번호	제목	글쓴이	조회	첨부파일
4	제4회 학술대회 보고서	관리자	1367
3	제3회 학술대회 보고서	관리자	408
2	제2회 학술대회 보고서	관리자	130
1	제1회 학술대회 보고서	관리자	139

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

2010년 한국의료패널 기초분석보고서(II)
출처 : 국민건강보험공단 건강보험정책연구원
발행일 : 2012-12-31
연구자 : 서남규 외

Abstract

요약

I. 한국의료패널 개요
1. 한국의료패널의 필요성 및 목적
2. 한국의료패널 설문항목 기본방향 및 설문내용
3. 조사 표본 유지율
4. 조사 대상 가구의 특성
5. 이탈가구의 특성

II. 민간 의료보험 가입 실태
1. 가구의 민간의료보험 가입 실태
2. 가구원의 민간의료보험 가입 실태
3. 가구의 민간의료보험 급여 수령 현황
4. 가구원의 민간의료보험 급여 수령 현황

III. 중증질환과 의료비 지출
1. 암
2. 뇌혈관질환
3. 심장질환

IV. 건강상태 : 삶의 질과 활동제한
1. 건강관련 삶의 질
2. 활동제한(1) – 만 18세 이상
3. 활동제한(2) – 만 65세 이상

V. 정신건강
1. 정신건강
2. 수면 시간

VI. 건강행태
1. 흡연
2. 음주
3. 신체활동량

VII. 구강 건강
1. 양치습관
2. 양치제품
3. 무자격자 치과시술

VIII. 노인장기요양
1. 노인장기요양

IX. 결론

부록. 2010년 하반기 한국의료패널 설문지

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

2009년 한국의료패널 기초분석보고서(III)
출처 : 국민건강보험공단 건강보험정책연구원
발행일 : 2012-12-31
연구자 : 서남규 외

Abstract

요약

Ⅰ. 한국의료패널 개요
1. 한국의료패널의 필요성 및 목적
2. 한국의료패널 설문항목 기본방향 및 설문내용
3. 조사 표본 유지율
4. 2009년 한국의료패널 기초분석보고서(III) 작성데이터 구조

Ⅱ. 건강행태
1. 흡연
2. 음주
3. 신체활동량

Ⅲ. 만성질환자의 약제비 및 의료비 지출
1. 고혈압
2. 당뇨병
3. 관절염

Ⅳ. 중증질환과 의료비 지출
1. 암
2. 뇌혈관질환
3. 심장질환

V. 일자리, 계층인지도와 건강수준
1. 경제활동 인구의 특성 및 의료이용
2. 종사상 지위별 특성 및 의료이용
3. 가구소득 분위 및 종사상 지위에 따른 의료이용
4. 종사상 지위 및 계층인지도에 따른 의료이용
5. 근무시간 및 형태에 따른 의료이용

Ⅵ. 임신 및 출산과 의료비 지출
1. 출산관련 의료이용 행태
2. 출산으로 인한 본인부담 의료비 지출

Ⅶ. 노인의 건강상태 및 의료이용
1. 노인 가구의 일반사항
2. 노인의 의료이용 및 본인부담 의료비 지출
3. 노인의 건강상태 및 건강행태
4. 노인장기요양

Ⅷ. 결론

부록. 2009년 한국의료패널 설문지

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

2012년 한국의료패널을 활용한 의료이용 심층연구
출처 : 한국보건사회연구원
발행일 : 2012-12-31
연구자 : 김대중 외

Abstract

요 약

제1장 서론
제1절 연구의 필요성 및 배경
제2절 활용 데이터의 구성과 특성

제2장 의료이용의 결정요인
2.1 우리나라 국민의 건강수준 및 의료이용 결정요인 분석
2.2. 거리접근성의 관점에서 본 의료이용 행태 분석 – 당뇨병, 고혈압을 중심으로 -
2.3 부모의 사회경제적 특성이 미성년 자녀의 의료이용에 미치는 영향
2.4 독거노인의 주관적 건강에 미치는 기능제한 영향 분석
2.5 한국의료패널을 활용한 노년기 외래의료서비스 예측요인 분석 – 스트레스취약 요인의 매개효과를 중심으로 -
제3장 급성기 환자의 의료이용
3.1 산재보험적용 및 자동차보험적용 환자 특성 분석
3.2 응급실 이용 관련 요인

