Editorial, Uncategorized

Photo: UNICEF Cambodia, Antione Raab


Chronic diseases have risen to the top as the leading causes of death and disability worldwide. Once considered a problem for the elderly in developed nations has now become a global pandemic. In 2012, over 50% of adults in the U.S. had one or more chronic disease. By 2020, chronic diseases will account for 73% of all deaths across the globe. However, nearly 80% of these deaths will occur in developing countries. The inequitable distribution of resources and access to healthcare will ultimately result in the greatest harm to the most vulnerable populations. 

Cambodia, like many other developing nations, is experiencing a rise in noncommunicable diseases (NCDs), pervasive and long-term ailments that include cancer, chronic respiratory disease, diabetes mellitus, and cardiovascular disease. There are various determinants that can contribute to the rising prevalence of NCDs, including genetics, lifestyle choices, and the environment. While negative behaviors can often be changed through targeted public health interventions, ultimately, the social and physical environments must also change in order to support individuals in making healthier choices.

From a macro perspective, the current health status of Cambodia’s population is greatly influenced by its economic state of development and health care infrastructure. Ranked as a low-income country by the World Bank, Cambodia has a Gini coefficient of 31.8 and a Gross National Income (GNI) of $2,890 per capita. 15 For the population of 14,865,000, inequity is high across socio-economic groups and noticeably different between rural and urban areas. This unequal distribution of wealth and resources inevitably impacts access to care. For instance, greater health care barriers are faced by 80% of the population, who populate rural and remote areas with minimal access to medical treatment facilities. Additionally, poverty is another barrier to care, as 45.9% of the population lives on less than $1.25 per day. 12 As a result, nearly half of Cambodia’s population struggles to obtain daily necessities and is unable to afford the high cost of medical care, which accounts for over 60% of total health expenditures. 12


Photo: Global Witness, Chean Chenda


Photo: Daily

It has also been speculated that the lack of access to health care has contributed to the country’s lower life expectancy at birth, which according to the World Health Organization (WHO) is 75 years for females and 70 years for males. 12 Furthermore, the crude birth rate is 25 live births per 1000 people, while the crude death rate is 6.70 deaths per 1000 people. 17 Additionally, the fertility rate is 2.9 births on average per woman over a lifetime. 11 All of these factors are contributing to the rising demand for health care to both meet the needs of the growing population and minimize preventable deaths. 11

The greatest suffering is experienced in rural communities, which lack access to available health care providers to adequately meet their needs. In 2008, there were only two physicians and eight nurses/midwives available for every 10,000 people living in rural areas17 Additionally, by 2011 there were only eight health facilities and 72 hospital beds available for every 100,000 people. 17 However, during the same year, there were 710 new nursing graduates and 134 new medical school graduates. 13 This illustrates that while the number of nurses entering the health care workforce was and is promising, the shortage of physicians and lack of available health care facilities still remains problematic.

In addition to a lack of medically trained providers, rural communities face numerous obstacles in accessing care. For one, quality is a major concern. A substantial part of the population, approximately 21%, receives care from the private non-medical sector, which is comprised mostly of traditional and religious healers. 13 This is concerning since most of these private facilities are not actively regulated, thus, making the quality of assurance questionable. Similarly, 49% of medical treatments occur through private facilities where quality assurance and regulation is minimal. 17 As a result, this negatively impacts the ability to prevent (via screening), treat, and manage NCDs for the most affected groups (e.g. low socio-economic status). This environmental barrier must change in order to provide greater access to health care nationwide.

While Cambodia has many environmental obstacles, there are also several opportunities that can be utilized to improve public health. For instance, the increasing rates of education can be a means to share knowledge and facilitate change. Currently, the primary school enrollment rate is at 98% and the total adult literacy rate is at 77.6%. 12 Education may serve as an outlet to inform the public on the negative consequences of poor behaviors (e.g. smoking) and how to alternatively make healthier choices.

Going back home

Photo: UNDP

Another opportunity is to utilize the international aid coming into Cambodia. In 2010, contributions targeting health care reached $199 million.12 However, more than half of this aid went towards treating communicable diseases, such as HIV, TB and Malaria. A focus on infectious diseases has swept across the international community, non-governmental organizations (NGOs) and the Cambodian government. Multi-sectoral collaboration (including many of the 30 aid partners), has given rise to new policies, which focus monetary funds primarily on lowering infectious disease rates. The implications of such an agenda is that the prevention and treatment of many noncommunicable diseases may be overlooked.

In order to develop a broad and accessible healthcare system that benefits all people, a stronger emphasis needs to be placed on the prevention and treatment of NCDs. Based on current rates, chronic diseases will have the greatest impact on population health overtime. The result of this focus will inevitably be perceived in the near and far future. Ultimately, a greater percentage of the population will benefit from access to healthcare and an improved standard of living overall.


