Sunday Times

Fat rav­ages minds as well as bod­ies

While re­search shows that many things we pre­vi­ously thought about obe­sity are un­true, World Obe­sity Day this Thurs­day aims to raise aware­ness about the prej­u­dice that larger peo­ple face ev­ery day, and to in­spire a lit­tle un­der­stand­ing in­stead

- By SHANTHINI NAIDOO Health · Medicine · Lifestyle · Healthy Living · Weight · Lookism · Discrimination · Human Rights · Society · Vanuatu · Body Shaming

It is sig­nif­i­cant that the two sib­lings in­ter­viewed for this story did not want to be iden­ti­fied or pho­tographed. Obe­sity is now a med­i­cal con­di­tion in SA but there is a long way to go be­fore the shame and stigma it car­ries are erad­i­cated. Thurs­day is World Obe­sity Day and Prof Tess van der Merwe, an ex­pert of meta­bolic medicine who has been study­ing obe­sity pat­terns in SA for three decades, hopes that the cam­paign to “end weight stigma” will help cre­ate more un­der­stand­ing. “Fam­i­lies, the me­dia and the med­i­cal fra­ter­nity need to get away from the nar­ra­tive that we have been us­ing to­wards pa­tients who are obese, the deroga­tory man­ner with which we have treated them,” she says. “Af­ter 25 years, we now know that there are three sets of con­cepts that we had com­pletely wrong. First, obe­sity is not all about glut­tony and sloth. Sec­ond, we know it is a brain-cen­tric is­sue, not a fat-cell-cen­tric prob­lem. And third, epi­ge­netic in­her­i­tance is far more im­pact­ful than we thought pre­vi­ously.”

New re­search shows that the pi­tu­itary gland in the brain, likely due to evo­lu­tion­ary fight-back against famine or star­va­tion, keeps the body at its high­est con­sis­tent weight in me­mory. This is called the body stat, she said.

“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.

“Pa­tients come in em­bar­rassed, say­ing they don’t eat that much. I know that. 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.”

Suc­cess and stress eat­ing

When I ar­range to meet Khosi (not his real name), I choose a venue care­fully: a restau­rant lounge near his of­fice, not far from the lifts, with com­fort­able, sturdy chairs and away from the main din­ing area, in case he doesn’t want to eat in the com­pany of oth­ers.

Khosi knows about these lo­gis­tics and is thank­ful; he car­ries his weight as he nav­i­gates life. He also car­ries the stigma of be­ing obese but main­tains a gen­tle smile.

“I know peo­ple find me in­tim­i­dat­ing at first, but I am a softie, re­ally,” he said.

He was not a chubby child and is not sure how he ended up a 250kg man. He thinks per­haps the fi­nan­cial stress his fam­ily was un­der drove him to at­tain suc­cess (he has an MBA and a top cor­po­rate job) — but also to drink up to 3l of sug­ary drinks a day. “We had to move in with my grand­mother and she would com­fort-feed us. There was al­ways cooldrink with meals. We would buy it by the trol­ley-load if it was on sale.

“But I don’t eat as much as peo­ple as­sume.”

His weight pre­vented him from go­ing to his ma­tric dance, which, he says, “made me want to suc­ceed in other ways”.

“There’s a per­cep­tion that obese peo­ple don’t have value in a cor­po­rate space, so you work twice as hard to be no­ticed. Peo­ple think if you are over­weight you aren’t pro­duc­tive. I don’t let my weight de­ter­mine how I ex­e­cute my job. We may be big, but we are also hun­gry for suc­cess.”

Para­dox­i­cally, try­ing to prove his worth also fed his junk­food habit. “When I was stressed at work, I turned to junk food. I don’t have time to stop for lunch, so I would snack be­tween meet­ings and eat big meals at night.”

When he found love, he was al­ways ask­ing him­self why she had cho­sen him. “She said it was the lov­ing, car­ing per­son in me. I take care of my par­ents and she saw my good side.”

