EDITORIAL

 

Obesity is South Africa's new HIV epidemic

 

 

World Obesity Day is on 4 March 2024, and our nation needs to pay attention. As with the HIV epidemic in the 1990s, we are facing a calamitous threat to the health of the population that has been ignored for too long. Weight-related diseases have eclipsed tuberculosis (TB) and HIV as leading causes of morbidity and mortality. Over two-thirds of South African (SA) women are overweight or are living with obesity.^[1] For example, type 2 diabetes, stroke and heart disease, conditions all directly linked to the disease of obesity, account for three of the top four causes of death nationally and incur massive health system costs.^[2,3] Moreover, excess weight gain has deleterious effects far beyond cardiovascular disease risk, with evidence strongly linking it to poor pregnancy outcomes, cancer, liver and kidney disease, mental illness, and sleep disorders.^[4,5].

As with HIV in the early 2000s, tools to prevent and treat obesity are available, but too often are being ignored or obfuscated through government inaction, industry interests, and societal inertia. Also, as with HIV, SA has waited too long to convert effective interventions into effective public health strategy. Instead, we remain trapped in a cycle of apathy while blaming and stigmatising those affected.

The medical establishment has not always been an ally in combating the obesity health emergency.^[6] A poor understanding of the physiology of the disease, the endocrinological complexity of fat tissue, and the contribution of diet and exercise to weight gain has led healthcare providers to preach the common refrain of 'eat less and move more'. This serves to further perpetuate shame and stigma for those with the disease, even as it is now well understood to be ineffective alone for most of those affected.^[7] Unsuitable weight loss advice contributes to confusion and anxiety for individuals with obesity, and in turn allows a diet, exercise and supplement industrial complex to thrive with minimal regulation.^[8]

But it is not too late for SA to implement an effective response to this established disease crisis. There are two important next steps. First, to apply the lessons from the HIV epidemic to reduce obesity-related stigma and facilitate widespread access to novel anti-obesity therapies using a public health approach; and second, to establish robust advocacy efforts that ensure that structural determinants of the disease, including food supply and the built environment, promote, rather than undermine, health.

Much as combination therapy was a game changer for the HIV response, modern obesity medicine has demonstrated that novel medications and/or surgery are critical elements to achieve sustained weight loss and improved health outcomes.^[9] For example, new classes of medications, such as the glucagon-like peptide (GLP)-1 receptor agonists, effectively control the disease, improve glycaemic control and reduce cardiovascular events, but are currently prohibitively expensive, prone to massive repeated supply shortages, and unavailable from state clinics and most medical aids.^[9,10] SA is uniquely positioned to build upon the success of HIV and TB programmes to change this situation, by including simplification of access alongside generic manufacture at scale to facilitate price reduction. Notably, these interventions do not conflict with lifestyle recommendations, with recent evidence suggesting greater efficacy when these drugs are used in combination with lifestyle changes.

The Standard Treatment Guidelines and Essential Medicines List currently contains no approach to the disease of obesity, and medication and surgical approaches were removed from the 2023 National Obesity Strategy, which barely mentions treatment, apparently owing to cost.^[12]

Obesity science is also teaching us how biomedical interventions are unlikely to be sufficient to tackle this epidemic alone. The obesogenic environment - structural societal conditions including both our food system and our built environment - is an important driver of the rise in obesity levels in the past 40 years in SA and elsewhere.^[13-15] For example, the introduction of ubiquitous, cheap, highly and ultra-processed food and sugar-sweetened beverages, offered in slick venues and spaza shops accompanied by marketing campaigns often aimed at children, alongside a built environment that hinders sufficient physical activity, are major driving forces.^[13,14,16] Focusing on our food supply, facilitating access to a diversity of affordable fresh, healthy, unprocessed food and the means to prepare it, and ensuring that the public is aware of the dangers of highly processed and ultra-processed food, is a necessary step.^[17] It is highly unlikely that these systematic changes will be possible without firm government and regulatory intervention. Profit margins on heavily processed goods are far higher than on their less packaged counterparts, and powerfully resourced industries oppose such action, including opposition to even the most tentative steps around regulating sugary drinks and, more recently, promotion of food labelling.^[12,18-20] One chilling difference from HIV is that the viral vector did not have a massive unregulated marketing machine behind it. Distressingly, there has been little sign of urgency on the part of government to take up the issue of food advertising, quality and affordability, and some of these industries clearly have the ear of senior officials, as in other countries.^[18].

