Fat, Fate, and Disease : Why we are losing the war against obesity and chronic disease (3 page)

At the end of his great tragic play
King Lear
, Shakespeare uses the metaphor of the wheel of fortune to make the fate of his characters even more poignant. Surely when fate has taken them to the depths of misfortune, the wheel cannot take them further down—surely life can only improve? Not so for Lear or, we fear, for the developing world. Things will almost certainly get worse. In developing countries we see diabetes occurring in much younger people than in the past, or than usually occurs in the West. We can only imagine the humanitarian and financial costs of large numbers of people developing such disease in their thirties, when their productive working lives may be drastically shortened and they still have young families to support. In addition they will need drug treatment for decades, and the accumulating costs of this will be horrendous. The wheel of fortune can take many people lower down still.

Why can’t we stop this wheel going down? We seem to clutch at it with feeble hands, as if we didn’t have the strength. But in reality we do not know
how
to slow it down. Nor do we yet seem to have built up the resolve to tackle the problem or mustered the right forces to do so. Why is this happening—why for example does an Indian or Chinese person not need to be as obese as a white European to suffer from heart disease or diabetes? Why are these diseases appearing at ever younger ages in developed countries and at even younger ages in developing countries? Providing some answers to these questions is central to this book.

Then there is a broader and even more worrying turn of events. The worry is that, beyond causing illness and death and slowing down economic development, diabetes and cardiovascular disease may have geopolitical consequences too. It is obvious that the changing pattern
of disease in India, China, and Indonesia is in some way associated with the adoption of aspects of the so-called Western lifestyle—foods high in calories and fat, often of low nutritional quality, lower levels of physical activity, and a number of other changes which we will come back to later. Could it be that, as the economic burden of hundreds of millions of people with diabetes and heart disease and their accompanying complications of strokes, kidney failure, blindness, and limb amputations descends on these developing nations, disabling people still in the prime of their lives and stretching healthcare systems beyond their limits, the West will be blamed for exporting an unhealthy lifestyle to these nations, driven by the profits of globalization? Will this create a new clash of cultures and give rise to a new set of tensions, or something even worse? At the very least it seems likely to damage relations between the developed and developing nations at a time when we need much closer collaboration if we are to address the other global challenges of climate change, fossil fuel use, water and food security, and terrorism.

As we have changed the way we live and what we eat, the incidence of obesity, diabetes, and cardiovascular disease has increased dramatically. The changes in the way we live are a direct result of many advances in technology, the nature of the food we eat, and the way we conduct our lives. Humans now live longer and healthier lives than ever before in our evolutionary history. Yet the irony is that the very technological advances that allow us to have these longer lives may now compromise the way we live them. There can be no doubt that changes in lifestyle are fundamental to the problems of obesity, diabetes, and cardiovascular disease, and we strongly believe in the importance of healthy eating, exercise, and avoidance of tobacco products. Nothing in this book is meant to undermine that message. But these measures in themselves, while necessary, will not be sufficient to slow the relentless downward lurch of the wheel of fortune.

Our longer lives are in no small part due to the tremendous improvements in public health over the past two centuries. We have
made great strides in developing vaccines, antibiotics, and antiseptic agents to prevent and treat many bacterial diseases, and drugs to combat malaria as well as worm and other parasite infestations. In addition, we have endeavoured to make supplies of clean water available to everyone and to channel our sewage safely away. This has been achieved in the developed world, although there is still much to be done across Africa and other parts of the less developed world.

In the West these improvements in public health and the development of modern medicine can be traced back to the beginning of the industrial revolution, although they gained prominence in the mid 19th and particularly the 20th centuries. But it is really only since the Second World War and the beginning of the end of colonialism that we have seen the same phenomenon happen in much poorer countries. The good news is that many improvements in public health are taking place much more quickly than they did in developed societies. In many developing countries, for example, the so-called nutritional transition—from hunger and famine to food security—is happening over just one generation, rather than over several generations as it did in developed countries.

The nutritional transition is not just about the amounts of food available. It is also about its quality. Food security, that is ensuring there is enough food reaching the world’s population, is a growing concern but this is largely, although not entirely, beyond the scope of this book. But food security is only part of the nutritional challenge we face. The nutritional transition is really a covert revolution in the way we feed ourselves. It involves a shift from basic unrefined foods such as pulses, grain, fruit and vegetables, fish or lean meat, to highly processed foods. In many places this has happened in a decade or less and everywhere it has had undesirable
biological effects on our bodies through new challenges, which our bodies cannot always handle.

Because of this nutritional transition there has been a marked change in our daily intake of high-calorie, sugary, and fatty foods. The food revolution has been given further impetus by sophisticated marketing and by the shift to fast or convenience foods associated with other lifestyle changes. This nutritional change has been played out against the background of apparently much lower physical energy expenditure as the burden of manual labour decreases and we move to mechanized transport and favour electronic entertainment over physical activities and sports for recreation.

Flagging up these changes is not a novel idea—so why are we doing it? Because of the widespread supposition that, as the modern diet and our lower level of daily physical exercise exacerbate the risk of obesity,
therefore
the best approach for addressing the problem must be to target diet or exercise, especially in people who are already obese. We believe that there are fundamental flaws in this argument and that more comprehensive and holistic approaches are urgently needed.

