Prevention works

I came across an article in Medscape this week that I couldn’t stop thinking about. The headline was dry enough. “Prediabetes Remission Halves MI and HF Risk.” But what sat underneath it is the kind of thing anyone with a family history of heart trouble should hear.

In plain language, that headline means reversing prediabetes cuts your risk of a heart attack and heart failure roughly in half. “MI” stands for myocardial infarction, the medical term for a heart attack, when blood flow to part of the heart muscle gets blocked and that muscle starts to die. “HF” is heart failure, when the heart grows too weak or stiff to pump the way the body needs. People end up breathless and exhausted, with fluid pooling in the lungs and legs. Both are among the most common and deadliest outcomes of cardiovascular disease.

It also raised a harder question. If reversing prediabetes is this powerful, why is it so hard for so many people to pull off? Part of the answer lives in the gap between the choices we ask individuals to make and the environments we make them in. We tell people to eat well and move more, then surround them with a world where the unhealthy option is the cheap, convenient default. Much of the data I went digging through turned out to be about that gap, and about how often health policy fails to make the healthy choice the easy choice.

The hopeful part: prediabetes doesn’t have to be a one-way street

The article was reporting on a study in The Lancet Diabetes & Endocrinology. Researchers pooled decades of data from two of the largest diabetes-prevention cohorts in the world, the US Diabetes Prevention Program Outcomes Study and China’s Da Qing Diabetes Prevention Outcome Study, following more than 2,400 people with prediabetes.

People who brought their blood sugar back into the normal range, achieving what doctors call remission, had a 58% lower risk of cardiovascular death or hospitalization for heart failure. Heart attack and heart failure risk were cut roughly in half, and so was the risk of dying early. Best of all, the protection lasted for years after blood sugar normalized.

That reframes prediabetes entirely. For a lot of people it’s a window that can still close, not a one-way door. The everyday work of eating better and moving more does more than dodge a future diabetes diagnosis. It might be one of the strongest heart-protection tools we have.

The part that stopped me cold

Then I reached the closing lines of the write-up:

“Germany lags in prevention. On the current Public Health Index, the country ranks second-to-last among 18 European nations in implementing evidence-based prevention measures. Consistent with that, the risk of dying from cardiovascular disease is significantly higher in Germany than in many other European countries.”

I’m half German and half Austrian, so I went looking. What I found was both worse and more interesting than that one sentence lets on.

What the data actually says

The Public Health Index 2025 is the first edition of a ranking built by the AOK-Bundesverband together with the German Cancer Research Center (DKFZ). It scores 18 northern and central European countries on how many evidence-based prevention policies they actually put into practice across four areas: tobacco, alcohol, nutrition, and physical activity.

The part that surprised me was the shape of it. This was never really a Germany-versus-Austria story. The whole German-speaking world shows up at the bottom together.

• United Kingdom, Finland, and Ireland lead the index, with Norway and France close behind.
• The whole DACH region (Germany, Austria, and Switzerland) sits at the bottom, along with Luxembourg.
• Germany lands second-to-last, 36.9 out of 100.
• Switzerland is dead last, at 32.4.
• Austria scored 38.1, a hair above Germany and tied with Luxembourg for third-to-last. Still firmly in the bottom group.

So both halves of my heritage are clustered at the wrong end of the table. Austria didn’t “lose” to Germany, and it isn’t quietly mid-pack either. All three German-speaking countries are the laggards, and the leaders are the UK and the Nordics.

The prevention paradox

What makes this genuinely strange is that these are wealthy countries with excellent, well-funded medical care. Germany is among the highest health spenders in the European Union. The index measures something money alone doesn’t buy. It looks at whether a country’s policies make the healthy choice the easy choice. That phrase is the whole game. Good prevention policy shapes the environment so the convenient, default option is also the healthier one, rather than leaving the job to individual willpower. Where countries get this right, healthy living takes less effort. Where they don’t, people spend their lives swimming upstream.

It helps to split prevention into two kinds. Primary prevention stops people from getting sick in the first place. Secondary prevention catches problems early and keeps them from getting worse, through screening and the follow-up care that keeps someone who’s already had a scare from having a second one. The German-speaking countries lag on both.

