‘There are worse things in this world than being fat,’ says Irish obesity expert

Stephen O'Rahilly struggles with his weight. "I have a very powerful appetite, I eat too much. I would find it impossible to skip lunch," the Cambridge academic tells The Irish Times.

His love affair with food is, perhaps, appropriate for a man who is an internationally-regarded expert on insulin and diabetes; but, most of all, on obesity and its crippling effects.

Each Monday, Prof O'Rahilly meets diabetic patients at his clinic at the Institute of Metabolic Science on the grounds of the Addenbrookes Hospital in the Cambridgeshire city.

“I see patients who have struggled all their lives with their weight and their appetite. A lot don’t admit it because they feel so ashamed. Despite developing diabetes, they just cannot get themselves to a safe weight,” he says.

The obese are abused, in O’Rahilly’s view, condemned by society as feckless, weak-willed and lazy. He disagrees, saying dryly: “I think it is much worse to cheat on your wife, or park in a disabled space.

“I don’t consider it as morally reprehensible as stuff that actively harms other people. You could be just as reprehensible by going off on a skiing holiday and costing the health service a fortune by breaking your leg.”

Twenty years ago, O’Rahilly, who was knighted by the Queen in 2013, discovered that some children, often wheelchair -bound because of their obesity, suffered from the lack of the leptin hormone.

Leptin makes people feel full after eating. Once the children were given replacement hormones they lost weight. In time, they were able to resume their lives as children.

“They were obese because they were eating too much. The difficulty in getting it across is that people find it incredibly difficult to think that biology can drive a behaviour,” he says.

Leptin, however, was not the magic bullet for a problem that is costing health services globally billions annually, since it worked only on those most chronically in need of the hormone.

Nevertheless, it drove O’Rahilly’s interest in the genetic causes of obesity where faulty genes make people fat not because calories are burned off slowly, but because people never feel they have had enough to eat.

“It is caused by genes affecting your behaviour, affecting what you think are conscious choices, he says, pointing to the experiments that they have done where children with a faulty gene, and those who do not, are put into a room.

“We give them infinite choices of buffets. The kids who happen not to have inherited the bad gene eat what they need. The kids with the broken bit of circuitry just eat and eat. We have seen this again and again.”

Some people are genetically-fated to be fat, he says. In the centuries past, it hardly mattered because only the rich could get enough calories, or people died of other causes before obesity could get around to causing ill-health.

Since the 1950s, the world of food for those in the West and, increasingly, others elsewhere has changed: “Food is much cheaper than it ever was before: due to the fall in transportation costs, refrigeration and packaging,” he says.

In laboratories, rats can have tiny changes made to the brain that will make some of them eat practically nothing, while another inches away can do nothing other than consume all the time.

“These are fundamental parts of the brain. They aren’t what we call the thinking parts of the brain: they are more the elements of the brain that control breathing,” he declares.

“My mother tells me about the days when you had to think about the food you bought very carefully. Now you can easily pack in the calories you need by going to a fast-food outlet, enough to make you obese.”

O’Rahilly calls for action at every level. The public environment has become “obeseogenic”: people do not exercise enough, fast-food shops are too close at hand, sugar has become pervasive.

“We have created an environment that facilitates obesity . However, the ones who are susceptible are not bad people. They are not making active, bad choices to become sick. They are wired differently, but they are uniquely the subject of vilification, that is why I get passionate about it,” says O’Rahilly, who now co-directs the Cambridge institute that he founded.

A decade ago, researchers in Ely and Wisbech in Cambridgeshire investigated the eating habits of 10,000 people, finding that fast-food consumption was directly linked to the number of such outlets near them.

In the United Kingdom, spending on food consumed outside the home has increased 29 per cent in the last ten years, driven by the growth in the number of takeaways and other such outlets, according to the paper, published in the British Medical Journal.

“You could start by regulating the proximity of fast-food restaurants to schools,” says O’Rahilly, agreeing with Waltham Forest Borough Council’s decision in London to ban them from within 400m of schools, and to ban clustering elsewhere.

Equally, portions should be reduced. Incentives should be given to encourage the drinking of non-sugared drinks, rather than those with a dozen spoonfuls of sugar, perhaps by subsiding one and taxing the other.

“We have created a crazy society where it is impossible to avoid food stimuli all the time. Go into our hospital here and the newsagent is promoting half-kilo bars of chocolate. There are people coming out of the diabetes clinic here and they are being asked if they would like a half-kilo bar of chocolate for less than a pound,” he says, half-disbelievingly.