Photo: Buffalotours

The Rising Burden of NCDs

Studies show that chronic diseases are increasing in prevalence, while communicable, maternal, neonatal, and nutritional causes of disability-adjusted life years (DALYs) are declining. 18 DALYs represent the number of healthy years lost to due disability or premature death. According to the World Health Organization’s 2014 Noncommunicable Diseases Country Profile on Cambodia, NCDs caused 44,200 deaths accounting for 52% of all total deaths. 15 By comparison, communicable, maternal, perinatal and nutritional conditions only accounted for 31,450 deaths or 37% of total deaths. 15 This trend has been quantified by various studies, which provide evidentiary support for why more agency should be placed towards the prevention, treatment and management of NCDs.

The Global Burden of Diseases, Injuries, and Risk Factors Study compared changes in disease rates in Cambodia from 1990 to 2010. 18 This study determined the greatest burden by the absolute number of DALYs lost and then ranked each disease from 1 (best) to 15 (worst) according to the age standardized DALY rates. In 1990, the leading causes of DALYs lost were due to lower respiratory infections (rank: 8), followed by diarrheal diseases (rank: 3), and then malaria (rank: 8). In 2010, the leading cause of DALYs lost still remained to be lower respiratory infections but with a lower ranking of 4. However, the disease with the second greatest burden was now ischemic heart disease (rank: 13), followed by stroke (rank: 12). Overall, from 1990-2010 lower respiratory infections declined by 50% while ischemic heart disease increased by 75% and stroke increased by 55%. 18 Additionally, diarrheal disease, which was once the leading cause of burden, showed the greatest decrease in DALYs by 50%. 18 Similarly, other communicable diseases have had great reductions in DALYs, such as malaria (40%), meningitis (25%), and tuberculosis (10%). 18 In contrast, from 1990-2010, many NCDs have increased in disease burden, such as diabetes (110%), Cirrhosis (85%), COPD (25%), and other cardio and circulatory diseases (20%). 18 This shows that infectious diseases are declining while NCDs are rising in prevalence and severity.

Cambodia's Homeless on the Streets of Phnom Penh

Photo: Paula Bronstein, Getty Images

Since 2010, the prevalence of NCDs has continued to rise. In 2014, 7,400 people suffered from a stroke, while diabetes prevalence rose to 229,000. 14 The annual environmental burden for cardiovascular disease was calculated at 4 DALYs per 1000 capita. 14 In addition, cancer now affects 6,842 males and 8,374 females in Cambodia. 21 The most common cancers in males include liver (1,444 cases), lung (796 cases), and colorectal cancer (445 cases). 21 By comparison, the most common female cancers are of the cervix uteri (1,512 cases), breast (1,255 cases), and liver (820 cases). 21 According to the WHO, the annual burden of lung cancer is 0.3 DALYs per 1000 capita, while for all other cancers is 2.0 DALYs per 1000 capita. 14 Overall, the burden of cancer is high, which means that there is a large number of preventable deaths that are associated with unhealthy environments.

NCDs cause tremendous suffering, especially for individuals who go untreated. This is compounded with the fact that a majority of NCD deaths occur in individuals under 60 years old, with males accounting for 56.2% and females accounting for 34.8%. 20 This is highly problematic since most NCD deaths impact the working population, which reduces the labor force in Cambodia. The economic impact is high, as the productivity losses associated with absences, accidents and disability were found to be 400% greater than the cost of treatment.26 Ultimately, the economy would benefit from increased population treatment for NCDs. However, when families have to contend with the early death and/or disabilities of a household financial provider, the families are pushed into poverty due to the high cost of chronic treatment. Therefore, it is clear that more cost effective prevention and treatment options are needed.




Photo: ICRC

Major Determinants and Risk Factors of NCDs

There are various underlying socio-economic, cultural, political, and environmental determinants of NCDs. For instance, globalization and urbanization have contributed to more sedentary lifestyles and the wide distribution of highly processed foods. Low-income households are large consumers of these high calorie, low nutrient items, due to their extensive availability and low costs. Similarly, current government policies in Cambodia make cigarettes affordable and widely available. For instance, at current rates, a pack of Marlboro cigarettes costs only $1.15, which is surprisingly less than the cost of a liter of Milk selling at $1.99. 25 The outcome is a physical environment that supports unhealthy behaviors, thus, enabling individuals to engage in common risk factors that are responsible for many chronic diseases.

This is evident in the high rates of modifiable risk factors such as unhealthy diets, physical inactivity, and tobacco use, as well as intermediate risk factors such as high blood pressure and obesity in the population. Currently, the prevalence of daily tobacco smoking among Cambodians is at 30%. 12 Also, 12.1% of the population is overweight, 11.2% are physically inactive, 2.1% are obese, and 27.6% have high blood pressure. 20 Furthermore, alcohol consumption is high at 5.5 liters per capita. 15 As such, it is no surprise that the leading risk factors that accounted for the greatest burden of disease in 2010 were dietary risks, household air pollution from solid fuels, and tobacco smoking, amongst others. 18

Of the total risk factors, dietary risks accounted for 9%, household air pollution accounted for 8.5% and smoking accounted for 7%. 18 These risk factors lead to cardiovascular and circulatory diseases, diabetes, cancer, diarrhea, lower respiratory infections, chronic respiratory diseases, and many other NCDs. Public health efforts should focus on educating and empowering the population on methods to minimize the risk of developing these high burdening diseases. For instance, behavior modification could target the four main modifiable risk factors, which include tobacco smoking, alcohol consumption, dietary risks, and physical inactivity. Engaging in these behaviors can drastically impact health. For example, smokers are 20 times more likely to develop lung cancer than those who have never smoked26 Similarly, inactivity and obesity resulting from poor diet increases the risk of death by at least 50%. 26 Thus, focusing policy and public health interventions on lowering these risks would dramatically aid in reducing NCDs.


