Obesity is reaching alarming proportions in South Africa, experts write, warning that apart from the potential health risks – heart disease, cancer, stroke, diabetes and metabolic dysfunction-associated steatotic liver disease, among others – the economic burden is significant.
In the first clinical practice guideline for treatment of adult obesity in South Africa, published this month in a Special Issue of the SA Medical Journal (SAMJ), was welcomed as a valuable tool in managing obesity in the country.
An adaptation of the comprehensive document produced by Obesity Canada, and which has also been adapted for use in several countries, the guideline has been customised to respond to South Africa’s local context and needs, writes Professor Ames Dhai, Acting Editor-in-Chief of SA Medical Journal.
Obesity epidemiology
In this chapter, J H Goedecke, J Hellig, M Conradie-Smit, W May, and A Cois write that management of obesity requires a collective co-ordinated effort across policy, healthcare systems and communities, and at an individual level.
Additionally, renewed focus should be directed to the implications of bias and stigma, which have potential and serious implications for people with obesity.
There is a need for continued and focused investment in research funding to support the scientific understanding of obesity, including non-experimental research on the biopsychosocial and environmental causes of and contributors to the condition, as well as experimental research to develop and test interventions to prevent obesity, and manage and and treat it.
Research on how best to implement evidence-based practice and policy is a priority.
Health-related quality of life is significantly lower for obese people than with the general population because of impaired mental health, increased depression and anxiety, greater pain and discomfort, and reduced mobility.
They also experience pervasive weight bias, stigma and discrimination that further affects their well-being and leads to health and social inequalities.
The increasing prevalence of the condition in SA is largely driven by obesity in women, among whom the prevalence increased from 29.5% in 1998 to 42.6% in 2017 (44% increase). This far exceeds that for men, among whom the prevalence increased from 10.1% in 1998 to 12.1% in 2017 (20% increase).
More recent data from the SA National Food and Nutrition Security Survey conducted in 2021 indicated that the overall obesity prevalence was 32.1%, with a higher prevalence in women than men (41.3% v 15.3%).
Among women, it decreased by 7% between 1998 and 2017, while Class 1 obesity increased by 30%, Class 2 by 46% and Class 3 by 95%, with as many as 3.34m women having severe obesity (BMI ≥35 kg/m2) in 2017.
Among men, the prevalence of overweight over the same 20-year period remained stable at 22%, while Class 1 obesity increased by 9.6%, Class 2 by 45% and Class 3 by 50%, with 770 000 men having severe obesity in 2017.
Although most South Africans diagnosed with obesity in 2017 were classified as having Class 1 obesity (21% of women and 8.0% of men), with fewer living with Class 2 (12.3% of women and 2.9% of men) and Class 3 (9.0% of women and 1.2% of men) obesity, the higher rate of increase in extreme obesity is a major concern, as it is associated with a much higher risk of ill health and premature mortality than Class 1 obesity.
Among women in 1998, the prevalence was highest in black African females (30.6%), followed by coloured (27.1%), white (26.2%) and Asian (21.4%) women. However, between 1998 and 2017, the rate of increase in obesity prevalence was highest in Asian women (76.7%), followed by white (66%), coloured (53%) and black African (40%) women.
Accordingly, the prevalence of obesity in 2017 did not differ markedly by ethnicity, with 42.8% of black African, 41.5% of coloured, 43.5% of white and 37.6% of Asian women being obese.
Recommendations
Healthcare providers should recognise and treat obesity as a chronic disease, caused by abnormal or excess body fat accumulation (adiposity) that impairs health, with increased risk of premature morbidity and mortality (Level 2b, Grade B), suggested the authors.
The development of evidence-informed strategies at the health system and policy level should be directed at managing obesity in adults (Level 2b, Grade B).
Continued longitudinal national and regional surveillance of obesity that includes self-reported and measured data (i.e, heights, weights, waist circumferences) should also be conducted regularly (Level 2b, Grade B).
Obesity varies by geographical region, and among women in 2017, those in the more urbanised provinces (Free State, KwaZulu-Natal, Western Cape, Eastern Cape, Gauteng and North West) had the highest rates of obesity (more than 40%), compared with 33%-38% in Limpopo, Mpumalanga and Northern Cape.
