Proper caloric and macro and micro nutrients intake has a significant influence in athletic performance among female artistic gymnasts (Applegate, 2001). Appropriate nutrition is an important portion of a female artistic gymnast’s training program because it provides the energy required by the body for optimizing performance during practice sessions and competitions (Achten et al., 2004). Following an adequate diet during the years gymnasts are engaged in extraneous exercise routines contributes for maintaining a healthy life after their athletic careers, delaying the effects of aging (Beals, 2002). Also, a balanced diet improves the immune system and enhances a person’s ability to concentrate (Applegate, 2001).

Although appropriate diet is extremely important for athletes, female artistic gymnasts are a group predominantly predisposed for engaging in unhealthy eating behaviors for weight management purposes (Benson & Gillie, 2001). In addition to the typical social pressure placed on females in general to be thin seen in the Western culture, these athletes are part of an environment that focuses on their bodies’ appearance (Nutter, 2000). Factors such as pressure from coaches, comparison with teammates, performance demands, aesthetics concerns, and physique-revealing uniforms are positively related to an increase in weight control practices in the sport context that female artistic gymnasts are inserted in (Yoon, 2002). Also, different researchers support the idea that the sport setting may contribute to heighten anxiety related to maintain a perfect body image and promote pathogenic eating behaviors among female gymnasts (Beals, 2002; Soares & Ribeiro, 2002).

The most common weight control practices observed among female artistic gymnasts are fasting and extremely low calorie intake (Phillips, 2004). Other methods include self-induced vomiting and the use of diet pills, diuretics, and laxatives (Hassapidou & Manstrantoni, 2001). Extremely low energy intake is associated with delayed puberty, growth problems, and amenorrhea, which has been shown to affect bone development among women (Beals, 2002).

In spite of the unquestionable importance of a balanced diet in terms of energy requirements and macro and micro nutrients for female artistic gymnasts, various researchers have demonstrated that there is a substantial lack of information about sport nutrition among artistic gymnastic coaches and athletes (Ziegler, Jonnalagadda, & Lawrence, 2001; Yoon, 2002). According to Beals (2002), it is not rare to find gymnasts with erroneous ideas about sport nutrition who engage in extremely low calorie diets in order to lose weight and modify their body composition and appearance (p.1934).

The interest in analyzing the food intake of female artistic gymnasts is attributed to the fact that even with evidences proving the importance of proper nutrition for athletic performance, many gymnasts neglect following a balanced diet. Many times, inappropriate weight control methods are adopted because of the lack of information about sports nutrition and/or constant concern about reaching a specific body composition (Applegate, 2001). Therefore, an analysis of the eating habits of female artistic gymnasts should be conducted in order to determine if their diet contains the proper amounts of calories and macro and micro nutrients.

1.1 Statement of the Problem

Appropriate nutrition is a key component on the athletic performance of female artistic gymnasts (Phillips, 2004). However, many athletes tend to adopt inadequate weight control practices that end up compromising their diet as a result of the constant concern with body composition and image (Burke, Gollan, & Read, 2001). Therefore, the goal of this paper is to answer the following question: On average, do females artistic gymnasts have a proper caloric and macro and micro nutrient intake based on their nutritional needs?

CHAPTER II

LITERATURE REVIEW

2.1 Artistic Gymnastics

According to the International Federation of Gymnastics, artistic gymnastics, also known as Olympic gymnastics is a sport in which athletes perform a set of exercises in different events. The movements of the gymnasts must be elegant and demonstrate strength, agility, flexibility, coordination, balance and control of the body. The events present in women’s artistic gymnastics are vault, uneven bars, balance beams, and floor. In 1881 the International Gymnastics Federation was founded and women’s artistic gymnastics entered the Olympics as a team event in 1928. After that, the participation of women’s teams in international gymnastics competitions gradually increased.

2.2 Body Composition

Body composition measurements are used to describe fat, bone, and muscle percentages in the human body (Berger & Shenkin, 2006). It is basically measured in terms of body fat percentage, which can influence athletic performance during competitions and training sessions (Applegate, 2001). Athletic performance in gymnastic is, to a large extent, dependent on the athlete’s ability to sustain power (both anaerobically and aerobically) and to overcome resistance. Both of these factors are interrelated with the athlete’s body composition (Burke et al., 2001).

Gymnasts with a higher body fat percentage than the desirable may be more prone to injury when performing difficult skills than athletes with a more optimal body composition. Also, excessive body fat can reduce speed and increase the metabolic cost of an action (Nieman et al, 2001). A high lean body mass, which is the sum of the nonfat parts of the human body like muscle, organs, blood and water, may aid athletic performance by improving the strength-to-weight ratio. A higher percentage of lean mass facilitate power production (Jonnalagadda, Nelson, Lawrence, & Bacick, 2002). A low body fat content also helps performance by lowering the resistance because the smaller the body profile, the less resistance the body is likely to produce. For example, a gymnast who weighs 110 pounds (50 kilograms) and is 5 feet (152 centimeters) tall with a body fat percentage of 15 percent will have a lower air resistance tumbling through the air than a gymnast with the same weight and height but with a body fat percentage of 20 percent (Burke et al., 2001).

However, many gymnasts when attempting to achieve an optimal body composition use counterproductive methods (Economos, Bortz, & Nelson, 2003). Diets and excessive training often result in such a severe energy deficit that, although total body mass may be reduced, the constituents of weight also change, commonly with a lower muscle and a relatively higher fat percentage (Singh, Evans, Gallagher, & Deuster, 2003). The resulting higher body fat and lower muscle mass is associated with performance reduction that motivates the athlete to follow regimens that produce even greater energy deficits, which can place gymnasts at serious health risk (Nutter, 2000).

2.3 Macronutrients

There are two types of essential nutrients, macronutrients and micronutrients.  Carbohydrates, proteins, and lipids are the three types of macronutrients (Burke et al., 2001). Macronutrients are the substrates required to maintain the different energy systems responsible for energy production in the body. Each macronutrient produces distinct amounts of energy and plays a unique role during extraneous physical activity (Baechle & Earle, 2008). In general, in a balanced diet 55-75% of the total energy comes from carbohydrates, 12-15 % from proteins and 25-30 % from lipids (p.74). A diet should be adjusted to the specific needs of each gymnast. Many aspects should be considered when prescribing a diet to an athlete, such as weight, height, sex, body fat percentage, age, metabolism and the type, frequency, intensity, and duration of training (Nutter, 2000).

