An alarming rise in obesity in Africa has been compared with the HIV epidemic, with stigma and lack of treatment having a disproportionate impact on women.
Almost half of women in Africa will be obese or overweight by the end of the decade, according to a recent study by the World Obesity Federation.
While people in richer countries embrace the use of weight loss jabs to slim, few have any confidence that the groundbreaking medicines will be available in sub-Saharan Africa in the near future.
And treatment for the host of diseases that accompany obesity, including diabetes, heart disease and high blood pressure, can be equally hard to access.
Dr Nomathemba Chandiwana, who specialises in obesity and non-communicable diseases (NCDs), is chief scientific officer at the Desmond Tutu Health Foundation in South Africa.
“Obesity feels like HIV but more compressed,” she said. “We’ve got a disease we don’t quite understand, it’s there, we’re not doing much about it. The drugs are kind of there, but not available. Stigma is also an issue. So you can make a lot of parallels.”
In another similarity between the conditions on the African continent, women are more likely than men to be infected with HIV. And while 25% of men in Africa are overweight or obese, for women the figure is 40%. In most other world regions the gap is much smaller, or reversed.
And the trend is accelerating. While 45% of women in Africa will be overweight or obese by 2030, for men the figure is 26%, according to the World Obesity Atlas.
Chandiwana said the question of why obesity was rising faster among women in Africa was complex, and involved multiple intersecting factors.
“Urbanisation and lifestyle shifts play a major role – many African cities lack safe spaces for physical activity, and long working hours, caregiving responsibilities, and safety concerns, etc, make movement harder for women. Unlike men, who may engage in occupational or leisure physical activity, women’s daily routines are becoming more sedentary,” she said.
“HIV and antiretroviral therapy (ART) add another layer. In high HIV-burden settings like South Africa, ART-related weight gain, especially with drugs such as dolutegravir, is becoming more noticeable, disproportionately affecting women.”
Biological factors such as reproductive health, menopause, and differences in cravings, metabolism, genetics and hormones are additional factors, she said.
“It is definitely going to get worse as ultra-processed foods become more ubiquitous, climate change increases and [because of] gender inequity,” said Chandiwana, with women facing more barriers to activities such as exercise because of their other commitments. “We need prevention and treatment targeted specifically at women in South Africa.”
Already, two-thirds of women in South Africa are overweight or obese, the second highest rate on the continent, after Eswatini.
The rates in women could be a warning sign. Research suggests that countries’ experiences of rising obesity typically begin with higher levels in women and higher-income groups before spreading through the population.
Chandiwana said she was excited by the possibilities of the new generation of anti-obesity drugs called GLP-1 receptor agonists, such as Wegovy or Mounjaro, which have been popularised in the west by celebrities and politicians such as Oprah Winfrey and Boris Johnson.
She said she had been about to get US funding for the first trial of semaglutide in women with HIV, shortly before the Trump administration froze most research spending.
“I think these drugs are a gamechanger and also they legitimise obesity as a chronic disease,” she said. “Without treatment, people always look at it as a personal failure. It’s you, you haven’t done enough. But when you have treatment, we’ve got more in our toolbox.”
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There is “an equity issue” she said, where patients’ access to the new, “best-in-class drugs” depend on where they live in the world. She said diabetes patients in South Africa are having to return to using insulin in glass vials, rather than the more modern alternative of pens with measured doses.
“It doesn’t matter where you are, there’s a drug that’s available that can help you with your disease. We do have to try the best we can to give people access,” Chandiwana said.
Johanna Ralston, CEO at the World Obesity Federation, said cultural norms and expectations around obesity in some African countries might play a role in making women more vulnerable to obesity. “As is the case in many Caribbean and Middle Eastern countries, it is more culturally acceptable for women to have excess weight, and in some cases is desirable.”
Ralston said: “Gender-responsive action is needed to address these disparities and more research is needed to understand the nuances.”
Brenda Chitindi of the Zambia NCD Alliance agreed that cultural attitudes to obesity were an obstacle to tackling the condition in her country.
“Obesity is a very big challenge in Zambia because we have not taken it seriously. Most of the time we think when you are obese, you eat well – without knowing that it is a disease,” she said.
Speaking at the NCD Alliance Global Forum, a conference for NCD advocates last month, Chitindi said: “The other big challenge is where the [food] industry right now have brought into the country these fast foods. Where a lot of people have been attracted and, ignoring the regional food we have … they rush to these fast foods to show people ‘we are well off, we eat well’, without knowing they contribute to obesity.
“The government is looking at the revenue that they get from this industry, which is a very big challenge as well.”
The latest edition of the World Obesity Atlas assessed countries’ “readiness” to address obesity by looking at factors such as their ability to provide treatment for NCDs, and policies for prevention such as taxes on sugary drinks, and restrictions on marketing unhealthy food to children.
These were lacking in many countries, the report’s authors found. But they warned that a reduction in the number of adults who are overweight or obese will require “dramatic policy interventions”.
