‘Reverse Ozempic’ epidemic putting east African women at risk

In spring last year a TikTok post by a Somali social media influencer went viral. Her videos usually featured footage of her strutting down the streets of Mogadishu, wearing a flowing abaya and a confident smile, as if she were on her own personal catwalk. If Somalia ran a beauty pageant, she would no doubt be its queen. In this video, however, her face was swollen and red and she was tearfully pleading for medical funds, claiming to need them because of her weight.

Although she provided no other details, there was widespread speculation on the internet that she had been using weight-gain pills, sparking online discussions about a largely undocumented public health issue within the country and across east Africa, where women are using medication not to lose weight, but to gain it.

While weight-loss jabs have exploded in the west, east Africa is experiencing an alternate, “reverse Ozempic” phenomenon. It is driven by women and brides-to-be who feel pressured to fit into a very different ideal. Across some African communities, a voluptuous and full figure has long been hailed as the standard of feminine beauty, celebrated as a sign of wealth, youth, fertility and of living a “soft life”.

“Most women do it because of pressure to be curvier and desired. Because for us Somalis, the men like their women to be big,” says Ayaan Mohamed, 23, a social worker based in Kenya whose relative and friend became severely ill after using the medication.

The substances range from the steroid-based pill dexamethasone to appetite-stimulant syrups such as Apetamin, as well as weight-gain gummies and topical creams containing mysterious ingredients.

They are sold openly in pharmacies and beauty shops across east Africa, thriving in the loosely regulated markets of Kenya and Somalia. But healthcare professionals warn that dexamethasone, rather than building healthy fat, causes fluid retention. Over time this can trigger health complications and even heart failure.

“What appears to be weight gain is often harmful fluid retention that can lead to serious long-term complications including diabetes, high blood pressure, kidney damage and heart problems,” says Mohamed Noor, a Nairobi-based clinician. “Misuse of dexamethasone for cosmetic weight gain is a widespread serious public health concern.”

This pharmaceutical misuse is being fuelled by intense social pressure. The idealised beauty standard for women in the Somali community demands a paradoxical silhouette: a full face, large hands and thick thighs, balanced against a tiny waist. “It’s impossible,” Mohamed says. “You’re telling me to be big in some areas and small in other areas?”

There are even traditional songs celebrating large legs. “Kub means calves in Somali,” Mohamed explains. “And the song goes: ‘The woman with kub has everything.’”

In Kenya, stalls along Nairobi’s River Road and Dubois Street abound with unregulated beauty products, where buyers can find everything from lipstick to breast and hip enhancements. Meanwhile in Sudan, reports have emerged of weight-gain pills being handed out in villages like “penny sweets”, rebranded with quirky names such as “chicken thighs”.

The idealisation of bigger bodies stands in stark contrast to western beauty trends, but experts warn it encourages an equally exclusionary standard. Maryam Ahlaam, who owns a business in Garowe, Somalia, says she was gripped by pressure during her graduating year at university.

“I was worried people would make comments about how skinny I was,” she recalls. “Being fuller in body is widely associated with attractiveness among young women in my community. I personally felt underweight and, like many others my age, I was influenced by peers who were actively trying to gain weight.

“Women encourage each other to take these medications. They believe skinny women have a disease. People want to look bigger because they don’t want others thinking they’re sick.”

Influenced by her peers, she began taking a combination of Apetamin and dexamethasone. The physical shift was dramatic: in just three weeks she gained 12kg.

“I started experiencing severe bloating and digestive issues. My stomach became very painful and swollen,” Ahlaam says. “I couldn’t walk, my legs were heavy and I was feeling extremely dizzy and sick. These symptoms forced me to stop immediately.”

Concrete data and statistics on the use of these drugs are sparse. This is in part due to the shame and stigma felt by users, but also because health consequences are rarely documented accurately. One public healthcare professional in Mogadishu estimated that half of all young women in the Somali capital had used the drugs at least once.

A year ago in Wajir county, north-east Kenya, where a high proportion of Somali Kenyans live, the crisis had escalated to the point where the governor, Ahmed Abdullahi, had to organise a town hall meeting, where he boldly declared on stage that qarxisa, a colloquial reference to weight-gain drugs that means “to explode” in Somali, had “destroyed our girls”.

The use of these steroid-based pills is intertwined with another major public health issue: skin bleaching.

Amira Adawe, a public health advocate and founder of the Beautywell Project, discovered the intersection while filming a documentary on skin-lightening. Somali women who used skin-lightening creams reported an odd side-effect, she said: “Their faces appeared thinner or ‘hollowed out’ after prolonged use. To counteract this, women reported using unregulated weight-gain products to achieve a fuller face, which is often culturally associated with health and beauty.”

Having a “moonface” is considered aspirational and a sign of youth and beauty for many in Somalia. Products that promise to create that look but contain toxic creams are widely available in TikTok shops.

“The moonface and fattening pills are more harsh in terms of impact on health than skin-lightening,” says Dr Ali Maalim Mohamud, the deputy governor of Mandera county in Kenya. “With skin-lightening your skin has barriers, so it goes through in small doses, but the weight pills are directly ingested into your body system, so there is a very high potential of fatality.

“It’s a major public health issue and I think it’s time to get some attention in terms of government, community leadership, in terms of elders, advocacy groups. All these people need to start engaging.”

Photograph by Brian Ongoro/AFP via Getty Images