Sweet, Fat, Deadly
The incidence of diabetes is skyrocketing in Israel, particularly among Ethiopians and Arabs. Fast food, the Internet culture and a lack of awareness are contributing to an explosion of the disease.
The patients squeezed into the narrow corridor outside Prof. Itamar Raz’s office in early November included an apparently fit young man, an elderly Holocaust survivor in a wheelchair, and several middle-aged folk, including a member of the Knesset. All were diabetics waiting to see Raz, head of the diabetes unit at Hadassah Hospital in Ein Kerem Jerusalem.
It was a typical day for Raz, a slender, energetic man of 56. In his 20 years in the field, he says, he has seen the incidence of diabetes in Israel and worldwide soar to epidemic proportions. Today, some 190 million people suffer from the condition, in which the body cannot create or utilize the insulin hormone, which converts sugar, starches and other food types into energy that fuels the body’s activities; in 1985, the figure was 50 million. Projections are that by 2025, 340 million people will have the disease; upwards of 600,000 in Israel alone.
Diabetes manifests itself in two main forms: Type 1, popularly known as juvenile diabetes (a misnomer because it can affect older people as well), is an autoimmune illness in which the body does not produce insulin at all. About 10 percent of sufferers fall into this category, and the number is growing. “We used to see 8- and 9-year- olds with juvenile diabetes, now we see 2- and 3-year-olds,” says Raz. The more common and even faster-growing Type 2 results from the body’s inability to produce or effectively use insulin. Sufferers of both forms of the disease are at risk for heart disease, stroke and other complications resulting from poor circulation. Untreated, diabetes can lead to blindness, kidney failure, nerve damage and limb amputations.
Known already in ancient Egypt, Raz explains, diabetes has spread in modern times, especially in the West, as people became more sedentary and started eating richer, fattier foods. Obesity, also increasing alarmingly in the West, is a strong contributing factor to diabetes, particularly for Type 2. But the West is no longer the exclusive domain of the disease, and experts say most future sufferers will be from the Third World, where American fast-food chains are making inroads. Diabetes in China, India and Africa is expected to double in the next 20 years, while in Europe, for instance, where the population has developed a partial genetic tolerance for absorbing fat- and sugar-rich diets, the disease will increase by only 10-15 percent during that same period.
When people with no genetic defense “start becoming flooded with new food and change their active lifestyle,” notes Raz, they become obese and at risk for diabetes. He cites the example of the hunter- gatherer Pima Indians of Arizona, who before 1920 had just a single documented case of diabetes. When a river they relied on for fishing and sustenance was dammed, however, they turned to American diets and by the 1970s tribe members were obese and diabetes among them was rife.
Not surprisingly, diabetes is spiking sharply in Israel, mostly among its large non-Western immigrant and Arab populations. Israel’s diabetes rate is already 7 percent of the population, higher than in the United States, where 6 percent of the citizenry, roughly 18 million people, are diabetic. And beyond Israel’s 400,000 diagnosed diabetics, says Raz, 100,000 more have the disease but are unaware of it. These people “feel terrific until the symptoms start to kick in,” including unquenchable thirst, weight loss and blurry vision. Another 600,000 suffer from some form of pre-diabetes or a metabolic syndrome that renders them “insulin resistant,” both of which increase their susceptibility to the disease.
Among Jewish immigrant populations, Yemenites, Kurds and Ethiopians all had low or nonexistent rates of diabetes when they arrived in Israel, but the disease spread quickly through all three groups. Within a few years of their immigration in the 1950s, Yemenites became the ethnic group with the highest incidence of the disease, says Raz. Among Ethiopians, both obesity and diabetes rates have soared since their arrival in the 80s, according to Dr. Anat Jaffe, head of endocrinology and diabetes at Hillel-Yaffe hospital in Haderah.
