One in three of us will develop cancer at some point in our lives. But survival rates have improved to the point that two-thirds of those diagnosed live more than five years.

This extraordinary shift over the past few decades introduces new challenges. A large and growing proportion of people diagnosed with cancer are living with it, rather than dying of it.

In our recently published research we examined the cancer experiences of 81 New Zealanders (23 Māori and 58 non-Māori).

We found survivorship not only entailed managing the disease, but also “wrangling” a complex health system.

Surviving disease or surviving the system

Our research focused on those who had lived longer than expected (four to 32 years since first diagnosis) with a life-limiting or terminal diagnosis of cancer.

Common to many survivors’ stories was the effort it took to wrangle the system or find others to advocate on their behalf, even to get a formal diagnosis and treatment.

By wrangling we refer to the practices required to traverse complex and sometimes unwelcoming systems. This is an often unnoticed but very real struggle that comes on top of managing the disease itself.

The common focus of the healthcare system is on symptoms, side effects of treatment and other biological aspects of cancer. But formal and informal care often falls by the wayside, despite being key to people’s everyday experiences.

The inequities of cancer survivorship are well known. Analyses show postcodes and socioeconomic status play a strong role in the prevalence of cancer and survival.

Less well known, but illustrated in our research, is that survival is also linked to people’s capacity to manage the entire healthcare system. That includes accessing a diagnosis or treatment, or identifying and accessing alternative treatments.

Survivorship is strongly related to material resources, social connections, and understandings of how the health system works and what is available. For instance, one participant who was contemplating travelling overseas to get surgery not available in New Zealand said:

We don’t trust the public system. So thankfully we had private health insurance […] But if we went overseas, health insurance only paid out to $30,000 and I think the surgery was going to be a couple of hundred thousand. I remember Dad saying and crying and just being like, I’ll sell my business […] we’ll all put in money. It was really amazing.

Assets of survivorship

In New Zealand, the government agency Pharmac determines which medications are subsidised. Yet many participants were advised by oncologists or others to “find ways” of taking costly, unsubsidised medicines.

This often meant finding tens of thousands of dollars with no guarantees. Some had the means, but for others it meant drawing on family savings, retirement funds or extending mortgages. This disproportionately favours those with access to assets and influences who survives.

But access to economic capital is only one advantage. People also have cultural resources – often described as cultural capital.

In one case, a participant realised a drug company was likely to apply to have a medicine approved. They asked their private oncologist to lobby on their behalf to obtain the drug through a compassionate access scheme, without having to pay for it.

Others gained community support through fundraising from clubs they belonged to. But some worried about where they would find the money, or did not want to burden their community.

I had my doctor friend and some others that wanted to do some public fundraising. But at the time I said, “Look, most of the people that will be contributing are people from my community who are poor already, so I’m not going to do that option”.

Accessing alternative therapies, almost exclusively self-funded, was another layer of inequity. Some felt forced to negotiate the black market to access substances such as marijuana to treat their cancer or alleviate the side effects of orthodox cancer treatment.

Cultural capital is not a replacement for access to assets, however. Māori survivorship was greatly assisted by accessing cultural resources, but often limited by lack of material assets.

Persistence pays

The last thing we need when faced with the possibility of cancer is to have to push for formal diagnosis and care. Yet this was a common experience.

One participant was told nothing could be found to explain their abdominal pain – only to find later they had pancreatic cancer. Another was told their concerns about breathing problems were a result of anxiety related to a prior mental health history, only to learn later their earlier breast cancer had spread to their lungs.

Persistence is another layer of wrangling and it often causes distress.

Once a diagnosis was given, for many people the public health system kicked in and delivered appropriate treatment. However, experiences were patchy and variable across New Zealand.

Issues included proximity to hospitals, varying degrees of specialisation available, and the requirement of extensive periods away from home and whānau. This reflects an ongoing unevenness and lack of fairness in the current system.

When facing a terminal or life-limiting diagnosis, the capacity to wrangle the system makes a difference. We shouldn’t have to wrangle, but facing this reality is an important first step.

We must ensure it doesn’t become a continuing form of inequity, whereby people with access to material resources and social and cultural connections can survive longer.

Kevin Dew, Professor of Sociology, Te Herenga Waka — Victoria University of Wellington; Alex Broom, Professor of Sociology & Director, Sydney Centre for Healthy Societies, University of Sydney; Chris Cunningham, Professor of Maori & Public Health, Massey University; Elizabeth Dennett, Associate Professor in Surgery, University of Otago; Kerry Chamberlain, Professor of Social and Health Psychology, Massey University, and Richard Egan, Associate Professor in Health Promotion, University of Otago

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Do you struggle to eat your fruits and vegetables? You are not alone. Less than 5% of Australians eat the recommended serves of fresh produce each day (with 44% eating enough fruit but only 6% eating the recommended vegetables).

