Fat, Fate, and Disease : Why we are losing the war against obesity and chronic disease (31 page)

The analogy between obesity, chronic diseases, and climate change can be drawn in several ways. The science is certainly very complex, it has multiple dimensions, and there are many things we still do not understand. There are vested interests in operation too, which would prefer to retain the status quo. And it is also a matter of values—how much emphasis to put on the health of the next generation and how much on the lifestyle of the current one.

In the climate change arena two approaches have been adopted to reconcile these conflicting views—mitigation and adaptation. Mitigation is about incentives to reduce greenhouse gas emission, through either fiscal incentives or green technologies. Adaptation concerns the active search for technologies that will allow us to cope with a much warmer world at some time in the future, even if we cannot prevent such warming. The technologies for adaptation that have been discussed include massive geo-engineering projects, literally on a global scale.

We would equally argue for a two-pronged approach to obesity and the chronic diseases. On the one hand, we must continue the current efforts aimed at promoting healthy living—mitigation—but in doing so we must understand their limitations. On the other hand, we must start thinking much more seriously about new solutions for the next generation—adaptation.

Any action plan will require a shift in resource, both fiscal and political. Lip service to the importance of the early stages of life is easy. It is like saying education is important—no one can seriously disagree with such a statement. But many societies do not value teachers highly or pay them well, and some have not made universal education compulsory. But then we will meet the very valid argument that resources are not limitless—so, as in any aspect of public policy, we have to be more specific as to how they should be deployed.

And this is where good science is so important in informing the policy makers about their options. A focus on promoting optimal development is no different from the anti-smoking campaign. We did not wait 30 years to find out with absolute certainty that reducing smoking would lower the incidence of heart disease or lung cancer in the population. The science was already good enough—from animal experiments that carcinogens in tobacco smoke caused cancer, epidemiological studies of the links between ‘pack years’ of smoking and disease, and so on. The problem for a long time was the uncertainty about this scientific data which was deliberately spread by the tobacco industry. But when that battle was finally won, governments moved fast. Legislation followed, doctors and teachers stopped smoking, advertising and vending machines were banned, taxes on cigarettes were increased, smoking was banned in public places, etc.

The recent introduction of immunization against the papilloma virus, which causes cervical cancer in women, followed a similar course. Once the scientific link had been made between the viral infection and cancer, and the vaccine had been developed and tested, it became feasible to vaccinate pre-pubertal girls safely and on a large scale. The introduction of this vaccine was far less controversial than might have been predicted by sceptics. In general, society did not feel the need to get caught up in the seemingly enormous barriers of
explaining to these girls ‘You have not reached puberty yet but after you do you might have unprotected sex with a range of partners who are also sleeping around a lot. We are not saying that you will behave like this, but if you do your risk of this nasty form of cancer will be higher. So, to be on the safe side, we’re giving you this injection.’ Instead of being mired in a complex debate about modern sexual mores, governments understood the reality of the risk, accepted it, and, took action.

The evidence is now clear that early development is an important piece of the puzzle that makes us what we are, and we need to use that information in formulating more effective strategies to improve the human condition on a global basis. The science is increasingly robust and is very consistent. It screams ‘Development matters!’ The developmental dimension explains why some people are more and others less sensitive to getting obese. It turns out to be a story that affects every one of us and not just those who are born small or prematurely—we are all creatures of our genes, of the world we live in, and of the way we developed. This new science offers exciting possibilities. It explains more of the biology of disease than previous attempts and it will allow us to measure early markers of disease risk and to explore possible interventions and monitor them. And it is more than just epigenetics, because we now have many other tools to look at development afresh. For example, with new imaging techniques we can look at body fat developing in different parts of the body, from birth throughout childhood. While there is much more to learn about this new dimension, the science of development is now sufficiently robust to demand action.

Because there have been a number of dedicated scientists and health professionals looking through the developmental lens for years, much of the work to formulate the best approach already exists but it is not being implemented systematically. While there may be differences in emphasis on what to do in different countries and different societies, there is a common set of themes.

Almost a decade ago a technical committee set up by the World Health Organization spent days debating the most appropriate types of interventions. It comprised over 30 experts from both developed and developing countries. They applied themselves diligently to the problem, and their work was followed by consultation meetings in several developing regions across the globe. One of the authors chaired this committee and both of us were involved in the subsequent consultation. Tellingly, the experts had initially been asked to focus on measures to reduce the number of babies of low birth weight, defined as those weighing less than 2,500 g, throughout the world. But even before the work started, the scientists charged with organizing the meeting realised that they had to shift the focus away from such a narrow perspective and aim the discussion at giving all children the best possible start in life.

One of the benefits of such expert groups is that it enables scientists of different perspectives to look at the problem from several angles. There was a considerable variety of disciplines and countries involved—high-technology and low-technology approaches, nutrition, women’s health, paediatrics, epidemiology, and basic science. World Health Organization reports go through multiple cycles of feedback and debate before they see the light of day publicly and individual bias nearly always gets subsumed into a consensus. So such reports ought to carry considerable weight.

The report of this group was unequivocal in its conclusion that the global burden of early and later life disability as a result of impaired fetal development is huge, both in developing and in developed countries, and that the promotion of better fetal and infant development would enhance social and economic health and well-being in many populations. The benefits it listed included school performance and skills, health during adolescence and adult life, better physical work capacity and greater learning skills, increased productivity and
economic gains, a reduced burden of infectious diseases, and, central to our argument, obesity, diabetes, and cardiovascular disease.

