tag:theconversation.com,2011:/uk/topics/ncds-1488/articlesNCDs – The Conversation2023-10-24T04:11:28Ztag:theconversation.com,2011:article/2124492023-10-24T04:11:28Z2023-10-24T04:11:28ZIndonesia needs to triple its funding to control tuberculosis – here’s where to start<figure><img src="https://images.theconversation.com/files/552901/original/file-20231010-24-za7ydt.png?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Image of a tuberculosis patient.
</span> <span class="attribution"><a class="source" href="https://en.wikipedia.org/wiki/Tuberculosis#/media/File:Depiction_of_a_tuberculosis_patient.png">Myupchar/Wikipedia</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Indonesia is still <a href="https://tbindonesia.or.id/wp-content/uploads/2023/02/Factsheet-Country-Profile-Indonesia-2022.pdf">struggling to fight tuberculosis (TB)</a>, with the second-highest number of cases worldwide.</p>
<p>In 2021, one study estimated Indonesia had a staggering incidence rate of TB <a href="https://rdi.or.id/wp-content/uploads/2023/08/Increasing-Financing-for-Tuberculosis-Programs-in-Indonesia.pdf">759 cases per 100,000 people</a> – more than double the World Health Organization’s 2021 estimate <a href="https://data.who.int/indicators/i/C288D13">354 cases per 100,000 Indonesians</a>. That compares with a global average of <a href="https://data.who.int/indicators/i/C288D13">134 per 100,000 people</a>.</p>
<p>Undeterred by the challenges posed by TB, Indonesia has set ambitious targets of reducing TB cases to <a href="https://tbindonesia.or.id/wp-content/uploads/2021/06/NSP-TB-2020-2024-Ind_Final_-BAHASA.pdf">190 per 100,000 individuals</a> by 2024 and to 65 per 100,000 by 2030. </p>
<p>With a staggering number of TB cases and those ambitious targets, the country urgently requires increased funding to combat this potentially deadly but preventable communicable disease. </p>
<p>Currently, insufficient funding is a significant obstacle in Indonesia to fight against TB. <a href="https://www.who.int/publications/digital/global-tuberculosis-report-2021/financing">Sustained adequate funding</a> would ensure the availability of essential resources, diagnostic tools, medications and healthcare services necessary to prevent, diagnose and treat TB effectively. </p>
<h2>Lack of funding risks more people getting sick</h2>
<p>Known as the <a href="https://www.who.int/publications/i/item/9789240013131">TB financing gap</a>, lack of funding can lead to inadequate diagnostic tools and equipment provision, resulting in delayed or inaccurate diagnoses. These delays have grave consequences.</p>
<p>Studies <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7558533/">have shown</a> delayed treatment of TB increases disease transmission, posing a greater risk to individuals and communities.</p>
<p>Worldwide, 1.6 million people died from TB in 2021, making it the <a href="https://www.who.int/news-room/fact-sheets/detail/tuberculosis#:%7E:text=A%20total%20of%201.6%20million,(above%20HIV%20and%20AIDS).">13th leading cause of death</a> – and the second leading infectious killer after COVID-19.</p>
<p>According to Indonesia’s national strategy, the country needs to spend <a href="https://tbindonesia.or.id/wp-content/uploads/2021/06/NSP-TB-2020-2024-Ind_Final_-BAHASA.pdf">Rp47.3 trillion (US$3 billion)</a> from 2020 to 2024 to control TB. However, the budget availability for that period is only around Rp15.7 trillion ($990 million). </p>
<p>Indonesia also lacks access to financing help pay for those extra control measures.</p>
<p>The <a href="https://www.who.int/publications/i/item/9789240013131">WHO Global Tuberculosis Report</a> said Indonesia needs US$429 million for TB prevention, diagnosis and treatment and US$87 million for tuberculosis care – a total of US$516 million. But it has only secured only US$111 million. </p>
<p>In fact, WHO data shows that since 2009, Indonesia has consistently <a href="https://rdi.or.id/wp-content/uploads/2023/08/Increasing-Financing-for-Tuberculosis-Programs-in-Indonesia.pdf">failed to meet the necessary TB financing requirements</a>, financing only 41% of the needed TB programs each year, on average.</p>
<p>This financing gap restricts the availability of essential medications for TB treatment. This issue is particularly concerning, as drug-resistant strains of TB are emerging, further complicating treatment efforts.</p>
<h2>The pandemic hit TB funding</h2>
<p>The COVID-19 pandemic has worsened the TB financing gap in Indonesia. </p>
<p>The government had to change its priorities during the pandemic, reallocating its health budget for COVID-19 treatment and mitigation efforts. </p>
<p>WHO said Indonesia’s TB funding decreased <a href="https://www.who.int/indonesia/news/campaign/tb-day-2022/fact-sheets">around 8.7% between 2019 and 2020</a>. </p>
<p>Upon closer examination,<a href="https://rdi.or.id/wp-content/uploads/2023/08/Increasing-Financing-for-Tuberculosis-Programs-in-Indonesia.pdf">Two significant reasons emerge</a> related to factors contributing to the funding gap. </p>
<p>First, the lack of adequate fund to cover the costs of TB services. This limits the reach and impact of programs. </p>
<p>There is also a tendency among patients to seek diagnosis and treatment at hospitals, rather than local primary healthcare centres and clinics. This leads to a heavier financial burden on the National Health Insurance system, because treatment costs in hospitals are more expensive.</p>
<p>Second, the lack of private sector involvement in diagnosis, reporting and treatment further compounds the problem, hindering progress. </p>
<h2>What should we do now?</h2>
<p>Increasing domestic financing for TB programs is crucial. </p>
<p>The Indonesian government should allocate a higher proportion of the national budget to prevent and control TB, as well as to conduct TB-related research. </p>
<p>Integrating externally-funded TB programs into the National Health Care system would ensure sustainability and align them with the national healthcare framework. </p>
<p>Strengthening the healthcare system is paramount, including bolstering the capacity and infrastructure of local health centres and clinics, training healthcare professionals, and improving diagnostic and treatment services. </p>
<p>Additionally, exploring innovative financing pathways – such as engaging the private sector through public-private partnerships and leveraging international funding mechanisms – could provide the necessary resources to drive progress.</p>
<p>Closing the TB financing gap is essential, not only to improve patients’ health, but to also safeguard the well-being and socioeconomic stability of communities as a whole. </p>
<p>Indonesia must pursue <a href="https://rdi.or.id/wp-content/uploads/2023/08/Increasing-Financing-for-Tuberculosis-Programs-in-Indonesia.pdf">strategic actions to overcome these challenges</a>.</p><img src="https://counter.theconversation.com/content/212449/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Para penulis tidak bekerja, menjadi konsultan, memiliki saham atau menerima dana dari perusahaan atau organisasi mana pun yang akan mengambil untung dari artikel ini, dan telah mengungkapkan bahwa ia tidak memiliki afiliasi di luar afiliasi akademis yang telah disebut di atas.</span></em></p>Indonesia has the world’s second-highest rates of TB – but lack of funding means not enough people are being diagnosed and treated fast enough.Rahmah Aulia Zahra, Children, Social Welfare, and Health Research Officer, Resilience Development Initiative (RDI)Wewin Wira Cornelis Wahid, Program Officer, Resilience Development Initiative (RDI)Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2092512023-07-20T08:13:46Z2023-07-20T08:13:46ZHalf of all South Africans are overweight or obese. Warning labels on unhealthy foods help change that<figure><img src="https://images.theconversation.com/files/538049/original/file-20230718-19-1u0mwr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Unhealthy diets are a major risk factor for diseases like cancers, diabetes.</span> <span class="attribution"><span class="source">Sheila Fitzgerald/Shutterstock</span></span></figcaption></figure><p>South Africa’s national health department recently invited public comment on <a href="https://www.gov.za/sites/default/files/gcis_document/202304/48460rg11575gon3337.pdf#page=11">regulations for warning labels on food packaging</a>. The regulations specify how pre-packaged food should be labelled. Broadly speaking, “front-of-pack” labels provide information about the overall nutritional quality of foods and beverages. </p>
<p>The aim is to allow consumers to make healthier food choices. The proposed rule is that food products containing added saturated fat, added sugar, or added sodium, and which exceed prescribed cut-off values, must have a warning label. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/536041/original/file-20230706-25-711c6b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/536041/original/file-20230706-25-711c6b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=142&fit=crop&dpr=1 600w, https://images.theconversation.com/files/536041/original/file-20230706-25-711c6b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=142&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/536041/original/file-20230706-25-711c6b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=142&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/536041/original/file-20230706-25-711c6b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=178&fit=crop&dpr=1 754w, https://images.theconversation.com/files/536041/original/file-20230706-25-711c6b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=178&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/536041/original/file-20230706-25-711c6b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=178&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">An example of the warning label proposed for food containing high sugar, fat or salt.</span>
</figcaption>
</figure>
<p>Globally there’s been an <a href="https://www.unicef.org/southafrica/press-releases/poor-diets-damaging-childrens-health-worldwide-warns-unicef">increase</a> in the availability and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9370540/">consumption</a> of unhealthy food. This has contributed to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7399967/">bad health outcomes</a>, including a rise in overweight and obesity. </p>
<p>Unhealthy diet is a major risk factor for noncommunicable diseases such as heart attacks, cancers and diabetes. People who are <a href="https://www.who.int/news-room/questions-and-answers/item/obesity-health-consequences-of-being-overweight">overweight or obese</a> are at greater risk of developing these conditions. </p>
<p>The figures in South Africa are especially worrying. Half of <a href="https://www.wits.ac.za/news/latest-news/opinion/2022/2022-09/obesity-costs-south-africa-billions-we-did-the-sums.html">all adults</a> are either overweight (23%) or obese (27%). Noncommunicable diseases account for <a href="http://www.statssa.gov.za/publications/P03093/P030932018.pdf">59.3% of reported deaths</a> in the country. </p>
<p>The effectiveness of front-of-pack warning labels is supported by <a href="https://www.paho.org/en/news/1-12-2022-adoption-front-pack-nutrition-warnings-can-help-decrease-obesity-cardiovascular">international evidence</a>. The adoption of these nutrition warnings can help combat obesity, cardiovascular disease, type 2 diabetes and some cancers. <a href="https://www.foodsafetyafrica.net/south-africa-releases-draft-labeling-regulations-envisioned-to-encourage-better-food-choices/">Several countries have introduced them</a>, including Singapore (1998), Thailand (2007), Chile (approved in 2012, implemented in 2016), Ecuador (2013), Indonesia (2014), Mexico (2016) and Colombia (2022). </p>
<p><a href="https://heala.org/what-is-front-of-package-labelling-and-why-does-south-africa-need-it/">Local evidence</a> has supported international evidence and found that <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0257626">South African consumers have a positive attitude towards warning labels</a> on ultra-processed foods and drinks. When asked if they would be open to having warning labels on food, study participants said that warning labels were easy to understand and would assist them in quickly identifying unhealthy products. </p>
<h2>The content of the regulations</h2>
<p>In addition to the warning labels, the regulations also introduce marketing restrictions. </p>
<p>Regulation 52 relates to any packaged food with front-of-pack warning labels. The regulation limits the advertisement of these foods in various ways. It prohibits the use of celebrities and cartoon characters, competitions, gifts, collectable items and other items that may appeal to children. The abuse of positive family values to encourage consumption of unhealthy food is also prohibited. The advertisements are also required to have a warning.</p>
<p>This is line with the <a href="https://www.unicef.org/media/116686/file/Front-of-Pack%20Nutrition%20Labelling%20(FOPNL).pdf">World Health Organisation’s (WHO) recommendations</a> to implement <a href="https://reader.elsevier.com/reader/sd/pii/S0950329322001665?token=A6F5C6FB12479AF33C18C009CBB1C9A72DF19FA43768E909E13683C324EE45B291B3C637B8353343541F153338F33491&originRegion=eu-west-1&originCreation=20230510133548">evidence-based policies</a>, which include mandatory front-of-pack warning labels and marketing restrictions on unhealthy foods and beverages. In particular, the WHO has noted that an unhealthy food environment includes the promotion or marketing of unhealthy foods and has linked this to the undermining of children’s rights.</p>
<p>In my opinion as a public health law and policy researcher, some aspects of the regulations deserve commendation. </p>
<p>The first is the fact that the front-of-pack warning labels are <a href="https://www.nature.com/articles/s43016-022-00552-5">mandatory</a>. This allows for the regulation of unhealthy products that play a role in noncommunicable disease development. </p>
<p>The second relates to the inclusion of a mandatory warning icon for <a href="https://www.cbsnews.com/news/aspartame-who-possibly-carcinogenic-artificial-sweetener/">sweeteners</a> alongside sugar, salt and saturated fat. These are important food components to regulate, considering the noncommunicable disease and obesity crisis in South Africa. </p>
<p>In addition, the limitations and prohibitions on when nutrition and health claims can be made are beneficial. In particular, section 50 states that products required to have a warning label may not include any health claims. </p>
<p>Another noteworthy inclusion is the fact that exceptions have been made for small-scale producers. This removes a potential barrier to South Africa’s informal food economy and small and micro food businesses. </p>
<h2>What’s missing</h2>
<p>There are a few areas of the regulations that could potentially be strengthened.</p>
<p>To give effect to the purpose of the marketing restrictions, the regulations should define advertising or advertisements. We, at the SAMRC/Centre for Health Economics and Decision Science, propose looking at the law in Chile. It defines advertising to include all forms of promotion, communication, recommendation, propaganda, information or action aimed at promoting the consumption of a certain product.</p>
<p>The section that restricts the use of competitions, tokens, gifts or collectable items which appeal to children is a great addition. This section should be clarified to ensure that in this context children are understood as persons under 18. This will align with the <a href="https://www.justice.gov.za/legislation/constitution/saconstitution-web-eng.pdf">Constitution of South Africa</a> and the <a href="https://www.justice.gov.za/legislation/acts/2005-038%20childrensact.pdf">Children’s Act 38 of 2005</a>. </p>
<p>The regulations should prohibit depicting children on products which carry a front-of-pack warning label. Any advertising in places where children gather, like schools and clinics, should also be prohibited. These are both restrictions suggested by the WHO to protect children from the harms of marketing.</p>
<p>To ensure that this regulation is effective, the Department of Communications and Digital Technologies and the Department of Education need to extend the protection of children from unhealthy foods and beverages as part of their mandate. This will allow for more comprehensive restrictions.</p><img src="https://counter.theconversation.com/content/209251/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sameera Mahomedy does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The increased availability and consumption of unhealthy food has contributed to poor health outcomes.Sameera Mahomedy, Researcher in Law and Policy, SAMRC/Centre for Health Economics and Decision Science - PRICELESS SA, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2024632023-03-29T09:26:43Z2023-03-29T09:26:43ZThe world is hooked on junk food: how big companies pull it off<figure><img src="https://images.theconversation.com/files/517888/original/file-20230328-14-w6mldq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock </span></span></figcaption></figure><p>It is almost impossible nowadays to listen to the radio, watch TV or scroll through social media without being exposed to an advertisement telling us that all we need for a little happiness and love is a sugary drink or <a href="https://www.youtube.com/watch?v=c65IZvuEXcA&ab_channel=McDonald%27sSouthAfrica">a fast-food snack</a>. There’s nothing that a tasty, affordable, ready-made meal cannot fix, we are asked to believe. </p>
<p>Over many decades our food environments have relentlessly been <a href="http://www.ci.uct.ac.za/sites/default/files/image_tool/images/367/Child_Gauge/South_African_Child_Gauge_2020/CG2020_ch3_corporate%20fast-food%20advertising%20targeting%20children.pdf">encouraging</a> us to make choices that are harmful to our health, through pricing, marketing and availability. This rise in advertising has contributed to a growing global obesity crisis as well as nutrition deficiencies as more and more people opt to <a href="https://pubmed.ncbi.nlm.nih.gov/31099480/">eat unhealthy food</a>.</p>
<p>We each have the right to buy whatever we can afford. But commercial forces limit our freedom of choice more than we think. <a href="https://www.thelancet.com/series/commercial-determinants-health">New evidence</a> published in The Lancet shows that key causes of ill health – such as obesity and related noncommunicable diseases – are linked to commercial entities with deep pockets and the power to shape the choices people make. They do this by influencing the political and economic system, and its underlying regulatory approaches and policies.</p>
<h2>Industry tactics</h2>
<p>The ways that commercial entities shape our food environments to maximise their profits are known as the “commercial determinants of health”. They create an environment that drives us towards unhealthy choices. </p>
<p>There are three main ways they do this:</p>
<ol>
<li><p>We are <a href="https://www.sciencedirect.com/science/article/pii/S0195666313001268?via%3Dihub">socialised to believe</a> that, as adults, our food choices are a direct result of free will, and of freedom of choice. Yet for people with a limited amount of money, that “freedom” is exercised in a context largely shaped – and limited – by what food and drink manufacturers and retailers choose to produce, market and sell.</p></li>
<li><p>Marketing creates demand. Supermarkets are filled with ultra-processed foods with lots of added sugars, unhealthy fats and harmful additives. These food products are designed to activate <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6550161/">your taste “bliss point”</a> and make you crave more. Food and beverage manufacturers use unethical tactics to market them. They target children with <a href="https://www.mdpi.com/2072-6643/11/4/875">manipulative imagery</a> and stressed-out parents with “easy” solutions for feeding and satisfying their family.</p></li>
<li><p>Food and beverage companies’ profits <a href="https://www.fooddive.com/news/where-the-dollars-go-lobbying-a-big-business-for-large-food-and-beverage-c/607982/">strengthen their political influence</a>. This is especially true in under-regulated markets in low- and middle-income countries. They use their economic power (employment, tax revenues) to support corporate lobbying that weakens government policy. </p></li>
</ol>
<h2>What can be done</h2>
<p>The Lancet series maps out four ways through which governments, businesses and citizens can reduce the harms caused by big corporations and curb the power of commercial entities. </p>
<p><strong>1. Rethink the political and economic systems.</strong></p>
<p>Developing countries, including <a href="https://weall.org/resource/bhutan-gross-national-happiness-index">Bhutan</a>, <a href="https://weall.org/resource/ecuador-legislative-and-regulatory-reform-for-social-and-environmental-rights">Ecuador</a> and <a href="https://weall.org/resource/porto-alegre-brazil-continuous-innovations-in-wellbeing-policy-design-and-implementation">Brazil</a>, as well as developed countries such as <a href="https://weall.org/resource/new-zealand-implementing-the-wellbeing-budget">New Zealand</a> and <a href="https://weall.org/norway-announces-new-national-wellbeing-strategy">Norway</a>, are beginning to pave the way for new frameworks that put people’s well-being first. In the UK, <a href="https://weall.org/resource/scotland-building-a-wellbeing-framework-through-public-consultation">Scotland</a> and <a href="https://weall.org/resource/wales-coordination-alignment-of-implementation-towards-wellbeing-goals">Wales</a> have also taken significant steps.</p>
<p>These frameworks measure commercial effects on health and the environment, and encourage commercial practices that promote health. Ways to do this include enforcing policies – such as the tax on sugar-sweetened beverages – that ensure commercial entities pay their fair share of taxes, and are obliged to account for the full costs of the health, social and environmental harms caused by the production, consumption and disposal of their products. </p>
<p><strong>2. Develop an “international convention” on commercial determinants of health.</strong></p>
<p>In practice, this would mean replicating and expanding global regulatory frameworks that work. The World Health Organization’s (WHO) <a href="https://fctc.who.int/who-fctc/overview">Framework Convention on Tobacco Control</a> has shown that public health policies can be protected from commercial interests. Since its adoption in 2003, the convention has had significant <a href="https://tobaccocontrol.bmj.com/content/28/Suppl_2/s119">impact</a> on public policy changes related to tobacco control around the world. It’s provided a framework for countries to develop and implement evidence-based measures to reduce tobacco use and the harms associated with it. Some examples include smoke-free laws; graphic health warnings on tobacco products; prohibition of tobacco advertising, promotion and sponsorship; and tobacco tax increases.</p>