Among men in 2017, the pattern was similar, with the highest prevalence in Western Cape (16.5%), followed by Free State (15.1%), and the lowest in Limpopo (9.4%).
While the discrepancy between provinces is reflected by the differences between urban and non-urban areas, these differences are more pronounced in men than women.
In 2017, the prevalence was 13.8% in urban men compared with 8.2% in non-urban men, representing a 68% difference. Among women, there was only a 12% difference between urban (44.4%) and non-urban (39.5%) women.
Consequences
Obesity increases the risk of developing a number of complications, increasing the risk of developing cardiovascular disease and cancer, two primary causes of premature mortality in SA, resulting in a reduction of life expectancy of six to 14 years.
The second South African Comparative Risk Assessment Study estimated that in 2012, more than 58 000 deaths (or 11.1% of the total number of deaths among people aged 20 and older), and 1 400 000 disability-adjusted life years (6.9% of the total burden) were attributable to a raised BMI.
Analysis revealed that 68% of deaths due to type 2 diabetes, 65% of deaths due to hypertensive heart disease, 43% due to haemorrhagic stroke and 26% of deaths due to ischaemic stroke; 30% of deaths due to ischaemic heart disease, 63% of deaths due to endometrial cancer, 25% due to kidney cancer, 32% due to oesophageal cancer and 10% were due to breast cancer, were all attributable to a raised BMI.
Weight-related stigma is highly prevalent and occurs at home, work, healthcare facilities and educational institutions, and in the media. Negative societal attitudes, stigma and prejudice towards obese individuals contribute to the large mental health burden observed.
This bias negatively affects their health through increased anxiety and depression, employment inequities, avoidance of healthcare professionals, and inequitable treatment received in the healthcare system. It is likely that bias also contributes to the increased risk of mortality observed in individuals with obesity.
Discrepancies
Differences in dietary habits are considered one of the main reasons for obesity discrepancies between urban and rural populations, leading to the term ‘nutrition transition’ to describe dietary shifts accompanying urbanisation.
This is associated with the intake of diets high in energy, fats and sugars but low in fibre, fruits and vegetables.
Notably, urbanisation also affects food accessibility.
Conversely, food insecurity leads to poor diet quality and limited food variety. Importantly, the intake of sugar-sweetened beverages (SSBs) has also been associated with weight gain in South Africans from low-income settings.
Another significant driver of obesity in both urban and rural SA communities is the decline in physical activity and the adoption of more sedentary lifestyles.
Weight bias, stigma
Weight bias and stigma are pervasive in our society, said the authors. It has been documented among parents and families, pre-adolescents and adolescent peers, teachers, employers and human resource professionals as well as healthcare professionals, and even among obese people themselves.
However, this can have several physical, psychological and psychosocial consequences, and has been associated with an increased risk for morbidity.
Chronic stress conditions experienced by people from stigmatised groups have a significant impact on mental health.
Alarmingly, and counter-intuitively, given that healthcare settings are designed to be health supportive, empirical studies over a 40-year period show that obese people experience weight stigma and discrimination from an array of healthcare professionals.
It has been reported that 69% of doctors, 46% of nurses and 37% of dieticians report biased attitudes towards obese people.
These negative attitudes are even reported by those specialising in obesity management, who have been reported as describing them as lazy, stupid, non-compliant, lacking willpower and undisciplined.
Implicit weight bias among healthcare providers can have an impact on the level of support, care and empathy these obese people receive. Evidence indicates that physicians spend less time in appointments, provide less education about health, and have less respect for those with a higher body weight, and report that caring for them is a greater waste of time compared with thinner people.
Acknowledgement of the detrimental effects of weight stigma in healthcare access and care provision is therefore key to understanding the impact of weight stigma on public health. In addition, there is a need for research that understands the role and impact of stigma in public health settings outside healthcare, reasons for the ambiguity identified among medical professionals, and whether it can be improved through improved education and professional guidelines.
Key to reducing weight bias, stigma and discrimination in healthcare settings is for the professionals themselves to be aware of their own attitudes and behaviours towards people with obesity.
Internalised weight bias is an important consideration for weight bias reduction strategies in healthcare.
For example, those with higher internalised weight bias report less weight loss, lower physical activity levels, higher caloric intake, greater disordered eating behaviours, and even greater cardiometabolic risk.
