274 BRITISH MEDICAL JOURNAL 3 FEBRUARY 1973

MEDICAL PRACTICE

Occasional Review

Some Diseases Characteristic of Modern Western

Civilization*
DENIS P. BURKITT

British Medical Journal, 1973, 1, 274-278 reported to be present in one-third of all necropsies on patients
over the age of 20.3 Cancer of the large bowel is, after bronchial
A number of diseases of major importance are characteristic of carcinoma, the most common cause of death from cancer. It has
modern Western civilization. These diseases are rare or un- been estimated that over 46,000 people would die from this form
known in communities who have deviated little from their of cancer in the United States and that over 76,000 new cases
traditional way of life, and a rise in their frequency follows would be recorded in 1972.4 Ulcerative colitis has been reported
adoption of Western customs. Available evidence suggests that to have a prevalence of about 80 per 100,000 population in
all these diseases were rare or uncommon even in the Western Britain.'
world a century ago and that they are rare or unknown in
undomesticated animals. Some appear or increase in frequency
within a few years of exposure to a new environmental factor,
others not until several decades later. The diseases to be con- COMMON VENOUS DISORDERS
sidered in this connexion are listed below, with indications of Varicose veins have been estimated to effect 10-17% of all
their prevalence and importance as causes of death and mor- adults.6-' According to Alexander,10 over half of all urbanized
bidity in Britain and the U.S.A., countries which represent the Western people would develop varicose veins if they lived long
type of civilization with which these diseases are most closely enough. Deep vein thrombosis is believed to occur in 20-30% of
associated. all surgical patients and in over 40% of those undergoing major
surgery.1' 12 Pulmonary embolism is responsible for over 2,500
deaths a year in Britain"' and is believed to occur to some extent
Diseases in the Western World in half of all the patients who develop ileofemoral thrombosis."
Haemorrhoids are believed to be present to some degree in
NON-INFECTIVE DISEASES OF THE LARGE BOWEL nearly half of all people over the age of 50.
Appendicitis is one of the commonest abdominal emergencies.
It has been estimated that over 300,000 appendices are removed
yearly in the United States. Diverticular disease is the commonest DISEASES ASSOCIATED WITH CHOLESTEROL METABOLISM
disorder of the large bowel and has been reported to be present
in over a third of subjects over the age of 40 and in up to two- These include coronary heart disease, which is the commonest
thirds of those over 80 years of age.1 2 Benign tumours have been gall stones, which are found at over 10% of
cause of death, and
all necropsies."5
Based on the Crookshank lecture delivered at the Royal College of Surgeons
of England on 19 May 1972 by invitation of the Faculty of Radiologists.

OBESITY AND DIABETES

Medical Research Council, 172 Tottenham Court Road, London
WlP 9LG Over 40% of the people in Britain are said to be overweight, and
DENIS P. BURKITT, F.R.C.S., F.R.S., Member of External Scientific Staff
obesity has become so common in the United States that a
BRITISH MEDICAL JOURNAL 3 FEBRUARY 1973 275
variety of intestinal bypass operations are now being recom- and coronary heart disease42 the prevalence in the Negro com-
mended for its relief. munity some 30 years ago was much less than that among whites,
It has been estimated that in affluent societies 3-10°h of the whereas there is no appreciable difference in incidence in the
population eventually develop known diabetes but that a much two population groups today.
greater proportion have the disease undetected.16

