Two weeks ago, my father and I made a trip to Rishikesh in northern India to scatter my mother’s ashes in the River Ganges at an idyllic location at the foothills of the Himalayas. This was in keeping with her wishes as a devout Hindu that her spirit be released at a place she loved and previously visited on pilgrimage. Our family lost a greatly cherished mother and wife who went before her time, at only 68 years old.
I believe that what was finally written on her death certificate – severe sepsis and discitis with concomitant myocardial infarction (heart attack) – was entirely avoidable.
For most of her adult life, my mum was vegetarian and significantly overweight. Growing up, I witnessed her regular consumption of starchy carbohydrates and ultra-processed snack foods of biscuits, crisps and chocolate. Our kitchen was flooded with these products. I still have a vivid memory of her only meal on a weekly fast day consisting of a large chapatti and what can only be described as a mountain of table sugar. Her weight contributed to developing high blood pressure in her 40s and as a result, she suffered a brain haemorrhage in 2003.
Despite making a full recovery, taking up going to the gym and even learning to swim at the age of 50, the next 10 years resulted in a gradual deterioration in her mobility. Obesity related osteoarthritis led to slipped discs and severe degeneration of her spine, forcing her to take early retirement from General Practice.
Her vegetarian diet required her to take Vitamin B12 and iron supplementation. Protein deficiency led to sarcopenia (a decline in muscle mass) which limited her mobility even further. In the last six months of her life, she had two hospital admissions with agonising spontaneous sequential bilateral osteoporotic fractures of her pelvis. By the time she passed away, even high doses of morphine weren’t enough to completely ease the additional excruciating back pain from an infection in her spine.
What I see in my job as an NHS cardiologist
Such cases are not unusual for me to see as a cardiologist working in the NHS. The majority of those admitted with heart attack are not obese but have a condition known as metabolic syndrome (photo: Pixabay)
Although, as in my mum’s case, it is widely acknowledged that obesity is associated with the development of chronic disease, a not well-known phenomenon of being “overfat” (defined as excess body fat that can impair health and contribute to chronic disease) is now estimated to affect 70 to 80 per cent of the Indian adults and 41 per cent of children.
A large percentage of overfat individuals will have a normal Body Mass Index, with up to 50 per cent having excess body fat linked to risk factors for disease.
I recently learned an uncle of mine who has been a “slim” physically active vegetarian all his life, and never smoked, had a triple coronary bypass for three occluded heart arteries aged only 69. This was less than a year after being diagnosed with type 2 diabetes and high blood pressure. When I spoke to him, he admitted for the last twenty years his diet was high in flour based and sugary foods, but he believed because he wasn’t overweight he was perfectly healthy.
The diabetes capital of the world
Such cases are not unusual for me to see as a cardiologist working in the NHS. The majority of those admitted with heart attack are not obese but have a condition known as metabolic syndrome with one of the major components being increased waist circumference. The significant limitation of BMI (calculated by dividing one’s weight in kg by height in metres squared) is that is that it fails to take into account age, ethnicity, bone structure, fat distribution and muscle mass.
‘It’s instructive to note that India, with more vegetarians and vegans than the rest of the world combined, is the “diabetes capital of the world”‘
In developed countries such as the USA, New Zealand, Greece, and Iceland the prevalence of having excess body fat has reached over 90 per cent. In the UK, it’s estimated that 86 per cent of the adult men and 77 per cent of women are overfat. Excess body fat, which acts as a substrate for chronic inflammation and insulin resistance, is now implicated in the development of type 2 diabetes, high blood pressure, cardiovascular disease, arthritis, osteoporosis, cancer and Alzheimer’s.
It’s instructive to note that India, with more vegetarians and vegans than the rest of the world combined, is the “diabetes capital of the world”. The city of Chandigarh has the highest prevalence of type 2 diabetes in the country and the state of which it is capital, Punjab, has 75 per cent of the population as vegetarian. In the subcontinent, the last 50 years have specifically seen significant increases in consumption of processed wheat, sugar and vegetable oils (which have overtaken animal fats as a percentage of calories).