But there have been other dif­fi­cul­ties. Fam­ily mem­bers called him “fatty”. Older cousins looked younger than he did. There is the ex­pense of hav­ing to buy cus­tom-made cloth­ing and med­i­cal bills for weight-re­lated con­di­tions, in­clud­ing im­mo­bil­ity.

“I could not walk even a few me­tres. I would drive to the mall and wait for my wife and kids in the car. On the play­ground, other kids would say, ‘Look at the gi­ant man.’ I didn’t want my kids to be af­fected by that.”

There’s a per­cep­tion that obese peo­ple don’t have value in a cor­po­rate space

Khosi tried many times to lose weight. “I have tried gym, sup­ple­ments and di­ets. You want to go to the gym, but peo­ple look at how much you sweat and how you ex­er­cise. In busi­ness, there are boys’ clubs, the guys who cy­cle … I’d han­dle the lo­gis­tics and sup­port to feel part of the crowd, but you are not and ev­ery­one knows it.”

Then he con­sulted endocrinol­ogist Dr Sun­deep Ruder, who has in­tro­duced life­style changes as well as med­i­ca­tion for thy­roid func­tion, di­a­betes and high blood pres­sure.

“It is daunt­ing, but I want to make a change,” says Khosi. “I lost 33kg in eight months. I’m not do­ing marathons yet, but I can walk again. I want to watch my kids grow up and be there for their wed­dings. I don’t want to fail them.”

The body that wouldn’t let go

Khosi’s sis­ter Di­neo (not her real name) mis­car­ried her sec­ond child in 2008. There­after, she sought so­lace in food. This pe­riod was the cul­mi­na­tion of years of shame around her weight, in­clud­ing hav­ing a pas­sen­ger ask to be moved away from the ad­join­ing seat in an air­craft and not be­ing able to at­tend a pic­nic with her daugh­ter “be­cause I was afraid I couldn’t pick my­self up off the ground if I sat down”.

Take­aways, creamy desserts and chips were her vices. “I would tease my brother about the cooldrinks, but I was also drink­ing 2l a day. It re­laxed me.” She also shopped com­pul­sively, buy­ing a new out­fit ev­ery week to ap­pear per­fectly groomed at all times. “If I had a big meet­ing, I had to shop. My hair, nails, and out­fit had to be on point. But I never wanted to be in pho­tos.”

Her weight crept up to 141kg. Yo-yo di­et­ing was a habit but her body did not al­low her to lose weight. Like her brother, Di­neo has suf­fered from the mis­per­cep­tion that be­cause she is big she is ag­gres­sive. “I was told some­thing so vile; that I come across as hard and stern be­cause I’m big.” When a col­league likened her to Julius Malema, de­pres­sion kicked in.

Then an­other col­league told her about bariatric surgery, in which the size of the di­ges­tive sys­tem is re­duced to achieve weight loss. “My first thought was that it would be ex­pen­sive. Med­i­cal aid cov­ers 80% of the cost and the short­fall was over R100,000. But I needed to do some­thing as I was start­ing to be­come im­mo­bile. I could drive but barely walk. So I started putting money away.”

The surgery is pre­ceded and fol­lowed by in­ten­sive test­ing and lengthy psy­cho­log­i­cal coun­selling, along with work­ing with a di­eti­cian and phys­io­ther­a­pist. “I had to learn to deal with why I was fat and how cruel peo­ple can be, be­cause they au­to­mat­i­cally be­lieve you did this to your­self,” says Di­neo.

A re­stricted diet must be fol­lowed for life or there can be com­pli­ca­tions. There is also a life­time of vi­ta­mins and sup­ple­ments to take be­cause di­ges­tion is al­tered. But it can put co-mor­bidi­ties like di­a­betes into re­mis­sion.

