In an essay published last November in Canada's Maisonneuve journal, physician Kevin Patterson described his experiences working as an internist-intensivist at the Canadian Combat Surgical Hospital in Kandahar, Afghanistan.
One detail he noticed: The Afghan soldiers, police and civilians he treated in Kandahar had radically different bodies from those of the Canadians he took care of back home.
"Typical Afghan civilians and soldiers would have been 140 pounds or so as adults. And when we operated on them, what we were aware of was the absence of any fat or any adipose tissue underneath the skin," Patterson says. "Of course, when we operated on Canadians or Americans or Europeans, what was normal was to have most of the organs encased in fat. It had a visceral potency to it when you could see it directly there."
In a conversation on Fresh Air, Patterson tells Terry Gross that the effects of urbanization are making people everywhere in the world both fatter and sicker.
"Type 2 diabetes historically didn't exist, only 70 or 80 years ago," says Patterson. "And what's driven it, of course, is this rise in obesity, especially the accumulation of abdominal fat. That fat induces changes in our receptors that cells have for insulin. Basically, it makes them numb to the effect of insulin."
For a long time, the human body can compensate — the pancreas secretes even larger amounts of insulin, which regulates blood sugar levels. But over time, the pancreas begins to fail to secrete enough insulin, and that is when diabetes develops.
He explains that the increase in abdominal fat has driven the epidemic of diabetes over the last 40 years in the developed world — and that he's now seeing similar patterns in undeveloped regions that have adapted Western eating patterns.
Patterson explains that in his Canadian practice, where he takes care of indigenous populations near the Arctic Circle, there is a marked increase in the number of diabetic patients he sees.
"The traditional Inuit culture of relentless motion and a traditional diet consisting mainly of caribou, Arctic char, whale and seal has been abandoned over this period of time for Kentucky Fried Chicken and processed food and living a life very similar to ours," he says. "[They're] spending a lot of time in front of a glowing screen."
Part of the problem, says Patterson, is that it's so much cheaper for processed food to be flown into the Arctic Circle than fresh food.
"There's no roads or rail access to any of those communities," he says. "So a 4 liter jug of milk can cost you $10 or $11. But there's a very clear parallel between that and the inner city. In poorer neighborhoods in North American cities, fresh food is either not available or extremely expensive compared to — on a calorie-by-calorie basis — compared to fast food available on every street corner."
And the diabetes epidemic correlates to a strain on health care systems around the globe, says Patterson.
"No country in the world has the resources to continue to treat diabetics the way that they're being treated now, if the prevalence rates increase at the rates that they're increasing for much longer," he says. "I worked in Saipan, which is in the Marianas Island in the Pacific, and there, the dialysis population was increasing at about 18 percent a year, all as a consequence of diabetes and acculturation — exactly the same process as what's going on with the Inuit.
"When you look at the curves, it's clear how unsustainable it is. In 20 or 30 years, everybody on that island will either be a dialysis patient or a dialysis nurse unless something fundamental is done about the rise in diabetes. That's no less true in Canada and in Samoa and Hawaii, and even in Omaha and Toronto. We all have exactly the same problem when we plot out those curves."
Patterson fictionalized his experiences working with the Inuit in Canada in his novel, Consumption, about an Inuit woman who spends her teen years in a sanitarium. His other books include Outside the Wire: The War in Afghanistan in the Words of its Participants and the short story collection Country of Cold, which won the Rogers Writers' Trust Fiction Prize in 2003.
TERRY GROSS, host:
My guest, Canadian physician Kevin Patterson, has witnessed the spread of diabetes in the Arctic and on islands in the South Pacific. He attributes this to obesity caused by an increasing reliance on processed foods and increasingly sedentary lifestyles, as traditional lifestyles disappear. Patterson lives in British Columbia on Salt Spring Island. But for the past 16 years, he's spent part of each year practicing medicine in the Arctic along the Hudson Bay. His novel "Consumption" is based on his experiences in the Arctic. He's also treated soldiers in Afghanistan, working as an internist and intensive care doctor at the Canadian Combat Surgical Hospital in Kandahar. He co-edited "Outside the Wire: The War in Afghanistan in the Words of its Participants," which was published in 2008.
Kevin Patterson, welcome to FRESH AIR. I want to start with an image that made a big impression on me. You write about how when you were a doctor in Afghanistan at the Canadian Combat Surgical Hospital in Kandahar, that you treated Afghan soldiers, police and civilians, and that the insides of their bodies were really different from the bodies you were used to seeing in Canada and in the Arctic. Would you describe the differences?