The Indian Dietetic Association recently put out a statement claiming 84 per cent of vegetarians in the country are protein deficient versus 65 per cent of meat eaters. As one of New Zealand’s most eminent dietitian’s Dr Caryn Zinn told me: “Calorie for calorie, meat is more proteinaceous and nutrient dense than vegetables. Of course, one can have a very healthy vegetarian diet but the majority of vegetarians in the world are clearly not following this.”
A large observational study conducted in Australia in 2016 concluded that contrary to popular belief, once other lifestyle factors were accounted for, vegetarians do not live longer than non-vegetarians in the developed world. Similarly, a large Austrian study published in the prestigious medical journal PLOS 1 found that despite having a lower BMI and less alcohol consumption, “a vegetarian diet is associated with poorer health (higher incidences of cancer, allergies and mental health disorders) a higher need for health care and a poorer quality of life.”
The totality of evidence does not find an association with the consumption of unprocessed red meat and reduced life expectancy. The association of the dietary saturated fat and heart disease found in high amounts in animal products has also been debunked in a paper I coauthored with two eminent cardiologists.
Taking much of this evidence into consideration after two days of debate and discussion at the international science and politics of nutrition conference jointly hosted by medical reinsurance company Swiss Re and the BMJ in June last year, the editor in chief of the journal Dr Fiona Godlee remarked: “The point about saturated fat is: the evidence is now looking pretty good, but the guidance hasn’t shifted […] there doesn’t seem to have been an enormous ‘mea culpa’ from the scientific community that we got it so wrong. That does surprise me.”
Dariush Mozaffarian, Dean of the Freedman School of Nutrition Science And Policy at Tufts University, Massachusetts, told me at the event in Zurich that population-wide strategies to curb obesity should now discard fat and saturated fat and focus on starch, sugar and salt reduction instead.
Ultra-processed food now makes up more than half of the British diet and is strongly linked to weight gain and even cancer. Ultra-processed is broadly defined as industrial formulations (any packaged food) with five or more ingredients. And when broken down into food groups, 77 per cent comes from sugary products and drinks, starchy foods and breakfast cereals, and ultra-processed fruit and vegetables. 19 per cent comes from ultra-processed meat, fish, eggs and dairy, and two per cent from “fats” and two per cent from salty snacks.
There’s been much media hype recently suggesting that adopting a meat or animal product free diet is best for human and planetary health, but this is not evidence-based.
An independent report from the US Department of Agriculture predicts complete removal of animals from the food supply would only reduce total US greenhouse gases by 2.6 per cent but simultaneously increase dietary energy consumption from a plant only system and worsen nutritional deficiencies.
“We don’t need less meat but better meat in the food supply,” said Dietitian and organic farmer Diana Rodgers. She recently wrote a devastating critique of the “nutritionally deficient” Eat Lancet report which recommends we consume less than half an ounce of red meat per day, the equivalent of one eight of a steak.
Red meat happens to be one of the best sources of zinc and Vitamin B12, a supplement of which needs to be taken by up to 92 per cent of vegans. “Well-managed cattle can also be one of our best tools at mitigating climate change,” Rodgers added, citing a study that shows how methane-emitting cattle can actually be a carbon sink, when looking at the full life cycle. “It’s not the cow, it’s the how.”
So whilst population health continues to suffer, the biggest beneficiaries could very well be the ultra-processed “meat and dairy free” food industry, the vitamin and supplement industry, and a predictable rise in the overfat epidemic and associated chronic diseases would be a cash cow for Big Pharma.
My mother dedicated most of her adult life to working as a GP in the NHS and was one of the most kind and compassionate people I have ever had the privilege of knowing. She wholeheartedly supported my public health advocacy work as it was in line with her philosophy as a Hindu to put Dharma (duty) to the community as paramount.
Sadly, her devout religious faith to avoid consuming animal products, combined with a high starch, high sugar diet, was ultimately to the detriment of her health. I very much hope that her premature and painful death was not in vain and we can learn that much of these ills are preventable.