However, he accepts that public attitudes have a long road ahead. Higher taxes on sugared drinks may work in time, if the experiment underway in Mexico is shown clearly to work, on lines of Ireland's smoking ban.

"But people get a little more irritated about portion sizes. They feel they are being short-changed. Michael Bloomberg did amazing things with tobacco in New York, but he couldn't get 48-ounce cans banned, for example."

Despite the looming onset of a cold, O’Rahilly is in full flow by now, happily citing “a nice theory” called “the protein leverage hypothesis” which argues that the quantity of food eaten has gone up because the protein content has gone down.

“For most of our history we have eaten diets where 15 per cent of our total calories came from protein. We eat to get that 15 per cent. So we eat more to get to that magic ratio if it is reduced,” he goes on.

The Irishman’s journey to Cambridge was filled with happenstance. Born in Artane in 1958, he moved with his family after his pharmacist father “who had been desperate to get his own place” saw a shop come on the market in Finglas.

"I was three when we moved to live above the shop on McKee Road," he says, recounting years spent subsequently in St Canice's Primary School and then Beneavin De La Salle college.

“Beneavin was a very good school, very supportive, good teachers, not many fripperies, not many bells-and-whistles; but lots of good solid teaching and lots of us did pretty well out of it,” he recalls.

Later, the family had moved to Willow Park in Glasnevin, from where O’Rahilly travelled each day to study medicine in University College, Dublin.

Foreign training was then required. Unusually, for the time, he chose to go to England, not the United States which was the more popular choice for those in search of post-graduate experience.

“I quite liked the idea of the National Health Service. I wasn’t that fond of some aspects of the private medical side in Dublin. What I had witnessed of it was rather unattractive.

"I was a bit romantic about the NHS. I know it is not perfect, but I am still romantic about the NHS," he says with a chuckle, "its ethos of public service medicine appealed".

Following training in Barts and Hammersmith in London, he met the Oxford University-based diabetes expert, Robert Turner, who died tragically young from a stroke in 1999. "He was a great, inspiring character," says O'Rahilly, sadly.

Having accepted an invitation from Turner, O’Rahilly went to Oxford, where he soon became enthralled by the idea of research: “Six months in, I remember sitting in the lab thinking, “My God, people are being paid to do this. This is such fun”.

Five years on, he decided that experience in the US was needed, so he moved to a laboratory in Boston sponsored, he says gratefully, by the UK Medical Research Council.

In time, his research was becalmed: “I just couldn’t see my way forward as to whether the research question I was asking was answerable and whether anyone would fund me. I was just stuck.”

An opportunity arose in 1990 to return to Ireland. First, however, O'Rahilly travelled back to Oxford to meet his then-estranged English girlfriend, Suzie: "She was rather puzzled to see me, I then asked her to marry me."

She agreed. The two travelled to Dublin for his interview for St Vincent’s in Blackrock and St Michael’s in Dun Laoghaire: “We sat in the carpark chatting about it, and I decided I wouldn’t.”

The couple moved to Boston. His wife died three years ago: “It was a very happy 25-year liaison, but, sadly, she died three years ago of a carcinoma...Very sad. It’s fine, it is nearly four years on now so I’m doing okay,” he says, his gaze turned to the window.

He soon returned to the United Kingdom from Boston after he persuaded the Wellcome Trust to fund research into patients who did not respond well to insulin.

Cambridge was the obvious place to go, since good insulin research was already underway there, even though it was then seen as being decades behind Oxford in medical research. In time, he and his team discovered the obesity gene affecting children. Funding bodies became interested. Cambridge University prioritised their work. Today, 200 people work in the institute.

In the years since, O’Rahilly has clearly wearied of questions that imply the obese have no one to blame but themselves, or those which seek news of the delivery of a magic pill that will cure society of all of its obesity ills without effort.

Research from Sweden into identical twins, who were separated at birth, shows that at 30 years old their weight has more to do with each other than the families they grew up with, regardless of those families' lifestyles.

“With that basic knowledge we do know that there is a basic genetically-built architecture in the body which really to a large extent determines our resistance, or susceptibility,” he goes on.

He relates, in a fascinated rush, a series of findings from other research: “There was a beautiful paper a few years ago on the relationship between how fat you are and how much you earn.

“If you are a white female in America the thinner you are, the more you earn. The relationship is really dramatic. The relationship is flatter for white males; it is completely flat for black females and it is the opposite for black males.”

