Jean is obese. She has a classic case history: a love of food but "no time" for exercise. Her weight problem has also led to chest pains, which forced her to give up her favourite hobby, acting. "A year ago I did lots of acting in a theatre, but I just don't want to go on stage any more."
If Jean was living in America instead of Kingston, Jamaica, she would not need to worry about being overweight, she need not feel guilty about her sedentary lifestyle. She could just pop a slimming pill instead. No longer considered simply a matter of over-eating or of eating disorders, obesity is now recognised as a disease by the medical profession. Many doctors both in the US and the UK are now calling for it to be treated like one - with drugs.
Enthusiasm for drugs as a treatment for obesity is growing, both among long-suffering dieters and pharmaceutical companies with an eye on the jackpot, especially in the US where their use has rocketed in the last five years. Dexfenfluramine, a new diet drug which suppresses appetite, has recently come under FDA review. If successful, it will be the first new diet pill to be approved in the US for 23 years. Recent publicity claiming that obesity is inherited is simply grist to the pharmaceutical companies' mill. In fact, as Professor Philip James, director of the Rowett Research Institute, Aberdeen, and author of a recent UK government report on obesity, points out, only one third of any individual's likelihood of becoming obese is down to their genes. The rest is due to diet and exercise.
The potential for the abuse of dieting drugs is obvious and alarming. In the Western culture of slenderness, the diet pill could be a dangerous panacea. The past use of amphetamines - "uppers" or "speed" - as a dieting drug still creates fears that these drugs may be both addictive and damaging. And, like any medicine, you will have to keep taking them if you want them to work. Stop and the weight comes back on.
While millions starve, more than half the adult population of the Western world is overweight, with a growing number in the rest of the world set to follow suit, the slimming pill may yet have its day. According to Professor James, it is a "disease" that has now reached epidemic proportions, despite the fact that the definition of obesity is itself a matter of dispute. Doctors worldwide are now recommending that women should aim to keep their waist measurement below 30in, since above 35in indicates obesity. For men, the figures are, mercifully, higher: 35in is cause for concern, while 40in is obese. An alternative measure, "Body Mass Index" (BNI), is calculated by dividing your weight (in kilograms) by your height (in metres) squared. The healthy average lies between 22 and 23, obesity at over 30.
The UK is no exception. The incidence of obesity in the UK has doubled in the past decade, despite the fact that since 1970 the average per capita energy intake has fallen by more than a fifth. Conservative estimates suggest that one in five of us is now obese, and another third are overweight. The figures are even higher in the US, where over one third of the population are obese.
But is obesity really a disease? Isn't it simply the result of over- indulgence and laziness? No, say experts like Professor James, it is a disease because "it specifically contributes to morbidity, causing selective problems like diabetes (a major cause of kidney failure), raised blood pressure, and heart disease". While we have been happy to accept that these side-effects of obesity are indeed diseases, using the term to describe obesity itself has been taboo. "People perceive an excess of weight as a manifestation of personal individual greed and therefore a complication, not a primary feature," says Professor James.
The economic and social consequences of obesity are astounding. Treating obesity consumes 2 per cent of the overall UK health budget - more than pounds lbn.That is equivalent to the amount spent in the UK on treating all cancers or all tobacco-related diseases. And that is before you count the cost of time taken off work due to related conditions such as diabetes.
Traditionally a condition associated with affluent lifestyles in the West, obesity is a fast-growing problem in developing countries, too. Jamaica is going through a transition towards more Westernised habits. As this "Western affliction" spreads, so the causes of death, coronary heart disease, diabetes and stroke associated with obesity become part of the cycle of life and death in the island.
