Hacker News Reader

Comment by adpirz | Hacker News Reader

There's a great book by Paul Dutton of Northern Arizona University called "Differential Diagnoses" comparing US and French healthcare in depth that talks about the ratio of GP's to specialists and its direct correlation with positive health outcomes, among other things. If you're interested in the field, worth a read, here's a good introductory portion:

http://digitalcommons.ilr.cornell.edu/cgi/viewcontent.cgi?ar...

View on HN

That looks like a very interesting read, skimming through it, it says that France spends around 10% of GDP on healthcare while the US spends 15%, but yet France gets a better health coverage, and a better life expectancy.

One of the first tables compares number and there's the most striking one : Obesity in France 9.4%, in the US it's 30.6%.

Could it be one reason that, with less obesity, French people are more healthy to start with, so they require less care? Does the book address this?

In other words, what if:

             Life expectancy with 0 healthcare , Life expectancy with healthcare
    France                 50 (made up)        ,     79.4
    USA                    35 (made up)        ,     77.5

That's weird data. By every measure I've seen France and the USA have almost identical obesity. https://www.google.com/search?ie=UTF-8&client=ms-android-spr...

France and the USA use a different threshold for obesity, so I'm not sure the comparison is straightforward. Someone who is borderline obese in France would be considered far from obese in the US. I can't whip up a source for this at the moment, but I'm speaking from personal experience (born in France, moved to the US when I was 9).

The 9.4% was data from 2002.

The french wikipedia page says a 2012 study shows that while 32,3 % are (25 ≤ BMI < 30 kg/m2), only 15 % are(BMI≥ 30 kg/m2).

If from 2012 to 2014 it jumped from 15 to 23.9 there would be a problem. I'm unable to track down where that 23.9% came from on the English wikpedia, but it looks like those WHO report anything above 25 BMI, whereas the other data is above 30 BMI

EDIT: Wikipedia is simply wrong, if you look at

http://apps.who.int/bmi/index.jsp and search for BMI adults % obese (>=30.0), then France most recent data is 16.9%, (USA is 33.9)

the Wikipedia article claims : Based on World Health Organisation (WHO) data published in 2014, 23.9% of French adults (age 18+) were clinically obese with a body mass index (BMI) of 30 or greater

EDIT2: Found an interactive map http://gamapserver.who.int/gho/interactive_charts/ncd/risk_f...

where it claims 22.0 for 2014 (still not 23.9), but it also claims 18.2% for 2005, but it says 12.4% for 2006 on the table, there's a different in reporting between the two. The interactive maps does an "age standardize estimate" whatever this means :)

Walking around France and walking around the US, that's not remotely what I see.

Walk around in France and you will notice the difference. You rarely see obese people.

Or might it also be that some of France's healthcare, being socialized, has an impact on obesity rates?

It's a combination of factors, of which Obesity is one of them. Part of routine healthcare is to tackle all these smaller issues at the same time before they balloon into larger problems. So it is conceivable that the lower rates of Obesity are a product of the healthcare practice in that country.

That's the theory. And it's certainly something that fits well with the idea that we're all better off with annual physicals and other types of preventative healthcare. From what I read, the evidence is pretty mixed. Sure, have your physical and do other preventative care, but the results are statistically at the margins from what I can tell. (which is, of course, relevant if you're at that margin.)

Other than some corner cases, the idea that there's a lot of spending on issues that could have been caught sooner is a non-starter. We're already doing most of it and it is reasonably cheap and not all that contentious: Vaccinations, pre-natal vitamins for pregnant mothers, etc. Most of the rest turns into the problem with false positives (and the treatment that entails) outweighing actual early detection.

> We're already doing most of it

Population health data suggests otherwise. There are a lot of things that we (readers of HN) do take for granted, but we represent a very biased (dare I say privileged?) cross-section of the population. I live in Altanta but if I look at data in my state but outside of the city, a very different story is taking place. There is a strong correlation with lack of preventative health and certain comorbilities.

Disclaimer: I used to work in population health.

A more plausible model is that doctors help sick people a lot, and are totally useless to healthy people.

From that point of view, consider the American system of providing great health care to people with stable lives and good jobs, and sparing no expense on attempts to save people who are beyond help, while denying treatment to the unemployed and to people with "pre-existing", i.e. long term, medical conditions. It's almost like they're trying to exert the most possible effort for the least possible effect; like someone has memorised the triage chapter of a first-aid manual, then set out to do the exact opposite.

Oh wait, they make lots of money that way, so it's all good.

> Could it be one reason that, with less obesity, French people are more healthy to start with, so they require less care?

French people eat fine cheese, and other fine foods. Americans are fed imitation cheese, and told that it's better for them because it doesn't have 'bad fat'.