Dr. KEVIN PATTERSON (Physician, Author): Typical Afghan civilians and soldiers would have been 140 pounds or so as adults. And when we operated on them, you know, what we were aware of so dramatically was almost the absence of any fat or adipose tissue, or just trace amounts around the - underneath the skin. But when, of course, when we operated on Americans or Canadians or Europeans, the -what was normal was to have most of the organs encased in fat. And this is an observation that has been made many times in lots of different places other than war, but it had a kind of visceral - if you'll forgive the pun - potency to it when you could see it directly there.
GROSS: You know, I have to say, I think often about how a body looks when it's fat from the outside. I've never really thought - you know, not being a doctor or not seeing surgeries, I've never really thought about how it looks different inside. So you actually see fat inside, surrounding organs?
Dr. PATTERSON: Yeah, absolutely. And more importantly, the visceral fat, the fat that, in the abdomen, that encases the organs is very metabolically active and is part of what has driven the epidemic of diabetes over the last 40 years in the developed world.
And what's driven it, of course, is this rise in obesity, especially accumulation of abdominal fat. And that fat, as I said earlier, is metabolically and endocrinologically active. It induces changes in our receptors that cells have to insulin. Basically, it makes them numb to the effect of insulin.
And for a long time, the body can compensate for that by secreting larger amounts than normal of insulin in an effort to keep the blood sugar levels normal. But over time, that numbness becomes too profound to be overcome by higher-than-normal insulin levels, and then the pancreas begins to fail. It can't secrete as much insulin as it had been, and this is when we develop diabetes.
GROSS: After reading your article about working in Afghanistan, I got the impression you were surprised that you never had to give insulin to Afghans.
Dr. PATTERSON: Mm, yeah. That's true. I do a lot of critical care here in Canada, and this is normal when people are very sick and stressed by infections or extensive surgery. We often have to give insulin even to non-diabetics in order to keep their blood sugar something like normal. When the blood sugar gets too high, it impairs the body's ability to fight off infection.
Among the Afghans who were critically ill, this was never necessary. And again, it has to do with the fact that they were - you know, their body fat percentages were a third or a quarter of what North Americans typically are. Presently, you know, about a quarter or 30 percent of North Americans are obese, and this representation rises quickly as people get older, which is the people who make up most of our patients in a North American intensive care unit. So this is a very common, almost normal problem for us.
GROSS: I don't want anyone to think that we're holding up the people from Afghanistan as models of health. The average age of death in Afghanistan is 39.
Dr. PATTERSON: Yeah. Exactly. The - it's interesting. We - there's an idea called the epidemiologic transition that describes how people get sick as a function of where their society is historically and culturally. And it begins with this idea of a hunter-gatherer society, and that's stage one. The Inuit, with whom I work in the Canadian Arctic, lived like that, certainly until the late 1960s. Their principal problems were starvation and predation and other situations.
That changes in the Middle East with the Mesopotamian civilizations and the advent of agriculture. And then people are still - have fairly precarious life spans in terms of average age being about 35, 40. But their principal problem becomes infectious diseases from the crowding. Starvation's still an issue. Stage three happens with the Industrial Revolution, where really, there's enough to eat, but industrial problems, malignancies, pollution start to bear on it. Stage four is with the advent of antibiotics, and some North Americans went through that in the '50s and '60s. And that's when, really, when life's expectancy starts to take off.
Viewed on this idea that Afghans are pretty clearly still in stage two, where they've got a subsistence agriculture existence and their life expectancy reflects what other cultures have had in living that existence.
GROSS: Now, you work part-time in the Arctic treating Inuit people, native people. Your novel, "Consumption," is about a doctor in the Arctic. I imagine some of it is based on what you experience and observed. The doctor in your novel comments on how the diseases and injuries he treats have changed since the time he arrived there. And he says: I don't see the head injuries and the dog maulings that I used to. Now they all waddle in to see me, and together, we talk about how we might control our diabetes better.
So what changed as the diabetes level increased? What's behind it?
Dr. PATTERSON: Well, acculturation. The traditional Inuit culture of relentless motion and a traditional diet - consisting mostly of caribou but also Arctic char and whale and seal - that's been abandoned over this period of time for Kentucky Fried Chicken and processed food and living a life very similar to ours, spending an awful lot of it in front of a glowing screen.
