obese women as statue
Non Recipes, Nutrition

The shocking truth about public health in Germany and North America

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Every year the Bloomberg Global Health Index ranks the countries of this world in regard to the health of the overall population. There are several factors that make up the final score of a country, for example:

  • Health risks (eg. smoking, obesity, high blood pressure)
  • Availability of clean water
  • Life expectancy
  • Malnutrition
  • Causes of death

Every ranked country gets a score between 0 to 100 with 100 being the top score. It is no surprise that industrialized countries always score better than developing countries. People in industrialized countries have better access to healthcare, clean water, and the air is a lot less polluted.

But what is actually very shocking about this ranking are the scores of Germany and the US. According to the 2019 Human Development Index Ranking, Germany shares 4th place with Hong Kong as one of the most developed countries in the world. The only countries outscoring Germany are Norway, Switzerland, and Ireland. The US shares 15th place with the UK.

Now, you might expect that Germany as a highly developed country might also be a leader among the world’s healthiest nations. But that is not the case. In the 2019 Bloomberg Global Health Index, Germany is on place 23 with a horrifying score of just 83.06 points. It’s devastating if you keep in mind the fact that two years earlier, in 2017, Germany was at least in position 16.

obese women walking the street
Two-thirds of men and half of the women in Germany are overweight or obese.

The US has an even lower score that’s borderline embarrassing in relation to its wealth. The US scores a mere 73.02 points and is currently in place 35.

According to the Bloomberg ranking, Spain is considered to have the healthiest people with a score of 92.75 points. The top five is completed by Italy, Iceland, Japan, and Switzerland.

One of the main reasons why Germany and America score so horribly on these charts is the diet of the population. People in our societies eat themselves to death.

People pay a high toll for their unhealthy lifestyles

Nowadays, more people in this world die because of an unhealthy diet than because of smoking. In 2017, 11 million deaths were attributable to an unhealthy diet. Adding to that, 255 million disability-adjusted life years are caused by an improper diet. The disability-adjusted live years are the number of years lost in a life span due to ill-health, disability, or early death.

https://upload.wikimedia.org/wikipedia/commons/thumb/1/19/DALY_disability_affected_life_year_infographic.svg/1024px-DALY_disability_affected_life_year_infographic.svg.png
Definition of Disability-adjusted life years. Source: !Original: PlanemadVector: Radio89 / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)

The main dietary risk factors that cause millions of deaths and disability-adjusted live years (DALYs) are:

  • High intake of sodium (3 million deaths and 70 million DALYs)
  • Low intake of whole grains (3 million deaths and 82 million DALYs)
  • Low intake of fruits (2 million deaths and 65 million DALYs)

A lot of diet-related diseases start to appear above the age of 60 in elderly people. Our life expectancy is increasing worldwide but despite that our health at older ages did not improve. We get older but often don’t have any benefits from it.

Modern medicine keeps us alive but it can’t stop or prevent us from developing age-related diseases. We need to act before it is too late which is unfortunately what a lot of people in our society don’t realize.

Let’s take a look at Finland. Finland is one of the few role models in Europe regarding public health. In the year 1969, Finland had the highest mortality rate of coronary heart disease worldwide. Almost 500 per 100 000 people aged 35-64 years died because of coronary heart disease. In the year 2002, the rate was down to a bit more than 100 per 100 000 people. An incredible decrease by 75 %.

Ambulance in Houston
Every few seconds, a person in this world dies as a result of cardiovascular disease caused by an unhealthy diet.

But how did Finland achieve that? They didn’t invest more money in the development of new drugs. What the government did was very simple. It changed its food recommendations and drastically reduced the salt in processed foods.

In the EU, the cost of treating and managing coronary heart disease events, like for example strokes, was over 265 billion euros per year. The cost of coronary heart disease treatments in Germany is horrendous. Nearly 80 million euros are spent every year for a disease that can be easily prevented. Country number two on the list is Poland with a cost of 30 million euros. That’s less than half of Germany. Even more impressive is Finland. It’s down to a mere 2.6 million euros yearly in healthcare costs for coronary heart disease.

Overconsumption of salt is a worldwide problem

It always bothers me when people on the internet claim salt and monosodium glutamate (msg) as completely harmless substances. We need salt from our diet and it doesn’t make any sense to cook completely salt-free unless you have some rare disease. I salt all my dishes. But what is very apparent is that worldwide salt consumption is too high.

The WHO estimates that 2.5 million deaths could be prevented each year if the global salt consumption would be reduced to the recommended level of about 5 grams or less a day. In many countries, about 80 % of the salt in the diet comes from processed foods. Nevertheless, the German government doesn’t act. There is no limit on how much salt is allowed to be added to food in industry products or restaurant dishes.

salt crystal in a bowl
People in this world consume excess amounts of sodium.

A lot of people claim that food with less salt is not tasty. But that is not true. The salt preference of a person is determined by his or her regular diet. If we often eat very salty food we get accustomed to it and our palate changes. It will then take our palate some time to adjust to lower sodium levels if we reduce our salt intake. However, that doesn’t mean that food lower in salt generally tastes bland. That’s just a subjective impression.