Jaffe, founder of a special Ethiopian diabetes-awareness program that disseminates information around the country to immigrants, stumbled onto the problem after a 12-year-old under her care turned out to have diabetes, prompting her to investigate whether the girl was an isolated case or part of a broader problem. In 2001, she tested 171 Haderah Ethiopians for diabetes and found that 45 percent were “affected,” with 16 percent already ill but unaware of it and the rest in pre-diabetic stages.
In rural Ethiopia, Jaffe explains, they ate fish and almost no meat, because of the high cost and problems with ritual slaughtering, consumed limited sweets and walked long distances from village to village as a means of transportation. “Here they started eating meat twice a day, for breakfast and dinner, filling baby bottles with Coca-Cola, and they quit walking. Many are also unemployed, so they just sit at home.” Jaffe says many Ethiopians take the view that “if you walk in Israel as a way to get somewhere, it means you have no car and are poor.”
Israeli Arabs are also at high risk. In a recent study of 100 over-40, overweight Arab men and women from the Galilee region, Dr. Muhammed Abdul-Ghani, 43, a family physician and diabetes expert in the Galilee town of Nahf, near Karmiel, made a stunning discovery. Twenty-six percent, he told The Report, were diabetic but didn’t know it; 42 percent had impaired glucose tolerance and were at risk. Only 31 percent had no diabetic symptoms. Additionally, he found abnormalities in the blood lipids, the “metabolic syndrome” that is closely related to diabetes.
“I was shocked,” he admits, but when he began to study medical literature on diabetes in the Arab world, he says it became clear that “people of Arab origin are at high risk for diabetes.” In Saudi Arabia, for example, a shocking 25 percent of the population has diabetes. In Bahrain, the figure is 32 percent. Abdul-Ghani points to a 2003 study of Arab immigrants living in the Detroit, Michigan, area that shows that fully 19 percent had some form of diabetes. “Clearly, something in our genetic structure puts us at risk.”
The widening effect of diabetes on Israeli society can be measured, in part, by the grim statistics relating to kidney dialysis. Raz reports that 20 years ago, diabetes accounted for only 20 percent of individuals receiving dialysis treatments (kidney failure is a frequent complication). Now, he warns, that figure is up to 50 percent and expected to rise to 70 percent in coming years.
The starring role played by Israelis in the illegal organ transplant trade (partly documented last May in media reports of a criminal medical network stretching from Brazil to South Africa) is in large part a consequence, says Raz, of Israel’s domestic diabetes crisis. Articles described desperate patients paying Israeli brokers up to $150,000 for the kidneys of impoverished Brazilians (who get a fraction of that amount) and surgeries performed in rogue South African hospitals. (Israeli law stipulates that living organ donations may only be made between relatives and no money may be exchanged, but no law prevents an Israeli citizen from purchasing a kidney or other organ abroad. In fact, the HMOs often partially reimburse patients and support them medically upon return.)
While acknowledging the moral problem implicit in offering cash to poor people for their body parts, Raz is not, in principle, against the practice and offers no criticism of doctors who perform the surgeries. “The average person on dialysis has about five years to live and will likely die waiting for a legal kidney transplant. The dialysis process itself is grueling – three times a week and each treatment takes a day to recover from. Who can live like that? I, as a doctor, have to think about my patients’ welfare. These operations, with all the moral questions involved, do save lives,” he maintains.
In addition to his clinical work, Jerusalem-born Raz wears several diabetes hats. He’s president of the Israel Diabetes Association, a 40-year-old organization with 30 branches around the country; and chair of the National Diabetes Council, an umbrella group established a year ago in partnership with the Ministry of Health to promote awareness and prevention. Last year, he established D-Cure, a nonprofit organization with offices in New York and Israel dedicated to helping boost funding for diabetes research in Israel, which he says is flooded with brilliant minds but stymied by a lack of government resources. In mid-October, in a lead-up to International Diabetes Day on November 10, several hundred leading diabetes scientists attended the group’ s first conference in Jerusalem.
