Fat, Fate, and Disease : Why we are losing the war against obesity and chronic disease (33 page)

The ethical issues arising from these observations cannot be ignored. They are similar to the concerns that emerged when genetic diagnosis first appeared on the horizon. There was considerable concern that genetic information would become the basis for setting the premium for an individual’s life insurance, for example, and laws were put in place to protect our genetic privacy. To a certain extent the broader ethical issues have emerged more slowly than anticipated because genetic prediction turned out not to be as informative as its early protagonists had hoped. In some situations, such as the diagnosis of parents carrying single gene defects which cause diseases including cystic fibrosis and Tay-Sachs disease in their child, genetic diagnosis has still not achieved its goals. There are many doctors in
the world who believe that there is great potential for better genetic screening, particularly for certain forms of childhood cancer. Sometimes these are more common in certain populations. This used to be termed an ethnic link, but now the term ‘ancestral’ is preferred for such markers. Even so, the implications have not been resolved—individuals in some populations are very sensitive about their ancestry, especially if there are tribal, religious, or other cultural implications. So the widespread use of neonatal blood samples is debated. These samples are routinely used to screen for treatable metabolic diseases such as phenylketonuria, and are usually stored for a period of time—and can therefore be valuable for research.

In the light of the issues raised by genetic screening, the future of epigenetic measurements is still not clear. Optimistically, we think it may be useful at an individual level in ascertaining the level of risk and thus suggesting how best to manage the future. It may help us to monitor interventions aimed at reducing risk and to optimize approaches to improving the start to life. But we emphasize that we are talking about risk and vulnerability—a person’s epigenetic state determines in part how they will respond to the environment. Early interventions can change those responses if they are instituted in time. If we know a baby is likely to be on a higher risk pathway for chronic disease, we would recommend prolonged breastfeeding and attention to diet and exercise to reduce that risk. Perhaps research will find even more effective interventions in the near future, which can be made more culturally and individually specific. In addition, an effective use of epigenetic information will provide new knowledge about how best to optimize conditions before the next generation is born.

When we move from Western culture to other cultures, we are on even more shaky ground in dissecting out rights and the ethical issues. But we can point out how this knowledge can assist in reducing the burden of the economic and nutritional transitions. Take, for example, the age of a woman at the birth of her first child. We discussed earlier the problems of teenage pregnancy. In many parts
of the developing world girls are married very soon after they start their monthly periods—in some places even before this time—and they become pregnant soon after puberty is complete. This problem is made worse by the fact that in many societies married women are expected to undertake a substantial amount of physical labour even during pregnancy: working in the fields, carrying water and firewood, etc. Often they are the last to eat in the family, after the husband and children. From what we discussed, we can envisage the signals which the mother will be sending to her developing fetus. This is a mismatch scenario in the making.

Resolving this problem, of course, comes down to the education and empowerment of women, but this is not a panacea and it has to be handled with great sensitivity. In particular, solving the problem must also involve the education of young men. In some societies girls who have started to menstruate are at particular risk of being raped if they are not married, and once devalued in this way they are less likely to be married. They can drift into prostitution or other forms of service which will not ensure a good future for them or their children. So to a certain extent, the young-bride scenario confers some protection on girls. However, once married they may be expected to work in the home or to become mothers. If they were attending school they are likely to stop doing so. This limits their ability to take control of their lives and to develop their own careers and it also severely limits opportunities to explain to them what they should do in relation to their health and that of future generations.

One of the obvious approaches to resolving the teenage pregnancy problem is to ensure wide access to contraception, but this is not acceptable in many cultures. Moreover, in some cultures anything which might be viewed as a Western imperialist influence is likely to be resented, and this will be counter-productive. We saw something
similar play out in the tragic delay in accepting the use of antiretroviral drugs to treat the South African HIV-AIDS epidemic during Thabo Mbeki’s presidency.

Even in the absence of well-organized educational structures in developing countries, all need not be lost in the drive for the empowerment of young girls. We should not underestimate the influence which social contacts with peers can have in influencing behaviour. For example, a pioneering study by Anthony Costello and colleagues from London was able to show that good birthing practices could be advertised and organized through social networking. Given that Costello and his team were working in rural Nepal, we don’t mean Facebook or Twitter—we simply mean discussions around the local well and at the market. Women are far more likely to adopt a behaviour if they hear about it from a friend or relative whom they respect than if they are simply told it by a health worker or see it on a poster. We all tend to trust information received from neighbours, relatives, and friends—whether over the fence, in the pub, or at the workplace—more than from some government-sponsored initiative which seems to smack of interference in our lives.

What we are discussing here is referred to as ‘health literacy’ and there has been considerable research in this area over recent years. It shows that the progression towards such literacy goes through phases where we assimilate information on health issues, turn it over in our minds, internalize it, and then begin to use it in a critical way to decide on courses of behaviour, actions, etc. It is only perhaps at this later stage that we start to communicate our conclusions and give recommendations to our family and friends. Perhaps surprisingly, the research shows that even relatively young children are good at this activity and that they can very often become crucial influences on lifestyle and health issues within the family. This was certainly what was found in Southampton when the impact of children’s attitudes and preferences on the diets of families was studied, but it extends far more widely to include a huge range of aspects
of life. Children naturally represent the future, and they begin to take control of this future, as well as of their own lives, at an earlier age than is perhaps often recognized.