Already the more affluent parts of the Caribbean are feeling the burden of obesity and related conditions on their healthcare facilities. In Barbados, where nearly half of women are obese, 80 per cent of female surgical beds in hospitals are occupied by those with obesity-related diabetes. Recent research from the University of the West Indies points to a relationship between earnings and incidence of obesity in the Caribbean. Run your finger along a globe from Nigeria, across the Atlantic, through the Caribbean and the south-eastern corner of the United States up to Chicago, the slave routes of the 17th and 18th centuries: you have traced a path of both rising earnings and rapidly rising obesity.
This is only the beginning. The experience of Western nations suggests the problem of obesity is going to get worse in Jamaica. As people have moved from country to town in a desperate attempt to alleviate the economic hardships of rural life, their eating habits have changed. More and more Jamaicans are opting for the fat-rich foods associated with the fast-food, high-living culture of the West, while the price of high-carbohydrate, unrefined and healthier food goes up. Foods are often bought for their quantity, not their quality - and fatty foods offer excellent value for money. "Poor people here can't afford the healthy foods," says Jean Rhone. "People here don't want to eat yams and sweet potatoes because life is hard and it's easier to go home and eat white flour and white sugar."
Dr Rainford Wilks, of the University of the West Indies, agrees: "We like to cook our food in oil. There has been an explosion here of food that is deep-fried and seasoned with a lot of salt. Fatty food is easily available, but fruit and vegetables are not, even though they used to be grown here."
Jamaicans have not just taken up Western eating habits. They have also adopted Western working habits. The decline in physical activity has exacerbated the problems of a steadily worsening diet. As the depressed economy leads to an increased crime rate, especially drug-related crime, streets become less safe and children have to be driven in cars across town to school, rather than walking.
But while they may have acquired the Western taste for food, Jamaicans have not followed the Western fetish for super-thin female bodies and toned-up, muscular male physiques. As Susie Orbach, author of the 1975 book Fat Is a Feminist Issue, points out, categories such as overweight or obese are not fixed: "All these things are cultural. Even within one culture, the idea of what's an ideal weight changes from decade to decade." Throughout the world, the cult of the body manifests itself in a different set of values: "There is absolutely a contrast between the West and other countries in how attractive we find different weights," says Clifford R Barnett, professor of anthropology at Stanford University. "The view of what is ideal is a cultural construct. In a number of African societies if women become what we consider very heavy, very fat, it is a sign of wealth and of eating well and reflects on the whole family in a very positive way."
The slow Westernisation of the Caribbean lifestyle may not be the only cause for worry. Obesity affects the world's racial groups in different ways; there is a higher incidence of obesity in non-Caucasian groups. Black Afro-Caribbeans are twice as susceptible to obesity and to the associated conditions than white Europeans. Those from the Indian subcontinent also fare badly.
However, the patterns of obesity vary widely between the three groups. While obesity in Afro-Caribbeans doubles their likelihood of suffering stroke and hypertension, south Asians are more at risk from cardiovascular disease. Both groups are more vulnerable to diabetes when obese than Europeans. "'It seems that Europeans can get away with being fat without getting diabetes so readily," says Dr Paul McKiegue, of the London School of Hygiene and Tropical Medicine.
This cannot simply be explained away by the effects of different cultural food preferences. Dr McKiegue's work on obesity-related conditions on migrant and non-migrant Indians has demonstrated that different racial groups do indeed have different susceptibilities to obesity. The crucial differences lie in how fat is deposited around the body. The waist is the danger zone for heart disease; south Asians, who easily develop a pot belly ("central obesity" in technical parlance), face double the risk of coronary heart disease of other groups. Black Afro-Caribbeans, who exhibit a "different pattern of fat deposits", are less at risk from heart disease.
The past association of "slimming pills" with addictive, amphetamine- like compounds means that in the UK, at least, physicians are still unwilling to prescribe them. Furthermore, there are still no suitable compounds for long-term treatment, says Dr Andrew Prentice of Cambridge University. But he is optimistic about their future: "Once the pharmaceutical companies do find the right drug, it will be a huge money-spinner - and deservedly so." Jean Rhone would be the first in the queue: "The men here like fat women - someone with a bit of 'meat on her body', but I wish I could lose the weight. I just wish there was some magic potion."
