A Diabetes Epidemic: Once a Disease of the Rich, Now of the Poor
Updated: May 3, 2020
“We are now living in a world in which war kills fewer people than suicide, and gunpowder is far less dangerous to your life than sugar. Unfortunately, we have gotten so used to this wonderful situation, that we take it for granted, and we are therefore becoming extremely careless.”
These words were spoken by legendary historian Yuval Noah Harari at the World Economic Forum in January 2020, part of his tirade cautioning us to think more carefully about the precarious position of global stability we have fostered. In far more eloquent language, he’s basically telling us to get our shit together, a message that can certainly be extended to matters of health.
It’s no secret that the world is getting fatter.
Today one out of three Americans is obese. This is twice as many as three decades ago, a stat ominous enough for the Center for Disease Control and Prevention to declare obesity an “epidemic.” 15 percent of children under the age of 18 are overweight, amounting to a threefold increase in the past four decades. The gold standard of health measurements, the National Health and Nutrition Examination Surveys (NHANES), announced that obesity rates have soared at a rate that is now considered a national risk.
Obesity is defined by your body mass index, or BMI, a simple calculation in which your weight is divided by your height. If it’s 25, you’re overweight. 30, you’re obese. Over 40, you’re ‘morbidly obese’. The NHANES estimates that 160 million Americans are clinically considered obese or overweight — nearly 40% of the population. And while these statistics might shock initially, it’s staggeringly evident that Americans have gotten much, much bigger. “The signs are all around us, from XXXL clothing sizes to supersize movie seats and even larger coffins.”
IS FAT THE NEW BLACK?
Possibly as a result of the normalization of widening girths, or perhaps an extension of a progressive “fat acceptance movement” from the ’60s, an omnipresent “body positivity” sentiment has been inching its way into public discourse. Packaged as an anti-discrimination protest, the body positivity saga is broadly embracing the fat, and smugly castrating many of its vocal opponents. The protest has become so acutely PC that brands are often publicly vilified if their formal endorsement of the movement is interpreted as insincere. We’ve seen this cultural transition in its extreme, with the excoriation of fashion icon Victoria’s Secret, famous for its svelte and practically alien-bodied models. Accused of everything from body shaming to causing eating disorders and depression, the notorious Victoria’s Secret Fashion Show’s cancellation after its 24-year run heralded the apex of this rhetoric. Facing increasingly acerbic condemnations for its “skinny image”, Victoria’s Secret has been annexed by more inclusive brands like Rihanna’s Savage X Fenty and Aerie that emphasize equal representation of all women, big, small, and…non-biological. “It’s simply become very gauche to articulate any negative feelings” against women of size.
OKAY, WE’RE FAT — SO WHAT? At the risk of being non-anodyne, there is a real elephant in the room here. It might be out of vogue to lean on statistics, but there is a disconcertingly high correlation between obesity and chronic illnesses like diabetes, heart disease and metabolic syndromes. While wide-birthed does not necessarily mean unhealthy, obesity as a lifestyle disease has been identified with numerous pathologies that are less than a century old. In many cases, we are suffering from ailments of our own creation, and we simply don’t know how to cope with the consequences.
Historically speaking, it used to be good to be fat. Until only a couple generations ago, “the scarcity of food led to the belief that corpulence was desirable, as reflected in the arts, literature, and even leading medical opinions. Only in the latter half of the nineteenth century did fat begin to be stigmatized for aesthetic reasons, and only in the early twentieth century was it recognized as a cause of increased mortality”. It’s now confirmed as the single-biggest determinant in the emergence of diabetes globally.
…but who is really to blame here? The Journal of the Academy of Nutrition and Dietetics examined the nutrition content of more than 480 non-chain restaurants across the United States, and found that the average dish contained 1,200 calories, about half the recommended daily intake for a moderately active adult. The standard American breakfast cereal makes a mockery of nutrition, sometimes packed with more sugar per bowl than is recommended per day, with absolutely zero nutritional value. Sugar has been claimed to be more physiologically addicting than cocaine, and is now loaded into everything from condiments to bread and even salad dressing. “Sugar is now the most ubiquitous foodstuff worldwide, and has been added to virtually every processed food, limiting consumer choice and the ability to avoid it. Approximately 80 percent of the 6,000,000 consumer packaged foods in the United States have added caloric sweeteners.” It’s no accident that the unhealthiest foods also happen to be the tastiest, the cheapest, the largest-portion and the most available. It’s gotten easier and cheaper to gain weight, and harder and more costly to avoid it.
Once a disease of the West, type 2 diabetes has now spread across the globe. Once a disease of affluence, it is now increasingly a conscription of the poor. Once an adult-onset disease almost unheard of in children, rising rates of childhood obesity have rendered it a distinct focus in pediatric medicine. According to the International Diabetes Federation, at least 463 million people worldwide suffer from diabetes, a figure which is projected to grow beyond 700 million by 2045. Two-thirds of these cases are coming from low- to middle-income countries.
