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: https://doi.org/10.1136/bmj.f1515 (Published 09 April 2013) Cite this as: BMJ 2013;346:f1515
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Excellent article which highlights the consequences of unwanted weight loss. Weight regain is a significant issue in any weight management service. We do come across weight regain after rapid weight loss more so after a Very Low Calorie Diet(VLCD). Weight regain can be prevented if efforts at reducing calorie consumption are accompanied by changes in habit.
At a population level significant weight loss in a population is encountered due to changes in poitics or ideology as seen in this study in Cuba and in Norway during the world war. Weight loss is usually followed by weight regain in these situations. This can be avoided by health care professionals taking proactive measures along with politicians when there is return to normalcy.
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It is widely quoted that Hippocrates had long stated that "If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health". The natural experiment in Cuba once again adds to the growing evidence.
However, the independent contributions of food restriction and increasing physical activity needs to be clarified. Almost 80% Indians adults have a BMI less than 20 and yet diabetes has descended down on India like a modern plague. One major change that has happened in India is that auto-two wheelers like motor cycle, scooter and mopeds have replaced the physical activity of Indians across all ages (from school children to retired persons)in urban and rural settings.
Physical activity does several things in addition to burning calories. Exercise speeds up the circulation and enhance the elimination of exogenous and endogenous toxins and release a host of chemicals. This is supported by the fact that, two well controlled experiments in monkeys could not produce concordant results.1,2 These suggest that there is fair amount of confounding between calorie intake and physical activity.
References
1.Mattison JA, Roth GS, Beasley TM, et al. Impact of caloric restriction on health and survival in rhesus monkeys from the NIA study. Nature 2012;489:318–321
2.Colman RJ, Anderson RM, Johnson SC, et al. Caloric Restriction Delays Disease Onset and Mortality in Rhesus Monkeys. Science 2009;325:201-204.
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Franco and colleagues’ results [1] are unique because no researchers have previously analyzed the impact on health of a famine,[2] forced work and walk in a nation devolving maintaining wrong domestic policies, exceeding the Soviet gulags and Nazi camps’ trials. Cuba’s warm weather prevented hundreds of thousands deaths seen in North Korea by identical causes.[3]
Since 1933 it is known that a diet low in fat in experimental animals produces atherosclerosis regression.[4] In 1946 old Jewish imprisoned in Nazi camps that died ending the II World War, shown arteries clean of atherosclerotic plaques in the autopsies,[5] being their survival rations scarce whale meat. On this basis, in Cuba, a slight fall in some atherosclerotic events in 1990-5 could be accepted, but it is not clear the apparent “diabetes mellitus rates improvements”,[1] when Cubans’ survival rations were reduced basically to scarce sugar cane and white rice.[6]
My parents’ diabetes became unstable and complicated. My mother had untreated anxiety, hypertension, and stroke by the GP. My father died in a hospital of mistreated cardiac failure and B viral hepatitis --by blood transfusion. My brother and I increased our blood glucose levels and risk of diabetes debut. We all lost between 20-30 kg. Daily I cycled between 8-12 km.
At Havana smoking and all kinds of liquors intake increased, alleviating people’s desperation; urban agriculture output was practically insignificant; CAM did not substituted antibiotics; and worst quality Chinese bicycles without spare parts quickly disappeared. This famine declined slowly when free agro-markets were reopened for people with enough money to buy in them.
The authors analyzed a re-worsening of diabetes figures (which in my view never improved),[6] through regain of weight due to slow recovery in living conditions after 1995, unconsciously of the constant worsening of all living and health conditions in 1959-2010.[7] Most statistics of Cuba’s community-based health care and surveillance are manipulated politically. [8] I was GP and health manager of four Tunas’s rural areas in 1972-74, and worked in my biostatistics residence in the MINSAP National Statistics Branch in 1975-77, and observed anomalies.
I heard Milton Terris (JHSH) discussing MINSAP’s inefficiency in 1987. I saw it growing to a peak, while exported half of doctors and medicines for Venezuela and other nations’ political campaigns, and weakened medical education in policlinics with poor-quality care standards.
