Fat, Fate, and Disease : Why we are losing the war against obesity and chronic disease (34 page)

In reality there are just too many cooks in the kitchen and very often they have different recipes and approaches, so they can waste time and resources by duplicating efforts and not jointly building the infrastructure needed for a sustained campaign. Sometimes they may even compete—a phenomenon which has been seen on a more dramatic scale when several agencies are involved in relief operations in famine or earthquake situations. We desperately need global coordination here, to bring these organizations together. We could then not only pool the resources which they have at their command but also deploy them according to their particular skills and personnel base. More and more we see the need for an international legal system to deal with issues such as genocide or torture. These are issues of human rights, and surely the right to the best possible start in life should be placed on an equivalent level internationally. It may be that empowering—and appropriately funding—an existing organization such as the World Health Organization would meet this need. We don’t know. But surely leaving something that is so fundamental to human life to take its chance in a haphazard way among the priorities of a range of disparate organizations is irresponsible, if not downright immoral.

At the end of this book, we have a simple message for governments, agencies, and aid organizations. The current approach to obesity, cardiovascular disease, and diabetes is not working. There are multiple reasons and we have discussed some of them. They lie partly in the fundamental nature of the problem: we now inhabit an obesogenic world which we have not evolved to live in healthily; the development of the problem has been fast—like an epidemic—and insidious, so that by the time it emerges in a society it is too late to prevent it; cultural and individual motivational issues have been ignored; but, most importantly, the science suggests that a key part of the story has been overlooked. It is no longer possible to ignore new discoveries in developmental biology. The time has come to look again at why we are losing the war against obesity and chronic disease, and to choose some strategies that are likely to be more effective.

We know that many people across the globe are not in a healthy place in their lives, but moving them to a better place is not easy and may not work at all for some individuals. To a great extent this is because we have been asking the wrong question. Instead of asking what we have to do to make these people healthy, we should be asking how they arrived at this point, what path they took to travel to this unhealthy place. It is as if we have arrived at the scene of a crime and are now trying to figure out how to stop it, rather than looking for clues to the events leading up to it. But the fact is that we have arrived too late. We have forgotten about human development and how the processes operating in our early lives will shape our future, literally the shape and size of the fat in our bodies. Just because we are struggling to help those who suffer from obesity and disease risk as adults, let’s not forget the need to prevent this problem recurring in the next generation.

We have presented the case that a fresh look is needed in the war against obesity, cardiovascular disease, and diabetes. Winning the war clearly involves more than just increasing our worries about how fat we are and much more than accusing each other of gluttony and sloth. We have reviewed the science and the biases and blinkered views that have affected the way strategies have been chosen in this war. We have argued for a much more holistic approach, one that recognizes the cultural, social, individual, community, and developmental factors in play. Just because it is complex does not make it impossible to address. We cannot afford—literally—to wait and let a large fraction of the world become unwell and disabled. But it is all very well sounding this call to action. What action are we proposing?

First, there needs to be a far better engagement between scientists and the public. How that engagement should be conducted is a book in itself, but we can make a start. We have seen the conflation of values and ideology which has allowed science to get tangled up in the blame game that places responsibility almost entirely on individuals. That this is not correct could be explained clearly. It is difficult to motivate people if they do not own the problem—in no small
part that contributes to the magnitude of the failure of current efforts. And people are not likely to own the problem if they do not understand clearly what it is.

True, the science of human development is complex and there are many things that we do not know. But this should not be an excuse for not communicating it. Any new ideas in science can engender fears and here we are dealing with something pretty fundamental: what makes us what we are? what explains why some of us do well and some poorly in this modern world? The scientists engaged in this area have a duty to explain the ideas, and their implications, clearly to us all. Most scientific research is funded by the public in one way or another. It has authority in a modern democracy only to the extent that it is understood and accepted. Too many scientists forget this or just do not understand that such communication is part of their job.

How might we apply these new scientific insights? The potential for prediction in early life of those at risk of later disease using a combination of epigenetics, genetics, and measurement of other risk factors is a good starting point. To be able to predict which children are more at risk of developing diabetes or cardiovascular disease is a good thing if prevention at that stage is possible, but it also brings problems. Do we want our children to be labelled? What possible discrimination might this lead to, for example from insurance companies or employers? Answers to these questions will depend on a conscious effort by scientists to communicate early and clearly the benefits of new technology and not to shy away from the ethical and practical issues that arise. Failure to do so will leave the wider public, and politicians too, confused about the issues—as the furore over genetically modified foods or stem cell therapy demonstrated. A Luddite approach cannot work—whether we like it or not, seeking new knowledge is fundamental to humans and new knowledge will lead to new technological applications. Post-genomic, that is epigenetic, science is a key part of the next biological revolution. It could improve the quality of life for many—if it is properly applied.

We should not allow ourselves to be daunted by the fact that we are dealing with a complex problem. We have stressed that a single intervention does not fit all scenarios, just as the simple remedy of reducing energy intake and increasing exercise has had limited success in adults. It is always easier to arrive at a viewpoint or to devise a slogan that conveys a simple and direct approach but, as always, the devil is in the detail. There is no single magic bullet. The biology is complex and we should exploit this fact by recognizing that a multidimensional approach is needed. While we encourage healthy lifestyles we can still work to optimize the developmental factors which determine how pathogenic any particular lifestyle is.