2.3.1 Carbohydrates

Carbohydrates are the most important source of energy for athletes because they provide adenosine triphosphate (ATP) for muscle contractions (Baechle & Earle, 2008). Once ingested, carbohydrates are broken down into smaller sugars, such as glucose, that are absorbed by the body and utilized as energy (p.76). Glucose molecules that are not immediately needed, get stored in the muscles and liver in the form of glycogen. Glycogen forms an energy reserve that can be quickly mobilized to meet a sudden need for glucose (Phillips, 2004). In the liver cells, glycogen can compose up to 8% of the fresh weight (100-120 g in an adult) soon after a meal. Only the glycogen stored in the liver can be made accessible to other organs. In the muscle, glycogen is found in a much lower concentration (1% to 2% of the muscle mass), but the total amount exceeds that in the liver (Baerchle & Earle, 2008).

Since ATP and muscle glycogen are immediately accessible in the muscle, they are the main fuels utilized for short and intense bouts of exercise, such as the ones performed by gymnasts (p.90). A short duration and high intensity exercise period is classified as an anaerobic, which utilizes primarily anaerobic pathways for energy production (without oxygen). There are two types of anaerobic energy systems: ATP and creatine phosphate (phosphagen) system and anaerobic glycolysis (p.80). Creatine phosphate molecules, which quickly re-synthesize ATP in the muscle cells, are stored in very limited quantities (Ziegler et al., 2001). So, the phosphagen energy system can only provide fuel for the muscle for approximately thirty seconds. After that, energy will be primarily produced by the anaerobic glycolysis process (Singh et al., 2003). Anaerobic glycolysis exclusively uses glucose as a fuel in the absence of oxygen or more specifically, when ATP is needed at rates that exceed those provided by aerobic metabolism (energy production with oxygen). The result of rapid glucose breakdown is the formation of lactate (Baerchle & Earle, 2008).

According to Singh et al (2003), glycogen has four main purposes in the body: functioning as a source of energy for muscles, sparing protein consumption, working as metabolic activator, and providing fuel for the brain (p.329). Muscular glycogen depletion leads to lower levels of blood glucose and liver glycogen (Singh et al., 2003). During prolonged physical activity, insulin secretion from the pancreas decreases, while glucagon and catecholamine concentrations in the blood increase. Catecholamine are hormones (adrenaline, noradrenalide and dopamine) released by the adrenal gland. Together with glucagon they stimulate the breakdown of liver glycogen, a process called glycogenolysis (Achten et al, 2004).

When glycogen storages reach a very low level, energy is originated from gluconeogenesis, an energy production process in which amino acids, lactate, and glycerol are converted into ATP for muscle contraction (Baechle & Earle, 2008). This process becomes an important source of energy during periods of prolonged exercise and low carbohydrate intake. In extreme condition, gluconeogenesis can cause a significant reduction in the lean body mass, which is associated with higher production of nitrogenous wastes (bi-products of protein breakdown) (Jonnalagadda et al., 2002).

One way of classifying carbohydrates is based on the glycemic index (GI), which is a measure of the effect of a carbohydrate rich food on blood glucose levels relative to glucose. Carbohydrates that break down quickly during digestion, releasing glucose rapidly into the bloodstream, have a high GI; carbohydrates that break down more slowly, releasing glucose more gradually into the bloodstream, have a low GI (Singh et al, 2003). A lower glycemic response is associated to a smaller insulin demand. Glucose and white bread are used as reference foods and have a glycemic index of 100. The glycemic index is determined by measuring the postprandial glycemia (glucose levels after a meal) for a time interval of two hours after the ingestion of 50g of a specific food (Berger & Shenkin). A glucose response curve is plotted depicting the relationship between blood glucose elevation and time. The area of the curve above the fasting level is measured and divided by the area of the curve of the standard food (either glucose or white bread) and multiplied by 100 (Jonnalagadda, 2002).

Up to two hours prior exercise, a meal that is rich in carbohydrates of low (milk and vegetables) or moderate GI (fruits) is preferred instead of one with a high GI. Foods with low to moderate GI will maintain the energy level balanced and avoid energy peaks by keeping the blood glucose and insulin levels low (Burke et al., 2001). In addition, these foods tend to be lower in fat and contain more vitamins, minerals and fiber than the ones with a high GI. Also, low to moderate IG foods promote glycogen storages, which will consequently improve performance during competition or practice session (Benson & Gillie, 2001).

Carbohydrate intake after physical activity is extremely important because it will replenish glycogen storages used during exercise (Burke et al, 2001). Also, after physical activity cells become more sensitivity to insulin, increasing glucose uptake by the tissues. After physical activity, muscle and liver glycogen is completely replenished in 24 hours. Therefore, adequate carbohydrate intake is extremely important for athletes (Nutter, 2000). According to Economos et al. (2003), 50 to 55% of the total caloric intake should come from carbohydrates. Other authors believe that the carbohydrate percentage in the diet of artistic gymnasts should vary from 55 to 75% of the total calories (p. 388). The American Dietetic Association (ADA) recommends a daily intake of 150 to 175 grams of carbohydrate for each 1000 calories consumed (Yoon ,2002). Lastly, the American College of Sports Medicine (ACSM) suggests that more than 55% of the total calories should be in the form of carbohydrates (Beals, 2002).

2.3.2 Proteins

Proteins are composed of one or more amino acids. A typical protein contains 200-300 amino acids but some are much smaller (the smallest are often called peptides) (Beals, 2002). More than 300 different types of amino acids are found in nature but only 20 exist in the human body. Among these 20 amino acids, eight are essential, which means that they cannot be synthesized by the body. The others are called non-essential amino acids, since they are produced by the organism (Phillips, 2004).

When the body does not have enough carbohydrate, protein is broken down to produce glucose for energy (Baerchle & Earle, 2008). Adequate carbohydrate intake helps prevent protein from being used as energy. Because the primary role of protein is to function as the building blocks for muscles, bone, skin, hair, and other tissues, relying on protein for energy (by failing to take in adequate carbohydrate) can limit the athlete’s ability to build and maintain tissues. Additionally, utilizing protein as an energy source stresses the kidneys because they have to work harder to eliminate the byproducts of protein breakdown (Soares & Ribeiro, 2002).