In the 1980s Nicholas Eberstad (Harvard) found secret ‘health crisis in the USSR, Cuba and North Korea’, mining data contradictions in diverse official sources.[9] With firsthand knowledge in 1969-2010 of Cuba’s registries, I have detected that the manipulation of data at all MINSAP and government levels increased since the 1990s, omitting the abrupt overall health and other living standards catastrophe, facts, and figures,[7,8] and magnifying the predicted “blessed impact in two chronic diseases” in 1990 of this trial, as if Cubans were animal models.
Usually, Cuba’s life expectancy, infantile, malnutrition, dengue, cholera, other epidemics, and chronic diseases figures in 1959-2010 have been manipulated, without in depth independent verification.[7,8,10,11] I have studied primary data and reports of health, other living standards, consumed products and services in Cuba from municipalities to the national level, as well as PAHO and UNICEF reports in 1969-2010. I have found that annual ratios dividing maternal between infant mortalities (ratios/rates) in Cuba 1980-2010 have increased to ‘ten’, the highest in 193 countries showing ratios around ‘three’.[7-8] Similar inconsistencies happened among education indexes, GDP per-capita, and other figures.[6,7] It is crucial for the 54-year rulers to give an appearance of Cuba’s top non-income human development indexes in UNDP reports (highest health and education, excluding lowest income growth),[12] to send a subliminal message that the “so successful and human Cuban revolution” should be extended worldwide.
The sad reality is that in Cuba the sick people can see a physician, but cannot be well diagnosed and treated due to prioritization of funds for domestic oppression and foreign subversion; while the elite and foreigners enjoy a world-class healthcare. Due to information manipulation and repression at all community, education and working centers, most people in Cuba have suffered in 1959-2012 a certain degree of acquired chronic mental and social retardation, more or less terrified and quasi-psychotic with robotic behavior. These entities disable the persons to discriminate between truth and fiction, moral and immoral, and effectively rebel against oppression. These entities have not been included in the WHO-ICD yet, even when the mental and social elements of the integral WHO health definition allow to classify them.[7-8]
References:
1. Franco M, Bilal U, Orduñez P, Benet M, Morejón A, Caballero B, and cols. 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:f1515.
2. Sen A. Development as Freedom. 1st ed. New York: Random House Inc., 1999.
3. Haggard S, Noland M. Famine in North Korea. Markets, Aid and Reform. 1st ed. New York: Columbia University Press, 2007.
4. Anitschkow N. “Experimental atherosclerosis in animals.” In: Cowdry E, ed. Arterioesclerosis: a survey of the problem. New York: McMillan, 1933:271-322.
5. Loscalzo J. Regression of coronary atherosclerosis. [editorial]. N Engl J Med 1990;323: 1337 -9.
6. Author’s name withheld. Health consequences of Cuba’s Special Period. CMAJ July 29 2008;179(3):257. http://www.cmaj.ca/cgi/content/full/179/3/257
7. Stusser RJ. Access to health, freedoms and other standards of living development in Cuba. Proc Cuba in Trans ASCE Conf 2012;22. http://www.ascecuba.org/publications/proceedings/volume22/pdfs/stusser.pdf
8. Stusser RJ. Demystifying the Cuban health system: Insider´s view. Cuba in Transition 2012;21. http://www.ascecuba.org/publications/proceedings/volume21/pdfs/stusser.pdf
9. Eberstadt N. The Poverty of Communism. New Brunswick: Transaction Books, 1988.
10. Anon. Correspondence. Cuba's delayed transition needs. Lancet 2006 368(9544):1323. (Oct 14) http://www.thelancet.com/journals/lancet/article/PIIS0140673606695445/fu...
