Fat, Fate, and Disease : Why we are losing the war against obesity and chronic disease (10 page)

One driver of this epidemic is obvious. The nature of the food consumed has changed. From eating unrefined foods, many people across the developing world are now turning to high-fat, refined foods for their basic diet. Foods are increasingly cooked in corn oil. And just as in the West, the cheapest foods are often the most energy-dense, with a high glycaemic index. The problem is aggravated by mass migrations from rural areas to cities. In rural settings, subsistence agriculture provides foods which are unlikely to exceed our metabolic capacity, especially as the rural
lifestyle is often associated with high levels of physical activity. But in cities these simple staples are often replaced by sweet drinks and fried food. This is a one-way process. As countries move through the economic transition they also move through this nutritional transition. Indeed in countries such as China, India, and Indonesia the rate of the rise in diabetes and cardiovascular disease correlates well with the economic growth of the country.

What does it all cost? This may seem a cynical question. Health and disease are about far more than just dollars. They are often about lives lived happily or ruined. But governments and agencies have to work in dollars because what they can do is essentially limited by resource allocation. Non-communicable diseases account for about 35 million deaths a year globally—that is more than one every second of every minute of every hour of every day of the year.

In 2009 the World Economic Forum calculated that there is a real chance that the likely cost of non-communicable diseases could approach close to several trillion dollars a year. Furthermore, they concluded that both the likelihood and the severity of detrimental consequences of non-communicable diseases are increasing. The numbers are astronomical, whether we look at developed or developing countries, and the argument for doing something about them is obvious—the question is, what? This enormous burden of disease is not going away; in fact it is getting worse year on year, and especially in the parts of the world least able to deal with it.

In 2000 the world’s leaders adopted a grand vision for the least developed world. They agreed to a set of goals to be achieved by 2015. These Millennium Development Goals were designed to put pressure on developed countries to assist the developing world in making advances, and to indicate to governments and agencies some simple measurable priorities. These Millennium Development Goals include
some fundamental targets such as eradicating extreme hunger and poverty (easy to say but hard to achieve), promoting maternal and child health, and providing universal primary education.

Progress on some of these goals has been slow and in 2010, when an audit was made, the failure to progress adequately on many of them was lamented. This has led to renewed commitments to address issues such as maternal and child health. For example, the 1,000 Days campaign launched by Hillary Clinton aims to improve child nutrition from conception through to two years of age, so as to promote a healthier start to life.

But it seems to us strange that, despite the scale of the problem which they represent, non-communicable diseases were not part of the Millennium Development Goals. Nowhere in the list of aims, which politicians, scientists, doctors, religious leaders, and educators drew up in the months leading up to January 2000, did non-communicable diseases make an appearance. It was almost as if the problem didn’t exist.

Why?

Perhaps it was too hard. Addressing this issue is complex, and besides, it is not as politically appealing to some member states as dealing with maternal mortality in relation to childbirth or gender inequality. Achieving the Millennium Development Goals is a necessary condition for progress towards global equality but it is doubtful that this is realistically possible unless we also ensure that the adult population is healthy and productive. Economic progress is necessary for social progress.

Perhaps the challenge posed by non-communicable diseases arose too quickly for even the most flexible and manoeuvrable of medical research or healthcare organizations to cope with. This is not helped by the fact that we did not recognize that the disease epidemic was developing fastest in unexpected places, such as sub-Saharan Africa, one of the poorest regions on Earth. And lastly, we really had very little idea what to do about it. An inability to address a problem soon leads to a sense of resignation.

So what’s new? We know that many readers will feel that they have heard all this before. Diabetes and cardiovascular disease are a problem whether you live in Manhattan or Bamako. We all know that if you eat a healthy diet and exercise more the problem will go away—won’t it? There have been many books and endless articles and television programmes on the problem of obesity and its consequences. Officials from Departments of Health around the world have emphasized that this is a major problem which requires urgent attention. Politicians have thumped their lecterns in political speeches and vowed that something
will
be done about it. Parents and teachers have been encouraged to play their part in reversing the trend and helping tomorrow’s children to be thinner and healthier. To be honest, we are all getting rather tired of hearing about this and just wish that the problem would go away. So why hasn’t it?