The experts call this a "paradox" [1]. I think we're being swindled.

[1] https://en.wikipedia.org/wiki/French_paradox

I seriously doubt it has to do with the type of cheese people eat.

One of the biggest difference is walking. Most cities I've visited in Europe are easily walkable. You can more or less get what you need. People in small and big cities seem to walk much much more.

In Atlanta, this simply isn't possible for most people. We've built out more than up and inhibited public transportation but that's another sorry. Savannah is a much more walkable city similar to places in Europe. I wonder if it's the difference beetween old and new cities.

It might be interesting to do an analysis but it's not obvious that public transportation is an overriding factor.

If I look at obesity by US city [1] it's true that a lot of the top southern cities don't have great public transportation AFAIK, but the greater NYC metro area is relatively high up on the list. And Las Vegas is about tied with Boston and San Francisco.

I suspect eating habits (the US South is notoriously bad in a lot of ways) and poverty have more to do with it than the state of the local public transit system.

[1] https://wallethub.com/edu/fattest-cities-in-america/10532/

I don't like the table but the inforgraph is great. What I really like is % of people overweight.

Here's an example using some CDC data and based on metro areas [1]. Atlantic City is the worst and Boston is 1% more than Atlanta. It doesn't really support my walkability claim.

http://www.governing.com/gov-data/obesity-rates-by-state-met...

I think it's the quality of food. Stay in France for a few weeks and eat French bread every morning and you will be fine. Eat American bread and you will gain weight. Same for milk. I can drink German milk without problems but American milk gives me stomach problems.

you do know whether you gain or lose weight has to do with calories consumed? 100 calories of american bread is no different weight gain wise versus 100 calories of french bread.

Does human body ingest the energy from food the same way calorimeters do when measuring calorie counts?

Calorie counts are typically adjusted; manufacturers don't typically just toss a bag of, say, Ho-Hos in a bomb calorimeter and use the raw numbers from Igor or whatever recording program happens to be around.

The usual macronutrient values (9kcal/g fat, 5 kcal/g EtOH, 4kcal/g carbs and protein) are surprisingly decently calibrated for metabolic inefficiencies.

They do not, however, take into account hormonal responses, which are probably quite a bit more important than once assumed. So there's that.

Actually, that's a myth.[1] It isn't that simple. For example, a calorie of protein is harder to digest, and gets converted to energy less efficiently, than a calorie of carbohydrate.

[1] https://en.wikipedia.org/wiki/A_calorie_is_a_calorie

American milk is just fine.

I suspect your gut bacteria are simply unused to the new environment (possibly including the milk). The same kind of thing happens to most people when they travel overseas. As a child I spent most summers in Mexico. Within the first few weeks I would have a bout of serious diarrhea and vomiting, literally every year. But native Mexicans who ate the same things didn’t have the same problem, being well adapted.

Anyway, what specific type of milk are we talking about? Full fat homogenized milk? Skim milk? Unhomogenized milk?

In the German case you might also be talking about UHT milk, which is common in many countries (not sure about Germany) but vanishingly rare in the USA? I think that stuff is awful, YMMV.

I really doubt that. Surely it can't be uncorrelated with America's pervasive habits of all-day-TV-watching, all-day-computer-use, multi-thousand calorie meals, junk foods, fast foods, car-commuting, and sedentarism?

Well, in France, except for car-commuting, we're going fast gain all those habits.

I didn't say that food quality is the only factor but in my view it plays a role. And I believe a lot of American regular food is very low quality. The things you have listed play a role too.

> Same for milk. I can drink German milk without problems but American milk gives me stomach problems.

There are many different kinds of 'American milk'. A primary difference is what the different farmers feed their cows.

A few years ago I suffered through the History Channel's Modern Marvels episode about cotton. There's a bit towards the about how cottonseed meal (a waste product of the cotton industry) is commonly used as feed for the dairy industry.

Someone commented about how they taste a difference for the week after farmers switch their cows from summer rations to silage -- it takes a week for the cows' bacteria to adjust. I should find that comment & favorite it... Ah, here:

  You can always tell when the cows switch 
  between grass and silage in the spring 
  and fall. Milk tastes like garbage for a 
  week or two until they get sorted out.

- https://news.ycombinator.com/item?id=12893287

The French paradox (and similar observations for the Japanese) is most easily explained by the fact that they eat smaller portions than the Americans. Anyone traveling from Asia or Europe to the US is easily astounded by the large portions of food the typical US denizen eats.

For what it's worth, the story in the post describes a person being helped by specialists who treated solely the condition that the subject had, and nothing else. Not exactly a ringing endorsement of GP's, none of whom were able to help the subject.

Reply on news.ycombinator.com