BY ANDILE MAKHOLWA, 18 DECEMBER 2014
THE rapid rise in lifestyle-related illnesses has become as much a developmental issue as it is a public health scare.
Higher rates of obesity in particular indicate that an unhealthy diet and sedentary lifestyle are fast replacing tobacco as one of the leading causes of preventable diseases.
Attempts by health minister Aaron Motsoaledi to proactively tackle the problem by regulating the amount of salt, fat and sugar in food and beverages before it becomes unmanageable have set him on a collision course with food producers.
The link between diet and health is complex and contested.
The fast food industry has responded in various ways, for example, introducing “wholesome” options, nutritional information on labels, and emphasising consumer choice, balanced diets and active lifestyles.
A few months ago, Motsoaledi took some flak after a research note proposed a 20% tax on sugar-sweetened beverages to reduce obesity.
The paper was independently produced by Wits University but some saw the recommendation as yet another government attempt to create a nanny state by telling people what not to eat.
In similar vein the liquor business is openly resisting Motsoaledi’s quest to ban alcohol advertising in a bid to reduce alcohol exposure to children especially, and to prevent abuse on health grounds.
While the matter remains at a stalemate the figures paint a grim picture: in SA nearly 70% of women and 40% of men over 20 are obese or overweight, according to a 30-year study by the University of Washington, published in The Lancet in May. That’s a large proportion of the working-age population, and doesn’t bode well for economic productivity. The figure for obese and overweight schoolchildren is a worrying 23%.
The World Health Organisation (WHO) defines overweight and obesity as “abnormal or excessive fat accumulation that may impair health”. They are measured by a body mass index (BMI) of weight (in kilograms) to height (metres) in adults, using the formula kg/m². As a rule, a BMI of 25 or more is overweight and 30 or greater equals obesity. The Washington study finds SA has the highest overweight and obesity rates in sub-Saharan Africa.
Having overcome malnutrition amid obscene socioeconomic inequalities, SA has all the features of an unhealthy nation. However, the discovery of rising obesity in adolescents is the most worrying trend.
“If 23% of school-going kids are classified as obese and overweight, in 10-15 years they will be lining up in our clinics with high blood pressure and diabetes. There’s no question about it,” says Motsoaledi.
Wits University public health professor Karen Hofman says obesity-related diseases together rival the burden of HIV/Aids in SA.
“According to an NHI (national health insurance) discussion paper released in 2011, noncommunicable diseases account for about 28% of total health-care spend in SA,” says Bobby Ramasia, principal officer at Bonitas medical aid. “Obesity is the main culprit, though other factors such as smoking and drug and alcohol abuse also play a role.”
SA isn’t the only country battling with obesity. Worldwide in 2010, overweight and obesity were estimated to cause 3.4m deaths, 3.9% of years of life lost and 3.8% of disability-adjusted life-years (DALS), The Lancet reports.
The picture looks worse when other sicknesses often linked to an unhealthy lifestyle and also known as noncommunicable diseases (NCDs) are taken into account. Major conditions include high blood pressure, diabetes mellitus, certain types of cancer and chronic lung diseases such as asthma.
In 2012, 38m (68%) of deaths reported worldwide were due to NCDs. Nearly three-quarters of these, or 28m, occurred in low-and middle-income countries, with about 48% dying before the age of 70. By 2030, it’s estimated NCDs will be the cause of 75% of deaths globally.
“In Africa it is projected that NCDs at current rates will overtake all other causes of mortality by 2030,” says Motsoaledi. “Globally, deaths due to NCDs are projected to increase by 17% over the next 10 years, but the greatest increase — 24% — is expected in the Africa region.”
In SA, he adds, an estimated 40% of deaths from NCDs among men and 29% among women occur before the age of 60. Data released this month by Statistics SA confirms this (see graph on page 20).
All of which suggests it may not be long before SA plunges into another public health crisis unless fatty, salt-and sugar-rich eating trends are reversed.
Motsoaledi points out that 30-40 years ago the disease and mortality profiles of the First and Third Worlds were distinctly different. Richer, developed countries had a high incidence of deaths from “lifestyle” disorders such as diabetes, while in poorer, developing countries infectious diseases spread by living organisms such as bacteria and viruses — germs, as they were called — took a major toll.
“That division has become blurred. People in the Third World now are dying of both. Infections are still there but what used to be First World diseases are increasingly found here,” says Motsoaledi. “The epidemiological shift has been brought about by the change in lifestyle.”
The risk factors vary but it seems clear that tobacco, alcohol, poor diets and sedentary lifestyles lie behind much of the new disease burden.
Developing countries such as SA are experiencing rapid urbanisation and with it greater access to “Western” processed and convenience foods high in carbohydrates, fat and salt, says Ramasia.
Where people used to “eat from nature”, they now buy their food from supermarkets. Even in rural areas, people no longer plough and harvest the fields for fresh food, says Motsoaledi. “The diet we are eating is completely new and is no longer controlled by individuals but by industry, which is not giving us what our bodies need.”
The minister says one of the biggest culprits is trans-fatty acids. “These are manmade fats, which our bodies hate but the industry loves. That’s because ordinary fat, including vegetable oil used in the frying business, gets denatured.”
The fast food industry, he adds, is able to create a long-shelf life for this oil artificially and the result is trans-fatty acids, which are harmful to our bodies.
Though obesity is the most heritable disease, it needs the environment to unleash that gene, says Prof Tess van der Merwe, an honorary professor and researcher at the University of Pretoria’s endocrinology department. “Studies have shown over decades that susceptibility is around 70%. It’s the most heritable disease. However, you still need the environment to unleash that gene, so you can control the situation,” she says.
