Experts describe rising obesity rates in South Africa as an "urgent crisis", "a tsunami" - even an "epidemic" - that is costing lives, not to mention billions of rands. Tackling the situation warrants an action plan that is as comprehensive and cogent as the problem is dire. But does South Africa's new national strategy fit the bill? On the one hand, obesity is a complex public health issue that many countries are grappling with. There are no easy answers. On the other hand, some experts are asking whether the new plan is really the best we can do.
A new strategy
The recently published 'Strategy for the Prevention and Management of Obesity in South Africa 2023 - 2028' includes the vision to ensure that "[a]ll South Africans lead a healthy lifestyle and maintain a healthy weight". The stated mission is to "[e]mpower South Africans to make healthy choices by enabling equitable access to healthy food, physical activity opportunities and a capacitated health care system that supports the prevention and management of obesity". Its goal is to reduce the prevalence of obesity and diet-related non-communicable diseases (NCDs).
The consensus from experts interviewed by Spotlight is that the interventions outlined in this document are highly unlikely to match up to this vision or mission.
"But we have to start somewhere, and, as a base policy, it's not bad," says Dr Nomathemba Chandiwana, Director and Principal Scientist at the Ezintsha Research Centre. "But it goes nowhere near addressing the emergency that is obesity in South Africa. Obesity is incredibly difficult to tackle because it's based on so many different factors, behaviour, history, social justice, food justice, physiology, low income, industry, and powerful commercial interests - to name a few. So I don't think we expect any document to be able to solve the problem completely, but this strategy definitely doesn't go far enough."
Professor Susan Goldstein, Deputy Director of the South African Medical Research Council (SAMRC)/Wits Centre for Health Economics and Decision Science (PRICELESS SA), agrees. "It's a start, and it's much better than the previous strategy, but it still only scratches the surface."
She adds that it is disjointed, as the initial overview of the problem is at odds with the planned interventions.
"The first part is actually very well-written. It talks about the role of the food environment and other structural drivers of obesity, and about how we need a 'whole of government' and 'whole of society' approach. But then when it goes onto what to do, the actual interventions, the focus is back to the individual and not enough on shifting the environment," she says.
It's a start, and it's much better than the previous strategy, but it still only scratches the surface. - Prof Susan Goldstein
The strategy is divided into six strategic objectives, with a cost estimate for each. Since it is a strategic overview, much of the detail on how these objectives will be actioned is missing. While we wait for the finalisation of these details, there is already enough information for local experts to weigh in on whether enough is being committed under each objective.
Food environment
Strategic Objective 1: An enabling environment exists in which healthy food is available and easily accessible in workplaces and schools. Total cost: R 598 345 999.
Having interventions aimed at children is absolutely critical, because "overweight children become overweight adults and obesity often starts in childhood", according to Chandiwana.
Data for 2017 from the National Income Dynamics Study shows that 13% of children under the age of five are overweight or obese, which rises to 16% in 5 -9-year-olds, 22% in 10 - 14-year-olds and 18% in children between the ages of 15 and 17.
Research, like this study published in the American Journal of Public Health, also suggests that patterns of behaviour related to food preferences (and physical activity) are consolidated in childhood and interventions aiming to change these patterns should be geared towards kids aged 12 and below.
Additionally, reversing established obesity is extremely difficult and rare without the help of medicines or surgery. One study found the probability for an obese man to attain normal weight to be 1 in 210 and for an obese woman 1 in 124. This shows why the prevention of obesity in children is a necessary cornerstone of any serious anti-obesity strategy.
Overweight children become overweight adults and obesity often starts in childhood. - Dr Nomathemba Chandiwana
The first intervention in this section of the strategy is the training of tuckshop owners and street vendors located close to schools around healthy eating and healthy food options. But whether training will be enough is questionable.
"Kids love these things because we introduce them to them. If we never introduced them, they would never have loved them. So we need to both reduce the availability and the demand for unhealthy food," says Rebone Ntsie, Director of Nutrition at the National Department of Health. "Our plan is not only to train vendors and tuckshop owners but also to revise the Life Orientation curriculum to increase the nutrition content so that they can also make their own choices to say I don't want to eat what is not good for me."
But Goldstein points out that "knowledge is not necessarily the problem". "People, including children, can't afford or even get to healthy food. There are a range of structural barriers they don't address in this strategy. It's easy to tell people what to do, but the harder part is actually helping them do it."
