Vietnam: Rise of the new fast food nation

As darkness falls, clusters of tiny plastic tables and stools spread across the pavements - improvised street-side restaurants to feed the armies of office workers. The acrid smell of pigs' trotters seared over charcoal braziers beside pans of meat bubbling on spirit burners fills the humid night air.

The transformation of this war-ravaged rural economy into a booming industrial power is happening at astonishing speed. Ten years ago, the bicycle was the dominant mode of transport. Now it is the motor scooter. Back then crisps, cola and ice-cream were novelties and fast-food restaurants featured only in Western magazines. Now they are part of the everyday scene. Vietnam, like its neighbour China to the north, is experiencing double-digit economic growth. Cranes festoon the skyline, factories complain of a shortage of labour - 20,000 extra workers are needed in the south of the country - and people are being drawn in growing numbers from the country to the towns.

But progress has a price. Across the Far East, growing urbanisation, rapid industrialisation and increasing obesity associated with decreased physical activity is fuelling an epidemic that has killed as many as Aids but has received a fraction of the attention.

The disease is diabetes, and its incidence is accelerating around the world. From 170 million affected in 2000, doctors predict the total will rise to 370 million by 2025, leading to an epidemic of amputations and blindness, the two commonest effects of the condition. Developing nations will be hardest hit; they bear 90 per cent of the burden but have only 10 per cent of the resources to deal with it.

Professor Pierre Lefebvre, president of the World Diabetes Foundation (WDF), told an international conference in Hanoi last week that there was a worldwide explosion in the disease.

"If we do not change this we face a catastrophe. It is called the tsunami disease. We know it is coming and it will come if we do not do something to prevent it." On the streets of Hanoi and Ho Chi Minh City, fast-food chains such as Kentucky Fried Chicken are starting to appear, alongside the snack bars, cake shops and mobile food carts catering for the worker on the move.

Traditional dishes that have sustained people over generations are disappearing, to be replaced by Western-style cooking that uses more fat, salt, sugar, oil and meat. Ordinary restaurants now offer a special version of the standard Pho Ga - chicken noodle soup - aimed at more affluent office workers that contains 22 per cent more calories than the basic dish.

The casualties of the trend can be seen in hospitals around the country. Squatting on an iron bedstead covered with a thin straw mat, Le Quang Can, aged 58, is unaware of the threat the disease poses to his life.

He arrived at the endocrinology clinic in Thanh Hoa province in northern Vietnam, 90 miles south of Hanoi, at 7 am for a routine test. He has unexpectedly been kept in for observation because his blood sugar level is sky high, and he could slip into a coma at any moment.

A retired soldier with six children, Mr Can waits for the insulin with which he has been injected to bring his blood glucose level down. He wears a woolly hat and blue pyjamas against the cold - it is winter in north Vietnam and a chill wind is blowing down from China. He and his wife work in the rice fields and the doctor will later warn him that unless he controls his diet he could end up a blind amputee, dependent on his family. Outside, scores of patients wait patiently on the steps under the corrugated iron roof for the results of tests carried out in the morning. The clinic, funded by the WDF, sees 130 diabetes patients a day in this provincial town, one of the poorest in Vietnam, and the scale of the need it has uncovered has persuaded the government to set up similar clinics across the country.

Diabetes is a chronic disease which first disables its victims and then slowly kills them. An estimated global total of 2.9 million deaths, equivalent to the number killed by Aids, were attributable to the disease in 2000, according to a study in Diabetes Care published in May 2005.

The most striking thing about the patients at the Thanh Hoa clinic is how few of them are fat. In the West, obesity is the chief driver of the epidemic - the Royal College of Paediatrics and Child Health has just released a new report showing that soaring levels of obesity among children in the UK are sparking a crisis of diabetes in under-16s. But Mr Can is lean and spry as are most of the other patients. Doctors do not know why Asians are more prone to the disease. One theory is that because of their slighter build, compared with Westerners, they have less muscle bulk and more fat, so do not need to gain much weight to put themselves at risk. Malnourishment in infancy or in the womb, which is known to increase the risk of diabetes, may also play a part. Seven out of 10 of the worst affected nations by the disease are in Asia. India already has a total of 31 million cases, the highest in the world, closely followed by China with 20 million. The Far East is expected to see the fastest growth by 2025, with a near doubling in the current total of 81 million cases to 156 million.

Becoming blind or losing a limb is a huge problem anywhere but in the developing world it is a disaster. In India, 45,000 amputations are carried out a year because of diabetes, all of them unnecessary with the correct care, according to Anil Kapur, vice-president of the WDF.

"We are faced with a diabetes pandemic," Dr Kapur said. But the world only recognised infectious diseases as a threat. Of the $2.9bn (£2bn) given in overseas aid for health in 2002, just 0.1 per cent was allocated to chronic diseases including diabetes, he said.

The road to Thanh Hoa from Hanoi passes small village stores selling crisps, ice-cream and soft drinks, which are often cheaper than water. It is thronged with scooters but is free of the children - who once walked beside it to school - they now travel by bus. The disappearance of traditional diets and lifestyles and their replacement with junk foods and motor transport are believed to be behind the growth in the disease.

"As the economy grows, lifestyle and eating patterns change," Dr Kapur said.

The public health message was to eat less and exercise more but this was hard to get across to people raised in the shadow of hunger, he added. Mothers are being urged to feed up their infants but then to curb the appetites of their adolescent children. Social custom, Dr Kapur explained, dictated that when food was available it should not be restricted. "Often in our society being overweight is seen as a sign of prosperity and good health. If you are well off you must have a paunch," said Dr Kapur. Only half of people with diabetes are diagnosed, the remainder living in ignorance of their condition often until it is too late and they suffer irreversible side effects. Yet even those who find their way into care are poorly managed.

Three studies of diabetes care in Asia, covering 45,000 patients, found one- third had kidney damage, while a similar proportion had damage to the nerves in their feet and a smaller number were developing eye damage. Only one patient in five was properly controlled.

"Care is inadequate, complications are common. There is an increased economic burden on society, on the family and on the individual. Those who believe treating diabetes is expensive should change their opinion. Not treating it is very expensive," Dr Kapur said.

The food companies exacerbate the problem with sales techniques such as mini-sizing, according to Gauden Galea, regional adviser for the World Health Organisation. Mini-sizing - selling soft drinks and fast foods in miniature portions - is a growing practice in the region. While the food companies argue they are offering customers a low cost option, Dr Galea claims it is a cynical way of boosting their business.

"They are sowing a taste for fast food by inveigling their way into people's eating habits. As people become more affluent they move from mini size to super size." But Dr Galea says the global trend towards increasing weight, which is fuelling the pandemic of diabetes, can be halted. Successful public health projects were carried out in Da Qing, China, a decade ago based on intensive education on diet and exercise, which led to a 47 per cent reduction in the incidence of diabetes over six years. Similar projects in the United States, Finland and India achieved comparable results.

"These projects demonstrate very conclusively that you can delay or prevent diabetes with only minor reductions in weight," Dr Galea said. The challenge, he added, was to ensure that the care given to Mr Can could be delivered across the Far East.