America’s Number One Export? Diabetes.
Standing in front of a roadside fruit stand in Thailand, I watched in eager anticipation as a fresh mango smoothie was being prepared for me. While the owner carefully sliced the fragrant local fruit into the blender, I was surprised to see her add a heaping scoop of mysterious clear syrup.
“Wait, what was that?” I asked curiously. “Sugar, of course,” she replied nonchalantly.
I had never seen sugar added like that when I had visited years before, so I was genuinely confused. “Why do you add so much sugar?”
Now it was her turn to look confused. “It wouldn’t taste good without it.”
In that moment, my heart sank. Not at the way smoothies had changed in Thailand, but at the larger transformation it symbolized. The rapid pace of globalization had brought the wholesale importation of food tastes from West to East. More incipiently, I knew it meant that a more dangerous import had arrived—the epidemic of obesity and diabetes.
According to the CDC, nearly 70% of adult Americans are now overweight or obese. What is less obvious is that this has fuelled the growth of type 2 diabetes, which has nearly doubled from 4.5% to 8.2% from 1995-2010. Researchers have warned that this once national epidemic has now turned into a worldwide pandemic — with global adult diabetes rates doubling within the past three decades.
The number of people with type 2 diabetes is rising in every single country in the world, and is expected to grow from 382 million in 2013 to 592 million by 2035. The reasons for this are complex, but ultimately boil down to a whole new type of exports—the West’s bad lifestyle habits. To better understand this phenomenon, let’s take a tour of the world’s diabetes ‘hot spots’.
Given that one in three people with diabetes in the world are Chinese, Asia is currently ground zero. Despite the fact that obesity has traditionally been rare, and less than one percent of Chinese had diabetes in 1980, diabetes rates have skyrocketed to 11.6% (114 million) and prediabetes rates to 50.1% (493 million) of Chinese adults by 2010. To put this in perspective, since 2007 alone, 22 million more Chinese developed diabetes—the size of the entire population of Australia. This growth rate has been “unparalleled globally” and described as a “catastrophe…which could bankrupt the health system” by Professor Paul Zimmet, Director of the International Diabetes Foundation.
China and other rapidly developing countries may be a fertile ground for a diabetes epidemic, due to genetic factors combined with how quickly lifestyle changes have taken place. In the West, diabetes is traditionally seen among the overweight and elderly. But Chinese are developing diabetes at much lower BMIs—with an average BMI of 23.7 vs 28.7 in Americans. Urbanization has also changed lifestyles particular among younger Chinese, who are now being disproportionately affected—with 40% of 18-29 year old Chinese and 47% age 30-39 having prediabetes. One theory is that poor nutrition in utero and early life, combined with over-nutrition and heavy alcohol use and smoking in later life, may cause a ‘perfect storm’ metabolically that leads to an accelerated rate of diabetes development.
Eastern economic prosperity has also allowed for the increased purchase of foods that are higher in saturated fat and carbohydrates. Compared to the 1960s, when the Chinese consumed a mostly vegetarian diet with just a few pounds of animal products a year, today the average Chinese now eats an amazing 215 pounds of meat, fish, poultry, and eggs. This rate that has doubled between 1990 and 2002 alone. This rapid dietary change has been paralleled in Thailand as well, where consumption in of carbohydrate-rich starchy roots, pulses, and fruit has increased. Research now suggests that the availability and consumption of sugar increases diabetes risk, independent of the effects of physical activity and obesity.
China’s food transformation was catalyzed by its open door trading policy and economic growth, which have brought a flood of western-style fast-food restaurants with it. Yum! Brands, who owns KFC and Pizza Hut, now has over 6,000 restaurants in China, and McDonald’s has grown from a single store in China in 1990 to more than 2,000 by the end of this year. McDonald’s has made such efforts to become an indelible part of local culture that it now offers wedding receptions to young couples in Hong Kong, called “McWeddings.” Coca-Cola and Pepsi consumption have also grown 145% and 127% between 2000 and 2010, compared to 12.6% in India around the same time.
A large study of 43,000 Chinese Singaporeans specifically examined their consumption of fast foods such as hamburgers, French fries, pizza, deep fried chicken, and hot dogs. Not surprisingly, eating such items more than twice a week was associated with higher rates of diabetes and coronary heart disease.
But unlike the West, where individuals with lower incomes eat more fast food, these individuals were actually more educated, smoked less, and were more likely to be physically active. These results suggest that fast food consumption is not just a marker for an overall unhealthy lifestyle, but may in fact be causing disease progression among the newly prosperous.
