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Sickly sweet
How did diabetes come to take more lives in a year than HIV, tuberculosis and malaria combined? And is a cure on the horizon? A special investigation by Tom Rowley
How did diabetes come to claim more lives than HIV, tuberculosis and malaria put together?
In 2015, diabetes claimed 5,000,000
At t he end of a long, hot Mississippi day, eight middle-aged women wearing bagg y T-shir ts and trainers were leaping across a church hall, as if they had decided to swap the unremitting sun for the prospect of some real sweat. In unison – well, almost in unison – they kicked their right legs in the air, then their left. Someone had brought along a stereo, which was barking out instructions and goading them into ever-greater exertion. ‘How low can you go?’ the male voice wanted to know.
‘This is about it, baby!’ quipped one of t he women, gasping for air. ‘That’s as low as it’s going.’
‘If my kneecap pops out,’ wheezed another, ‘somebody will have to put it back in.’
On this Thursday evening, as on every Thursday evening for the past seven weeks, they had gathered in Plantersville, just down the road from Elvis Presley’s home town of Tupelo. Some of them were very chubby, with big thighs and bulging stomachs; others, though, seemed not far from a ‘normal’ size. They came to weigh themselves, learn new exercise routines and swap healthy recipes. Mostly, though, they talked. They talked about how much exercise would burn off their favourite foods (‘Holy moly! An hour of canoeing is not even a Snickers bar!’), about substituting turkey for beef, and about how much weight they had already shed.
‘I’ve lost five and a half pounds,’ one of them said – ‘and that’s with my shoes on.’
This, though, was no ordinary exercise class. Unassuming though Plantersville may have seemed, we were in fact on the front line of a new campaign aimed at curbing one of the most per vasive – and costly – diseases facing America: diabetes. These sessions, part of a programme being rolled out across the country, target people at risk of developing type 2 diabetes – by far the most prevalent variant of the disease, and the only one usually linked to being over weight. Lose a few pounds, the reasoning goes, and you might avoid a lifelong condition.
‘It was set up a lot like Alcoholics Anonymous,’ said Sherry Smit h f rom Mis si s sippi St ate Univer sit y, who r uns t he Plantersville class. ‘You know, having a food problem is a lot like that.’
Around here, plenty of people have food problems. Within five minutes on one Mississippi highway, I passed a Mcdonald’s (‘Muffins all day’), a Burger King (‘Two for $10 Whopper meal deal’), a Sonic Drive-in, a Domino’s, a Waffle House, a Dodge’s Fried Chicken and a Huddle House (‘Tr y our fully loaded value meals – only $4.99’). The portions are huge, and even the chocolate bars are deep-fried. ‘In our state,’ Smith went on, ‘we love to eat.’
So perhaps it is no surprise that more than 13 per cent of the state’s adults are diabetic – the second-highest prevalence in America – with another eight per cent categorised as ‘at risk’. In the same region where evangelical Christianity was once on the march, waistlines are now expanding so fast that scientists have rechristened much of the area girding Mississippi – known as the Bible Belt – the countr y’s ‘diabetes belt’. The state’s Diabetes Coalition organises an annual conference on the crisis named, with a nod to the music that inspired Elvis, Giving Diabetes the Blues.
But this food problem has long since burst over state lines and bulged across the ocean. Just as American health officials were at last beg inning to g rapple wit h t he issue, diabetes diagnoses were spiking across the world. First came Europe: the disease is now Britain’s fastest-growing epidemic. Then the Middle East saw a huge surge in cases, too. Since 1980, t he global number of diabet ics has nearly quadr upled, to 422 million.
Ninety per cent of this number have type 2 diabetes, which occurs when the cells in someone’s pancreas that make insulin – an agent the body uses to process glucose – produce too little, or the body becomes resistant to it. This leaves the diabet ic with sur plus sugar in t heir blood, impeding its f low around the body and often leading to complications such as blindness or ulcers that can require leg amputations.
