In Sub-Saharan Africa, ~31.4% of women are classified as overweight or obese. This number is substantially higher in South Africa. In 2016, ~68% of South African women and ~30% of men were classified as either being overweight or obese.¹

Classification of obesity

The World Health Organization (WHO) defines obesity as a condition of abnormal or excessive fat accumulation in adipose tissue to the extent that health may be impaired (see Table 1).³

According to the Obesity Medicine Association definition, obesity is defined as a chronic, progressive, relapsing, and treatable multi-factorial, neurobehavioural disease.⁴

A new study (2022) showed that living with obesity or being overweight is not merely the consequence of a long-term energy imbalance between too many calories consumed (over-eating) and too few calories expended (sedentary lifestyles), but that it is also related to how our brains develop. The study focused on how genes and environmental factors affect the way our brains develop and how this can impact our weight later in life.^5,6

The researchers looked at mice and found that a specific part of their brain called the arcuate nucleus goes through important changes in how genes are used during early life. These changes can be influenced by both genetic factors and the environment we are exposed to during critical periods of development.⁵

They also compared the findings in mice to data from studies in humans and found that the same regions in the human genome that are associated with obesity are also involved in the development of the arcuate nucleus.⁵

This suggests that our risk of obesity might be influenced by how our brain develops early on, which can be affected by both our genes and the environment we are exposed to. The researchers believe that understanding these developmental processes could be crucial in preventing and addressing the worldwide problem of obesity.⁵

Gender as a risk factor for obesity or being overweight

Obesity is caused by a complex interplay between several other factors, which influences an individual’s risk of becoming overweight or obese. These include gender, genetic predisposition, psychological makeup, and environmental factors.^6,7

Studies show that women have a two-fold increased risk of obesity or being overweight compared to men. Factors that influence weight gain in women include for example:^7,8,9

• Pregnancy
• Use of hormone contraceptive pills
• Limited breast-feeding duration
• Infertility treatment
• Menopause
• Contrasting biological craving for food (women have significantly higher craving scores than men)
• Women have higher single nucleotide polymorphisms-based heritability for waist-hip-ratio
• Differences in the insulin/insulin-like growth factor (IGF)-1 axis (IGF-1 directly regulates protein, carbohydrate, and fat metabolism. IGF-1 also enhances insulin sensitivity, independently of its effect on growth hormones)
• The impact of gonadal hormones (in women, obesity is associated with androgen excess disorders such as polycystic ovarian syndrome and idiopathic hyperandrogenism)
• The emerging role of adipocytokines (women of reproductive age have substantially greater adipose tissue and less lean mass. With advancing age, the differences in accumulation of visceral fat among men and women become less marked as men begin to lose muscle mass from the age of 50, whereas post-menopausal women, while suffering a similar decline in lean mass, often gain more fat mass than men, which increases visceral fat).

Impact of obesity on quality of life

According to a 2020 analysis of the Global Burden of Disease Study (1990-2017), the global deaths and disability-adjusted life years (DALYs) attributable to high body mass index (BMI) have more than doubled for both females and males.²

Furthermore, the analysis showed the age-standardised rate of high-BMI-related deaths remained stable for females and only increased by 14.5% for males, and the age-standardised rate of high-BMI-related DALYs only increased by 12.7% for females and 26.8% for males.²

Both high-BMI-related death and DALY rates were lower in females in age groups <75-years than in males in the same age groups, whereas the rates were higher in females than in males in age groups ≥75-years.²

The number of high-BMI-related deaths peaked in the age group 75- to 79-years in females, whereas the peak in males was observed in the age group 65- to 69-years. The number of high-BMI-related DALYs peaked in the age group 60- to 64-years in both sexes.²

Furthermore, the numbers of high-BMI-related deaths and DALYs were both lower in females than in males in age groups <70-years, whereas the numbers were higher in females than in males in age groups ≥70-years. The reason for this phenomenon is not completely understood.²

In 2017, the six causes of high-BMI-related DALYs were ischaemic heart disease (483.4 per 100 000 population), stroke (406.8 per 100 000 population), diabetes (379.4 per 100 000 population), chronic kidney disease (117.3 per 100 000 population), hypertensive heart disease (85.1 per 100 000 population), and low back pain (53.8 per 100 000 population).²

Challenges in the management of obesity

There are several challenges that need to be overcome to successfully manage the growing obesity pandemic. These include:^10,11

• Inadequate knowledge among healthcare professionals about obesity management guidelines resulting in low rates of obesity diagnosis, and evidence-based management, resulting in sub-optimal care.
• Knowledge gaps about available treatments, their efficacy and safety for obesity guidelines and lack the understanding of obesity medication efficacy & safety.
• Communication barriers between patients living with obesity and healthcare professionals. Surveys have shown that healthcare professionals are often uncomfortable initiating a conversation about weight for fear of offending patients. Surveys also show ~70% of patients want the doctor to initiate the conversation.
• On the other hand, some healthcare professionals have negative attitudes and beliefs about patients living with obesity, which are reflected in their care for these patients. According to the 2023 International Federation of Gynecology and Obstetrics (FIGO) best practice advice on the management of obesity across women's life course, obesity assessment and health optimisation strategies should be incorporated into training programmes for all healthcare professionals, including obesity awareness and health optimisation components.
• Furthermore, patients’ misconceptions about weight are associated with fewer weight loss attempts. Studies show that men - especially middle-aged men - are less likely to have an accurate weight perception and, therefore, less likely to have weight dissatisfaction, attempt weight loss, and successfully lose weight compared to women. Studies show that the causes of distorted body weight perception in women were mostly psychological in nature.
• Patients living with obesity are often stigmatised, which causes psychological distress. A Canadian national cross-sectional study found that weight-related discrimination even exists in the healthcare system (also see above), emphasising the need to reform and reduce weight-related social stigma for patients living with obesity to improve their outcomes. Of note, women face more weight bias, stigma, and discrimination than men.