Debates on where to focus resources, programming, and attention on the prevention or treatment of clinical obesity are also reminiscent of the early HIV epidemic. Then, many prevention advocates regarded people with HIV as sad casualties of failed prevention programmes, too expensive and complex to treat. The language 'medicalising a social problem' has similarly started to creep into the discourse about obesity and its management, occasionally with a moral touch of 'they brought it on themselves'.^[7] Allowing this language to persist would be a dreadful mistake. To destigmatise obesity, and effectively combat the obesity epidemic, it will be important to maximise the use of all prevention and treatment strategies simultaneously. The activist and medical communities were critical in advocating for the introduction of antiretroviral drugs and provision of healthcare that allowed individuals with HIV to live healthy, productive lives. We think that we have a moral imperative to advocate just as vigorously for individuals with obesity (Table 1).

It is past time for our government and medical community to develop a laser-like focus on responding to the disease of obesity. Doing this will require policy, legislation, programming, and funding actions that will both facilitate access to innovative medical tools for obesity and deliver these in an environment that promotes healthy food choices and active lifestyles accessible to all. SA's HIV programme 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 established obesity epidemic now demands the same energy, commitment and focus from all of us.

Dr Nomathemba Chandiwana, Ezintsha, Faculty of Health Sciences, University of the Witwatersrand

Prof. W D Francois Venter, Ezintsha, Faculty of Health Sciences, University of the Witwatersrand fventer@ezintsha.org

Dr Jennifer M Manne-Goehler, Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School

Prof. Alisha Wade, Research in Metabolism and Endocrinology, Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand

Prof. Carel W le Roux, Diabetes Complications Research Centre, University College Dublin; Chemical Pathology, University of Pretoria

Nzama Lawrence Mbalati, Communication Sciences, Healthy Living Alliance

Angelika Grimbeek, Community Paediatrics, Healthy Living Alliance

Petronell Kruger, Healthy Living Alliance

Eunice Montsho, Healthy Living Alliance

Zukiswa Zimela, Healthy Living Alliance

Anele Yawa, General Secretary, Treatment Action Campaign

Sibongile Tshabalala, National Chairperson, Treatment Action Campaign

Ndivhuwo Rambau, Project Co-ordinator, Treatment Action Campaign

Ngqabutho Mpofu, Communications and Research Manager, Treatment Action Campaign

Sasha Stevenson, Executive Director, Section 27

Bridget McNulty, Sweet Life Diabetes Community and SA Diabetes Advocacy

Prof. Ntobeko A B Ntusi, Department of Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital; University of Cape Town/SAMRC Extramural Research Unit on Intersection of Noncommunicable Diseases and Infectious Diseases; ARUA/Guild Cluster of Research Excellence on Noncommunicable Diseases and Associated Multimorbidity

Dr Yogan Pillay, Director, HIV & TB Delivery, Bill and Melinda Gates Foundation, Pretoria; Department of Global Health, Stellenbosch University

Prof. Joel A Dave, Division of Endocrinology, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town

Dr Angela Murphy, Sunward Park Medical Centre

Prof. Sue Goldstein, SAMRC/Wits Centre for Health Economics and Decision Science; PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand

Prof. Karen Hofman, SAMRC/Wits Centre for Health Economics and Decision Science; PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand

Dr Sameera Mahomedy, SAMRC/Wits Centre for Health Economics and Decision Science; PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand

Dr Elizabeth Thomas, SAMRC/Wits Centre for Health Economics and Decision Science; PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand

Prof. Busi Mrara, Professor and Head of Anaesthesiology and Critical Care, Walter Sisulu University

Prof. Jeff Wing, Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand

Prof. Jeanne Lubbe, Head, Upper Gastrointestinal Surgery, Tygerberg Hospital and Stellenbosch University; President, South African Metabolic Medicine and Surgery Society

Prof. Zack Koto, Chair, Department of Surgery, Dr George Mukhari Academic Hospital and Sefako Makgatho Health Sciences University; President, College of Surgeons of South Africa; Senior Vice-President, Colleges of Medicine of South Africa, President, Association of Surgeons of South Africa

Dr Marli Conradie-Smit, Head, Division of Endocrinology, Tygerberg Hospital

Prof. Sean Wharton, McMaster University, York University, and Wharton Weight Management Clinic

Dr Wayne May, Cape Town Bariatric Clinic

Dr Ian Marr, Cape Town Bariatric Clinic

Dr Hilton Kaplan, Cape Town Bariatric Clinic

Mariam Forgan, Cape Town Bariatric Clinic

Dr Graham Alexander, Cape Town Bariatric Clinic

Dr J S Turner, Honorary Senior Specialist, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town; Cape Town Bariatric Clinic