Many of us have tried to lose weight, and have failed to keep the lost kilograms off. This is probably why there are an extraordinary number of ‘experts’ who claim to be able to help us. Amazon.com currently lists more than 22,000 different books about weight loss—many of them claiming their own special way of guaranteeing success. And along with all this advice from the gurus in their books and magazine articles there is an enormous industry of weight loss regimes, very often based on the purchase of expensive diets, treatment, or advice sessions—it’s a huge industry. The plethora of different approaches suggests that there is both a real problem to be addressed and an enormous marketing opportunity.

Why is the weight loss industry so big? Partly because so many people are indeed overweight or obese—or at least would like to look different. But the underlying reason is that losing weight is hard and these so-called ‘cures’ usually don’t work—or, if they do work,
do so only for a short time, after which the unhappy slimmer gains weight and is soon back to where he or she started. All of this is of course great for the weight loss industry. ‘You have tried three different diets and none of them worked? Ah, well, that is because the ones you tried were not right for you. Instead this is the one for you … sorry it’s a bit more expensive’, and so on.

And commercially marketed diets and programmes are only part of the story—there is the question of exercise. There is an increasing number of pseudo-exercise devices that claim to help us lose weight by some less energetic means—‘three minutes a day will be enough …’—when the simple logic is obvious: exercise largely works by burning calories and by changing aspects of our metabolism by inducing more muscle to be built. And there is no way to burn calories except by putting in the effort. Jogging for half an hour a day for an average man probably only burns off up to 400 calories, and a kilogram of fat has almost 8,000 calories in it! There is simply no way a very short period of exercise can replace prolonged effort which burns off fat and builds up muscle and sets it to work. And it turns out that building up the muscle is an important part of the story—for this reduces the chances of insulin resistance and slows the pathway to diabetes and cardiovascular disease.

Nevertheless, despite all the disappointments and all the money wasted on the latest diet or gadget, the orthodox view persists that losing weight, and consequently reducing one’s disease risk, is simply a question of mind over matter, of willpower. Eat less or differently, exercise more, and avoid smoking, and we will be all right. This is all we have to do—do it and we will beat the global problem of diabetes and cardiovascular disease and we will all look, and be, healthy. We still read somewhere every day, somewhat to our frustration, that beating obesity and therefore the risk of non-communicable disease is simply a matter of eating fewer calories than we expend—so eating less and more wisely
and exercising more will solve the problem. And if it doesn’t? Well then the answer is obvious—it is our own fault!

But now we know that the picture is not so black and white.

As we described in
Chapter 3
, it is likely that if we all ate and lived as our ancestors did 20,000 years ago very few of us would be obese, and chronic disease would be very rare. We even have modern examples of this. The Pima Indians are a tribe who live in Mexico and also in Arizona. Many of those Pima who live in Mexico have lifestyles involving hard physical work in growing their food. They eat subsistence diets. Their level of obesity, diabetes, and cardiovascular disease is relatively low, at least compared to their northern cousins. In contrast, the Pima of Arizona live on reservations with high incomes from casinos and other enterprises, and lead very sedentary lives. They eat very energy-dense, high-glycaemic North American diets, rich in fats and refined sugars. They have some of the highest rates of diabetes and heart disease and obesity known—so high that it was thought for a long time that they had a special genetic defect. But what we can see is that two genetically very similar groups of people, of the same tribal origin, have very different rates of diabetes and cardiovascular disease because they have two very different lifestyles.

But while this sounds simple, a central feature of the human condition is that our culture and society also continue to evolve. We are not living in the Neolithic Stone Age and it is unrealistic to imagine that human aspirations would allow us to return to that kind of lifestyle. Understandably we want comforts, we want to enjoy our lives, we want to take advantage of the myriad of opportunities and pleasures that technology has brought us.