There is, therefore, a need for more research to better understand, and more effectively assess and reduce, internalised this bias
This is perhaps because behaviour change interventions may not be maximising their potential benefits by ignoring internalised weight bias. Health professionals are advised to address internalised weight bias within any obesity management strategy (i.e, self-compassion as a resource, inducing empathy and influencing controllability attributions, and careful and considered use of language and terminology).
More research also is vital to understand the prevalence and impact of weight bias, stigma and discrimination on care for obese people in South Africa.
There is a need for more research, beyond convenience or treatment-seeking groups, towards replication with more generalisable populations. The development and testing of novel interventions is also needed to reduce weight bias, or its impact on behaviour, in medical trainees, practising physicians, other health professionals, and other health staff.
This is a global phenomenon that needs urgent and aggressive intervention.
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The science of obesity
W May, JH Goeodeke and M Conradie-Smit write that the genetic and epigenetic variability among individuals influences how they self-regulate food and explains why not all people exposed to obesogenic factors develop obesity. Many genes have been linked to its development and more than 140 genetic regions are now known to influence obesity traits.
The regulation of appetite, body weight and energy balance is highly complex, governed by a network of hormonal signals from the gut, adipose tissue and other organs, as well as neural signals that shape eating behaviours. Many of these signalling pathways are disrupted in obese people.
Since body weight is homeostatically regulated, weight loss triggers physiological adaptations that promote weight regain. These include a decrease in energy expenditure, and hormonal changes that enhance appetite while reducing satiety.
Adipose tissue, they wrote, influences the central regulation of energy homeostasis, and excess adiposity can become dysfunctional, with production of pro-inflammatory cytokines and associated metabolic health complications.
Individual variations in body composition, fat distribution and function result in a highly variable threshold at which excess adiposity begins to negatively affect health.
They add that the brain probably plays the most important role in obese people and energy balance. A simple approach to understanding the neurobiology of these individuals may be to divide the brain into three main areas that regulate weight: the hypothalamus, the mesolimbic area, and the frontal lobe. Understanding the regulation of each area and the importance of the connections between these areas creates a greater understanding of obesity.
Prevention and harm reduction of obesity (clinical prevention)
Z Bayat, J Lubbe, M Conradie-Smit and W May recommend obesity prevention take place in settings that access whole populations or high-risk groups, and that primary care clinicians initiate discussion around weight gain early and contemplate interventions that consider its complex causes, providing guidance beyond ‘eat less and move more’.
Many medications are associated with side effects that can contribute to long-term weight gain, and the risks and benefits of these should be weighed up for each person before prescribing.
Excess pregnancy weight gain and post-pregnancy weight retention are significantly reduced with behavioural interventions, and clinicians should counsel women attending prenatal care not to exceed weight gain guidelines.
Health benefits of smoking cessation outweigh the cardiovascular consequences associated with smoking cessation-related weight gain, and short-term behavioural interventions (generally six months or less) aimed at preventing weight gain during young adulthood, menopause, smoking cessation and breast cancer treatment, have not yet been shown to be effective.
Longer-term interventions may be needed to properly examine strategies for preventing weight gain for many of these high-risk groups and in the general population.
Enabling participation in activities of daily living for obese patients
Asking patients about their performance in daily activities – personal care, mobility and interactions with the built and social environment – provides valuable information about facilitators of and barriers to engagement in daily activities, including treatment recommendations, and can help healthcare providers to tailor interventions for obesity treatment and management, write M Conradie-Smit, SA Bhana and W May.
Places and spaces where healthcare service delivery takes place can be made physically accessible, to these patients so they can access the services, including assessment and treatment.
Consideration of the accessible features surrounding the clinic space, including access to parking, public transport and door widths to accommodate mobility equipment, is also vital.
The authors suggest appropriate equipment be available with recognition of structural dimensions, composition and safe working load. Attendance can be affected by these challenges, and consideration should be given with regard to rescheduling or an alternative virtual appointment.
Assessment of people with obesity
A Murphy, P N Diab, J H Goedecke, M Conradie-Smit and W May write that screening for obesity should be performed regularly by measuring the BMI and waist circumference. The clinical assessment should aim to establish the diagnosis and identify the causes and consequences of abnormal or excess adiposity on a patient’s physical, mental and functional health.