<p>The Lancet suggests that, with support from the WHO and its member states, an “international convention” on commercial determinants of health should be developed. It is proposed that public health policy leaders and politicians replicate the tobacco control convention by making it legally binding for countries to comply with a set of principles or rules. The framework would have to be broad enough to cover the full range of commercial influences on health. These include <a href="https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2005.064410">mining</a>, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3154234/">fossil fuels</a>, <a href="https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(21)00098-0/fulltext">gambling</a>, <a href="https://pubmed.ncbi.nlm.nih.gov/21610130/">automobile industries</a>, <a href="https://pubmed.ncbi.nlm.nih.gov/18982834/">pharmaceuticals</a>, <a href="https://www.tandfonline.com/doi/full/10.1080/23753234.2022.2086891">technology and social media</a> (beyond the better-known alcohol and food industries). </p>
<p><strong>3. Comprehensive food-environment policies.</strong></p>
<p>One type of government policy proven to help protect and improve health is <a href="https://www.who.int/publications/i/item/9789240018341">public procurement</a> – how governments purchase goods and services. Governments can use their purchasing power to influence the food industry by encouraging the production and distribution of healthy food and limiting the availability of unhealthy food products. </p>
<p>In <a href="https://www.ajpmonline.org/article/S0749-3797(13)00633-8/fulltext">2008</a>, the mayor of New York City ordered city agencies to meet public food procurement standards for over 260 million annual meals and snacks. The standards apply to food from over 3,000 programmes at 12 agencies, including schools, hospitals and shelters. Nutritional requirements cover dairy, cereals, meat, fruit and vegetables, and set meal nutrient thresholds. </p>
<p>The <a href="https://www.cambridge.org/core/journals/public-health-nutrition/article/brazilian-school-feeding-programme-an-example-of-an-integrated-programme-in-support-of-food-and-nutrition-security/4245C868F05FC9E7FA43F9CACEF24A1B">Brazilian School Food Programme</a> is another example of a national public-procurement policy with direct health benefits. The programme provides healthy meals to millions of students in public schools across Brazil.</p>
<p>It’s required to purchase 30% of its supply from family farmers. The programme has improved the health and well-being of students, and promoted sustainable and ethical food production practices. It has also successfully regulated the sale and marketing of food within and outside school premises. </p>
<p>Countries across the globe could benefit from adopting this model, including South Africa, where despite industry pledges not to sell to schools, unhealthy foods and beverages <a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2021.1898130">remain easily accessible and available in schools</a>.</p>
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Read more:
<a href="https://theconversation.com/south-africa-must-ban-sugary-drinks-sales-in-schools-self-regulation-is-failing-160621">South Africa must ban sugary drinks sales in schools. Self regulation is failing</a>
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<p><strong>4. Social mobilisation.</strong></p>
<p>Citizens, civil society groups, activists, public health practitioners and academics can demand their right to health by calling for government action on commercial determinants of health. This can be done using a variety of strategies. They can raise their collective voice in support of evidence-based health measures; expose and oppose the harmful effects of commercial determinants on health and equity; and insist that commercial actors and governments are held accountable. </p>
<p><em>This article is part of a media partnership between The Conversation Africa and PRICELESS SA, a research-to-policy unit based in the School of Public Health at the University of the Witwatersrand. Researchers from the SAMRC/Wits Centre for Health Policy and Decision Science also contributed to the Lancet Series on the commercial determinants of health.</em></p><img src="https://counter.theconversation.com/content/202463/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Agnes Erzse is supported by the SAMRC/ Wits Centre for Health Economics and Decision Science, PRICELESS, University of Witwatersrand School of Public Health, Faculty of Health Sciences, Johannesburg South Africa (23108).</span></em></p>Over many decades our food environments have relentlessly been encouraging us to make choices that are harmful to our health, through pricing, marketing and availability.Agnes Erzse, Researcher, SAMRC/Centre for Health Economics and Decision Science- PRICELESS SA, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2023682023-03-27T15:55:33Z2023-03-27T15:55:33ZProfit versus health: 4 ways big global industries make people sick<figure><img src="https://images.theconversation.com/files/517610/original/file-20230327-23-bpdhjq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock </span></span></figcaption></figure><p>It’s now more commonly known that <a href="https://www.who.int/news-room/fact-sheets/detail/alcohol">alcohol</a> and <a href="https://www.who.int/news-room/fact-sheets/detail/tobacco">tobacco use</a> make us ill. Less known is that just four industries account for at least one-third of global preventable deaths. These industries are: unhealthy processed food and drinks, fossil fuels, alcohol and tobacco. Collectively they cause 19 million deaths every year, according to a <a href="https://www.thelancet.com/series/commercial-determinants-health">recent series of reports</a> published in The Lancet. </p>
<p>These deaths happen because of accepted business practices that prioritise profit over health - and not only through the companies’ products. This include cigarettes that <a href="https://cansa.org.za/files/2021/05/Fact-Sheet-on-Tobacco-Products-May-2021.pdf">cause cancer</a>, sugary drinks that result in <a href="https://www.cdc.gov/nutrition/data-statistics/sugar-sweetened-beverages-intake.html">obesity</a> or coal that drives <a href="https://www.carbonbrief.org/the-carbon-brief-profile-south-africa/">carbon dioxide emissions</a>, for example. The world’s largest commercial companies routinely operate in a way that masks their practices and allows them to continue and expand in the name of <a href="https://journals.sagepub.com/doi/full/10.1177/1024529420910382">neoliberal economic freedoms</a>. </p>
<p>These transnational corporations <a href="https://www.thelancet.com/series/commercial-determinants-health">drive</a> rapidly rising sickness and death levels, disability, environmental damage, and widening social inequities. The Lancet series describes a “pathological system” in which a substantial group of commercial actors are increasingly enabled to cause harm and to make others pay the costs of doing so. They profit without bearing any of the costs of the harmful products marketed to an unsuspecting public. </p>
<p>Commercial actors must meet the actual costs of the harm they
cause if further damage is to be prevented. Governments will need to hold commercial actors to account. And norms need to be reshaped in the public interest, drawing attention to the right to health and the governmental obligation to protect health, not just corporate freedoms.</p>
<p>The commercial sector exists to make a profit. In the logic of the private sector, this outweighs public health and well-being considerations. Commercial activity’s health impacts can be positive, such as employing people in communities. But most are harmful. In public health, we call these <a href="https://www.who.int/health-topics/commercial-determinants-of-health#tab=tab_1">“commercial determinants of health”</a>.</p>
<p>The commercial practices that lead to these impacts range from legal to illegal, evident to subtle. They often overlap. At the same time, several types of practices used by commercial actors harm us. The most obvious are marketing, reputation management, questioning scientific evidence, and financial manipulation. </p>
<p>This matters because it is the unsuspecting public that pay. They bear the suffering and the costs of the global epidemic of noncommunicable diseases, and the rapidly accelerating climate emergency.</p>
<h2>Marketing: making people consume more</h2>
<p>The commercial sector uses various “dark marketing” strategies to create demand for brands and increase product consumption. Advertising for fast food and other ultra-processed food (high in fat, sugar and salt) dominates many countries’ advertising space. <a href="https://www.researchgate.net/publication/350707676_Exposure_of_Children_to_Unhealthy_Food_and_Beverage_Advertisements_in_South_Africa">Nearly half</a> of the advertisements viewed during child or family time in South Africa are for ultra-processed food and drink products. </p>
<p>A case study from South Africa that features in the Lancet series, on Coca-Cola’s marketing of sugar-sweetened drinks, illustrates how seemingly “normal” business practices can have devastating health impacts.</p>
<p>Coca-Cola and other beverage companies operate in South Africa in the context of alarming rates of obesity. Of <a href="https://health-e.org.za/2023/03/02/obecity-index-capetonians-carry-least-weight/">the obese</a> population, 68% are women, 31% are men and 13% are children. School children aged 10-13 consume at least <a href="https://www.ajol.info/index.php/jfecs/article/view/53995">two servings of sugary drinks</a> daily. This makes South Africa one of the <a href="https://www.coca-colacompany.com/press-releases/the-coca-cola-company-sabmiller-and-coca-cola-sabco-to-form-coca-cola-beverages-africa">top 10</a> global consumers of Coca-Cola products. </p>
<p>The company’s marketing practices target mostly poor South Africans, seen as its growth market. Its products are available everywhere, from supermarkets to street vendors and remote rural areas. Branding is pervasive, from school and shop signs to billboards, TV advertisements and social media presence. One under-discussed aspect of this practice is how marketing reshapes cultural norms. It makes a deadly product aspirational – much as the <a href="https://www.cdc.gov/tobacco/data_statistics/fact_sheets/tobacco_industry/marketing/index.htm">tobacco industry</a> did decades ago.</p>
<h2>Reputation management: covering their tracks</h2>
<p>Creating brand loyalty can fall into the realm of reputation management, sometimes in the guise of “corporate social responsibility”.</p>
<p>For example, some big food companies distributed unhealthy products with no nutritional value during the <a href="https://ncdalliance.org/news-events/news/new-report-details-hundreds-of-examples-of-unhealthy-commodity-industries-leveraging-the-covid-19-pandemic">COVID-19 pandemic</a>. Coca-Cola donated sugary drinks in <a href="https://www.youtube.com/watch?v=av2I8mhmWwY">Ghana</a>. Krispy Kreme donated doughnuts to <a href="https://www.independent.co.uk/life-style/food-and-drink/krispy-kreme-coronavirus-free-doughnuts-healthcare-workers-may-a9432236.html">frontline emergency workers</a> in the US. South African Breweries claimed to have recycled beer crates to make <a href="https://www.bizcommunity.com/Article/196/348/202947.html">face shields for health workers</a>.</p>
<p>The commercial sector seeks to influence policies so that they support the trade of harmful products or services. For example, the sugar industry in South Africa <a href="https://www.vitalstrategies.org/wp-content/uploads/Lessons-From-South-Africa-Campaign-for-a-Tax-on-Sugary-Beverages.pdf">successfully lobbied</a> to halve the proposed tax on sugary drinks.</p>
<p>The world’s largest tobacco company, Philip Morris International, has been <a href="https://www.businesslive.co.za/bd/national/health/2022-09-22-philip-morris-sa-calls-for-different-rules-for-its-differing-products/">calling for relaxed regulations</a> on advertising its “smoke-less” products in South Africa ahead of a new <a href="https://www.parliament.gov.za/bill/2307574">Control of Tobacco Products and Electronic Delivery Systems Bill</a>. </p>
<p>The alcohol industry once formed an <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3260574/">interest group</a>, known as the Association for Responsible Alcohol Use, to influence government policies in South Africa.</p>
<h2>Skewing science</h2>
<p>Commercial influences on the scientific process can be subtle but pervasive. Funding research in non-transparent ways creates bias. Many commercial sectors attempt to manipulate scientific findings in their favour or to hide or falsify results. In 2017, for example, independent researchers uncovered how Exxon Mobil had intentionally <a href="https://www.globalcitizen.org/en/content/exxon-mobil-lied-about-climate-change/?gclid=CjwKCAjw_MqgBhAGEiwAnYOAemTBgfHbezOyci6Lzgrr8eTn0riC3PdzMzp7PT-jkUGscOc55G5bYBoCVVMQAvD_BwE">misled the public about how extractive activities contributed to climate change</a>.</p>
<p>Pharmaceutical companies use intellectual property rights to keep drugs at a high price. This limits access to medicines. Recently, <a href="https://www.npr.org/sections/goatsandsoda/2021/11/10/1052078529/why-low-income-countries-are-so-short-on-covid-vaccines-hint-its-not-boosters">COVID-19 vaccines</a> were affordable for only the wealthiest countries. The same thing happened <a href="https://oxfamilibrary.openrepository.com/bitstream/handle/10546/620381/bn-access-to-medicines-south-africa-010201-en.pdf?sequence=1&isAllowed=y">two decades earlier</a> with antiretroviral drugs for HIV.</p>
<h2>Financial manipulation: tax avoidance and more</h2>
<p>Multinational mining companies continue to <a href="https://www.imf.org/en/Blogs/Articles/2021/11/05/blog-countering-tax-avoidance-sub-saharan-africa-mining-sector">cheat Africa out of billions of dollars</a> by under-reporting profits and paying lower taxes. In Zambia, for example, copper earns transnational copper mining companies billions annually. It’s estimated that their corporate tax avoidance denies the country US$3 billion in taxes yearly. This is more than 12.5% of Zambia’s <a href="https://www.imf.org/en/Publications/Departmental-Papers-Policy-Papers/Issues/2021/09/27/Tax-Avoidance-in-Sub-Saharan-Africas-Mining-Sector-464850">entire GDP</a>.</p>
<p>Some companies exploit labour (for instance, in the agricultural sector) and pollute the environment (for example, in the mining sector). These practices harm human and environmental health but were previously considered “normal” modes of doing business.</p>
<h2>Looking ahead</h2>
<p>Many of these “routine” commercial methods overlap and support each other. Transnational corporations with deep pockets can use them particularly well in weakly regulated low- and middle-income countries.</p>
<p>Individuals and their families, civil society, and governments increasingly bear the costs of harm caused by corporations. </p>
<p>It will take concerted joint efforts, such as an international convention, to change the system. This change needs to be in the direction of prioritsing societal and environmental well-being and health impacts. Until this happens, health and equity will continue to be threatened, causing significant economic damage and declining social development. </p>
<p><em>This article is part of a media partnership between The Conversation Africa and PRICELESS SA, a research-to-policy unit based in the School of Public Health at the University of the Witwatersrand. Researchers from the SAMRC/ Wits Centre for Health Policy and Decision Science - also contributed to the Lancet Series on the commercial determinants of health.</em></p><img src="https://counter.theconversation.com/content/202368/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Teurai Rwafa does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The public bears the suffering and costs of the global epidemic of noncommunicable diseases, and the rapidly accelerating climate emergency.Teurai Rwafa, Visiting Lecturer - Wits School of Public Health, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1960782023-01-29T18:34:37Z2023-01-29T18:34:37ZChildren and teens aren’t doing enough physical activity - new study sounds a health warning<figure><img src="https://images.theconversation.com/files/505850/original/file-20230123-14-iwjhhc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Regular physical activity helps to prevent and manage many chronic diseases.</span> <span class="attribution"><span class="source">Amorn Suriyan/Shutterstock</span></span></figcaption></figure><p>Physical inactivity is the <a href="https://www.sciencedirect.com/science/article/abs/pii/S0140673612608988?via%3Dihub">fourth leading cause of death</a> worldwide. It’s also associated with chronic illness and disability. Recent <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(22)00464-8/fulltext">research</a> estimates that the world could see close to half a billion new cases of major chronic diseases by 2030 if people don’t get more active. Regular physical activity helps to prevent and manage many chronic diseases. Popular ways to be physically active include walking, cycling, and playing sports. </p>
<p>The World Health Organization (WHO) <a href="https://www.who.int/news-room/fact-sheets/detail/physical-activity">recommends</a> that children and adolescents (5-17 years old) get an average of at least 60 minutes per day of moderate to vigorous intensity physical activity. This should incorporate vigorous aerobic activities, as well as those that strengthen muscle and bone, at least three days a week. It’s also recommended that children spend no more than two hours a day on recreational screen time. These recommendations aim to improve children’s physical and mental health, as well as cognitive outcomes. </p>
<p>Before the COVID-19 pandemic, physical activity among children and adolescents was already below the recommended levels. In 2016, <a href="https://www.sciencedirect.com/science/article/pii/S2352464219303232?via%3Dihub">81%</a> of adolescents around the world aged 11-17 were considered physically inactive. Girls were less active than boys. </p>
<p>The pandemic has made matters worse. Physical inactivity in children and adolescents has become a global public health priority. It is now included in global action plans. </p>
<p>For example, using 2016 as baseline, the WHO through its Global Action Plan on Physical Activity <a href="https://apps.who.int/iris/bitstream/handle/10665/272722/9789241514187-eng.pdf#page=21">targeted</a> a 15 percentage point reduction in prevalence of physical inactivity among adolescents by 2030. This call to action also implored other international organisations and governments to help track progress in physical activity promotion among children and adolescents. </p>
<p>In response to this global physical inactivity crisis, the international call to action, and the need to systematically collect comparable data, the <a href="https://www.activehealthykids.org">Active Healthy Kids Global Alliance</a> recently published a major <a href="https://doi.org/10.1123/JPAH.2022-0456">study</a>, the first to provide a comprehensive assessment of physical activity among children and adolescents. Published in October 2022, the study included data that were collected before and during the COVID-19 pandemic. We were among the 682 experts who assessed 10 common physical activity indicators for children and adolescents around the world. </p>
<p>Our <a href="https://doi.org/10.1123/jpah.2022-0456">study</a> shows physical activity among children and adolescents has not gotten better. About one-third of children and adolescents globally were sufficiently physically active while a little over one-third met the recreational screen time recommendation for better health and well being. These findings indicate that a significant proportion of children and adolescent who do not meet recommended physical activity guidelines are at an increased risk of negative outcomes as well as developing related chronic diseases at a much earlier age. </p>
<h2>COVID effect</h2>
<p>Most of the experts involved in our <a href="https://doi.org/10.1123/jpah.2022-0456">study</a> agree that the childhood physical inactivity crisis is an ongoing public health challenge and the COVID-19 pandemic appears to have made it worse. When surveyed, more than 90% of the experts reported that COVID-19 had a negative impact on children’s sedentary behaviours, organised sport and physical activity. Our findings are supported by numerous studies. </p>
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Read more:
<a href="https://theconversation.com/heres-how-much-kids-need-to-move-play-and-sleep-in-their-early-years-107024">Here's how much kids need to move, play and sleep in their early years</a>
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<p>Lockdowns imposed at the height of the COVID-19 pandemic led to school shutdowns and closures of public parks, which hampered children’s levels of physical activity. Research <a href="https://jamanetwork.com/journals/jamapediatrics/fullarticle/2794075">suggests</a> that children’s moderate-to-vigorous physical activity decreased by 17 minutes per day during the pandemic. That represents a reduction of almost one-third of the recommended daily activity. Another <a href="https://www.sciencedirect.com/science/article/pii/S2214109X22003618?via%3Dihub">global study</a> representing 187 countries showed a collective 27.3% decrease in the daily step counts of individuals after 30 days of COVID-19 related restrictions.</p>
<h2>Our study</h2>
<p>Four African countries participated in our study –<a href="https://www.activehealthykids.org/botswana/">Botswana</a>, <a href="https://www.activehealthykids.org/ethiopia/">Ethiopia</a>, <a href="https://www.activehealthykids.org/south-africa/">South Africa</a> and <a href="https://www.activehealthykids.org/zimbabwe/">Zimbabwe</a>.</p>
<p>The grading ranged from as high as A+ (large majority, 94%-100% of children and adolescents achieving recommended levels) to as low as F (less than 20% achieving recommended levels). </p>
<p>Children and adolescents from the four African countries were marginally more physically active than children from the rest of the world. They received C- (47%–53% of them met recommendations) for overall physical activity compared to the D (27%–33% met recommendations) for the rest of the world. More children and adolescents from the African countries used active transport (B-; 60%–66%), were less sedentary (C-; 40%–46%) and were more physically fit (C+; 54%–59%), compared to the rest of the world (C-, D+ and C-) respectively. </p>
<p>An important success story from this global comparison of grades is that despite the lack of infrastructure, average grades for individual behaviours were generally better for the African countries. This could be reflecting necessity, rather than choice. For example, children might be forced to walk to school because there’s no affordable transport. Nonetheless it shows that it is still possible to promote healthy lifestyles even when resources are limited.</p>
<p>Factors such as having supportive family and friends, safer communities, positive school environments and adequate resources are often associated with better participation in physical activity. Average grades for these sources of influence were generally lower for the four African countries than those of the rest of the world. These findings demonstrate the challenges related to community safety, a general lack of infrastructure, and funding to support healthy behaviours for children and adolescents in African countries. </p>
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<strong>
Read more:
<a href="https://theconversation.com/young-women-in-soweto-say-healthy-living-is-hard-heres-why-118198">Young women in Soweto say healthy living is hard. Here's why</a>