제4장 만성질환자의 의료이용
4.1 복합만성질환자 유병률 및 의료이용: 치료 지속성이 피할 수 있는 입원에 미치는 영향 중심으로
4.2 상용치료원과 건강성과

제5장 임신 및 출산관련 의료이용
5.1 출산결과(Birth Outcome)에 따른 영아기 의료이용 및 의료비지출 실태
5.2 사회경제적 특성별 임신‧출산 관련 의료이용 분석

제6장 처방의약품 이용
6.1 의료기관종별 처방의약품 비용 및 순응도
6.2 만성질환자의 복약순응도가 의료이용 및 의료비 지출에 미치는 영향

제7장 기타 의료이용
7.1 운동자와 비운동자간 의료이용 차이의 계량적 분석
7.2 은퇴가 건강에 미치는 영향
7.3 소득계층별 의료이용에 따른 과부담 의료비 발생 차이 분석

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

2010년 한국의료패널 기초분석보고서(I)
출처 : 한국보건사회연구원
발행일 : 2012-12-31
연구자 : 정영호 외

Abstract

요 약

제1장 한국의료패널 개요
제1절 한국의료패널의 필요성 및 목적
제2절 한국의료패널 설문항목 기본방향 및 설문내용
제3절 조사 표본 유지율
제4절 이탈가구의 특성

제2장 조사가구의 특성

제3장 입원 및 외래서비스 이용과 본인부담 의료비
제1절 응급 서비스 이용 및 본인부담 의료비 현황
제2절 입원서비스 이용 및 본인부담 의료비 현황
제3절 외래 서비스 이용 및 본인부담 의료비 현황
제4절 간병현황과 간병비

제4장 만성질환관리와 본인부담 의료비
제1절 고혈압 관리 현황 및 연간 본인부담 의료비
제2절 당뇨병 관리 및 연간 본인부담 의료비

제5장 임신 및 출산을 위한 가구의 의료비 지출
제1절 출산에 따른 가구의 본인부담 의료비
제2절 산전후 관리를 위한 본인부담 의료비
제3절 임신 및 출산으로 인한 가구의 의료비 지출 규모

제6장 신생아의 생후 2년간 본인부담 의료비
제1절 신생아의 생후 2년간 의료이용
제2절 신생아의 생후 2년간 본인부담 의료비

제7장 고령자의 건강수준과 본인부담 의료비
제1절 고령자의 만성질환 현황과 본인부담 의료비
제2절 고령자의 건강행태별 본인부담 의료비

제8장 질병예방 및 건강관리비
제1절 건강검진과 본인부담 의료비
제2절 예방접종과 본인부담 의료비

제9장 결론

참고문헌

부록
부록 1. 추가샘플링
부록 2. 2010년 하반기 한국의료패널 설문지

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

2009년 한국의료패널 기초분석보고서(II)
출처 : 한국보건사회연구원
발행일 : 2011-12-31
연구자 : 정영호 외

Abstract 1

요약3

제1장 한국의료패널의 개요 19
제1절 한국의료패널 조사의 필요성 및 목적 19
제2절 한국의료패널 설문 및 조사현황 22
제3절 표본설계 및 가중치 30
제4절 연구 내용 37

제2장 건강관련 삶의 질 41
제1절 건강관련 삶의 질 척도 41
제2절 건강관련 삶의 질 프로파일 48
제3절 건강관련 삶의 질 : EQ-5D index 60

제3장 상용치료원 보유별 의료이용의 차이 71
제1절 선행연구 및 분석 대상 71
제2절 상용치료원 보유와 의료이용과의 관계 73
제3절 고혈압 환자의 상용치료원 보유 유무와 의료이용 86

제4장 활동제한과 미충족 의료 91
제1절 활동제한 91
제2절 미충족 의료 97

제5장 만성질환으로 인한 의료이용 및 의료비: 우울증을 중심으로 107
제1절 서론 107
제2절 우리나라 성인의 만성질환 분포 108
제3절 65세 이상 노인의 우울증으로 인한 의료이용과 의료비 차이 비교 110
제4절 정책적 함의 116