GROSS: So whale is very fatty food. I mean, whale, it's blubber. It's whale fat, right?
Dr. PATTERSON: Mm-hmm.
GROSS: So what's the difference between whale fat and, you know, fried chicken or French fries?
Dr. PATTERSON: Well, I think the big thing is that your body will forgive you for eating almost anything if you move enough. And if the way you get your whale is by being out on a boat in the ocean working very, very hard to stick a harpoon in a beluga whale, then you won't get large.
The other thing, too, is that historically, carbohydrates were almost not a part of the Inuit diet. They'd get some when they ate the berries that were available for a few weeks in the fall, and that would be about it. Now our diet is so full of simple carbohydrates that they're not adapted to, and we're not adapted to, either. And that's one of the big drivers of the rise of obesity worldwide.
GROSS: You've written about how much cheaper it is in the Arctic to eat processed food than it is to eat fresh food, in part because fresh food has to be shipped in a refrigerated truck or train or whatever, plane, in order to get there. And that's pretty expensive compared to, what, like, processed food that can be packaged, and you could take a long time to ship it, and it still be edible.
Dr. PATTERSON: Yeah. It's all flown in. There's no roads or rail access to any of those communities.
Dr. PATTERSON: So a four-liter jug of milk can cost you 10 or $11. But, you know, this - and part of the point in my writing has been to draw the parallels between the experience of the Inuit and southern North Americans. There's a very clear parallel between that and the inner city. In poorer neighborhoods in North American cities, fresh food, healthy food is either not available or extremely expensive compared to - on a calorie-per-calorie basis - compared to fast food available on every street corner.
And so something about the way we've structured the economics of food privileges the least healthy food available to us. You know, we subsidize the high fructose corn syrup products and make fresh beans and broccoli much more expensive, again on a calorie-per-calorie basis.
GROSS: Are there fast food restaurants on the tundra now?
Dr. PATTERSON: It's amazing to think about it, but yeah, there are. There are fried chicken outlets and burger joints in Rankin, in the little community I work in mostly. And they're just stacked. The people love that food.
GROSS: So what do you do when you're in the Arctic, when you're working there and you don't want to have a fast-food, high-fructose-corn-syrup, lots-of-fat kind of diet?
Dr. PATTERSON: It's really difficult, you know? The fresh food and milk is all flown in, and is very expensive. And so it's easy to understand why people eat so much of the highly processed, packaged food. But really, the answer for the Inuit, I think, is to preserve some of that hunting tradition and continue to eat caribou and fish. There's a public health effort to do just that. They call it country food, and there's an effort to make Arctic char and caribou available to families where there aren't hunters, and to encourage those hunters who are still active to attempt to harvest as much food as they can for the community.
It's difficult, though, because salty, sweet food appeals to the human palate, and people crave it for reasons that have to do with food that we're designed to crave, going back 50,000 years.
GROSS: The rise of diabetes in the Canadian Arctic must be a very expensive prospect for the Canadian health care system, especially if more and more people need dialysis.
Dr. PATTERSON: Absolutely. The fact is, is that no country in the world has the resources to continue to treat diabetics the way that they're being treated now if the prevalence rates increase at the rate that they're increasing for much longer. I worked in Saipan, which is in the Marianas Islands in the Western Pacific. It's an American possession. And there, the dialysis population was increasing at about 18 percent a year, all as a consequence of diabetes and acculturation - exactly the same process that's going on with the Inuit.
You know, when you look at the curves, it's just clear how unsustainable it is. In 20 or 30 years, everybody on that little island will either be a dialysis patient or a dialysis nurse, unless something fundamental is done about the rise in diabetes. And so change will be forced upon us. It's going to happen. It would just be - it would be nice to do it in a considered fashion earlier, rather than waiting for the crisis that's coming our way. And that's no less true in Canada and no less true in Samoa and Hawaii, and even in Omaha and Toronto. You know, we all have exactly the same problem when we plot out those curves.
GROSS: Dr. Patterson, thank you so much for talking with us.
Dr. PATTERSON: Oh, you're welcome.
GROSS: Dr. Kevin Patterson practices medicine in British Columbia and the Arctic. His novel, "Consumption," is based on his experiences in the Arctic. You can read an excerpt on our website: freshair.npr.org. Transcript provided by NPR, Copyright NPR.