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<p>Overall, there wasn’t enough data to accurately grade all the indicators for the African countries. <a href="https://doi.org/10.1123/jpah.2022-0456">Botswana</a> was the only country for which we were able to assign grades for each of the 10 common indicators. The other three countries had at least one incomplete grade each. Lack of representative data is a common and often recurring problem in many low- and middle-income countries. It also means that our findings must be interpreted with caution. For example, we can’t say with certainty that these findings are representative of all the children and adolescents from these four countries or the region as a whole. </p>
<h2>Way forward</h2>
<p>In many parts of Africa, the prevalence of infectious and other diseases justifiably demands attention and resources. These needs can out compete the messages about physical inactivity, whose negative impact may be silent but still detrimental to population health. </p>
<p>We need to persistently advocate for policies and practices, anchored in the African context, and promote equitable opportunities for children to engage in physical activity. These can include active school recesses and extracurricular programmes. Countries need to ensure access to safe, free public spaces, green spaces, playgrounds and sporting facilities. </p>
<p>Finally, researchers and public health practitioners must track the progress towards meeting the WHO’s targets.</p><img src="https://counter.theconversation.com/content/196078/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Factors such as having supportive family and friends, safer communities, positive school environments and adequate resources, are often associated with more physical activity.Taru Manyanga, Assistant Professor-Physical Therapy, University of Northern British ColumbiaChalchisa Abdeta, PhD candidate, University of WollongongDawn Tladi, Senior Lecturer of Exercise Physiology, University of BotswanaRowena Naidoo, Associate Professor in Sport Science, University of KwaZulu-NatalLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1954792022-12-13T13:27:56Z2022-12-13T13:27:56ZHypertension, diabetes, stroke: they kill more people than infectious diseases and should get a Global Fund<figure><img src="https://images.theconversation.com/files/499986/original/file-20221209-19531-9yfpxs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">shutterstock</span> </figcaption></figure><p>Noncommunicable diseases such as diabetes, hypertension and cardiovascular conditions account for <a href="https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases">41 million deaths</a> each year. That’s more than 70% of all deaths globally. Most of these deaths (77%) are in low-income and middle-income countries – including those in Africa. </p>
<p>These conditions are currently <a href="https://www.researchgate.net/publication/356360474_Tanzania_Non-communicable_Diseases_and_Injuries_Poverty_Commission_Findings_and_Recommendations">more prevalent</a> than infectious diseases. Sixty-seven percent occur before the age of 40. Besides being the leading causes of death worldwide, noncommunicable diseases carry a <a href="https://apps.who.int/iris/handle/10665/274512">huge cost</a> to individuals. These also undermine workforce productivity and threaten economic prosperity.</p>
<p>Healthcare provision in much of Africa still relies on <a href="https://www.brookings.edu/blog/future-development/2019/03/01/closing-africas-health-financing-gap/">external donors</a>. There’s insufficient funding to help low-income and middle-income countries control noncommunicable diseases. Most <a href="https://jamanetwork.com/journals/jama/fullarticle/2320320">development assistance for health funding</a> provided by international donors is allocated for infectious diseases and maternal and child health. In <a href="https://vizhub.healthdata.org/fgh/">2019</a>, funding for HIV amounted to US$9.5 billion. The amount allocated to noncommunicable diseases was US$0.7 billion. </p>
<p>Evidence suggests that addressing the noncommunicable disease pandemic can also mitigate other challenges like HIV, tuberculosis (TB), maternal and child health, and universal health coverage. </p>
<p>The <a href="https://www.theglobalfund.org/en/">Global Fund</a> to Fight AIDS, TB and Malaria is an international partnership. The fund invests US$4 billion a year to fight these three diseases. </p>
<p>I believe it’s now time to think of establishing a Global Fund for noncommunicable diseases, or expand the mandate of Global Fund beyond AIDS, TB and malaria. The epidemics of these conditions overlap. For example, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8872228/#:%7E:text=The%20most%20prevalent%20HIV%20comorbidities,and%20hepatitis%20C%20%5B14%5D.">research</a> has shown that <a href="https://jamanetwork.com/journals/jama/article-abstract/2757599">comorbidities</a> such as diabetes and cancers are common in people living with HIV. </p>
<h2>Broadening healthcare provision</h2>
<p>Disease specific programmes have <a href="https://academic.oup.com/heapol/article/33/3/381/4812662">limitations</a>. As public health practitioners we should learn from our mistakes. We must build integrated programmes and health systems that address the interlinkages and co-morbidities. One example would be to include diabetes screening in TB treatment programmes. </p>
<p>In addition to integration, noncommunicable diseases require increasing investments. </p>
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<a href="https://images.theconversation.com/files/499973/original/file-20221209-22427-6zj374.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/499973/original/file-20221209-22427-6zj374.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/499973/original/file-20221209-22427-6zj374.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=280&fit=crop&dpr=1 600w, https://images.theconversation.com/files/499973/original/file-20221209-22427-6zj374.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=280&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/499973/original/file-20221209-22427-6zj374.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=280&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/499973/original/file-20221209-22427-6zj374.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=352&fit=crop&dpr=1 754w, https://images.theconversation.com/files/499973/original/file-20221209-22427-6zj374.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=352&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/499973/original/file-20221209-22427-6zj374.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=352&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<p>The Global Fund is seeking US$18 billion this year. At the same time <a href="https://www.thelancet.com/ncd-countdown-2030">The Lancet NCD Countdown 2030</a> projects that interventions for noncommunicable diseases need US$18 billion a year. That’s what it would take to meet the UN target of reducing noncommunicable diseases by a third by the year 2030. </p>
<p>I would argue that the case for <a href="https://pubmed.ncbi.nlm.nih.gov/35339227/">investment</a> in noncommunicable diseases has never been stronger. </p>
<h2>A roadmap</h2>
<p>The World Health Assembly recently <a href="https://www.who.int/news-room/feature-stories/detail/world-health-assembly-approves-a-global-implementation-roadmap-to-accelerate-action-on-noncommunicable-diseases-(ncds)">approved</a> the World Health Organization’s roadmap for the prevention and control of noncommunicable diseases covering the period 2023-2030. </p>
<p>The roadmap recommends actions to: </p>
<ul>
<li><p>promote “best-buys” interventions with a high return for every dollar spent, such as smoking cessation programmes </p></li>
<li><p>strengthen health systems </p></li>
<li><p>reduce noncommunicable disease risk factors such as tobacco use and unhealthy diets </p></li>
<li><p>embed noncommunicable diseases within primary healthcare and universal health coverage. </p></li>
</ul>
<p>This roadmap needs to be followed in line with the commitments to reduce air pollution and promote mental health and well-being.</p>
<p>The lessons learned from the COVID-19 pandemic offer opportunities for strengthening emergency preparedness and responses beyond pandemics. Emergency risk management and continuity of essential health services for all hazards – addressing the foundational health system gaps – can improve health security.</p>
<h2>What should be done</h2>
<p>How should Africa respond to the increasing burden of noncommunicable diseases? There needs to be a strong political will and buy-in from governments, with strong multi-stakeholder participation. </p>
<p>The <a href="https://www.who.int/teams/noncommunicable-diseases/on-the-road-to-2025">UN General Assembly</a> decision on HIV and noncommunicable diseases commits governments to identify and address the comorbidities of HIV and other links to pressing global health challenges. These include links to noncommunicable diseases, learning from the perspectives of people living with these conditions and underscoring the importance of focusing on comorbidities. </p>
<p>The WHO’s <a href="https://www.who.int/initiatives/global-noncommunicable-diseases-compact-2020-2030#:%7E:text=The%20Global%20NCD%20Compact%202020,of%20people%20living%20with%20NCDs.">noncommunicable disease compact</a> proposes concrete actions. These actions need to be data-driven and supported by noncommunicable disease-related indicators in health systems performance and access to healthcare metrics. </p>
<p>Monitoring systems need to be more diverse. The systems should capture and monitor progress made through sectors that affect health, such as housing and sanitation. Doing this would strengthen the monitoring of national systems and the capacity to address noncommunicable diseases comprehensively.</p>
<p>Health system strengthening and quality of care will improve significantly with additional resources for noncommunicable diseases through an entity like the Global Fund. </p>
<p><em>This article is part of a media partnership between The Conversation Africa and the 2022 Conference on Public Health in Africa.</em></p><img src="https://counter.theconversation.com/content/195479/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kaushik Ramaiya is Honorary General Secretary of Tanzania Diabetes Association and we work with Ministry of Health (Tanzania) in implementing National NCD program which has been funded by World Diabetes Foundation (WDF) and Novo Nordisk Foundation. </span></em></p>Addressing the noncommunicable disease pandemic can also mitigate challenges facing people living with HIV and complement efforts against TB.Kaushik Ramaiya, Honorary Professor of Medicine & Global Health , Liverpool School of Tropical MedicineLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1945742022-12-05T13:54:47Z2022-12-05T13:54:47ZMore South Africans are smoking - higher taxes and stronger law enforcement are needed<figure><img src="https://images.theconversation.com/files/496103/original/file-20221118-22-tla1jx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">South Africa has seen an increase in people who smoke.</span> <span class="attribution"><span class="source"> Lefty Shivambu/Gallo Images via Getty Images</span></span></figcaption></figure><p>Tobacco use imposes a <a href="https://cancercontrol.cancer.gov/brp/tcrb/monographs/monograph-21">significant</a> health and economic burden on countries. <a href="https://pubmed.ncbi.nlm.nih.gov/32832993/">Research</a> estimates that the cost of smoking in South Africa amounted to 0.97% of the country’s GDP in 2016. These costs are likely to have increased as a result of the observed rise in smoking prevalence over the past five years.</p>
<p>In 2021, South Africa conducted its first Global Adult Tobacco Survey. This is a nationally representative household survey that monitors tobacco use among adults aged 15 years and older. According to the <a href="https://www.health.gov.za/wp-content/uploads/2022/05/Global-Adult-Tobacco-Survey-GATS-SA_FS-Populated__28-April-2022.pdf">results</a>, 25.8% of the South African population (11.1 million adults) currently smoke tobacco. This is significantly higher than the <a href="https://tobaccocontrol.bmj.com/content/tobaccocontrol/29/Suppl_4/s234.full.pdf">19.9%</a> estimated in the most recent wave of the National Income Dynamics Study that was conducted in 2017. Tobacco use is associated with a myriad of illnesses including cancers.</p>
<p>Research has shown that one way to <a href="https://cancercontrol.cancer.gov/brp/tcrb/monographs/monograph-21">reduce</a> tobacco use is consistent, year-on-year increases in tobacco excise taxes. The excise tax increases have to be sustained over time and adjusted annually, at the very least. These tax increases should be well above the inflation rate to have a meaningful impact on the affordability of tobacco products. Reductions in the affordability of tobacco products will ensure significant reductions in tobacco use. </p>
<p>A major challenge to this strategy is the proliferation of the illicit tobacco trade in the country. Independent <a href="https://www.econ3x3.org/article/how-big-illicit-cigarette-market-south-africa">research</a> suggests that illicit cigarette sales constituted a staggering 54% of the total market in 2021. Illicit cigarettes are relatively cheap because they bypass taxes. This makes cigarettes more affordable, which increases smoking rates. </p>
<p>The tobacco industry has <a href="https://blogs.bmj.com/tc/2020/10/15/illicit-tobacco-trade-not-exacerbated-by-tobacco-tax-increases-in-low-middle-income-countries-research-shows/">worked</a> tirelessly in South Africa, and across the globe, to convince policy makers that increases in the tobacco taxes cause increases in illicit trade. This argument is self-serving and has no credible research backing. </p>
<p>In fact, South Africa’s own tobacco taxation record shows that excise taxes can be increased aggressively, without exacerbating the illicit market. When it comes to tobacco use, the country has dual but unrelated problems. The first is the government’s inadequate excise tax increases on tobacco. The second is the thriving illicit tobacco market. To address these, the government must increase tobacco taxes faster to reduce their affordability, and improve enforcement to reduce the presence of illicit tobacco products in the market. </p>
<h2>Excise taxes</h2>
<p>Between 1994 and 2009, inflation-adjusted cigarette excise taxes in South Africa <a href="https://tobaccocontrol.bmj.com/content/27/1/65">increased</a> five-fold. This resulted in a near-tripling of real cigarette retail prices. </p>
<p>These price increases and other factors, including the introduction of tobacco control legislation, saw a <a href="https://tobaccocontrol.bmj.com/content/27/1/65">decrease</a> in South Africa’s smoking prevalence from approximately a third of the population to less than a fifth between 1994 and 2012.</p>
<p>Peer-reviewed <a href="https://tobaccocontrol.bmj.com/content/27/1/65">research</a> examining trends in illicit trade in South Africa between 2002 and 2017 finds no evidence that the illicit market grew when cigarette excise taxes were growing rapidly in the 1990s and early 2000s. Instead, the <a href="https://tobaccocontrol.bmj.com/content/29/Suppl_4/s234">research</a> shows that the illicit cigarette trade only became a significant problem in South Africa from 2009 onwards. The illicit market grew from less than 5% in 2009 to around 17% in 2014 – and then increased to more than 30% in 2017.</p>
<p>During this period, the real (inflation-adjusted) excise tax on cigarettes remained largely unchanged. This fact dispels the tobacco industry’s <a href="https://tobaccotactics.org/wiki/illicit-tobacco-trade/">arguments</a> about the link between tobacco taxes and illicit trade in South Africa.</p>
<p>The rapid growth in illicit trade between 2009 and 2017 can be attributed to the erosion of the revenue services’ investigative capacity. Between <a href="https://www.thepresidency.gov.za/sites/default/files/SARS%20Commission%20Final%20Report.pdf">2014 and 2018</a> it disbanded specialised units that had been established to investigate the tobacco industry. </p>
<p>Under new leadership, in early 2019, the revenue service set up an <a href="https://www.news24.com/fin24/economy/kieswetter-sars-illicit-economy-unit-has-recovered-r26bn-so-far-20200124-3">Illicit Economy Unit</a>. In the 2019/2020 fiscal year cigarette tax revenue and the number of cigarettes on which excise tax was levied <a href="https://cramsurvey.org/wp-content/uploads/2021/02/11.-Van-Walbeek-C.-Hill-R.-Filby-S.-Van-der-Zee-K.-2021-Market-impact-of-the-COVID-19-national-cigarette-sales-ban-in-South-Africa.pdf">increased</a>. </p>
<p>Unfortunately, the 20-week ban on tobacco sales, imposed by the government in 2020, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9383820/">undid</a> this progress. <a href="https://tobaccocontrol.bmj.com/content/31/6/694">Research</a> suggests that the ban entrenched the illicit market by creating a situation where manufacturers and traders operated in an exclusively illicit market for an extended period of time. During the sales ban, most cigarettes were sold through informal retail outlets. </p>
<p>Because it leads to lower tobacco prices, illicit trade directly <a href="https://documents1.worldbank.org/curated/en/677451548260528135/pdf/133959-REPL-PUBLIC-6-2-2019-19-59-24-WBGTobaccoIllicitTradeFINALvweb.pdf">increases</a> tobacco consumption. It also <a href="https://academic.oup.com/ntr/article-abstract/15/4/767/1068791">undermines</a> non-tax policies to reduce tobacco use. Cabinet has recently approved the <a href="https://www.gov.za/sites/default/files/gcis_document/202209/46994rg11494gon2560.pdf">Tobacco Products and Electronic Delivery Systems Control Bill</a> of 2018. Among other things, the bill seeks to introduce plain packaging and graphic health warnings for all tobacco and nicotine products. These policies have been <a href="https://www.bath.ac.uk/case-studies/debunking-big-tobaccos-arguments-against-standardised-packaging/">proven</a> effective in decreasing smoking initiation and encouraging quitting. </p>
<p>But their effectiveness will be significantly undermined if cheap, illicit cigarettes are widely available.</p>
<h2>Illicit trade</h2>
<p>Illicit trade concerns criminals and money. It can only be addressed through effective enforcement mechanisms which include, amongst other things, measures to secure the tobacco supply chain. The South African government has not ratified the <a href="https://fctc.who.int/protocol/overview#:%7E:text=The%20Protocol%20to%20Eliminate%20Illicit,solution%20to%20a%20global%20problem.">Protocol to Eliminate Illicit Trade in Tobacco Products</a>, despite multiple requests by civil society organisations to do so. </p>
<p>Should South Africa ratify the Protocol, the country will commit itself to implement measures that have been proven to reduce the illicit trade in cigarettes. Measures include the adoption of track and trace technology that is independent of the tobacco industry, and licensing of agents in the tobacco supply chain, amongst other things. </p>
<p>Illicit trade also significantly reduces government revenue. The tobacco sales ban provided an extreme example of how dramatic these revenue losses can be. During the 20-week sales ban, government <a href="https://cramsurvey.org/wp-content/uploads/2021/02/11.-Van-Walbeek-C.-Hill-R.-Filby-S.-Van-der-Zee-K.-2021-Market-impact-of-the-COVID-19-national-cigarette-sales-ban-in-South-Africa.pdf">lost</a> approximately R6 billion in excise duties on cigarette sales alone. Most, if not all, tobacco companies continued to produce and sell cigarettes during the sales ban. No excise taxes were paid on these sales. </p>
<p>Recent media <a href="https://www.sars.gov.za/latest-news/media-statement-on-gold-leaf-tobacco/">reports</a> have documented the revenue services’ investigation into Gold Leaf Tobacco Corporation. This action is a good first step in addressing tax evasion by cigarette manufacturers as it is likely to incentivise tax compliance among other tobacco companies. </p>
<p>However, given the scale of South Africa’s illicit trade problem, more needs to be done. It is of the utmost importance that government ratifies the Protocol to Eliminate Illicit Trade in Tobacco Products and implements its provisions. At the same time, it is imperative that the Treasury substantially increases the tobacco excise tax each year to discourage tobacco use in South Africa.</p>
<h2>Immediate steps</h2>
<p>The Treasury should implement a strategy in which they increase the tobacco excise tax by a pre-announced percentage (for example 10% above the inflation rate) on a multi-year basis. </p>
<p>It has been demonstrated in countries such as <a href="https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(19)30203-8/fulltext">Australia</a> and <a href="http://journal.waocp.org/article_89099.html">the Philippines</a> that such a multi-year tobacco taxation strategy reduces the affordability of tobacco products over time. This has improved public health outcomes, and raised government revenues.</p>
<p>It would also align South Africa’s tobacco taxation strategy with the recommendations of the <a href="https://fctc.who.int/publications/i/item/9241591013">World Health Organization Framework Convention on Tobacco Control</a>, an international treaty that requires ratifying countries to implement policies to reduce the demand and supply of tobacco products. South Africa ratified the treaty in 2005. But is yet to implement the treaty’s recommendations on best-practice tobacco taxation policy. Until it does, government will continue to miss out on the opportunity to raise much-needed additional revenue, and save lives.</p><img src="https://counter.theconversation.com/content/194574/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sam Filby is a Research Officer at the Research Unit on the Economics of Excisable Products, based at the University of Cape Town. REEP receives funding from the African Capacity Building Foundation (in turn funded by the Bill & Melinda Gates Foundation), Cancer Research UK, the CDC Foundation and the DG Murray Trust. Sam is also a co-founder of byegwaai, South Africa's first app-based smoking cessation programme. </span></em></p><p class="fine-print"><em><span>Corne van Walbeek is the Director of the Research Unit on the Economics of Excisable Products (REEP). REEP receives funding from the African Capacity Building Foundation (in turn funded by the Bill & Melinda Gates Foundation), Cancer Research UK, the CDC Foundation and the DG Murray Trust.</span></em></p>Reductions in the affordability of cigarettes will ensure significant reductions in tobacco use.Sam Filby, Research Officer, Research on the Economics of Excisable Products,, University of Cape TownCorne van Walbeek, Professor of Economics and Director of the Research Unit on the Economics of Excisable Products, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1911912022-10-04T15:45:56Z2022-10-04T15:45:56ZDiabetes in South Africa: 60% aren’t being screened for complications, according to new study<figure><img src="https://images.theconversation.com/files/487728/original/file-20221003-18-l1d9q2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Eleven percent of South African adults live with diabetes. </span> <span class="attribution"><span class="source">GettyImages</span></span></figcaption></figure><p>The world is experiencing a <a href="https://www.who.int/news-room/fact-sheets/detail/diabetes">steep rise</a> in the number of people living with diabetes, a chronic condition of significant public health concern. Many developing countries like South Africa now bear the greatest burden. </p>
<p>Diabetes refers to a high level of glucose in the blood.