Primary prevention: what the leaders actually do (beyond taxes)

Taxes get the headlines, but the Public Health Index shows the leaders pulling several other levers that the DACH countries mostly leave alone.

• Advertising and marketing limits. Top performers put real, binding limits on marketing junk food to children, and on tobacco and alcohol advertising. Germany was one of the last countries in the EU to ban outdoor tobacco advertising, only phasing it in from 2022, and it still leans on voluntary industry pledges for junk-food marketing.
• Plain packaging and graphic warnings. Leaders like the UK and Ireland require standardized “plain” cigarette packs with large pictorial health warnings. Germany uses the warnings but still doesn’t mandate plain packaging.
• Front-of-pack food labelling. Clear, mandatory front-of-pack labels (traffic-light style or warning symbols) let people see at a glance what’s in a product. The leaders require them, while in Germany the Nutri-Score stays voluntary.
• Healthy school environments. Binding national standards for school meals, plus rules covering vending machines and snack sales, are normal among top performers. In Germany these standards aren’t binding nationwide.
• Smoke-free spaces and alcohol availability. Leaders run more comprehensive smoke-free laws and tighter limits on where and when alcohol can be sold. On alcohol policy overall, Germany scored just 9 of a possible 40 points.
• Designing movement into daily life. The index also rewards building physical activity into everyday life, through safe cycling and walking infrastructure and movement programs at school and work. Paris’s push to become a cycling city is exactly the kind of “active environment” the DACH region has been slower to build.

Taxes still matter, and the index scores them on tobacco, alcohol, and unhealthy food alike. That includes levies on sugar-sweetened drinks and taxes on processed products loaded with sugar, fat, or salt. The leaders use these “junk-food” taxes. Germany and Austria mostly don’t. Adjusted for local purchasing power, a pack of cigarettes costs roughly twice as much in Ireland or the UK as it does in Germany.

Secondary prevention: the gap doesn’t close after diagnosis

The Public Health Index only scores primary prevention, but the same pattern shows up once people are already at risk. Take screening. In 2023, around 83% of eligible women joined breast-cancer programs in Denmark and Sweden, against roughly 52% in Germany, well below the EU average and the 70% target. Across Europe, large surveys of heart patients (the EUROASPIRE studies) found that fewer than half get into cardiac rehabilitation after a coronary event, and most never hit the guideline targets for managing their risk factors afterward.

The index’s authors are blunt about why Germany lands here. The evidence exists, and the public largely supports action. What’s missing is the political will to act. The system treats illness brilliantly once it appears and invests far too little in stopping it from appearing, or coming back, in the first place.

The view from my third country: how the US compares

This gets personal in another way too. I may be German and Austrian by blood, but I’ve lived in the United States for more than twenty years. So of course I wondered how the country I actually live in stacks up against my two prevention-laggard homelands.

The honest answer is that it’s hard to compare cleanly. The US isn’t in the Public Health Index, and unlike European countries it sets most of these policies state by state rather than nationally, so this comes from separate data rather than one ranking. The broad picture is still clear, and it isn’t flattering. On structural prevention, the US generally sits behind even the DACH countries.

• Sugary-drink and junk-food taxes. Around 17 European countries levy a national tax on sugar-sweetened drinks. The US has none nationally. A handful of cities like Philadelphia and Seattle have their own, and several states have actually passed laws banning local soda taxes.
• Tobacco taxes. US cigarette taxes average roughly 40% of the price and swing wildly by state, from about 17 cents a pack in Missouri to $4.50 in Washington, DC. That sits below the WHO’s recommended 75%, and across much of the country cigarettes stay cheaper than in European leaders like Ireland or the UK.
• Food labels and marketing to children. Largely voluntary and industry-self-regulated. Mandatory front-of-pack warning labels are still only a proposal at the FDA, while the European leaders already require them.
• One bright spot. The US has national nutrition standards for school meals. Federal school-food rules there are actually firmer than Germany’s, where those standards aren’t binding nationwide.

The outcomes track the policy. US adult obesity sits around 42%, far above Western Europe, where even the UK is near 28%. American life expectancy, about 78 to 79 years, trails the EU average of roughly 81.5. And while cardiovascular death rates keep falling across Western Europe, premature cardiovascular deaths in the US, among people aged 35 to 74, have actually been rising in recent years, especially among younger adults.