Rise in Incidence with Changing Environment

HIATUS HERNIA
The prevalence of these diseases in populations of developing
Zeppa and Polkl 7 and Polk"8 found hiatus hernia in one of five in countries appears to relate to the extent of their departure from
35,000 patients undergoing radiological examination of the traditional patterns of life. In Africa and Asia most if not all
upper gastrointestinal tract. these diseases first appear or become common in the upper
socioeconomic groups and in urbanized communities. In
Africa this has been evident in the case of appendicitis,2"43
OTHER DISEASES ischaemic heart disease,44 diabetes,32 4" obesity,"2 33 gall stones,"4
varicose veins, venous thrombosis, and haemorrhoids,' 0 4" all of
There are a number of other diseases, such as thyrotoxicosis, which are more prevalent in the more Westernized communities.
pernicious anaemia, rheumatoid arthritis, multiple sclerosis, and Available information suggests a rapid rise in the incidence
coeliac disease, which are common in the Western world but of these diseases in Japan since the 1939-45 war, particularly
rare in developing countries, but they are not discussed here in urban communities. In the case of many of these diseases an
since no acceptable explanation has yet been suggested for their increase in incidence has been observed among Japanese who
geographical distribution. have emigrated to Hawaii relative to that recorded in Japan.
Stemmermann47 estimated that adenomatous polyps of the
large bowel are three times as common in the Hawaiian Japanese
and that bowel cancer is at least seven times as common. Diver-
RACIAL DISTRIBUTION
ticular disease and ischaemic heart disease are also much more
It is of particular significance that the prevalence of most of prevalent in Hawaiian Japanese, but deep vein thrombosis and
these diseases is now comparable in the white and coloured hiatus hernia are still very rare in both countries.
communities in the United States. The incidence of fatal
pulmonary embolism, which is very rare in Africa, is actually
higher in American Negroes than in whites.19 In the few con- Relation between Diseases
ditions where the prevalence is still lower in Negroes than in
whites-for example, ulcerative colitis-it is much closer to that Many diseases characteristic of modem Western civilization are
in white Americans than to that in Africans. not only associated geographically but are also frequently found
associated with one another in individual patients. Some have
been recorded, but other associations which have not been
The Contrast in Developing Countries specifically looked for may well exist. These diseases have also
been related to one another in their time of emergence as im-
All these diseases are rare or unknown in communities who still portant clinical entities, both historically in the Westem world
adhere to their traditional way of life. Many published reports and, more recently, in developing countries. Moreover, the
have been confirmed by replies to questionnaires from, and by order in which the frequency of each rises in different com-
personal interviews with, doctors representing over 200 hos- munities following the adoption of a Westem pattem of life
pitals in developing countries in Africa and Asia. The rarity in appears to be relatively constant, and it is suggested that this
these communities of diverticular disease2 0-22; appendicitis23 24; reflects both the intensity of and the time of exposure to some
bowel cancer25; adenomatous polyps2" 26; ulcerative colitis27-2'; new environmental factor which in time results in the appear-
varicose veins, deep vein thrombosis, pulmonary embolism, and ance of clinical disease.
haemorrhoids30; and hiatus hernia"3 has been documented. All the effects of a common cause tend to be associated with
Cleave et al.32 and Trowell27, from an extensive survey of the one another, each being most common where the causative
literature and personal experience, drew attention to the rarity factor is maximum and being rare or absent where the cause is
of these diseases in less economically developed communities. minimal. All the effects of related causes will also tend to be
associated. Conversely the recognition that certain diseases are
more or less consistently related to one another suggests the
possibility that they may be different results of common or
Historical Emergence related causes.'6 48
Available evidence suggests that most of these diseases were rare
even in the Western world before the present century and that
the prevalence of each has greatly increased during the past 50 A Possible Common Causative Factor
years. Obesity became prevalent at an earlier date, but evidence
from art and literature indicates that it was rare in the common Epidemiological evidence indicates that environmental factors
man in Europe before the late eighteenth century." The emer- must be primarily responsible for the diseases being considered.
gence of diabetes as a clinical problem is more difficult to assess It is therefore in the environment with which these diseases are
but it was well recognized in the last century. related, both in their geographical distribution and chrono-
A rapid rise in frequency of pulmonary embolism seems to logical emergence, that clues to their causation must be sought.
have occurred in the first quarter of this century,34 from which it A carcass in the African bush is most easily discovered by
may be inferred that deep vein thrombosis was uncommon half locating the readily recognized and constantly associated tell-
a century ago. Diverticular disease'20 and coronary heart tale vultures. The same approach could be profitably followed
disease'5 became prominent only after the first world war. The in medical research, though it is often precluded by narrow
frequency of appendicitis was apparently rising steeply at the specialization which does not encourage the following of guide
turn of the century." lines provided by other fields of medical practice. Since a con-
It is highly significant that in the case of appendicitis,36 37 mon cause can be suspected for diseases constantly associated
diverticular disease,"' cancer,39 40 polyps of the large bowel,4 with one another it seems wise, once such associations are
276 BRITISH MEDICAL JOURNAL 3 FEBRUARY 1973
recognized, to search first for the cause of the disease that can be Non-infective Diseases of the Large Bowel
more readily investigated, and I propose to start with the non-
infective diseases of the large bowel. Diverticular Disease.-There is strong evidence that diverticular
The main environment of intestinal mucosa is the faecal disease is the direct result of raised intraluminal pressures con-
content of the bowel, and in the colon and rectum this is largely sequent on a low-residue diet.68-60 Not only is this disease
determined by the undigested fibre in the diet. This is not virtually unknown in all communities examined on a high-