제6장 베이비 부머의 가구특성 및 건강상태 121
제1절 서론 121
제2절 분석 데이터 개요 122
제3절 베이비 부머 가구의 노후 준비 124
제4절 베이비 부머의 소득과 경제활동 126
제5절 베이비 부머의 건강상태 130

제7장 결론 145
제1절 우리나라 성인의 건강관련 삶의 질 145
제2절 상용치료원, 활동제한 및 미충족 의료 146
제3절 65세 이상 노인의 우울증과 의료이용 및 의료비 147
제4절 베이비 부머의 건강상태와 만성질환 관리 148

참고문헌 151

부록: 2009년 한국의료패널 설문지 157

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

2009년 한국의료패널 기초분석보고서(I)
출처 : 한국보건사회연구원
발행일 : 2010-12-31
연구자 : 정영호 외

1. 한국의료패널 개요
2. 조사가구의 특성
3. 응급서비스 이용과 본인부담 의료비
4. 입원서비스 이용과 본인부담
5. 외래이용과 본인부담
6. 의약품 복용 행태와 의약품비 지출
7. 만성질환과 의료비 지출
8. 출산과 의료비 지출
9. 가구경제와 의료비 지출
10 민간의료보험 가입 실태
11. 주요 기대효과 및 향후 연구계획

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

2008년 한국의료패널 기초분석보고서(II)
출처 : 한국보건사회연구원
발행일 : 2010-12-31
연구자 : 정영호 외

1. 한국의료패널 개요
2. 조사가구의 특성
3. 응급서비스 이용과 본인부담 의료비
4. 입원서비스 이용과 본인부담
5. 외래이용과 본인부담
6. 의약품 복용 행태와 의약품비 지출
7. 만성질환과 의료비 지출
8. 출산과 의료비 지출
9. 가구경제와 의료비 지출
10 민간의료보험 가입 실태
11. 주요 기대효과 및 향후 연구계획

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

2008년 한국의료패널 기초분석보고서 (I)
출처 : 한국보건사회연구원
발행일 : 2009-12-31
연구자 : 정영호 외

Ⅰ.한국의료패널 개요
1. 한국의료패널 조사의 필요성 및 목적
2. 한국의료패널 설문항목 기본방향 및 설문내용
3. 한국의료패널 조사의 추진체계 및 조사방법
4. 조사 완료율 및 자료 입력
5. 표본설계

Ⅱ. 조사가구의 특성
1. 가구 특성 및 가족 구성
2. 가구주 및 가구원 특성
3. 사망 가구원의 특성

Ⅲ. 가구 경제
1. 가구 소득 및 소비
2. 주거 유형 및 관련 비용
3. 개인의 경제활동상태

Ⅳ. 만성질환 및 의약품 복용 행태
1. 만성질환자의 의약품 복용 행태
2. 주요 만성질환자의 의약품 복용 행태
3. 일반의약품 복용 행태

Ⅴ. 개인의 의료이용
1. 응급서비스 이용
2. 입원서비스 이용
3. 외래서비스 이용
4. 출산관련 의료이용

Ⅵ. 의료비 지출
1. 가구의 의료비 지출
2. 개인별 의료비 지출
3. 의료서비스 이용 유형별 의료비 지출
4. 의료비 재원

Ⅶ. 민간의료보험 가입 실태
1. 가구의 민간의료보험 가입 실태
2. 가구원별 민간의료보험 가입 실태
3. 민간의료보험 급여 실태

Ⅷ. 정책적 시사점 및 활용 방안
1. 가구 및 개인단위의 본인부담 의료비 지출 규모 제공
2. OECD 보건계정체계 및 한국의료패널의 자료 생산
3. 민간의료보험 가입 실태 및 민간재원조달
4. 의료서비스 이용 실태
5. 동태적 의료비 지출 변화
6. 개인의 건강결정요인 분석을 위한 기초자료
7. 향후 연구과제