Sculpture and jaw-wiring: heavy tactics for shedding pounds
Ann Watts is 47. In 1993, she underwent liposculpture.
I was eating and drinking too much. I'd shot up to 11st 9lb, which was too much for someone of 5ft 2in. I was envious of older women who still looked good.
Then I saw an advert for the Transform Clinic, giving free consultations for liposculpture. My husband, Jimmy, and I went along, and saw a counsellor and the surgeon, who talked me through the operation.
I went into the clinic in September 1993 and was out again the same day. It was done under local anaesthetic. I didn't feel any pain.
"I had fat removed from under my bust right down to my knees, which was a lot to have done at once. The surgeon made punctures at various points and injected a pink saline solution under my skin, which started to break down the fat cells. Then he inserted a syringe with a canula attached to it, and moved it around, sucking out the fat cells.
Liposculpture is more controlled than liposuction, which is done under general anaesthetic with a vacuum machine and can leave you with a bumpy result. The actual procedure lasted two hours and they took six litres of fat from me. Afterwards I saw it put in jugs for measuring. It was horrible - all yellow and greasy. I couldn't cook a chicken for a long while after that.
I could walk out after the treatment, but I was bruised and achy for a couple of days. When the swelling went down I noticed a difference. I'd not lost much weight - just a few pounds - but I'd lost inches, two from under the bust, and about three from the thighs. I went on a diet as well and started feeling fantastic.
I now weigh 9st 5lb and take a size 10/12 in clothes. The liposculpture cost pounds 3,000. It was the best money I've ever spent.
Liposuction and liposculpture are not conventional treatments for obesity. They remove subcutaneous fat, but that fat can be quickly replaced by the body. Ann is an exception - she managed to keep her weight down. But it wasn't the treatment that achieved this - it was the fact that she changed her eating habits.
Jab Claydon is 35. In the late Eighties she had her jaw wired.
All I wanted was something to stop me putting food in my mouth. I always ate the wrong things. By my mid-twenties I weighed 18 stone and was desperate. Eventually, my GP referred me on the NHS to the Manchester Dental Hospital.
First, they made a mould of my teeth. The pointed ones at the front had to be ground down so they were all level. Then a splint was made which fitted over my teeth, covering them completely. It was stuck in place with black cement. As it was setting it felt like my teeth were being dragged out of my gums. After 24 hours I went back and had the splints wired shut through hooks in the top and bottom.
For six months I lived on coffee, tea and tomato soup. I tried to eat mashed potato, and every now and then I'd have curry sauce, for a change. After a while I didn't feel so hungry, but the smell of fresh bread still made my stomach rumble.
I had to talk like a ventriloquist and when I spoke I looked like Jaws in Moonraker.
For six months I had to take wire-cutters wherever I went, just in case I felt sick and needed to get my mouth open. But I was so looking forward to being thin that I didn't really care - I lost six stone in those six months.
When the splints came off it was agony. They had to be prised off. The cement around my teeth was ground away with a machine. My mouth was so stiff that at first I couldn't yawn.
The first thing I did was go out for a huge meal. I celebrated all the way. I felt great and could wear nice clothes. But while I was having a great time, the weight was going back on. Six months later I was back where I'd started.
I'm now about 15 stone, and have lost some weight just by eating sensibly. I'm not as desperate to be thin as I was 10 years ago. I used to think that I wasn't accepted because I was fat. Now I realise life is too short and that the people who matter like me for who I am, not how I look.
Dental splintage does seem to be a safe procedure; you can ingest a balanced diet in liquid form. However, the results are usually disappointing because most patients regain any weight they have lost once the splints are removed.
Medical comments by Dr Peter Kopelman, senior lecturer in Medicine, Royal London Hospital.Reuse content