Fat, Fate, and Disease : Why we are losing the war against obesity and chronic disease (26 page)

Unfortunately, as our research proceeds, we realize that the answer to this is clearly no. The various intergenerational pathways to transmission of obesity, diabetes, and cardiovascular disease will not disappear. Why should we think that we could change our biology, evolved over so many millennia, so quickly? Taken together, the many causes of a poor start to life and the growing incidence of gestational diabetes and maternal obesity make the implications very clear. The majority of children are likely to start life with increased risk of developing obesity and chronic disease.

Gestational diabetes appears to be a particularly dangerous feed-forward situation and it is emerging rapidly in some developing countries. There is no brake on this system—diabetes will beget diabetes and the rate of increase in gestational diabetes in Asia, as the nutritional transition proceeds, may lead to a situation where the majority of pregnancies will be complicated by it within a generation. Modelling of these intergenerational effects makes it seem inevitable.

Breaking this cycle is unlikely to be achieved by waiting until people develop diabetes; we must start thinking now about strategies that reduce the risk of gestational diabetes and its impact on the fetus. This has several components—it means focusing on the developmental factors that lead women to be at greater risk of metabolic compromise before and during pregnancy. We will discuss these
strategies in the next two chapters. And it means managing gestational diabetes with much better nutritional education and support, in order to reduce the risk of high glucose levels attacking the fetus during pregnancy.

The question we pondered in earlier chapters is at least partially answered—our experience as embryo, fetus, and infant explains in no small part why some of us are more likely to become obese, and some are more at risk of diabetes and cardiovascular disease. Development is one missing piece of the puzzle and it is important to place it back into the picture.

When we are losing a war it is important to stand back and look at our strategy. Has the target been wrong, is the choice of weapons wrong, are we focused on winning one battle rather than adopting a long-term plan aimed at winning the war?

Some wars to promote health have been won. Think of the war on tobacco—while it is not a complete victory, we are winning it in most countries. In that case there was a simple enemy, one that could be removed—even if it turned out to be quite difficult to do so. There were the vested interests of the tobacco growers and the tobacco industry which had to be countered. There was the question of the large tax revenue from tobacco. There was much blurring of the evidence in order to create uncertainty as to whether tobacco really is harmful. There was the simple fact that many people are biologically addicted to tobacco products and that there are social and cultural contexts in which they smoke, which are not easy to change. But despite all this, after a long campaign, smoking is now restricted or illegal in many places in developed countries. Sadly and irresponsibly, the tobacco industry has turned its attention to the developing countries to boost its sales.

Why do people continue to smoke even in developed countries, where the information that it is harmful is widely disseminated?
For many it is a question of time preference. In their minds they discount the risks of later cancer or heart disease for the more immediate pleasures derived from nicotine and the social context that they share with other smokers. Some evolutionary psychologists such as Dan Nettle, whose work we described in
Chapter 7
, would argue that, particularly for people in poor communities, this discounting of the future is part of an even greater problem. In effect, they unconsciously predict a shorter life and therefore are less willing to invest for the future rather than live for the present. This might explain why smoking is more prevalent among poorer parts of Western societies—for them the future is now. It’s another example of a life-course strategy, a trade-off, although here perhaps it has a social element.

We need to consider this argument because it also applies to lifestyle and chronic diseases in general—poorer people are less willing or able to plan for the future. These are not decisions that are easy to change—they are inherent in the way our brains are constructed as a result of our evolution over many millennia—and we need to understand this context rather than just to put the blame on people in such situations. Understanding this should provide reasons for society to invest in these communities. David Sloan Wilson, a biologist who has applied evolutionary principles to studying neighbourhood health in Binghamton, a city in upstate New York, has shown that morbidity is reduced where neighbourhoods feel valued and supported. We might bear this in mind for the diseases we are focused upon in this book.

While targeting ‘gluttony’ and ‘sloth’ has been the focus of most public health initiatives, throughout this book we have pointed out that these may not be our real enemies in this war. There are many reasons why some of us cope better, and some worse, with the nutritional transition. Some of them lie in our genes, some in our social and cultural circumstances. But much starts in our development. We can do nothing about our genes, and tackling social and cultural issues
takes much time and is a real challenge. Indeed, as we saw in the first part of this book, simple assumptions about how effective this tactic is can turn out to be wrong.

So our development stands out as an area for immediate attention. We have described the multiple pathways by which biological processes in early life can lead to a greater risk of diabetes and cardiovascular disease, and how these turn out to be much more important than we could have imagined even a decade ago. These reasons alone make development a key point for attention, but there are other reasons as well. Diabetes and cardiovascular disease are appearing at younger and younger ages in both the developed and developing worlds—so we must shift our focus to earlier points in our life-course if we are to prevent them.

In addition, we are beginning to understand how early life experiences influence food preference, appetite, and exercise motivation for the whole of life. How we want to eat and how we want to exercise are influenced by what happens in the first few years of life. And the epigenetic studies described in
Chapter 8
demonstrate that we may be able to pick up markers of risk very early in life. With all this information we should be able to do
something
—what is holding us back?

The morning of 1 January 2000—the champagne had gone flat in abandoned glasses and the last fireworks had smouldered out wherever they landed. The 21st century staggered to its feet, pretty much to take up where the last century had left off. But the evening just passed was not a celebration for everyone—it was really only an event for the Western world. Not everyone drinks champagne, or any other alcohol for that matter. Not everyone could afford to celebrate. Some had nothing to celebrate. Many did not even know that it was the start of a new millennium.

