There are perhaps 3 factors in question 1) lifestyle--fast food, increase in consumption of food away from home, decreased physical activity, occupation 2) agricultural subsidies and 3) growth in agricultural productivity (smaller % of household food budget, global phenomenon).  Studies are not definitive.  Economic simulations have found that removing subsidies for grains and oilseeds would have negligible effects on caloric consumption and eating habits (Rickard B. Health Econ. 22: 316-339 (2013). There are also a number of other plausible contributors--sleep deprivation, pharmaceutical-induced weight gain (see this comprehensive review article).  This is a complex question and is probably multifactorial with the BIG 2 most targeted at this time.  (

More employers are offering high-deductible health plans and more workers are willing to choose lower-priced plans that require them to pay more out of pockets for health care.  This strategy is embraced by public and private exchanges to keep the rising costs of healthcare down (will it?).  Supporters of high-deductible plans claim that people will become smarter health care consumers more aware of health care costs and willing to discuss choices and options with providers.  It may be a good deal for people who are generally healthy, rarely see doctors and could afford ($1000-7000 range deductibles) thousand dollars for medical care when needed.  So what are the down sides?

A study by Galbraith in JGIM showed that the odds of reporting delayed or forgone care due to cost were 3-4 times greater for adults and children with high deductible health plan compared to traditional plan families.  Lower-income families in HDHPs have increased rates of cost-related delayed and forgone care.  According to a recent article by Reed in Health Affairs, 19% of plan members surveyed reported delaying or avoiding a preventive office visit, test, or screening because of cost even though it was exempted from their deductible.  Most health plan members surveyed have low awareness of preventive cost-sharing exemptions. 

Health insurance is supposed to protect members from financial worries, debts, promote healthy lifestyle and prevention practice.  A study published in AJM suggested that about 62% of all bankrupcies in 2007 were medical before the major impact of the housing collapse and recent economic downturn.  We are indeed full of contradictions when it comes to health care policies and practices.  We believe in safety net and we have supported many on Social Security disability programs, but we don't believe in health insurance that is straightforward and well-designed--protect all of us from medical expenses we could not easily afford on our own.  Perhaps our health system is getting too complex (understatement), too many band-aids and too many self-interest groups wanting status quo.  There is an alternative proposal.  To find out more...

According to a recent study by Ho published in Health Affairs this month, a significant gap (2/3 of the difference for males and 2/5 for females) between the US and the mean of the comparison countries in life expectancy at birth is explained by mortality differences below age 50.  The major drivers of differences in life expectancy at birth for males in 2007 were homicide, unintentional injuries, perinatal conditions and NCDs; for females, unintentional injuries, NCDs and perinatal conditions are the main contributors to excess mortality under 50. The author (and my own bias included) alluded to policy implications focusing on younger ages such as: income inequality, urban poverty, residential segregation, gun ownership and availability, public transportation, traffic safety (annual number of km driven in the US exceeds that in the comparison countries), prescription drug monitoring programs (Americans consume more prescription medications than any other populations as well). Along the same theme...

In the Global Burden of Disease 2010 Study, violence as a cause of YLLs (years of life lost due to premature mortality) is 7 per 100,000 in the US (seven times higher than high-income Asia-Pacific, western Europe or Australasia); but in tropical and central Latin America, the rates are substantially higher 30+/100,000.  The huge variation in violence mortality reflects (again) socioeconomic inequalities, political contexts and public health strategies.  There are lessons, policy implications for governments, leaders if they care about these outcomes.  

A study by Kindig and Cheng in the same issue in Health Affairs added to the body of literature on the regional variation in health outcomes in the US. The authors examined trends in male and female mortality rates from 1992-96 to 2002-06 using county-level data from the County Health Rankings, BRFSS, CDC database and US census with a number of covariates including geographic regions, household income, educational levels, single-parent households, children below federal poverty level, smoking, obesity, PCPs, insurance coverage, preventable hospitalizations, etc.

Sure mortality rates are falling in most US counties but a large number of counties (43%) had no reduction in female mortality rates during the study period.  The authors identified a number of factors most strongly asociated with  mortality change including education levels, the region the county was located in (south vs. northeast), and smoking rates.  Higher proportions of Hispanics and adults with a college degree (see my previously blog and our journal club) were associated with reductions in mortality rates.  And remember mortality rates (male or female) were NOT predicted by any of the medical care factors such as rates of primary care providers, preventable hospitalizations or precentage of uninsured.