Willpower won’t stop the craving
New revolutionary drugs are set to debunk myths around obesity, Wits professor Francois Venter tells Claire Keeton
Stop blaming and shaming people who are obese for not losing weight, because research shows that diets and exercise do not work for most people in the long term, says Wits professor of medicine Francois Venter.
What does work well is the new generation of weight-loss drugs revolutionising the treatment of obesity globally, he said in his inaugural lecture at Wits University recently,
“They all seem to act on areas in the brain where you are craving food and they just seem to shut down the need for food,” said Venter. Researchers also observed that the breakthrough drugs seemed to reduce craving in other areas.
“They are doing research on them at the moment for opiate addiction, for alcoholism, cigarettes and gambling ... so for South Africans we should just put in the water a fluoride/semaglutide combo, and be done,” Venter said to laughter in the packed auditorium.
Studies show that the new drugs achieve 15%-25% weight loss, compared with only about 2%-5% from lifestyle modification. But the benefits of healthy food and exercise go far beyond weight loss, said Venter, promoting them as “potent interventions” for general and mental health and wellbeing.
Unexpected weight gain among patients with HIV/Aids, which he worked on for some 20 years, led him to focus on obesity, and once again he is fighting for patients’ rights. He believes that affordable access to the new weight-loss drugs is vital to control the obesity epidemic, as ARVs were for HIV/Aids.
“The new drugs are revolutionising everything in a good way, and the treatment is complicated and it’s messy,” said Venter, comparing them to the Holy Grail in the obesity field.
But, he said: “They cost an absolute fortune and are way beyond anything that medical aids will pay in this country.” Semaglutide costs roughly R6,000 a month in South Africa — even though research by his Wits unit, Ezintsha, shows it costs about a tenth of that to manufacture with a profit.
But even people who can afford the drugs are struggling to get their hands on them, said Venter. “You might have been trying to get semaglutide, the active ingredient of Ozempic. Good luck with that because the injectable — the only form available in South Africa — is out of stock, not just in Joburg and in South Africa, but across the world.
“The alternative, liraglutide, and the third GLP-1 dulaglutide, are now sadly almost unavailable across the world. The problem is that many of these drugs are actually indicated for diabetes as well, so the people whose diabetes was controlled on these drugs cannot get them.” The drugs are hot property in Hollywood.
Suggesting that obesity on its own may not be a bad thing, Venter noted that “obesity plus anything else — hypertension, diabetes, you name it — makes everything else worse ... so if you have obesity and any other condition, losing some weight will help to treat it”, for example by dropping blood pressure among hypertensive patients.
Venter outlined existing weight-loss treatments as follows:
● Eat less, move more — 2%-5%;
● Prescriptive nutritional intervention, such as weight-loss shake — 5%-10%;
● New-generation drugs — 15% -25%;
● Balloons in the stomach — 10%-20%; and
● Bariatric surgery and a range of procedures — 20%-40%
The problem with the first two is that the effects are temporary for most people.
“The people who write the diet books, the ones who won’t shut up at the dinner table, those that go on talk shows, they [are the minority] who can shed that weight and keep it that way,” he said, noting that genes often play a role.
“The rest of us suffer in shame and it’s been shown again and again that the vast majority of diets eventually will fail. And most people who actually exercise will gain weight but nobody talks about that,” said Venter, referencing a recent study in the Journal of the American Medical Association showing only 5% of Americans who tried managed to sustainably lose weight.
Social determinants, genes and the modern food supply — the environment — are driving the obesity epidemic, say experts.
“Wits professor Jeff Wing ... one of South Africa’s leading endocrinologists, says that the way to deal with obesity is choose your parents carefully,” Venter said. “I think we need to acknowledge that there’ sa war going on. There are lots of people who make a lot of money from all of us feeling pretty [bad] about being overweight. That’s not just the diet industry. It’s the exercise industry, the gym industry, the book industry, you name it. Snake oil salespeople like Dr Oz [on TV] and all our own oddballs, they’re all out there.”