In the body, proteins play other important roles such as functioning as hormones, enzymes and neurotransmitters, participating in the process of energy production, and regulating several metabolic pathways important during physical activity. Amino acids also have a small participation in energy production during extenuating physical activities (Economos et al., 2003). Whereas carbohydrates provide more than 80% of the fuel utilized in the metabolic pathways, amino acids contribute for only 5 to 10% in physical activities of long duration (Jonnalagadda et al., 2002). The recommended protein intake for gymnasts is around 1.1 grams/kg of body weight or 12 to 15% of the total caloric intake (Burke et al., 2001).

2.3.3 Lipids

The main lipids in the human body are triglycerides, phospholipids, steroids, and lipoproteins. Triglycerides, which are composed by one glycerol molecule and three molecules of fatty acids, are the most common lipids in the diet and are stored by the body (Nieman, 2001).

During a prolonged exercise period, such as a long gymnastic practice, stored triglycerides in the adipose tissue are broken down into fatty acids and glycerol by the enzyme lipase (Economos, 2003). Adrenaline and glucagon secreted in response to low levels of blood glucose stimulate the release of triglycerides from the adipose tissue. High levels of insulin and blood glucose have the opposite effect, since it is associated with the deposit of triglycerides in the adipose tissue (Singh et al, 2003). Glycerol is phosphorylated in the liver into glucose-6-fosfate, resulting in substrate for the formation of glucose (glyconeogenesis) (Baerchle & Earle, 2008). The American Dietetic Association (ADA) recommends that 30% of the total caloric intake should come from lipids. The American College of Sports Medicine (ACSM) suggests a lipid intake of 25-30% of the total caloric intake.

2.4 Micronutrients

Vitamins and minerals play an important role in regulating energetic pathways, contracting and building muscles, functioning as antioxidants, and participating in the immunologic system (Economos, 2003).

2.4.1 Minerals

Minerals represent 4% of total body weight. The two most important minerals in the diet of athletes are iron and calcium because the body concentrations of these are more likely to be affected by intense training periods. Also, they play significant roles in athletic performance (Singh et al., 2003).

Calcium plays an important role in muscle contraction. It is stored in the sarcoplasmatic reticulum of muscles and released when muscles fibers are stimulated, forming actine-miosine bridges and causing the muscle to contract (Yoon, 2002). Besides, according to Phillips (2004), there is a correlation between a poor diet in calcium and the occurrence of stress fractures. Low calcium levels in the diet of female athletes are also related to the incidence of earlier osteoporosis than in the average women after menopause (Nutter, 2000). Athletes should have a daily intake of calcium equal to 1.2 grams (Achten et al., 2004).

Besides calcium, iron is also significant in the diet of athletes. Since iron is found in the hemoglobin and myoglobin, lack of this mineral directly affects oxygen transport in the blood and to muscles (Beals, 2002). Iron deficits in the body can cause anemia, condition in which hemoglobin is reduced in the blood and red blood cells become small and pale (Berger & Shenkin, 2006). Common symptoms associated with iron-deficiency anemia are: slow recover after physical activity, irritability, tiredness, depression, insomnia, and consequently a decrease in athletic performance (Beals, 2002). For female athletes the recommended dietary intake of iron is 18mg/day (Baerchle & Earle, 2008).

2.4.2 Vitamins

Vitamins A, D, E, and K are denominated lipossoluble and vitamins B1 (thiamin), B2 (riboflavin), niacin (B3), pyridoxine (B6), cobalamin (B12), pantotenic acid, and vitamin C are called hydrosoluble (Willmore & Costill, 2001). Vitamins from the B complex function as co-factors and coenzymes in reactions related to the energetic metabolism, such as glycosis, tricarboxylic acid cycle, and beta oxidation of fatty acids (Singh et al., 2003).

Vitamin C is important for iron absorption and plays an important role in the synthesis of collagen, carnitine, epinephrine, and serotonin (Yoon, 2002). Vitamin C, E, and beta-carotene (precursor of vitamin A) function as antioxidant, protecting the organism against infections and preventing any harm that free radicals (toxic substances released during physical activity) may cause to tendons and ligaments (Nutter, 2000). Therefore, a proper intake of beta-carotene and vitamin C and E are important in the diet of athletes, since they will help in the elimination of free radicals. Lack of vitamin C may cause muscular weakness, decrease lipid breakdown, and increase occurrence of injuries (Applegate, 2001). Restrictions in energy and nutrient intake in the diet of gymnasts may cause lack of vitamins in the body (Mullinix, Jonnalagadda, Rosenbloom, Thompson, & Kicklighter, 2003).

2.5 Caloric Intake

Energetic expenditure is determined by the thermic effects of food (5-10%), basal metabolic rate (60-65%) and intensity, duration, and frequency of physical activity (25-35%). The thermic effect of food is the energy required to process and store nutrients for use. The basal metabolic rate (BMR) is the amount of energy spent by the body at rest to maintain in the vital organs functioning. A low body fat percentage and a high muscle mass increase BMR (Baerchle & Earle, 2008).

Female artistic gymnasts should have a caloric intake adequated to their energy expenditure in order to maximize proper performance, body composition, and health (Phillips, 2004). A low energy intake or an inadequate diet in terms of macro and micro nutrients may result in improper intake of important nutrients for the energetic metabolism and muscle tissue regeneration (Ziegler et al., 2001). Female artistic gymnasts usually practice for long periods (5 to 6 hours a day), which results in high energy expenditure, so they should have a caloric intake of 40-45 kilocalories/kilogram of body weight (Economos et al., 2003).

Excessive concern with body image and weight control may affect caloric intake among female artistic gymnasts (Ziegler et al., 2001). Inadequate energetic consumption and eating disorders are frequently seen among athletes who participate in sports in which performance is associate to low body weight, such as ice skating and gymnastics (Ziegler et al, 2001; Yoon, 2002). Soares & Ribeiro (2002) reported that 75% of gymnasts who have been told to be overweight from their coaches adopted strong measures in order to loose weight. Therefore, coaches play important roles in avoiding extreme weight control measures and consequently excessive low calorie diets among gymnasts. Also, female artistic gymnasts should consult with sports dietitian in order to minimize this type of problem (Hassapidou & Manstrantoni, 2001).

2.6 Eating Behavior:

Benson and Gillie (2001) evaluated the eating habits of 32 female artistic gymnasts (20 to 24 years old) from six different gymnastics schools in Canada based on their food intake of three distinct days in which they had normal practice schedules. The average caloric intake (2,838 calories (kcal)/day) was relatively low compared with the energetic recommendation for female artistic gymnasts. Besides, 40% of the athletes had diets that were low in calcium, folic acid, vitamin E, and pyridoxine and 53% showed a low iron intake. On average, the diet of athletes was constitued of 15% of proteins, 36% of lipids, and 49% of carbohydrates (p.83).