digested by alimentary enzymes, so that it is scarcely altered residue diet and common in those who over a generation ago
during its passage through ,the small intestine. It is degraded adopted a low-residue diet2 0 but it can be produced experiment-
partially by bacteria in the large bowel. Careful attention must ally in animals put on a fibre-free diet. 61 It can in most cases be
therefore be paid to any changes in diet in the Western world successfully treated in man by restoring as little as 2 g of cereal
towards the end of the last century which preceded the rise in fibre to the diet.57
incidence of non-infective diseases of the bowel and the changes Appendicitis.-This disease has likewise been attributed to
now taking place in developing countries. Particular notice raised intraluminal pressures beyond an obstruction due to
must be taken of alterations in fibre intake. faecalith or muscular contraction.23 Alterations in faecal bacteria
resulting from changes in intestinal content or from faecal
arrest may be a contributory factor.32
Cancer.-The high incidence of cancer in Europe and North
Dietary Changes 1860-1960 America has been attributed to carcinogens produced by the
action on bile acids in the colon, of bacteria that are particularly
During the years 1860-1960 fat consumption increased by less prevalent in the faeces of Western nations.62 Hill et al.63 believe
than 50% and sugar consumption more than doubled.49 Though that increased fat in Western diets alters not only the bacterial
the greatest reduction in quantity of fibre consumed occurred composition but also the concentration of bile acids in the faeces.
during the eighteenth century, the proportionate fall between Whether or not fat is the responsible dietary constituent the
1880 and 1960 was more than 90%. Robertson'0 estimated that faecal arrest resultant on a low-residue diet will not only provide
the fibre content of white flour in 1860 was between 0-2 and more time for bacterial proliferation and their degrading of bile
0 5% and that the amount of fibre supplied daily in bread was acids but will result in carcinogens so formed being concen-
between 1 1 and 2-8 g. With bread consumption halved and the trated in a small faecal mass and retained for a prolonged time
fibre content of white flour reduced to between 0-1%500 and against the intestinal mucosa.25 64 65
0 01-0 04% 51 the daily fibre intake in bread is now reduced to Polyps.-The close association between cancer and polyps,
about a tenth of the pre-1860 level. In addition porridge oats, not only in geographical distribution26 but also in anatomical and
which have a high fibre content, have been largely replaced by age distribution, and in their tendency to be associated in indi-
packaged cereals, some of which are poor in fibre. viduals,66 together with the fact that they can both be produced
by the same experimental means,67 68 suggests that thay are
merely differing manifestations of the same common cause.2 5 6 9
Changes from Traditional Food Ulcerative Colitis.-The close association between this disease
and bowel cancer both geographically and in individual patients
The first change in traditional food is usually the addition of suggests some common aetiological factor. The commonly
sugar. This is followed by substituting white bread for part of accepted explanation of a mere cause-and-effect relationship
the less processed cereals customarily eaten. Lubbe52 showed fails to account for the rarity of this condition in all known areas
that the greatest alterations in diet associated with a change from where the incidence of bowel cancer is low.25
rural to urban life in South Africa are an increase in sugar and
meat consumption and a fivefold reduction in consumption of
fibre.
Venous Disorders related to Faecal Arrest
Effect of Fibre on Intestinal Behaviour and Content Since a fibre-deficient diet has been shown to be closely related
to the non-infective diseases of the large bowel the possibility
Since epidemiological evidence appears to point an incriminating first suggested by Cleave70 that other associated diseases may
finger at the lack of fibre in food it is essential to investigate the also be causally related to fibre lack must be considered. Not
effect of this on intestinal content and behaviour. It has been only does faecal arrest result in raised intraluminal pressures, also
shown that intestinal transit times and stool weights and in raised intra-abdominal pressures while straining to evacuate
consistency are closely related to the content of fibre in food. hard stools. These unnatural pressures could well be responsible
Average transit times vary from some 35 hours in African vil- for the following diseases, which are associated epidemiologic-
lagers on a high-residue diet to over 70 hours in English volun- ally with low-residue diets.
teers on a low-residue diet. In the latter subjects transit times Varicose Veins.-It is well known that raised intra-abdominal
commonly exceed 100 hours. Stool weights and consistency are pressures are readily transmitted down the superficial leg veins
inversely related to transit times and often average 400-500 g after the valves have become incompetent. An impulse detected
of soft, unformed stool daily on high-residue diets and under on coughing is the classical clinical test for valve failure. Such
150 g of firm, formed stool on low residue diets. Communities on pressures, which can exceed 200 mg Hg,71 must therefore be
mixed diets, such as Indians, more Westernized Africans, and sustained by the valves when competent, and they may well be
English vegetarians, have stool weights and intestinal transit the cause of their failure and thus initiate the process which
times intermediate between the two extremes. 25 53-5 6 leads to varicosities.30
It seems probable that the removal of the few grammes of Deep Vein Thrombosis.-It seems unlikely that venous changes
cereal fibre that remained in Western diets until about a century resulting from valve incompetence would be confined to the
ago, part of which may be attributed to changes in milling tech- visible superficial veins. Changes in the deep muscle plexuses
niques introduced between 1850 and 1890, could have been the with consequent venous stagnation that might predispose to
last straw breaking the camel's back. This contention is sup- thrombosis during enforced recumbency could account for the
ported by the evidence that in formerly constipated patients high incidence of deep vein thrombosis in the lower limb in
bowel habit can be restored and stools altered from hard to soft communities with a corresponding high incidence of varicose
by restoring to the diet as little as 2 g of cereal fibre daily in the veins. Though stool consistency is held to be of prime import-
form of unprocessed bran.57 (A heaped dessertspoonful of bran ance the squatting position adopted for defaecation in all but
contains rather more than a gramme of fibre.) Western countries is believed to be an additional factor protect-
BRITISH MEDICAL JOURNAL 3 FEBRUARY 1973 277

