Weight loss and regain in relation to diabetes and cardiovascular disease mortality: Cuba 1980-2010

Cardiovascular Disease and Diabetes are currently
two of the most important diseases worldwide But population science has given us the tools
to combat these epidemics – with control of the major risk factors for both diseases – Unhealthy
Diet, Physical Inactivity, and its Overweight/Obesity – we can greatly reduce the disease burden. Therefore it is critical that we put into
action strategies to prevent and control Cardiovascular Disease and Diabetes on a global scale. The population prevention strategy described
by Geoffrey Rose seeks to affect the underlying causes that make these conditions common. The population approach to preventing Cardiovascular
Disease and Diabetes requires a shift of the whole distribution of physical activity and
diet in the favorable direction. Our hypothesis is that changes in the Whole
Cuban Population in terms of Physical Activity, Dietary Energy Intake, and Body weight led
directly to changes in Cardiovascular Disease and Diabetes for the period of 1980 through
2010. In order to test this hypothesis, we examined
public health trends during an unusual historical period in Cuba. This analysis is unique for
the following reasons: First, Cuba has a homogeneous population of
around 11 million people with minor health differences in terms of race, income and education
levels Second, The Cuban Population has undergone
large economic changes in the last three decades After the loss of the Soviet Union as a trading
partner in 1989, Cuba entered the economic crisis known as the Special Period that worsened
continuously over the next 5 years. Sustained shortages in the food-rationing
system led to reductions in per capita daily energy intake. In response, Cuba implemented
several new “green” policies, like commercial neighborhood gardens and use of draft animals
in agriculture. The lack of public transportation resulted
in increased energy expenditure from active forms of transportation as walking and cycling. The Cuban government imported 1,5 million
bicycles from China at that point and produced another half million. Complete economic recovery did not occur until
the year 2000. Since then, economic growth has occurred until now. The final reason to conduct this study in
Cuba is the amount of high quality health research data that we could analyze. In collaboration with Cuban researchers at
the University of Cienfuegos we analyzed cardiovascular health data for over 20 years within the CARMEN
initiative. At the same time, primary Care Chronic Disease
Registries offered extremely valuable data on the burden of Diabetes for the 3 decades
of the study. Finally, mortality data are publicly available
in the Ministry of Public Health website. During the worst years of the economic crisis,
dietary energy intake fell slowly and consistently at the same time that physical activity due
to walking and bicycling increased. Consequently obesity prevalence that was already
low (around 12%) in the soviet era reached a nadir of 7% in 1995 and rebounded promptly
to reach 19.7% in 2010. Focusing on the changes in the distribution
of body weight in the city of Cienfuegos overtime, we can observe a whole population bodyweight
loss of an average of 5 kg from pre crisis year 1991 until 1995 pick of the crisis. From 1995 on we can follow a whole population
weight regain phase through the years 2001 and 2010. These Population-wide Weight Loss and Regain
overtime follows perfectly Geoffrey Rose’s idea of shifting the whole distribution of
chronic diseases risk factors. Coronary heart disease mortality that had
declined sharply after the years of obesity reductions halted its decline as obesity prevalence
continued increasing. Finally, the burden of diabetes has been widely
affected by these bodyweight changes. Diabetes prevalence increased hand in hand
with obesity Diabetes incidence shows a decline and increase
following obesity patterns And finally Diabetes mortality that had decreased
dramatically after the crisis rebounded in the weight gain period. So what is the Relevance of these results
for clinicians? We should not disregard that population approach
in the efforts of chronic disease prevention and individual behavior change recommendations
and programs in the clinical setting are complementary. Following the results of our research two
burning questions arose: What can we learn from our study in order
to prevent cardiovascular disease and diabetes in countries like the UK, the US or Spain
where more than half of their adults are overweight or obese? One important lesson is that transportation
policies are fundamental. Therefore, we should encourage walking and bicycling as means of
transportation. These results also highlighted the need for
Physical Activity and Diet changes to happen at the same time and affecting the whole population. The next question would be: Can we compare
the circumstances of the Special Period in Cuba with the current economic crisis in many
European countries in terms of its population health consequences? This comparison is problematic since all segments
of the Cuban population live under very similar social and economic conditions. Populations of European countries are very
heterogeneous in regard to the levels of physical activity and diet of the different population
strata. No clear shift of the whole distribution of cardiovascular risk factor as Physical
Activity, Diet or Bodyweight is currently occurring. The authors we would like to highlight the
fruitfulness of international scientific collaboration. Researchers in Cuba, Spain and the US in our
team have worked together for the last 20 years in public health and medicine research. This is more than a story about statistics;
it is also a story about people. In conclusion, therefore, 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 in the world

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