A non-judgmental, stigma-free environment is crucial, and they suggest healthcare providers use the ‘5As’ framework to initiate the discussion by asking for the patient’s permission and assessing their readiness to initiate treatment.
A comprehensive history is necessary to identify root causes of weight gain as well as complications of obesity and potential barriers to treatment – and should be included in the assessment.
Initial screening involves anthropometric measures: BMI, a widely used but imperfect indicator of body fat, and WC, a better predictor of visceral fat and cardiometabolic risk.
Ethnic-specific cut-offs are crucial, especially in black African and Asian populations. A comprehensive assessment should also include a physical and mental health history, lifestyle factors and laboratory tests.
The role of mental health in obesity management
Healthcare providers need to be aware of the links between mental health and obesity, and ensure they manage weight-promoting medications used in the treatment of psychiatric conditions. Mental health can affect obesity management efforts, so they should screen obese patients for potential mental illnesses that need to be addressed (with a focus on depression, binge-eating disorder (BED) and attention deficit hyperactivity disorder).
K Mawson, E J Barnard, J Lubbe, M Conradie-Smit and W May write that off-label use of antipsychotics should be avoided, as significant metabolic adverse effects can occur even when these are prescribed at lower doses.
When initiating antipsychotic treatment for the first time, avoid medications with higher metabolic risk, as individuals in their first episode respond well regardless of which medication is prescribed (and are at greatest risk for weight gain).
For patients with severe mental illness who gain weight on antipsychotic treatments, metformin can be used in conjunction with behavioural obesity management interventions. For patients with severe mental illness who gain weight on antipsychotic treatments, glucagon-like peptide-1 (GLP-1) receptor agonists have the most safety and efficacy evidence among medications indicated for chronic obesity management.
For people with obesity and BED, evidence suggests that lisdexamfetamine, topiramate and second-generation antidepressants (duloxetine and bupropion) may be effective.
However, all are off-label pharmacological interventions in South Africa, and while effective in reducing eating, their effect on weight loss is less certain.
Referral for more intense and behavioural interventions – like cognitive behavioural therapy (CBT) – should be considered for those with significant binge-eating and depressive symptoms
Patients undergoing metabolic and bariatric surgery (MBS) should undergo a pre-surgical mental health screen by a qualified MBS clinician with experience in mental health to identify early risk factors for poor weight loss outcomes or mental health deterioration, and comorbidities. An active psychiatric disorder does not exclude patients from MBS, but warrants further assessment of potential impact on long-term weight loss.
Medical nutrition therapy in obesity management
V R Fourie, M Conradie-Smit and W May write that there is no one-size-fits-all eating pattern for management of obese patients but doctors may consider various nutrition intervention options that are client centred and flexible.
Evidence suggests this approach will better facilitate long-term adherence. Nutrition interventions should focus on achieving health outcomes for chronic disease risk reduction and improvements in quality of life, not just weight changes, and where significant changes in caloric intake are required, this must be medically supported in conjunction with nutritional interventions.
Physical activity in obesity management
Physical activity has a range of health benefits across all body mass index categories, even in the absence of weight loss, write M Conradie-Smit, V R Fourie and W May, who suggest that aerobic and resistance exercise can favour the maintenance of, or improvements in, cardiorespiratory fitness, mobility, strength and muscle mass during obesity management interventions.
This can be important, as these outcomes are not targeted and are sometimes negatively affected by other therapies, like caloric restriction, medications, and metabolic and bariatric surgery.
Weight stigma is linked to reduced engagement in physical activity, and healthcare providers should provide non-judgemental support for this as a health-promoting behaviour, regardless of body size or complexity of disease.
It’s also important for preserving lean tissue and reducing metabolic effects of higher levels of fat mass in older adults (higher levels of fat tissue and lower levels of lean tissue).
Obese adults should incorporate exercise as an integral component of all obesity management strategies, as it offers a range of health benefits that are partly independent of weight loss.
Psychological and behavioural interventions in obesity management
Behavioural change interventions should be an integral component of all obesity management programmes. To be effective, J Bantjes, C Arendse, M Conradie-Smit, W May and K Mawson write that these programmes need to be informed by theory, delivered by skilled practitioners, and include multi-component strategies and techniques.
