• Another excuse bites the dust

    Whenever I present data showing that we under-perform other health care systems. or that our health in general is worse than other countries’, someone tries to blame it on our lifestyle. They claim that other countries’ people are healthier when they live over there, but when they move here, they start to eat terribly, etc., and then they get diabetes or some other disease. In other words, it’s not the health care system’s fault – it’s the fault of our lifestyles.

    Here’s Health Affairs, “Undiagnosed Disease, Especially Diabetes, Casts Doubt On Some Of Reported Health ‘Advantage’ Of Recent Mexican Immigrants“:

    Newly arrived Mexican immigrants in the United States generally report better health than do native-born Americans, but this health advantage erodes over time. At issue is whether the advantage is illusory—a product of disease that goes undiagnosed in Mexico but is discovered after immigration. Using results from the National Health and Nutrition Examination Survey, we compared clinical to self-reported diagnosed disease prevalence and found that Mexican immigrants are not as healthy as previously thought when undiagnosed disease is taken into account, particularly with respect to diabetes. About half of recent immigrants with diabetes were unaware that they had the disease—an undiagnosed prevalence that was 2.3 times higher than that among Mexican Americans with similar characteristics. Diagnosed prevalence was 47 percent lower among recent Mexican immigrants than among native-born Americans for both diabetes and hypertension, but undiagnosed disease explained one-third of this recent immigrant advantage for diabetes and one-fifth for hypertension. The remaining health advantage might be explained in part by immigrant selectivity—the notion that healthier people might be more likely to come to the United States. Lack of disease awareness is clearly a serious problem among recent Mexican immigrants. Since undiagnosed disease can have adverse health consequences, medical practice should emphasize disease detection among new arrivals as part of routine visits. Although we found little evidence that health insurance plays much of a role in preventing these diseases, we did find that having health insurance was an important factor in promoting awareness of both hypertension and diabetes.

    I have heard on any number of occasions the argument that newly arrived Mexican immigrants are healthier than their American-born counterparts. This study basically showed that this was largely in part due to undiagnosed, not an absence of, disease. Half of the immigrants who had diabetes just didn’t know they had it.

    So it’s not just that the people moving here were healthier before they got here. Living in the US doesn’t give all of them diabetes. Let’s put this one to bed.

    *I’m going to add (in response to some twitter critique), that I’m not claiming that we don’t have an unhealthy lifestyle. Nor am I claiming that getting obese doesn’t increase your chance of getting diabetes. I’m claiming that the pat answer of saying that people are healthier in other countries and sicker here and that completely drives our bad outcomes is a bad argument.

    @aaronecarroll

    UPDATE: Crossed out a bad line! Added a sentence!

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    • Aaron — I think maybe you’re misreading it a bit? You say “Half of the immigrants who had diabetes just didn’t know they had it.” But the abstract you quote says this:

      “Diagnosed prevalence was 47 percent lower among recent Mexican immigrants than among native-born Americans for both diabetes and hypertension, but undiagnosed disease explained one-third of this recent immigrant advantage for diabetes and one-fifth for hypertension.”

      That’s a bit different from “half didn’t know they had diabetes.” Instead it’s only half as many are diagnosed, and of *that* difference (the one half), 1/3 of the diabetes difference is explained by under diagnosis, and 1/5 of the hypertension difference is explained by under diagnosis. Right?

      If that’s the case, then 2/3 of the difference for diabetes and 4/5 of the difference for hypertension — ie, the majority of the difference — is still unaccounted for. The authors speculate that maybe that’s due to the healthy immigrant effect, but that’s different from showing definitively that lifestyle isn’t driving at least a big chunk of the effect.

    • Or as they say in the DIscussion section: “Our diabetes and hypertension analyses suggest that the primary “healthy immigrant” patterns for Mexican immigrants still remain when we use a more comprehensive measure of diabetes and hypertension prevalence, taking into account high levels of undiagnosed disease among
      Mexican immigrants.” (The magnitude just gets smaller.)
      They also note that the remaining effect “might be explained by changing immigrant selectivity across cohorts or immigrant assimilation to the American lifestyle.”

      So a better title for this might be “Another excuse is undercut somewhat”…

      • Here I’ll disagree with you. There are lots of reasons for differences, and the one people often “want” to believe keeps getting smaller and smaller. This study removed a decent amount of that argument.

    • But wouldn’t the fact that the US diagnoses more disease go into the column of reasons US healthcare is better?

      P.S. Pete Dominick’s show is horrible and even worse when you’re on it.

    • So I think Aaron’s overall point in re health systems is much stronger than this particular example. Mexico is almost the only country in the world which is in the same league as America in terms of obesity and many American bad habits (eg massive reliance on big box stores selling processed foods (Walmart is its largest retailer)) are well established there. Also, I am familiar with America’s health system being compared to Europe or Asia in these rankings but where do we stand against Mexico? Are we better? Worse? Would have been helpful to know in the post as I am sure Aaron does…

    • I am having a very hard time understanding this post. Are you saying Mexico’s health care system outperforms our own? That’s absurd.