This dominant public health message, urging dietary restraint and more exercise, is part of a set of strongly held beliefs among many doctors and public health specialists. We say ‘beliefs’ in the plural, because there is no agreement on a single effective strategy for reducing obesity. There has been a debate between the experts who claim that tackling it is primarily about promoting exercise, and those who claim that it is all about diet, a particular kind of diet, or avoiding certain food components such as trans-fats or omega-6 fatty acids. But as yet no one has come up with the magic bullet intervention which works infallibly to reduce obesity. We do not think that this bullet will ever be found because, while the goal is laudable, these approaches are oversimplified and, unfortunately, are based on incomplete knowledge of human biology. We don’t seem to be willing to look more broadly at the scientific
evidence. Beware the expert who claims that a complex problem has a simple answer.

We know that the problem we face is associated with our modern lifestyle, even if it is not simply caused by it. So is the solution just to return to a traditional pre-industrial lifestyle? Maybe in theory, but unfortunately this is not realistic—even though many books have been written on the benefits of the hunter-gatherer or Palaeolithic diet, and so on. The majority of these represent folksy science rather than objective and reliable knowledge. They are effectively meaningless. It is no more feasible for the majority of the world’s population to move back to such a lifestyle than it would be to propose living in today’s world without the internet.

This is not to say that we should not encourage healthier eating and more walking, cycling, and exercise in general, which like stopping smoking, have health benefits at any age. Indeed we are strong advocates for the value of such measures. But, equally, we have to realize that there is a limit to what can be achieved through such initiatives, and to the benefits which we can expect from such an approach. To achieve more—and we absolutely have to achieve more—we have to take a different, more sophisticated, and more scientific approach.

What we have just said could be seen as heresy. The relationship of obesity with diabetes, cardiovascular disease, and other non-communicable diseases is well recognized and we do not dispute the general association. In the main the thinner people are, the healthier they will be. However, governments, the World Health Organization, and other agencies have focused their attention almost entirely on smoking and obesity for the past decade. The battle against tobacco is being won, at least in developed if not in developing countries. But despite the millions of dollars spent, the obesity strategy is not
working—the incidence of obesity and chronic disease is rising in every country, from rich to poor. We have been dismayed, and not a little angered, that this approach to the problem—eat less high-energy food and exercise more—seems to have remained unchanged even though it has not delivered the hoped-for benefits. Quite simply, people are getting fatter.

The sad reality is that for a great many people diet and exercise just do not work, at least over the long term. Many people try hard to diet, but find it tougher than fighting well-recognized addictions such as smoking. This in itself raises the question: can eating itself be an addiction? There is evidence that for some people it really is, although, as we will see, there may be different underlying biological mechanisms. But even if a person is able to curb their appetite and stick with one of the myriad popularized diets which are pushed at them—the Atkins diet, the grapefruit diet, the low-carb diet, the low-fat diet, and so forth—they may lose weight initially but many cannot keep that weight off. Then again, some people find taking more exercise easy while others find it hard to sustain. Some succeed in beating obesity, but many others do not. Should we be surprised by this? Hardly—just as in other aspects of our lives, we are all different and our biology is designed to make it hard to lose weight.

Such differences are the stuff of anecdotes in almost every family—the great aunt who had an enormous appetite yet was as thin as a twig all her life, and the uncle who starved himself but could still never buy trousers wide enough to fit him. There are people who are fat but do not suffer from disease, while others suffer from diabetes and/or heart disease but do not appear to be very fat. These simple observations about our biological differences are a fundamental theme which runs through this book. We will explain some aspects of human biology which probably won’t surprise many non-scientists—because they are reminiscent of those family stories—but which somehow seem to have eluded the attention of the specialists in this field. People are different—some people appear to
be at greater risk of ill health than others even if they exercise and eat the same diet. This is true in every society even if some societies seem more at risk than others.

That non-communicable diseases have become a critical issue for the world community is now indisputable. In September 2011, while this book was in press, the United Nations General Assembly held a special Summit devoted to non-communicable disease prevention and treatment, especially in developing countries. During the planning stages there was little indication that its focus would shift much from the traditional view narrowly focused on adult lifestyle. We felt that too many policy makers and their advisers still wear blinkers when it comes to seeing what to do and how to go about doing it.

But we are not saying that everything should be left to governments and the organizations that represent them, such as the United Nations. There are other important and influential non-government organizations that can play a major role, and some of these have more funds to deploy than many governments. An example is the Bill and Melinda Gates Foundation. So far, the Gates Foundation has largely been engaged in the prevention of communicable disease. It has provided millions of dollars for research on new technologies such as developing vaccines to fight malaria and HIV-AIDS. So far it has scarcely turned its attention to non-communicable diseases—and this is revealing.

The Gates Foundation would acknowledge that for infectious diseases vaccines are only part of the answer. Fighting malaria requires a range of coordinated approaches—draining swamps, providing chemically treated mosquito nets, developing new drugs for those who have caught resistant strains of malaria to stop the transmission of these strains, and so on. Combating HIV-AIDS similarly requires education about drugs and safe sex, access to condoms or other barrier contraceptives, and advanced drug therapies. A vaccine is not yet on the horizon despite years of work because this is difficult science—the biology of the HIV virus is such that a vaccine is hard to
devise, hard to develop, and hard to test. And so the Gates Foundation and others have had the insight to shift to a much more multidimensional approach to communicable disease. We need to take a similar approach to fighting non-communicable disease and we need the charitable and philanthropic sector to realize that this merits as much attention as infectious disease, even though it is apparently less dramatic and less easily fixed.