There is a strong correlation between socio-economic class and obesity: “But there are three possible ways that could work. Being poor could make you fat, being fat could make you poor or something else could make you both fat and poor.”

However, O'Rahilly says he recently received a telephone call from a researcher in Houston in Texas, who had asked Fortune 500 chief executives to have their genomes fully sequenced. Ninety agreed.

Two had the same obesity gene he had identified in Cambridge in the 1990s “but they had managed, despite the prejudice against the obese, to be highly successful businessmen, so this (link between poverty and obesity) is not universal”.

The link is largely a Western issue, anyway. In developing countries, obesity is more common amongst the wealthier, as it was in England during the 1700s and 1800s, when the rich struggled with gout.

“Then, it was much commoner amongst the wealthy. There’s a lovely quote from an 18th century medical journal: “No age has seen more evidence of corpulency than our own”. This was in 1760, so the idea that obesity is a new problem is nonsense.”

The best example of the era was Daniel Lambert, the heaviest man recorded up to that point, who was 52 stone weight when he died, even though he never drank and ate little. Lambert put himself on public display for a time to break out of poverty. In the end, he died wealthy, though his coffin required 112 square feet of timber.

Besides needing a forest of timber, the Leicester native’s coffin was also fitted with wheels, while his grave was dug with a sloping approach. Still, it took 20 men half-an-hour to drag his coffin to his final resting place.

Despite today’s obsession in the West about obesity, it seems that white Caucasians, blessed in life’s lottery with earlier riches, are luckier, too, when it comes to the one of the consequences of riches, Type 2 diabetes.

In Shanghai in China, on the back of accelerated change over the last two decades, Type 2 diabetes is now rampant, affecting one-in-five of the city's population. In the UK, the figure is closer to five per cent.

“Western Caucasians are almost uniquely protected from the consequences of obesity,we seem to be able to become very fat, many of us, without developing diabetes.

“Many Hispanics, or American-Indians are not so lucky. If you develop obesity with that background and you become obese then you are almost guaranteed to get diabetes,” he goes on.

To explain, O’Rahilly draws an analogy between obesity, diabetes and an overflowing bath: “Quite a lot of very fat people can safely store it without becoming diabetic, paradoxically. The bath is bigger.”

By contrast, lean people of certain backgrounds – particularly South Asians, who convert quickly from a physically-active lifestyle, with simple food to a more sedentary one filled with processed foods –rapidly fall victim to Type 2.

“Many of their genes restrict the amount of fat that they can develop, so they quickly develop Type 2. If the bath is small, as it were, it will quickly overflow,” he adds.

Initially, only the wealthy can become obese, but societies gradually evolve into into a situation where the maximum obesity rates drop down the socio-economic classes as countries get richer.

Having telescoped rapid economic development into just a few years, countries like Mexico, India, even those in sub-Saharan Africa more commonly associated in the public mind with famine face a looming health crisis.

“Type 2 diabetes doesn’t only kill you. It can cause blindness, renal failure, amputation if isn’t properly managed. Most of the countries experiencing this don’t have the chronic disease management systems needed to cope with it,” he says.

Obesity has not been a feature of mankind’s existence for long enough to spur Darwinian evolution, though there are concerns an obese pregnant woman with diabetes may be likely to pass it on to the unborn. “One of the concerns is that the intra-uterine environment is somehow toxic,” he says, “if a woman has a baby and her blood sugar is raised when the baby is in the womb the chance of that child later developing diabetes is higher.”

The higher risk exists compared with an equally obese woman who never had diabetes, or if the woman had the child before she herself developed diabetes,” says Prof O’Rahilly.

However, obesity faces biological boundaries, like everything else in nature: “The idea that everyone is going to become fat is nonsense, it is already flattening off. There will be people who will never be susceptible . . .Public health changes may have helped, but it is also possible that the ones who are susceptible have already got it.”

For O’Rahilly, the key to his attitudes are the Monday afternoon clinics: “I do have sympathy for these people. Lean colleagues tell me that they skip lunch. If I did that I could not work in the afternoon.

“Some of my colleagues tell me that they don’t know what being hungry means,” he goes on, clearly finding the thought incomprehensible.

“I find it very difficult to not eat, I don’t think it makes me a bad person.”

Because of his love of the table, O’Rahilly is himself currently carrying excess pounds. However, he has great hopes that his return to the tennis courts following a two-year absence caused by an elbow injury will soon deal with that.