Many things we previously thought about obesity are big fat lies

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 junk-food 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."

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 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."