“Evidence supports cognitive and behavioural interventions focused on enhancing cognitive control through cognitive skills training like problem solving, self-monitoring, goal setting and activity scheduling,” they write.
Psychoeducational interventions that help these patients deepen their understanding of the biological and psychological processes underlying obesity are also helpful, particularly if they alleviate feelings of shame and guilt while promoting self-insight and enhancing self-efficacy.
Interventions grounded in motivational theories, including biological theories about the brain’s reward system, can also help patients understand and regulate food cravings and curb unhealthy eating.
Pharmacotherapy for obesity management
Pharmacological treatments are an effective and scalable approach to treating obese patients and an important pillar in the management of the condition.
The focus of obesity management should be the improvement of health parameters (metabolic, mechanical, mental, and/or quality of life), not solely weight reduction, and should include outcomes that patients identify as important.
There are four medications indicated for long-term management of obese patients in South Africa as adjuncts to health behaviour changes: liraglutide (Saxenda), naltrexone/bupropion (Contrave) in a combination tablet, orlistat (Xenical) and semaglutide (Wegovy).
All four are effective in producing clinically significant weight loss and health benefits greater than placebo over at least one year.
Obesity medications are intended as part of a long-term treatment strategy. Clinical trials of these consistently demonstrate regain of weight when treatment is stopped.
Medications that are not approved as pharmacotherapy for obesity management should not be used for this purpose.
Metabolic and bariatric surgery: Selection and preoperative work-up
Criteria for selecting appropriate candidates for metabolic and bariatric surgery (MBS) have been established to minimise surgical complications and to maximise the benefit, write J G M Smit, J Lubbe, A Murphy, K Mawson, M Z Koto, M Conradie-Smit and W May, and preoperative work-up should evaluate a person’s medical, nutritional, mental and functional health status.
Special attention should be given to the care of patients with type 2 diabetes (T2DM) who are considering MBS, to minimise complications from uncontrolled diabetes in the perioperative period.
Limited high-quality evidence has reviewed preoperative malnutrition status in obese patients seeking MBS, but nonetheless, observational studies have indicated they have a higher risk for inadequate nutritional status and malnutrition.
Preoperative evaluation and collaborative support from a registered dietician are recommended for all obese patients considering MBS.
MBS is a life-altering and effective obesity management intervention. Several considerations are necessary to prepare a person for the surgery, and their medical, mental, nutritional and functional health should all be carefully evaluated beforehand.
Metabolic and bariatric surgery: Postoperative management
J Skelton, A Murphy, M Conradie-Smit and W May write that adherence to consistent postoperative behavioural changes (behaviour modification for nutrition plans, physical activity and vitamin intake) can optimise management and health of people with obesity who have had metabolic and bariatric surgery (MBS), while minimising postoperative complications.
Working in partnership, the MBS centre, the local bariatric medicine specialist, the primary healthcare provider (HCP) and the patient need to establish and commit to a shared care model of chronic disease management for long-term follow-up.
Complications can occur, but many gastrointestinal (dumping syndrome) and metabolic complications (e.g. bone, kidney stones) can be prevented by following the recommended post-MBS nutrition plan and vitamin intake.
Additionally, although MBS is one of the most effective treatment options, medical practitioners should be aware of the potential post-MBS psychological issues that may arise, including depression, suicide, body image disorder, eating disorders and substance and alcohol abuse.
Primary care and primary healthcare in obesity management
In a recent series in The Lancet, Dietz et al highlighted that the management of people with obesity is not ideal in current health systems. They cited concerns in several areas: training of the healthcare workforce, unfounded assumptions of the patients, lack of experience working in interdisciplinary teams, and lack of training in behaviour change strategies.
There is a tremendous gap between evidence-based recommendations and current clinical practice. International data have demonstrated this gap, identifying issues such as both primary healthcare providers and the patients being reluctant to initiate a conversation about weight.
Primary care interventions should be used to increase health literacy in individuals’ knowledge about and skills in weight management, write P N Diab, Z Dire, J Hellig, M Conradie-Smit and W May.
The healthcare providers should refer patients to primary care multi-component programmes with personalised obesity management strategies as an effective way to support obesity management, and also use collaborative deliberation with motivational interviewing to tailor action plans to individuals’ life context in a way that is manageable and sustainable to support improved physical and emotional health, and weight management.