Adults should aim to eat at least five serves of vegetables (or roughly 375 grams) and two serves of fruit (about 300 grams) each day. Fruits and vegetables help keep us healthy because they have lots of nutrients (vitamins, minerals and fibre) and health-promoting bioactive compounds (substances not technically essential but which have health benefits) without having many calories.

So, if you are having trouble eating the rainbow, you might be wondering – is it OK to drink your fruits and vegetables instead in a juice or smoothie? Like everything in nutrition, the answer is all about context.

It might help overcome barriers

Common reasons for not eating enough fruits and vegetables are preferences, habits, perishability, cost, availability, time and poor cooking skills. Drinking your fruits and vegetables in juices or smoothies can help overcome some of these barriers.

Juicing or blending can help disguise tastes you don’t like, like bitterness in vegetables. And it can blitz imperfections such as bruises or soft spots. Preparation doesn’t take much skill or time, particularly if you just have to pour store-bought juice from the bottle. Treating for food safety and shipping time does change the make up of juices slightly, but unsweetened juices still remain significant sources of nutrients and beneficial bioactives.

Juicing can extend shelf life and reduce the cost of nutrients. In fact, when researchers looked at the density of nutrients relative to the costs of common foods, fruit juice was the top performer.

So, drinking my fruits and veggies counts as a serve, right?

How juice is positioned in healthy eating recommendations is a bit confusing. The Australian Dietary Guidelines include 100% fruit juice with fruit but vegetable juice isn’t mentioned. This is likely because vegetable juices weren’t as common in 2013 when the guidelines were last revised.

The guidelines also warn against having juice too often or in too high amounts. This appears to be based on the logic that juice is similar, but not quite as good as, whole fruit. Juice has lower levels of fibre compared to fruits, with fibre important for gut health, heart health and promoting feelings of fullness. Juice and smoothies also release the sugar from the fruit’s other structures, making them “free”. The World Health Organization recommends we limit free sugars for good health.

But fruit and vegetables are more than just the sum of their parts. When we take a “reductionist” approach to nutrition, foods and drinks are judged based on assumptions made about limited features such as sugar content or specific vitamins.

But these features might not have the impact we logically assume because of the complexity of foods and people. When humans eat varied and complex diets, we don’t necessarily need to be concerned that some foods are lower in fibre than others. Juice can retain the nutrients and bioactive compounds of fruit and vegetables and even add more because parts of the fruit we don’t normally eat, like the skin, can be included.

So, it is healthy then?

A recent umbrella review of meta-analyses (a type of research that combines data from multiple studies of multiple outcomes into one paper looked at the relationship between 100% juice and a range of health outcomes.

Most of the evidence showed juice had a neutral impact on health (meaning no impact) or a positive one. Pure 100% juice was linked to improved heart health and inflammatory markers and wasn’t clearly linked to weight gain, multiple cancer types or metabolic markers (such as blood sugar levels).

Some health risks linked to drinking juice were reported: death from heart disease, prostate cancer and diabetes risk. But the risks were all reported in observational studies, where researchers look at data from groups of people collected over time. These are not controlled and do not record consumption in the moment. So other drinks people think of as 100% fruit juice (such as sugar-sweetened juices or cordials) might accidentally be counted as 100% fruit juice. These types of studies are not good at showing the direct causes of illness or death.

What about my teeth?

The common belief juice damages teeth might not stack up. Studies that show juice damages teeth often lump 100% juice in with sweetened drinks. Or they use model systems like fake mouths that don’t match how people drinks juice in real life. Some use extreme scenarios like sipping on large volumes of drink frequently over long periods of time.

Juice is acidic and does contain sugars, but it is possible proper oral hygiene, including rinsing, cleaning and using straws can mitigate these risks.

Again, reducing juice to its acid level misses the rest of the story, including the nutrients and bioactives contained in juice that are beneficial to oral health.

So, what should I do?

Comparing whole fruit (a food) to juice (a drink) can be problematic. They serve different culinary purposes, so aren’t really interchangeable.

The Australian Guide to Healthy Eating recommends water as the preferred beverage but this assumes you are getting all your essential nutrients from eating.

Where juice fits in your diet depends on what you are eating and what other drinks it is replacing. Juice might replace water in the context of a “perfect” diet. Or juice might replace alcohol or sugary soft drinks and make the relative benefits look very different.

On balance

Whether you want to eat your fruits and vegetables or drink them comes down to what works for you, how it fits into the context of your diet and your life.

Smoothies and juices aren’t a silver bullet, and there is no evidence they work as a “cleanse” or detox. But, with society’s low levels of fruit and vegetable eating, having the option to access nutrients and bioactives in a cheap, easy and tasty way shouldn’t be discouraged either.

Emma Beckett, Adjunct Senior Lecturer, Nutrition, Dietetics & Food Innovation – School of Health Sciences, UNSW Sydney

This article is republished from The Conversation under a Creative Commons license. Read the original article.