Obesity – a new treatment frontier

1 January 2024 - Lem Chetty

Current treatments are complex and expensive but new studies reveal that obesity medication could be the answer to this epidemic.

What is the biggest threat to the lives of most people in the world today? You would be wrong if you imagined natural disasters, war, crime, or famine. The global pandemic that far outweighs any other is associated with lifestyle related diseases such as diabetes, hypertension, and heart disease, among other ‘preventable’ illnesses. Obesity is a driver and co-condition of these illnesses.

Wits researchers say that obesity is a real yet ignored global pandemic. In southern Africa, 41% of women and 11% of men over the age of 15 years are affected. This ‘obesogenic environment’ features “a rapidly changing diet driven by an aggressive processed food industry and a genetic hand that predisposes one to obesity.” New research shows that there could be a cost-effective pharmaceutical treatment that could help solve obesity. So why aren’t we giving it to people who so desperately need it?

Lessons from HIV

HIV researchers Dr Nomathemba Chandiwana and Dr Simiso Sokhela in the Faculty of Health Sciences, and Professor Francois Venter of Ezintsha, a division of the Wits Health Consortium, have taken up the challenge of fighting for access to lifesaving medication that tackles obesity, that something they have done previously with great success with antiretrovirals (ARVs).

In their article, Tackling obesity with medication: New hope and real challenges, the researchers write about their successful use of medication to treat patients battling obesity – but these drugs are expensive and need to be carefully monitored, including by an endocrinologist.

“[The] results [of using obesity medication] are pretty predictable and amazing! Every person that we have treated who tolerated the drugs, including lots of people who do not have HIV, have shown between 7% to as much as 20% weight loss in just over a year. Regrettably, if you stop the medication, weight steadily comes back … so people with obesity may be on some form of these drugs permanently,” says Venter.

The team had explored traditional weight loss interventions in both HIV patients and HIV negative people who had unexpectedly gained weight. For both groups, lifestyle and dietary changes proved ineffective.

“We learned that exercise and dieting only occasionally achieve sustainable weight loss. Although eating properly and being active is very, very important for good health, for the majority of people it won’t make you lose weight, except in the very short term,” says Venter.

Obesity drug hurdles

Venter and the team’s secondary focus into obesity research emerged from their 2019 study, ADVANCE,?which sought to compare new ARVs to historic ones. While weight gain initially was thought to be a side effect of certain ARVs, it now seems rather linked to genetics, access to healthy food, or the obesogenic environment.

Intrigued, the HIV researchers found that “a new world of weight physiology, exciting new treatments, and even new non-stigmatising language around obesity emerged,” says Chandiwana. While the results of the obesity treatment trial are remarkable, it also showed that access will be the main barrier for the general population.

A 2023 Lancet paper in the journal Obesity, titled Pharmacotherapy of obesity: an update on the available medications and drugs under investigation, showed that it is possible for patients to access obesity drugs and keep pharmaceutical companies profitable at the same time – but South Africa is way off being able to access these obesity drugs, other than in the private sector.

While there may be some similarities to the hurdles faced with ARVs, the obesity epidemic is “killing us more slowly” and is indirectly and directly responsible for earlier death. The issue of obesity lacks prioritisation and a coordinated civil society response. “Obesity does not receive the same level of attention and funding as other health issues, which impedes progress,” says Chandiwana.

There are also significant gaps in the pharmaceutical supply chain, from research and development, through regulatory processes, to affordability and accessibility.?“Ensuring that anti-obesity medication is affordable and accessible to everyone living with obesity, including those with limited resources, is a significant challenge,” she says.

Prioritise beating obesity

Chandiwana outlines her wish list for tackling obesity in South Africa:?

• The first step is the acknowledgement and prioritisation of obesity as a chronic disease and pressing public health issue by government, healthcare systems, and society.
• Then, comprehensive prevention efforts, including promoting healthier food, simple and honest food labelling, and creating supportive and safe environments for physical activity and nutritious eating.
• Next, treatment options need to be accessible and scaled up in primary healthcare clinics for greater impact.?
• Finally, health equity – ensuring that interventions and resources reach all segments of the population, particularly those most vulnerable to obesity, including black women and children.

“It is going to take multidisciplinary collaboration between researchers, healthcare professionals, policymakers, community organisations, and individuals affected by obesity to address the multifaceted nature of the epidemic,” says Chandiwana.

Venter concludes that it will be a “long time” coming before new medicines to tackle obesity are widely available unless more urgency and attention is paid to the issue. “First, the Department of Health needs to be more proactive about classifying obesity as something it actively wants to do something about.”

5 healthy lifestyle tips

Dr Gudani Mukoma, Director of the African Centre for Obesity Prevention, shares these non-pharmaceutical tips to help prevent and manage obesity: 

1. Exercise. Increasing your heart rate for 30 minutes a day is beneficial.
2. Sleep. Adults typically require seven to nine hours per night.
3. Move. Be less sedentary. Move briskly every 30 minutes. Stand up more and consider a standing desk if you’re a ‘desk-jockey’.
4. Eat better. Improve food choices including whole grains, fruits, vegetables, healthy fats, protein and drink eight glasses of water daily. Fibre fills you for longer. Eat smaller portions. Limit refined grains, sweets, processed meats, and sugary drinks.
5. Cook smarter. Steam, boil or grill, rather than frying.

10 reasons to improve your lifestyle before popping obesity pills

While drugs like semaglutide are a valuable tool in treating obesity and diabetes, they can’t replace the benefits that lifestyle changes provide, however challenging! Professor Shane Norris, Director of the Developmental Pathways for Health Research Unit explains the benefits:

1. Holistic benefits: Beyond weight loss, diet and exercise improve cardiovascular health, mental wellbeing, bone density, and reduce the risk of certain cancers.
2. Sustainability: Medication may result in rapid weight loss, but without lifestyle changes, weight often returns once the medication is stopped.
3. Side-effects: All medications have potential side effects.
4. Accessibility: The cost, insurance limitations, or availability of drugs may restrict access.
5. Individual variation: While drugs like semaglutide are generally effective, individual responses vary. Lifestyle interventions are more widely beneficial.
6. Psychological benefits: Research proves that physical activity and a balanced diet positively affect mental health, reducing symptoms of depression and anxiety which medication may not achieve.
7. Co-morbidities: Lifestyle changes can help manage or even reverse other conditions like Type 2 diabetes, hypertension, and dyslipidemia.
8. Prevention: Drugs may treat obesity, but lifestyle behaviours can prevent it.
9. Empowerment: Take control of your own health.
10. Comprehensive treatment: Most healthcare professionals advocate a multi-faceted approach to managing obesity but lifestyle changes can complement the effects of medication, leading to better outcomes.

• Lem Chetty is a freelance writer.
• This article first appeared in?Curiosity,?a research magazine produced by?Wits Communications?and the?Research Office. 
• Read more in the 16^th issue, themed: #Drugs, where we highlight the diversity, scope, and multi-dimensional nature of drug-related research at Wits University.