The headaches and tiredness weren’t the only hangovers from which it would take time to recover. In 2000, the leaders of 189 nations and many international agencies had signed a declaration establishing the Millennium Development Goals, setting up targets aimed at improving the social and economic conditions in the poorest countries by 2015. They were all laudable initiatives
that would improve the health and well-being of millions of people worldwide. Many of these initiatives were seriously overdue.

A number of the goals focused on women and children. For example, the third Millennium Development Goal aimed to eliminate gender disparity in primary and secondary education by 2005, and at all levels by 2015. The fourth goal aimed to reduce the child mortality rate by two-thirds and the fifth to reduce maternal deaths by three-quarters and to achieve, by 2015, universal access for all women to reproductive health.

Now it is more than a decade since those New Year parties. We can see that the Millennium Development Goals, like most other New Year resolutions, are going to be broken. While we have not yet reached 2015, it is clear that not a single one of the goals will be met, although a number of them were identified as needing urgent attention by a gathering of world leaders at the United Nations in September 2010, organized to take stock of the situation.

These issues have attracted wider attention too. Sarah Brown, the wife of the former UK Prime Minister, took up the cause of women’s health. In an interview with the
Guardian
newspaper she said, ‘If we can fix things for mothers—and we can—we can fix so many other things that are wrong in the world. Women are at the heart of every family, every nation. It is mostly mothers who make sure children are loved, fed, vaccinated, educated. You just can’t build healthy, peaceful, prosperous societies without making life better for girls and women.’ She was right even if, to a certain extent, this is stating the obvious. But action has been patchy and very much aimed at achieving the numerical goals themselves rather than improving the situation of women and children in general in many countries.

Indeed, perhaps as a result of the Millennium Development Goals, the major focus of international activity in the area of maternal and child health has actually narrowed. Because of the influence of a few opinion leaders, and particularly that of the dominant philanthropic foundation in this arena—the Bill and Melinda Gates Foundation—much
activity has become focused on a reduction in maternal and neonatal mortality. While this is important in itself, it ignores many of the other considerations about this important phase in our life-course, which can have many other longer-term consequences. Perhaps this is the trap of setting goals—they become ends in themselves, rather than being used as indices of a larger problem. No one would deny the urgent need to reduce the risk of maternal and neonatal death, but it is no less a concern to ensure that the children who do survive have the best chance to live healthy, productive lives.

It is easy to be critical but, while practical solutions seem apparent, we have to recognize that delivery remains a problem. This comes down partly to matters of cost and partly to societal attitudes in some communities which limit the priority given to women’s and children’s health. For example, when funds are available, the purchase of weapons and supporting the local political powerbase sometimes take priority over these basic needs.

Cultural change is needed if women are to be more empowered, so that they become pregnant at a time of their choice, a time that allows them to have completed their education, and receive adequate care during pregnancy. Too many women are not in a position to control critical aspects of their life, but the cultural issues are deep and very complex—look at Iran, Afghanistan, and many societies in Africa. Consider the consequences of female circumcision or of young girls forced into early marriage. We cannot impose Western ideals on other cultures, but equally, it is a shame that progress on matters concerning maternal health is so slow. Quite apart from the humanitarian issues, these practices slow economic development and the progression to social stability which all sections of the population want in many countries.

Returning to the question of maternal and infant mortality, we can see that the issues which underlie many of the Millennium Development Goals could be fixed if sufficient resources were available. Ensuring that well-trained midwives or birth assistants are present
at births in the developing world, equipped with a sterile piece of cloth which can be used to tie off the umbilical cord and a sterile scalpel blade to cut that cord, will make a huge difference. An adequate supply of antibiotics will prevent the all too often fatal consequences of puerperal fever. A supply of clean water for those mothers who feed their infants with infant formula would prevent the two to three million infant deaths from diarrhoea that still occur every year.

Our millennium headache is far from over. And there is more to feel bad about. Not only will we fail to deliver on the Millennium Development Goals by 2015, but some of the major problems we face weren’t even part of those goals. For example, the problems of adjusting to nutritional and socio-economic transition, which are the focus of this book, were not even mentioned.

In 2011 the United Nations turned its attention to the non-communicable diseases and a high-level meeting of the General Assembly was held in New York. Some developing nations had urged that these diseases be included in a modified set of Millennium Development Goals but there was a consensus that this is not the way forward—we need action and progress more than symbolism. As the Director General of World Health Organization, Margaret Chan, put it, ‘Why would we want to try to jump on a train that left the station ten years ago?’

Our concern is that a much more holistic approach is needed than has been demonstrated to date. We have focused our attention too much on the adult—too much on the simple assumption that it is feasible to shift people’s eating and exercise habits and that, if this can be achieved, the challenge of obesity and chronic disease can be tackled. But clearly that is not so. As long as we keep our primary focus on the adult rather than adopting a much broader perspective, some gains may be possible but the war cannot be won. Until it is
appreciated that there are both individual and population differences in our biological sensitivity to an increasingly obesogenic world, we cannot adopt the right tactical approach. This will require a culturally and socially appropriate approach for each society. It will require governments to get beyond the avoidance of their responsibilities by shifting the blame to individuals. And most of all it will require a much greater focus on ‘development’ in both meanings of the word.

Earlier in this book we described how difficult it has been to get the developmental perspective into the frame. It is worth asking why this is the case, because unless we understand that we cannot expect the situation to improve significantly. For despite the accumulation of such strong evidence, the role of development and its impact on disease continue to be seen as a marginal issue. Perhaps this will change soon—don’t the enormously exciting data on the life-course and epigenetic contribution to disease risk create an imperative that cannot be ignored much longer? We would think so. Yet we are not optimistic. There remain many vested interests that may well keep the focus of effort on the adult rather than the child. There are many reasons why the developmental dimension is easy to ignore. If we are to make progress, we need to explore them.