Diabetes eats £674 billion of health budgets a year, and it kills: in 2015, it cla imed f ive million lives, according to an International Diabetes Federation (IDF) estimate – more than the combined death toll for HIV, tuberculosis and malaria. By 2040, one in 10 of us will have it. It is, said Cherian Varghese of the World Health Organization, ‘a tsunami in slow motion’.
And now it is heading for Africa. For decades, television fundraising appeals and the worthier sort of billionaire have focused on tackling the many communicable diseases that have plagued that continent. But as it has slowly grown richer (really, less poor), it has also fallen vulnerable to what were once diseases of the West. In much of Africa, famine remains a constant threat: the UN has warned that as many as 20 million people across t he cont inent a nd in Yemen cur rent ly face potential starvation due to a toxic combination of conflict and drought. Yet in some rapidly expanding African cities, where people are splurg ing new-found disposable income on fast food, the problem is no longer too little food, but too much.
Ethiopia, whose horrific 1980s famine inspired the Live Aid appeal, still suffers from droughts that inflict hunger on its
rural population even today. But as its economy booms, more and more of its city dwellers are being diagnosed with type 2. Across the continent, the number of diabetics is expected to more than double in the next two decades – ‘a health time bomb’, according to the IDF. ‘Our health system would be over whelmed,’ said Ahmed Reja, the British-trained doctor who heads t he federat ion in Af r ica. ‘The whole economy would be overwhelmed.’
All of which means diabetes is now a long away from home. ‘We thought of this as an American problem,’ said Edward Gregg of the US Centers for Disease Control and Prevention. ‘It’s been fascinating – and disturbing in some ways – to see it unfold.’
How did diabetes spread so far? And can anything – or anyone – halt its march?
To understand how diabetes spiralled, you have to go to Tokelau – and that is easier said than done. Marooned in the South Pacific, midway between Hawaii and New Zealand, this series of three tiny atolls has no sandy beach resor ts, no mobile sig nal and no airport. The closest runway is on Samoa, a gruelling threeday boat ride away.
Yet these islands – 300 miles from the nearest supermarket or restaurant – make up the world’s diabetes capital. As recently as the 1960s, the condition was almost unheard of here; now, nearly a third of islanders are diabetic, the highest prevalence on earth. Unravelling
These islands – 300 miles from the nearest supermarket – are now the world’s diabetes capital 1 in 3 On the islands of Tokelau, almost adults suffers from diabetes
Tokelau’s journey from innocence to insulin helps to explain how type 2 conquered the world.
The smallest of the atolls, which measures only 1.4 square miles, was ‘discovered’ by the British commodore John Byron (the poet’s grandfather) in 1765. It is called At afu, and it is governed by routine. Saturdays are for fishing, Sundays for church and strictly not for drinking, Tuesdays for fan making. At three every afternoon, the women play bingo in their thatched meeting place; anyone feeding their pigs after 6.15pm commits an offence.
Now a significant minority of islanders have submitted to another, less welcome routine. At about six o’clock ever y Tuesday morning, 29 men gather outside a consulting room at Atafu’s tiny hospital. At the same time on Thursdays, 14 women do the same. A nurse pricks their fingers with a needle then writes down their blood-sugar levels in a large red notebook.
When I visited one Tuesday last autumn, I was greeted by Rosa Toloa, who was born on At afu in 1969 and has recently moved back from New Zealand (which has maintained the atolls as a dependency since 1926) to serve as Tokelau’s healthinformation officer. As the diabetics queued for medicine, she began to explain how her island has changed so much.
When she was a child, she said, islanders had a very simple diet of coconut and fresh fish. Chickens and pigs were kept but only slaughtered for occasional feasts. ‘When we were hungry, we would have a piece of dried fish and some coconut.’
Islanders were more active, too. Her father was a carpenter but, like most of the men, he would also fish every day. Every Saturday, they would climb the trees to claim the latest haul of coconuts. After a party of researchers visited in the late 1960s, they remarked on the ‘low rates of coronar y hear t disease, obesity and diabetes’. Back then, seven per cent of women were diabetic and only two per cent of men.
