기억납니다.


        1998년, 그해 겨울


        그 매섭던 겨울보다 더 싸늘하고 무섭던 국가부도 사태가 있었고, 사고는 재벌이 쳤는데 부도난 국가를 살리겠다며 금모으기 운동을 하겠다고 나섰던 국민들의 모습이 떠오릅니다.

        지금은 그로부터 12년이 지난 2010년입니다. 외국에서 공부하다보면, 간혹 사람들이 IMF 구제금융을 통해 경제회복에 성공한 모델로 간혹 한국을 이야기하는 경우가 있습니다.


        보건학을 공부하는 저로서는 그런 이야기를 들을 때마다, 그 기간 동안 증가한 비정규직의 숫자가 얼마인데 그 속에서 경제고에 못 이겨 자살한 사람들의 숫자가 얼마인데, 이처럼 쉽사리 경제회복이라는 단어를 쓰는지 답답하고 야속하기까지 합니다.


        배임과 조세포탈로 징역 3년에 벌금만 1000억을 넘게 선고받은 이건희 회장이 사면되어 화려한 시간을 보내는 동안, 다니던 회사에서 계속 일하게 해달라는 이유로 파업을 했던 쌍용자동차 노동조합의 사람들은 국가 경제를 망친 주범이라는 낙인속에서 징역을 살아야 하는 모습을 보고 있노라면 더더욱 그렇습니다.

        저 같은 사람이 ‘이런게 무슨 경제회복이야, IMF 경제위기는 국가와 재벌이 만든 건데, 대가는 노동자와 서민들이 치르고’라고 투덜되는 동안, 옥스포드 대학의 데이비드 스터클러(David Stuckle)는 흥미로운 연구를 했습니다. (Stuckler D, King LP, Basu S. PLoS Med. 2008 Jul 22;5(7):e143.)


        IMF 구조조정과 사람들의 건강


        과거 공산주의 국가였던 동유럽과 구소련 국가들이 1990년대 초, 중반에 거의 모두 IMF 구제금융을 받았거든요. 그 나라들을 대상으로 경제위기, 민주화 정도, 군부나 인종간 갈등, 정치적 변화, 전쟁, 질병 감시시스템의 변화, 도시화 정도 등을 모두 고려해서 모델을 만들어 본 거예요.


        경제위기나 전쟁 등의 다른 요소로 인해 사람들의 건강이 안 좋아진 것을 감안하더라도, 진짜 IMF 구조조정 프로그램이 사람들의 건강에 어떤 영향을 미쳤는지를 본 것이지요.


        건강 상태의 변화 기준으로, 모든 건강 요소를 다 본다는 것이 힘들기 때문에, 데이비드 스터클러는 결핵으로 인한 사망율을 살펴봤어요. 결핵이라는 질병이 아직 의료나 위생 시스템이 온전히 갖추어 지지 않은 나라에서는 그 나라의 경제위기이나 의료수준에 따라 예민하게 변하는 녀석이어서, 결핵으로 인한 사망율을 본 것이지요.

        결과는 놀랍습니다. 위에서 말한 여러 조건들을 감안하더라도, IMF 구조조정 프로그램에 참여할 경우 결핵 발생율과 사망율이 각각 14%, 16% 유의하게 증가하는 것으로 나타난 것입니다. 그리고 IMF 구조조정 프로그램에서 빠져나올 경우에 결핵 사망율이 평균적으로 31% 가량 줄어드는 것입니다.










           
          ▲ 2001년 8월 23일, IMF로부터 빌린 195억달러를 모두 갚으며 3년 8개월만에 IMF사태는 공식 종료된다


        물론 경제 수준의 변화 등을 비롯한 다른 요소들을 감안하더라도 말이예요. IMF 구조조정 프로그램에 참여하면 결핵으로 죽는 사람들의 숫자가 늘어나고, 그 프로그램에서 빠져나오면 그 숫자가 줄어든다는 것이지요.


        많이, 오래 빌릴수록 사망률 높아져


        심지어 IMF로부터 돈을 더 많이 빌릴수록, 더 오래 빌릴수록 결핵으로 인한 사망률이 올라가는 거예요. 이 말을 듣고서, 이게 어떻게 된 일인가 하면서, 경제위기에 돈을 빌리는 나라들은 경기도 어렵고 사회의 의료시스템이 망가져서 다 어쩔 수 없는 것 아니겠나라는 질문을 하실 수도 있을 거예요.