Ntsie, who is also one of four members of the Obesity Strategy management team, says that exactly how they plan to reduce the availability of junk food products in and around schools has not yet been decided.
"We are doing some groundwork with UNICEF to identify food items that can be introduced as healthy alternatives. Then we may have to look at ways to reduce unhealthy foods in tuckshops, maybe limiting the number of types of these products. If there are 10 types of sugary drinks being sold, bring that down to one or two, for example."
While revising the Life Orientation curriculum does appear in the strategy, an explicit reference to reducing the availability of unhealthy products in tuckshops or amongst vendors does not.
"Vendors are business people. They will sell things that are popular. Looking at this strategy, I don't see how healthy food options can really be enforced or encouraged in any real way," says Chandiwana.
She adds that education is not likely to result in a child choosing to buy an apple over a chocolate. "If we want a child to eat an apple, we have to make it free."
Asked if there was any plan to subsidise healthy food for any group, including children, Ntsie said there was not and the fact that many healthy products are zero-rated means that, technically, there is already a 15% subsidy in place.
"Yes, they are zero-rated, but they are still expensive. To make a real difference, we need to make nutritious food free for the most vulnerable in our society," says Chandiwana.
A study published in the journal Nutrition estimated that a healthy diet will cost the average person in South Africa between 10 and 110% more than a typical household menu, which has a high proportion of unhealthy food items.
Other interventions in this objective include standardising food preparation methods and recipes for the National School Nutrition Programme (NSNP) to ensure they are healthy. By all accounts, this is a laudable intervention, but of the estimated 20 million children in the country, only 9.6 million actually benefit from the programme.
And even for those who are beneficiaries of the NSNP, "this strategy only speaks to what kids do at school, but what about when they go home?", asks Dr Yogan Pillay, who is a board member of the Healthy Living Alliance, an advocacy organisation that focusses on NCDs and the regulation of the food environment.
The only intervention in this section that is aimed outside the school system is creating and implementing a guide "for healthy meal provisioning" in government departments.
"The fact that occupational health interventions are limited to government workplaces is just silly and seems like theatre for theatre's sake," says Professor Francois Venter, Executive Director of Ezintsha.
He says that, along with reducing the cost of healthy food items, there needs to be an intervention to tackle the availability of these products in low-income areas. "In rural areas and low-income urban areas, you will see Coca-Cola and ultra-processed food everywhere you look. But you will be hard-pressed to find a variety of fruit and vegetables. This is a major problem that is not even mentioned in the strategy."
According to Venter, these interventions will fail to achieve the crux of this objective - to create an "enabling environment" - because they do not do enough to make healthy options affordable, accessible, and attractive.
Physical activity
Strategic Objective 2: An enabling environment in place to facilitate equitable access to physical activity (PA) opportunities. Cost: R 255 555 444.
Goldstein says increasing exercise and levels of physical activity is "important for everything, including for mental health, general health, and longevity". She adds that it can help prevent obesity and maintain weight in people who are already overweight, but it won't lead to any real reduction in the current obesity rates.
"You can't exercise your way out of a bad diet," says Dr Mosima Mabunda, who is the Head of Wellness for Vitality, Discovery Health's behaviour change programme. She says that it's "important to prioritise eating a healthy, balanced diet" as bad diets are responsible for millions of deaths each year around the world. However, she stresses that exercise is also crucial for good health, an essential ingredient of a healthy lifestyle and should be a part of any anti-obesity strategy.
The interventions in this section of the strategy include five large exercise events per year; the provision of free exercise facilities, including the annual provision of 10 outdoor gyms and children's play parks, and training of the staff to manage them; and implementing physical activity programmes in government departments during work hours.
"Even if 10 000 people use each of these gyms, it is still a drop in the ocean. It's insane to think that this is something that will really reduce obesity. For the few overweight people who actually make use of these facilities, it may stop further weight gain but, in reality, it amounts to theatre," says Venter.
According to Goldstein, the way in which this strategy approaches physical activity is problematic as it "frames the low rates of activity in a way that implies the fault lies with individuals". "The deep structural and environmental issues that prevent people from exercising are not even vaguely addressed. Like making it safe for people to walk or cycle to work or school. People are exercising less and less in their daily lives because it is so unsafe. Throwing money at an event once in a while or at education is not going to change anything until these bigger issues are addressed."