Mullinix et al. (2003) analyzed the dietary intake of 13 members of two different collegiate women’s artistic gymnastic teams (19 to 25 years old) based on the dietary intake of six days collected during 2 weeks. The average caloric intake was equal to 1,845kcal/day and athletes presented a lower caloric intake inferior to the recommendation, like the previous study. Fifty-five percent of athletes consumed less than 50% of the recommended intake for pyridoxine, folic acid, calcium, and iron (p.590).

Yoon (2002) also studied the eating habits of ten collegiate athletes using the food intake and activity level of three days. It was estimated on average the daily energy expenditure was 2,855kcal/day. However, the caloric intake was, on average, only 1,357kcal/day, representing a deficit of 1,498 calories per day. More than 50% of the gymnasts had a low intake of calcium, iron, and vitamin A (p.1553)

In a study conducted by Ziegler et al. (2001), twenty American gymnasts (22 years old on average) recorded their food intake during three days in which they had training. After analysis, it was possible to conclude that, on average, there was a lack of vitamins A, D, folic acid, calcium, magnesium, phosphorus, and zinc. One fourth of the athletes were taking vitamin supplements. The average caloric intake was equal to 1,771kcal/day (56g of proteins, 75g of lipids, and 218g of carbohydrates) (p.106).

In a study conducted by Soares and Ribeiro (2002), the food intake of 20 Brazilian gymasts was evaluated (18-20 years old). In order to analyze the eating behavior of athletes, the authors recorded their food intake for three days and asked participants to do a 24 hour food recall. The average caloric intake was equal to 1,521kcal/day. The carbohydrate content in their diet ranged from 50% to 58% and the protein intake from 15% to 19%. On average, there was a deficit of calcium (45% below the recommendation), magnesium, iron, and zinc (p.350).

Hassapidou & Manstrantoni (2001) compared chances in the diet of 25 Greek female artistic gymnastics between competitive and non-competitive stages of training. Authors reported that there was no variation in the diet among these two different periods. In both stages, there was a negative energy balance in the diet of 68% of athletes, which was below the recommended caloric intake for gymnasts. Protein intake and micronutrient intakes were, on average, within the recommendation for athletes. Adequate micronutrient intake was attributed to the high consumption of vegetables and fruits, which is a characteristic of the Mediterranean diet (p.395).

3. CONCLUSION

In order to achieve a good performance, female artistic gymnasts should adopt a balanced and adequate diet. Athletes should have a varied diet that provides them with proper caloric and macro and micronutrients intake. Factors, such as pressure from coaches to keep a perfect body composition lead many gymnasts to adopt inappropriate weight control methods. In the last decade, eating behavior of gymnasts has caught the attention of many researchers in the field of sports nutrition and exercise science. Recent studies have indicated a constant anxiety related to weight control among many gymnasts, which frequently results in inappropriate eating habits and extremely low calorie diets compared to the recommendations.

The studies presented showed that, on average, gymnasts follow low calorie diets, which are below the recommended caloric intake and do not provide athletes with the proper amounts of macronutrients. Besides, also according to the studies there appears to be a low mineral and vitamin intake in the athletes’ diet. As a result, performance is very likely to be compromised since appropriate nutrition is essential for optimal functioning of the body and health. The only exception was the study conducted by Hassapidou & Manstrantoni (2001), in which Greek gymnasts had an adequate intake of micronutrients. This can be attributed to the fact that athletes were probably eating according to the Mediterranean diet, which is rich in fruits and vegetables.

In conclusion, the analysis of the studies showed that, on average, the eating behavior of female artistic gymnasts does not follow the nutritional recommendations and adequate intake of calories and macro and micro nutrients. For future studies, in order to improve their eating behavior and mindset about body image, the food intake of athletes should be evaluated after exposure to psychological counseling and nutritional reeducation for a reasonable period of time.

In consideration of the known gaps in access to mental health care for veterans, there have been many initiatives that have been put in place to address and bridge these gaps. One initiative in particular is called Healthcare, Evaluation, Advocacy, and Legislation (HEAL), which helps by connecting veterans to case-managers provided by the private veterans’ group called AMVETS, or American Veterans, a federally chartered veteran’s organization and corporation. AMVETS has partnered with the Department of Veterans Affairs (VA) in an attempt to help U.S. veterans who suffer from mental illness and have had issues with accessing and/or utilizing healthcare services. This initiative has many elements to it, which involves reaching out to veterans through various public forums and hiring the case managers to assist in getting veterans connected to healthcare services by working with the VA to coordinate services, and is not limited to services within the VA, but outside as well. Additionally, the initiative included the introduction of a telephonic hotline, allowing veterans to reach out to licensed clinicians if they choose to do so themselves.

The ultimate goal of this initiative is to help veterans with medical needs receive the help they need by connecting them with healthcare services to include mental health as well as specialized services that deal with other illnesses or disorders like traumatic brain injuries and post-traumatic stress (PTSD). The AMVETS Heal Program believes that our vets have earned their right to quality healthcare, and they intend to ensure all veterans have the access and assistance they need. War and prolonged exposure to combative environments certainly takes its toll and inflicts permanent damage to the human psyche which manifests itself by developing illnesses and disorders such as depression, anxiety, PTSD and the likes, which is why veterans are at a higher risk of suicide than their civilian counterparts (Fox, 2018). The HEAL program created their goals in an effort to address and lessen the barriers that veterans face when accessing healthcare, and more importantly in obtaining the quality of care they deserve, especially when it comes to socioeconomic issues such as addiction and suicide (amvets.org).

The way in which they plan on meeting this goal includes increasing access to healthcare, whether inside or outside of the VA, for all veterans and especially the ones suffering from particularly bad health situations to decrease the likelihood of veteran suicides and move toward a multifaceted system that is effective and consistent with a focus on continuous improvement in the delivery systems and services. AMVETS hired experienced clinical specialists and registered nurses to assist with the program by helping veterans overcome the aforementioned barriers to healthcare access and connecting them to much needed services. By improving appointment wait times, offering work and housing related help, and making it easier for veterans to receive and utilize all sides of health services, AMVETS believes that the overall health of veterans can progress and improve, and in doing so may also reduce the social, societal, and cultural stigma surrounding mental health.