The lay public and most health workers have colluded in the false science and stigma that people with obesity are at fault — echoes of what happened to people with HIV — because they have poor selfcontrol, are lazy and do not exercise enough, he said.
“For decades, the medical community has ignored mountains of evidence to wage a cruel and futile war on fat people, poisoning public perception and ruining millions of lives. It is time for a new paradigm,” Venter said, quoting the Huffington Post, which ran a story titled “Everything You Know About Obesity is Wrong”.
With the development of new drugs, a more hopeful era is dawning in the understanding and treatment of obesity, he said.
Despite the shortages of the latest drugs, there are old ones available in South Africa, with manageable side-effects, which could be offered to people. “We are certainly able to use them, and we aren’t using them,” he said.
Studies using newer drugs for weight loss have begun in Joburg, said Venter. Studies are planned with new drugs for people with HIV, diabetes and women stopping breastfeeding, as well as adolescents, in Johannesburg, Cape Town and KwaZulu-Natal, he said.
Wing has experience in treating patients with these drugs and has been teaching Venter. “Jeff’s been using them for the last 20 years, mainly because he saw diabetics getting bigger and bigger, and he needed to do something.”
Of the new-generation drugs much remains unknown, including how long they can be taken and the long-term side-effects. “There are side-effects but so far, in the grand scheme of things, they look quite good.”
Study results on these drugs from the last few years show they are “probably as good as surgery, they are that effective”. When people stop the drugs, they regain the weight, however. Venter said he is puzzled why people are upset about this, given that many drugs work that way. If you stop hypertensive drugs, your blood pressure goes up. If you interrupt diabetes meds, your diabetes symptoms get out of control.
Diabetes, which is strongly correlated with obesity, is now the number one killer of women in South Africa, he said. This used to be HIV and TB.
The obesity epidemic has, like HIV, come along in our lifetimes, he noted. In South Africa there was a slow and steady weight gain among the white population which exploded in the late 1970s, followed by a second explosion among the black population in the 1980s.
The efficacy of the latest generation of obesity drugs could in future supplant the need for other drugs, such as hypertensives, he said, emphasising that drugs alone will not be enough to manage the obesity epidemic and that no single solution suits everyone. But, said Venter: “It is clear that what you need to do is to move ... away from processed food and be addressing food supply issues. The problem is that fresh fruits and vegetables are steadily becoming more and more expensive and processed food is becoming cheaper and more delicious.”
Processed food is being engineered to hit the part of your brain that activates cravings and is being tailored to people’s taste buds, making it increasingly hard to resist.
“I think there is a growing consensus that dealing with the obesity epidemic will require government intervention,” he said. “Many people don’t like that either because the government just doesn’t seem to be able to mow a lawn, let alone come up with something as useful as this, but we really are going to need them to get stuck in.”
People are dying of undernourishment and overnourishment depending on South Africa’s current food supply, which is also seeing a breakdown in quality, said Venter. “This listeria outbreak [20172018] was the worst the world has ever seen and killed so many people.”
Experienced activists from the Treatment Action Campaign and HEALA are fighting for measures such as food labelling and government subsidies for fresh fruits and vegetables. Wins, like the sugar tax, have made a difference in the concentration of sugar in food products, showing the potential for change.
Venter explained the similarities between HIV and obesity:
● Both are common, complex, hugely important health issues;
● They are preventable but need government intervention;
● They are highly dependent on external social factors;
● Black women are highly vulnerable;
● Stigma and blame;
● New drugs are transformative;
● Drug delivery systems will be the Achilles heel, as they already are in rich countries; and
● No one size fits all to stop either.
Venter said the Ezintsha unit, which he leads, is working on these challenges and researching new fields such as sleep. Sleep patterns affect weight gain.
“The obesity epidemic is very highly dependent on external social factors and we need to understand this. It’s not simply sheer willpower that’s going to solve all of this.”
I think we need to acknowledge that there’s a war going on. There are lots of people who make a lot of money from all of us feeling pretty [bad] about being overweight
— Professor Francois Venter, above