Several factors contribute to diabetes, but obesity and unhealthy lifestyle behaviours are the major drivers. It is a costly disease, and it reduces the quality of life and lifespan, especially if not properly managed. </p>
<p>Eleven percent of South African adults now <a href="https://idf.org/our-network/regions-members/africa/members/25-south-africa.html">live with diabetes</a>, the highest prevalence in Africa. Most of them have poorly controlled diabetes. And many others are yet to be diagnosed. A lot of people develop <a href="https://www.cdc.gov/diabetes/managing/problems.html#:%7E:text=Common%20diabetes%20health%20complications%20include,how%20to%20improve%20overall%20health.">complications</a> as a result of poorly controlled diabetes. These include eye problems, kidney disease and cardiovascular diseases. Some even develop wounds that don’t heal, resulting in limb amputation. </p>
<p>When people develop such complications, they spend more money on healthcare. And it places a greater burden on the already overstretched health system. Some even lose their livelihood which, in turn, affects their families.</p>
<p>There have been <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4565451/">some</a> <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4709478/">studies</a> in South Africa looking at the level of screening for complications for people living with diabetes. But there’s very little focus on the primary healthcare level. And some of these <a href="https://www.researchgate.net/publication/14037605_Public_sector_primary_care_of_diabetics_-_A_record_review_of_quality_of_care_in_Cape_Town">studies</a> were conducted many years ago, so the data may no longer be valid. </p>
<p>It is imperative to determine the current situation, especially at primary healthcare level. Our recent <a href="https://www.researchgate.net/publication/360198427_Coverage_of_diabetes_complications_screening_in_rural_Eastern_Cape_South_Africa_A_cross-sectional_survey">study</a> focused on the Eastern Cape province. It’s one of the poorest provinces in South Africa, with a high prevalence of poorly controlled diabetes.<br>
We assessed the extent of screening for diabetes-related complications at primary healthcare clinics in this province.</p>
<p>We found that the rate of screening for these complications was very low. Our findings are similar to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4709478/">research</a> done in another rural province in the country. This points to the need to promptly implement measures to improve screening coverage for people with diabetes in South Africa. Doing this will improve health outcomes and quality of life, and reduce the incidence of devastating diabetes complications.</p>
<h2>Checking for complications</h2>
<p>To keep blood glucose levels under control and avoid complications, people with diabetes need to pay detailed attention to their health. They must be involved in their care, live a healthy life, and undergo important tests and examinations that help to quickly identify potential problems. </p>
<p>There are <a href="http://www.jemdsa.co.za/index.php/JEMDSA/article/view/647">guidelines</a> for diabetes management and complications screening in South Africa. Healthcare providers also have a duty to check whether these individuals’ blood glucose is under control, so they don’t develop complications which can cut their life short or disable them. </p>
<p>Primary healthcare clinics are the entry points into the healthcare system. Most people with diabetes are first managed at these facilities. Here they receive medication and are supposed to check their blood glucose level at every visit. </p>
<p>In addition, primary healthcare providers are supposed to check patients’ eyes and kidney function when they make the diagnosis – and every year after that. Healthcare workers are also supposed to check the patients’ feet at least once a year. Patients at higher risk of developing foot ulcers need more frequent check-ups to prevent complications like leg amputation. </p>
<h2>Our study</h2>
<p>We wanted to find out how the people living with diabetes in some rural areas of the Eastern Cape, South Africa are being managed. We recruited participants with diabetes from six primary healthcare facilities. By asking them questions and by looking at their medical records, we determined if these measures and examinations were in place at these primary healthcare clinics.</p>
<p>Our analysis showed that out of 372 people, only 71 (19%) of them had been checked for blood glucose control in the past year. Sixty (16%) of them had been assessed for kidney function and 33 (8.9%) had been checked for blood cholesterol levels. Just 52 (14%) had undergone eye examinations in the past year. </p>
<p>Foot examination, which helps to prevent leg amputation, was done for only 9 (2.3%). More than half (60%) of these patients had not undergone any form of examination for these potential complications in the past year. </p>
<p>None of them had undergone all of these five important screenings.</p>
<h2>Way forward</h2>
<p>Our study shows that without urgent intervention, a lot of people with diabetes will soon develop complications that could be prevented through proper screenings. This will affect the individuals, their families, jobs, and even the overburdened health system. </p>
<p>Prevention is cheaper than cure. Understanding the potential reasons for the gaps in diabetes management and finding effective solutions for improving screening coverage will cut healthcare costs, prolong the life of patients and enable them to lead a quality life. </p>
<p>There are a number of approaches that the country can take. For instance <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3617530/">mobile health technology</a> can be used as a tool to facilitate screening. A similar approach is being used in developed countries. As a result, many of them have been able to cut down the number of <a href="https://link.springer.com/article/10.1007/s00125-018-4711-2">diabetes-related complications</a>. </p>
<p>Other countries have also embraced <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7398859/">technology-based solutions</a> to train community health workers to conduct some of these examinations under the guidance of experts.</p><img src="https://counter.theconversation.com/content/191191/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Eyitayo Omolara Owolabi received funding for her PhD from South African National Research Foundation. </span></em></p><p class="fine-print"><em><span>Anthony Idowu Ajayi is affiliated with African Population and Health Research Center. </span></em></p>Most people with diabetes are poorly controlled. This makes them vulnerable to complications like eye problems, kidney disease, and even amputations.Eyitayo Omolara Owolabi, Postdoctoral fellow, Arizona State UniversityAnthony Idowu Ajayi, Associate research scientist, African Population and Health Research CenterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1887682022-09-13T15:09:04Z2022-09-13T15:09:04ZObesity costs South Africa billions. We did the sums<figure><img src="https://images.theconversation.com/files/479882/original/file-20220818-22-qz382c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Quantifying the financial costs of overweight and obesity is important for national policy. </span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Globally, it is widely <a href="https://www.mdpi.com/1660-4601/14/4/435">acknowledged</a> that obesity-related conditions and their complications add hugely to healthcare costs and productivity losses. In turn this adds a large burden on individuals, their families and on governments.</p>
<p>One estimate suggests that of the total health expenditure on the continent, <a href="https://s3-eu-west-1.amazonaws.com/wof-files/970_-_WOF_Missing_the_2025_Global_Targets_Report_ART.pdf">9% is attributed</a> to dealing with people who are overweight and obese. </p>
<p>We conducted <a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2022.2045092">research</a> to calculate the cost of obesity to South Africa’s health system. Our aim was to estimate the direct healthcare costs associated with the treatment of weight-related conditions based on public-sector tariffs.</p>
<p>Based on our calculations overweight and obesity are costing South Africa’s health system R33 billion (US$1.9bn) a year. This represents 15.38% of government health expenditure and is equivalent to 0.67% of GDP. Annual per person cost of overweight and obesity is R2,769.</p>
<p>Among the most expensive conditions to manage were diabetes and cardiovascular diseases. </p>
<p>Our analysis shows that overweight and obesity impose a huge financial burden on the public healthcare system in South Africa. It suggests an urgent need for preventive, population-level interventions to reduce overweight and obesity rates. The reduction will lower the incidence, prevalence, and healthcare spending on noncommunicable diseases.</p>
<p>Quantifying the financial costs of overweight and obesity also gives national policy-makers a sense of the scale of the cost to the state, those of managing their diseases, and the costs to the community.</p>
<h2>Scale of the problem</h2>
<p>Half of all adults in South Africa are overweight (23%) or obese (27%). And the World Obesity Federation anticipates an additional 10% increase (37%) <a href="https://www.worldobesityday.org/assets/downloads/World_Obesity_Atlas_2022_WEB.pdf">in obesity among adults by 2030</a>. Overweight and obesity hugely increase the risk of noncommunicable diseases. This burden contributes to the country’s high prevalence of diabetes, or example. An estimated 11% of people older than 15 had diabetes in 2021. This is much higher than Nigeria’s prevalence of <a href="https://worldpopulationreview.com/country-rankings/diabetes-rates-by-country">4%</a>. </p>
<p>Around 12 million people suffer from weight-related diseases for which they receive treatment in the public sector. These include diabetes, hypertension, cardiovascular disease, arthritis and some cancers. </p>
<p>This does not include the numerous undiagnosed people with diabetes and hypertension who are not on treatment. Nor does it include people being treated in the private sector.</p>
<p>These noncommunicable diseases cause life-altering illness, disabilities, and premature death.</p>
<h2>What we found</h2>
<p>Our research calculated the cost of obesity starting at age 15. In doing our calculations we looked at the following: cancers , cardiovascular diseases , diabetes , musculoskeletal disorders , respiratory diseases and digestive diseases. </p>
<p>We costed each in detail and used the prevalence of those diseases to measure the cost to the system, taking account of healthcare use patterns.</p>
<p>In South Africa, the biggest share of the R33-billion (US$1.9 billion) annual cost comes from treating diabetes (R19,86-billion). Cardiovascular disease (ZAR 8,87-billion) had the second biggest share. These costs are, in turn, mainly driven by the cost of medication and hospitalisation. Diabetes and hypertension-related conditions are among South Africa’s top-ten causes of death. Digestive diseases, such as gallstones and diseases of the gallbladder, contribute the least (R395-million).</p>
<p>Diabetes (95%) and arthritis (58%) are the diseases that are mostly caused by overweight and obesity. </p>
<p>Overall, 53% of total healthcare costs of managing and treating these diseases in the public sector was attributable to the overweight and obesity problem. South Africa shares this dubious distinction with other high- and middle-income countries such as Brazil, South Korea, Thailand and Colombia. <a href="https://data.worldobesity.org/economic-impact/countries/#ZA">Our results are similar to the World Obesity Federation’s estimate of R36bn</a>.</p>
<p>We also warn that the R33-billion is an underestimation of the economic cost. We used public-sector tariffs, which we calculated as 60% of private sector costs. We also excluded costs such as clinical screening and the treatment of comorbidities, such as amputations as well as potential costs for the undiagnosed. </p>
<p>And our findings don’t include the indirect costs of productivity losses resulting from absenteeism. We also didn’t consider premature death as a result of overweight- and obesity-related diseases.</p>
<h2>Next steps</h2>
<p>Putting a health problem in monetary terms may create a sense of urgency to find ways to reduce future expenditure on the direct costs of healthcare, and to reduce future losses to the state from the consequences of illness and premature death, including the knock-on effects of worsening poverty as a result.</p>
<p>This is particularly problem in a setting such as South Africa, which already has a drastically under-resourced public-health system, <a href="https://worldpopulationreview.com/country-rankings/unemployment-by-country">shockingly high unemployment</a>, and <a href="https://www.hst.org.za/publications/South%20African%20Health%20Reviews/SAHR_NO_BlankPages_3_8_Artifacts_07052021.pdf">both under- and over-nutrition crises that are aggravated by obesogenic environments</a> and poverty-driven food choices.</p>
<p>Until now, no detailed country-specific information on the economic cost of overweight and obesity in sub-Saharan Africa has existed. Based on our research, South Africa’s burden is even higher than the African or global averages: <a href="https://www.hst.org.za/publications/South%20African%20Health%20Reviews/SAHR_NO_BlankPages_3_8_Artifacts_07052021.pdf">15.38%</a>of overall government health budget, which equates to <a href="https://www.statssa.gov.za/publications/P0441/P04414thQuarter2020.pdf">0.67%</a> of GDP.</p>
<p>Unless rapid steps are taken to decrease obesity and overweight, the health system will buckle under this strain, and the planned National Health Insurance scheme will not succeed in producing equity in health services.</p>
<p>The opportunity costs of overweight and obesity – and the diseases they often bring with them – are both personal and national. It is difficult to quantify the personal disability in monetary terms – the benefits of vastly improved quality of life are priceless.</p><img src="https://counter.theconversation.com/content/188768/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Micheal Boachie does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Lowering obesity and overweight rates will lift the burden on healthcare spending.Micheal Boachie, Senior Researcher, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1837362022-06-01T15:07:15Z2022-06-01T15:07:15ZSouth Africa’s hunger problem is turning into a major health crisis<figure><img src="https://images.theconversation.com/files/465491/original/file-20220526-26-qp2590.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Food parcels are handed to residents at a food distribution organised by the grassroots charity Hunger Has No Religion, in Westbury, Johannesburg.</span> <span class="attribution"><span class="source">MARCO LONGARI/AFP via Getty Images</span></span></figcaption></figure><p><a href="https://borgenproject.org/hunger-in-south-africa/">One in ten South Africans</a> go hungry every day. As a result malnutrition levels are high. Malnutrition has three simultaneous dimensions: undernourishment, micronutrient deficiencies and over-nutrition. </p>
<p>These can manifest in stunting – being short for one’s age because of long-term undernutrition. In 2016 it was <a href="https://www.frontiersin.org/articles/10.3389/fpubh.2020.00166/full">estimated</a> to be 27% among South African children. This is high. Africa is currently the only continent where <a href="https://www.frontiersin.org/articles/10.3389/fpubh.2020.00166/full">stunting rates continue to rise</a>, with 27% of African children classified as stunted in 2018. </p>
<p>Another consequence of malnutrition is overweight and obesity. There has been a dramatic increase in both among adults in the country <a href="https://dhsprogram.com/pubs/pdf/FR131/FR131.pdf#page=174">from 29.6% in 1998</a> to <a href="https://dhsprogram.com/pubs/pdf/FR337/FR337.pdf#page=319">39.8% in 2016</a> in women aged 15–24 years. In women aged 45–54 years it increased from 72% in 1998 to 81.9% in 2016. Obesity and overweight increased in men too. </p>
<p>The number of overweight children in South Africa has also grown. It increased from 10.6% in 2005 to 13.3% in 2016. This is more than <a href="https://health-e.org.za/2022/04/06/obesity-stunting-on-the-rise-among-sas-children/">twice the global prevalence</a> of 5.6%. </p>
<p>Lifestyle diseases related to nutrition such as diabetes, heart disease, stroke and some cancers are among the top causes of death in the country. Together these conditions account for about <a href="http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742016000500013">40% of total deaths</a>. </p>
<p>The main reasons for the rise in obesity and overweight are urbanisation and the “nutrition transition” – the move away from typical traditional diets to a “western” diet and lifestyle. Changes in diet are toward less unrefined foods and carbohydrates, accompanied by an increase in animal protein, saturated fat, and sugar. This lifestyle pattern is also associated with lower energy expenditure. </p>
<p>Dietary and lifestyle changes can be seen in patterns of consumption of food, alcohol and tobacco, reduction in physical activity, and a shift to a diet high in sugar, salt and saturated fat. </p>
<p>Several environmental factors also affect what people eat. Highly palatable, energy dense food is increasingly available. And powerful food stimuli (like commercials, vending machines, school tuck shops and fast food) are present in urban environments. </p>
<p><a href="https://www.sun.ac.za/english/faculty/healthsciences/interdisciplinary-health-sciences/Documents/Title%20page.pdf">Affordability</a> also plays a big role in food choices, with profound health implications.</p>
<p>There are solutions. For example, efforts should be made to encourage people to eat pulses and legumes. They are affordable sources of good quality protein, carbohydrates, dietary fibre, vitamins and minerals and phytochemicals. They are low in energy, fat and salt. They can improve diet quality and protect against lifestyle diseases. </p>
<h2>Why it’s a worry</h2>
<p>A <a href="https://dhsprogram.com/pubs/pdf/FR337/FR337.pdf">2016 survey</a> showed that the majority of women in all ethnic groups were overweight and obese. Also of concern is the increase in prevalence among younger women see above</p>
<p>These high proportions in are overweight and obese is of particular concern. Raised BMI is a <a href="https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight">major risk factor</a> for noncommunicable diseases such as cardiovascular disease and diabetes.</p>
<p>When it comes to children, the <a href="http://www.sajcn.co.za/index.php/SAJCN/article/view/286">prevalence</a> of zinc deficiency appears to be high in South African children, ranging from 39.3% to 47.8%. Zinc deficiency can lead to loss of appetite, growth retardation and impaired immune function. </p>
<p>A typical feature of the nutrition transition both maternal overweight and child malnutrition are found <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-019-7412-y">in the same household or community in South Africa</a>.</p>
<p>In South Africa just over a quarter of the population are still food insecure despite sufficient food being produced at national level, <a href="http://www.hsrc.ac.za/uploads/pageNews/72/SANHANES-launch%20edition%20(online%20version).pdf">according</a> to the South African National Health and Nutrition Examination Survey.</p>
<p>The World Health Organisation has <a href="https://globalnutritionreport.org/resources/nutrition-profiles/africa/southern-africa/south-africa/">set nutrition targets</a> which, if met, would reduce malnutrition in the country. </p>
<h2>What are the solutions?</h2>
<p>In 2003 the South African government introduced <a href="https://foodfacts.org.za/food-fortification/">legislation</a> for the mandatory fortification of bread flour and maize meal with vitamin A, zinc, iron, folic acid, thiamine, riboflavin, niacin and pyridoxine. </p>
<p>Since then, increased folic acid intake by pregnant women has resulted in <a href="https://pubmed.ncbi.nlm.nih.gov/18338391/">a 30% decline</a> in the incidence of neural tube defects in babies. Neural tube defects are birth defects of the brain, spine, or spinal cord. They happen in the first month of pregnancy, often before a woman even knows that she is pregnant. The two most common neural tube defects are spina bifida and anencephaly.</p>
<p>However, <a href="https://dhsprogram.com/publications/publication-fr337-dhs-final-reports.cfm">studies</a> have shown that deficiencies of vitamin A, iron, and zinc still exist in adults. </p>
<p>There are other interventions that could, and should be taken, to ensure that the WHO nutrition targets are met by 2025. </p>
<p>The targets include achieving:</p>
<ul>
<li><p>40% reduction in the number of children under-5 who are stunted;</p></li>
<li><p>50% reduction of anaemia in women of reproductive age;</p></li>
<li><p>30% reduction in low birth weight</p></li>
<li><p>no increase in childhood overweight.</p></li>
</ul>
<p>South Africa is on track to meet some of them, but there is a need to accelerate the work. The following steps would make a major contribution:</p>