        데이비드 스터클러는 그래서 같은 시기 동유럽 국가 중 거의 유일하게 IMF에서 돈을 빌리지 않고, 다른 곳에서 돈을 빌렸던 슬로베니아 등의 나라와 IMF 구제금융을 받은 러시아 같은 나라의 결핵 사망율을 비교해요. 그랬더니, IMF가 아닌 곳에서 돈을 빌렸던 슬로베니아 같은 나라는 오히려 결핵 사망율이 유의하게 감소했어요. 어찌된 일일가요?

        IMF는 돈을 빌려준 나라에게 사회안전망이나 공공의료 시스템이 들어가는 돈을 줄이라고 직접적으로 요구하지는 않는다고 알려져 있습니다. 하지만, IMF 구제금융을 받는 나라들의 관료들은 모두 공공 의료시스템, 교육 시스템에 들어가는 돈을 줄이지 않고서는 그들이 제시하는 경제적 수준을 맞출 수 없다는 것을 알고 있지요.


        데이비드는 또 다른 논문에서 IMF구조조정 프로그램이 사람들의 건강을 해치는 이유로, 의료 인력이 외국으로 빠져나가고, 노동시장을 보호하는 것과 같은 사회 안전망이 축소되고, 빈곤층이 늘어나고, 질병 감시체계에 대한 사회적 투자가 줄어드는 것 등을 가설로 내세우고 있어요.(Stuckler D, Basu S. Int J Health Serv. 2009;39(4):771-81.)


        그러면서, IMF 구조조정 프로그램이 그 나라의 모든 사람들에게 똑같이 영향을 미치는 것은 아니라는 것도 분명히 합니다. 구조조정을 핑계삼아 자신의 재산을 불렸던 구 소련의 정치 관료들을 언급하면서요.


        27세, 이상관의 자살

        2009년 2월 IMF는 라트비아(Latvia)에게 공공영역에 대한 투자를 줄이지 않으면 돈을 빌려주는 일을 중단하겠다는 경고를 했었습니다. IMF가 제시한 기준을 만족시키기 위해서는 라트비아는 의료와 교육 그리고 노동시장 보호와 관련된 공공투자를 40% 가량 줄어야 하는 상황이었다고 합니다.


        우크라이나에서는 실제로 사회투자(social spending)을 국가가 줄이지 않자 IMF 꿔준 돈을 강제로 회수한 사례가 있기도 하구요.

        다시 한국으로 돌아가보지요. 1998년 당시 IMF 총재였던 미셸 캉드쉬는 한국은 경제위기라 할지라도 사회안전망이 너무 취약하기 때문에 그에 대한 투자를 줄이면 안된다는 이야기를 했었어요. 그런데, 그러면 뭐하나요. 그런 정치적 수사로는 무엇도 실제로 움직이지 않는 걸요.


        1999년 산업재해를 당한 후 강제로 치료 종결이 되어, 막막한 상황에서 자살을 했던 27살의 이상관이라는 젊은 노동자가 있었어요. 그의 자살을 산업재해로 인정해 달라고 싸우던 와중에, 발견된 공문서가 있었어요. 공기업 구조조정이라는 명목하에 산재보험으로 치료 요양 중인 환자를 절반으로 줄이라는 내용이 담겨 있었지요. 저는 그 젊은 노동자를 자살로 몰고간 세상이 무엇인지 이제야 조금 알 것 같아요.

        1998년 그 혹독했던 겨울로부터 12년이 지났습니다. 지난 12년이 누군가에게는 경제가 회복되고 다시 세계로 나아가는 시간이었을지 모르지만, 많은 이들에게는 삶이 점점 더 어려워지고 더 혹독한 시련을 견디어 내야 하는 시간 아니었는지 모르겠습니다. 우리에게 IMF는 무엇이었나요.







        2010년 03월 02일 (화) 09:03:03 김승섭 / 하버드 보건대학원 직업병 역학 박사과정 skim@hsph.harvard.edu

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