Interventions that target a specific ethnic group should consider the diversity of psychological and social practices with regard to excess weight, food and physical activity as well as socioeconomic circumstances, as they may differ across and within different ethnic groups.
Interventions that use technology to increase reach to larger numbers of people asynchronously should be a potentially viable lower-cost method in a community-based setting.
Sustainable care of these patients in SA must be anchored in system-level changes that prioritise health-focused, multi-component approaches over simplistic weight-centric models.
Improving training, creating accessible referral pathways, addressing social determinants of health, and challenging weight bias are essential to building trust and improving outcomes.
Implementation of these strategies requires investment in primary healthcare systems, workforce development, and research that bridges the gap between evidence and practice.
Emerging technologies and virtual medicine in obesity management
Strategies to manage obesity can be delivered through web-based platforms (e.g. online education on medical nutrition therapy and physical activity) or mobile devices (e.g. daily weight reporting through a smartphone phone application), and F H Van Zyl, M Noeth, P N Diab, M Conradie-Smit and W May recommend that healthcare providers incorporate individualised feedback and follow-up (e.g, personalised coaching or feedback via phone or email) into technology-based management strategies to improve weight loss outcomes.
General data-protection regulations and additional relevant local and institutional processes and legislation relating to cybersecurity and the protection of patient data should be central to any inclusion of technology in healthcare.
They warned that healthcare providers should always consider protection of personal information legislation as regulated by local authorities (in SA, the Protection of Personal Information Act [POPIA], Act No. 4 of 2013).
W May – Cape Town Bariatric Clinic, Life Kingsbury Hospital, Cape Town, South Africa
J H Goedecke – Biomedical Research and Innovation Platform, South African Medical Research Council, Cape Town
M Conradie-Smit – Division of Endocrinology, Department of Medicine, Stellenbosch University and Tygerberg Academic Hospital, Cape Town
Z Bayat – Division of Endocrinology, Department of Internal Medicine, Helen Joseph Tertiary Hospital and University of the Witwatersrand, Johannesburg
J Lubbe – Division of Surgery, Department of Surgical Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town
S A Bhana – Centre of Advanced Medicine, Waverley, Johannesburg; Chris Hani Baragwanath Academic Hospital and University of the Witwatersrand
A Murphy – Sunward Park Medical Centre, Boksburg
P N Diab – Atrium Diabetes Centre, Gillitts, KwaZulu-Natal; Department of Family Medicine, University of Pretoria
K Mawson – Department of Psychiatry, Stellenbosch University and Tygerberg Academic Hospital, Cape Town
E J Barnard – M-Care Optima Psychiatric Hospital and Bloemcare Psychiatric Hospital, Bloemfontein
V R Fourie – Cape Town Bariatric Clinic, Life Kingsbury Hospital, Cape Town
J Bantjes – Mental Health, Alcohol, Substance Use and Tobacco Research Unit, South African Medical Research Council, Cape Town; Department of Psychiatry and Mental Health, University of Cape Town; Institute for Life Course Health Research, Department of Global Health, Stellenbosch University
C Arendse – Department of Psychiatry, Stellenbosch University; Department of Psychology, Tygerberg Academic Hospital, Cape Town
M Noeth – Zuid-Afrikaans Hospital, Pretoria; Department of Internal Medicine, University of Pretoria
F H Van Zyl – Private Practice and Clinical Projects Research Trial Centre, Worcester; Mediclinic Worcester Hospital
J Hellig – Cape Town Bariatric Clinic, Life Kingsbury Hospital, Cape Town
J Skelton – Busamed Gateway Private Hospital, Umhlanga
A MurphySunward Park Medical Centre, Boksburg, South Africa
Z Dire – Division of Endocrinology, Department of Internal Medicine, Chris Hani Baragwanath Academic Hospital and University of the Witwatersrand
SA Medical Journal – Obesity Guideline (Creative Commons Licence)
SA Medical Journal article – Epidemiology of adult obesity (Creative Commons Licence)
Prevention and harm reduction of obesity (clinical prevention)
Enabling participation in activities in daily living for people with obesity
Assessment of people living with obesity
Medical nutrition therapy in obesity management
Physical activity in obesity management
Effective psychological and behavioural interventions in obesity management
Pharmacotherapy for obesity management
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