the veins in the leg against abdominal pressures. When the Obesity and Diabetes
valves have become incompetent a cough imnpulse readily
detected when standing is not transmitted in the squatting Cleave attributes the association between various diseases of
position. modem civilization to different aspects of the two complement-
Haemorrhoids.-It has been postulated that haemorrhoids are ary results of refining carbohydrate foods-excess consumption
also the result of transmitted intra-abdominal pressures. The of energy in the form of sugar and refined starch on the one hand
observation that the frequency of haemorrhoids in developing and fibre depletion on the other.32 70 He attributes obesity to
countries always appears to rise before that of varicose veins or overconsumption of refined carbohydrate foods, and diabetes to
deep vein thrombosis could be explained on the grounds that the overconsumption as well as the increased rate of absorption of
haemorrhoidal veins lack the initial protection afforded to the these foods which results when concentrated starch and sugar
leg veins both by their valves and by their occlusion when are consumed. In these circumstances, he argues, the pancreas
squatting.3 0 is inevitably overloaded, with consequent pathological changes
in some people. This could explain why the incidence of diabetes
rises with the years during which the pancreas is subjected to
this unnatural strain.
Obesity is primarily a disease of modem Westem man and
Hiatus Hernia and Faecal Arrest is rare, particularly in rural situations, in developing countries.
The close epidemiological relationship between hiatus hernia It is the commonest form of malnutrition in the West and known
and a low-residue diet could well be accounted for by the raised to be associated with many of the diseases referred to here.
intra-abdominal pressures consequent on such a diet. Con-
strictive clothing and adiposity have been considered to be
causes of increased intra-abdominal pressures contributing to Conclusion
hiatus hernia, but these must cause insignificant pressure change
compared with straining at stool. The close association geographically, chronologically, and in
individual patients between many diseases characteristic of
modem Western civilization could be explained on the basis of
a deficiency of undigested fibre, in particular cereal fibre, in food.
This supposition is a modification of the original hypothesis of
Diseases associated with Cholesterol Metabolism Cleave, whose work was the main stimiulus which initiated the
studies and considerations outlined above. His emphasis is
CORONARY HEART DISEASE
placed on the potential dangers of excess sugar consumption,
The geographical distribution of ischaemic heart disease is very whereas the complementary result of carbohydrate refining-
similar to that of diverticular disease. The former has been fibre depletion-has been emphasized here. I endorse Sir
observed often without the latter, but not the reverse. Once Richard Doll's assessment of this work in his foreword to
again a common causative factor linking not only these diseases Diabetes, Coronary Thrombosis and the Saccharine Disease by
but also other diseases of economic development must be sought. Cleave et al.32 Referring to the possibility that the predictions
Trowell,72 73 who drew attention to the close geographical made may be proved correct, he affirmed that "If only a small
relationship between intake of dietary fibre, serum cholesterol, part of them do, the authors will have made a bigger contribu-
and ischaemic heart disease, reinterpreted certain dietary experi- tion to medicine than most university departments or medical
ments planned for different purposes to show that serum research units make in the course of a generation."
cholesterol levels rose or fell while diminishing or increasing the It is, of course, not suggested that in any of the diseases dis-
amount of fibre consumed. Communities such as the Masai in cussed fibre deficiency is a sole causative factor, merely that it
East Africa, who adapted to a low fibre diet from time im- may be one important factor. The associations between these
memorial, are exceptions. These people metabolize their choles- diseases may be more or less close according to the part played
terol differently.74 The mechanisms whereby dietary fibre in- by lack of fibre in the aetiology of each. Any hypothesis postu-
fluences serum cholesterol levels are open to question, but there lated to explain these diseases will be inadequate unless it
is evidence that more bile acids are excreted in the large stools accounts for (a) their geographical distribution, (b) their chrono-
characteristic of an unrefined diet.75 Reabsorption of bile acids logical emergence, and (c) their interrelationship.
is thus reduced. Moreover, it seems likely that absorption of If these observations can be further substantiated it may not
ingested cholesterol is reduced in the presence of a high fibre be an exaggeration to predict that a return to a high-residue diet
content in the faeces.76 could have an effect on the health of Western nations as bene-
It is, of course, admitted that many other factors almost cer- ficial as would be the elimination of cigarette smoking.
tainly contribute to the development of ischaemic heart disease.
It is merely suggested that a fibre-depleted diet may be an I wish to express my gratitude to Miss Ella Wright for her
important factor which has been overlooked. help in preparing the text and to the many doctors in mission
and other rural hospitals in Africa and elsewhere whose co-oper-
ation in epidemiological studies has been invaluable.

