Fat, Fate, and Disease : Why we are losing the war against obesity and chronic disease (2 page)

The consequences of these changes in the way we live leave us with a fundamental discrepancy with our biology—a
mismatch
. And this mismatch has consequences which will make Sir John’s ‘storm’ look even more frightening and urgent. The storm clouds are darker and deeper than we had realized, because they herald another tempest, one that threatens our health and much more. For many of us around the world striving to have better lives, it will undermine our chance of doing so.

Most of us, if asked about today’s major global health problems, would focus on HIV-AIDS, on the risk of a flu pandemic, on malaria, and maybe even on polio or tuberculosis. Some of us might refer to dengue fever and other tropical diseases, which are common in many developing countries but unfamiliar to many of us in the West. These infectious, or communicable, diseases cause an enormous burden of death and suffering across the world and have been the major focus of campaigns funded by organizations such as the Bill and Melinda Gates Foundation. But this book goes beyond the challenges of infectious disease. We are writing about health issues that are even more pressing. There is urgency to what we will discuss, partly because it has not been sufficiently recognized but also because new health problems, which are emerging quickly, may take more than a generation to fix and so we cannot afford to delay doing something about them.

The health issues which this book is about are the so-called non-communicable diseases—the major ones being cardiovascular disease (heart attacks, strokes, high blood pressure), diabetes, cancer, and lung disease. Other non-communicable diseases are linked to these—kidney and bowel disease, bone and joint disease, skin disease, asthma, some forms of blindness, mental and cognitive disorders … the list soon becomes extensive. Together these diseases account for more than 36 million deaths every year—that is nearly two-thirds of all global deaths. These deaths are premature, in other
words they kill many of us when we are still in our prime, possibly even when we are young, and they are certainly not just problems of old age.

On an optimistic note, these diseases are preventable, which means we don’t have to accept this dreadful death toll. However, nearly 80 per cent of these diseases occur in low- and middle-income countries—developing countries where the resources to prevent them scarcely exist.

In this book we will focus largely on two of these non-communicable diseases which are of growing concern everywhere, namely, diabetes and cardiovascular disease. These diseases are closely linked, and in general when we talk about non-communicable diseases in this book this is what we mean. One of the reasons why the problem which these non-communicable diseases pose is not sufficiently recognized is that we might not automatically link them together. If they occurred individually they might be tackled one by one. But they don’t—and herein lies much of the problem. Many of the reasons as to why we develop diabetes and cardiovascular disease also underlie some forms of cancer and other non-communicable diseases.

A related problem is that these diseases generally do not kill us straight away—they emerge slowly and subtly and do not create the emotional impact of malaria or HIV-AIDS (someone is either HIV-positive or they are not). Indeed, because diabetes and cardiovascular disease are perceived as being a result of how we each live our lives—almost part of normal life, some might say—the collective ownership by society of the problems they create is often not recognized or is played down. We will explain why we cannot continue to think in this way.

When we write about diabetes in this book we are not referring to the well-known type 1 diabetes of young people, which is thought to be due to the destruction of the insulin-making cells of the pancreas by the body’s own immune system, but rather to type 2 diabetes, which used to be called ‘maturity onset diabetes’. This has a different biological basis
and is largely due to insulin not working sufficiently well in the liver and muscle for a person to control their blood sugar levels. It is linked to obesity because this makes it harder for insulin to work, and to cardiovascular disease because the metabolic disturbances of the disease interfere with blood vessel and heart function.

We will not focus on the diseases themselves in the book—this is not a medical book. Nor will we burden the reader with unnecessary jargon or technical information. Our purpose is to go beyond them to understand
why
they occur,
why
they are becoming much more common, and
why
we are failing so badly in our attempts to deal with them. We will argue that collectively we have misunderstood the nature of the problem. We have been fighting the wrong enemies in our war on these diseases and this has led us to use the wrong strategies. If we are to win this war we need to undertake some urgent rethinking about the real foes we face and what our strategy should be.

In addition to the personal and family tragedies which non-communicable diseases cause, economists calculate that if unchecked they will cost the global economy far more than the infectious diseases, more than many conflicts. The World Economic Forum calculates that in global risk terms they rank with climate change or a global financial meltdown as a major threat to human society and the way we live.

Doctors, health ministries, and philanthropic organizations are becoming increasingly aware of the challenge of non-communicable diseases and are trying to deal with it. But they are coming to it rather late in the day. It is only now that they recognize what an enormous problem it represents in the developing world as well as in the developed world. We will contend that they largely have a mistaken idea of what needs to be done. Their current range of interventions are poorly focused, incomplete, and inadequate.

A medical problem is far easier to tackle if we know what causes it. When we first understood in 1982 that AIDS was a communicable disease, the hunt began for the agent which was responsible for it. Once the HIV virus had been identified it was easier to devise drugs to combat it, and to start developing a vaccine against it. After it had been shown to be a virus of a particular type, scientists had a clear target and were able to make the drugs to combat it. Is the situation similar for non-communicable diseases? To a certain extent, it is. For some cancers, such as those of the liver or cervix, an infectious agent is clearly one of the triggers, so vaccination campaigns should be effective. But such links have not been found for diabetes and cardiovascular disease, so we have to think again.

We have good ways of treating these diseases once they develop—we know how to lower blood sugar with drugs or insulin, and we can treat high blood pressure and arterial blockages—even if the cost of these treatments puts them beyond the reach of most people in developing countries. But prevention is always better—and cheaper—than treatment. Condoms, safe sex, care about blood transfusions, and avoiding dirty needles are far better strategies for dealing with HIV-AIDS than the expensive triple drug therapy now developed.