      • Huh? Where did I say that?

        I think it’s quite clear. Much of the reason recent immigrants seem to have less diabetes than their already arrived counterparts is because they haven’t been diagnosed yet. The idea that they were healthier in Mexico and then got diabetes because they live here is not as true as many think.

        That is all.

    • I have always assumed that this was true. The interesting thing to me is despite having a higher rate of diabetes and obesity and having less access to health care Hispanic have greater life expectancy than non-Hispanic whites. This makes it look like genetic differences are important but it also undermines the idea that medical care is a big effect.

      BTW reading more and more on the subject makes me think that obesity (but perhaps not very extreme obesity) has little negative effect on health but that unhealthy people are more likely to get obese.

      • This is a little of topic but:

        It might be prejudice that makes us assume that causation runs from obesity to bad heath.
        After all it is not hard to make a case that that genetics could cause low energy, low metabolism and or low muscle and could lead to obesity and bad health. Yet few studies seem to look in that direction.

        • Floccia, this is an excellent point that I don’t think gets enough discussion. There is evidence that a number of the causes of obesity are genetic and behavioral factors that also lead to poor health independent of obesity itself.

          1. Low desire to exercise. We know lack of exerise causes lower metabolism (other things equal), which causes more weight gain for a given caloric input. And we know lack of exercise at any weight level is bad for health.
          2. Poor nutrition. Junk food tends to have a lot of calories, but research indicates that it is the type of calories (few nutrients, simple carbs, saturated fat, etc.) more than the number that is the big problem.
          3. Depression. Being depressed is associated with eating more, eating worse (comfort/junk food), exercising less, higher stress, etc.
          4. Metabolism dysfunctions can be a cause of both obesity and bad health.
          5. Genetic conditions like predisposition to high cholesterol on diets with high fats and refined sugars amplify the association between being overweight and being in poor health. To use my own case, I can’t control my cholesterol without drugs unless I exercise a lot and have a very virtuous diet. Higher weight is a symptom I’m not doing those things, and thus have high cholesterol, but it is not a cause.

          I know there has been research on this, but the big picture that seems to be dawning has not been at all well conveyed. Obesity is a *symptom* of bad health more than it is a *cause*, with the possible exception of morbid obesity.

    • We spend more because we pay higher prices. Period. Now, all together, heads down, eyes closed. Shhh.

    • I had thought the argument along these lines is not that we are less healthy but rather that we jump out of more airplanes, ride more “donor-cycles”, try to rescue more premature babies, is that right?

    • The infant mortality rate is 5.4 in the UK and 7.0 in the US, according to Wikipedia. You can argue the numbers, but not the fact that the US does poorly compared to most of the developed world.

      Here’s a picture:

      In the US, a newborn’s first post-hospital discharge visit to a doctor is five days after birth. In the UK, someone from the NHS — a nurse — will come to your house within 24 hours of the mother’s coming home with the baby. I gave birth in a private hospital in London and they made sure a local NHS practice in Surrey, where I lived, took responsibility for further care. A newly arrived foreigner who didn’t know the system was automatically referred, not merely advised to find a family doctor.

      Nurses or health visitors visited my home several times in the first few weeks to check on the baby’s soft spot, to weigh him — to ensure he was thriving.

      In the US, the standard is that the first new baby visit after hospital discharge is 5 days. With my first child, in the States, I had trouble feeding her and she has lost more weight than was desirable by that first visit. In the UK, any feeding problems would have been caught and fixed earlier.

      Is it any surprise that the UK has a lower infant mortality rate than the US?

      • Infant mortality rates are higher in the USA because of PRE-BIRTH factors, not post-birth. The US has a shoddy prenatal care system where many poor/minority women go months not seeing an ob/gyn doc and they never get any prenatal care. That simply does not happen in Euro countries.

        Post-birth factors dont account for any kind of significant difference between US and European infant mortality. Our post-hospital discharge care and NICUs are just as good as theirs.

    • My (nonexpert) understanding is that the US already has examples of health care systems that approximate the cost per person and quality of of outcome measures achieved by other advanced countries. The best example is probably the VA. Possibly also the Mayo Clinic model? A few years ago, Atul Gawande wrote an article in the New Yorker describing a study that compared two demographically comparable counties in Texas that differed enormously in their medical costs, and that came to the conclusion that the only factor that could account for the cost difference was the difference in the system of reimbursement. This would seem to argue that the higher cost of the US system (excluding these exceptions) can’t be attributed to a difference in lifestyle. (Presumably veterans don’t have a dramatically healthier lifestyle than everyone else. Although one component of the VA success might be that the veterans do have a more intelligent use of their health care system, perhaps with a greater emphasis on preventive care, continuity of provider, etc. Possibly one might even consider the possibility that such properties of the medical system indirectly lead to an improvement in lifestyle. But such effects should probably be categorized as a difference in the medical system, not a difference in lifestyle of the population).

    • But Mexico is the one country that is comparable to the US in terms of obesity levels. How does this analysis look for immigrants from other countries?