Photo: Phnom Penh Post

Health Policy Suggestions

Prevention: reducing risk by targeting tobacco, alcohol, physical activity, and diet

In order to promote population health and well-being, education efforts should focus on the most wide spread and damaging habits. Scientific evidence has shown this to be smoking, alcohol consumption, physical inactivity, and unhealthy diets. 18 One method to change these behaviors is through policy change. For instance, public health interventions can be implemented in primary schools, which have high attendance rates and therefore, serve as prime locations to educate children on nutrition early on. Also, government subsidies for fruits and vegetables may help alleviate the financial barrier for those unable to afford fresh produce. Additionally, the Cambodian government could legislate to follow global agreements by supporting the commitments under the Framework Convention on Tobacco Control (FCTC). Furthermore, public smoking bans in certain areas (e.g. schools) and tighter advertising regulations may also help reduce current smoking rates. Overall, education should approach the four main risk factors with an aim to change social norms, all the while implementing policies that promote a healthier physical environment.


Photo: Khmer Times

Cambodian villagers play volleyball at Sre Ampel village,  Kanda

Photo: Financial Times

Treatment: strengthening quality and access to primary health-care systems

Increasing quantity and quality of healthcare providers

A greater medical workforce is needed to keep up with population growth and the expanded coverage of care. One method to increase healthcare professionals, such as physicians and nurses, is by providing financial incentives (e.g. loan forgiveness) for students to pursue healthcare in Cambodia. However, before newly trained professionals enter the field, there needs to be a national standard for quality of care that is implemented and assured. In order to do so, the health workforce strategy must be revised, and training (both pre-service and in-service) must be strengthened. 12 Also, capacity building and knowledge sharing is needed in order to effectively spread information on standard treatment protocols and quality accreditation. This must occur across various health care groups, including the private sector and universities.

Increasing access to care – expanding coverage and reducing costs

One reason NCDs are negatively impacting Cambodia’s population is due to the lack of access to affordable quality care for screening, treatment, and disease management. However, the government has been making changes towards improving access. The Cambodian Government recently implemented the second Health Strategic Plan 2008-2015 (HSP2). Focus has now moved towards implementing the National Strategic Development Plan (NSDP) 2014-2018, which aims to improve population health and access to resources in a sustainable fashion. 12 One positive outcome is the expansion of Health Equity Funds (HEFs), which now cover 80% of the poorest people in the country and helps reduce the financial obstacles to receiving care. However, 20% of the poorest population still lacks access and the financial resources to obtaining quality healthcare. Therefore, this underserved population should be targeted through outreach services and facility based coverage. Strengthening and coordinating the resources of NGOs to assist in supporting the WHO’s Cooperative Strategic Agenda (2008-2015) may help achieve full coverage. 12 This would also support the development of a national social health protection policy and financing mechanisms that target the poor.

In addition, low-cost medications should be provided to high-risk patients (e.g. hypertensive) or those requiring long-term treatment due to chronic disease (e.g. cancer). With advancing technologies, cost effective strategies for NCD prevention and treatment are becoming more common. Optimism is high, as new strategies are estimated to prevent 80% of diabetes and global heart disease in the future. 26 For instance, high blood pressure can be effectively managed with medication at a low cost of only a few cents per day. 26

Furthermore, with expanded coverage, screenings for disease must also increase. This is vital, since many NCDs are not curable, and most have a slow onset and long duration. Thus, early detection combined with treatment and management will provide the greatest benefit for patients. This has occurred in many high-income countries which have had increased rates of survival due to cancer treatments combined with early detection and screening. 26 For instance, the 50-year relative survival rate for all cancers diagnosed in the US from 1975-1977 was 49% compared to 68% from 2004-2010, reflecting advances in treatment and early diagnosis. 24

Overall, a serious problem faces Cambodia. On the one hand, policy makers must consider how to manage the growing element of NCDs and how to reduce the negative physical, financial, and national burden that they have on the population. On the other hand, decision makers must utilize the countries current resources of international aid and upcoming policy reform in order to emphasize education and implement broad-based healthcare availability. Ultimately, in order to reduce the impact of NCDs in the future and improve the health of Cambodia’s population, policy efforts should focus on expanding healthcare coverage, reducing treatment costs, and both increasing and improving screening, treatment, and disease management. 