We are uniquely social beings and as human culture has evolved so has the place that food plays in our social lives. It is now a central part of our interactions and our social structure, both private and
communal. Family events are celebrated with special meals, as are national events like Thanksgiving and many religious events. Eating with friends, whether in a restaurant or at a barbecue, is essential to the way we live our social lives. Even funerals are usually followed by a meal for the mourners. And much business is done over a meal—the business lunch appears to be surviving the credit crunch.

One of the features of our contemporary culture is that we now think of obesity as a problem. Many of us want to lose weight and cannot—we find it as hard as a smoker does to change our habits. As Mark Twain remarked about smoking (‘It is easy to give it, up—I have done it hundreds of times’), so it is with weight loss. One of the authors of this book has lost about 20 kg three times in his life, getting down to a respectable 75 kg, and each time has put it back on gradually over several months. As he embarks on his fourth attempt he swears that he will succeed this time … really? Given that he is particularly well informed on the subject and very clear about the health benefits of reducing his body weight, why is he finding it so difficult? And why does the other author not have such problems—he can eat and drink as much as he likes and yet remain thin. He has never even considered dieting, and is never aware of eating too much. Both of us have equal motivation to be healthy—or maybe just to look good around campus—we both have detailed knowledge of the biology and understand the consequences of being overweight, but we are obviously very different in our ability to regulate our body weight.

Even casual observation will reveal some marked behavioural differences between the two of us. Place a bowl of cashew nuts in front of us as we are typing away here, and Mark will eat a few of them and then lose interest, whereas Peter will nibble and nibble and nibble until none are left. Mark does not need to think about it; Peter has to consciously stop himself from having another handful and he
will still probably eat them. Yet Mark may announce in mid-afternoon that he is absolutely ravenous and cannot survive until suppertime unless he has fruit cake for tea. For Peter hunger in the middle of the afternoon is not the issue, and he has to avoid such snacks—because snacking for Peter does not mean one slice of cake: it means all the slices on the plate.

We are clearly very different in our metabolic biology. And it is only through understanding why we have such differences that we will get a broader perspective on why simple magic bullet strategies—that new diet for example—will not be effective in assisting or sustaining weight loss for most individuals. By the same reasoning, one standard approach is not going to deal with the burden of diabetes and cardiovascular disease in different individuals and across populations. We would go further—we believe that unless we understand the biology of the problem better we have little hope of getting to the right solution to the problem at all. This is one of the key messages of this book.

This is an inconvenient truth (as Al Gore called his film on global warming, and for somewhat similar reasons) for many governments, public health organizations and individual experts who want to treat or prevent obesity, diabetes, and cardiovascular disease with a simple single remedy. They seem to believe that there is a magic bullet which will solve the problem. This is illogical and it will not work. Ban sugary soft drinks, they say, or ban the use of trans-fats in prepared foods, or ban butter, or make the fast food chains reduce their portion sizes, etc., and there will be no problem.

There is a political dimension here because the debate rapidly gets wrapped up with issues of our individual rights to make choices versus the business of the State in controlling our lives. There are those who believe the State has no business to intervene in matters of personal choice, and others who expect the State to play a major role in
managing our lives. The debate can be between extremes or it can be a matter of degree. Few people would disagree with the State demanding that we wear seat belts in our cars, or that motorcyclists wear safety helmets. It is clear that in doing so the State is helping us, for our own good, but it probably also reduces the cost to the State and to us all if there is an accident. Some countries require that children are vaccinated before going to school, while others do not, and issues of personal choice—here on the part of the parents—underlie that debate too. And so it goes on. Should the State require you to have energy-saving light bulbs in your house or is it none of their business? Should the State require you to have social security or health insurance? These debates of individual freedom versus State influence rage in different ways in every democracy. Only the issues vary across the world.