The report identified many opportunities for population-based intervention, using a public health approach, and others that would be more appropriate on an individual basis. All of the report’s recommendations applied equally to developed and developing countries, although their relative importance, it was recognized, would differ. None of the recommendations will come by now as a surprise to the reader of this book—and none really should have surprised public health professionals worldwide at the time.

Much of the report focused on the condition of the mother before she became pregnant. It was clear that women needed to be in a much better nutritional condition when they conceived. It was pointed out that far too many women in the world have their first child at a very young age—strong sociological forces lead to this being the case in many societies. But this means that young girls do not receive an adequate education and are disempowered. Biologically it is clear that optimal fetal development is more likely if at least four years have passed from the time a girl has her first period and when she conceives. Only then has her pelvis reached a maximum size, which allows the fetus to grow optimally, and only then has her biology reached the point where she no longer needs to hold back nutrients for her own growth at the expense of her fetus. In much of the developing world this is not the case. Strong recommendations were made to encourage a delay in first pregnancy. This would have greatly empowered women in many societies by allowing them to stay longer in education—or indeed to receive an education at all. There is now growing evidence that the empowerment of women is a key step in the economic advancement of every country and the importance of allowing every girl a chance to delay reproduction until an appropriate age must not be overlooked.

Given what we now suspect, we would probably want to add in the health and nutrition of the father as well. Indeed, in some trials in South Asia it has been found that unless such interventions also include the father, the mother will still miss out because she will be seen as subservient to him; even if a food supplement is given to her, it will be reserved for the father.

Other recommendations of the World Health Organization report focused on the woman once she became pregnant. These included specific recommendations about adequate and balanced nutrition and weight gain in pregnancy and efforts to support the mother during pregnancy through reduced physical workload and stress. Many women in the world walk miles each day to collect water and undertake heavy, physical farming work even during late pregnancy, and often pregnant women do not have priority in the family when food is limited. Far too many women are subjected to physical abuse during pregnancy, and the resulting stress hormone changes can affect the baby.

The need to reduce smoking in pregnancy was affirmed by the World Health Organization committee, and alcohol and drug exposure remains an ongoing concern. Malaria and HIV-AIDS are major problems during pregnancy for far too many people—malaria in particular invades the blood-rich placenta and the parasites consume the oxygen and food that should go to the fetus. Malaria is a major cause of fetal growth retardation in developing countries and the importance of continued efforts at its eradication is obvious.

Other recommendations of the committee focused on the birth process itself and then on the baby once born. They emphasized that
many babies are still born without a trained midwife. If the delivery goes badly and the mother dies or becomes infected, the baby will inevitably have a bad start to life. This is an ongoing issue, and in the last year we have seen much attention, especially from the Gates Foundation, on improving the conditions of birth. Several hundred thousand women still die each year in pregnancy or childbirth—clearly, addressing this is a priority in its own right but we should also recognize the long-term costs of poor obstetrical care.

Lastly, the committee focused on the importance of exclusive breastfeeding for several months. But then, and since, little attention has been paid to post-weaning foods. The committee concluded that much more attention should be given to individuals in terms of matching postnatal nutrition to the circumstances into which they had been born.

While the recommendations above were framed for the developing world it is easy to see how they can be extended to the developed world. They were published six years ago and yet have had little impact. The report remains on the shelf. Why were agencies and governments unwilling to take steps to implement such recommendations?

As usual in politics, there are several reasons for this lack of action. Of course it takes more than the report of one World Health Organization committee to change the emphasis of healthcare recommendations, so we should not expect too much. But the report never even progressed through the World Health Organization machinery itself. Part of the explanation may have been political. The report gave high prominence to the rights of girls, to their empowerment, and to delaying the age of first pregnancy. Maybe it was this that buried it. After all, this was the era of the Bush administration in the USA and contraception was considered by some on the political far right to be equivalent to abortion. Further, there were many patriarchal societies in
Africa and Asia where this kind of argument would fall on deaf ears. But change has to start somewhere, and where countries in the developing world have empowered women the evidence of economic and social progress is clear.

Other reasons for the report not progressing very far are more pragmatic. The division of the World Health Organization dealing with it was small and not well linked to the big agendas of the time—such as HIV-AIDS. And with personnel changes the momentum was lost. When the report was finally made public, along with those of some of the regional consultation committees, it seems not to have been discussed further within the World Health Organization to any significant degree—it does not get a mention in subsequent reports, such as those dealing with chronic disease. But perhaps its influence grew slowly within the organization. The current Director General of the World Health Organization, Margaret Chan, spoke in 2011 with passion about the need for young women to be educated, of their empowerment, and of the importance of breastfeeding and a healthy environment for the first two years of life after conception for every child.

It was clear then, as now perhaps, that even the influential governments of the developed world have few scientific and medical advisers who really understand the issues. Why should they? They are highly intelligent and well-educated people, but even if they are medically trained they will not have spent much time during their studies, or since, considering the long-term consequences of the developmental environment. Development forms only a very small part of the syllabus for doctors in training. The long-term consequences of poor development are only now beginning to be clearly seen. So are we expecting the experts to advise their governments to take a new course of action? We are.