Fat, Fate, and Disease : Why we are losing the war against obesity and chronic disease (37 page)

The simple fact is that through our technologies applied to modern industrial agriculture and food processing, and through the built environment, we have created a world that provides energy and nutrients in proportions beyond the capacity of our bodies to cope. This failure of our bodies to cope is most obvious in the increase in visceral obesity and the insidious onset of diabetes and cardiovascular disease, processes that start much earlier in the life-course than most experts realize, and often before we are born.

But while we may be able to change our nutritional world to some extent through healthier foods, better diets, and exercise, it is totally unrealistic to imagine that we can return to some historical world. The world has more than ten times the population of 200 years ago, and ensuring that no one starves must take priority over worries about chronic disease. Moreover the totalitarian nature of the policies that would be needed to exert the necessary levels of control on the food industry would be unacceptable in virtually every society. We cannot deal as societies with more acutely harmful practices and
agents, so is it realistic to imagine that we will be able to do so with food? Ideas about food and its social value are central to every culture, every religion, and every society. And many cultures have different perspectives on the ideal body image too.

There are certainly unacceptable and undesirable practices within the food industry which must be tackled urgently. The aggressive marketing of high-energy, nutritionally poor foods to children must be stopped. There is no value in alco-pops or high-energy caffeine-loaded ‘power’ drinks, all of which can have adverse health consequences. There is a growing industry of health foods sold at a high premium where in most cases there is no evidence for the claims made, and well-intentioned people are having their pockets emptied by the marketeer. Perhaps financial disincentives can deal with very unhealthy foods, but care will be needed to ensure that the disadvantaged do not become more disadvantaged through food insecurity. And is it not paternalistic to say that the answer lies in controlling what poor people can eat rather than in dealing with the fundamental question of why they are in that situation?

But we also have to defend some aspects of the food industry. We cannot stigmatize it in the universal way which we could the tobacco industry. Rather the world needs the food industry to be engaged constructively in the enormous challenge of food security, arguably the most direct challenge to most developing nations, which will get worse as populations expand and the planet continues to warm.

If food is to be an effective weapon in our global war against non-communicable disease, we need to shift the focus from claims about the ‘new age’ health foods to developing scientific evidence on which to base claims for ‘foods for health’. There is little doubt that nutrition and nutriceuticals will be an important part of the solution to the problems of diabetes and heart disease, but claims for health benefits from particular foods should be scientifically regulated and based on evidence, so that we can make informed choices. The regulatory mechanisms in place for food and health claims are not well developed,
are confusing, and inhibit rather than encourage research. This should be a priority for regulatory agencies around the world. We need to create frameworks within which the food industry can work with the health sector to produce products that genuinely do help and which justify the research investment by companies.

But in the end the food industry both creates the market and also changes the market in response to consumers’ preferences—that is the fundamental nature of the free market economy which most societies espouse to some degree. And that creates another challenge for us—to educate consumers about what they should buy and what they should eat, not just for this generation but for the next. And that will not be possible without consistent, easy-to-understand food labelling that is designed to help rather than confuse.

It is often said that it is only junk food that poor people can afford to buy. That is often the case but it need not be so—in many cases it is the lack of nutritional awareness that leads to many of us making poor choices. Nutritional education for people of all ages must be a core part of our strategy in both high- and low-income countries. It is obvious to us that this must be a starting point, but it requires coherent and well-informed educators provided with context-appropriate support materials. Nutritional and health literacy is as important as any other form of literacy for a healthy world.

And in the developing world much needs to be done. For example, the tragedy of the heavy subsidy of corn by the US government cannot be underestimated. It was started by Earl Butz, agricultural secretary in the Reagan administration, but it continues today. It drastically changed the nature of the processed food industry and the type of fats and sugars used in the food supply across the world. It is depressing that domestic politics in the USA makes this subsidy, which has global impact, untouchable even though the First Lady, Michelle Obama, has proclaimed her ambition to tackle childhood obesity. The removal of these distorting agricultural subsidies, and those operative in the European Union, would have considerable impact. Opening up
the international food trade would greatly assist the economies of many developing countries, for which agricultural production and export to the West remain the most rapid way for economic advancement. But sadly the West still uses tariffs and domestic subsidies to inhibit the developing world’s capacity to sell their food globally.

The paradigm shift which Semmelweis brought about resulted from a strategy based on evidence which, when we look at it dispassionately, is totally compelling. One group of medical professionals examine a patient with dirty hands carrying pathogens; those in another group wash their hands before doing so. The mortality rate of the patients of the first group is much higher some days after examination than that of the second group. Therefore, see what difference it makes to patient mortality if the first group of doctors wash their hands. The intervention is simple and inexpensive, and any effect should be manifest in a short time.

We believe that the arguments we have made for the importance of development to the prevention of non-communicable disease globally are equally clear and compelling. Look at the map of deaths around the world from non-communicable diseases. It is dominated not by the West but by Asia. It will explode soon in other regions of the world. It is obvious that we won’t be able to have much impact in Asia by merely applying the approaches we have used in the West—no more than strict adherence to the ‘bad humours’ theory of disease was able to prevent any deaths from infection in the wards where Semmelweis worked. The current approach is not working—people are dying. Something must have been overlooked.