But why is the overconsumption of salt unhealthy? The problem with excess sodium intake is that our kidneys have trouble to excrete excess sodium accumulated in the blood. Our body holds onto water to dilute the sodium. This increases the volume of blood in the bloodstream which means more work for our heart and more pressure in our blood vessels. Over time, this will stiffen blood vessels which leads to high blood pressure, heart attack, and stroke. This is also why you feel thirsty after eating salty food. Your body needs the water to dilute the sodium.

If we take a look at worldwide sodium consumption levels, we can see that Asian countries are the leaders in worldwide sodium consumption. People in Kazakhstan consume on average 5.98 milligrams of sodium each day which equals about 14.95 grams of salt a day. That’s three times as much as the recommendation of the WHO.

Salt intake world map
Worldwide daily sodium and salt consumption levels. Source: Harvard Public Health Magazine

A few reasons why Asian countries have such high sodium consumption levels are:

  • They eat lots of preserved foods due to lack of refrigeration/ hotter climate.
  • They use large amounts of table salt and monosodium glutamate (msg) for seasoning.
  • They eat out a lot.

So, it doesn’t surprise that the top salt consumers of Kazakhstan have the highest age-standardized death rates per 100 000 people for stroke and coronary heart disease.

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Age-standardized death rates per 100,000 for stroke (the left panel) and coronary heart disease (the right panel) across countries of different regions of Asia in 2002. Source: Cardiovascular Disease and Risk Factors in Asia: A Selected Review

The fruit and vegetable intake in the Western diet is too low

Let’s move away from salt and look at another common reason for diet-related diseases which is the low consumption of fruits. Only 64 % of the European population consumes fruit on a daily basis. Germany and the Eastern European countries, which score lower on the Bloomberg Health Index, are below the EU average in fruit consumption whereas the healthiest nations of the EU like Italy and Spain report higher daily consumption of fruit.

https://ec.europa.eu/eurostat/documents/4187653/9699107/Fruit+consumption+2017
Daily Consumption of fruit in Europe. Source: Eurostat

If we look at the daily vegetable consumption in Europe, it gets even more depressing. In Germany, only 54 % of the population consume vegetables at least once a day. This sets us far apart from our French neighbors where 71 % of the population eats vegetables at least once a day. The biggest vegetable consumers in Europe are Ireland and Belgium where 84 % of the population eats vegetables at least once a day.

Ranked bar chart of vegetable consumption in 2017
Daily Consumption of vegetables in Europe. Source: Eurostat

Germans consume too little whole grains despite their bread culture

Even though Germany has a huge bread culture with tons of variety when it comes to whole grain bread, 52 per 100 000 people die because of a diet low in whole grains. Germans often like to complain to French or Spanish people that they only eat white bread. But these countries have a mortality of 32 (France) and 52 (Italy) per 100 000 people. Germans really shouldn’t judge other countries on their bread culture.

Mortality rate per 100 000 in Europe due to a diet low in whole grains. Source: EU Science Hub

Besides that, the myth that Germans are large consumers of wholegrain bread is a fairytale. What most people nowadays consider to be wholegrain bread is in reality white bread that has been colored with for example caramel color. Only 10 % of the bread sold in Germany is whole grain bread whereas toast has a market share of 20 %. Yes, Germans like to pride themselves on their sophisticated whole-grain bread culture while in reality, it’s much more likely that they eat a slice of toast for breakfast or dinner.

Die liebsten Brotsorten der Deutschen: Mischbrot und Toastbrot machen die Hälfte aller angebotenen Brotsorten aus. (Quelle: statista.com)
Market share of different types of bread in Germany. Source: T-Online

The major consumers of whole grains in this world live in Sub-Saharan Africa and Southeast Asia as can be seen in the figure below.

What's the world eating?
Dietary intake of major foods across the world. Source: Whole Grains Council

Vegetables, fruits, and whole grains are the key to a healthy diet

But why is it so important that we consume an adequate amount of fruits, vegetables, and whole grains each day? It’s because these foods are packed with micronutrients.

You might’ve heard of the term “hidden hunger” before. It refers to a lack of vitamins and minerals which is not immediately apparent and which can exist for a long time before clinical signs of malnutrition become obvious.

A lot of people in the developed world assume that they enjoy a nutritionally sound diet. However, this is not reality. While it is true that micronutrient deficiencies are much less common in the developed world than in the developing world they still exist.

It is not uncommon for Western people to be deficient in folic acid, Vitamin D, Vitamin E, iron, and iodine. You won’t notice a deficiency immediately but over the long term, it can lead to a wide number of health problems like impaired cognitive development, lower resistance to disease, and complications during childbirth for pregnant women.

Western people usually have the biggest issues with inadequate folic acid intake and low levels of Vitamin D. Leafy green vegetables and citrus fruits contain plenty of folic acid but whole grains like brown rice, cereals, or whole-grain bread are also rich in folic acid.

Fresh apricots
Apricots are one of the healthiest and tastiest fruits in this world.

Vitamin D is a special case because it is formed on our skin through sun exposure. The reason for a deficiency among Western people is simple. We sit in closed rooms and don’t see the sun enough anymore.