11. Mendoza-Rivero D, Fuentes I. [Dengue! The Secret Epidemic of Fidel Castro]. Miami, FL: Rodes Printing, 2001.
12. United Nations Development Program. Human Development Reports 1990-2011. http://hdr.undp.org
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Bruce Keogh is right to identify the provenance of poor quality healthcare as the shop floor. It is salutary to learn that a substantial body of doctors appear to have failed to recognise the perils, or lacked the necessary sense of professional accountability, to confront a management that prioritised process and targets to the detriment of health outcomes.
When I trod wards in the seventies, a medical firm comprised two housemen, perhaps an SHO, a registrar and one or more consultants. Junior doctors were on call every other night, ensuring they knew their patients, they rapidly acquired the necessary skills and experience, and that the consultant was involved at a strategic medical management level as necessary. It was tiring and sometimes scary, but it ensured almost continuous informed medical accountability wherever and whenever needed.
Contemporary secondary care is more sophisticated, and tired doctors cannot perform optimally, but doctors must abjure the imposition of systems that preclude the robust exercise of medical accountability in day to day patient care in acute settings. Happily the revalidation process, with its relentless focus on the obligations doctors have towards patient care, should empower doctors to influence hospitals priorities.
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I read with thie research with interest. It shows a a linear correlation between weight loss and diabetes/cardiovascular events. The picture from the Third World says that weight loss due to a natural calamity or political crisis leads to significant starvation among people of that nation, and a subsequent decrese in the incidence of diabetes and cardiovascular events.
Another side of the coin says that weigt loss results in a decrease in body immunity, and an increase in the incidence of diseases like tuberculosis. Dibetetes is common among tuberculosis patients. Weight loss related to undernutrition leads to a deficiency in essential vitamins , which can play a significant role in a cardiovascular event.
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WEIGHT is by far the most important indicator of health, because if you control it, you can prevent many other health problems : cholesterol, hypertension, osteoarthritis, gallstones, diabetes, hypertension, etc
If you control weight you target the CAUSE (root) of a tree with many branches. If you control cholesterol or hypertension you only target a problem (branch or ramification) among many others.
Do not make only clinical analysis (checkups), but rather state with your physician an optimal weight threshold for you and maintain it along your life.
This is my conclusion after more 30 years of clinical experience in Africa and Europe
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This research paper only reaffirms the already well-established fact that weight loss reduces burden of non-communicable diseases. But, what about the malnutrition and burden of infectious diseases in malnourished population. The best approach is exercise/ physical activities and consumption of healthy diets instead of just starving.
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If anyone needs any further convincing on relationship on food intake, obesity and diabetes, this is it
I have no doubt that those obese diabetics who claimed they are doing their best not 'eating much' could do more.
Starvation voluntarily by surgical means, or involuntarily by food crisis, is an effective mean to lose weight.
A note for the authors: would you think the increase in cancer mortality is due to poor nutrition in food crisis exacerbating the effect of cancer and related treatment on the body?
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Re: 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
This article essentially concludes that population-wide weight loss was associated with better health and lower mortality, and population-wide weight gain was associated with the opposite. These "benefits" occurred in the setting of a severe economic crises resulting in weight loss and forced increased physical activity in the Cuban population during the study period.
I found this study to be, not only insulting to my intelligence, but morally repugnant. In 2013 physicians don't need a study to conclude that weight loss and increased physical activity are beneficial. But to arrive at this conclusion by studying a period of immense human suffering is reprehensible. Why don't these authors also conduct a retrospective study of the incidence of diabetes and cardiovascular disease on prisoners before and after internment in the Nazi concentration camps of WW II. Maybe they'll discover a health benefit of weight loss and increased physical activity there too! These authors didn't include mortality from suicides during this economic hardship nor deaths that resulted from those trying to flee the island.
So called researchers have the luxury of studying isolated benefits but we as physicians avoid this myopia by looking at the complete individual or the suffering of the population as a whole. I think physicians everywhere, but especially Cuban and Cuban-American doctors, should be outraged by this trash masquerading as a study in a previously respected medical journal. We should demand a retraction of this article and an apology from the BMJ for publishing this disgraceful rubbish.
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