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

The Daily Telegraph - Telegraph Magazine - - NEWS -

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.

Tabitha Mcrun­nels (cen­tre) leads ex­er­cises at a di­a­betes-pre­ven­tion pro­gramme meet­ing in Plantersvi­lle, Mis­sis­sippi. Pho­to­graphs through­out by Ju­lian Sim­monds

Above Rosa Toloa, the health-in­for­ma­tion of­fi­cer for Toke­lau, at the South Pa­cific is­lands’ clinic. Be­low Atafu is the small­est of the three atolls that com­prise Toke­lau

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