An obese couple sits on the beach. Overweight and obesity have been recognised as crucial health issues and have been included in the sustainable development goals. (Getty Images)

Obesity weighs heavily on Africa's meagre resources

Big Food is just one driving force behind unhealthy eating, and strategies are needed to cut the high cost of associated diseases.

COMMENT

South Africans are becoming increasingly corpulent and it's being driven by the  corporates, as well as cultural, social and economic factors. 

Despite development, the dominant nutritional problem in Africa is undernutrition, which affects physical and mental development and renders people susceptible to infectious diseases. 

But obesity in South Africa, Africa and elsewhere in the world is driving the rapid development of diet-related noncommunicable illnesses such as diabetes, heart disease, hypertension (high blood pressure) and some cancers. Rates of obesity are rapidly increasing among the wealthy and the poor in Africa, with 27% of adults over the age of 20 being overweight and 8% being classified as obese, according the World Health Organisation (WHO). 

This is particularly concerning among poorer populations who suffer a double burden of infectious and chronic diseases. Women are also far more likely than men to be obese. This negatively affects pregnancy, and maternal and infant health. 

Childhood overweight and obesity in Africa in 2010 affected 8.5% of this group and is expected to rise to 12.7% by 2020, according to a 2010 study published in The American Journal of Clinical Nutrition. Moreover, a 2014 study in The Lancet showed that the rate of increase is higher in developing than developed countries. 

Lifestyle choices such as eating too much and not enough exercise are often invoked when obesity and related noncommunicable diseases are discussed. As a result, activities and resources to address obesity are primarily focused on changing individual risk behaviour. 

Business of 'seed and field to fork'
Although biological, cultural, and psychological factors are important and require action that counters obesity, there is growing evidence that corporate practices are changing the way people eat and significantly influence the risk and burden of diet-related noncommunicable diseases. 

A 2012 study in the journal Science showed that policy and environmental changes can make it easier for individuals to adopt healthy behaviours. Obesity prevention requires changing both individual behaviour and the food environment, and, by implication, corporate practices.

Transnational corporations have become the world's dominant social and economic powers, supplanting governments, religion, families and communities in their ability to influence behaviour, beliefs, health and environments. 

South Africa, entrenched in the global economy in terms of trade, investment and finances, is a stark exemplar of transnational corporations' domination of all aspects of the food system – from "seed and field to fork". 

The food environment, which is increasingly being implicated in unhealthy eating, is dominated by Big Food – large commercial entities that monopolise food and beverages. A 2012 report in the open-access journal, PLoS Medicine, names Nestlé and Unilever, and South African companies such as Tiger Brands and Pioneer Foods, as being among the transnational companies controlling the consumer food market.

Food retail in South Africa is largely concentrated in four companies – Shoprite, Pick n Pay, Spar and Woolworths – whose supermarkets are spreading at a much faster rate than supermarket growth in the United States or Japan. 

And fast-food outlets are proliferating, even in poor periurban areas and small towns, as shown in a 2005 study in the journal Food Policy. 

The research published in PLoS Medicine showed that an increasing proportion of food in both urban and rural areas is bought at supermarkets, and that packaged and processed foods (often high in sugar and salt) are significantly cheaper in energy (calorie) terms than healthier fresh foods. 

Added to the cost and time involved in cooking, as well as a low awareness of the dangers of such foods, it is not difficult to understand the rapidly changing dietary habits of especially poor South Africans. 

And South Africa, exploiting the liberalisation of trade in the region, is now also exporting obesity with the penetration of its supermarket chains and fast-food outlets in Africa. A 2015 article in Global Health Action outlined how sweet snacks and sugary drinks are being sent in increasing quantities from South Africa to other African countries. 

The expansion of supermarkets in Africa is mainly spearheaded by South Africa, with more than 80% of all processed products in Namibia, Botswana and Zambia being imported from South Africa, a 2009 study published in the agricultural online journal, Agrekon, showed. The introduction of fast-food outlets means that people are more exposed to obesity-causing food. 