<ul>
<li><p>Ensure there’s a focus on the first 1000 days of a baby’s life (from conception to 24 months). Receiving good nutrition in the womb and through early life is essential for a child’s future health. <a href="https://www.unicef.org/nutrition/maternal">Research has shown</a> that what a mother eats, her weight and her lifestyle habits can influence how the baby’s metabolism, immune system and organs develop. Poor nutrition during pregnancy and early life can lead to obesity, heart disease and stroke later on. </p></li>
<li><p>address micronutrient deficiency such as anaemia. One important step would be to screen and treat all pregnant women with anaemia. </p></li>
<li><p>reduce obesity. This particularly important when it comes to adolescent girls, to optimise nutrition later in life. </p></li>
<li><p>increase coverage of <a href="https://theconversation.com/whats-missing-in-south-africas-strategy-to-get-breastfeeding-levels-up-165548">exclusive breastfeeding</a> in the first six months. Breastfeeding protects against obesity and non-communicable diseases such as type-2 diabetes, cardiovascular disease and certain cancers later in life. In South Africa, the exclusive breastfeeding rate in infants under six months increased from <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6799928/">8% in 2003 to 32% </a>in 2016. The WHO global nutrition target to be accomplished by the year 2025, is increasing exclusive breastfeeding among infants younger than 6 months to 50% by the year 2025.</p></li>
<li><p>provide supplements for those experiencing food insecurity through the Intergrated Nutrition Programme. This was introduced in 1994 to address malnutrition in South Africa. <a href="https://borgenproject.org/hunger-in-south-africa/">Approximately 11% (6.5 million)</a> of South Africa’s population is hungry and food insecure.</p></li>
</ul>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/whats-driving-hunger-in-gauteng-south-africas-economic-power-house-181802">What's driving hunger in Gauteng, South Africa's economic power house</a>
</strong>
</em>
</p>
<hr>
<ul>
<li><p>provide iron, folic acid and calcium supplements to all women at antenatal care sites and through community health workers.</p></li>
<li><p>food supplementation by the Integrated Nutrition Programme together with counselling of caregivers to reduce stunting of children under two years old in food insecure settings.</p></li>
<li><p>Regulate, monitor and strengthen the fortification of maize meal and wheat flour to ensure compliance with fortification standards. </p></li>
<li><p>Continued support of the <a href="https://www.education.gov.za/Programmes/NationalSchoolNutritionProgramme.aspx">National School Feeding Programme</a> to address malnutrition in South Africa. Over 9 million children are fed under the scheme every day. </p></li>
<li><p>Introduce additional laws and taxes to curtail advertising and the distribution of unhealthy food and drinks. South Africa implemented legislation <a href="https://www.gov.za/sites/default/files/gcis_document/201710/41164gon1071.pdf">on salt</a> in 2016 and <a href="https://www.sars.gov.za/customs-and-excise/excise/health-promotion-levy-on-sugary-beverages/">sugar taxes in 2017</a>.</p></li>
<li><p>Provide education on nutrition to counter the effect of urbanisation on obesity rates. People need guidance to make the best possible food choices with the money they have available. They should, for example, be encouraged to choose foods that are adequate in energy but are also relatively rich in nutrient content. The <a href="http://www.sun.ac.za/english/faculty/healthsciences/nicus/how-to-eat-correctly">South African Food Based Dietary Guidelines</a> were developed to provide nutrition education in South Africa. </p></li>
</ul>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/you-love-amagwinya-puff-puff-bofrot-heres-a-healthier-version-of-africas-favourite-snack-170845">You love amagwinya/puff puff/bofrot? Here's a healthier version of Africa's favourite snack</a>
</strong>
</em>
</p>
<hr>
<ul>
<li>Encourage plant-based diets.</li>
</ul><img src="https://counter.theconversation.com/content/183736/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Irene Labuschagne does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Problems caused by malnutrition - such as obesity - are on the rise in South Africa, with serious health consequences.Irene Labuschagne, Principle dietitian at the Nutrition Information Centre, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1775752022-03-09T14:32:37Z2022-03-09T14:32:37ZWhy South Africa should introduce mandatory labelling for fast foods<figure><img src="https://images.theconversation.com/files/447754/original/file-20220222-21-1x1vqbb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Nutrition-related chronic diseases such as diabetes, hypertension, and cardiovascular diseases, remain a serious health issue. In the near future, these diseases are likely to become increasingly prevalent in developing countries like South Africa due to rapid and unplanned urbanisation.</p>
<p>Urbanisation is the <a href="https://www.sciencedirect.com/science/article/abs/pii/S1570677X17300497?via%3Dihub">main driver</a> of the obesity pandemic and associated chronic diseases. This is because urbanisation comes with unhealthy lifestyle changes, including increased consumption of ultra-processed and energy-dense foods which are generally unhealthy. A large proportion of these unhealthy foods are fast foods, which are convenient to obtain at relatively low prices but are generally high in energy, fat, salt and even sugar.</p>
<p>Nutritional labelling of fast foods has <a href="https://onlinelibrary.wiley.com/doi/10.1111/obr.12364">been seen</a> as an effective way of assisting consumers to make healthier food choices. Research <a href="https://www.mdpi.com/2072-6643/11/10/2425">shows</a> that in the absence of nutritional labels, consumers tend to estimate nutrient content poorly. As a result, a host of countries have made it mandatory for fast-food outlets to provide nutritional information. Examples include the US, Canada, Australia, Ireland, Saudi Arabia, South Korea, Taiwan and United Arab Emirates. </p>
<p>However, African countries lag behind. None have introduced mandatory nutritional labelling of fast foods. South Africa is no exception. It has no laws or regulations requiring fast-food restaurants to provide any form of nutritional information to their consumers.</p>
<p>In our recent <a href="https://www.tandfonline.com/doi/full/10.1080/16070658.2021.2003058">study</a> we investigated two things: do South African fast-food restaurants provide nutritional information to the public? And secondly, we looked at the nutritional content of fast foods offered in South Africa.</p>
<p>We looked at the websites of 31 fast food restaurants in the country. We contacted the outlets when no information was found on their websites. Our findings showed that about 58% of the biggest South African fast-food restaurants provided nutritional information. This was mostly made accessible through the restaurants’ websites, but a few restaurants made it available only on request. </p>
<p>A third of the restaurants that provided the nutritional information were international franchises. This suggests that some of the nutritional information had been compiled in response to regulations from other countries where they also operate.</p>
<p>On the nutritional content we found that all meal combinations exceeded the total recommended energy, carbohydrates, sugar and salt content, and most also exceeded the recommended fat content. These levels are set by the <a href="https://www.health.gov.za/wp-content/uploads/2020/11/nnow2020-concept-document.pdf">National Department of Health</a> for individuals four years and older.</p>
<p>We concluded that the South African government should introduce regulations that mandate nutritional labelling of fast foods. This will help consumers make informed dietary choices. It is important that the nutritional labelling is easily understood by all South African.</p>
<h2>Nutritional content</h2>
<p>In our research we described the nutritional information of standard fast-food items (burgers or pizzas) and meal combinations (burger/pizza + medium fried chips + a 440 ml sugar sweetened beverage) across the fast-food restaurants. </p>
<p>Burgers and pizzas were high in protein. Some were also high in fat and salt, as indicated by percentages of the nutritional reference ranges above 30% level. </p>
<p>All meal combinations exacerbated the total energy, carbohydrates, sugar, and salt content, and mostly fat.</p>
<p>In the absence of nutritional labels, consumers tend to estimate nutrient content poorly. Consumers are often forced to rely on portion sizes and on the perception that similar food types contain similar nutrients.</p>
<p>For example, the nutritional content of similar looking food items may vary in nutrient quality due to different ingredients and preparation methods used by each restaurant. This variation highlights the importance of nutritional labelling. </p>
<h2>A traffic light labelling system</h2>
<p>It’s important that information about the nutritional makeup of fast food is available. It’s equally important that the labelling is easy to understand and recognisable by consumers. </p>
<p>One way to achieve this could be through the use of the “Traffic light labelling” system which has been adopted by countries like Australia and the <a href="https://www.foodstandards.gov.scot/downloads/FoP_Nutrition_labelling_UK_guidance_November_2016.pdf">UK</a>.</p>
<p>The traffic light labelling system uses traffic light colours to indicate whether salt, sugar and fat content are high (red), medium (orange) or low (green). </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/447789/original/file-20220222-27-18zed1b.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="INSERT ALT TEXT HERE" src="https://images.theconversation.com/files/447789/original/file-20220222-27-18zed1b.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/447789/original/file-20220222-27-18zed1b.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=404&fit=crop&dpr=1 600w, https://images.theconversation.com/files/447789/original/file-20220222-27-18zed1b.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=404&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/447789/original/file-20220222-27-18zed1b.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=404&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/447789/original/file-20220222-27-18zed1b.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=507&fit=crop&dpr=1 754w, https://images.theconversation.com/files/447789/original/file-20220222-27-18zed1b.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=507&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/447789/original/file-20220222-27-18zed1b.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=507&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Assigned traffic light colours for the South African fast foods. (Red: High; Amber: Medium; Green: Low; Light grey: Colour could not be assigned due to missing information)</span>
<span class="attribution"><span class="source">AUTHOR SUPPLIED</span></span>
</figcaption>
</figure>
<p>In the last part of the study, we used the traffic light labelling system and graphically showed that most of the standard burgers and pizzas and medium fried chips were high in fat and salt content. </p>
<p>Sugar content was relatively low in burgers, pizzas and medium fried chips. But the inclusion of a sugar-sweetened beverage in a meal combination ensured high sugar content in fast foods.</p>
<h2>What next</h2>
<p>Our findings provide evidence that consumption of fast foods may contribute disproportionally to daily nutrient intakes for energy, fat, salt and sugar. This is especially the case when eaten as meal combinations, as these often exceed the daily recommended intakes for a meal. </p>
<p>These findings are important as consumers may benefit from understanding how choosing to purchase fast food items or combination meals contribute to their dietary intake of fat, salt and sugar and overall energy intake.</p>
<p>Fast-food consumers in South Africa may be underestimating their daily nutrient intakes and making misinformed dietary choices.</p>
<p>We recommend that consumers limit their fast-food intake and avoid eating meal combinations.</p>
<p>We also recommend that government makes it mandatory for fast-food outlets to provide nutritional information so that consumers are better informed.</p><img src="https://counter.theconversation.com/content/177575/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Siphiwe Dlamini receives funding from the DSI-NRF Centre of Excellence in Human Development at the University of the Witwatersrand, Johannesburg, South Africa. </span></em></p>South Africa should introduce regulations that mandate the nutritional labelling of fast foods. This will help consumers make informed dietary choices.Siphiwe Dlamini, Post-Doctoral Research Fellow, SAMRC/Wits Developmental Pathways for Health Research Unit, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1730962021-12-06T09:33:18Z2021-12-06T09:33:18ZA new report shows worrying growth of the diabetes pandemic<figure><img src="https://images.theconversation.com/files/435559/original/file-20211203-23-1e4nzh5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many people with diabetes are undiagnosed. </span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Diabetes is rising at an alarming rate. One in 10 adults worldwide – 537 million people – now live with the disease. This is higher than the <a href="https://www.idf.org/e-library/epidemiology-research/diabetes-atlas/159-idf-diabetes-atlas-ninth-edition-2019.html">463 million</a> adults who lived with the condition in 2019. It presents a significant global challenge to the health and well-being of individuals, families and societies. Diabetes now ranks among the <a href="https://diabetesatlas.org/">top 10</a> causes of global mortality, responsible for an estimated 6.7 million deaths in 2021. </p>
<p>Africa account for 6% of these deaths. One in 22 (24 million) adults in Africa are living with diabetes. </p>
<p>The continent’s highest prevalence rate (11.3%) is in South Africa, where one in nine adults have diabetes: 4.2 million people. Yet almost half are undiagnosed. This year South Africa is predicted to register 96,000 deaths due to diabetes and an estimated US$7.2 billion rise in diabetes-related health expenditure. This is a huge hit to the country’s economy and equates to $1,700 per person.</p>
<p>These new figures are revealed in the <a href="https://diabetesatlas.org/">10th edition of the International Diabetes Federation Diabetes Atlas</a>, which gathers information on the burden of diabetes from countries across the world. It is compiled by the federation’s Atlas Committee, which I am a part of. </p>
<h2>Sharp increase</h2>
<p>The Atlas projects that 783 million adults will be living with diabetes by 2045. That’s an estimated 46% increase, compared to expected population growth of 20% over the same period. </p>
<p>With such a sharp increase expected in global prevalence, it’s clear that diabetes is spiralling out of control. It can no longer be ignored.</p>
<p>This year marks <a href="https://www.nature.com/articles/s41591-021-01418-2">100 years</a> since the discovery of insulin. Insulin is a hormone that lowers the level of blood glucose. There has never been a more appropriate time to reflect on the impact of diabetes and highlight the urgent need to improve access to care for the millions affected.</p>
<p>The urgency is even greater because COVID-19 has placed an additional burden on people living with diabetes, making them more susceptible to the worst complications. We are yet to see the impact of lockdowns, use of masks and the potential risk of COVID-induced diabetes on population health. There is a widely held concern that the pandemic may have caused a further rise in the prevalence of diabetes and its complications that will manifest over the coming years.</p>
<p>When diabetes remains undetected or is not adequately addressed, people with diabetes are at higher risk of serious and life-threatening complications, such as heart attack, stroke, kidney failure, blindness and lower-limb amputation. These complications result in a significantly reduced quality of life and higher healthcare costs.</p>
<h2>Access to diabetes care</h2>
<p>Diabetes does not discriminate: it is a disease that can affect anyone regardless of socioeconomic status or national boundaries. Globally, 88% of adults living with undiagnosed diabetes are in low- and middle-income countries. But even in high-income countries, almost a third of (29%) people with diabetes have not been diagnosed. </p>
<p>Low rates of clinical diagnosis are often a result of insufficient access to healthcare and lower capacity in existing health systems.</p>
<p>And even 100 years after the discovery of insulin, one in two people with diabetes who need insulin are unable to access or afford it. Left untreated with insulin, type 1 diabetes is fatal. </p>
<p>Other fundamental components of diabetes care, such as oral medicines, self-monitoring equipment and supplies, education and psychological support and access to healthy food and a place to exercise, are also unavailable to many people living with or at risk of diabetes across the world.</p>
<h2>Action to turn the tide</h2>
<p>Fortunately, much can be done to reduce the impact of diabetes. Evidence <a href="https://www.hsph.harvard.edu/nutritionsource/disease-prevention/diabetes-prevention/preventing-diabetes-full-story/">suggests</a> that type 2 diabetes can often be prevented. And early diagnosis and access to appropriate care for all types of diabetes can avoid or delay complications in people living with the condition.</p>
<p>It is vital to secure affordable access to the fundamental components of diabetes care for all who need them, ensure prompt diagnosis and timely treatment, and improve efforts to prevent type 2 diabetes.</p>
<p>I believe there are some rays of hope. The centenary of insulin has attracted greater attention to the diabetes cause. Earlier <a href="https://theconversation.com/diabetes-targets-would-cost-more-but-the-impact-would-be-worth-it-heres-how-167155">this year</a>, the World Health Organisation launched the <a href="https://www.thelancet.com/journals/landia/article/PIIS2213-8587(21)00111-X/fulltext">Global Diabetes Compact</a> and United Nations member states adopted a resolution that calls for urgent coordinated global action to tackle diabetes.</p>
<p>These are important steps towards addressing the continued and rapid rise of diabetes prevalence, particularly in countries that do not have a national diabetes plan or coverage for essential health services. But more action is needed. We cannot wait any longer for diabetes medicine, technologies, support and care to be made available to all that require them.</p><img src="https://counter.theconversation.com/content/173096/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ayesha Motala does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>With such a sharp increase in global prevalence, it’s clear that diabetes is spiralling out of control. It can no longer be ignored.Ayesha Motala, Professor and Head Department of Diabetes and Endocrinology, University of KwaZulu-NatalLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1716792021-11-21T09:03:43Z2021-11-21T09:03:43ZDiabetes can be controlled. But there’s no medicine for some people who need it.<figure><img src="https://images.theconversation.com/files/432429/original/file-20211117-9381-107ll2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Diabetes can be controlled using medicines, diet and lifestyle modification. </span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The burden of diabetes is increasing globally. There are about <a href="https://idf.org">half a billion</a> people in the world living with the disease. In sub-Saharan Africa, 23 million people had diabetes in <a href="https://diabetesatlas.org/data/en/region/2/afr.html">2021</a>. This number is expected to increase to 33 million by 2030 and 55 million by <a href="https://diabetesatlas.org/data/en/region/2/afr.html">2045</a>. </p>
<p>Currently, diabetes has no cure. But it can be controlled using medicines, diet and lifestyle modification. </p>
<p>As part of its 2013–2020 <a href="https://apps.who.int/iris/bitstream/handle/10665/94384/9789241506236_eng.pdf;jsessionid=033405B41D881C42450C0F144CF01944?sequence=1">Global Action Plan</a> the World Health Organisation set targets for prevention and control of noncommunicable diseases. It said essential medicines and basic technologies should be at least 80% available in public or private healthcare facilities. For diabetes, these medicines include insulin and oral agents that reduce blood sugar. There should also be medicines like aspirin and statins that reduce the risk of related heart diseases. The technology includes glucometers (for testing blood sugar) and test strips for urine protein and ketones.</p>
<h2>Out of reach</h2>
<p>Sub-Saharan Africa faces the dual burden of communicable and noncommunicable diseases straining countries’ health resources and fragile health systems.
