Fat, Fate, and Disease : Why we are losing the war against obesity and chronic disease (11 page)

Let us use smoking as an example. The evidence that smoking harms our health is now 50 years old. Yet it took a long time before efforts to reduce smoking were ‘owned’ by the State. There were vested commercial interests trying to confuse the picture but nicotine addicts also did not want the State limiting their freedom to smoke. They claimed they had the right to make their own choices, even if these harmed their health. But what about passive smoking? It too does harm. This increased the justification for banning smoking. Four things happened more or less simultaneously to put the final nail in the smoking coffin: the industry was vilified by activists; smokers were ostracized; governments started restricting where smoking could be allowed, first on planes, then in restaurants and all public places; and taxes were raised to higher and higher levels on tobacco products—the last has probably been the most effective measure. And although it took many years to implement, the reduced incidence of smoking has clearly improved public health and is a great example of what such a policy can do.

But there is one fundamental difference about smoking—we do not need to do it. We can live without cigarettes and tobacco—after all, Europeans only started smoking tobacco, chewing it, or snorting it about 500 years ago. Yes, it turned into a giant industry and made a lot of people rich and, yes, its tax dollars have appealed to many governments. In China, for example, where there are more than 350 million smokers, who consume one-third of the world’s cigarettes smoked every day, 8 per cent of the state revenue comes from tobacco. Its addictive properties are associated with some apparently beneficial psychological effects for many. But its deleterious effects on health far outweigh all this. So once the evidence that it did harm was accepted, and particularly once the evidence that other people’s smoke also did harm to non-smokers became clear, the political process of acting to reduce smoking became feasible and is now generally accepted. Plans to ban smoking in public places were put in place in China in 2011 and are starting to be effective.

So would it be logical for state-enforced public health interventions to be introduced to reduce obesity, diabetes, and cardiovascular disease? Superficially it might seem so and the approach has its advocates. But it is based on faulty logic.

Smoking is an indulgence (tobacco) rather than something essential (food, exercise, sleep). If there is a similarity between eating and smoking, it might be that for some people eating too much, and eating unhealthy foods, is an addiction in the same way that smoking is an addiction. There is some limited evidence that nicotine and some types of food can stimulate the same pleasure-producing areas in the brain. This makes make both habits hard to break. But even if obesity were the sign of an addiction—which we generally do not think it is—we have learnt that legislation hardly helps with addiction in many societies. Class A drugs may be illegal but addicts will often do anything, whether legal or not, to get their supply. And surely we do not think that taking insufficient exercise is addictive?

So are we saying that there is nothing that the State should ban or regulate when it comes to food? Hardly. There are some things that would make sense, like banning the advertising of unhealthy foods to young children. But should we ban Coca-Cola because it is basically a sugar load, or foods made with corn oil? Should we try to regulate portion sizes in fast food outlets? If we do any of this do we have to have clear scientific justification, and to be certain that there is no downside? It seems clear to us that there is no downside to banning advertising of certain foods targeted at children – the issue is how to define such foods and, we suspect for reasons that will become clear as this book proceeds, it may well not have as much impact as we would hope. We also see little nutritional justification for consuming soft drinks, but we cannot advance an argument that they should be banned from sale to everyone, because the harmful effect of an occasional soft drink is minimal—the problem is how to encourage people to drink fewer of them.

So the issue we raise is whether measures which might not really make a difference justify interference in our lives and our freedom to choose what we consume. We believe that our attitude to this will also be coloured by our political leaning. The libertarian view would be that it is largely a matter of personal choice. This may be rational if voluntary gluttony and sloth are at the root of the problem. But it becomes more difficult if there are more complex underlying biological factors that make some individuals more or less vulnerable to developing disease in the modern nutritionally rich, technologically dense world. The alternative view might be that the State has the duty to protect us—if necessary, from ourselves.

Before going further we might ask the question—how much do we really need to worry about these issues? Surely, modern medicine will find wonderful treatments for diabetes and cardiovascular disease?

Indeed, once vascular or heart disease is diagnosed, we can use a variety of techniques, both medical and surgical, to keep blood flowing to the coronary arteries which supply the heart muscle. They are very successful and can often return an individual’s heart to a healthy state if there is not too much underlying damage. But this is the realm of advanced medicine. Blood pressure lowering pills are not cheap. The surgical opening of the blood vessels supplying the heart costs tens of thousands of dollars. It is unrealistic to imagine that such expensive techniques can be made available to everyone across the world. So if we think about the burden of coronary heart disease at a global level, prevention rather than treatment has to be our priority.

Diabetes is even more complicated to address—with one possible exception, we have no real cure for it; we can only offer lifestyle advice, drugs, and insulin replacement therapy. Moreover, none of the complications of diabetes are easy or cheap to deal with. Once diabetic renal failure sets in, dialysis or a kidney transplant are the only possible options, neither of which is a feasible response to the growing epidemic. There is no treatment for the nerve damage caused by diabetes, or the blindness, and, sadly, limb amputation remains necessary for those with the most advanced diabetic vascular complications.

So what is the exception we mentioned? It is not medical but surgical. In people with obesity, stomach bypass surgery or banding can cure them of their diabetes. But the surprising thing is that this procedure reverses the diabetic state well before it produces any effect through weight loss. We now think that there are hormones made by the lining of the stomach which affect the way that other hormones, and possibly the brain, work to control metabolism. So this aggressive procedure in some way changes the hormonal balance and restores the ability of insulin to work properly. We really do not yet fully understand how this therapy works and it suggests that there is much more about our biology to be found out, which may lead to new ways to intervene.