Photo: UNICEF Cambodia

CHECK OUT Covert KillerTobaccoMaternal Mortality


  1. Cambodia: Demographic and Health Survey. National Institute of Statistics. Directorate General for Health, Ministry of Health, Cambodia. 2010. Web. Received from:
  2. Recent Fertility and Family Planning Trends in Cambodia. Department of Planning and Health Information, Ministry of Health, Reproductive Health Association of Cambodia, PRB. 2003. Web. Received from:
  3. Data: Cambodia. The World Bank Group. 2015. Web. Received from:
  4. Cambodia Falls Short of Early Childhood Nutrition Goals. Department of Planning and Health Information, Ministry of Health, Reproductive Health Association of Cambodia, PRB. 2003. Web. Received from:
  5. Maternal Mortality a Leading Cause of Death in Cambodia. Department of Planning and Health Information, Ministry of Health, Reproductive Health Association of Cambodia, PRB. 2003. Web. Received from:
  6. Degan, Guy. Lack of adequate sanitation triggers child health concerns in Cambodia. UNICEF. 7 May 2008. Web. Received from:
  7. Shepherd-Johnson, Denise. Nutrition campaign helps make Cambodia’s children strong, health and clever. UNICEF. 24 April 2013. Web. Received from:
  8. Shepherd-Johnson, Denise. In Cambodia, a push to bring healthcare to remote areas. UNICEF. September 2012. Web. Received from:
  9. Cambodia- Poverty Reduction Strategy Paper and Joint Assessment. The World Bank Group. 2003. Web. Received from:­reduction­strategy­paper­prsp­joint­assessment
  10. Cambodia. The World Bank Group. 2015. Web. Received from:
  11. 11. Cambodia: WHO Statistical Profile. World Health Association. 2012. Web. Received from:
  12. Cambodia Country Cooperation Strategy: at a glance. World Health Organization. May 2014. Web. Received from:
  13. Cambodia Population Statistics. World Health Organization. 2013. Web. Received from:
  14. Cambodia Country Profile of Environmental Burden of Disease. World Health Organization. Public Health and the Environment, Geneva. 2009. Web. Received from:
  15. Noncommunicable Diseases (NCD) Country Profiles, 2014. World Health Organization. 2014. Web. Received from:
  16. WHO Global Database on Vitamin A Deficiency. World Health Organization. 2007. Web. Received from:
  17. Western Pacific Health Databank, 2012-2013, Cambodia. World Health Organization. 2013. Web. Received from:
  18. Global Burden of Disease Profile: Cambodia. Institute for Health Metrics and Evaluation. 2301 Fifth Ave., Suite 600, Seattle, WA. 2010. Web. Received from:
  19. Cause-Specific Mortality and Morbidity. World Health Organization. World Health Statistics 2009. Web. Received from:
  20. Cambodia NCD Country Profiles, 2011. World Health Organization. 2011. Web. Received from:
  21. Cambodia. International Agency for Research on Cancer. World Health Organization. 2012. Web. Received from:
  22. Tackling NCDIs in Cambodia: an opportunity for inter- and intra-sectoral synergies. Health, Nutrition, and Population Knowledge Brief. World Bank. 2014. Web. Received from:
  23. Prevalence of Non-Communicable Disease Risk Factors in Cambodia. STEPS Survey, Country Report. Ministry of Health, Cambodia. 2010. Web. Received from:
  24. Cancer Facts & Figures 2015. American Cancer Society. 2015. Web. Received from:
  25. Cost of Living in Cambodia. NUMBEO. 2015. Web. Received from:
  26. Wipfli, Heather. “Busting the Myths of NCDs.” University of Southern California. Lecture. 3 Feb. 2015.
  27. Cambodia. Water Aid. 2015. Web. Received from:
  •  Cover photo:


Table 1. Demographic and economic indicators for Cambodia
Indicator Data Latest year Source
Total population 15,205,539






Crude death rate (per 1000) 6.70 2004 17
Crude birth rate (per 1000) 25 2004 17
Life expectancy at birth (yrs)

72 (Both Sexes)

75 (Female)

70 (Male)

2012 12
Total fertility rate 2.9 per woman 2013 11
Total adult literacy (%) 77.6% 2008 12
School Enrollment rate 98% net, primary 2012 3
Ranked low, middle or high income? Low-income 2012 3
GNI per capita ($) $2,890 2013 13
Gini coefficient 31.8 2011 3
Population living below $1.25/day (%) 45.9% 2010 12

Major imports

Refined Petroleum  (10%)

Light Rubberized Knitted Fabric (10%)

Other Synthetic  Fabrics (3.6%)

Raw Sugar (2.1%)

Gold (2%)

2014 3

Major exports

Postage Stamps (14%)

Knit Sweaters (12%)

Knit Women’s Suits (7.7%)

Non-Knit Women’s Suits (5.5%)

Non-Knit Men’s Suits (5.3%)

2014 3
% deaths due to infectious disease 20.16% 2011 8
% deaths due to NCDs 52% 2014 15
Top 3 diseases (in terms of deaths): 1. Ischemic heart disease (10.1%), 2. TB (9.6%), 3. Stroke (8.7%) 8.5