Access to essential medicines and diagnostic tests remains a challenge in the region. Public health facilities are faced with frequent stock-outs of medicines and patients often pay for medicines themselves.</p>
<p>Insulin and oral medicines for diabetes are mostly not available at the recommended <a href="https://assets.researchsquare.com/files/rs-16103/v1/8658fa2b-e836-4637-be29-a445e5abef79.pdf?c=1631831420">level</a> in the region. A recent <a href="http://dx.doi.org/10.1136/bmjgh-2019-001410">study</a> conducted in 13 low- and middle-income countries (including countries in sub-Saharan Africa) found 55-80% availability of insulin in health facilities that should have had insulin. An earlier <a href="https://www.hindawi.com/journals/ijhy/2012/584041/">survey</a> had shown 0% availability of insulin in health facilities in Benin and Eritrea. The trend is similar with tests for <a href="https://assets.researchsquare.com/files/rs-16103/v1/8658fa2b-e836-4637-be29-a445e5abef79.pdf?c=1631831420">blood glucose, urine protein and ketone</a>. </p>
<p>The monthly dose of the lowest-priced generic medicines, metformin and glibenclamide, costs about <a href="https://assets.researchsquare.com/files/rs-16103/v1/8658fa2b-e836-4637-be29-a445e5abef79.pdf?c=1631831420">two days’ wages in sub-Saharan Africa</a>. This is based on the wages of the lowest-paid government worker. </p>
<p>The cost is even higher for the newer generation agents. For example, glimepiride costs an equivalent of three days’ wages in <a href="https://equityhealthj.biomedcentral.com/articles/10.1186/s12939-017-0651-6">Uganda</a>. Short-acting and intermediate-acting insulin cost about five days’ wages in <a href="https://equityhealthj.biomedcentral.com/articles/10.1186/s12939-017-0651-6">Uganda</a> and four days’ wages in <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0111812">Cameroon</a>. Various tests also cost a few days’ wages in Uganda and Cameroon.</p>
<p>Some brands of insulin cost much more. For example, the innovator brand of intermediate-acting insulin costs about 20 days’ wages in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2636320/">Malawi</a> and pre-mixed insulin costs 19 days’ wages in <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0111812">Cameroon</a>. </p>
<h2>How do we improve access?</h2>
<p>There are a number of ways to improve access to affordable medicines. They include increasing financing for medicines by governments and international bodies. Legislation could promote the entry of generics into the market. Generic medicines should be priced appropriately and subsidised so that patients don’t have to pay the full price. The selection and use of medicines needs care. And robust electronic monitoring systems would minimise stock-outs. </p>
<p>The responsibility to make changes falls on governments, local and international non-governmental organisations, pharmaceutical companies and health workers. </p>
<p>Some global biopharmaceutical companies have established initiatives targeting low- and middle-income countries. An example is the <a href="https://www.novartis.com/esg/access/creating-sustainable-business-models/novartis-access">Novartis Access programme</a>, currently running in Kenya, Uganda, Tanzania, Rwanda, Malawi, Ethiopia and Cameroon. The programme offers subsidies to governments, non-governmental organisations and other institutional customers for a portfolio of medicines to treat noncommunicable diseases. It also builds health system capacity for the prevention and management of noncommunicable diseases, including diabetes. </p>
<p>Another company, Novo Nordisk, started in 2009 to supply insulin at a subsidised cost to selected low-income countries in sub-Saharan Africa. With partners, it supports the “<a href="https://www.novonordisk.com/sustainable-business/access-and-affordability/changing-diabetes-in-children.html">Changing Diabetes in Children</a>” programme in 10 countries in sub-Saharan Africa. It offers free glucometers and insulin to children and adolescents with type 1 diabetes. </p>
<p>But more needs to be done. Government health ministries and other implementing agencies should encourage healthcare practitioners to follow evidence-based, locally relevant treatment guidelines. They should undergo continuous professional development on diabetes care. National lists of essential medicines should be routinely updated and include cost-effective medicines. </p>
<p>Lastly, governments and the private sector in sub-Saharan Africa should invest in the local production of high-quality generic medicines for diabetes.</p><img src="https://counter.theconversation.com/content/171679/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard E. Sanya does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Insulin and oral medicines for diabetes are mostly not available at the recommended level in the African region.Richard E. Sanya, Post-doctoral Research Scientist, African Population and Health Research CenterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1703862021-11-09T14:54:54Z2021-11-09T14:54:54ZFive reasons South Africa isn’t ready for health claims on food labels<figure><img src="https://images.theconversation.com/files/428263/original/file-20211025-13-ilubrh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Labels are not the only tool needed in the effort to prevent noncommunicable disease</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>South Africa has a high number of <a href="https://www.who.int/nmh/countries/zaf_en.pdf">deaths</a> from noncommunicable diseases, which are largely <a href="https://www.who.int/gho/publications/world_health_statistics/2018/en/">linked</a> to diet and lifestyle. Under particular scrutiny are the so-called ultra-processed foods, such as soft drinks, potato chips, chocolate and sweetened breakfast cereals. <a href="https://onlinelibrary.wiley.com/doi/10.1111/obr.13146">Evidence is mounting</a> of their role in the development of diabetes, cardiovascular disease, cancers and chronic lung illnesses. </p>
<p>There are <a href="https://theconversation.com/the-rise-of-ultra-processed-foods-and-why-theyre-really-bad-for-our-health-140537">several reasons</a> why consumption of ultra-processed food is on the rise. Industrialisation of food systems, technological change and globalisation all play a role. Another <a href="https://onlinelibrary.wiley.com/doi/10.1111/obr.13126">frequently cited reason</a> is the growth of transnational food corporations in countries with inadequate policies to protect nutrition. </p>
<p>One way to help people choose healthy food might be to add health claims to the packaging of food that qualifies as healthy. Such claims could lay out health benefits in an accessible way and guide consumers’ choices towards foods with better nutritional profiles. Health claims are used in the European Union. But at the moment, South Africa only has <a href="https://www.greengazette.co.za/notices/foodstuffs-cosmetics-and-disinfectants-act-54-1972-regulations-relating-to-the-labelling-and-advertising-of-foods-amendment_20140529-GGR-37695-00429">draft legislation</a> that would permit some health claims. </p>
<p>Before we conducted our research, not much was known about what stakeholders in the food labelling landscape thought of the proposal. These include doctors, dietitians, public health practitioners, food scientists, food business owners and consumers. </p>
<p>The intention of <a href="https://www.sciencedirect.com/science/article/abs/pii/S0195666321005134?casa_token=S58aLZl3794AAAAA:-Y-wtc92r40REaPN5zlWsl7rmdMnzXcpcaXr7Ma0t5akKL4bVxM4kYQxJxurV170XIfm-rMZE4I">our research</a> was to gain in-depth insight from a broad range of stakeholders about how effective health claims on labels might be in influencing consumption. We also wanted to explore how feasible it might be to execute in a developing country such as South Africa. </p>
<p>It emerged that there are still unresolved questions about the substantiation and enforcement of health claims. And there’s no apparent way to reach consumers in the informal market. These problems would limit the benefits of health claims at this point in time. </p>
<p>Labels are not the only tool needed in the effort to prevent noncommunicable disease.</p>
<h2>Main findings</h2>
<p>We conducted 49 interviews and asked participants to share their views on whether including health claims on food labels could help consumers to make healthier food choices. </p>
<p>The research yielded insights under five themes.</p>
<p><strong>Practical barriers:</strong> Literacy, legibility, language, the actual presence of a label on a product, and socio-economic circumstances could all be barriers. These factors mean a person cannot use a food label to inform their choice. South Africa has 11 official languages, but English (as used on food labels) is the home language of only <a href="https://www.tandfonline.com/doi/full/10.1080/01434632.2015.1072206">12% of the population</a>. </p>
<p><strong>Relevance:</strong> Assuming all the practical barriers were overcome, someone might still not use the label. They might lack the knowledge or motivation to make the information relevant to themselves. Or they might not read the label if they were in a hurry.</p>
<p><strong>Messaging:</strong> There are differences in how people prefer to receive messages and information. Labels typically have a dry, scientific format which doesn’t appeal to the average consumer. Most respondents suggested labels could warn them about health risks of the food or rate it on some sort of scale. </p>
<p>Some people liked the idea of health claims. To our surprise, though, many rejected the idea, saying the food industry might take advantage of health claims for commercial reasons. </p>
<p><strong>Enforcement:</strong> Moving away from the label itself, stakeholders were concerned that health claims could create a gap for unscrupulous players to take advantage of the fact that there isn’t really adequate regulatory enforcement in South Africa.</p>
<p><strong>Trust:</strong> There was also evidence of a lack of trust between the food industry and the healthcare industry. This appeared to stem from differences in responsibilities. Food manufacturers are under pressure to sell cheap food in a very unequal society and healthcare picks up the burden if people get unhealthy.</p>
<p>Finally, we found support for the idea of ambassadors for change. These would be individuals, professionals or even businesses going the extra mile to help people make better food choices and to drive compliance. In particular, retailers were keen to push for compliance with legislation on food labels. </p>
<h2>Recommendations</h2>
<p>The list of what’s needed to get South Africa healthy is a long one. But here are some key things to consider.</p>
<p>Food scientists and technologists need to design better foods. The nutritional profile of new foods could be better and existing ones can be improved. Technologies could, in future, make it possible for foods to have fewer additives and to be more affordable.</p>
<p>Labelling does not have to remain in the dark ages. It may be possible to work on the size and legibility of the information that is on the package or to use technology to overcome barriers to legibility and language. </p>
<p>Retailers need to stock and promote an increasing number of healthier choices. This will make it easier for consumers to make healthier choices, whether they read the label or not. </p>
<p>Food and health related education in schools must be engaging, relevant and practical. </p>
<p>The intersection between food and health is far more complex than can be addressed using a food label alone. All the stakeholders need to have a mature conversation about the facts (the huge burden of noncommunicable diseases) and the practicalities (how to feed a nation where millions go hungry or experience malnutrition due to poverty).</p><img src="https://counter.theconversation.com/content/170386/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Melvi Todd receives funding from The National Research Foundation and the German Academic Exchange Service (NRF-DAAD). She has previously received funding from the Department of Science and Innovation (DSI). She is affiliated with the South African Association for Food Science and Technology (SAAFoST) as a professional member. </span></em></p>It’s not clear how health claims could be substantiated, enforced or understood, but there are other ways to encourage healthy food choices.Melvi Todd, PhD candidate (Food Science), Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1671552021-09-23T10:00:51Z2021-09-23T10:00:51ZDiabetes targets would cost more but the impact would be worth it: here’s how<figure><img src="https://images.theconversation.com/files/421845/original/file-20210917-15-1alo6s0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Early detection of diabetes is important in setting treatment targets </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/nov-14-2019-a-doctor-makes-free-blood-sugar-test-on-world-news-photo/1182443866?adppopup=true">Xinhua/Mohamed Khidir via Getty Images</a></span></figcaption></figure><p>Setting global health targets, which is often done by multinational organisations, such as the United Nations or World Health Organisation (WHO), is commonly used to improve health outcomes. For example, the United Nations <a href="https://www.avert.org/global-hiv-targets">target</a> to improve access to treatment for HIV has resulted in many more people receiving the treatment that they need, which has <a href="https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2020/july/20200706_global-aids-report">saved</a> lives. </p>
<p>Now, the WHO <a href="https://www.thelancet.com/journals/landia/article/PIIS2213-8587(21)00111-X/fulltext">Diabetes Compact</a> to support people living with diabetes is under development. The content of the Compact will not be finalised until 2022. However, to help inform whether targets should be part of the Compact, we asked what the health benefits from achieving various targets for people with diabetes would be, and whether these could be cost-effective over the next 10 years. </p>
<p>The WHO is considering whether targets should be set, and our <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(21)00340-5/fulltext">analysis</a> feeds into that process as there was little previous evidence to inform what the targets should be. We were involved in some of the WHO processes for the Compact, and our results have been shared with WHO, but the analysis we did was independent. Similar to the UN targets for HIV/AIDS, the targets we considered were the percentages of people with diabetes and its associated cardiovascular disease risk factors (for example high blood pressure and choesterol) who were diagnosed, treated and controlled.</p>
<p>Our study was based on data from 23,678 people with diabetes living in 67 low- or middle-income countries. These countries were chosen as they had data available and they are home to <a href="http://www.healthdata.org/gbd/data">80% of the world’s people</a> with diabetes. </p>
<p>We found that setting targets for 80% of people with diabetes to have the condition (and other risk factors) diagnosed, treated, and controlled would substantially reduce death and improve healthy-years lived. And it would also be highly cost effective. </p>
<h2>Diabetes is often overlooked</h2>
<p>The most common form of diabetes, type 2 diabetes, is often associated with obesity and usually starts in later life. It is seldom noticed unless picked up by a medical professional. Over time it causes complications such as cardiovascular diseases (like heart attacks and strokes), kidney disease and blindness. These complications are far more likely to happen if a person with diabetes also has high blood pressure (hypertension), another condition that often goes unnoticed. </p>
<p>Treating diabetes and raised blood pressure markedly reduces the risk of future complications. Whether or not cholesterol is raised, giving a medication called a statin to lower it also <a href="https://journals.plos.org/plosmedicine/peerReview?id=10.1371/journal.pmed.1003485.r005">reduces</a> risk. These treatments to reduce risk in people with diabetes are also <a href="https://www.who.int/nmh/publications/essential_ncd_interventions_lr_settings.pdf">recommended</a> by the WHO. </p>
<p>However, our research has <a href="https://www.thelancet.com/journals/lanhl/article/PIIS2666-7568(21)00089-1/fulltext">previously shown</a> that fewer than 6% of people with diabetes get all the treatment they need to reduce risk of future complications.</p>
<h2>Three targets</h2>
<p>We therefore asked two questions. How would achieving certain targets reduce future complications from diabetes? And, in looking at costs relative to the health benefits, could achieving these targets be cost effective?</p>
<p>Reducing complications from diabetes requires interventions to reduce elevated blood sugar, blood pressure and cholesterol. We asked what benefits would be seen, and at what cost, for all three of these interventions combined.</p>
<p>We studied combinations of three targets. The first is that patients with diabetes are actually diagnosed, and their high blood pressure, if present, is also diagnosed. Second, that they are on treatment for blood sugar, blood pressure and cholesterol using a statin medication. And third, that their blood sugar and blood pressure are controlled to below internationally recommended levels. We tested these at targets of 60%, 70%, or 80% for each of diagnosis, treatment, or control. In other words, what would happen if 80% of people with diabetes and high blood pressure were diagnosed, 80% of those patients were treated and 80% of them were controlled.</p>
<p>We compared this to a baseline scenario in which diagnosis, treatment and control continued at current levels. </p>
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Read more:
<a href="https://theconversation.com/how-changing-blood-pressure-targets-in-south-africa-could-save-costs-and-lives-153674">How changing blood pressure targets in South Africa could save costs and lives</a>
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<p>We found that achieving each of these targets dramatically reduced deaths and improved the number of years people could live in good health. The number of years that people can live in good health is captured by a measure called <a href="https://www.who.int/data/gho/indicator-metadata-registry/imr-details/158">Disability Adjusted Life Years or DALYs</a>. One DALY is equivalent to the loss of a year in full health, hence it captures both early death and being unwell due to a disease.</p>
<p>We found that the greatest impact of achieving the targets would be from reducing the risk of cardiovascular diseases. Other risks like blindness and kidney diseases would be less affected by achieving the targets. </p>
<p>In addition, most of the benefits came from improving treatment of high blood pressure and giving a statin for cholesterol, rather than from treating or controlling high blood sugar.</p>
<p>Overall, at the highest target of 80% diagnosis, 80% treatment, and 80% control, we found that healthy-years-lived were improved by around 6%. This means that around 6% more people with diabetes would be expected to live healthier lives. Even achieving the lower targets of 60% resulted in substantial improvements. </p>
<p>We also showed that achieving the 80% targets would greatly reduce deaths, especially those from cardiovascular diseases.</p>
<p>There was substantial variation in benefits by world regions. For example, reduction in deaths due to cardiovascular diseases was greatest in east sub-Saharan Africa. In this region, deaths would fall from around 46 per 1,000 people in the baseline scenario to 27 per 1,000 with a target of 80% for diagnosis, treatment, and control. In central Latin America deaths fell from around 18 per 1,000 people at baseline to 14 per 1,000 with this target.</p>
<h2>Achieving targets is cost effective</h2>
<p>In our <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(21)00340-5/fulltext">study</a>, we considered the costs of diagnosing and treating diabetes and hypertension, and giving a statin, and the costs of treating the complications of diabetes, for the baseline scenario (current diagnosis, treatment, and control levels continued for the next 10 years) and each of the targets. </p>
<p>In the baseline scenario, the costs of managing diabetes in the countries in the study would be $2,222,882 per 1,000 people with diabetes over the next 10 years. </p>
<p>If diagnosis, treatment, and control were scaled up to achieve 80% targets for each, the costs would increase by a small amount, to $2,832,000 per 1,000 people with diabetes. Most of the increased costs would come from achieving the target for increasing treatment of hypertension. But the costs of treating cardiovascular disease complications would fall. </p>
<p>Overall this gave an incremental cost-effectiveness ratio (effectively the costs per extra healthy-life-year lived, or DALY averted) of $1,362. These costs are well below the WHO <a href="https://www.valueinhealthjournal.com/article/S1098-3015(15)00574-4/fulltext#relatedArticles">thresholds</a> for cost effectiveness of three times GDP per capita for each country. So, each extra year of healthy life would cost $1,362, but the WHO has a benchmark of three times GDP per capita as a worthwhile investment in a year of healthy life. For example, GDP per capita in Angola is $2,790, therefore an intervention would be considered cost effective (by WHO) if it cost less than $8,370 per DALY.</p>
<p>We have shown that targets for diabetes would improve healthy lives and reduce deaths, and that they would be cost effective. But these targets should not be for managing the blood sugar element of diabetes alone; they must include treating hypertension and giving statins to patients with diabetes. </p>