Then came the imports. More reg ular shipping brought unthinkably exotic foodstuffs: mutton flaps, turkey tails, even ice cream. Cooperative stores opened up on each atoll, and the United Nations supplied the islanders with freezers. In the 14 years after the researchers’ first visit, coconut consumption fell by a fifth. Meanwhile, islanders discovered sugar: in 1961, each Tokelauan imported only 7lb; by 1980, it was 69lb.
The effect was swift. When the researchers returned in the early 1980s, twice the number of women and three times the number of men were diabetic.
In 1979, cyclone damage prevented the islands’ supply ship calling for five months. Fishermen ran out of fuel for their motors and returned to more labour-intensive sailing. Sugar ran out. But when a ship at last called, the passengers did not discover star vation and miser y. ‘Tokelauans had been ver y healthy and had returned to the pre-european diet of coconuts and fish,’ the New Zealand Herald repor ted that June. ‘Many people lost weight and felt very much better, including some of the diabetics.’
When shipping resumed, so did the new eating habits. As well as white rice, potatoes, instant noodles and chocolate drink, islanders now import tinned mackerel and tuna. The shelves of Atafu’s shop, which dispenses change in chewing g um rather than coins, are lined with corned beef, pears in syrup, custard powder, chocolate-cake mix and crisps. Every week, adult Tokelauans work their way through 236 teaspoons of sugar. And, although walking from one end of town to the other takes only 10 minutes, many drive imported cars.
The result s a re predict able. Nine in 10 adult s a re overweight; two-thirds are obese. None of the adults I met was skinny, but after a while none of them looked fat either – when ever yone is car r ying a stone or two too much, it is hard to remember what ‘normal’ looks like.
‘If you look at some of t he old photos of t he weddings, there’s a big difference,’ said Toloa. ‘There were a lot of elderly people dancing – ver y lea n, healt hy-look ing people. You hardly see old people now. There are only a small g roup of them that are past the age of 65.’
Toloa and the nurses are trying. Atafu’s first gym will open this year, and its only advertisements warn about the dangers
of smoking and eating badly. Yet it is difficult to tackle the causes of the epidemic. ‘It’s not like somewhere where you have a choice of food. The food you get is the food you get,’ Toloa said. It is very difficult to grow vegetables on the coral and islanders cannot always rely on good weather for fishing. Besides, she continued, they are now hooked on sugar. ‘They just have a taste for it.’
One of the nurses, a kindly but spirited middle-aged woman named Valisi Rikim, knows this well. Her mother, sister and sister-in-law, and her sister-in-law’s mother, are all diabetic. Her aunt is also at risk. But, she explained when Toloa introduced us, she was most t roubled by t he condit ion of her brother, Foliga Filo.
Filo had been diagnosed 10 years earlier, in his late 30s. Like many type 2 patients, his initial treatment involved only taking tablets, but now he needed to come to the hospital twice a day so that a nurse – sometimes his sister – could inject insulin into his stomach.
It was not going well. The target blood-sugar level for type 2 diabetics is less than 8.5 mmol/l (millimoles of glucose per litre of blood) – Filo’s had sometimes reached 19. His feet had twice been treated for sepsis and often he could not feel his legs.
When he arrived for his injection, Rikim introduced us. Filo was nervous and appeared withdrawn. ‘You know, sometimes I have to go and look for him,’ Rikim explained. ‘He just doesn’t want to come. He says he is tired of getting the injections. But I always try to talk to him and emphasise the condi- t ion he is in and how important it is to take his medicine.’
Sometimes, she no longer recognised her brother’s character. ‘He liked to go fishing. He liked to husk coconuts. Now, most of the time, he just sits. It is very sad.’
As his sister spoke, Filo, whose black hair was sprinkled with a little grey, rested his forehead on his elbow and gave out long sighs. ‘There are so many diabetics in my family,’ he said. ‘I wish I was the only one.’
Was he scared? ‘Sometimes, when my blood-sugar level is high. But I am prepared,’ he said, pointing to the sky, ‘whenever He calls me.’