2012 11
Top 3 diseases (in terms of DALYs lost): 1. Lower respiratory infections,  2. Ischemic heart disease, 3. Stroke

6,600 (Age standardized DALYs 1-15: 4)

8,500  (Age standardized DALYs 1-15: 13)

7,400 (Age standardized DALYs 1-15: 12)

2012, Age stand. DALYs: 2010



DALYs lost (%) N/A

Top 3 causes of DALYs lost: 1. Maternal, neonatal, nutritional, 2. Other NCDs (non-malignant neoplasms; endocrine, blood and immune disorders; sense organ, digestive, genitourinary and skin diseases; oral conditions; and congenital anomalies),    3. Cardiovascular diseases and diabetes

Risk Factors accounting for most disease burden: 1. Dietary Risks, 2. Household Air Pollution, 3. Smoking

~ 820,000

~ 610,000

~ 600,000

9% DALYs

8.5% DALYs

7% DALYs



11, 18

Table 2. Environmental situation for Cambodia
Indicator Data Latest year Source
Environmental Health
Environmental Burden of Disease (%) Deaths: 25% of total burden 2004 14
Top 3 greatest contributors to environmental burden of disease (DALYs): 1. Diarrhea, 2. Respiratory Infections, 3. Unintentional injuries (other than road traffic)




(DALYS/1000 capita)  per year

2004 14
Deaths due to Indoor Air Exposure (Deaths/year) 6,600 deaths/year 2004 14
Deaths due to Outdoor Air Exposure (Deaths/year) 300 deaths/year 2004 14
Global Climate Change Threat N/A
Water and Sanitation
Water Situation (scarcity) 33% people lack access to safe water 2008 27
Population using improved  water and sanitation (%)


22% (Rural)

76% (Urban)

Overall: 67%


61% (Rural)

90% (Urban)

2011 12
Burden of Disease from Diarrheal Disease 27 DALYs/1000 capita (per year)                   10,000 children die/year





Table 3. Maternal, child and nutritional health situation for Cambodia
Indicator Data Latest year Source
Maternal health
Antenatal coverage, at least once (%) 89% 2010 1
Antenatal coverage, at least four times (%) 59% 2010 1
Skilled attendant at birth (%) 71% 2010 12
Contraceptive prevalence (%) 51% 2007 11
Maternal mortality ratio 250/100,000 live births

170/100,000 live births



Child health
Annual number of under-five deaths 40/1000                   (38/1000 live births ) * 388,880 births = 14,777.44 deaths





Infant mortality rate 45/1000 live births 2010 17
Child mortality rate Prob. of dying before age 15: M: 20%, F: 16% 2012 11
Neonatal mortality as proportion of all under-five mortality (18/1000 live births) * (38/1000 live births) = 0.47368 deaths (6,999.77 deaths/year)

18/1000 live births




Percent of babies born with low birth weight 8.2% 2012/13 17
Children exclusively breastfed < 6 months (%) 73.5% 2012/13 17
Children still breastfeeding 20-23 months (%) 3.51% 2010 1
Children moderately or severely underweight (%) < 5 yrs old: 28% 2012/13 17
Children moderately or severely wasted (%) 11% 2010 1
Children moderately or severely stunted (%) 39.5%                         (under 5 years old: 40%)

2012/ 2013




Vitamin A supplementation full coverage (%) 71% 2010 1
Households consuming iodized salt (%) 84% 2010 1
Children 1-year-old receiving measles immunization (%) 90% 2007 11
Table 4. Noncommunicable Disease situation in Cambodia
Indicator Data Latest year Source
 Major Diseases
Total # of NCD deaths 44,200 2014 15
% of NCD deaths to people under 60 yrs. Males: 56.2%         Females: 34.8% 2008 20
Stroke 7,400                               Age Standardized Death rate: 101.49/100,000 ppl




COPD 1.1 DALYs/1000 capita per year 2004 14
Diabetes prevalence 229,000 2014 22
Cancer Deaths & Cases

Deaths: 13% = 11,050


M: 6842

F: 8374





Top 3 cancers (males)        1.Liver, 2. Lung, 3. Colorectal

1444 cases

796 cases

445 cases

2012 21
      Top 3 cancers (females)            1. Cervix, 2. Breast,3. Liver

1512 cases

1255 cases

820 cases

2012 21
Risk Factors
Current Daily Tobacco Smoking prevalence (%) overall, males, females








Physical inactivity            overall, males, females




2008 17
Alcohol consumption per capita    5.5 liters 2010 15
Overweight (%)                 overall, males, females




2008 20

Obesity (%)                         overall, males, females




2008 20

Covert Killer

Editorial, Uncategorized

By 2020, cancer cases in the United States are expected to increase by 24% in men and 21% in women.

Some of the most common types of cancer expected to rise include melanoma, prostate, liver, kidney, lung and breast cancers.