참고문헌

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

한국 의료패널 예비조사 결과 보고서
출처 : 한국보건사회연구원
발행일 : 2008-12-31
연구자 : 정영호 외
제1장 조사 개요
제1절 한국의료패널의 필요성 및 목적
제2절 한국의료패널 예비조사 개요

제2장 1차 예비조사 진행 및 결과 분석
제1절 1차 예비조사의 목적 및 설계
제2절 1차 예비조사의 설문 내용
제3절 1차 예비조사의 실사 과정 및 결과 분석
제4절 향후 본 조사를 위한 개선사항

제3장 2차 예비조사 진행 및 결과 분석
제1절 2차 예비조사 목적 및 조사 개요
제2절 2차 예비조사 내용 및 실사과정
제3절 2차 예비조사 결과
제4절 향후 본 조사를 위한 개선사항

제4장 향후 개선 방향
제1절 조사 및 패널관리 개선사항
제2절 설문내용관련 개선사항
제3절 데이터관리관련

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

2008년 한국의료패널 조사 진행 보고서
출처 : 한국보건사회연구원
발행일 : 2008-12-31
연구자 : 정영호 외
제1장 조사 개요
제1절 한국의료패널 조사의 필요성 및 목적
제2절 한국의료패널 조사의 추진체계 및 수행절차
제3절 표본설계

제2장 설문지 및 건강가계부 설계
제1절 설문지 설계
제2절 건강가계부 설계

제3장 예비조사 및 가구유치조사
제1절 예비조사
제2절 가구유치조사

제4장 2008년 한국의료패널 조사 진행
제1절 인지조사 및 자문회의를 통한 개선사항
제2절 2008년 한국의료패널 실사 과정
제3절 조사 완료율 및 자료입력

제5장 한국의료패널 가구 관리
제1절 패널가구 관리의 중요성
제2절 패널 관리 및 운영

제6장 한국의료패널 향후계획 및 기대효과
제1절 한국의료패널 향후 계획
제2절 기대효과

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

• Article


• Related content


• Article metrics

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. 
   
   ¹Social and Cardiovascular Epidemiology Research Group, School of Medicine, University of Alcalá, Alcalá de Henares, Madrid, Spain
   
   
2. 
   
   ²Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
   
   
3. 
   
   ³Department of Epidemiology, Atherothrombosis and Cardiovascular Imaging, Centro Nacional de Investigaciones Cardiovasculares Madrid, Spain
   
   
4. 
   
   ⁴Project for Chronic Disease Prevention and Control, Pan American Health Organization, Washington, DC, USA
   
   
5. 
   
   ⁵Centro de Estudios sobre Enfermedades Crónicas, Universidad de Ciencias Médicas, Cienfuegos, Cuba
   
   
6. 
   
   ⁶Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, USA
   
   
7. 
   
   ⁷Division of Community Health Sciences, University of Illinois at Chicago School of Public Health, Chicago, IL, USA
   
   
8. 
   
   ⁸Department of Public Health Sciences, Loyola University Stritch School of Medicine, Maywood, IL, USA

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

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:

• View Popup
  
• View Inline

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:

• In a new window

• Download as PowerPoint Slide

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:

• In a new window

• Download as PowerPoint Slide

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

View larger version:

• In a new window

• Download as PowerPoint Slide

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:

• In a new window

• Download as PowerPoint Slide

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/.

References

1. ↵
   
   
   

   West KM. Epidemiology of diabetes and its vascular lesions. Elsevier North-Holland, 1978.

   
   


2. ↵
   
   
   

   Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser2000;894:i-xii,1-253.

   
   

   Medline


3. ↵
   
   
   

   Olshansky SJ, Passaro DJ, Hershow RC, Layden J, Carnes BA, Brody J, et al. A potential decline in life expectancy in the United States in the 21st century. N Engl J Med2005;352:1138-45.

   
   

   CrossRefMedlineWeb of Science


4. ↵
   
   
   

   Ford ES, Mokdad AH. Epidemiology of obesity in the Western Hemisphere. J Clin Endocrinol Metab2008;93(11 suppl 1):S1-8.

   
   

   CrossRefMedlineWeb of Science


5. ↵
   
   
   

   Durazo-Arvizu RA, McGee DL, Cooper RS, Liao Y, Luke A. Mortality and optimal body mass index in a sample of the US population. Am J Epidemiol1998;147:739-49.

