A South African woman named Dineo* long struggled with obesity. Her vices included takeout food, creamy desserts and chips, and she drank two litres of sugary drinks a day. “It relaxed me,” she recalls. Her weight crept up to 141 kg. Yo-yo dieting never worked. In 2008, she miscarried her second child due to weight-related complications. The stigma of being overweight led to depression.
Then she learned about bariatric surgery, a procedure that involves reducing the size of the stomach with a gastric band, removing a portion of the stomach, or shortening the intestine to a small stomach pouch. “Medical aid covered 80 % of the cost and the shortfall was over 100,000 rands [USD 6,800],” she says. “I needed to do something as I was starting to become immobile. I could drive but barely walk. So I started saving money.” Dineo had the surgery six months ago, and has since lost about 40 kg.
Around the world, 1.9 billion adults are overweight and 650 million are obese. There is currently no country on track to meet targets to halt obesity, which is a major risk factor for noncommunicable diseases such as cancer, diabetes, cardiovascular and hepatic diseases. Together, these count for more than 70% of deaths worldwide. The social stigma of obesity can lead to social isolation, suicidal thoughts and avoidance of medical care.
In South Africa, 30% of the population is obese and an additional 20% are overweight. Professor Tess van der Merwe, honorary president of the South African Society for Obesity and Metabolism, says there are two approaches that actually work to tackle the disease. “The first is intense cognitive behaviour modification combined with the Dash diet [low-sodium foods that help lower blood pressure and are rich in potassium, magnesium and calcium] and weight-bearing exercise, such as Pilates. This strategy aims to undo automated learned responses to food,” she explains. “The second option for obese to morbidly obese people is bariatric surgery.”
Van der Merwe has been studying obesity patterns in South Africa for three decades.
She believes the first step towards fighting the condition is to foster understanding. “Families, the media and the medical community need to get away from the narrative that we have been using with obese patients, the derogatory manner in which we have been treating them,” she says. “We now know that obesity is not all about gluttony and sloth. It is a brain-centric issue, not a fat-cell-centric problem – and epigenetic inheritance is far more impactful than we had previously thought.”
New research shows that the pituitary gland, in the back of the brain, keeps the body at its highest consistent weight in memory. This is called the body stat and is probably an evolutionary response against famine or starvation. “What we have done incorrectly in the past is to allocate the disease process to the frontal lobe, the reasoning centre. From that arose terminology like ‘food addiction.’ The ridiculousness of those kinds of statements has only become apparent in the past five to seven years,” says Van der Merwe, noting that, as a result, patients are embarrassed even when they don’t eat to excess. “Our calorie intake is only about 180 calories more than it was two decades ago, and our fitness has reduced, but it does not equate to this epidemic,” she notes.
Bariatric surgery’s immediate benefits include guaranteed weight loss, immediate reversal of comorbidity conditions such as diabetes and high blood pressure, and prevention of long-term health issues related to obesity.
Preceded and followed by psychological counselling, the intervention requires the patient to follow a strict lifelong diet to avoid complications. He or she must take a lifetime of vitamins and supplements, because the digestive system is forever altered.
Endocrinologist Dr. Sundeep Ruder says that while surgery is effective, it should be looked upon only as last resort, because of the risks involved. “The biggest drivers of obesity are environmental factors,” he says. “It is very expensive to make surgery accessible to the masses of obese people in the world. But it is considered an alternative after we fail with lifestyle interventions.”
Private healthcare surgery costs up to 500,000 rands in South Africa, but obesity is so prevalent in the country – including in low-income communities– that bariatric surgery is now being tested in the public sector. Professor Zach Koto, a renowned surgeon who specialises in minimally invasive keyhole surgery, is leading the multidisciplinary project. “There are lots of issues at play, so you need a psychologist, endocrinologist, physiotherapist, anaesthetist and a surgeon,” he notes.
“We want to offer a comprehensive service in all the academic hospitals in South Africa,” Koto adds, believing there should be dedicated facilities for these procedures. “We want to make this available to those who can’t afford it.”
But the surgery is far from a miracle solution to obesity. “It is only for patients who qualify and show they are willing to maintain,” Koto says. “People think the surgery is a silver bullet, but it needs a support structure and a complete lifestyle change.”
* Not her real name