The Modern Paradox – Luxury is Toxic


The modern lifestyle is one of luxury and convenience. From beverages to beauty products, todays consumers have a vast array of options to choose from to satisfy their daily needs. Freedom of choice in a competitive marketplace, that is the beauty of living in the United States.

In a minimally regulated system, overconsumption in the pursuit of luxury has become toxic. Companies now use chemicals to enhance products, reduce costs, and increase profits. The Food and Drug Administration (FDA) and the Environmental Protection Agency (EPA) are supposed to regulate exposure to toxic chemicals. However, the system has failed. There are approximately 85,000 registered chemicals, but only 200-300 have been tested for safety.

Chemicals are “innocent until proven guilty” in the U.S.

Laboratory Glassware

In America’s free marketplace, consumer products are considered safe until proven otherwise. The 1976 Toxic Substances Control Act (TSCA) was enacted to regulate potentially hazardous exposures. However, the act does not require chemicals to be tested for safety before being released to the public.

On June 22, 2016, the TSCA was updated with the passing of the Lautenberg Chemical Safety for the 21st Century Act (LCSA). The intention is that the EPA will improve the screening of active chemicals used today for toxicity in humans. Whether or not this will actually work is unknown.

The number of chemically engineered goods has and continues to rapidly surpass the regulatory systems in place. Each year, approximately 2,000 new chemicals are introduced into consumer items. Personal care products, foods, and household cleaners are just a few places where they are present. We are all eating, drinking and using toxic products everyday. However, with the backlog in toxicity testing, we may never know what is killing us before it’s too late.

The Covert Killer: Caramel Color

Glasses with cola and ice cubes

Caramel coloring types III and IV in carbonated beverages contributes to 25% of the U.S. population’s exposure to the carcinogen, 4-Methylimidazole or 4-MEI (1). The U.S. National Toxicology Program (NTP) conducted experimental studies on rats and found that exposure to 4-MEI led to increases in leukemia, as well as adenomas and carcinomas of the lung. While no human data is available yet, these findings were enough to categorize 4-MEI as a carcinogen.

This manufactured caramel color has no other purpose than to make beverages appear darker. Companies believe that by including this chemical into soft drinks, it will ultimately lead to an increase in sales. Apparently, people prefer soda that’s brown not yellow.

CA Proposition 65: Labeling Toxic Consumer Goods


In 2011, California listed 4-MEI as a carcinogen under Proposition 65 of the Safe Drinking Water and Toxic Enforcement Act of 1986. Proposition 65 requires warning labels for any carcinogen exceeding a “no significant risk level” (NSRL). A no significant risk level is the lifetime average daily exposure associated with a 1-in-100,000 cancer risk (1). This amount for 4-MEI is equal to 29 μg/day. In response, soft drink manufacturers announced that they would lower the concentration of 4-MEI in products sold in California.

Years later, did they really follow through?

In a 2015 study by Johns Hopkins University, researchers tested the concentration of 4-MEI in 110 soft drink samples from stores in California, New Jersey, Connecticut, and New York (1). Various brands were tested, including A&W Root Beer, Diet Coke, Malta Goya, Diet Pepsi, Pepsi One and Regular Pepsi. The average and maximum amount of 4-MEI concentrated in beverages varied dramatically across brands and states. The highest and lowest concentrations across all locations was found in Malta Goya (mean: 945.5μg/L; maximum: 1104μg/L) and Diet Coke (mean: 9.8μg/L; maximum: 10.4μg/L).

A&W Root Beer Diet Coke Malta Goya Diet Pepsi Pepsi One Regular       Pepsi

4-MEI (μg/L)

CA 68.2 9.5 963.3 78.4 119.7 75.9
NY 61.8 10.2 915.8 304.5 501.5 291.2

Researchers found that 4-MEI concentrations were overall higher in samples purchased in the NY area compared to those purchased in CA. This is evidence that Proposition 65 and other state-level interventions can incentivize manufacturers to reduce chemical exposures and associated risks among consumers.

Soda Consumption: A Social Epidemic


The National Health and Nutrition Examination Survey (NHANES) calculated the average daily consumption of carbonated beverages in the United States (1). The highest consumption of soda was found among adolescents (ages 16 to 20 years old) and young adults (ages 21 to 44 years old), with approximately 57% of this population consuming 2-3 cans daily. However, this trend varied by beverage type. Colas were found to be the most popular beverage consumed, regardless of age. In contrast, root beer and pepper colas were the least popular.

Soft Drink Consumption A& W Root Beer Diet Coke Malta Goya Diet Pepsi Pepsi


Regular Pepsi
Mean               4-MEI (μg/L) CA 68.2 9.5 963.3 78.4 119.7 75.9
NY 61.8 10.2 915.8 304.5 501.5 291.2
 Age Range  (years old) Soft Drink Consumption (% pop.)
Children (3-5) 30.1%
Adolescents (11-15) 56.5%
Young Adults (16-20) 57.1% 1.6 – 3.2 cans daily
Adults (21-44) 57.9% 1.5 – 3.5 cans daily
Adults (45-64) 48.4%
Older Adults (65-70) 34.9%

Cancer Risk

For this study, risk is defined as the lifetime excess risk of developing cancer associated with the consumption of soft drinks. United States federal regulatory agencies set an acceptable cancer risk goal for consumer products as 1 case per 1,000,000 exposed individuals.