Ten thousand miles away from Tokelau, on a tattered beige sofa in his fly-ridden home, Berhe Gebremedhin looks on as his city remakes itself. Almost ever y day, it seems, t he dust y st reets spawn a new concrete tower and the interminable traffic jams g row longer and longer. Addis Ababa is on the up. Gebremedhin is not.
This 60-year-old Ethiopian ought to be prospering: he is a building-site foreman and, right now, it seems his entire countr y is under construction. Recently, the economy has grown as much as 10 per cent a year. But he was forced to g ive up work two years ago and is unlikely ever to return. Since both his legs were amputated last year, when his diabetic foot ulcers grew gangrenous, he has been confined to the sofa. During the day, he sits there; at night, he sleeps there. He can’t afford a wheelchair. His sole companions are his wife, who is also sick, and a little g rey radio, which he uses only occasionally in case t he batter ies r un out. He can’t afford those, either.
‘The only thing I do is sit,’ he said, when I visited recently. ‘I feel very trapped.’
Like many Ethiopian diabetics I met, he was thin and did not at all resemble t he diabet ics of Tokelau or Mississippi. Many have shed a lot of weight since being diagnosed; others, like Gebremedhin, say they were never overweight.
Gebremedhin is one of the first of a new breed of diabetic, as Africa g rapples with the same changes in consumption patterns and lifestyles that first swept through the West and t hen reached as far as Tokelau. In 1982, shor tly before t he famine, only 0.34 percent of Ethiopians were diabetic, according to one study. Since then, that figure has increased more than sevenfold. As urbanisation continues – the urban population is due to triple by 2037 – diabetes rates are expected to surge, too.
People have become hooked on sugar. ‘They just have a taste for it’
20 Every day, people in England have a diabetes-related amputation
‘I mean, we want economic development,’ said Dr Reja, the Africa head of the IDF, who also runs Ethiopia’s own diabetes association. ‘There is no doubt about it: we have to come out of poverty. But we are also saying, it has to be regulated.
‘Addis and the other major cities are growing like anything. When I was a high-school student, there were only two pastry shops for the whole city. Now, on ever y corner you will see pastry shops, fast-food shops. People’ s dietary habits are changing dramatically.’
In the West, obesity is often a marker of poverty. In Ethiopia, the ability to eat large quantities of fatty or sugary food implies affluence. ‘In this country, when people become rich and their living standards improve, they tend to eat unreasonably,’ Dr Reja said. ‘The children of this newly affluent middle class also assume a very unhealthy diet. Being overweight and obese is regarded as a sign of status.’
Ethnicity may exacerbate the looming crisis in Africa. In Britain, black people and those with South Asian ancestry are two to four times as likely to develop type 2 than are white people or Brits with mixed ethnicity. On Tokelau, the odds are weighted by Polynesians’ natural predisposition to the condition.
Ethiopians might also prove particularly susceptible since, according to one theory, countries where the food supply has historically fluctuated breed people better equipped to store fat and therefore survive periods of scarcity. In previous centuries, Polynesians would have found this capability useful for surviving long journeys by sea; so might Africans whose countries endured periodic famine. But the same capacity to store fat, when coupled with a ready and constant food supply, could wrong-foot them.
Predisposition, though, only becomes problematic once there is too much food readily available. The point is best illustrated by the Pima tribe of Native Americans, who live on reservations in Arizona. A related group of Pima live in the mountains of rural Mexico, largely cut off from outside influences. The two groups are genetically similar, but when scientists studied them, they found much less obesity and far higher rates of physical act iv ity among t he Mexican Pima. While 38 per cent of the American Pima had type 2 diabetes, only seven per cent of those in Mexico had the condition.
In Ethiopia, famine has been a persistent danger for centuries. During the famine of 1983-85, as many as a million people are thought to have died. Even today, despite the rapid pace of development in cities, about 80 per cent of Ethiopians live off the land, making them vulnerable to droughts.
In the countryside, cases of type 2 diabetes remain rare. But I did meet one rural diabetic, in the northern village of Arato Shugala. Taeme Taddesse was only 12 when his village ran out of food during the 1980s famine. But he was lucky: his family was taken in by relatives in another, more prosperous part of the country.