It appears that the excessive levels of fats, salt, sugar, trans fats in these fast foods are contributing to the damage, not to mention the simple excess calories. Portion sizes at fast food restaurants have increased by a mind-boggling 2-5x over the past several decades. A typical KFC chicken lunch and Starbucks coffee has nearly enough calories for an entire day’s recommended intake. According to Nutrition Professor Barry Popkin, marketers have also introduced the practice of snacking—which largely did not exist in China prior to 1950—as a normal part of eating habits.
Another key driver is how much calories are being consumed in the form of sugary drinks. Mexico recently made headlines for surpassing the US as the world’s fattest country—with 1 in 3 Mexicans today being obese—and having the world’s highest rate of soda consumption. The average Mexican consumes 43 gallons annually—that’s about 9 cans of soda per week—prompting the recent passage of soda tax to curb consumption.
US agricultural policies—high tariffs on sugar combined with subsidies for corn farmers—has resulted in cheap High Fructose Corn Syrup (HFCS) that is cheaply exported south of the border. The 1994 NAFTA free trade agreement led to a tidal wave of cheap exported junk food—including a 1200% increase in HFCS exports between the US and Mexico between 1996 and 2012.
An even more remarkable example of dumping unhealthy foods is the bizarre story of turkey tails in American Samoa. Turkey tails were originally concerned an undesirable byproduct of the turkey industry that were only fit for pet food. But after World War II, US marketers schemed to export them cheaply to Samoa, where they became a local favorite. Turkey tails, which are up to 40% fat and began replacing leaner local seafood, contributed to Samoa’s whopping obesity rate of 75%—the highest of any territory in the world.
New Zealand has allowed followed suit by exporting high-fat lamb and mutton flaps that have also become a staple in Pacific Island nations, where 9 out of the 10 most obese nations in the world are now located. Samoans have gotten so heavy that local airline Samoa Air began offsetting their increased fuel costs by charging passengers about 50 cents per pound for both their bags and body weight. Samoan officials even banned turkey tails and mutton flaps in 2007, though the law was overturned last year due to economic pressures to join the World Trade Organization.
Even places like Qatar, the world’s wealthiest country with the resources to buy better food, are not immune. The rapid transition from desert-dwelling nomadic lifestyles to metropolitan luxury has caused a dramatic decrease in physical activity. Oil wealth has promoted a culture where cars are not only symbols of wealth, but have significantly reduced walking, child care has been largely outsourced to nannies, and fast food and home deliveries have replaced trips to the grocery store. As a result, Qatar’s diabetes rate is over 15% and obesity is projected to affect nearly 75% of Qataris in the next five years.
This increase in sedentary lifestyles may especially been driven by the exportation of Western devices like televisions, computers, and cars. The Prospective Urban Rural Epidemiological Study (PURE), tracked 153,996 people’s use of such devices in 17 countries that represent a range of economic conditions. Interestingly, owning more of these devices, especially televisions, was associated with greater rates of obesity and diabetes. This association was greatest in lower-income countries like Bangladesh, India, Pakistan, and Zimbabwe, where the risk of obesity and diabetes rose respectively from 3.4% and 4.7% for people who owned no devices to 14.5% and 11.7% for people who owned all three.
Besides the fact that online social networking promotes being sedentary, it appears that social networks themselves actually spread obesity. Researchers followed a social network of 12,067 people for 32 years from the Framingham Heart Study and found that that obesity may in fact be ‘contagious’—spreading from person to person, much like a virus. Their findings showed that if a friend, sibling, or spouse became obese, the likelihood that their counterpart would follow suit was 57%, 40%, and 37% respectively. Experimental research has provided some explanations for how social influence spreads—simply exposing people to pictures of overweight people makes them unconsciously consume more candy and cookies, and people look to others around them to decide what portion sizes to eat. This suggests that social influence plays a significant role in determining our default norms about diet and other habits.
While the tide of globalization and economic growth cannot be turned back in the developing world, the obesity and diabetes pandemics are not inevitable. Countries are increasingly experimenting with behavioral economics approaches like taxing or limiting the consumption of foods high in fat, sugar, and salt, and providing financial incentives to employees and employers who meet certain health targets. Furthermore, research has shown that shown that lifestyle modification programs can help at-risk people lose weight and reduce their risk of developing type 2 diabetes. Large clinical trials in the US, China, Japan, India, Finland, Sweden, and Italy have consistently shown that these lifestyle programs consistently work around the world.
Ironically, there is a new export from the West that has the potential to be a positive influence. The booming field of ‘digital health’ has brought such evidence-based lifestyle programs online, which leverage the power of social networking and behavioral science to prevent diabetes.If we export smart health policies and persuasive technologies, there is an enormous potential for the West to influence global public health—this time for good.