Based on average daily consumption patterns and the concentrations of 4-MEI found in soft drinks, researchers identified which beverages posed the greatest risk for consumers. Malta Goya, Pepsi, Diet Pepsi and Pepsi One resulted in 4-MEI exposures with associated risks exceeding 1 excess case per 10,000 exposed individuals.

The lifetime risk of developing cancer is 100 times greater for consumers of caramel colored soft drinks with 4-MEI (Malta Goya, Pepsi, Diet Pepsi and Pepsi One)


Acceptable Risk: 1 case/1,000,000 exposed individuals

Current Risk: 1 case/10,000 exposed individuals


Cancer Burden

The consumption of soda is contributing to rising rates of cancer. But to what degree?

Burden is the lifetime (70 years) excess cancer cases associated with the consumption of beverages by the U.S. population. The number of people who will develop cancer in their lifetime from Pepsi One is approximately 1,000 in California and 4,000 in New York. Comparatively, the number of Malta Goya consumers predicted to develop cancer in their lifetime is roughly 5,000 in both states.

Average Exposure Pepsi Pepsi One Diet Pepsi Malta Goya Coca Cola Diet Coke
CA 1,044 958 628 5,011 167 76
NY 4,009 4,014 2,437 4,764 156 82


What Can We Do?

1. Federal Regulation

Advocates, NGOs and constituents should pressure policy makers to increase regulation on consumer goods with 4-MEI. Toxic exposure to this carcinogen is unnecessary and should be eliminated.

2. FDA Intervention    

The FDA could set a maximum 4-MEI concentration level for beverages sold in the United   States.

3. Avoid Drinking Soda  

Individuals should avoid drinking soda with caramel coloring, especially Malta Goya, Pepsi, Diet Pepsi and Pepsi One.

Ultimately, relying on political regulations is not enough. The process of creating and implementing restrictions on carcinogens is too slow to keep up with the rapid pace of chemical engineering. Everyday, new toxins are being introduced into consumer products. Chemicals are continuously being modified and exposures are on the rise.

However, advocates should still pressure regulatory bodies to progress towards a system that more effectively minimizes harm to the population’s health. California’s Proposition 65 is one example of success where other states should follow.

People have power as consumers. By avoiding the consumption of soda, individuals can make a statement to companies about the quality of products desired. By choosing healthier alternatives to chemically enhanced products, people are shifting trends that influence what businesses produce in the future.

The most effective way to limit toxic exposure is with you. You have the power to create an immediate impact towards a healthier life. You choose what you eat, drink and use everyday. While our products may be toxic, our choices don’t have to be.

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1) Caramel color in soft drinks and exposure to 4-methylimidazole: a quantitative risk assessment, Tyler Smith, et al., PLOS One, doi:10.1371/journal.pone.0118138, published online 18 February 2015.

2) Another reason to cut back on soda, Consumer Reports, news story accessed 20 February 2015 at

3) Popular soda ingredient poses cancer risk to consumers, Johns Hopkins University Bloomberg School of Public Health news release accessed 20th February 2015 Via EurekAlert!



Editorial, Uncategorized


The Rising Prevalence of Tobacco Use in Developing Countries



“Tobacco is the only legal drug that kills many of its users when used exactly as intended by manufacturers” (15).

According to the World Health Organization (WHO), tobacco use is responsible for six million deaths each year (15). This includes an estimated 600,000 people who die from second-hand smoke. Health outcomes include death and/or disability from chronic diseases, such as cancer, stroke and chronic respiratory diseases. Additionally, smoking increases the risk of death from infectious diseases.

Overwhelming evidence suggests that tobacco marketing greatly influences tobacco use and initiation (3-5). As such, bans on tobacco marketing can greatly reduce individual tobacco use.


↓ Developed Countries   ↑ Developing Countries

Tobacco use in many high income countries is decreasing rapidly. This is due to government marketing bans and increased public education about the harms of smoking. In contrast, the prevalence of smoking is increasing in many middle- and low-income countries. According to the WHO global report on trends in tobacco smoking 2000-2025, males are more likely to smoke than females, and the prevalence is rising most dramatically in the African Region and the Eastern Mediterranean Region (13).


Photo by: Merinews

Table 1. Age-standardized prevalence of current tobacco smoking among persons aged 15 years and older (14,16).

  Year 2000 Year 2015
Men Women Both sexes Men Women Both sexes
Canada 29.3 27.5 27.5 17.7 12.2 14.3
Sweden 32.8 32.9 32.9 20.4 20.8 20.6
China 56.2 3.3 30.4 47.6 1.8 26.3
India 33.8 5.7 20.2 20.4 1.9 11.0
Pakistan 35.2  7.5 21.8 41.9 3 22.9
Zimbabwe 29.8 2.7 16.1 31.2 2.1 16.65


Tobacco marketing is 81 times greater in Pakistan, India and Zimbabwe than in the United Arab Emirates, Canada and Sweden (7). 

