Stigma, inaction and cost — will South Africa treat obesity with lessons learnt from HIV?

By Nomathemba Chandiwana and Francois Venter

4 Mar 2024

About two-thirds of women and almost a third of men in South Africa are overweight or have obesity. It’s a new public health threat, which, if not acted on now, will have serious consequences for the well-being of the country. But rather than making it a game of blame and shame, there are two things that can be done right now.

South Africa should wake up. The country is facing a new public health threat – and as with the HIV epidemic of the late 1990s, apathy will be our downfall.

About two-thirds of women and almost a third of men in South Africa are overweight or have obesity, and with excess weight closely linked to developing a long-lasting health problem such as type 2 diabetes, high blood pressure, certain cancers, liver and kidney disease, mental illness or a sleep disorder, it’s a killer that’s silently creeping up on us. In fact, diabetes already causes the second-most deaths after tuberculosis – and has been in this spot for almost a decade.

According to the World Health Organization, being overweight or obese means someone carries too much fat around their bodies, to such a degree that it’s dangerous for their health. At the moment, body mass index (BMI) – the ratio between weight and height – is the most commonly used measure to check if you have a healthy body weight.

To get your BMI, divide your weight (in kilograms) by your height (in metres) squared. For instance, if you weigh 74kg and your height is 1.63m, your BMI will be 28. A number above 25 signals overweight, and anything from 30 up means someone is obese.

But BMI is actually a poor measure of whether the fat someone carries around is unhealthy, since it doesn’t show whether it’s fat or muscle that’s adding the weight, whether the kind of fat is unhealthy or sits in places that are bad for your health (such as around the waist), and also doesn’t take into account the level of physical activity, diet, genetic factors or underlying health issues, leading to many people being either missed as having obesity or mistakenly being diagnosed as such. Moreover, the BMI-linked cut-off values for obesity don’t apply equally well to people from different race groups.

Even when not blaming, many health promoters focus only on how to prevent obesity, ignoring that effective treatment is available.

Moreover, health practitioners still have a fairly patchy understanding of how weight gain actually works in our bodies, where hormones come in and how diet and exercise feed into the problem, which means many doctors and health workers are stuck on telling people to simply “eat less and move more” – even when science tells us that for many people who have obesity this won’t help much for weight loss (although it’s important for general health and well-being).

All of this makes obesity a game of blame and shame: Being fat is your own fault and best you carry the guilt along with those extra kilograms. Even when not blaming, many health promoters focus only on how to prevent obesity, ignoring that effective treatment is available.

It’s not different from what the early days of responding to a patient’s HIV diagnosis was. Becoming infected with HIV was an individual moral failure, with an initial focus on prevention alone and very little on medicines for treating the infection as they became available. Denial and inaction ultimately cost hundreds of thousands of people their lives unnecessarily.

Here are two things South Africa can do to halt the emerging crisis of obesity – now.

Trust the science, then make the meds cheaper

Research is starting to show a clearer picture of what turns obesity into a disease and what drives its occurrence in a population. Moreover, scientists are getting a better grip on how the way we live plays into what people eat.

Current thinking around getting people with obesity to lose weight – and keeping it off – is that it’s near impossible without adding medicine or surgery into the treatment mix – and it’s unthinkable to ignore this new arsenal of medical tools.

New types of medicines, such as semaglutide or liraglutide, mimic a naturally occurring hormone in your gut that helps to control blood sugar levels, slows down how quickly your stomach empties into the small intestine and tells your brain that you’ve eaten enough. Because you feel full faster and for longer, you eat less.

Discomfort with ‘medicalising a social problem’ has similarly started to creep into talking about obesity and how it should be dealt with.

But these are currently inexcusably expensive (up to R6,000 per month in South Africa), with semaglutide registered only for treating type 2 diabetes in South Africa and unavailable from state clinics and most medical aids – not unlike the with HIV treatment in the form of antiretrovirals (ARVs) 20 years ago.

However, exactly because of South Africa’s ARV lessons, the country is uniquely placed to push for focused public health approaches that will scale the supply of these medicines to the millions worldwide who need them, including making it simpler for patients to get these medicines prescribed and putting pressure on pharma companies to allow generic versions of the drugs to be made so that bigger volumes can bring down prices.

Fix the food system

Medicines alone won’t fix South Africa’s obesity crisis – it needs to be part of a lifestyle that supports healthy eating and more physical activity. But inequalities in access to affordable, healthy food and safe places to exercise, particularly in poorer communities, make this difficult. While the benefits of addressing structural issues like these may seem obvious, it won’t be easy and nowhere in the world has a government been able to reverse its obesity epidemic.

Focusing on giving people access to enough unprocessed food (especially fresh fruit and vegetables) and having the means to prepare it, together with making people aware of why it’s unhealthy to eat heavily processed and fatty, sugary or overly starchy foods (such as pap, slap chips and lots of bread) often, would solve many health problems.

But it is unlikely that this will be possible without the government putting strict regulations in place, as processed (packaged) foods and fast foods have become more easily accessible and affordable. Big, well-resourced industries such as those making sugary drinks and selling fast food don’t want regulations, and are already using tactics straight out of Big Tobacco’s playbook, to oppose steps around regulating sugary drinks and promoting food labelling. Yet there has been little sign of urgency on the part of the government to take up the issue of food quality and affordability, and some of these industries are doing their lobbying behind closed doors, as in other countries.

Debates on whether to allocate money, time and personnel to preventing or treating obesity remind us of the early days of grappling with the HIV epidemic. Many prevention advocates regarded people with HIV as sad casualties of failed prevention programmes, too expensive and complex to treat. Discomfort with “medicalising a social problem” – meaning that social issues are recognised as having caused a health problem but that medical solutions either distract from or undermine prevention efforts – has similarly started to creep into talking about obesity and how it should be dealt with, sometimes with a moral touch of “they brought it on themselves” added into the conversation.

Allowing this language to persist would be a dreadful mistake. To destigmatise obesity, and really get somewhere in combating the unfolding epidemic, we will have to combine all the prevention and treatment strategies we have.

The activist and medical communities were critical in advocating for getting ARVs and healthcare to people with HIV to afford them healthy, productive lives. We believe we have a moral imperative to advocate just as vigorously for those with obesity.

Our government and health workers alike should shed themselves of industry influence so that suitable policies, regulation and funding will become available not only to give people access to new medical interventions to tackle obesity but also to create an environment that makes healthy food choices and active lifestyles accessible for everyone.

South Africa’s HIV programme – the world’s largest with about six million people on treatment – is often held up as the global model, thanks to decades of health activism, community engagement and science-based policy, along with government resources and commitment. Our emerging obesity epidemic now demands the same. DM

Nomathemba Chandiwana is a research clinician with extensive experience in clinical trials at Ezintsha. Ezintsha is a research and policy unit based at the faculty of health sciences at Wits University.

Francois Venter is the head of Ezintsha. Ezintsha is a research and policy unit based at the faculty of health sciences at Wits University.

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.

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South Africa

Trust the science, then make the meds cheaper

Fix the food system