Sugar hit: Can Type 2 diabetes be stopped?

From a tiny Pacific atoll to Africa and the West, diabetes is spiralling out of control. Can it be stopped? By Tom Rowley

Tokelau, a series of three tiny atolls in the South Pacific, is the world’s diabetes capital.

At the end of a long, hot Mississippi day, eight middle-aged women wearing baggy T-shirts and trainers leap across a church hall, as if they have decided to swap the unremitting sun for the prospect of real sweat. Someone has brought a stereo, which is barking out instructions and goading them into ever-greater exertion. “How low can you go?” the male voice wants to know. “This is about it, baby!” quips one of the women, gasping for air.

On this Thursday evening in Plantersville, these women have come to weigh themselves, learn new exercise routines and swap healthy recipes. It’s part of a new campaign aimed at curbing one of the most pervasive – and costly – diseases facing the US: diabetes. These sessions, part of a program 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 one usually linked to being overweight.

Lose a few kilos, the reasoning goes, and you might avoid a lifelong condition. “It was set up a lot like Alcoholics Anonymous,” says Sherry Smith from Mississippi State University, who runs the Plantersville class. “You know, having a food problem is a lot like that.” Around here, plenty of people have food problems. So perhaps it is no surprise that more than 13 per cent of the state’s adults are diabetic – the second-highest prevalence in the US – with another eight per cent categorised as “at risk”. Waistlines are expanding so fast that scientists have rechristened the area girding Mississippi – known as the Bible Belt – the “Diabetes Belt”.

But this food problem has long since burst over state lines and bulged across the ocean. Just as American health officials are at last beginning to grapple with the issue, diabetes diagnoses are spiking across the world. In Europe, the disease is now Britain’s fastest-growing epidemic. The Middle East has seen a huge surge in cases. It’s on the march in Australia, too: more than one million of us have Type 2 diabetes; it is the fastest-growing chronic condition here, with a disproportionately higher rate among indigenous Australians.

Since 1980, the global number of diabetics has nearly quadrupled to 422 million. Ninety per cent have Type 2 diabetes, which occurs when the cells in the pancreas that make insulin – used by the body to process glucose – produce too little, or the body becomes resistant to it. This leaves the diabetic with surplus sugar in their blood, impeding its flow around the body and often leading to complications such as blindness or ulcers that can require leg amputations. In 2015 it claimed five million lives, according to an International ­Diabetes Federation estimate – more than the combined death toll for HIV, tuberculosis and malaria. By 2040, one in 10 of us will have it.

It is, says Cherian Varghese of the World Health Organisation, “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.

Ethiopia still suffers from droughts that inflict hunger on its rural population. But as its economy booms, more and more of its city dwellers are being diagnosed with Type 2 diabetes. “We thought of this as an American problem,” says 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?

Mitigating the risk: an exercise class in Plantersville. Picture: Julian Simmonds

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 resorts, no mobile signal and no airport. The closest runway is on Samoa, a 24-hour boat ride away. Yet these islands – 480km from the nearest supermarket or restaurant – make up the world’s diabetes capital. As recently as the 1960s, the condition here was relatively rare; now, nearly a third of islanders are diabetic, the highest prevalence on Earth.

Unravelling Tokelau’s experience helps to explain how Type 2 diabetes conquered the world. The smallest of the atolls, which measures only 360ha, was “discovered” by the British ­commodore John Byron (the poet’s grandfather) in 1765. It is called Atafu, 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. Feeding one’s pigs after 6.15pm is an offence.

Now some islanders have submitted to another, less welcome routine. At about six o’clock every 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 and then writes down their blood-sugar levels in a large red notebook. I am greeted by Rosa Toloa, who was born on Atafu in 1969 and has recently moved back here from New Zealand (which has maintained the atolls as a dependency since 1926) to serve as Tokelau’s health information officer. As the diabetics queue for medicine, she begins to explain how her island has changed so much.

When she was a child, she says, 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 also fished daily. Every Saturday they would climb the trees to fetch coconuts. A party of researchers who visited in the late 1960s remarked on the “low rates of coronary heart disease, obesity and ­diabetes”. Back then, seven per cent of women were diabetic and only two per cent of men.

Then came the imports. Regular shipping brought exotic foods: mutton flaps, turkey, even ice cream. Cooperative stores opened on each atoll, and the United Nations supplied freezers. In the 14 years after the researchers’ first visit, coconut consumption fell by a fifth. Meanwhile, islanders discovered sugar: in 1961, 3kg was imported for each Tokelauan; by 1980 it was 31kg. 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 starvation and misery. “Tokelauans had been very healthy and had returned to the pre-European diet of coconuts and fish,” The New Zealand Herald reported. “Many people lost weight and felt very much better, including some of the diabetics.”

After shipping resumed, however, so did the unhealthy eating habits. These days, as well as white rice, potatoes, instant noodles and chocolate drink, islanders import tinned mackerel and tuna. The shelves of Atafu’s shop, which dispenses small change in chewing gum rather than coins, are lined with corned beef, pears in syrup, custard powder, chocolate-cake mix and chips.

Each week, on average, an adult Tokelauan consumes the equivalent of 236 teaspoons of sugar. And although walking from one end of town to the other takes only 10 minutes, many drive imported cars. The results are predictable. Nine in 10 adults are overweight; two-thirds are obese. None of the adults I meet is skinny, but after a while none of them looks fat either; when everyone is carrying around 10kg too much, it is hard to remember what “normal” looks like. “If you look at some of the old photos of the weddings, there’s a big difference,” says Toloa. “There were a lot of elderly people dancing – very lean, healthy-looking people. You hardly see old people now. There are only a small group of them that are past the age of 65.”