So what about diabetes and cardiovascular disease—how can we prevent them? On the face of it the villain causing the problem does not seem hard to find—it is obesity. But, as we will see, while obesity is an important factor, for many people it is not the real culprit, and the plot is not that simple.

Obesity is not just about being a bit fatter, needing to wear a larger size in clothes, and not being able to skip up a flight of stairs. It is not just about the need for wider aeroplane seats or stronger seats on toilets or relabelling the sizes on women’s clothes—although a size 12 is not what is used to be. Obesity has major health effects in
raising the risk
of diabetes, heart disease, stroke, asthma, depression, and some forms of cancer. But does it
cause
these diseases? Most doctors
and medical scientists, asked to give an instant answer to this question, would say ‘Of course it does.’ But when we, and they, pause for thought it becomes apparent that the answer is not that simple. We realize that, while there is no doubt that obesity increases the risk of non-communicable disease, it is also clear that it does not cause such disease
directly
. After all, many relatively obese people are as fit as a fiddle. And there are literally millions of relatively young people in, for example, India who have diabetes but who don’t appear to be overweight by North American or European standards. So it must be more complicated than just being ‘fat’. There must be some other villains missing from the story, some enemies we have not recognized. Tracing those hidden enemies is partly what this book is about.

In a surprisingly short space of time the United Nations, governments, departments of health, doctors, teachers, economists, and the media have become alarmed about obesity. Many young people are quite rightly very worried by it too—for them the publicity about the risks of diabetes and cardiovascular disease associated with obesity is as frightening as that about HIV-AIDS was for adolescents of the previous generation. But while it might seem obvious that the problem would be solved if everyone ate less and exercised more, the solution has turned out not to be so simple. We all know that losing weight is hard and keeping it off is even harder. One of the authors has lost more than 20 kg on three separate occasions and, despite his motivation and a career devoted to the issue, has put it back on within months each time!

It is now clear that current and very intensive attempts to tackle the problem of non-communicable disease by aiming to reduce obesity are not working in general. The sad reality is that the global burden of diabetes and cardiovascular disease is getting worse. We are losing this war.
The rates of diabetes and cardiovascular disease are high in Western countries, which have well-designed public health systems, despite the enormous efforts of many agencies to make people lose weight. And now these very diseases are also appearing in epidemic fashion in countries far less wealthy—and where most people are not fat by Western standards—such as India, China, and Brazil.

When a proposed solution to a problem fails, there are two possibilities—either the solution is wrong or something is missing in our understanding of the problem. We think that both of these explanations underlie our failure to cope with the global problem of diabetes and cardiovascular disease. We believe that there is a collective misunderstanding of the nature of what is going on and how to address it. But, in addition, could it be that the war is being lost because we are aiming at the wrong target?

Whatever the answer to this question, it seems clear that at best our strategy has been too naive, largely based as it is on attacking a single target—adult obesity. We think that this has come about because those concerned with addressing the problem, from scientists and doctors to health policy makers and funding agencies, have ignored some of the fundamental science. They appear to have been biased towards a particular view of the solution—largely based on the idea that obesity arises from the biblical sins of ‘gluttony’ and ‘sloth’ and that diabetes and cardiovascular disease are the inevitable consequences. Then, in the face of evidence that their solution to the problem is not working, they have become even more zealous in their attempts to deal with these two sins and to attack the same target even harder—as if they wore blinkers to prevent them looking for others. A good general would be considering at this point whether there are other ways to win the war. This book aims to remove these biases and to take the blinkers off—before it is too late.

Obesity has been the focus of many public health initiatives. But just because it is a risk factor for diabetes, cardiovascular disease, and some forms of cancer does not mean that it is a disease in itself.
Laying down fat in our bodies is part of normal human biology and we do it from the beginning of our lives, even before we are born. How this fat deposition is controlled, and when it may become a disadvantage, is a subject that we will explore. But we must get away from the ‘obesity equals disease’ mindset if we are to concentrate less on treating the symptoms and more on preventing the diseases. Many health professionals and organizations focus on interventions in the increasing number of people who are obese. While this is undoubtedly important, we will see that it is as urgent to focus on the pathways that lead children to
become
obese.

The rise in the incidence of diabetes and cardiovascular disease in India, China, parts of South-East Asia (especially Malaysia and Indonesia), the Middle East, and South America has occurred within a generation. The speed of this effect is alarming and the implications are enormous. Already 100 million people in China and perhaps even more in India now have diabetes. Cardiovascular disease, manifest as stroke, high blood pressure, heart attack, or heart failure, is also rife. The rate of diabetes in the Middle East and North Africa is almost incomprehensible—over 20 per cent of people in the United Arab Emirates now have diabetes and there is no sign that this number is falling. More than 70 per cent of adults and 22 per cent of children are overweight in this region. Similar figures for diabetes exist for Colombo in Sri Lanka. The statistics for small Pacific states like Nauru and Tonga exceed even these numbers.

Worse still, we are now starting to see the same thing happening in sub-Saharan Africa, in societies which have only just begun to climb out of the abyss of poverty. Across the developing world a tragedy is about to be played out with sickening speed, because these countries are almost totally unprepared to deal with such a rapidly rising burden of new disease. They cannot afford to vaccinate every child against infectious diseases such as polio or measles, or to provide antibiotics to treat patients with tuberculosis. They cannot afford mosquito nets for every bed. If they do not have the resources to address the
long-standing problems of infectious, or communicable, disease, what hope do they have of tackling diabetes and cardiovascular disease?