<p><em>This study was done by multiple co-investigators, and this article is written on behalf of the co-investigator team.</em></p><img src="https://counter.theconversation.com/content/167155/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Justine Ina Davies receives funding from the UK National Institute for Health Research, the UK Medical Research Council, and the US National Institute of Health. </span></em></p><p class="fine-print"><em><span>David Flood receives funding from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). He also serves as an unpaid Staff Physician for Maya Health Alliance and GlucoSalud, which are two non-governmental health organizations in Guatemala; in his role with these organizations, he occasionally carries out diabetes advocacy and solitics funding for clinical diabetes programs.</span></em></p><p class="fine-print"><em><span>Sanjay Basu receives funding from the US Centers for Disease Control and Prevention, the Clinton Global Health Access Initiative, and the US National Institutes of Health.</span></em></p><p class="fine-print"><em><span>Jennifer Manne-Goehler does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Targets for diabetes would improve healthy lives, reduce deaths, and be cost effective. But they should not be for managing diabetes alone; they must include treating hypertension.Justine Ina Davies, Professor of Global Health, Institute for Applied Research, University of BirminghamDavid Flood, Research Fellow, University of MichiganJennifer Manne-Goehler, Research Fellow in Medicine, Harvard UniversitySanjay Basu, Director of Research, Center for Primary Care, Harvard UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1669272021-09-13T14:46:57Z2021-09-13T14:46:57ZHow big companies are targeting middle income countries to boost ultra-processed food sales<figure><img src="https://images.theconversation.com/files/418484/original/file-20210830-25-h5v6ld.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Xu Chang/Xinhua via GettyImages</span></span></figcaption></figure><p><a href="https://www.health.harvard.edu/blog/what-are-ultra-processed-foods-and-are-they-bad-for-our-health-2020010918605">Ultra-processed foods</a> might not be a familiar term to many people. But it is an emerging, and increasingly dominant type of food in the world. They are foods typically created through a “<a href="http://www.fao.org/3/ca5644en/ca5644en.pdf#page=10">series of industrial techniques and processes</a>”.</p>
<p>They are designed to be <a href="https://www.nytimes.com/2021/03/12/books/review/hooked-michael-moss.html">potentially more addictive</a>. They are also hyper-palatable, meaning that they can create a “<a href="https://www.researchgate.net/publication/337039170_Hyper-Palatable_Foods_Development_of_a_Quantitative_Definition_and_Application_to_the_US_Food_System_Database">highly rewarding eating experience that may facilitate overconsumption</a>”. And they are heavily marketed products, such as soft drinks, instant noodles and baby formula.</p>
<p><a href="https://www.cambridge.org/core/journals/public-health-nutrition/article/un-decade-of-nutrition-the-nova-food-classification-and-the-trouble-with-ultraprocessing/2A9776922A28F8F757BDA32C3266AC2A">Ultra-processed foods are often high</a> in calories, added sugars, trans-fats, and sodium. They also undergo extensive industrial processing and often contain many artificial additives. This makes them harmful to health. <a href="https://www.mdpi.com/2072-6643/12/7/1955">Their consumption</a> is associated with higher risks of obesity, cardiovascular disease, type 2 diabetes, certain cancers, and other noncommunicable diseases (NCDs).</p>
<p>Ultra-processed foods <a href="http://www.fao.org/publications/card/en/c/CA5644EN/">consumption is already high</a>. But it is unlikely to increase further in high-income countries like Australia and the US where sales have peaked. This means that corporations producing these products are rapidly expanding their operations in industrialising countries. Examples include South Africa, Indonesia, China and Brazil. This raises major concerns for global public health, given that these countries represent the bulk of the world’s population.</p>
<p>In <a href="https://www.ijhpm.com/article_4050.html">our recently published study</a>, we find that total sales of ultra-processed foods in these industrialising countries will be equivalent to those in rich countries by 2024. These projected expansions of Big Food and ultra-processed food markets in middle income countries raises major concerns about the global capacity to prevent and treat NCDs.</p>
<p>How then, despite the well-documented harms of ultra-processed foods for health, is the food industry managing to establish, grow and sustain their markets worldwide? </p>
<p>Below, we highlight the key market and political practices that corporations (which we termed Big Food in our paper) use in pursuit of these goals, and also make recommendations on how to curb their influence.</p>
<h2>Market practices – supra-national and hyper-local</h2>
<p>The market practices used by the ultra-processed foods industry to grow and sustain their markets can be classified into three main categories.</p>
<p>Firstly, the establishment of global production networks by foreign companies has seen a rapid growth of investment in local assets, such as factories, in middle-income countries. This indicates their intentions to expand in these countries. In many instances, this rapid growth has been driven by partnerships with, or acquisitions of domestic competitors. An example is the <a href="https://www.nestle.com/media/pressreleases/allpressreleases/nestle-to-enter-partnership-with-chinese-confectionery-company-hsu-fu-chi">the acquisition of the confectionery company Hsu Fu Chi in China</a> by Nestlé. </p>
<p>Investments like these can translate to greater political leverage, as governments compete for these often lucrative business deals.</p>
<p>Secondly, the creation of extensive local distribution networks that facilitates the expansion of large companies at a sub-national level. This has enabled ultra-processed foods to be widely sold via local supermarkets and convenience stores. These are <a href="https://doi.org/10.1186/s12992-016-0223-3">proliferating in middle-income countries</a> to reach poorer and rural populations. </p>
<p>Other strategies are also employed, such as Nestlé’s micro-distribution system of using door-to-door salespeople <a href="https://www.nytimes.com/interactive/2017/09/16/health/brazil-obesity-nestle.html">to reach thousands of households in Brazilian favelas</a>, as well as a <a href="https://emporionestle.com.br/produtos/emporio-nestle-nacional">direct sales service</a> to customers during the COVID-19 pandemic.</p>
<p>Finally, Big Food uses diverse marketing strategies to target previously unreached populations. Using the techniques of “<a href="https://blogs.lse.ac.uk/lsereviewofbooks/2019/11/04/book-review-the-age-of-surveillance-capitalism-the-fight-for-the-future-at-the-new-frontier-of-power-by-shoshana-zuboff/">surveillance capitalism</a>”, these corporations are able to collect more and more behavioural data, and create personalised advertising. This enables them to better influence consumer behaviour <a href="https://doi.org/10.1080/09581596.2017.1392483">through their digital marketing</a>.</p>
<p>They further increase the visibility and desirability of their products by sponsoring large sporting events. This could be seen in South Africa, where Coca-Cola <a href="https://www.fifamuseum.com/en/about/fifa-partners/coca-cola/">was one of the sponsors</a> of the 2010 FIFA World Cup.</p>
<h2>Political practices to undermine effective health promotion</h2>
<p>To grow and sustain its markets, Big Food has not only made large investments in marketing and promotion. It has also implemented political strategies to prevent, delay or weaken regulations that constrain its marketing activities. They can be grouped into three main categories.</p>
<p>Firstly, lobbying is a key corporate political activity used to get policies implemented which represent the interests of Big Food. </p>
<p>This lobbying power was evident in Colombia, where <a href="https://www.nytimes.com/2017/11/13/health/colombia-soda-tax-obesity.html">over 90 lobbyists worked</a> to influence legislators during the soda tax bill debate. It led to the bill not being passed, despite widespread community support.</p>
<p>Policy substitution is also commonly used to make policies more amenable to a corporation or industry. For example, <a href="https://doi.org/10.3390/ijerph18083856">South Africa</a>, <a href="https://doi.org/10.1111/ijpo.12144">Mexico</a>, <a href="https://doi.org/10.1186/s12992-018-0432-z">Thailand</a> and <a href="https://doi.org/10.4172/2324-9323.1000210">Brazil</a> all have self-regulatory codes on advertising to children. Initially, government regulation had been proposed. But this was watered down and altered through extensive lobbying.</p>
<p>Large corporations also engage in diluting, obscuring and obstructing legitimate science. They fund research that favours industry and criticise evidence to emphasise uncertainty. An example is the industry-funded research organisation, the <a href="https://www.nytimes.com/2019/09/16/health/ilsi-food-policy-india-brazil-china.html">International Life Sciences Institute</a>. It <a href="https://www.bmj.com/content/364/bmj.k5050">successfully lobbied the Chinese government</a> to reframe its obesity policy to focus on physical activity, instead of diet.</p>
<p>Finally, Big Food also uses strategies such as public-private partnerships and corporate social responsibility initiatives to generate a smokescreen of goodwill with civil society. The aim is to reshape its image, as well as to co-opt some parts of civil society to advocate for its interests.</p>
<p>In Indonesia, <a href="https://biz.kompas.com/read/2020/07/03/225437728/kolaborasi-nestl-indonesia-dan-menko-marves-bantu-2000-pekerja-pemungut-sampah">Nestlé</a>, <a href="https://money.kompas.com/read/2020/04/14/171441626/bantu-atasi-pandemi-corona-coca-cola-donasikan-rp-10-miliar-ke-pmi">Coca-Cola</a>, and <a href="https://wartakota.tribunnews.com/2020/08/08/mondelez-indonesia-donasi-miliaran-rupiah-dalam-beragam-bentuk-via-cadbury-biskuat-dan-cocoa-life">Mondelez</a> have all undertaken significant corporate social responsibility projects to strengthen their relationships with the government, local NGOs and religious institutions.</p>
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Read more:
<a href="https://theconversation.com/whats-missing-in-south-africas-strategy-to-get-breastfeeding-levels-up-165548">What's missing in South Africa's strategy to get breastfeeding levels up</a>
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<p>Similarly in South Africa, having partnered with the Department of Basic Education, <a href="https://www.gov.za/speeches/basic-education-nestl%C3%A9-healthier-kids-initiative-15-may-2018-0000">Nestlé aimed to provide its products</a> to over half of all South African primary school students in the guise of “nutrition”.</p>
<h2>Fighting back to protect health - what can be done?</h2>
<p>Taking on the ultra-processed food industry with its considerable political and economic power is an enormous task. Nevertheless, drawing upon evidence of successful campaigns from around the world, there are concrete and effective steps that can be taken.</p>
<p><strong>Get the right people</strong>: The right people, with the right skills, training, and experience are crucial to tackling the power of Big Food. These factors were essential in <a href="https://doi.org/10.1080/23288604.2019.1669122">the passage of the sugar-sweetened beverage tax in Mexico</a>. They were also crucial <a href="https://doi.org/10.1186/s12961-019-0464-8">in Thailand’s multi-dimensional response</a> to the noncommunicable diseases pandemic.</p>
<p><strong>Build networks to pool resources</strong>: Individuals and organisations with a shared purpose working together is <a href="https://onlinelibrary.wiley.com/doi/10.1111/obr.12871">essential when creating political commitment and securing nutrition policy changes</a>. Networks should have a diversity of members, including those from low- and middle-income countries, to build credibility. They can collaborate and pool resources, and partner with people and organisations from other disciplines to mount more comprehensive, effective, and <a href="https://actonncds.org/">successful campaigns</a>.</p>
<p><strong>Governments need to step up</strong>: They should monitor what drives the consumption of ultra-processed foods. They should also be transparent about political donations, funding of research, and the legislative environment around ultra-processed food products.</p>
<p><strong>Expand what counts as public health skills</strong>: People with diverse skill sets that are often missing in traditional public health responses should be recruited to limit corporate power. This includes people with lived experiences of noncommunicable diseases, digital strategists, experts in business, trade and governance, investigative journalists, and lawyers.</p>
<h2>Transnational cooperation is needed</h2>
<p>To address the power of transnational corporations, a transnational response is required. The power and size of these large corporations often enable them to circumvent the laws and regulations of the countries their products are produced and consumed in. </p>
<p>A truly cooperative approach between international organisations, governments, and civil society – using the above recommendations – can rein in the harmful activities of Big Food globally. People’s health must be prioritised over corporate profits.</p><img src="https://counter.theconversation.com/content/166927/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Edwin Kwong has received funding from the World Health Organization to conduct research on salt consumption and reduction.</span></em></p><p class="fine-print"><em><span>As a PhD candidate, Joanna Williams receives funding from the Australian Government.</span></em></p><p class="fine-print"><em><span>Phillip Baker currently receives funding from the World Health Organization to conduct research on infant and young child feeding. He has received funding from the Food and Agricultural Organization, World Bank, UNICEF, Department of Foreign Affairs and Trade, and the Australian Research Council. </span></em></p><p class="fine-print"><em><span>Rob Moodie has received funding from the National Health and Medical Research Council and the Victorian Health Promotion Foundation. He is a board member of Movember and SugarbyHalf and is the Chair of the start up social enterprise Health Futures Australia. </span></em></p><p class="fine-print"><em><span>Thiago M Santos receives or has received funding from the Associação Brasileira de Saúde Coletiva, and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior. </span></em></p>Big Food companies producing ulta-processed foods are using a range of key market and political practices to increase their reach, particularly in developing countries.Edwin Kwong, Research Fellow, The University of MelbourneJoanna Williams, PhD Candidate, Swinburne University of TechnologyPhillip Baker, Research Fellow, Institute for Physical Activity and Nutrition, Deakin University, Deakin UniversityRob Moodie, Professor of Public Health, The University of MelbourneThiago M Santos, PhD candidate, Federal University of PelotasLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1630292021-06-27T08:44:23Z2021-06-27T08:44:23ZStudy shows a huge burden of undiagnosed disease in a rural South African district<figure><img src="https://images.theconversation.com/files/407238/original/file-20210618-14443-83lsoi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Healthcare worker, Boitsholo Mfolo, inside the digital x-ray truck at one of Africa Health Research Institute’s mobile screening camps in rural KwaZulu Natal, South Africa. </span> <span class="attribution"><span class="source">Samora Chapman/ Africa Health Research Institute</span></span></figcaption></figure><p>South Africa’s <a href="https://www.avert.org/news/hiv-testing-south-africa-rises-45-12-years">massive effort</a> over the years to test and treat people for HIV has drastically improved public health. But in that process, other diseases that are highly prevalent may have been neglected.</p>
<p>The country has been reporting lower rates HIV-related deaths. But more South Africans are presenting with noncommunicable diseases such as diabetes and hypertension. And tuberculosis (TB) remains the <a href="http://www.statssa.gov.za/?p=14435">leading cause of death</a> in people living with HIV.</p>
<p>We recently <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(21)00176-5/fulltext">published the findings</a> of research we did in a rural area of northern KwaZulu-Natal, South Africa. It aimed to get a clearer picture of the state of health and disease in the area and to identify the prevalence and overlap of infectious and noncommunicable diseases.</p>
<p>The ultimate goal is to design better interventions to improve people’s health.</p>
<p>We set up mobile health camps and screened for diabetes, high blood pressure, HIV, TB, nutritional status (obesity and malnutrition), and use of tobacco and alcohol. </p>
<p>The detailed data allowed us to develop a profile of which diseases were being well managed, and which neglected, in the community. For example, we found that HIV was well treated relative to all other diseases. But TB, elevated blood glucose, and elevated blood pressure were poorly diagnosed and treated. </p>
<p>The study also allowed us to identify overlaps between disease patterns and their geographical location. For example, it was very interesting to see that the areas with the highest prevalence of TB and noncommunicable diseases were mostly in the remote parts of the district and did not overlap with those with the highest rates of HIV. </p>
<p>Our findings raise important questions about how healthcare and screening can most effectively be offered in rural and remote areas. One of our conclusions was that South Africa needs a public health response that expands the successes of the country’s HIV testing and treatment programme to provide multi-disease care targeted to specific populations.</p>
<h2>Key findings</h2>
<p>Our study drew on data collected over 18 months from 2018 to 2019 in uMkhanyakude district, a remote rural area in the east of the country. We screened 17,118 people aged 15 years and older by taking mobile camps into the community and providing screening within 1 km of each participant’s home. </p>
<p>The study provides an in-depth snapshot of the health of a rural population in South Africa.</p>
<p>It shows that:</p>
<ul>
<li><p>there are high and overlapping burdens of HIV, TB, diabetes and hypertension among men and women,</p></li>
<li><p>four out of five women over the age of 30 are living with a chronic health condition,</p></li>
<li><p>HIV-negative people and older people, particularly those over 50, bear a high burden of undiagnosed or poorly controlled noncommunicable diseases such as diabetes and hypertension.</p></li>
</ul>
<p>We found the highest burden of HIV in the vicinity of the main roads. This is similar to other <a href="https://academic.oup.com/ije/article/47/2/537/4781374">studies</a> and has been observed throughout the <a href="https://www.unaids.org/en/resources/presscentre/featurestories/2011/july/20110711transporthiv">region</a> and world. </p>
<p>Just over half of all people 15 years or older (52%) were found to have at least one active disease, while 12% had two or more diseases. Over a third (34%) of people were living with HIV. This number was particularly high among 25 to 44-year-old women. The prevalence of HIV among them was 62%. </p>
<p>We attempted to measure the level of virus in every HIV-positive participant’s blood and found that 78% had no detectable virus, meaning that their antiretroviral therapy was working very well. </p>
<p>But the study also revealed that there are some demographic groups, including men in their 20s and 30s, who still have high rates of undiagnosed and untreated HIV and therefore have virus circulating in their blood. This means that they can pass HIV on to others. Our study highlights the importance of preventing new HIV infections, especially among young people.</p>
<p>In contrast to HIV, we found that most people with TB, diabetes or hypertension had disease which was previously undiagnosed or not well controlled. We found that 1.4% of the population had active TB, which is a <a href="https://www.who.int/news/item/17-06-2021-who-releases-new-global-lists-of-high-burden-countries-for-tb-hiv-associated-tb-and-drug-resistant-tb">very high rate</a> in national and global context. Of these only 30% were already diagnosed and on medication for TB. This meant that approximately 1 in 100 people in this community had undiagnosed TB. </p>
<p>Despite being a curable disease, TB remains one of the <a href="https://www.knowledgehub.org.za/elibrary/first-national-tb-prevalence-survey-south-africa-2018">leading causes of death</a> in South Africa. We found higher rates of TB in men with just under half of all men over age 45 having had TB in his lifetime. The high rates of undiagnosed TB and the finding that men in particular are affected by TB are echoed in South Africa’s recent national TB prevalence <a href="https://theconversation.com/first-ever-national-survey-shows-the-extent-of-south-africas-tb-problem-155153">survey</a> and are a huge cause for concern.</p>
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<strong>
Read more:
<a href="https://theconversation.com/first-ever-national-survey-shows-the-extent-of-south-africas-tb-problem-155153">First ever national survey shows the extent of South Africa's TB problem</a>
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<p>We found that 8.5% of the population had high blood sugar (diabetes) and 23% had high blood pressure (hypertension). These conditions were mostly found in people older than 45 and were not well diagnosed or controlled. </p>
<p>Only 43% of people with high blood pressure and only 7% with high blood sugar had these conditions well controlled with medications. Women in particular bore a particularly high burden of disease with over 4 of 5 (80%) of those over 30 years old having at least one of these conditions.</p>
<p>When we asked participants about their experience in the study, they told us that they appreciated not having to travel long distances to receive <a href="https://pubmed.ncbi.nlm.nih.gov/33165556/">screening</a>.</p>
<h2>Next steps</h2>
<p>The data provide indicators for where the most urgent interventions are needed. It sets the stage for researchers to examine the biological, social and environmental determinants of disease in the area. It also provides detailed information to guide the Department of Health in development of decentralised models of rural healthcare that integrate management of HIV, TB and noncommunicable diseases.</p>