In 2003, member states of the World Health Assembly adopted the Framework Convention on Tobacco Control (FCTC) (6). This agreement provided 180 nations with evidenced-based steps to minimize tobacco sales and ban tobacco marketing. This legally binding treaty even provided agricultural alternatives to those growing tobacco, so as to minimize the economic hardships faced by local producers. Nearly 13 years later, what is the present state of tobacco marketing trends?

A recent study led by the World Health Organization examined the global tobacco marketing environment by comparing 462 communities located in 16 low-, middle- and high-income countries (1). Researchers found that exposure to tobacco marketing is 81 times greater in Pakistan, India and Zimbabwe than in the United Arab Emirates, Canada and Sweden (7). Additionally, the tobacco industry is targeting poor urban youth in developing countries (10-12). This is due to cheaper marketing costs and the greater potential to reach more people in densely populated regions. Furthermore, according to the WHO study (1), high levels of tobacco marketing (e.g. posters, print media and cinema) was even found in 14 middle- and low-income countries that had ratified the FCTC. Countries that ratified this agreement were required to implement a comprehensive ban on tobacco advertising, promotion and sponsorship. However, many developing countries are lacking in agency and governmental capacity to fully implement the recommendations of FCTC (2). This is worsened by the alarming influence of the tobacco industry in lobbying their interests (8,9).

Governments, NGOs, and other key stakeholders need to take a stand against the tobacco companies. Media and advocacy work must continue to focus on the populations currently being abused by corporate greed. Urban youth in developing countries are the greatest target of the tobacco industry, and therefore, should become a major focus for public education initiatives about the harmful effects of tobacco use. Nations across the globe have already taken a positive step forward by agreeing to the Framework Convention on Tobacco Control. People must now take the next step by supporting fellow nations in implementing this agreement to ban tobacco marketing. Financial resources, capacity building and continued media attention are needed now more than ever. A healthier and more equitable world is possible in the future, but there is a long way to go.

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3) The role of the media in promoting and reducing tobacco use. NCI Tobacco Control Monograph No.19. Bethesda: National Institutes of Health; 2008.

4) DiFranza JR, Wellman RJ, Sargent JD, Weitzman M, Hipple BJ, Winickoff JP; Tobacco Consortium, Center for Child Health Research of the American Academy of Pediatrics. Tobacco promotion and the initiation of tobacco use: assessing the evidence for causality. Pediatrics. 2006 June ;117(6):e1237–48. doi: PMID: 16740823

5). Pierce JP, Choi WS, Gilpin EA, Farkas AJ, Berry CC. Tobacco industry promotion of cigarettes and adolescent smoking. JAMA. 1998 Feb 18;279(7):511–5. doi: PMID: 9480360

6) World Health Organization. Parties to the WHO Framework Convention on Tobacco Control.  Updated 26 July 2016. Retrieved from

7) Gilmore, Anna. Big tobacco targets the young in poor countries – with deadly consequences. The Guardian. 1 December 2015. Retrieved from

8) AMESCA regional plan 1999-2001. London: British American Tobacco: 1999. Available from: [cited 2014 Jul 15].

9) Lee S, Ling PM, Glantz SA. The vector of the tobacco epidemic: tobacco industry practices in low and middle-income countries. Cancer Causes Control. 2012 Mar;23(1) Suppl 1:117–29. doi: s10552-012-9914-0 PMID: 22370696

10) Perlman F, Bobak M, Gilmore A, McKee M. Trends in the prevalence of smoking in Russia during the transition to a market economy. Tob Control. 2007 Oct;16(5):299–305. doi: PMID: 17897987

11) Gilmore AB, Radu-Loghin C, Zatushevski I, McKee M. Pushing up smoking incidence: plans for a privatised tobacco industry in Moldova. Lancet. 2005 Apr 9-15;365(9467):1354–9. doi: 6736(05)61035-5 PMID: 15823388

12) Neuwirth B. Marketing channel strategies in rural emerging markets: unlocking business potential. [Internet]. Evanston: Kellogg School of Management; 2012. Available from: http://www.kellogg.northwestern. edu/~/media/files/research/crti/marketing%20channel%20strategy%20 in%20rural%20emerging%20markets%20ben%20neuwirth.ashx [cited 2013 Aug 15].

13) World Health Organization. Global Health Observatory (GHO) data: Prevalence of tobacco smoking. Accessed 1 December 2016. Retrieved from

14) World Health Organization. Prevalence of tobacco smoking. Accessed 1 December 2016. Retrieved from

15) World Health Organization. WHO global report on trends in tobacco smoking 2000 – 2025. Updated 2016. Accessed 1 December 2016. Retrieved from

16) World Health Organization. WHO global reports on trends in prevalence of tobacco smoking 2015. (2015). Retrieved from