If in the developing world girls are conceiving too early in their reproductive lives, in the developed world there is a problem at the other end of reproductive life too. In the UK the average age of first pregnancy is now 31 years. Because this is an average, clearly many women are conceiving much later than this. Evidence is accumulating that the signals sent by the mother to her fetus change if she is older, potentially creating a greater mismatch, and there is concern that this may contribute to the rising risk of diabetes and/or heart disease later. Once again this is an issue that will have to be tackled on a wider cultural scale.

One achievement of second-wave feminism was to liberate women from the close link between their sexual lives and reproduction; to give them the opportunity to plan when they have children in relation to their careers, their choice of partners, and so on. Women face a difficult choice with regard to important career moves which might mean that they must remain in fulltime employment or undertake further training at a time when they may also wish to be starting a family. No society has managed to make this choice easy. Feminists would argue that until reproduction itself is adequately reimbursed financially as an activity, the choice between career and family will remain an agonizing one for many women and their partners. Some of those who believe that the obesity problem lies largely in adult lifestyles would even argue that the careers of women have taken them out of the kitchen, reducing the time that they might have had to cook traditional meals and giving them the cash to buy faster options that are less healthy.

Even though no society has tackled the issue of reproduction as a wage-earning activity head on, many developed countries nonetheless attempt to mitigate the situation by providing financial support during late pregnancy and nursing. The problem then arises of the level at which this support should be set and for how long. In most developed countries child support terminates when the youngest child enters school, but in a few it extends until the child leaves secondary school—the value of this prolonged support is highly debated. In some countries such as New Zealand it has been suggested that this support makes it better financially for a young woman living in a disadvantaged situation to have children than to take on a job. This is very controversial but there is enough anecdotal information to suggest it may influence some teenage girls who have dropped out of school, and so we can see that a well-intentioned strategy to resolve one problem might make another one worse.

The UK’s coalition government and its opposition are currently engaging in discussion on the importance of these issues and their impact on families. For example, it has been argued that the provision of child benefit allowances should now be limited to those who pass a means test and have a low income. This is perhaps basically fair, but it is tricky because however the rules are set, there will be some who unfairly miss out and others who can exploit the system. Such problems can be addressed but they raise deeper issues. Should couples be discouraged from having more children than they can afford to support, even without the allowance?

Who will decide the answers to these questions, and in whose interest should the considerations be made? Throughout the developing world it has been found repeatedly that poverty is associated with larger family size. There is no surprise here—especially in some societies where it is the tradition for the children to remain in close contact with their parents, and in fact to support them as soon as they are able to do so. This is particularly true of rural agricultural communities in the developing world, just as it was true of Britain in
the Middle Ages, because children provide the next generation’s labour for tasks such as agricultural work. But as prosperity improves, so family size shrinks.

Economists such as Jeffrey Sachs would argue that saving the planet through reducing population growth is intimately linked to economic growth. It would appear that families have fewer children both as their economic prosperity grows and as child survival becomes more reliable. And yet this too creates a paradox for, as we have seen in both China and Europe, the development of fat and the risk of later obesity and perhaps diabetes or cardiovascular disease are greater in a first-born child. We need a demographic shift, in that we need population growth to slow down if we are to sustain our increasingly resource-constrained world, but we also need to pay attention to the quality of life of the next generation. It is clear that the pattern of heart disease and diabetes is different in different countries. Particularly in countries that have undergone rapid recent nutritional transition, it occurs at earlier ages than in the West. We need to confront this challenge if the drivers to reduce family size are to be sustained.

There are enormous institutional and structural impediments to progress and the issues we have just raised illustrate the complexities. But beyond that is the problem of inertia in both the scientific and medical communities. Finding ways to promote a healthy start to life does not have the instant appeal of cancer or HIV research, perhaps because prevention grabs fewer headlines than cure. Governments have short-term objectives linked to the electoral cycle, informed by treasuries that adopt an econometric approach.

International agencies such as the World Health Organization also suffer from inertia and are often very encumbered by protocol—they can spend longer debating whether a representative
from a particular country should be at a meeting than planning a strategy on which the lives of thousands depend. For the World Health Organization, the issue is also complex because its members are the 192 countries which it represents, not representatives from civil society groups such as the World Diabetes Foundation, or indeed from the private sector. This situation is changing, as it must if we are to make any real progress in the prevention of chronic disease, especially in developing countries. In some areas, such as infectious disease, the World Health Organization has played a superb role, but sadly, in the area of development it has been a different story up until now.

In low-income countries the role of voluntary philanthropic agencies such as the, Gates Foundation has thus become dominant, if only because they have far more funding to disperse. Donors are entitled to define where and how they want to spend their money, and Bill and Melinda Gates and Warren Buffett represent enormously generous donors. However, their funding is often targeted at specific, relatively short-term goals, for understandable reasons: this is where results can be seen very quickly, rather than the more difficult holistic approach which is necessary to tackle longer-term problems, such as improving human development and reducing the risk of chronic disease. However, the dependency of many developing societies on philanthropy skews the locus of control and the health promotion agenda of governments.

Lastly, and perhaps strangest of all at first sight, is the problem that arises from too much enthusiasm. Whether we look at attempts to promote physical activity in school children in developed societies, or at those offering nutritional support in developing countries, we find that there is a plethora of organizations avidly taking on the task. Some may be sponsored by government departments, some by international agencies, some by global philanthropic organization, and others by local charities.