   
   

   Abstract/FREE Full Text


6. ↵
   
   
   

   Flegal KM, Graubard BI, Williamson DF, Gail MH. Excess deaths associated with underweight, overweight, and obesity. JAMA2005;293:1861-7.

   
   

   CrossRefMedlineWeb of Science


7. ↵
   
   
   

   Capewell S, O’Flaherty M. Rapid mortality falls after risk-factor changes in populations. Lancet2011;378:752-3.

   
   

   CrossRefMedlineWeb of Science


8. ↵
   
   
   

   Franco M, Orduñez P, Caballero B, Tapia Granados JA, Lazo M, Bernal JL, et al. Impact of energy intake, physical activity, and population-wide weight loss on cardiovascular disease and diabetes mortality in Cuba, 1980-2005. Am J Epidemiol2007;166:1374-80.

   
   

   Abstract/FREE Full Text


9. ↵
   
   
   

   Lazo M, Franco M, Cooper R, Orduñez P. Better health statistics: the Cuban experience. Lancet2006;367:985-6.

   
   

   Medline


10. ↵
    
    
    

    Ríos Massabot NE, Fernández Viera RM, Jorge Pérez ER. [Medical registries in Cuba]. Revista Cubana de Salud Pública2005;31:345-52.

    
    


11. ↵
    
    
    

    Borowy I. Similar but different: health and economic crisis in 1990s Cuba and Russia. Soc Sci Med2011;72:1489-98.

    
    

    CrossRefMedline


12. ↵
    
    
    

    World Bank. World Bank data: Cuba profile. 2012. http://data.worldbank.org/country/cuba.

    
    


13. ↵
    
    
    

    Benet Rodríguez M, Morejón Giraldoni A, Espinosa Brito A, Landrove Rodríguez O, Peraza Alejo D, Orduñez García P. Factores de Riesgo para Enfermedades Crónicas en Cienfuegos, Cuba 2010. Resultados preliminares de CARMEN II. MediSur2010;8:56-9.

    
    


14. ↵
    
    
    

    Ezzati M, Riboli E. Can noncommunicable diseases be prevented? Lessons from studies of populations and individuals. Science2012;337:1482-7.

    
    

    Abstract/FREE Full Text


15. ↵
    
    
    

    Rose G. Sick individuals and sick populations. Int J Epidemiol1985;14:32-8.

    
    

    Abstract/FREE Full Text


16. ↵
    
    
    

    Franco M, Orduñez P, Caballero B, Cooper RS. Obesity reduction and its possible consequences: what can we learn from Cuba’s Special Period? CMAJ2008;178:1032-4.

    
    

    FREE Full Text


17. ↵
    
    
    

    Cooper RS, Orduñez P, Iraola Ferrer MD, Munoz JL, Espinosa-Brito A. Cardiovascular disease and associated risk factors in Cuba: prospects for prevention and control. Am J Public Health2006;96:94-101.

    
    

    CrossRefMedlineWeb of Science


18. ↵
    
    
    

    Keck CW, Reed GA. The curious case of Cuba. Am J Public Health2012;102:e13-22.

    
    

    Medline


19. ↵
    
    
    

    Campion EW, Morrissey S. A different model—medical care in Cuba. N Engl J Med2013;368:297-9.

    
    

    CrossRefMedlineWeb of Science


20. ↵
    
    
    

    Barceló A, Díaz O, Norat T, Mateo de Acosta O. [Diabetes mellitus en Cuba (1979-1989), I: variaciones relacionadas con edad y sexo]. Rev Cub Endocrinol1993;4:59-66.

    
    


21. ↵
    
    
    

    Arnold Y, Castelo L, Licea M, Medina I. [Comportamiento de indicadores epidemiológicos de morbilidad por diabetes mellitus en Cuba, 1998-2009]. Rev Peru Epidemiol2012;16:6.

    
    


22. ↵
    
    
    

    Espinosa-Brito A, Viera-Yaniz J, Chavez-Troya O, Nieto-Cabrera R. Death of the teaching autopsy: autopsy is a success story in Cuba. BMJ2004;328:166.

