Recently I worked as an internist-intensivist at the Canadian Combat Surgical Hospital in Kandahar. Most of our casualties were Afghans: National Army soldiers, National Police and civilians caught in crossfire. They were diminutive men, almost always less than 140 pounds. I cannot comment on the body masses of the Taliban—they were never brought to us. But they are not likely larger than those of the soldiers and the police. And because, in war, soldiers are fed first—prospering right up to the moment they are pierced—the civilians were even thinner.
For someone used to the life and the pathologies of the rich and settled, much about practicing medicine in Afghanistan felt unfamiliar. One of the striking differences was the way gunshot victims’ abdomens looked in CT scans. Back home, I was used to seeing organs stand out with some prominence from the abdominal fat. In fact, in Canadians, the state of the kidneys can be partly assessed by the degree of inflammation in the perinephric fat that envelops them. It’s the same with the pancreas, and the liver often looks like it belonged to a French goose fattened for foie gras...Not the Afghans. The surgeons, in fact, often commented on how the abdominal contents spilled out once the abdominal wall was opened; every loop of bowel immediately visible, unobscured by mesenteric fat, which, in Canadians, would cling to every organ like yellow oily cake.
Excessive fattiness is precisely why, when caring for the critically ill in North America, glucose levels are tightly controlled with insulin—a procedure necessary even for those not thought to be diabetic. Stressed by the infection, or the operation that has brought us to the intensive care unit, our sugar levels rise, paralyzing our white blood cells and nourishing the bacteria chewing upon them. But it was never necessary to give the Afghans insulin, no matter how shattered they were.
Among North American adults, 40% of us maintain normal glucose levels only by secreting larger than normal quantities of insulin from our pancreas. So we wander in and out of our family doctors’ offices and, if some blood work is done, we are reassured that our glucose levels are normal, that we don’t have diabetes. Mostly, they are and mostly, we don’t. But our bodies are not normal. The Afghans’ bodies are normal. We are so commonly ill we take it to be normal. Here is our normal: 40% of North American adults have metabolic syndrome. The syndrome is caused by being fat, even at levels North Americans would not recognize as abnormal. Obesity prompts the receptors that insulin acts upon to become numb to its effects. As we grow fatter, and insulin resistance proceeds, higher and higher levels of insulin are necessary to get the sugar out of the blood. Eventually, overt diabetes may supervene, as it has for 8% of North American adults, a tenfold increase since the turn of the last century. But even prior to the development of diabetes, metabolic syndrome insidiously eats away at the bodies of those it affects.
Metabolic syndrome’s elevated insulin level is why we order a second Whopper; getting fatter, cruelly, stimulates our appetite. It is also why high blood pressure is more common among Westerners, too, and why our cholesterol panels are more alarming. Ultimately and especially, it is why heart attacks are almost unknown among traditional peoples like the Pashtun, while half of us will spend our last minutes with the impression that a large kitchen appliance is sitting on our chests. Afghans die through causes that are widely considered avoidable—war being chief among those, but also tuberculosis, complications of childbirth, measles, meningococcus and polio. This fact is revealed conclusively by the life expectancy in Afghanistan, the lowest in the world: 39. Westerners are made ill by diseases the Afghans avoid—even among the very elderly, traditional peoples do not suffer cardiovascular disease—while the Afghans perish from diseases we are too rich to tolerate.
It might satisfy certain notions about comeuppance, but there is as yet no scientific reason behind wealth’s relationship with obesity and cardiovascular disease. To start with, it is the poorest Westerners—indigenous peoples, African-Americans, Hispanics—who are the most overweight and most likely to be diabetic. Within any population, the poor always bear the brunt of that population’s most characteristic and lethal pathologies. Much in epidemiology is mysterious, but this is constant.
Around the world, as traditional peoples and societies have been absorbed into the global monoculture, the prevalence of diabetes has exploded. Since 2001, premature death from obesity has exceeded death from malnutrition. The milestone was reached at almost the same time as another: for the first time in history, the number of urbanites exceeds the number of rural dwellers. Canada is an example. For all its magnificent and extensive wilderness, 87% of the population lives in a community with at least ten thousand neighbours. Afghans are at the other end: less than 12% live in cities. No lattes, no internet, no phone, no pool. And no XXXL elastic stretch pants. After wealth and death rates, the biggest difference between Afghanistan and Canada—and the hallmark of the world’s creeping homogeneity—is urbanization.
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The same process is underway across the Pacific, where the most acculturated islands have the highest rates of obesity, metabolic syndrome and diabetes. In 2001 I worked in Saipan, which is American soil in the Northern Marianas. The indigenous Chamorro, numbering just over 62,000, were in an awful state. The dialysis population, all of whose kidneys had failed due to diabetes, was growing at 18% per year—doubling every three and half years. The miracle of compound interest would have half the population on dialysis within a generation or two. (The other half, presumably, would find thriving careers as nephrologists.)
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One of the common pitfalls for clinicians who treat Type 2 diabetes occurs when they prescribe metformin to young women. Metformin decreases insulin resistance, which helps reduce blood sugar. Insulin resistance is also what causes infertility in women with polycystic ovary syndrome, as well as type two diabetes. Often, women thought to be infertile become pregnant after taking metformin. Sometimes, of course, this delights them, but sometimes it does not. Contraception does not normally seem like one of the things diabetes doctors need to emphasize. But obesity commonly underlies infertility in women, just as it also causes the growth of facial hair. And, in men, the growth of breast tissue. Adipose tissue secretes estrogens and insulin resistance increases levels of androgens. Diabetes is overwhelmingly the most common cause of male impotence in the developed world. Men and women are designed to move, and when we do not, our immobility reduces us in every respect. ...