Many factors were considered throughout the inception and development of the HEAL Program, but the biggest in particular is the suicide factor that may result from the failure to receive proper care. AMVETS grasped the reality of vets’ vulnerability and increased susceptibility to homelessness, joblessness, mental illness, substance abuse, and suicide, and was also very aware of the mental illness stigmas within the military and societal cultures that posed a great barrier to vets accessing and receiving much-needed care. With that in mind, AMVETS’ mission, according to their Strategic Plan, was to network with other local, county, state, and federal agencies/governments as well as the community on a voluntary basis to ensure each veteran had the support they needed to mitigate and eliminate any potential negative outcomes of not receiving the appropriate care (amvets.org). As mentioned previously, the goal is to connect veterans with healthcare services to manage and treat any mental and physical needs both in and outside of the VA; in addition to this, the program collaborates with healthcare providers within the private sector as well to guarantee all avenues are explored.

Another consideration of this initiative was the proper implementation of the hotline. Despite the massive costs, it was important to the program that all hotline staff were registered, licensed clinicians offering professional guidance and assistance to those who opted to utilize the free service. According to AMVETS Chief Strategy Officer, Sherman Gillums Jr., “staffing up with clinicians is worth the expense because the expertise is meaningful to those who are more at risk.” The cost to make this happen is roughly $700,000.00 (Athitakis, 2018), which is what sets this particular initiative apart from some of the others. By creating a hotline that guarantees each call to be received by health care professionals with the expertise in clinical matters, it offers a feeling of comfort and safety knowing that there are professionals on the other end that have the tools and resources to truly assist in meeting their needs. They are also working toward creating chat and electronic mail options in an effort to widen the ability for vets to obtain resources.

One last consideration for the development of this initiative was to take the proper steps and precautions to ensure that any barriers that may have hindered veterans’ ability to access healthcare were addressed and eliminated. In the efforts to acquire equity and quality of care, it was important that barriers such as appointment wait times, technological barriers, stigmas, and other potential barriers surrounding the lack of community awareness and participation were seen to in order to make the initiative a success, which is why partnerships and collaborations with other agencies and departments were vital throughout the programs beginnings and continuous development.

There are many resources that are required to fund this initiative, but the biggest resources are those that come from the partnerships and collaborations with state and local governments, who take on vital roles in the organization and finance aspects, as well as the delivery of veteran services within the program. The HEAL Program also coordinates with resources such as Objective Zero, Veterans Crisis Line, VA Office of Mental Health, Cohen Veterans Network, and VA Veterans Experience Office (American Veterans Department of Illinois, 2018). According to AMVETS Strategic Plan, the “behavioral health treatment and service funds flow from the state health authority or single state agency to counties or regions within the state, and these funds are then awarded to various service providers to deliver care.” (amvets.org). In addition to counties, territories, states and other local governments, funding and resources also come from local communities by charities and collecting donations to support veteran-related programs. Scholarships and grants are also awarded/allocated to the program/organization.

On Tuesday, March 5th, 2019, President Donald Trump signed an executive order that consists of a Cabinet-level task force meant to assist in tackling the prevention of veteran suicides (CNN, 2019). This measure is called the PREVENT initiative, which is short for President’s Roadmap to Empower Veterans and the National Tragedy of Suicide, and was created to come up with legitimate plans to prevent veteran suicides across the board and to include not just community, local, and state involvement, but also to include the involvement of federal agencies and Congress. The coordination and collaboration with Congress is key in this measure. The task force consists of secretaries from several governmental agencies, including the Department of Veterans Affairs, Department of Defense, the U.S. Department of Health and Human Services, as well as Homeland Security, and will be instrumental in allocating grants to state and local governments while simultaneously keeping an eye on any trends regarding veteran suicides (Krause, 2019). In addition to the already existing partnerships, coordinations, and collaborations that the Heal program has with so many local, state, and federal organizations, this is just one more great addition to the list of resources that will help fund and maintain the AMVETS Heal Program initiative.

The somewhat newly born AMVETS Heal Program, whose primary purpose is to tackle the trend in suicide rates amongst veterans with no access to healthcare, may still require some improvement. Since its implementation of the hotline, it seems the services they offer have been in high demand. To accommodate the vastly growing need for their services, they extended the hours of operation for the hotline (amvets.org); however, it calls in to question whether the expansion may be enough to make the intended impact.

An even bigger issue the initiative has been presented with are the challenges that have come up since the launch of the program and its partnership with the VA. One reason that many U.S. Veterans fail to obtain and receive healthcare services from the VA is because of the overwhelming enrollment process, which is so convoluted that they are then discouraged from seeking the care they require due to the highly involved eligibility determination processes (Walsh, 2018). This issue has since been spotted by the White House, and in an effort to address it, an executive order was made which now requires vets to be automatically enrolled in mental health care for twelve (12) months.

Despite the efforts, funding, and plethora of resources being applied toward this initiative, there still seems to be no change in the rate of suicides among veterans. In 2015, the Clay Hunt Suicide Prevention for American Veterans Act was enacted following a 2011 suicide of an activist for United States Marine Corps (USMC) veterans (Shane, 2019). This act requires the VA, AMVETS’ main partnership, to provide a report called “VA Mental Health Program and Suicide Prevention Services Independent Evaluation”, which is meant to serve as a thorough analysis and overall review of mental health care and suicide prevention programs on an annual basis. This evaluation was put into place as a way to track the progress, impact, and efficacy of suicide prevention programs, as well as highlight any potential trends surrounding veteran suicides. Up until now, the VA states that the outcome has been generally positive; however, according to the 2018 Annual Report, the suicide rates of veterans have not decreased and there is no evidence toward improvement (amvets.org).

While there may be many improvements to be made within this initiative and the partnerships and collaboration AMVETS has with the VA and other agencies/organizations, it seems as though this particular gap in healthcare has even captured the attention of the White House and other U.S. officials. With the implementation of federally-governed executive orders, measures, and other iniatives, comes additional resources and funding, which will hopefully contribute to the AMVETS Heal Program purpose in bridging this gap and ensuring that U.S. veterans are taken care of.

References:

• Fox, M.. (2018, June 18). Veterans die by suicide at greater rates, VA finds. Retrieved May 28,

  2019, from https://www.nbcnews.com/health/health-news/veterans-more-likely-civilians-

  die-suicide-va-study-finds-n884471

• AMVETS (n.d.). AMVETS Heal Program. Retrieved May 26, 2019, from

  https://amvets.org/vet-heal/.