    
    

    FREE Full Text


23. ↵
    
    
    

    National Cancer Institute. Joinpoint regression program. 2012. http://surveillance.cancer.gov/joinpoint/.

    
    


24. ↵
    
    
    

    The Cuba Neuropathy Field Investigation Team. Epidemic optic neuropathy in Cuba—clinical characterization and risk factors. N Engl J Med1995;333:1176-82.

    
    

    CrossRefMedlineWeb of Science


25. ↵
    
    
    

    Orduñez-Garcia PO, Nieto FJ, Espinosa-Brito AD, Caballero B. Cuban epidemic neuropathy, 1991 to 1994: history repeats itself a century after the “amblyopia of the blockade”. Am J Public Health1996;86:738-43.

    
    

    MedlineWeb of Science


26. ↵
    
    
    

    National Institutes of Health. Weight loss does not lower heart disease risk from type 2 diabetes. 2012. www.nih.gov/news/health/oct2012/niddk-19.htm.

    
    


27. ↵
    
    
    

    Simmons RK, Echouffo-Tcheugui JB, Sharp SJ, Sargeant LA, Williams KM, Prevost AT, et al. Screening for type 2 diabetes and population mortality over 10 years (ADDITION-Cambridge): a cluster-randomised controlled trial. Lancet2012;380:1741-8.

    
    

    CrossRefMedlineWeb of Science


28. ↵
    
    
    

    Barton P, Andronis L, Briggs A, McPherson K, Capewell S. Effectiveness and cost effectiveness of cardiovascular disease prevention in whole populations: modelling study. BMJ2011;343:d4044.

    
    

    Abstract/FREE Full Text


29. ↵
    
    
    

    Arnold AM, Newman AB, Cushman M, Ding J, Kritchevsky S. Body weight dynamics and their association with physical function and mortality in older adults: the Cardiovascular Health Study. J Gerontol A Biol Sci Med Sci2010;65:63-70.

    
    

    MedlineWeb of Science


30. ↵
    
    
    

    Rzehak P, Meisinger C, Woelke G, Brasche S, Strube G, Heinrich J. Weight change, weight cycling and mortality in the ERFORT Male Cohort Study. Eur J Epidemiol2007;22:665-73.

    
    

    CrossRefMedlineWeb of Science


31. ↵
    
    
    

    Taing KY, Ardern CI, Kuk JL. Effect of the timing of weight cycling during adulthood on mortality risk in overweight and obese postmenopausal women. Obesity (Silver Spring)2012;20:407-13.

    
    

    CrossRefMedline


32. ↵
    
    
    

    Wannamethee SG, Shaper AG, Walker M. Weight change, weight fluctuation, and mortality. Arch Intern Med2002;162:2575-80.

    
    

    CrossRefMedlineWeb of Science


33. ↵
    
    
    

    Stevens VL, Jacobs EJ, Sun J, Patel AV, McCullough ML, Teras LR, et al. Weight cycling and mortality in a large prospective US study. Am J Epidemiol2012;175:785-92.

    
    

    Abstract/FREE Full Text


34. ↵
    
    
    

    Field AE, Manson JE, Laird N, Williamson DF, Willett WC, Colditz GA. Weight cycling and the risk of developing type 2 diabetes among adult women in the United States. Obes Res2004;12:267-74.

    
    

    MedlineWeb of Science


35. ↵
    
    
    

    Waring ME, Eaton CB, Lasater TM, Lapane KL. Incident diabetes in relation to weight patterns during middle age. Am J Epidemiol2010;171:550-6.

    
    

    Abstract/FREE Full Text


36. ↵
    
    
    

    Houston TK, Person SD, Pletcher MJ, Liu K, Iribarren C, Kiefe CI. Active and passive smoking and development of glucose intolerance among young adults in a prospective cohort: CARDIA study. BMJ2006;332:1064-9.

    
    

    Abstract/FREE Full Text


37. ↵
    
    
    

    Yeh HC, Duncan BB, Schmidt MI, Wang NY, Brancati FL. Smoking, smoking cessation, and risk for type 2 diabetes mellitus: a cohort study. Ann Intern Med2010;152:10-7.