The interventions in this section aimed at schools are important and include ensuring schools have physical activity facilities and that physical activity educators are capacitated and trained. However, by the final year of the strategy, the aim is to have these facilities in only 25% of schools - and there is no mention of what constitutes a physical activity facility in this context.
Education and behaviour change campaigns
Strategic Objective 3: Education and communication at different levels are evidence-based to prevent and manage obesity. Cost: R 264 490 710.
To achieve this objective, the first intervention is the implementation of a social and behaviour change communication campaign to promote obesity prevention and management, including a budget for radio, TV, and print advertisements.
Goldstein, who has previously been heavily involved in social and behaviour change communication projects for HIV, says the success of this intervention will hinge on whether affected individuals are included in developing the messaging and whether the social norms and environmental drivers of obesity inform the content.
"An issue that impedes many social and behaviour change communication campaigns is that the 'social' part falls away and it only focuses on the 'behaviour' element, which means targeting the individual. We know that this will be fruitless because individual agency can't overcome the environmental drivers of obesity," she says.
"A good social and behaviour change campaign will have extensive public participation and engage people, including those living with obesity, about their challenges and what drives unhealthy behaviours. We don't know if this is planned, but it's not mentioned in the strategy and I strongly suspect that it won't happen," Goldstein says.
people don't have money, they have busy jobs, these foods are often irresistible, and they do the best they can for their families with what they have. - Chandiwana
Chandiwana says that "weight-related stigma and discrimination is comparable to racism and other stigma". It impacts a range of factors, including employability and mental health, but remains largely unchallenged in terms of public perceptions. She says a lot is needed to shift the attitude of blame, where people who are obese are seen as weak-willed or as if they don't care about their health or the health of their loved ones, to recognise that "people don't have money, they have busy jobs, these foods are often irresistible, and they do the best they can for their families with what they have".
Goldstein adds that tackling stigma in this way is tricky. "We want people to love themselves and their bodies, but at the same time, we don't want them to be obese. How do you frame this as a health issue without stigmatising? A way that doesn't fuel bullying in schools, for instance. We have to do a lot of research and we have to really listen to people."
She also points out that an anti-obesity campaign promoting healthy eating and choosing healthy food products is at a serious disadvantage, effectively competing with food giants with advertising budgets to match.
The beverage industry alone spent R3 683 million on advertising its products in South Africa between 2013 and 2019, according to a new study published in April in the Journal of Public Health Research.
This is compared to the obesity strategy's media advertising budget of R261 483 387 for a similar time period and notably, five years later, subject to inflation-related increases.
But she points out that anti-obesity awareness campaigns have a particular weapon that wasn't available for HIV. "If we can show people how they are being duped, manipulated, and exploited by industry, through advertising as well as how products a purposefully manufactured to be tempting, this can be a powerful mobilisation tool."
Healthcare system
Strategic Objective 4: The Health Care System is equipped to address obesity prevention and management. Cost: R43 081 519.
To equip the health system to prevent and manage obesity, the strategy aims to "integrate the screening, management, and referral of obese clients by all healthcare cadres". The plan is to create a screening, treatment, and referral protocol, as well as training healthcare workers, with a special reference to capacitating community health workers.
However, according to Venter, any plan that aims to effectively treat and manage people with established obesity to bring their weight down to healthy levels is "empty" without offering patients drug therapy or surgical intervention.
He says that the new anti-obesity drugs on the market are highly effective and relatively safe, but they are "ludicrously expensive" and unavailable in the public sector. Ozempic, for example, can cost up to R6 000 per person per month in the private sector. (Spotlight previously reported on the role new weight loss medicines may have in combatting obesity in South Africa.)
According to Ntsie, when developing the strategy, these interventions were looked at and, hypothetically, they would work as part of a referral system. Community healthcare workers would screen people in communities and refer them to a primary healthcare setting where a nurse would assess the patient and refer them to a dietician if they meet the criteria. If the patient does not improve, they would then be referred to a multi-disciplinary team and be managed with drug therapy or surgery as a last resort.
"But the health system is not capacitated for these interventions at this stage. The drugs are much too costly, even though I do think we need them. Hopefully, this is something we can consider including in the next strategy," she says.