V R Fourie, Cape Town Bariatric Clinic

Dr Jocelyn Ann Hellig, Cape Town Bariatric Clinic

Mandy Banks, Cape Town Bariatric Clinic

Dr K E Ragsdale, Cape Town Bariatric Clinic

Dr M Noeth, Zuid Afrikaans Bariatric Clinic

Dr Farzahna Mohamed, Acting Clinical Head of Endocrinology, Charlotte Maxeke Johannesburg Academic Hospital and Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand

Prof. Landon Myer, Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of Cape Town

Dr Limakatso Lebina, Africa Health Research Institute

Prof. Salome Maswime, Global Surgery Division, Faculty of Health Sciences, University of Cape Town

Prof. Yunus Moosa, Southern African HIV Clinicians Society; Department of Infectious Diseases, Nelson R Mandela School of Clinical Medicine, University of KwaZulu-Natal

Dr Teressa Sumy Thomas, Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand

Dr Mzamo Mbelle, Division of Gastroenterology, Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand and Charlotte Maxeke Johannesburg Academic Hospital; Institute of Liver Studies, King's College Hospital

Dr Phumla Sinxadi, Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town

Prof. Linda-Gail Bekker, Desmond Tutu HIV Centre, Faculty of Health Sciences, University of Cape Town

Dr Sindeep Bhana, Honorary lecturer, Chris Hani Baragwanath Academic Hospital and Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand

Prof. June Fabian, Wits Donald Gordon Medical Centre, Faculty of Health Sciences, University of the Witwatersrand

Associate Prof. Eric Decloedt, Head, Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital

Dr Zaheer Bayat, Academic Head of Endocrinology, University of the Witwatersrand; Clinical Head of Medicine, Helen Joseph Hospital

Dr Reyna Daya, Clinical Head of Endocrinology, Helen Joseph Hospital; Chair, Society for Endocrinology, Metabolism and Diabetes of South Africa

Dr Bilal Bobat, Wits Donald Gordon Medical Centre, Faculty of Health Sciences, University of the Witwatersrand

Fiona Storie, Southern African HIV Clinicians Society

Julia H Goedecke, Biomedical Research and Innovation Platform, South African Medical Research Council

Prof. Kathleen Kahn, SAMRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand

Prof. Stephen Tollman, SAMRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand

Dr Brett Mansfield, Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand

Associate Prof. Mark J Siedner, Africa Health Research Institute, Harvard Medical School

Dr Vincent C Marconi, Division of Infectious Diseases and Department of Global Health, Emory University School of Medicine and Rollins School of Public Health

Dr Aaloke Mody, Division of Infectious Diseases, Department of Medicine, and Center for Dissemination and Implementation, Institute for Public Health, Washington University

Dr Ntombifikile Nokwethemba Mtshali, Shout-It-Now

Prof. Elvin Geng, Division of Infectious Diseases, Department of Medicine, and Center for Dissemination and Implementation, Institute for Public Health, Washington University

Dr Suman Srinivasa, Division of Endocrinology, Metabolism Unit, Massachusetts General Hospital and Harvard Medical School

Prof. Mohammed K Ali, Department of Family and Preventive Medicine, School of Medicine, and Hubert Department of Global Health, Rollins School of Public Health, Emory University

Dr Samanta Lalla-Edward, Ezintsha, Faculty of Health Sciences, University of the Witwatersrand

Dr Alison Bentley, Restonic Ezintsha sleep clinic, South African Society for Sleep and Health

Dr Gustaaf Wolvaardt, Foundation for Professional Development

Dr Andrew Hill, Department of Pharmacology and Therapeutics, University of Liverpool

Dr Jeremy Nel, Division of Infectious Diseases, Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand

 

References

1. National Department of Health, Statistics South Africa, South African Medical Research Council, and ICF. South Africa Demographic and Health Survey 2016: Key findings. Pretoria, South Africa, and Rockville, Md, USA: NDoH, Stats SA, SAMRC, and ICF, 2018. https://www.dhsprogram.com/pubs/pdf/SR248/SR248.pdf (accessed 19 February 2024).         [ Links ]

2. Boachie MK, Thsehla E, Immurana M, Kohli-Lynch C, Hofman KJ. Estimating the healthcare cost of overweight and obesity in South Africa. Glob Health Action 2022;15(1):2045092. https://doi.org/10.1080/16549716.2022.2045092        [ Links ]

3. Statistics South Africa. Mortality and causes of death in South Africa: Findings from death notification, 2018. Statistical release P0309.3. Pretoria: Stats SA, 2021. http://www.statssa.gov.za/publications/P03093/P030932018.pdf (accessed 19 February 2024).         [ Links ]