Raz is also continuing his research, together with Prof. Yaron Cohen of the Weizmann Institute, on a groundbreaking vaccine that he hopes may be useful in treating Type 1 diabetes. In initial tests, the experimental drug was administered once every three months over a period of three years to 120 people, aged 16 or older; in 31 cases there have been positive results.
Experts are also concerned by the lack of awareness among Israelis about diabetes. Sufferers who do not receive relevant medication and treatment, Raz says, “triple or quadruple” their chances of early death and raise the likelihood of limb amputation by 15-20 percent and kidney failure “by hundreds of percentage points.” On the other hand, early detection and treatment dramatically change the picture. A 1977-97 British study that tracked 5,000 diabetics demonstrated that with treatment, including weight loss and change of diet, diabetes sufferers reduced by 100 percent damage to the eyes and kidneys. Raz points out that a diabetic between the ages of 20-30 who does not get treatment will live 8 to 10 years less than his or her healthy equivalent. With treatment however, the diabetic’s life expectancy is the same as a healthy person’s.
Unfortunately, prevention is not Israel’s strong suit. Despite the clear-cut correlation between obesity and diabetes and an increase in children who are overweight (15 percent of American kids between ages 5 and 12 now fall into that category), Israel has not enacted any laws against the sale of candy bars or sweetened sodas in schools. (“Water’s the best, but it’s better to drink Diet Coke than Coke,” says Raz.) In Denmark, by contrast, sweets are banned from school vending machines. “Studies show that Israeli kids are still in relatively good shape weight-wise, but we are heading toward problems unless we do something about it now because they eat plenty of junk food, drink Coke, and sit for hours in front of the computer.” Raz, not surprisingly, takes a dim view of the Israeli fast-food craze. But once McDonald’s and the others came, he says, he could “kick myself for not intervening. They ought to have been required by law to provide low-fat meal options.”
However, fast food is only one of the culprits among the immigrant and Arab high-risk groups. Dr. Jaffe, who runs her Ethiopian-diabetes project on a shoestring $120,000 annual budget, says strong cultural biases in her target groups have required her to custom-tailor awareness programs to immigrants, including specially trained social workers and dieticians. For example, Jaffe points out, in Third World countries, the idea of being corpulent is usually positive, “it means you have money.” Indeed, the average Ethiopian has put on weight since arriving here, she notes.
Jaffe’s patients often refuse to believe they are ill. “Their idea of a serious illness in their culture is usually something with obvious symptoms and contagious, like AIDS.” Moreover, she explains, in Ethiopian culture, “if you are ill, you stop working and are taken care of. It’s often incomprehensible to them that they can be ill with a potentially deadly condition which is, initially, asymptomatic.” Jaffe recalls stressful initial meetings with patients: “Many thought I was a bad, even stupid doctor, somebody talking nonsense. A serious disease that could be treated, in part, by exercising seemed totally preposterous to them.” Since then, however, she notes attitudes have improved; a recent study showed some 55 percent of patients being treated for diabetes now report they are more conscious of what their family eats and are trying to stay fit.
Dr. Abdul-Ghani says he also has his hands full in driving home the ills of diabetes to a society that is deeply traditional in lifestyle and diet, where village fitness studios simply don’t exist and walking for exercise is unheard of.
He also blames the Arab community. “We Arab doctors have to do a better job to alert patients to diabetes and to urge everyone to start exercising and stop cooking heavy Arab foods.” He is constantly exhorting fellow Nahf villagers, especially those who are on the chunky side, to “immediately lose 10 percent of their weight and exercise 150 minutes a week to prevent or control diabetes.”
Some are listening. Several diagnosed pre-diabetics have lost weight and lately he’s starting to see people walking in Nahf for exercise. “It’s encouraging,” he says. The severity of the incidence of diabetes across Israeli populations, says Raz, means they have no choice but to put down the fries and follow suit.