GALL-BLADDER DISEASE
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Contemporary Themes
Role of the School Eye Clinic in Modern Ophthalmology
R. M. INGRAM

British Medical Journal, 1973, 1, 278-280 also fit in with a unified health service administration
structure and be better placed to indicate, evaluate, and
Summary control future developments towards the prevention of
amblyopia.
Routine sight tests for children at intervals throughout
their school career are clearly important; three-quarters
of those referred to the school eye clinics in this area had Introduction
some ocular defect. It is probably no longer necessary for
myopic schoolchildren to be treated by a consultant School eye clinics are an integral part of the medical services
ophthalmologist after their initial examination. provided for schoolchildren and yet the way they are run has
Forty-five per cent. of children referred to the school hardly changed since their inception in 1910. The role of these
eye clinics in this area were found to have squint and/or clinics in the overall picture of the ophthalmic services probably
hypermetropic/anisometropic/astigmatic refractive er- varies from area to area.
rors. Priority should be given to this group because of the The high birth rates in Northamptonshire draw attention to
association of amblyopia with these conditions. Their the medical problems of children, putting pressures on the re-
treatment requires closer association with the hospital sources (not least in manpower) available to deal with them.
ophthalmic department, perhaps even complete unity. In the new town of Corby, as in other new towns, a high pro-
Transfer of children at present seen in the school eye portion of the population is in the preschool and school age
clinic to a hospital-based "children's eye clinic" would groups. This is reflected in the patients seen in the hospital and
local authority ophthalmic clinics where problems of refractive
errors, squint, and amblyopia predominate. It became neces-
Kettering General and Northampton General Hospitals sary to review the organization of the school eye clinic to decide
R. M. INGRAM, M.A., D.M., Consultant Ophthalmic Surgeon on priorities. This gave a chance to review the place of this