One in every three adult South Africans is obese, and yet the condition is not treated as a chronic disease in this country – as it should be – write Tanya Pampalone, Anna-Maria van Niekerk and Mia Malan for Bhekisisa.
Concerningly, a recent study about weight-loss medications published in the British Medical Journal found that less than two years after stopping medications like Ozempic, the weight came back.
All health benefits from the drugs – lower blood pressure, improved cholesterol levels, reduced risk of type 2 diabetes and heart disease – disappeared even faster, returning to pre-treatment levels in just 1.4 years.
The Oxford University researchers had looked at 37 studies involving more than 9 300 people, and while they were surprised by how quickly the weight returned, some experts say the drugs are acting just as they would expect – a chronic disease needs chronic treatment.
Obesity is associated with dozens of non-communicable diseases (NCDs), like type 2 diabetes, high blood pressure, kidney disease and some types of cancer, so why is it still not classified as one in South Africa?
Unlike the World Health Organisation, South Africa’s current obesity strategy prioritises prevention, with less emphasis on obesity as a chronic disease. It’s an important point: classifying obesity as a chronic disease could open up healthcare treatment coverage and make it less of a societal stigma, rather than being seen as a personal failing or lack of willpower.
Endocrinologist Angela Murphy, who worked on the first clinical practice guidelines in the country for the treatment of adult obesity (which are not the country’s official guidelines), published in the South African Medical Journal last year, hopes the guidelines might influence the Health Department to rethink its position.
As Murphy told Bhekisisa recently, up to 70% of the reason a person is obese is genetic.
“It’s a biological response to weight loss because the body wants to defend the weight it sees as the normal weight. We also have to have healthy, balanced diets, and we have to have exercise. But the statistics tell us that a healthy lifestyle alone, on average, can possibly get up to 5% weight loss.”
Part of the guidelines she worked on recommend GLP-1s (glucagon-like peptide-1 receptor agonists) like Ozempic, which help lower blood sugar levels, slow digestion and increase the feeling of fullness.
In a recent episode of Bhekisisa’s programme Health Beat, Mia Malan spoke to Nomathemba Chandiwana, chief scientific officer of the Desmond Tutu Health Foundation, about why South Africa needs to shift how it thinks about obesity, what lessons our HIV response can offer, and why access to drugs like GLP-1s in the public health sector could be a game-changer for millions of people.
She said although there was no one solution or magic bullet, drugs, “especially GLP-1s, are an amazing thing in our toolbox, and should be made available”.
MM: Do you have any hopes for those drugs becoming cheaper?
NC: We’ve seen this with HIV, where these drugs were very expensive at the beginning. What happened was sustained advocacy by the civil society, researchers and governments coming to the party. If we use that blueprint for obesity, working with drug producers, we’re going to have generics in the market. Also, there are so many drugs coming that competition naturally reduces prices.
However, we can’t wait. We can’t say all these things will become available in five to 10 years. Obesity is a disease of our time.
By addressing it as a disease, you’re able to reduce the risk of all these other diseases that we don’t have the manpower, the facilities to deal with. Addressing obesity using drugs, but also having an enabling environment around food policies, (unhealthy food) advertising towards children and being able to know what’s in our food, is part of what we can do to make a dent in obesity.
MM: How does obesity look among children?
NC: We’ve got some of the highest obesity rates among children. This results in overweight adults. Childhood obesity is a big concern, because you’re going to see that bulge in 20 to 30 years.
MM: How do we deal with the obesity crisis going forward? Are there lessons we can learn from how we’ve dealt with HIV, where we now have a chronic, but manageable disease?
NC: HIV taught us a lot of lessons about advocacy, about research and about the healthcare system. But one thing about HIV and … obesity is that they’re similar threats to public health.
We saw images that any South African would remember – having to take people in wheelbarrows to hospitals, women having children born with HIV. There was an urgency…which drove a lot of advocacy.
But when it comes to obesity and its complications, which are affecting so many more people, it’s almost silent. We don’t see obesity being the killer that it is in the long term. The heart disease, the type 2 diabetes… that happens decades after people start gaining weight. So we need to use that same urgency we used for HIV.
It’s also addressing stigma. At the beginning of the HIV epidemic, people were so scared to talk about their disease; they were scared to go to the hospital. Doctors and nurses and community members didn’t know how to deal with it. Addressing that stigma opened the doors for many conversations to happen.
We need to do the same for obesity, where we can centre care around health, not body size. It’s not about shaming people … but about helping people with evidence-based ways of dealing with their weight. We know that “move more, eat less” doesn’t actually work for a lot of people. Because obesity is a combination of your genes, of the environment, of your sex, and all these things come together to make this a very complicated disease. So having medication is important, because someone can then come and admit they are obese, and say, ‘can you help me?’
See more from MedicalBrief archives:
First obesity guideline for SA as experts flag growing burden
Rethinking how we look at obesity in South Africa
Rising global obesity presents ‘unparalleled’ health threat – Lancet report
Concern as NCDs rise in young South Africans – Limpopo study
Childhood obesity tied to early, serious health issues – SA study