Chandiwana points out that obesity is referred to as a "risk factor" and a "public health challenge", but nowhere in the 57-page document is it described as a disease, despite the evidence to show it is a chronic condition in and of itself. She says that without recognising it as the "chronic, remitting, relapsing, and multifactorial disease" that it is, it will not be given the same weight, attention, and resources afforded to other diseases. "If you read a strategy like this aimed at hypertension or diabetes, you would laugh. I think it's important to consider this context."
Pillay suggests this language may have been intentional. "By recognising obesity as a disease in and of itself, the implication would be that it would need to be treated with medical interventions [drug therapy and surgery] and these are not feasible in the public sector at this point," he says.
Strategic Objective 5: An effective monitoring, evaluation, and research system is in place. Cost: R 1 317 382.
This is self-explanatory and won't be covered here.
Regulation through policies and legislation
Strategic Objective 6: Policy and legislation support a healthy food environment. Cost: R 1 317 381,80.
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This is the most important part of any strategy to tackle obesity, according to Professor Karen Hofman, Director of PRICELESS SA. Tackling the food environment so that it supports individuals to eat healthily is a herculean ask, especially for our government, for many reasons that span from poverty to powerful industries with commercial interests and massive advertising budgets.
She says that regulation by way of policy and legislation is the only real way to make a difference to obesity rates in South Africa in the short to medium term. Hofman explains that regulatory interventions will make the most difference in the shortest space of time.
Despite this, it is the intervention with the lowest resource allocation (the estimated costs fall just under those for Objective 5).
There are two interventions listed under this objective - Extending the health promotion levy (HPL) to apply to other unhealthy food products and the successful enactment of legislation to limit the advertising of unhealthy food to children.
The HPL, often referred to as the sugar tax, was introduced in 2018 and amounted to a 10% tax levelled at sugar-sweetened beverages. A study published in The Lancet medical journal estimated a 28% decrease in the volume of SSBs purchased the year after the tax was implemented.
"In my view, nothing will change in South Africa when it comes to obesity until the sugar tax is increased. It's almost six years since it was introduced, and it has not even been increased in line with inflation. It is probably worth something like 6% now," says Hofman.
She says that at the time it was implemented it was "promised" that after two years it would be reviewed and an increase would be considered. She says that recent research suggests there is a high growth rate in the sugar-sweetened beverage industry with the proliferation of lower-cost products available made by local manufacturers.
"The supply of raw juice materials has increased as well and we know fruit juice has higher levels of sugar than soft drinks and despite us asking for fruit juice to be included in the HPL it never was," she says.
Chandiwana says that extending the HPL to cover other products is a necessary intervention because it has been shown that people are price sensitive, especially in South Africa. But she says that the plan to extend the HPL doesn't inspire confidence when one considers that the current tax hasn't been increased, either in line with inflation or expectation.
Both Pillay and Chandiwana emphasise the importance of regulating the advertising of junk food to children, an intervention that compliments those aimed at school-going children in the preceding objectives.
But Pillay says that much more needs to be done. "We need to think about more ways we can regulate unhealthy food products but also how government can use regulation to support the provision and accessibility of healthy foods."
According to Hofman, the failure to increase the existing sugar tax doesn't bode well for future regulatory interventions and indicates a lack of political will in the face of vehement opposition from industry - "Big Food, Big Sugar all using tactics from the Big Tobacco playbook".
Crisis and strategy "mismatched"
"The fact is we are in big trouble, and, at this rate, it is only going to get worse. The NHI (National Health Insurance) will not cope with the obesity tsunami," says Hofman.
Research conducted by PRICELESS SA estimated the healthcare costs attributable to obesity exceeded R30 billion for 2020 alone. In comparison, the estimated total cost of implementing the national obesity strategy over five years is less than R2 billion.
Venter says that while the strategy is "a nod in the right direction, bordering a miracle, it will fail to achieve its purpose".
"Industry is powerful, and they are 10 steps ahead of us. At this rate we will never catch up unless we are much more proactive and obesity is recognised as the crisis it is," says Chandiwana. "This strategy is optimistic and aspirational. But, this document and where we are is totally mismatched."
NOTES: Dr Yogan Pillay is quoted in this article in his capacity as a board member of the Healthy Living Alliance. Pillay is also an employee of the Bill and Melinda Gates Foundation (BMGF). Spotlight receives funding from the BMGF.
Professor Francois Venter is quoted in this article. Venter is a member of Spotlight's Editorial Advisory Panel. You can read more about the role of the panel here.