Many public health campaigns focus on reducing the number of people at the extreme of a range—perhaps those who are clearly ill. Yet from a health perspective, and in terms of saving money in the long term, it is more important to shift the health of the majority of the population—of those of us who are ‘normal’, even though we may be at lesser risk—in a favourable direction. That said, this does not mean spending the same amounts of money on improving the health of all of us. Some sections of the population, especially the poor and poorly educated, will require more investment to shift their health to a more favourable position.

Next we need to do better at championing health and nutritional literacy. The more we understand about our bodies the more able we are to make better choices. Most of us believe that the role of the State is to empower its citizens to make healthy choices rather than to tell them to do so. This requires that the State take the lead in ensuring a level of health literacy and nutritional education from the earliest ages. Too much has changed to expect knowledge to percolate through families—active education is needed.

The more we understand about healthy eating from an early age, the more likely we are to eat better throughout our lives. Much of this book has focused on the earliest stages of life, and the more we learn about development the more we realize the importance of
the period around conception. But a large percentage of women do not plan their pregnancies. And even if they do, the information available about what they should eat is very basic and unattractive. Ensuring the best start for the next generation requires that potential mothers—and probably fathers too—eat more healthily throughout their reproductive years. Such a change in habits requires an understanding of the implications of intergenerational health.

One argument sometimes put forward is that, while these suggestions seem like a great idea, we would have to wait a generation to findout whether they work, and the world cannot afford to invest in such a speculative manner. This is a false argument on both direct and indirect grounds. The use of epigenetics and other biomarkers will likely enable us to show short-term benefit. For example, we can now use rather simple and non-invasive measures to study how the body develops in infants or when blood vessels start malfunctioning.

But even more obvious is that these initiatives will do a lot of good in their own right, in the short term as well as in the long term. Empowered and educated young women will play a much greater role in social and economic development in their communities. The measures we recommend will in themselves reduce the number of premature births, neonatal deaths, and cases of infant illness, and will also improve brain development in children. Each of these justifies the suggested approaches in their own right.

So the argument for waiting for even more research to be undertaken is simply prevarication. The real argument relates to inter-generational equity. Those who argue that our limited resources for health should be focused solely on adults alive today are failing to recognize the right to health of the next generation.

We need to find a way to make the food industry an ally, not an enemy. It made sense to vilify the tobacco industry, but it is illogical to extrapolate from that strategy to the food industry. We have to eat; we do not have to smoke. We must address the bad practices of the food industry—the marketing of junk food to children, the ridiculously large portions served in fast food outlets. But let us be realistic because, for much of the world, food security—that is, a reliable and safe food supply—is the bigger and more urgent issue. A flourishing food industry, active at every level in every community, is essential if food security is to be sustained.

Some futurologists argue that a failure of food security is potentially a grave risk to world stability and will be the source of future conflict. Somehow we need to engage the food industry and give them incentives to make products that meet their goals while serving each population’s needs better. Such a dialogue is now on the cards, even at the World Health Organization, in an attempt to build a multi-stakeholder approach to solving the problem. If the food industry lets us down by concentrating only on the short-term profits which serve their immediate vested interests, then more serious controls and constraints will have to be put in place. But provided that they are honest and transparent about where their conflicts of interest lie, we have to work with them.

Innovative approaches are emerging but they require lateral thinking and collaboration between groups that may previously have been at loggerheads. In an earlier chapter we described how gestational diabetes confers the risk of chronic disease on the next generation. Recently we visited some colleagues in China who were well aware of the issue. With support from the food industry and the Chinese Ministry of Health, Tony Duan at Tongji University in Shanghai and Huixia Yang from Beijing have established over 100 centres to provide nutritional advice to young couples and trained 150 health workers to
give that advice. In a period of less than two years over 170,000 people had attended these centres. A key focus has been to manage dietary intakes during pregnancy to avoid excessive fetal fat deposition—and they believe that they are succeeding.

We know that many paediatricians in the West believe that it is unacceptable to collaborate with the food industry, particularly in the area of infant foods, under any circumstances, just as virtually all scientists would agree that no collaboration with the tobacco industry is ethical. There are many memories of the active discouragement of breastfeeding by infant food companies when they promoted their formulas in developing countries in the 1970s—well-meaning parents shifted from breast to bottle with devastating increases in mortality from infection in their children. A lot has been learnt from that experience by the infant food companies and by doctors and regulators. It is time to move on. We have to accept that the very organizations which have been part of the problem must also be part of the solution.

While this book is focused on the role of development, we would not want the reader to interpret what we have written as saying that nothing we can do in adulthood is of any value. Of course there is much we can do to be healthy adults. What we are saying is that it is hard to make sufficient changes in adult life to bring individuals back onto a low-risk pathway for non-communicable disease. Some of us will benefit from weight loss programmes but many will revert in time to where we started. Clearly, diets low in saturated fats, sugars, and salt are of value for those on the high-risk pathway to chronic disease, and exercise both improves insulin sensitivity and adjusts the body’s energy balance favourably. But the reality is that at a global scale a focus on these measures alone is not working. We cannot rerun the early life development of millions of people
around the world to reverse the steps they took many years ago. Adult interventions are too little, too late for them.