If you can’t go out regularly in the afternoon to enjoy the sun it does make sense to supplement Vitamin D. Especially for people older than 65 years, an optimum Vitamin D supply is of utmost importance. An optimum Vitamin D level is associated with a higher bone density. This reduces the risk of falls and fractures for older people. In Finland, the problem of Vitamin D deficiency was solved by mandatory fortification of milk and spreads with Vitamin D.

What do the healthiest countries do right?

After all this bad news, let’s take a look at what we can learn from the healthiest communities on this planet. Places like Sardinia, Italy, which has the world’s highest concentration of male centenarians. Or Ikaria, Greece, which has one of the world’s lowest rates of dementia. But also Okinawa, Japan, where the world’s oldest women live. California has such a community as well, Loma Linda, where people live on average 10 years longer than other North Americans.

The diets of all these places are remarkably similar. They all feature a high intake of:

  • Fish, which is an important supplier of omega-3 fatty acids.
  • Fruits, which are rich in antioxidants, fibers, vitamins, and carotenoids.
  • Vegetables, which are rich in vitamins, minerals, and fibers.

So, there you have it. Nothing new or surprising. That’s stuff everyone knows. Just take a look at the Harvard Medical School Healthy Eating Plate:

Healthy Eating Plate
Healthy Eating Plate. Source: Harvard Medical School

It’s a wonder why people still fall for all the fad-diets which can have severe negative side-effects in the long-term when the solution is so simple. It’s all for free on the internet put up by trustworthy organizations.

Maybe it’s because the Western world approaches health and nutrition in the wrong way. People make diets to lose weight and to look good rather than to get healthy. That is really the worst motivation one can have.

People should always first ask themselves what they should eat more of instead of what foods they should eliminate from their diet. We should let go of the idea of looking at food from a macronutrient and caloric perspective. What matters are the micronutrients. Once a person’s diet is sufficient in micronutrients there will be no stomach space left to eat much of the processed junk that a lot of Western people regularly consume.

What will our future look like?

Unless there’s going to be a big change in the dietary patterns across Western Europe and North America, the next generation is going to be the first one to have a shorter life expectancy than their parents. But not just the general life expectancy will go down. People will also suffer from chronic diseases earlier than their parent generation so that their average healthy lifespan is also decreasing.

Graveyard in autumn
Life expectancy in the Western world will decrease if we don’t change our lifestyle.

We might live longer than our ancestors’ thanks to medical innovation. But that cannot be the end goal. Without an extension of the healthy lifespan, every additional year of life is just another year of wasted healthcare money. We are good at keeping sick people alive. But why don’t we prevent them from getting sick in the first place? That is so much cheaper and more efficient than the best medical treatment will ever be.

It’s your individual lifestyle choices that will determine what your health is going to look like as an elderly person. Unfortunately, the majority of Germans and Americans are making the wrong choices. We live with the burden of exploding health care costs for easily avoidable diseases. I wonder, how long will our society be willing and able to pay the price for that?

Health insurance costs in Germany are steadily rising. Almost no money is spent by the insurance companies on keeping people healthy and providing health services for the active and healthy members of society. Instead, the community has to pay for the devastating lifestyle choices of individuals. This is serious maladministration of resources.

Resources:

These Are the World’s Healthiest Nations

Health effects of dietary risks in 195 countries, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017

Global health 2035: a world converging within a generation

Salt reduction

Salt and Sodium

Cardiovascular Disease and Risk Factors in Asia: A Selected Review

Whole Grain Partnership- A unique ‘Stealth Health’ Opportunity

Do you eat fruit and vegetables daily?

Hidden Hunger in the Developed World

Healthy Eating Plate

2 Comments

  1. Sasha Anderson

    An interesting read, for sure. It’s a sorry state of affairs, considering all of the food options, exercise options etc.
    I was raised German in America, as I am first generation, born in America. I say this, because I ate mostly Southern German foods- and when my grandparents moved to America to be near their grandchild, it was even more German food.( which I live, by the way). We always ate healthily and exercised- as Germans used to do. My family was very “old world”, so none of us were overweight, or very often ill .
    My own family eats a great combination of fresh fruits, vegetables, and lovely German food. It takes an effort to balance all- but, worth it.
    Thank you for your great articles and lovely foods.

    • Thanks for your comment, Sasha. I also think that traditional German food is very healthy and balanced. It’s not just heavy meat dishes with tons of noodles and potatoes on the side. If you look at Europe nowadays from a health perspective, it’s a very obscure situation. The Mediterranean and Nordic countries have a much lower prevalence of obesity and diet-related diseases than Germany and the Eastern European states. Switzerland is about 2 hours south of where I live and yet they have lower obesity rates and higher life expectancies than Germans. Years ago, German people would make negative comments about American people living unhealthy lifestyles by eating a lot of fast food and driving everywhere by car. Nowadays, Germany is not much different in that regard. Somehow the situation worsened over the years an there is no initiative by the government to react unlike in the Nordic countries that implemented policies to improve public health. Well, maybe it will take a few more years until Germans realize that this situation could cause serious problems in the future. Let’s hope that realization will come rather fast – Tim

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