Diabetes can cause severely debilitating health issues like kidney failure, adult blindness, and most significantly, nerve and blood vessel damage leading to other degenerative diseases like heart failure and cancers. It is caused by the body’s inability to produce or effectively use its own insulin, which helps regulate blood sugar levels to provide energy to body cells and tissues. Without insulin, the body’s cells would be starved, causing dehydration and destruction of body tissues. While type 1 diabetes is typically genetic, type 2 diabetes, which accounts for at least 90 percent of all cases, can be controlled — both positively and negatively — by lifestyle and diet.
THE WEST IS MOVING EAST
In recent decades, Asia has undergone rapid economic development, urbanization, and transitions in nutritional status, with the disposition of diabetes increasing precipitously in parallel with its development. In the 1980s diabetes was a rarity affecting just one percent of China’s population. Now, thanks to urbanization and the ubiquity of high-calorie diets, automotive transport and increasingly sedentary lifestyles, China has the highest number of diabetics in the world. And science shows that Asian populations tend to develop diabetes at younger ages and lower BMI levels than Caucasians due to lower subcutaneous fat stores, which puts them at an even higher risk. The World Health Organization projects that by 2040, 150 million people in China will be diabetic, with around 500 million believed to be pre-diabetic — more than the entire population size of the United States and Canada combined.
The percentage of Americans living with diabetes is problematic — at about 11 percent — though countries like Pakistan, Malaysia and Mexico actually range higher, at 20 percent, 17 percent and 14 percent respectively. The number of diabetes patients living in Southeast Asia will increase by 174 percent from 55 million in 2019 to 153 million in 2045. Africa’s propensity is expected to rise by 143 percent from 19 million to 47 million in the next 25 years. Though like most other things, when it comes to the number of adults having diabetes, China tops the list with 116 million, India is placed at second place with 77 million, and the US comes in third with 31 million.
The scale of this public health problem is dire, and is felt particularly sharply in countries like China, where traditional health systems are under reform. The Chinese government has acknowledged its inability to appropriately respond to this health onslaught, and has recently opened its doors to foreign hospital ownership, including transitioning to a private investment model. “It will take huge resources to deal with the burden of those with diabetes,” said Paul Zimmet, president of the International Diabetes Federation. “It’s perhaps insurmountable.”
This trend is not unique to China, but its expression is most staggering due to the government emphasis on consumption and growth. And despite the awareness of an impending health crisis, China has done very little to regulate the intake of fats, sodium, sugar in a meaningful way. McDonalds for example, has been expanding in China at the rate of 10 new restaurants per week; “the rise of American chains in China is as remarkable as it is almost incomprehensible in its scope. According to a report from IBIS, the fast-food industry in China generated roughly $150.9 billion in 2017, up 9.6 percent from 2016. Over the past five years, industry revenue has grown at rate of 11.2 percent annually, compared to 3.1 percent in the U.S. over the same period”. KFC’s latest three-story restaurant in China’s capital, seating up to 500 people, is their largest store globally.
These alarming figures reveal how much American fast-food culture has already permeated China, never mind the rest of the developing world. Foreign fast-food restaurants have historically represented quality and modernity, but at what cost? American fast-food chains serve consumers Western-style food products: heavy in saturated fat, simple carbohydrates and sugar, with a whole lot of processing and a whole little nutritional density.
In China, it has been suggested that the drive towards fast food has been amplified by the one-child policy, which for more than three decades limited most families to having one child. As a result of this policy, single children held a glorified status within the family structure, and were even affectionately called xiao huangdi, which means “little emperors.” As is often typical in a single child family, adults tend to dote on them, offering them toys (and junk food) to their heart’s content. It’s a loose correlation at best, but regardless of whether the high rates of diabetes and childhood obesity in China can be blamed on urbanization, fast food, “Little Emperor Syndrome” or a combination, these issues demand serious public health attention.
PATTERNS OF DEVELOPMENT LEADING TO OBESITY What can be claimed with certainty though, is that there is no straightforward culprit causing an appetite for junk food. Researchers have attributed rising obesity rates to factors related to globalization processes, which are believed to contribute to obesity by flooding low-income country markets with inexpensive but obesogenic foods. The growing omnipresence of “Big Food” brands such as KFC, McDonald’s, and Coca-Cola — defined as “ultra-processed products made by transnational food corporations”, demonstrates the rapid diffusion of Western-style fast food outlets…sometimes before pharmacies and supermarkets. Trade liberalization has shifted populations away from traditional plant-based diets, and rural–urban migration has led to increasingly sedentary living environments. These factors are inextricably linked to the fast-rising increase in non-communicable diseases in lower income nations.