• Athitakis, M. (2018, May 15). AMVETS Partners With VA to Address Veteran Suicide Crisis.

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• American Veterans Department of Illinois (2018, October). AMVETS, VA Formally Partner to

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• CNN. (2019, March 06). President Trump signs measure aimed at preventing veteran suicides.

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Health Promotion is the process of enabling people to have a control over their wellbeing—physical, emotional, socio-cultural and spiritual. Without encouragement from health professionals, improvement of health and reduction of the incidence of illnesses and disabilities is impossible to attain. Thus, health strategies in promoting health must take priority. In this paper, a health promotion plan on Heart Disease in Women, which is one of the objectives of the New Zealand Health strategies will be presented.

New Zealand has a growing frequency rate of heart disease mainly because of its rising population, an ageing population and lifestyle variations such as smoking, having secondary lifestyle or physical inactivity and changes in diet. According to the Ministry of Health (2014), heart disease is the number one cause of mortality in New Zealand and is responsible for 30% death cases per year. One dies from heart disease every 90 minutes, giving a total number of 16 deaths per day in New Zealand.

The Health Strategy for New Zealand gives a background for the health sector to inflate the total health status of New Zealanders and to lessen inequalities amongst New Zealanders. The unequal distribution of social determinants in terms of age, sex, hereditary factors, financial, education, occupation and housing conditions are associated with health inequalities. According to Ministry of Health (2012), “addressing these social determinants of inequalities requires a total health approach that takes justification and explanation of all the influences on health and in what way they can be commenced to improve overall health status. This method necessitates both intersectoral action that addresses the social and economic determinants of health and action within health and disability services.”

Ministry of Health (2012), recommend philosophies in health that should be applied to any activities to safeguard inequalities in health in those activities. In the proposed framework, it includes making and imposing extensive strategies which are the following:

1. Structural – social, financial, national and historical health inequalities root grounds identification
2. Intermediary pathways – comprises psychosocial and behavioral factors that intercede the influence of structural factors on health
3. Health and disability services – it is a thorough actions undertaking
4. Impact – on socioeconomic situation minimization (MOH, 2012)

Further, the key to Health Promotion here in New Zealand is the founding document of the Treaty of Waitangi. It is an agreement between the relationship of the Crown and the Maori. The crown represents the non-Maori people and the New Zealand government. The treaty of Waitangi is a document that provides the framework of Maori and non-Maori health development and well-being. This is to ensure that both parties are equally respected in terms of providing their health care needs. Also, to reduce the incidence of inequities between the Maori and Non-Maori, it is very important to acknowledge the Treaty of Waitangi and the treaty principles which is

participation, partnership and protection

.

In participation, it emphasizes the involvement of Maori in planning, monitoring and evaluating programs. While the principle of partnership, refers to the relationship of Maori and non-Maori in making health plan, policies and programs. In making all these strategies and health promotion, it is important to include the principle of protection. This is to ensure that the interest of the Maori is protected and both Maori and Non-Maori have equal health status and outcomes (Ministry of Health, 2003).

Moreover, the Ottawa Charter was first created during the first international conference on Health Promotion which was held in Ottawa, Canada in November, 1986. It is the key founding document of health promotion in New Zealand. This framework has provided a useful tool guide for actions and implementation of health promotion (Ministry of Health, 2003).

Health Promotion Plan on Women’s Heart Disease

The annual plan includes assessment, prevention and control programs, monitoring and evaluation, indirect management and administrative operations.

Goal

: The program aims to reduce the incidence of Women’s heart disease and control its complications by ensuring that Women in New Zealand have opportunities to access the health services/ programs.

General Objectives

:

1. To conduct health assessment of women who are at risk for developing heart disease;
2. To implement prevention and control program, such as eat well and be heart healthy, stretch and sweat, and fight against tobacco related death;
3. To monitor and evaluate improvement of health and effectiveness of programs;
4. To ensure practitioners are skilled and well-trained to be efficient in providing health promotion campaigns and education;
5. To support operations in the conduct of the programs;

Health Control and Prevention Programs

Title:



How’s your heart? Heart disease assessment and education

Rationale:


Screening tests and knowledge on heart disease are the keys to prevent cardiovascular disease (American Heart Association, 2014). Regular screening tests should begin at age 20 because this would serve as an eye-opener for women to modify their lifestyle or make necessary changes to prevent development of heart diseases. Education provides knowledge to women on how to make heart healthy and how to prevent heart diseases

Goal:


To provide free heart screening services in public health hospitals or centers monthly and provide regular health education campaigns and educational materials such as brochures, flyers, posters, pamphlets.

Target population:


Women living in New Zealand starting age 20.

Strategies:

Actions:


Communicate and ask support to the Ministry of Health and Board of Trustees of the hospital for the implementation of the program, Involvement of Maori, Pacific, and other locals or migrants to support, contribute and participate in program development.

Range of Activities:


Vital screening tests are blood pressure, body weight, Fasting Lipoprotein Profile (cholesterol and triglycerides), blood glucose.

Health Education

Settings:


Public Health Hospitals and Community Health Centers for the screening, University and Workplace for Education and a door-to-door campaign

Title:



Eat well and be heart healthy

Rationale:


Improving nutrition to reduce the prevalence of weight gain or obesity, a precursor to heart disease takes priority and be addressed (Willett, Koplan, Nugent, Dusenbury, Puska, & Gaziano, 2006). In New Zealand, obesity is also one of the targets Health Strategies.

Goal:


To ensure mothers’/ women’s class shall be conducted to provide adequate knowledge on proper diet and menu preparation.

Target population:


Women living in New Zealand starting age 20.

Strategies:

Actions:


Communicate and ask support to the Ministry of Health and Community authorities for the implementation of the program, Involvement of Maori, Pacific, and other locals or migrants to support, contribute and participate in program development.

Range of Activities:


Healthy food policy development, Food diary and menu planning, Health Education

Settings:


Public Health Hospitals and Community Health Centers, University and Workplace for Education and a door-to-door campaign

Title:


Stretch and Sweat Activities

Rationale:


Sedentary activity among women is known to be a major risk factor in developing heart disease next to smoking. In the year 2009, 246 New Zealanders had premature death caused by lack of physical activity). Failing to do physical inactivity can highly contribute to another risk factor like high cholesterol and high blood pressure. Sedentary activities may lead to poor health outcomes (Auckland Council, Waikato Regional Council, and Wellington Regional Strategy Committee, 2013).