But stomach banding and gastric bypass procedures are not free of side effects. They can lead to a variety of gastrointestinal problems which the individual then has to live with, and to metabolic complications. But in a case of morbid obesity, particularly where diabetes and cardiovascular disease have set in, surgery is a sensible option. Critically, such procedures seem to reduce fat inside the abdomen, the visceral fat which has the most damaging effects. They also limit the capacity of the intestinal system to absorb fats so that the energy balance is changed. And the reduction in stomach size leads to an earlier sensation of a full stomach during a meal, so the individual eats less.

In gastric banding both the problem of obesity and diabetes and the underlying biology are tackled together. Contrast this with another surgical technique—liposuction. All that the plastic surgeon is doing by sucking out the fat under the skin is providing cosmetic support. The individual may feel that his or her biological problem is being addressed but in reality it is literally only skin deep. The biology driving the obesity remains unchanged. It is no different from using wallpaper to cover the structural defects in a house before it is sold. Sooner or later the problem will appear again.

These two different surgical approaches to obesity raise the question of who should pay the bill. This might depend on whether the surgery is for cosmetic or for medical reasons. It is not always clear, and different medical insurers and governments are struggling with this question. Even if it is certain that the reason is medical, the answer to this question may still be determined by whether we believe that obesity is the individual’s own fault, or whether it is understood that for many of us there are deeper underlying biological causes for our obesity.

One of the major problems in discussing overweight and disease is understanding the motivation of the person wanting to undergo weight loss, and the possible psychological and other benefits which might follow the treatment. Is the goal of the treatment related to appearance
or to health? The reality is that in the West most attempts at weight loss have more to do with social perception than with health.

The Western ideal body image, particularly for a female, is increasingly about thinness and a particular body shape—an ideal that for most people is neither realistic nor necessarily healthy. There have been many books written on the question of the female body image and the issue is certainly not simple. Contrast the Western ideal with the body image from the areas of Mauritania we discussed earlier, where the ideal body image for a female (or maybe it is for her partner?) is unhealthily obese. We all live within our own societies and cultural networks and in dealing with matters of body size we need to understand these various cultural dynamics.

The psychotherapist Susie Orbach, whose clients have included public figures like Princess Diana, has published books about these issues—
Fat is a Feminist Issue
, which she wrote in 1978, and more recently
Bodies
, about Western women and their bodily concerns. In recent interviews Orbach explained that at the time when
FIFI
(as she likes to call her book) was published, she had no idea that the issue would still be current 30 years later.

In
FIFI
, Orbach argued that overeating in women can be a sign of their unhappiness with their position in society, and also a comfort and something which becomes an end in itself. At one extreme some women might feel that by allowing themselves to become overweight they make themselves less attractive, to men in particular, and therefore remove themselves from the sexual game, distancing themselves from the industry and the media hype focused on thinness. Why spend the week starving yourself so that you can have that magazine-image body and allow yourself to eat only at the weekend with your boyfriend or partner? Why bother—are you really a different person if you gain a few, or even a few dozen, kilograms? Susie Orbach admits
that it was her preoccupation with dieting which took her to a self-help group, and it was there that she realized just how deep the hatred of their bodies was among the women who attended the group.

In her later book
Bodies
, Orbach goes on to explore wider issues of the management of the body, from steroid therapy to breast enlargement and other uses of plastic surgery. The theme which concerned her in
FIFI
arises again. No one seems to feel happy with their body as it is, and they feel that they have to work on it—or have work done on it—to spend money, and undergo pain and suffering in order to turn it into the body which should really be theirs—if the advertising is true. Other worries about work, about relationships, about simply getting old and the fear of death become focused on perfecting the body. What has happened naturally cannot possibly be right—there must be some way of correcting it, of improving on it. The fact that it is not right must be the fault of the owner of the body, of his or her laziness or greed or lack of dedication to the cause of perfect beauty.

There is another extremely worrying undercurrent here. The glossy magazines and the media sell images of the idealized bodies of celebrities and glamour models with their perfect pregnancies, giving birth to perfect children, and of course living perfect lives. All this costs an extraordinary amount of money and lesser mortals can only aspire to such a body or such a life. As an actress is supposed to have said some years ago, ‘Money does not buy everything, but the other things are so expensive.’ And so an industry has grows, built on the conspicuous consumption of what is essentially an artificially constructed fashion.

A generation ago there were wider margins in what was acceptable as the ‘ideal’ female shape, although thinness has had a premium in the West for a long time (think of Twiggy in the 1960s). Then having the right tan was equally important, and the package holiday industry was built on this myth. Luckily, we now realize the dangers of sunbathing in relation to skin cancer, and so our body image cannot be fixed just by a two-week holiday in the sun. But while
most people are more sensible about this aspect of their appearance, we do not seem to have gotten there in relation to obesity.

We cannot get away from considering the social dimension. It seems no accident then that the problems of obesity, diabetes, and cardiovascular disease are particularly associated with lower socioeconomic status in Western societies. This appears to accord with Orbach’s idea of disenfranchisement with the values of society, where some people feel that they do not relate to them. But it also makes it clear that the problem is intractable.

Poverty is connected with an unhealthy lifestyle in many ways. For example, when researchers in the UK asked a selection of women how often their family sat down to have a meal together at the table, the question was met with puzzlement from a substantial proportion—as many as 50 per cent in some parts of the country—‘Sit round a table? But we don’t have a table.’ In these households meals are consumed on the sofa in front of the TV, or in bedrooms, or as snacks taken around the house. Clearly this is not likely to be conducive to a balanced diet. Beyond that, the simple and sad reality is that the cheapest foods tend to be least healthy.