Over the past decade, diabetes prevalence rose faster in low- and middle-income countries than high-income ones. These chronic conditions disproportionately affect these more vulnerable regions, with more than 422 million adults living with the disease hailing from poor countries. In many places, eating fresh produce is simply cost-prohibitive, since the recommended serving of two fruits and three vegetables per day can account for as much as 52 percent of household income.
Within the US, African Americans and Hispanics are more likely to be obese than their white counterparts. In many low-income U.S. cities, dinner comes in the form of chips, soda or frozen meals, sold on the cheap at local bodegas. Yet, these very meals are one of the country’s biggest public health menaces. Supersizing Urban America, a new book by the historian of public health, Chin Jou, “shows that fast food did not just find its way to low-income urban areas; in fact, it was brought there by the federal government. In the wake of the 1968 riots, Nixon’s law-and-order presidency launched programs that funded fast food franchise expansion. The administration asserted that black-owned businesses serving fast food would help to cure urban unrest by promoting an entrepreneurial spirit in poor communities; ironically the subsequent federal subsidization of fast food chains to enter urban markets was meant to promote a positive culture of ‘black capitalism’. While some black entrepreneurs did profit off this scheme, it was predominantly a boon to fast food giants searching for new market demographics. Supersizing Urban America makes clear that addiction to fast food is not a moral lapse or a brain chemical but the effect of poverty”. It is simple economics; low wages affect the type of diets households can afford, and sadly the cheapest is always the worst.
BURDEN ON HEALTHCARE
A King’s College London study estimates that diabetes accounted for 12 percent of health expenditures in 2018, or approximately $1.3 trillion — a figure expected to nearly double to $2.5 trillion by 2030. Its increasing prevalence and associated health complications threaten to reverse economic gains in developing countries. With limited infrastructure for or education on diabetes care, many countries are ill-equipped to manage this epidemic. Consider the following stats:
Direct medical costs and lost productivity attributable to diagnosed diabetes was estimated to be $327 billion in 2017,
Among people with diagnosed diabetes, direct medical costs are twice as high compared with people without diabetes
U.S. spending on diabetes-related medications increased from $43.9 billion to $51.5 billion from 2015 to 2016
One in 7 healthcare dollars is spent treating the condition and associated complications
The International Diabetes Federation estimates that 13 percent of medical expenditure in China is directly caused by diabetes, with annual costs estimated to reach $47 billion in China alone, by 2030.
FOCUSING ON HEALTHSPAN
With the expansion of our waistlines over the past few decades, many factors in our environment that promote obesity have come into scrutiny. To reverse the trend, health officials have begun experimenting with a number of different policies, though none has been officially regulated. Taxation of sugar is the lowest common denominator, and if governments can agree on the science revealing sugar’s toxicity, processed foods may suffer the fate of cigarettes. Several countries including the UK, France, Hungary, Chile, and Mexico are experimenting with taxes on junk foods. Of course, in countries like the US where Big Food has omnipotent lobbying power, taxes may be a slower approach.
Athletes, celebrities and NGOs have been helping boost the profile of nutritious foods through campaigns like the 2016 Olympics supermarket sponsor Aldi, Jamie Oliver’s Get Set to Eat Fresh cooking education program, and the Clinton Health Access Initiative’s Healthy Schools program. These types of corporate partnerships help educate and inspire people to make healthier choices where available, along with incentivizing Big Food companies to clean up their menus. Countries like Chile are even experimenting with “nutrients of concern” warnings on food labels to help consumers better identify sinister ingredients.
Recognizing awareness alone is not going to cut it for a global lifestyle shift, nonprofits like Wholesome Wave are working with the US government to offer fruit and vegetable subsidies for the poor, through their National Nutrition Incentives program. When people on food stamps shop at farmers markets or participating grocery stores, their stamps double in value. They’re also experimenting with produce prescriptions provided by doctors to patients with limited food access through their FVRx initiative.
To be clear, this is not a quick fix situation. It is convoluted, complex, and truthfully one of the world’s most wicked problems. But the evidence is irrefutable: the processed fast-food diet we have so gleefully embraced is taking us on an express route to obesity, which catalyzes all kinds of health problems and avoidable costs. We need real and systemic change, through collaborations between governments, corporates, the medical industry and NGOs. It’s time to attack this problem from the top, bottom and even the wide sides.
And while no person should be subject to discrimination or emotional abuse on account of their physical appearance, “loving your body at any size” is not a solution. We need to reroute the conversation away from mass and girth, and towards the composition of your body. Science tells us that some people are perfectly healthy at a BMI of 25, and others may be rotting inside at a BMI of 15. But no matter your constitution, you are going to end up sick from a diet of McDonald’s and coke. It is imperative that we facilitate healthy consumption of nutrient-rich and sugar-poor diets, rather than allowing our people to putrefy from the inside out. It’s simply inhumane to suffocate a growing economy with junk food and have them suffer the consequences in the future.