We contend that what has been overlooked is development, in both senses of the word. For early life development and socioeconomic development are not independent of each other: they interact and are interdependent. In statistics, when two processes
interact we do not just add the two effects to assess the total effect—we multiply them together. Understanding the importance of this interaction, development multiplied by development, is a major missing piece in solving the puzzle of non-communicable disease.

Given that we are losing the war against obesity, diabetes, and cardiovascular disease in the West, except by using intensive medical interventions, why should we imagine that our currently favoured strategies will work in the less developed world? The solution must lie in the broader development agenda and its increasing focus on education as a route to empowerment. We have at least one international agency which is increasingly taking the lead in this regard—the United Nations Development Programme. While this agency has traditionally focused on crisis situations such as famine, civil war, and earthquakes, increasingly its leadership is thinking about women’s empowerment and education, child development, and gender equality. Focusing on the mother-to-be from a young age must be a priority even though in some cultures this will be very challenging. It will require insightful leadership at international, national, and local levels.

For reasons that we hope stand out from every page of this book, we hope that such programmes are reinforced and developed further. The United Nations Development Programme and its sister agencies including UN Women, now led by Michelle Bachelet, a former paediatrician and past president of the Republic of Chile, and the United Nations Children’s Fund need to be engaged and supported in this battle. They may even play a more important role than the World Health Organization, because the problem is not simply medical. And the major non-governmental organizations and philanthropic donors need to play their role too. We remain very concerned that such agencies seem to have been largely excluded from defining the global strategy needed to win the war.

Different people clearly have very different sensitivities to living in the obesogenic world which we have created. And it is now very clear that much of this difference is established so early in our lives that it is no longer right to say ‘It is mainly your own fault’ to people who are obese or who are developing chronic disease.

Genes explain some of this difference in sensitivity between individuals but not that much, and in any case we cannot do anything about our genes any more than we can choose our parents or rerun human evolution. But the ways in which we develop from a fertilized egg to a child depend on much more than our genes, and appear to influence a substantial component of our risk of developing non-communicable disease by priming us for how we will respond to the world as we grow up. Those developmental processes are moulded by the developmental environment, and we
can
do something about that.

Many factors operating before our birth can have enormous influences on our later health. Much of that effect is mediated by epigenetic processes and the science of unravelling this is advancing fast. It has revealed how the changes in gene switches induced by factors such as the mother’s diet put some people more at risk later than others. We think this science will soon create new approaches to the problem—it will tell us much more about how to create a healthy start to life. It will shift the point of focus from adults to potential parents, to both mothers and fathers, and to their babies.

Developmental risk is not about extremes of birth size or extremes of maternal stress or food intakes. Rather our biology was set up tens of thousands of years ago for ensuring that we pass our genes on to the next generation, and the echoes of that biology restrict how we can now adjust to a new world, a world we never evolved to inhabit. Perhaps the most dramatic demonstration of those echoes is in the simple observation that first-born children are
biologically different at birth from subsequent children, an observation with extraordinary implications for both Europe and China.

As we look at it in more detail, it becomes apparent that different developmental factors could play a significant role in different parts of the world. In India an important factor is constraint of fetal growth in stunted mothers. In much of the developing world the initiating factors may be poor maternal nutrition, often associated with heavy workloads in pregnancy, and maternal stress. In other places indoor pollution from cooking on smoky fires or charcoal, or pollution from traffic or industry, plays a major role. In still other places, such as urban China, it is the rapid increase in maternal obesity and gestational diabetes. Few of the 130 million births which occur each year will be unaffected by at least one of these factors.

Our development does not stop at birth. In our infancy and early childhood we learn eating habits from our parents, and some of these become hard-wired in our brains. Our food and taste preferences, our appetite controls, some metabolic settings, and possibly even the amount of exercise we are willing to undertake are all established in our brains in the first few months and years of our lives.

And the evidence is now accumulating fast that we can do things in early life that will make a difference—even if we have a way to go before we can be sure how effective these measures will be. Prolonged exclusive breastfeeding, appropriate maternal nutrition in pregnancy and lactation, and nutritional education for potential parents and young children are three simple measures that could be implemented in many parts of the world. They would have many other benefits as well, in reducing infant deaths and improving both maternal health and brain development in children.

In writing this book we have expressed on different pages emotions of frustration, excitement, and hope.

We are frustrated because it is manifestly obvious that we are failing to deal with one of the most important issues of our time—we are getting fatter in every country and are starting to see very high rates of non-communicable disease in some places. Even in some of the poorest parts of the developing world, where such disease is not yet common, nonetheless we see warning signs of its arrival. The burden of disease in the world is shifting from infectious to non-communicable disease, yet the resources spent on prevention of the former continue to far outweigh those spent on the latter. It is understandable and natural that we should focus our resources on acute problems, because that is only fair to those who are already sick, but in doing so we must be cognizant that life-course equity requires consideration of the prevention of what may happen in future years both at an individual and at a population level.

This issue of intergenerational equity is acute. We have seen it operate in the debate over climate change. Do we have to act now or can we afford to wait in the hope of a future technological solution? We see it in relation to non-communicable disease risk in the next generation. Should we wait and hope that they can solve this in their time?