Evidently, active physical activities are beneficial to maintain a good health. It is helpful for maintaining a healthy heart and body. It is not only considered to be a preventive measure, but also a treatment itself (Auckland Council, Waikato Regional Council, and Wellington Regional Strategy Committee, 2013). According to Heart Foundation (2004), active physical activity can reduce up to 50% of incidence and fatality rate of heart disease. While, those with existing heart disease will have 25% decrease chance of dying from another heart attack.

Goal:


To incorporate 30 minutes of moderate to intense physical activities into the daily activities of women at least 5-7 times a week (Heart Foundation, 2004).

Target Population:


To achieve a maximum health benefit, it is important for people to be physically active

.

According to Active New Zealand Survey (2015), they identified that women are most likely to be inactive than men. This is due to the different factors that hinder them from participating in any physical activities. As stated by the World Health Organization (2015), lower income of women may be a barrier to access physical activity. Aside from that, women have limited time to engage in physical activities because of their caregiving roles at home.

Strategies:

Actions:


Communicate and ask support to the Ministry of Health and Community authorities for the implementation of the program, Involvement of Maori, Pacific, and other locals or migrants to support, contribute and participate in program development.

Range of Activities:


Free yoga every Tuesday and Thursday morning and afternoon, Free Zumba class during weekends, Fun run activities and bike and hike activities

Settings:


Parks and open fields

Title:


Fight against Tobacco related death

Rationale:


According to the Ministry of Health, the main cause of avoidable morbidity and mortality in New Zealand is tobacco use. It is responsible for an estimated 4,300 to 4,600 deaths per year and it contributes considerably in the development of some heart disease. Tobacco consumption is one of the health inequalities in New Zealand as increased smoking incidence are seen amongst groups that have low income.

On the other hand, approximately 1.3 billion individuals uses tobacco worldwide and it causes five million premature deceases annually. At the present stage, it is responsible for the mortality ratio of one in ten adults worldwide. As per WHO (2014), tobacco usage will result in to 10 million deaths annually by year 2020 if present patterns remain.

Goal:


The three key objectives of tobacco control strategies are to lessen initiation of smoking, to double the likelihood of quitting and to lessen the exposure to second- hand smoking.

Target Population:


The no smoking strategies are intended to become routine practice for all health care workers in connection to those individual who smoke. Nevertheless, within the population of individual who consumes tobacco there are specific target population. These are Maori and Pacific people as these population display considerably increase incidence of tobacco use compare to other population. New Zealand Health Survey 2013, found out that Maori women were two times probable to be a smoker in comparison in women in entire population while both Maori and Pacific men were 1.5 times probable to be smoker in comparison in the entire population.

Another important target population are parents’ ages 15 to 45 years of age. Helping parents to stop smoking is vital to further lessening smoking initiation by children and young age.

Strategies:

Actions:


Communicate and ask support to the Ministry of Health and Community authorities for the implementation of the program, Involvement of Maori, Pacific, and other locals or migrants to support, contribute and participate in program development.

Range of Activities:


Health Education, Smoke free celebration activities, individualized quit smoking plan, house-to-house monitoring, also promotion of nicotine replacement therapy.

Nicotine Replacement Therapy comes in five forms that has been approved by the Food and Drug Administration. These are nicotine patches (transdermal nicotine system), nicotine gum (nicotine polacrilex), nicotine nasal spray, nicotine inhalers and nicotine lozenges.These are locally available which can be consumed for eight weeks, and double the chances of quitting as these will diminish smoking cravings without affecting one’s health.

Monitoring and Evaluation:

Each program must be monitored and evaluated whether effective or not in order to modify the program and conduct research studies on how to improve health.

Indirect management and administrative operations:

Attendance to meetings, convention, trainings, and summit is very important to ensure that the practitioners are skilled and effective in promoting health on heart disease.

Support to operations:

The funding and budget allocated for the health programs, which includes the education and campaign materials

By and large, health promotion is critical in the health care delivery system, and that must be practiced to prevent or eradicate onset of diseases. Further, the involvement and consultancy of the people in the community in the development of programs are extremely significant to identify health threats and problems properly, and make necessary intervention programs tailored to their needs. Consequently, would address and prevent health inequalities and improve health outcomes.

References

Auckland Council, Waikato Regional Council, Wellington Regional Strategy Committee. (2013).

Information for General Practice on Physical Activity and Heart Disease.

Retrieved on March 30, 2015, from

http://wellington.govt.nz/~/media/about-wellington/research-and-evaluation/people-and-community/2013-costs-physical-inactivity-regional-accounting-perspective.pdf

Active New Zealand Suvey. (2015).

Part 1: How active are we? how active do we want to be?

Retrieved on March 30, 2015, from

http://www.activenzsurvey.org.nz/Results/NZ-Sport-and-Physical-Surveys-9701/SPARC-Facts-97-01/Part-1/

American Heart Association. (2014). Heart-Health Screenings. Retrieved on March 30, 2015 from

http://www.heart.org/HEARTORG/Conditions/Heart-Health-Screenings_UCM_428687_Article.jsp

Heart Research Institute. (2013).

Heart Disease in New Zealand.

Retrieved on March 18, 2015, from

http://www.hri.org.nz/about-heart-disease/heart-facts/

Heart Foundation. (2004).

Information for General Practice on Physical Activity and Heart Disease.

Retrieved on March 30, 2015, from

http://www.heartfoundation.org.au/SiteCollectionDocuments/GP-PA-and-heart-disease.pdf

Ministry of Health. (2003).

A Guide to Developing Health Promotion Programmes in Primary Health Care Settings.

Retrieved on March 31, 2015, from

http://www.hauora.co.nz/assets/files/PHO%20Info/dvpinghealthpromotionprogs.pdf

Ministry of Health. (2013).

Implementing the ABC Approach for Smoking Cessation

. Retrieved on March 18, 2015, from

https://www.health.govt.nz/system/files/documents/publications/implementing-abc-approach-smoking-cessation-feb09.pdf

Ministry of Health. (2013).