So all three of my countries tell a version of the same story, and the country I live in tells the starkest version of it.

What this means for the rest of us

Put the two side by side and the lesson is hard to miss. The Lancet shows what individuals can pull off. Reverse prediabetes, and you can halve your risk of a deadly heart event. The Public Health Index shows the world those individuals live in. In my two European homelands, and even more so in the US, policy does too little to make the healthy choice the easy one.

That tension is worth sitting with. Personal effort clearly works. But willpower runs uphill when the surrounding world is tilted against it, when sugary drinks are cheap and untaxed, junk food is aimed at children, cigarettes stay affordable, and the convenient option is almost always the worst one for you. Good policy doesn’t take away personal choice. It changes the slope of the hill, so the healthy choice takes less heroism. Blaming individuals while leaving that environment untouched is how rich countries end up treating heart disease brilliantly and preventing it poorly.

The encouraging part is that both levers genuinely work. Prevention pays off, sometimes dramatically, and the protection can last for decades. So whether you live in Germany, Austria, Switzerland, or the US, the question worth asking goes beyond whether you’re making good choices. It’s whether the place you live makes the healthy choice the easy one, or the hard one.

References

1. Vazquez Arreola E, Gong Q, Hanson RL, et al. “Prediabetes remission and cardiovascular morbidity and mortality: post-hoc analyses from the Diabetes Prevention Program Outcome study and the DaQing Diabetes Prevention Outcome study.” The Lancet Diabetes & Endocrinology. 2026;14(2):137–148 (published online Dec 12, 2025). doi:10.1016/S2213-8587(25)00295-5. https://www.thelancet.com/journals/landia/article/PIIS2213-8587(25)00295-5/fulltext
2. Medscape. “Prediabetes Remission Halves MI and HF Risk, Lancet Study.” 2026. https://www.medscape.com/viewarticle/prediabetes-remission-halves-mi-and-hf-risk-lancet-study-2026a100001a
3. AOK-Bundesverband & Deutsches Krebsforschungszentrum (DKFZ). “Neuer Public Health Index: Deutschland auf vorletztem Platz bei wissenschaftlich empfohlenen Präventionsmaßnahmen.” Press release, Dec 4, 2025. https://www.dkfz.de/aktuelles/pressemitteilungen/detail/neuer-public-health-index-deutschland-auf-vorletztem-platz-bei-wissenschaftlich-empfohlenen-praeventionsmassnahmen
4. AOK-Bundesverband & DKFZ. Public Health Index 2025: Gesundheitsschutz im europäischen Vergleich (full report, PDF). 2025. https://www.dkfz.de/fileadmin/user_upload/Krebspraevention/Download/pdf/Buecher_und_Berichte/2025_Public-Health-Index.pdf
5. OECD/European Commission. Health at a Glance: Europe 2024. https://www.oecd.org/en/publications/health-at-a-glance-europe-2024_b3704e14-en.html
6. OECD. EU Country Cancer Profile: Germany 2025. https://www.oecd.org/content/dam/oecd/en/publications/reports/2025/02/eu-country-cancer-profile-germany-2025_5a805dca/f3a3cfcf-en.pdf
7. Kotseva K, Wood D, De Bacquer D, et al.; EUROASPIRE Investigators. “EUROASPIRE IV: A European Society of Cardiology survey on the lifestyle, risk factor and therapeutic management of coronary patients from 24 European countries.” European Journal of Preventive Cardiology. 2016;23(6):636–648. doi:10.1177/2047487315569401. https://academic.oup.com/eurjpc/article/23/6/636/5927390
8. Tax Foundation. “Soda Tax & Sugar Tax (SSB) Analysis.” https://taxfoundation.org/research/all/global/sugar-tax-soda-tax-ssb/
9. Crosbie E, Schillinger D, Schmidt LA. “State Preemption to Prevent Local Taxation of Sugar-Sweetened Beverages.” JAMA Internal Medicine. 2019;179(2):291–293. doi:10.1001/jamainternmed.2018.7770. https://pmc.ncbi.nlm.nih.gov/articles/PMC7083242/
10. Li H, Adair T, et al. “Analysing premature cardiovascular disease mortality in the United States by obesity status and educational attainment.” BMC Medicine. 2024;22:533. doi:10.1186/s12916-024-03752-x. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11566442/