Managing obesity

According to FIGO the focus of care in patients living with obesity should be on optimising health outcomes rather than on weight loss. Treatment for obesity requires individualised care plans that address the root causes of obesity and provide support for behavioural change.¹¹

In terms of gender differences in weight loss management, Almubark et al found that men are more likely to attempt weight loss, exercise more, and eat less fat compared to women who prefer to take prescription medication and follow specific diets for weight loss.¹⁰

FIGO recommends nutritional therapy, exercise and physical activity, psychological and behavioural interventions, pharmacotherapy, and surgery.¹¹

Weight loss achieved with health behavioural changes is usually 3%–5% of body weight, which can result in meaningful improvement in obesity-related comorbidities.¹¹

FIGO’s best practice advice include:¹¹

• Primary care providers, fertility clinics, contraception clinics, obstetrics and gynaecology services, and community healthcare providers should support those with fertility potential with health and weight optimisation prior to pregnancy
• Lactation support should be available for all parents
• In addressing obesity-related health with patients, care providers should ask permission to discuss weight and health, perform a physical assessment and an assessment of the root causes of obesity, discuss available care options, and plan for follow-up
• Obesity assessment and health optimisation strategies should be incorporated into training programmes for all health professionals
• Pragmatic practice advice
• Where resources are limited, BMI can be assessed and consideration should be given to exercise and nutrition to optimise health and weight prior to pregnancy
• Postpartum liver assessment is recommended for women with non-alcoholic fatty liver disease
• Routine screening of women with class III obesity for cholelithiasis every five-years, post-weight loss interventions (eg: conservative, medical, or surgical management) that result in greater than 10% total body weight loss
• In the absence of weight loss surgery, women living with obesity are at risk of micronutrient deficiency and may require nutritional assessment and supplementation
• Annual screening for micronutrient deficiencies in women who have had weight loss surgery is recommended, with subsequent supplementation as needed
• Screening for osteopenia and osteoporosis via bone density scan is recommended one- to two-years after malabsorptive weight loss surgery
• Weight loss and specialised cancer screening are recommended to reduce the risk of obesity-related cancers
• Early assessment of women living with obesity and abnormal uterine bleeding is recommended
• Women living with obesity should be screened for impaired renal function by laboratory testing of estimated glomerular filtrate rate, blood urea nitrogen, creatinine, and microalbuminuria at three months post-partum and at intervals up to three- to five-years postpartum
• Assessment and treatment for obstructive sleep apnoea is recommended for women to reduce health risks
• Postpartum deep vein thrombosis prophylaxis is recommended for both caesarean and vaginal birth in women with obesity
• Preventive breast healthcare is recommended for postmenopausal women living with obesity
• Vasomotor symptoms in women aged ≥65 years living with obesity should be evaluated and treated using an individualised approach, recognising the increased risks of breast and endometrial cancers associated with obesity in women
• Osteoporosis in women aged ≥65-years living with obesity should be evaluated and treated using an individualised approach.

When is pharmacotherapy recommended?

The management of obesity requires a similar approach to other chronic diseases. First-line therapy is lifestyle modification (eg: kilojoule restriction and or portion control and physical activity).¹²

However, lifestyle interventions alone are insufficient in achieving long-term weight loss maintenance in most patients. An estimated 30%-60% of lost weight is regained within one-year following the end of dietary treatment, and >95% weight is regained within five-years.¹²

Anti-obesity medications (AOMs) are indicated in combination with lifestyle modification for the management of patients who have failed to achieve clinically significant weight loss, defined as ≥ 5% of baseline weight after six months of lifestyle interventions.¹²

Professional bodies including the Obesity Society, the Endocrine Society, and the American Association of Clinical Endocrinologists recommend AOMs for individuals with BMI ≥30kg/m² or BMI ≥27 kg/m² with comorbidities.¹²

The role of support programmes assisting patients in success

Behavioural weight management programmes are effective in aiding > 5% weight loss. These interventions focus on modifying eating and physical activity behaviors through education and behaviour change techniques. These techniques include self-monitoring, planning, and problem-solving. On average, participants in such programmes lose twice as much weight as those in standard care, increasing the likelihood of achieving the 5% weight loss goal. These programmes offer valuable support for individuals striving to improve their dietary and physical activity habits, leading to successful weight loss outcomes.¹⁶

Conclusions

Obesity is a chronic, neurobehavioral disease influenced by genes and environmental factors affecting brain development. Research reveals that early brain changes can impact weight later in life. Women have a higher risk of obesity due to factors like pregnancy, hormones, and genetic differences. Obesity's global impact on health and quality of life has increased significantly. Managing obesity faces challenges like inadequate knowledge, communication barriers, and stigmatisation. Individualised care plans should focus on optimising health outcomes, not just weight loss AOMs are recommended for patients who haven't achieved significant weight loss through lifestyle changes. Integrated approaches are essential to address the obesity pandemic effectively.

REFERENCES

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