“Can we afford to sit with 70% of our women in the obese category? The answer is categorically no. Every person who is obese now, who doesn’t lose weight, is going to become an incredible burden to look after as they retire,” Van der Merwe adds.
Though obesity is caused by multiple factors, what we eat and how much we eat is the major factor, says Hofman, referring specifically to sugar-sweetened beverages, ultra-processed foods and fast foods.
“One sugar-sweetened beverage a day increases the likelihood of being overweight by 55% in children and 30% for adults,” she says. “There is an average of eight teaspoons of sugar in a 330ml fizzy drink or packaged fruit juice.
“Sugar consumption is a major risk factor, both from discretionary sugar in tea or coffee but also a lot of ‘hidden’ sugar. Added sugar is contained in 75% of all packaged foods, even baby food, and not just in desserts and sweets.”
Then there’s the issue of how food is grown and processed. Genetically modified food producers have been under the hammer for some time.
Linked to this is the use of antibiotics in animal husbandry, which is said to be affecting people by creating antimicrobial resistance. Some food producers inject growth hormones into animals.
Van der Merwe says that among the worrying changes is that girls are entering puberty in their pre-teens — at an average age of eight — because “something” has happened to their hormonal development.
Motsoaledi contends that precocious puberty is one of the main reasons SA is battling with teenage pregnancy.
Sedentary lifestyles and physical inactivity are other factors in the growth of NCDs. As a result of SA’s changing socioeconomic circumstances, says Motsoaledi, African people, for example, used to exercise without being aware of it because they had to walk long distances, but that is no longer the case because of the availability of modern transport.
The short-term costs of an unhealthy workforce can be measured in production days lost due to sick leave and medical bills. Long-term costs for companies include disability costs and death benefits.
“We all end up paying for obesity directly or indirectly,” says Hofman. “Health-care costs are 20% more for moderately obese individuals and 50% more for severe obesity. The accumulated losses to SA’s GDP from strokes, heart disease, and diabetes between 2006 and 2015 are estimated to cost SA US$1.88bn.
“Obese workers cost their employers 50% more in paid time off than non-obese colleagues. Being obese places individuals and their families under financial strain with more medical bills and penalties for life and health insurance,” she says.
“To put a diabetic patient on insulin costs the medical aid between R1 500 and R3 000 a month, not counting the treatment they would require to treat associated conditions,” says Van der Merwe.
Whereas the developed world, which has had this problem for years, has the resources to control it, poorer, developing countries do not. “In 2011 I published a gazette reducing the amount of trans-fatty acids in food to try to protect the population. I must confess it never worked for me because you need a lot of resources and technical skills to check if the industry is sticking to the rules,” says Motsoaledi. “They will stick to the rules only if they know there’s a mechanism to catch them. We don’t have that at present. The only way for Africa to survive this is prevention,” he says.
Motsoaledi says it is only a matter of time before developing-country health ministers will struggle to present credible budgets. That is why the WHO has referred the issue of NCDs to the UN General Assembly for inclusion in the post-2015 millennium development goals.
The Wits University study proposing a 20% tax on sugar-sweetened beverages estimates such a move would reduce obesity by 3.8% in men and 2.4% in women, cutting the number of adult obesity cases by 220 000. A similar tax in Mexico has reportedly resulted in a 5% decrease in sales in six months.
Motsoaledi says the Wits research report may be one of the “best buys” for preventing noncommunicable diseases, but that there are a number of factors that would need to be carefully considered before he could adopt it as his recommendation.
He says regulation or taxation may not be needed if the industry finds equally effective solutions. However, there is no consensus among food companies on voluntary measures to reduce sugar or salt content. Also, healthy food options are generally expensive and many South Africans might not be able to afford what producers offer in this regard.
Motsoaledi refers to a 2009 study of supermarkets in rural SA that found healthier foods typically cost between 10% and 60% more than “unhealthy” ones on a rand/weight basis and 30%-110% more in rand/food energy terms.
He believes the answer lies largely in regulation and is encouraged by the success of the tobacco advertising ban introduced in the 1990s by democratic SA’s first health minister, Nkosazana Dlamini-Zuma.
“I don’t accept the view that we shouldn’t be a nanny state,” says Motsoaledi.
He is unrepentant about his quest to ban alcohol advertising, despite the resistance and threats of protracted legal challenges.
The only area in which Motsoaledi seems to be winning is in the regulation of salt content in food. Salt is needed for the functioning of cells. The problem is that in SA the salt intake is 2½ times more than the body needs.
Excessive salt causes high blood pressure, which leads to heart attacks, strokes, and kidney damage. Six foodstuffs have been identified in which the amount of salt will be reduced over the next four years — namely, bread, brine in chicken, cereals, spices, snacks, and soups (see table).
Hofman says prevention is the key as it gives us the “best bang for the buck”. She says industry, government, and public health experts can all play a role.
“Information about food content must be easily understood to allow the public to make comparisons. For example, the Food & Drug Administration in the US has just passed regulations to ensure that calorie counts appear on every food item, even popcorn at movies,” she says. “Regulations are needed for adverts, especially in or near schools, and for children on TV, the Internet, and their cellphones.”
The idea, she says, is that a tax on sugar-sweetened beverages would reduce obesity and raise revenue.
“Evidence shows that the general public around the world supports this kind of tax, especially when the revenue is used appropriately — for example, to fund obesity-prevention initiatives that would encourage people to shift towards healthier diets.”
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