4. Dai H, Alsalhe TA, Chalghaf N, Ricco M, Bragazzi NL, Wu J. The global burden of disease attributable to high body mass index in 195 countries and territories, 1990-2017: An analysis of the Global Burden of Disease Study. PLoS Med 2020;17(7):e1003198. https://doi.org/10.1371/journal.pmed.1003198        [ Links ]

5. Larsson SC, Burgess S. Causal role of high body mass index in multiple chronic diseases: A systematic review and meta-analysis of Mendelian randomisation studies. BMC Med 2021;19(1):320. https://doi.org/10.1186/s12916-021-02188-x        [ Links ]

6. Cummings DE, Rubino F. Obesity: What's in a word? Lancet Diabetes Endocrinol 2021;9(7):408-409. https://doi.org/10.1016/S2213-8587(21)00122-4        [ Links ]

7. Rubino F, Puhl RM, Cummings DE, et al. Joint international consensus statement for ending stigma of obesity. Nat Med 2020;26(4):485-497. https://doi.org/10.1038/s41591-020-0803-x        [ Links ]

8. Batterham RL. Switching the focus from weight to health: Canada's adult obesity practice guideline set a new standard for obesity management. EClinicalMedicine 2020;31:100636. https://doi.org/10.1016/j.eclinm.2020.100636        [ Links ]

9. Perdomo CM, Cohen RV, Sumithran P, Clement K, Fruhbeck G. Contemporary medical, device, and surgical therapies for obesity in adults. Lancet 2023;401(10382):1116-1130. https://doi.org/10.1016/S0140-6736(22)02403-5        [ Links ]

10. Levi J, Wang J, Venter F, Hill A. Estimated minimum prices and lowest available national prices for antiobesity medications: Improving affordability and access to treatment. Obesity (Silver Spring) 2023;31p):1270-1279. https://doi.org/10.1002/oby.23725        [ Links ]

11. Lundgren JR, Janus C, Jensen SBK, et al. Healthy weight loss maintenance with exercise, liraglutide, or both combined. N Engl J Med 2021;384(18):1719-1730. https://doi.org/10.1056/NEJMoa2028198        [ Links ]

12. National Department of Health, South Africa. Strategy for the prevention and management of obesity in South Africa, 2023-2028. Pretoria: NDoH, 2023. https://www.health.gov.za/wp-content/uploads/2023/05/Obesity-Strategy-2023-2028_Final_Approved.pdf (accessed 19 February 2024).         [ Links ]

13. Dicken SJ, Batterham RL. Ultra-processed food: A global problem requiring a global solution. Lancet Diabetes Endocrinol 2022;10(10):691-694. https://doi.org/10.1016/S2213-8587(22)00248-0        [ Links ]

14. Swinburn BA, Sacks G, Hall KD, et al. The global obesity pandemic: Shaped by global drivers and local environments. Lancet 2011;378(9793):804-814. https://doi.org/10.1016/S0140-6736(11)60813-1        [ Links ]

15. Eisenberg MJ, Atallah R, Grandi SM, Windle SB, Berry EM. Legislative approaches to tackling the obesity epidemic. CMAJ 2011;183(13):1496-1500. https://doi.org/10.1503/cmaj.101522        [ Links ]

16. He Z GB, Yaya S, Cheng Z, Zhou Y. Perceived neighborhood safety and exercise behavior among community dwellers in Gauteng, South Africa. Medicine (Baltimore) 2020;99(51):e23552. https://doi.org/10.1097/MD.0000000000023552        [ Links ]

17. Vermeulen H. A balanced food basket approach to monitor food affordability in South Africa. PhD thesis. Pretoria: University of Pretoria, 2020. https://www.repository.up.ac.za/bitstream/handle/2263/73175/Vermeulen_Balanced_2020.pdf?sequence=1 (accessed 19 February 2024).         [ Links ]

18. Mulrenan C, Jenner K, Knai C. Tackling the obesity epidemic. BMJ 2023;381:1072. https://doi.org/10.1136/bmj.p1072        [ Links ]

19. Delobelle P. Big tobacco, alcohol, and food and NCDs in LMICs: An inconvenient truth and call to action. Comment on 'Addressing NCDs: Challenges from industry market promotion and interferences. Int J Health Policy Manag 2019;8(12):727-731. https://doi.org/10.15171/ijhpm.2019.74        [ Links ]

20. Du M, Tugendhaft A, Erzse A, Hofman KJ. Sugar-sweetened beverage taxes: Industry response and tactics. Yale J Biol Med 2018;91(2):185-190.         [ Links ]