Reducing Inequalities in Health

. Retrieved on March 18, 2015, from

https://www.health.govt.nz/system/files/documents/publications/reducineqal.pdf

Quitline. (2013

). Nicotine patches, gum and lozenges

. Retrieved on March 18, 2015, from

http://www.quit.org.nz/62/help-to-quit/nicotine-patches-gum-and-lozenges

Willett, W.Koplan, J.Nugent, R.Dusenbury, C.,Puska, P. &Gaziano, T. (2006). Disease Control Priorities in Developing Countries 2

^nd

ed. Retrieved March 29, 2015 from

http://www.ncbi.nlm.nih.gov/books/NBK11795/

World Health Organization. (2015).

Physical Activity and Women.

Retrieved on March 30,2015, from

http://www.who.int/dietphysicalactivity/factsheet_women/en/

World Health Organization. (2015).

Health Promotion.

Retrieved on March 30, 2015, from

http://www.who.int/healthpromotion/conferences/previous/ottawa/en/

World Health Organization. (2014).

Why is tobacco a public health priority?

Retrieved on March 18, 2015, from

http://www.who.int/tobacco/health_priority/en/print.html

.

Introduction

Singapore is an interesting nation in which to compare to the United States in regards to health care for several reasons. Singapore’s government is a Parliamentary Representative Democratic nation. The United States is a Federal Republic and a Constitutional Democracy. This means that Singapore has a President and a Prime Minister, whereas the United States only has a President. In addition, the population is vastly different, with Singapore’s population being almost 6 million and the United States population being over 322 million. The differences in government and population can influence how health care is funded and provided to citizens, which makes comparing the two nations quite interesting.

Health Statistics and Costs

According to the World Health Organization, life expectancy in Singapore in 76 years old for men and 81 years old for women. In the United States, life expectancy for men is 81 years old and for women is 85 years old (WHO, United States, 2019). Life expectancy is slightly better for those who live in the United States rather than in Singapore. The mortality rate for those under the age of 5 in Singapore is 3 per 1,000 live births (WHO, Singapore, 2019). The mortality rate for those under the age of 5 in the United States is 7 per 1,000 live births (WHO, United States, 2019). The mortality rate for those under the age of 5 is greater in the United States. The mortality rate for those between the ages of 15 and 60, in Singapore, per 1,000 citizens for men is 65 and for women is 38 (WHO, Singapore, 2019). The mortality rate for those between ages 15 and 60, in the Unites states, per 1,000 citizens for men is 142 and for women is 86 (WHO, United States, 2019).  This shows that the mortality rate is greater in the United States than in Singapore, which could be influenced by culture, population amount, government, and health care access.

The health care expenditure per capita is 4,047 in Singapore (WHO, Singapore, 2019). The health care expenditure per capital is 9,403 in the United States (WHO, United States, 2019). This means that the United States pays more per person for healthcare than Singapore. The health care expenditure as a percentage of the gross domestic product in Singapore is 4.9% (WHO, Singapore, 2019). The health care expenditure as a percentage of the gross domestic product of the United States is 17.1% (WHO, United States, 2019). This means that the United States relies more heavily on health care being a gross domestic product than Singapore does.

Health Care Financing

Singapore’s health care is divided into three categories. The health care categories are Medisave, Medishield, and Medifund (Singapore, 2019). Medisave is mandated and every person in Singapore pays a percentage of their income into it, which employers meet. Medishield is low cost insurance that one can pay for in addition to Medisave. Medishield covers prolonged illness and severe injuries, it has copayments and deductibles. Medifund is paid for by the government and covers those who are indigent. Citizens in Singapore can also opt to enroll in private health insurance as well, but the government insurance is mandatory. In addition, you only receive what you have paid into mandatory government healthcare. For example, if you have paid in $3,000, but your bill is $5,000 you are responsible for $2,000.

In the United States one pays taxes for Medicaid/Medicare, but not every citizen is eligible to receive Medicaid/Medicare. In 2016, 17.2% of the population had Medicare (Djordjevic, 2019). Medicare tax is 1.45% of a person’s income. Employers can offer insurance, which employees pay premiums to be able to be considered ‘covered’. Individuals can purchase their own health care as well. In the United States Medicare is totally funded by taxpayers. In Singapore, Medisave is funded entirely by employees paying into the fund. In both the United States and Singapore, they have private health insurance that can be fully funded by individuals in addition to health insurance that are partially paid for by employers.

Health Care Administration

In Singapore, health care is overseen, regulated, and dispersed by the Ministry of Health. In the United States, Medicare and Medicaid are overseen by the U.S. Department of Health and Human Services. Health care is regulated by the U.S. Department of Health and Human Services, Congress, and even state laws when they are applicable.  Singapore utilizes the Medifund to help those who are unemployed, low income, or homeless. Military members in Singapore, as well as, veterans, all obtain their health care through the branches of the SAF Military Medicine Institute. In the United States, military members and veterans have something called TriCare. The United States government, funded by the taxpayers, pays for the health care of military members and their immediate family. The United States offers Medicare/Medicaid to all who would meet the requirements, but those who fall just beyond the requirements will be denied. For example, a low-income household could be denied insurance because they make too much money.

Health Care Facilities

There are 2.4 hospital beds for every 1,000 people in Singapore (Bank, Hospital Beds (per 1,000 people), 2019). In the United States there are 2.9 hospital beds per 1,000 people (Bank, Hospital Beds (per 1,000 people), 2019). In Singapore there are 7.2 Nurses/Midwives for every 1,000 people (Bank, Nurses and Midwives (per 1,000 people), 2019). In the United States there are 8.6 Nurses/Midwives for every 1,000 people (Bank, Nurses and Midwives (per 1,000 people), 2019). There are 2.8 Physicians for every 1,000 people in Singapore (Bank, Physicians (per 1,000 people), 2019). There are 2.6 Physicians for every 1,000 people in the United States (Bank, Physicians (per 1,000 people), 2019). Examining these numbers makes both Singapore and the United States appear to be under equipped, in terms of availability for treatment, but more so the United States because its population is so much greater than Singapore.

Conclusion

Health care has been perfected in neither Singapore nor the United States. There are still citizens in both nations who must avoid treatments because they cannot afford it. It could be because they have not paid enough into Medisave to cover treatment in Singapore, or they simply do not have insurance in the United States. Low-income people tend to be the ones caught in the middle, they are not considered indigent but they do not have a great enough income to be able to pay for their own health care coverage. Those who are extremely poor in the United States may be able to seek assistance at a free health clinic, but they are not always available.  In both nations, it appears as though the better off one is, economically speaking, the better health care they can afford.

References

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