Intended for healthcare professionals

Rapid response to:

Editor's Choice Editor’s Choice

Learning from a crisis

BMJ 2013; 346 doi: (Published 12 April 2013) Cite this as: BMJ 2013;346:f2321

Rapid Response:

Re: Learning from a crisis

In the Editor's choice article “Learning from a crisis” published on 12 April 20131 attention was drawn to the support of the implementation of population-wide interventions "to curb obesity, diabetes, cancer and cardiovascular disease”. References to one editorial2 and one research paper3 were mentioned. Both were published in the same issue. The prospective and existing evidence gleaned from the “tragic experiment” reported provides an unfortunate, yet useful method of studying the effects of weight loss.

However, the fact that the Cuban economic crisis led to healthier behaviour and better management of obesity and diabetes does not seem to be reflected in countries such as Greece that have not experienced the same political transition, and where a more westernised life style has been established during the past few decades.

The economic crisis affecting Greece has also introduced a “diet crisis” whereby “Greeks have abandoned traditional foods,” a fact which is frequently reported via different websites. []. This appears to result from the fact that junk food is seen as a cheaper option than fresh food, rendering the Mediterranean diet a difficult option for the lower socio-economic status (SES) population. There is evidence that even on Crete the Mediterranean diet started to become abandoned some years before the economic crisis,4,5 together with the recognition that elderly people of lower SES followed a less healthier diet in comparison with people with higher SES.6 Behavior modification and health promotion regarding weight loss and prevention of chronic disease is a key issue requiring further attention within primary care settings in Greece.7 Furthermore, the beneficial effects of initiatives such as the use of bicycles as a means of contributing to weight loss are difficult to instigate in Greece. This is because the majority of Greek cities are constructed differently to other Western European cities, and sustainable development has not previously been at the centre of interest for Greek development. Likewise, the Greek mountainous terrain and climate, do not lend themselves easily to healthy lifestyle activities such as cycling or running.

However, although interventions relating to diet and exercise are currently difficult to address in Greece, there are certain other health assets which are becoming a focus of research, and a possibility for inclusion in population-wide interventions. These include the concepts of spirituality and religiosity as positive preventative assets regarding cardiovascular disease. These concepts are under investigation in a cross-sectional study implemented on Crete, where the psychosocial determinants of cardiovascular disease have also received a prompt attention.8

In conclusion, it is interesting that some positive findings can emerge from something tragic as with the Cuban crisis. It is also of interest that the reverse seems to be true in countries such as Greece, where a high societal and human cost is being experienced and where interventions aimed towards weight loss are unlikely to be very effective in the near future. The long term effect of economic crisis in Greece relies on many visible and invisible disease determinants which will need to be assessed and evaluated over years to follow.

Christos Lionis* and Sue Shea**

*Professor of General Practice and Primary Care, Clinic of Social and Family Medicine, School of Medicine University of Crete, Greece
** Psychologist and Researcher at the Clinic of Social and Family Medicine, School of Medicine, University of Crete, Greece

1 Merino JG. Learning from a crisis. BMJ. 2013;346:f2321 (12 April.)
2 Willet WC. Weight changes and health in Cuba. BMJ. 2013;346:f1777 (10 April.)
3 Franco M, Bilal U, Ordunez P, Benet M, Morejon A, Caballero B, Kennelly JF. Population-wide weight loss and regain in relation to diabetes burden and cardiovascular mortality in Cuba 1980-2010: repeated cross sectional surveys and ecological comparison of secular trends. BMJ. 2013;346:f1515 (9 April.)
4 Karlen J, Lowert Y, Chatziarsenis M, Faith-Magnusson K, Faresjo T. Are children from Crete abandoning a Mediterranean diet? Rural and Remote Health. 2008;8:1034.
5 Vardavas K, Linardakis ML, Hatzis CM, Saris WH, Kafatos AG. Cardiovascular disease risk factors and dietary habits of farmers from Crete 45 years after the first description of the Mediterranean diet. Eur J Cardiovasc Prev Rehabil.2010;17:440-6.
6 Katsarou A, Tyrovolas S, Psaltopoulou T, Zeimbekis A, Tsakountakis N, Bountziouka V, Gotsis E, Metallinos G, Polychronopoulos E, Lionis C. Socio-economic status, place of residence and dietary habits among the elderly: the Mediterranean islands study. Public Health Nutrition. 2010;13:1614-1621.
7 Lionis C, Symvoulakis EK, Markaki A, Vardavas C, Papadakaki M, Daniilidou N, Souliotis K, Kyriopoulos I. Integrated primary health care in Greece, a missing issue in the current health policy agenda: a systematic review. Int J Integr Care. 2009;9.
8 Lionis C, Anyfantakis D, Symvoulakis EK, Shea S, Panagiotakos D, Castanas E. Bio-psychosocial determinants of cardiovascular disease in a rural population on Crete, Greece: formulating a hypothesis and designing the SPILI-III study. BMC Res Notes. 2010;3:258.

Competing interests: No competing interests

03 May 2013
Christos Lionis
Prof. of General Practice and Primary Care
Sue Shea
School of Medicine, University of Crete, Greece
Voutes Residential Area, Heraklion, 71003