A 2014 study in the United Kingdom, published in the British Medical Journal showed how exposure to takeaway food outlets is associated with higher consumption of that kind of food, a larger body mass index and greater odds of obesity.

So what is to be done?
Overweight and obesity have now been recognised as crucial health issues and have been included in the sustainable development goals – the 17 goals set by the United Nations in 2015 to end poverty, address inequality and fight climate change over the next 15 years. 

Interventions to reduce the occurrence and effects of obesity are needed, especially in African countries where the focus has been on the control and management of acute and infectious diseases. 

In Africa, the belief that being overweight is a sign of prosperity is an obstacle to changing behaviour. 

Health staff must create an awareness of the risks of overweight and obesity at clinics and health centres, and this must form part of a wide initiative to raise public awareness about the issue. Addressing the problem requires the involvement of communities, the healthcare system and policymakers.

South Africa has introduced ways to combat overweight and obesity, and diet-related noncommunicable diseases and, although not all the strategies have been successful, the rest of Africa can learn from these. 

The adoption in 2011 of the Declaration on the Prevention and Control of Noncommunicable Diseases includes targets to reduce the use of tobacco, alcohol and salt, increased physical activity, and ways to control diabetes, hypertension and asthma. 

The 2013-2017 strategic plan by the department of health proposes an integrated strategy and intersectoral approach to tackle the burden of noncommunicable diseases, which must be implemented by the government, civil society and other stakeholders. 

An intersectoral approach will ensure that stakeholders from the different sectors will be involved in the fight against noncommunicable diseases. These should include departments such as trade and industry, transport and town planning. 

Recently the minister of health announced policies to address the prevalence of obesogenic food, including possibly taxing sugary beverages, hoping to provoke the industry to regulate itself. One health expert likened this to getting the fox to guard the chickens.

• In a growing number of African countries, undernutrition coexists with obesity and both need to be addressed, especially since studies show that undernourished children and those fed formula milk have a greater tendency to become obese adults. 

Key focus areas for preventing undernutrition include ensuring adequate nutrition for mothers during pregnancy and the postnatal period; promoting infant and young child nutrition, which requires the promotion of exclusive breast-feeding – which  a recent  study in South Africa  showed to be only 8% in babies under six months, and the lowest rate globally – and improving complementary feeding practices; and the monitoring of healthy weight gain in childhood. 

Strategies to support breast-feeding necessarily include legislation to prevent the marketing of breast milk substitutes and supporting breast-feeding in the workplace. 

To meet the World Health Assembly's goal of a 0% growth in obesity globally by 2025, governments must implement policies that support healthier eating and encourage physical activity. 

Policies and regulations that restrict the marketing of foods rich in fats, sugar and salt to children, and of sugary beverages and unhealthy foods, like refined grains and sweets, processed meats and snacks at schools, should be developed. 

School curricula should promote healthy eating and active living throughout the school day. This demands that teachers must display healthy behaviours and that school nutrition programmes must incorporate healthy foods and should favour small-scale suppliers, who may not benefit in the current procurement processes that tend to favour more established suppliers with a known reputation. 

In addition, small-scale suppliers could be given incentives to supply mainly fresh foods, as is done in Brazil. The government should invest in advertising and media messages promoting healthier food options. 

Strategies to increase physical activity, especially in poor populations, are required but this will require a greater investment in public transport systems and recreational facilities. 

Ultimately, fiscal measures that tax unhealthy foods, such as sugary beverages and snacks, and subsidise the cost of healthy fresh foods are needed to arrest the rapid increase of diet-related noncommunicable diseases. 

As shown in a 2013 paper published in the journal Health Research Policy and Systems, these investments will be dwarfed by the cost of not taking action – the massive costs, both human and financial, of treating ever-increasing numbers of people with long-term and expensive diseases such as diabetes, heart disease, osteoarthritis and cancer.


The authors are staff of the School of Public Health at the University of the Western Cape. David Sanders is an emeritus professor, Lungiswa Tsolekile is a lecturer, Mark Spires is a researcher and Thandi Puoane is an emeritus professor.

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