“You can’t eat any­thing un­healthy be­cause your tummy re­acts im­me­di­ately. But I was will­ing to do it,” she says. “This surgery forces you into a life­style change. I’ve started telling peo­ple about it. Judge me or not, I don’t care. It is my jour­ney. I want to get to goal weight and I don’t even feel the urge to shop yet. I just ac­knowl­edge what I’ve ac­com­plished.”

Six months since the surgery she has lost about 40kg. “Peo­ple who would snub me be­fore now want to be my friend,” she says.

Could surgery of­fer a so­lu­tion?

Prof Tess van der Merwe is also hon­orary pres­i­dent of the South African So­ci­ety for Obe­sity and Me­tab­o­lism. She said there are two ap­proaches to tack­ling obe­sity. “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.

“The sec­ond op­tion for obese to mor­bidly obese peo­ple is bariatric surgery, in which we can al­ter cer­tain im­por­tant sig­nals be­tween the brain and the or­gans.”

Ruder says that while surgery is ef­fec­tive, it should be a fi­nal re­sort, be­cause other in­ter­ven­tions should come first.

“The big­gest driv­ers of obe­sity are en­vi­ron­men­tal fac­tors,” says Ruder. “The so­ci­etal im­pact of life­style stress, not hav­ing time to eat prop­erly and eat­ing what is eas­ily and cheaply avail­able is ter­ri­ble for us. Af­ter decades of bad choices, if we are truly go­ing to help pa­tients, we need to get un­der the skin. It is a great cost to make surgery ac­ces­si­ble to the masses of obese peo­ple in the world. But it is con­sid­ered af­ter we fail with other in­ter­ven­tions.”

Bariatric surgery in­volves ei­ther re­duc­ing the size of the stom­ach with a gas­tric band, re­moval of a por­tion of the stom­ach or short­en­ing the in­tes­tine. A com­plete shift in diet and ex­er­cise is re­quired to main­tain it.

Pri­vate health-care surgery costs up to R500,000 but obe­sity is so preva­lent in SA that bariatric surgery is now be­ing tested in the pub­lic sec­tor, be­cause the need among im­pov­er­ished pa­tients is great. The project is be­ing led by Pro­fes­sor Zach Koto, a renowned sur­geon who spe­cialises in

I was told some­thing so vile; that I come across as hard and stern be­cause I’m big

min­i­mally in­va­sive key­hole surgery.

“We want to have a com­pre­hen­sive ser­vice of­fered at all the ter­tiary aca­demic hos­pi­tals in SA,” says Koto. It was not pre­vi­ously con­sid­ered a pri­or­ity, but Koto be­lieves there should be ded­i­cated fa­cil­i­ties.

“This must not com­pete with more ur­gent cases,” he says. “The is­sue is ac­cess to the­atres. We need an en­vi­ron­ment where we can do 25 surg­eries a week, not 25 a month. We want to make this avail­able to those who can’t af­ford it. For­tu­nately the min­is­ter recog­nises the need and is on board.”

He says a mul­ti­dis­ci­plinary team is needed. “And it is only for pa­tients who qual­ify, with ill­nesses linked to obe­sity, and who show they are will­ing to first lose some weight and then main­tain it. Peo­ple think the surgery is a sil­ver bul­let but it needs a sup­port struc­ture.”

Di­neo said it be­gins with sen­si­tiv­ity and em­pa­thy for peo­ple who are obese. “Re­spect that ev­ery­one’s jour­ney is dif­fer­ent, and that you may not know their story.”

 ?? Pic­ture: Ce­bisile Mbo­nani ?? Hav­ing tried di­et­ing in vain, this woman plans to have bariatric surgery, in which the size of the stom­ach is re­duced, in a bid to re­duce her weight.
Pic­ture: Ce­bisile Mbo­nani Hav­ing tried di­et­ing in vain, this woman plans to have bariatric surgery, in which the size of the stom­ach is re­duced, in a bid to re­duce her weight.

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