    
    

    Medline


38. ↵
    
    
    

    Vartiainen E, Laatikainen T, Peltonen M, Juolevi A, Mannisto S, Sundvall J, et al. Thirty-five-year trends in cardiovascular risk factors in Finland. Int J Epidemiol2010;39:504-18.

    
    

    Abstract/FREE Full Text


39. ↵
    
    
    

    Borowy I. Degrowth and public health in Cuba: lessons from the past? J Clean Prod2013;38:17-26.

    
    

    CrossRef


40. ↵
    
    
    

    Stuckler D, Meissner C, Fishback P, Basu S, McKee M. Banking crises and mortality during the Great Depression: evidence from US urban populations, 1929-1937. J Epidemiol Community Health2012;66:410-9.

    
    

    Abstract/FREE Full Text


41. ↵
    
    
    

    Cooper RS. Which factors confound or modify the relationship between body weight and mortality? Int J Obes (Lond)2008;32(suppl 3):S47-51.

    
    

    CrossRefMedline


42. ↵
    
    
    

    Colditz GA, Wei EK. Preventability of cancer: the relative contributions of biologic and social and physical environmental determinants of cancer mortality. Annu Rev Public Health2012;33:137-56.

    
    

    CrossRefMedlineWeb of Science


43. ↵
    
    
    

    Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010. JAMA2012;307:483-90.

    
    

    CrossRefMedline


44. ↵
    
    
    

    Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010. JAMA2012;307:491-7.

    
    

    CrossRefMedlineWeb of Science

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

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

.

Eating fish linked to longer life: US study

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

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

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

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

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

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

Perspective   |   1 December 1987

Prophylaxis of Atherosclerosis with Marine Omega-3 Fatty Acids: A Comprehensive Strategy

CLEMENS VON SCHACKY, M. D.

사망 원인 ‘자살이 4위’ 80대~60대 가장 많아 
 
    김소연 기자   
 
출처 : 한겨레신문 기사등록 : 2010-01-11 오후 08:55:06 
http://www.hani.co.kr/arti/society/society_general/398302.html
 
60살 이상 노인들의 자살 비율이 10년 사이에 크게 늘어난 것으로 조사됐다.

한국보건사회연구원은 11일 펴낸 ‘한국인의 사망수준’이라는 제목의 보고서에서, 지난 2008년 자살한 사람을 연령별로 분석해 보니 60살부터 80살 이상 노인이 가장 많았다고 밝혔다. 80살 이상 노인이 인구 10만명당 112.9명으로 자살 비율이 가장 높았고, 70~79살이 72명, 60~69살이 47.2명으로 뒤를 이었다.

증가 속도도 노인층이 빨랐다. 80살 이상 노인의 경우 1998년에는 자살한 사람이 10명만당 50.8명이었으나 2008년에는 112.9명으로 10년 사이 122.2%나 늘었다. 70대는 77.3%, 60대는 40.9%가 늘었다.

노인뿐 아니라 국민 전체 자살자도 많아진 것으로 나타났다. 1998년에는 인구 10만명당 18.4명이 자살해 한국인의 사망원인 가운데 7위였으나, 2008년에는 26명이 자살해 4위로 껑충 뛰었다.

한편 사망원인 가운데 가장 큰 비중을 차지한 것은 암(28%)이었으며, 뇌혈관질환(11.3%), 심장질환(8.7%)이 뒤를 이었다. 특히 암으로 숨진 사람은 인구 10만명당 139.5명으로 10년 전(108.6명)에 견줘 30.9명 늘었다.

김소연 기자 dandy@hani.co.kr

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

참고 : 2008년 사망원인통계 결과

출처 : 통계청 2009-08-30
http://www.nso.go.kr/nso2006/k04___0000/k04b__0000/k04ba_0000/k04ba_0000.html?method=view&board_id=144&seq=85&num=85

태어나기 전에 모체의 자궁 내에서 1918년 인플루엔자 바이러스에 노출된 사람들은 60년 후 심장질환에 약 20% 가량 더 많이 걸렸다는 연구결과가 나왔습니다.