Toloa and the nurses are trying. Atafu’s first gym will open this year, and the atoll’s only advertisements warn about the dangers of smoking and eating badly. But it’s hard to tackle the underlying causes. “It’s not like somewhere where you have a choice of food. The food you get is the food you get,” Toloa says. It is difficult to grow vegetables here and islanders cannot always rely on good weather for fishing. Besides, she says, they are now hooked on sugar. “They just have a taste for it.”

One of the nurses, a 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 explains when Toloa introduces us, she was most troubled by the condition 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 needs to come to the hospital twice a day so that a nurse – sometimes his sister – can inject insulin into his stomach. It is not going well. His feet have twice been treated for sepsis and often he cannot feel his legs.

When Filo arrives for his injection, Rikim introduces us. He is nervous and withdrawn. “You know, sometimes I have to go and look for him,” Rikim explains. “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 how important it is to take his medicine.” Sometimes, she no longer recognises 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.”

Suffering: Berthe Gebremedhin lost his legs to the disease. Picture: Julian Simmonds

On a tattered beige sofa in his home, 16,000km away from Tokelau, Berthe Gebremedhin looks on as his city remakes itself. Almost every day, it seems, the dusty streets spawn a new concrete tower and the traffic jams grow 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 it seems his entire country is under construction. Recently, the economy has grown as much as 10 per cent a year. But he was forced to give up work two years ago and won’t ever return. Both his legs were amputated last year, when his diabetic foot ulcers grew gangrenous, and since then 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 radio, which he uses only occasionally because he can’t afford spare batteries, either. “The only thing I do is sit,” he tells me. “I feel very trapped.”

Like many Ethiopian diabetics I meet, he is thin and does not at all resemble the diabetics 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 grapples with the same changes in consumption patterns and lifestyles that first swept through the West and reached as far as Tokelau.

In 1982, shortly before his country’s terrible famine, only 0.34 per cent 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.

“I mean, we want economic development,” says Dr Ahmed Reja, the International Diabetes Federation’s representative in Africa. “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 every 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. Being overweight and obese is regarded as a sign of status.”

Ethiopians might prove particularly susceptible to Type 2 diabetes since, according to one theory, countries where the food supply has historically fluctuated produce 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 who had to endure periodic famine. But the same capacity to store fat, when coupled with a ready and constant food supply, could wrong-foot them.

Across the ocean in England, a grey-haired man is focusing relentlessly on the condition. ­Professor Roy Taylor, a professor of medicine and metabolism at Newcastle University, will travel to Portugal in September to attend the European Association for the Study of Diabetes’ annual meeting, where he will address scientists from across the continent. His topic? Reversing diabetes. “This is the first session on reversing Type 2 diabetes that there’s been at any diabetes meeting, national or international,” Taylor says excitedly. It will, he adds, mark “a watershed”.

Taylor has spent the past five years probing the assumption that it’s a lifelong condition. A raft of long-term studies tracking people with Type 2 diabetes have shown the condition getting steadily worse. “The insulin-producing cells get less and less competent. It’s a dismal picture,” he says. “[But] every one of those studies has involved a group of people who have stayed at least as fat as they were at the beginning.”

So Taylor instead subjected 11 diabetics to a very low-calorie diet for eight weeks. The results were startling: every one of them saw their insulin production return to normal. In other words, their diabetes was put into remission. The results might point to an error in our understanding of how Type 2 affects the body. “It is standard belief among experts in diabetes that at the time of diagnosis about half the insulin-producing cells have already died off,” Taylor says. But his study suggests that rather than dying, the cells stop working temporarily when there is too much fat in the pancreas for them to produce insulin. “If you take away the fat, the metabolic stress goes away and, remarkably, they switch back on the insulin gene and are happily making insulin again.”

As Taylor puts it, everything suddenly seems “startlingly simple”: shed enough fat and the diabetes will go away. It is, of course, more complicated than that. “We need to be quite precise about how optimistic,” he says.

The first trials were conducted with only a small group of volunteers, monitored by Taylor. The diet could have hidden downsides, and some patients may not be motivated enough to stick to it. And his method did not work for those who had been diabetic for more than 10 years. Since those with Type 2 often do not know they are ­diabetic until they develop complications – sometimes years in – this could significantly reduce the number who could benefit. Taylor concedes that his research provides only a “glimmer of hope”. “We’re facing up to a battle here,” he says. “Understanding the enemy is crucial.”

An email arrives from Rosa Toloa, the ­hospitalworker I met on Tokelau. “Can you recall Foliga Filo?” she asks. “Nurse Valisi’s brother.” He died, she tells me – only five days after we met. He was 50. He suffered a heart attack brought on by his diabetes. I recall that day at the hospital when he had pointed to the sky. “I am prepared,” he had said. Now, so soon, the epidemic has claimed another casualty. “He was one of the people we struggled to get to understand his ­condition,” Toloa writes.

Our exchange reminds me that, despite the hope offered by the likes of Taylor, people are dying from diabetes every day. In fact, according to the International Diabetes Federation, someone dies from the disease every six seconds. Relying on potential medical advances won’t be enough: ­concerted political action is needed. “We need to get the politicians on board,” Taylor had told me. “This is the most difficult step.”

In the absence of an effective global plan, ordinary nurses such as Filo’s sister, Valisi Rikim, are left to fill the void as best they can. When we visited Atafu, she was preparing to travel abroad for training. She had learnt of her brother’s death on the outward journey. “I almost couldn’t make it,” she says. “But his courage as a brother motivated me to come this way and this far.” For so long, she had seen her patients struggle with diabetes; now, it had taken her beloved brother. And if it will not halt, Rikim decided, neither can she.

©The Telegraph