아직까지 태아 상태에서 인플루엔자 바이러스에 노출된 사람이 심장질환에 더 많이 걸렸는지에 대해서는 명확한 원인이 규명되지 않은 상태이며, 연구진들은 산모의 스트레스가 영향을 끼쳤을 것으로 추정하고 있다고 합니다.

Pre-Birth Exposure to 1918 Flu Raised Heart Risks, Study Finds

By Steven Reinberg

THURSDAY, Oct. 1 (HealthDay News)

– People exposed to the deadly 1918 Spanish flu pandemic while still in their mother’s womb were about 20 percent more likely to have heart disease 60 years later, a new study has found.

The flu outbreak in 1918 killed 20 million to 40 million people worldwide, including 500,000 in the United States. That flu, like the current H1N1 swine flu pandemic, began as a mild disease, but it then came back in a much more lethal form. What the current H1N1 flu will do is unknown, but so far its genetics have not changed and there is a vaccine to protect against it, researchers say.

That’s especially good news for pregnant women.

“There are long-term effects of being exposed prenatally to flu,” said lead researcher Caleb Finch, director of the Gerontology Research Institute at the University of Southern California. “There is a danger to the fetus from exposure to maternal flu that has shown up 60 years later from the 1918 influenza epidemic.”

Why exposure to flu in the womb has this effect is not known, Finch said, but he added that it’s “a likely outcome of maternal stress.”

Maternal stress increases a number of developmental problems, including the risk for autism and schizophrenia, Finch said.

Whether these same effects can be traced to other flu strains also is unknown, he said. “Each flu is different, and the 1918 epidemic remains the most virulent,” he said. “Subsequent epidemics have not been as severe. This could have been something unique to that, but we can’t tell. It took 60 years to find this out.”

The findings are reported in the Oct. 1 issue of the Journal of Developmental Origins of Health and Disease.

For the study, Finch’s team collected data on 101,068 people born around the time of the 1918 flu pandemic — specifically, between 1915 and 1923. Information came from national surveys conducted from 1982 to 1996, when most participants were 63 to 78 years old.

The researchers found that men born in early 1919 — meaning their mothers were in their second or third trimester of pregnancy during the height of the epidemic — had a 23 percent increased risk for heart disease at age 60, compared with the general population.

Yet women born in early 1919 were not significantly more likely to develop heart disease, which may have to do with gender differences in the effects of flu exposure, Finch’s group said.

However, women born in the second quarter of 1919 — whose mothers, then, were in the first trimester of pregnancy during the height of the epidemic — were 17 percent more likely to develop heart disease than the general population, the study found.

In addition, among 2.7 million men born between 1915 and 1922, the researchers looked at their height at the time they signed up for service in World War II. They found that the men’s height increased every year, except among men born during the flu pandemic.

Moreover, men who’d been exposed to the 1918 Spanish flu while in the womb were slightly shorter than men born just a year later or a year before. The findings remained significant even after controlling for season-of-birth effects and any malnutrition among the mothers, the study reported.

Dr. Marc Siegel, an associate professor of medicine at the New York University School of Medicine in New York City said that “it is reasonable that, if you had the flu in 1918, it could lead to a maternal disruption that would increase the incidence of long-term medical problems if you’re a fetus.”

The 1918 flu, he said, was particularly deadly, which is not likely to be the case with every flu variation.

“The current H1N1 flu is mild and certainly has less teeth than the 1918 flu, in terms of its virulence,” Siegel said. “You cannot conclude that the 2009 swine flu pandemic is going to lead to heart disease 60 years later.”

But the study is a reminder of just how problematic and tricky flu can be, especially in pregnancy, Siegel said. “Pregnant women should get flu shots, especially the H1N1 shot,” he said.

The U.S. Centers for Disease Control and Prevention agrees that the best protection against the flu is to get vaccinated. This year, that means getting a seasonal flu shot and an H1N1 flu shot when the vaccine is available.

Because pregnant women are at a high risk for complications from the flu, the CDC has put them at the front of both the seasonal and H1N1 vaccine line.

“If you are a woman of reproductive age and likely to be pregnant, be very sure you have gotten vaccinated,” Finch advised.