<p>This work has highlighted the immense burden of undiagnosed or untreated diabetes and hypertension in rural South Africa. As the country faces another surge of COVID-19, it is more important than ever to identify and treat people living with these diseases.</p><img src="https://counter.theconversation.com/content/163029/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Emily B. Wong works for the Africa Health Research Institute and the University of Alabama at Birmingham. She and members of her research group receive funding from the National Institutes of Health, Bill and Melinda Gates Foundation, the African Academy of Sciences and the South African Medical Research Council.</span></em></p>South Africa needs a public health response that expands the successes of the country’s HIV testing and treatment programme to provide care for multiple diseases.Emily B. Wong, Assistant Professor, Africa Health Research Institute (AHRI)Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1618302021-06-22T16:08:53Z2021-06-22T16:08:53ZBlunting the impact of poor social conditions in South Africa will have big health benefits<figure><img src="https://images.theconversation.com/files/406505/original/file-20210615-3832-1nn4rw1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many South Africans live in poor conditions with no access to running water.</span> <span class="attribution"><span class="source">Rodger Bosch/AFP via Getty Images</span></span></figcaption></figure><p>Poverty and socio-economic disparity are among the greatest obstacles facing South Africans. About <a href="https://ilifalabantwana.co.za/wp-content/uploads/2016/05/SA-ECD-Review-2016-low-res-for-web.pdf">63%</a> of children younger than six live in poverty. The country is also experiencing increasing levels of <a href="https://www.statista.com/statistics/370516/unemployment-rate-in-south-africa/">unemployment</a>. In addition there’s a high prevalence of <a href="https://eprints.qut.edu.au/80249/1/Norman%202010%20PHM.pdf">femicide and inter-partner violence</a> which is often <a href="https://substanceabusepolicy.biomedcentral.com/articles/10.1186/s13011-018-0182-1">associated</a> with excessive alcohol consumption and substance abuse.</p>
<p>Harsh socio-environmental factors, especially when they happen in the early years of a child’s life, can establish a developmental <a href="https://www.irp.wisc.edu/wp/wp-content/uploads/2019/04/foc291a.pdf">‘biology of misfortune’</a>. This involves neurobiological and epigenetic processes that go on to steer a person’s life towards poor health, unrealised potential and a shorter life. </p>
<p>Neurobiology here refers to normal brain development. This is, at times, controlled by epigenetic mechanisms. These are biological reactions involving certain proteins that interact with DNA, physically altering its structure. Epigenetics can be influenced by our physical environment and surroundings. Adverse environments can profoundly alter gene expression and have detrimental health effects including disturbed brain development.</p>
<p>There are clear disadvantages to ignoring the physical environment in relation to adverse epigenetic programming. Firstly, it can result in a future population with deteriorated physical and mental health – these individuals would also be more susceptible to infectious diseases. Secondly, it can affect the future health and economic development of the country. </p>
<p>That’s why child and adolescent health is an urgent priority and should be placed at the centre of the healthcare system.</p>
<p>In <a href="https://sajs.co.za/article/view/8638">our recent paper</a> my colleagues and I described how adverse socio-environmental factors in early life can programme the outcome of obesity, diabetes, cardiovascular disease and mental health disorders in adulthood. These noncommunicable diseases are on the rise and are taking a heavy toll on people’s lives, and the country’s healthcare system.</p>
<p>We set out the social and environmental conditions experienced by young South Africans, and discuss the potential contribution of epigenetics to the current and future prevalence of noncommunicable diseases.</p>
<p>We also unpack some early interventions that can help improve child and adolescent health. The cornerstones are: providing optimum nutrition, providing a secure environment, physical activity and education.</p>
<h2>Social conditions</h2>
<p>South Africa is one of <a href="https://www.worldbank.org/en/country/southafrica/overview">most unequal societies </a> in the world. Children who are exposed to such levels of poverty can suffer immediate and longterm effects. Children from poor families have higher rates of chronic illness and experience worse health in adulthood. </p>
<p>More than half (55%) of the population <a href="http://webcms.uct.ac.za/sites/default/files/image_tool/images/367/South%20African%20Child%20Gauge%202018%20-%20Nov%2020.pdf">experiences poverty</a>, with childhood poverty affecting <a href="http://webcms.uct.ac.za/sites/default/files/image_tool/images/367/South%20African%20Child%20Gauge%202018%20-%20Nov%2020.pdf">63% of children</a>.</p>
<p>With diet being <a href="https://www.sciencedirect.com/science/article/abs/pii/S088985290800056X?via%3Dihub">intertwined</a> with emotions, cognition and behaviour, close attention should be paid to nutrition.</p>
<p>Research has shown that certain diets are hugely beneficial to peoples’ health. One example is a diet that’s high <a href="https://www.sciencedirect.com/science/article/pii/S2212877819304971?via%3Dihub">in polyphenols</a>. These are plant compounds found in tea, chocolates, herbs and spices, fruit, vegetables and nuts. Several have been shown to be able to reduce illnesses by preventing oxidative stress and inflammation in the brain.</p>
<p>On top of this, South Africa sits on a <a href="https://www.sciencedirect.com/science/article/pii/S0254629911001190?via%3Dihub">botanical ‘goldmine’ of indigenous medicinal plants</a>. Many have anti-obesity, anti-cancer, anti-diabetic as well as anti-ageing properties among others.</p>
<p>Finally, while the benefits of breastfeeding for both mother and child
<a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003517.pub2/full">have long been known</a>, South Africa, like most countries, is still not doing enough to support mothers to breastfeed, despite <a href="https://academic.oup.com/heapol/article/34/6/407/5522499">the immense economic implications</a>. </p>
<h2>Champions</h2>
<p>The failure to optimise nutrition, especially during the critical periods of development for vulnerable young children, should be avoided at all costs. There is a definite requirement for efforts directed at improving the national diet. </p>
<p>But healthier foods <a href="https://www.sciencedirect.com/science/article/abs/pii/S089990071000002X?via%3Dihub">are far more expensive</a> than less healthy, nutritionally poor foods. Products like lean meat, fish, fruit and vegetables generally <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001253">cost more</a> than oil heavy processed foods which contain more sugar and fat.</p>
<p>This makes the promotion of a quality diet difficult, because it is simply unaffordable for many South Africans. </p>
<p>International research has shown that the best strategies for changing the dietary environment in favour of healthier foods are those aimed at population level, and are accomplished by mass media nutrition campaigns and transparent food labelling. Some countries have <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001253">taken more drastic action </a> through regulation and taxation of unhealthy foods.</p>
<p>South Africa needs champions for child and adolescent health. The plight of young children needs to be prioritised and placed at the centre of the country’s goals.</p>
<p>An early investment in childrens’ health, education, development, security and well-being would provide benefits that compound during a person’s lifetime. It would improve their prospects – and those of their children and thus society as a whole.</p><img src="https://counter.theconversation.com/content/161830/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ebrahim Samodien receives funding from the South African Medical Research Council through it's Division of Research Capacity Development and Biomedical Research and Innovation Platform. </span></em></p>Harsh socio-environmental factors, especially when they happen in the early years of a child’s life, can establish a developmental “biology of misfortune”.Ebrahim Samodien, Post-doctoral researcher, South African Medical Research CouncilLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1606212021-05-16T07:51:45Z2021-05-16T07:51:45ZSouth Africa must ban sugary drinks sales in schools. Self regulation is failing<figure><img src="https://images.theconversation.com/files/400513/original/file-20210513-21-1bdlcs8.jpg?ixlib=rb-1.1.0&rect=418%2C23%2C1083%2C812&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">White River Primary school in South Africa, sponsored by Coca Cola.</span> <span class="attribution"><span class="source">Roo Reynolds/Flickr</span></span></figcaption></figure><p>In 2017, Coca-Cola Beverages South Africa voluntarily <a href="https://www.timeslive.co.za/sunday-times/news/2017-08-12-how-coke-is-keeping-sugar-on-the-school-menu/">announced</a> that it would stop supplying sugary beverages to primary school outlets. The company also pledged to remove all branding and advertising from schools. The announcement took the form of a letter noting that that Coca-Cola Beverages wanted to play “an active role in addressing rising obesity rates in South Africa, especially among children”. </p>
<p>Childhood obesity is a serious and growing problem is South Africa. More than <a href="https://www.samrc.ac.za/sites/default/files/attachments/2019-01-29/SADHS2016KeyFindings.pdf">13% of children</a> are either obese or overweight. The consumption of liquid sugar is particularly harmful because it is absorbed so quickly into the bloodstream. Not surprisingly, sugary drinks and their marketing has been linked to obesity especially among children. Just a single sugary beverage per day increases that child’s chance of overweight by 55%. Similarly, once they become an overweight teen, there is a 70% chance they will not be able to lose the weight.</p>
<p>The food environment in schools plays a significant role in increasing access to sugary drinks. Children spend a lot of time in school during their developmentally important periods. Among others, the types of food and beverages children are exposed to at school influence their eating patterns and food preferences. </p>
<p>This is a concern for South Africans as children are exposed to <a href="https://pubmed.ncbi.nlm.nih.gov/26513442/">aggressive marketing</a> and <a href="http://www.sajcn.co.za/index.php/SAJCN/article/view/528">unhealthy foods and beverages</a> at schools. Of particular concern is learners’ excessive sugary drinks consumption. An average grade 4 learner (10-year-old) has around one to two <a href="https://www.ajol.info/index.php/jfecs/article/view/53995">sugary drinks per day</a>, with each soft drink containing up to nine teaspoons of sugar. </p>
<p>Obesity prevention efforts are clearly needed in schools. But what should these efforts entail? Our <a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2021.1898130">new research</a> shows that voluntary actions by industry are not part of the recipe. </p>
<p>The aim of our research was to see what drinks were available at schools after Coca-Cola’s announcement. Our audit showed that the company’s brands remained available in most of the schools. Our study highlights that ceding regulation to industry is risky; government regulations and legislation are needed.</p>
<h2>Tuck shop audit</h2>
<p>We studied the food environment across 105 public primary schools in South Africa’s Gauteng province. Schools were located in both affluent and in poorer areas. This allowed us to see if there were any differences in outcomes based on the socioeconomic status of the school. Fieldworkers visited tuck shops and other food outlets on school premises. They spoke to school staff to find out what was being sold to the children through the school stores or tuck shops. </p>
<p>In general, food consumed at schools can constitute up to <a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2021.1898130">20%–30%</a> of learners’ total daily caloric intake. This is either through the government school meal programmes in poorer areas, from the school tuck shops or learners’ lunch boxes brought from home. </p>
<p>Our study showed that two years after Coca-Cola Beverages pledge, carbonated sugary drinks were available in 54% of primary school tuck shops. These drinks were more available in fee-paying schools (86%) than no-fee schools (21%). When researchers looked at the availability of alternative low-calorie products, they found that none of the school tuck shops sold only low-calorie drinks. </p>
<p>Decision makers explained that schools faced challenges such as financing general school maintenance and staff salaries. They felt like they had to make a trade-off between revenue generation and the healthfulness of the products they sold in the tuck shops. We found that Coca-Cola Beverages South Africa is not the sole distributor to school tuck shops. Therefore, even when Coca-Cola Beverages South Africa would not supply sugary beverages, schools stocked their tuck shops through general commercial wholesalers. </p>
<p>When it came to advertising, only some schools reported that the company had done what was promised in the pledge, to remove all branding and advertising from schools. But this was the exception rather than the norm. Nearly one-third (31%) of schools had Coca-Cola branding or advertising on school premises. Much of the branding are billboards with the name of the school. Respondents reported that branding, in particular branded fridges, remained unchanged. </p>
<p>Less than half of the school decision makers interviewed in the study were aware of the pledge. This suggests that they either did not recall the letter or had not seen it. The study also revealed that there was easy access to unhealthy products outside school premises through informal food vendors and nearby stores.</p>
<h2>Recommendations</h2>
<p>Despite the common reliance on self-regulatory measures by commercial food entities there is no evidence to support either their effectiveness or safety, according to policy expert <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)62089-3/fulltext">Professor Rob Moodie and colleagues</a>.</p>
<p>A ban on sugary drinks sales and advertising is likely to hold more promise than voluntary actions in improving the diets of school-going children and contribute to obesity prevention efforts among children. There is promising evidence from other developing countries, like <a href="https://ajph.aphapublications.org/doi/10.2105/AJPH.2019.305159">Chile</a>, where a ban on unhealthy foods and beverages resulted in substantial reduction in sales of such products in schools.</p>
<p>Change must also happen in the wider school community, in line with our constitutional basis in the best interests of the child. </p>
<p>Students, school staff, parents, and tuck shop owners all play a significant role in creating a healthier food environment at schools. Making a change at the tuck shop might feel risky but small changes such as banning sugary drinks are an excellent start. This already happening across the globe. </p>
<p>Lastly, it is important that these changes are communicated with the wider school community. The health benefits of the changes should be explained, emphasising the positive impact on students’ nutrition, well-being and school performance. Learners should be able to question what they can buy at school tuck shops or are served for lunch. Every school child in South Africa is entitled to an easy and healthy dietary choice on a daily basis.</p><img src="https://counter.theconversation.com/content/160621/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Agnes Erzse receives funding from from the SA MRC, IDRC Canada, the UK National Institute for Health Research through the University of Cambridge and Bloomberg Philanthropies, through UNC Chapel Hill.</span></em></p><p class="fine-print"><em><span>Karen Hofman receives funding from the SA MRC, IDRC Canada, the UK National Institute for Health Research through the University of Cambridge and Bloomberg Philanthropies, through UNC Chapel Hill.</span></em></p><p class="fine-print"><em><span>Nicola Christofides receives funding from European Research Council, UKRI. </span></em></p>A ban on sugary drinks sale and advertisements in schools is likely to hold more promise in improving the diets of children and help prevent obesity in children than voluntary actions.Agnes Erzse, Researcher, SAMRC/Centre for Health Economics and Decision Science- PRICELESS SA, University of the WitwatersrandKaren Hofman, Professor and Programme Director, SA MRC Centre for Health Economics and Decision Science - PRICELESS SA (Priority Cost Effective Lessons in Systems Strengthening South Africa), University of the WitwatersrandNicola Christofides, Associate Professor, School of Public Health, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1602752021-05-10T14:55:12Z2021-05-10T14:55:12ZOur research shows gaps in South Africa’s diabetes management programme<figure><img src="https://images.theconversation.com/files/398929/original/file-20210505-19-898bla.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Diabetes is a leading cause of death in the country.</span> <span class="attribution"><span class="source"> PixelCatchers via GettyImages</span></span></figcaption></figure><p>Diabetes is currently the ninth most common cause of death in the world. Around <a href="https://www.thelancet.com/journals/landia/article/PIIS2213-8587(21)00111-X/fulltext">420 million people or 6% of the world’s population is affected</a>. This number is expected to rise beyond half a billion by the end of the decade with the biggest increase occurring in low- and middle-income countries. </p>
<p>Most people with the condition have <a href="https://www.who.int/news-room/fact-sheets/detail/diabetes">type 2 diabetes</a>. This type of diabetes is the result of excess body weight and physical inactivity. </p>
<p>In South Africa, diabetes affects <a href="https://diabetesatlas.org/en/">approximately 4.5 million</a> people. The proportion of the adult population living with the condition is estimated at 12.8%. It’s the leading <a href="https://www.statssa.gov.za/publications/P03093/P030932017.pdf">cause of death</a> among women. In 2019, 89,834 people died of diabetes. This number exceeds the capacity of <a href="http://www.stadiummanagement.co.za/stadiums/fnb/">Soccer City</a>, the biggest football stadium in South Africa.</p>
<p>Most people living with diabetes in South Africa access treatment and care in primary healthcare facilities. Unfortunately, the clinics are often congested and patients have to wait in long queues to receive their medication during their monthly visits. To address these challenges, the National Department of Health initiated a programme in 2014 to improve access to medication and patient adherence. </p>
<p>The programme gives patients with controlled diabetes the option of collecting their medication at pick-up points of their choice such as shops, places of worship, community halls or schools.</p>
<p>But our <a href="https://pubmed.ncbi.nlm.nih.gov/33764132/">recent research</a> found that only a minority of patients enrolled in the programme achieved the treatment targets at the time of the study. We audited the files of patients who had been on the programme for an average of two years (minimum of one year and maximum of five years). Our findings suggest that the criteria used to select people with diabetes for the programme should be revised. In addition, healthcare managers should explore strategies to incorporate diabetes education into the programme.</p>
<h2>Better access to medicines but suboptimal management</h2>
<p>The <a href="https://getcheckedgocollect.org.za/ccmdd/">centralised chronic medicine dispensing and distribution programme</a> was launched in February 2014.
The service is free and benefits the patient in a number of ways. These include: </p>
<ul>
<li>fewer clinic visits, </li>
<li>taking less time off work, </li>
<li>not having to travel long distances, </li>
<li>not waiting in queues, and </li>
<li>collecting medication at any time and place. </li>
</ul>
<p>By definition, patients who are on the programme are stable – meaning that they are doing well. </p>
<p>The clinic nurse or doctor measures the levels of sugar in the blood with a test called <a href="https://www.diabetes.co.uk/fasting-plasma-glucose-test.html">Fasting Plasma Glucose</a>. If two consecutive tests are normal the patient qualifies for the programme. Once enrolled, the patient does not have to come to the clinic to collect medication. Patients on this programme visit the clinic every six months to get checked. </p>
<p>We conducted an audit of the medical records of people with type 2 diabetes who were enrolled in the centralised chronic medicine dispensing and distribution programme at 23 primary healthcare facilities in the Tshwane District of the country’s capital city. The aim was to assess how well the patients were doing at the time. We looked at the most recent test results recorded in their files, namely <a href="https://www.webmd.com/diabetes/guide/glycated-hemoglobin-test-hba1c">haemoglobin A1C or HbA1c</a>, blood pressure and blood cholesterol. Test results were missing from some patient records, suggesting that patients are not always receiving the tests they are entitled to.</p>
<p>Only 29% of patients in the study had acceptable blood sugar levels. This is concerning because to be eligible for enrolment in the programme, these patients should have been stable controlled patients. Our findings suggest that some patients enrolled in the programme were not stable to begin with. </p>
<p>The suboptimal management of people with type 2 diabetes is worrying especially in the era of the COVID-19 pandemic because <a href="https://www.idf.org/aboutdiabetes/what-is-diabetes/covid-19-and-diabetes/1-covid-19-and-diabetes.html">people living with diabetes are more vulnerable</a> to becoming ill or dying from COVID-19. The consequences of high levels of sugar in the blood include blindness, kidney failure, heart attack, stroke, and leg amputation. These complications result in reduced quality of life and higher healthcare costs, and place unnecessary stress on families.</p>
<p>To ensure that patients benefit fully from this programme, the selection criteria should be revised. Instead of using Fasting Plasma Glucose to determine whether a patient qualifies, the HbA1c should be used. Fasting Plasma Glucose is not a reliable indicator of how well a person with diabetes is doing because it measures blood sugar levels at a single point in time. In contrast, HbA1c provides an indication of blood sugar concentrations over the previous two to three months. The benefit of measuring HbA1c is that it gives a more reasonable and stable view of what’s happening over time (three months). And the value does not vary as much as finger-prick blood sugar (Fasting Plasma Glucose) measurements.</p>
<p>This programme limits a patient’s contact with healthcare providers. An unintended consequence is that the person has limited opportunities to be informed about the condition and to be educated on how to best manage diabetes. </p>
<p>For people with chronic conditions such as diabetes, education and empowerment are crucial to ensure better outcomes. The person with diabetes should be equipped to eat well, get enough physical activity and take the correct amount of medication at the right time. </p>
<h2>Addressing the gaps</h2>
<p>Authorities have <a href="http://www.kznhealth.gov.za/mediarelease/2018/nearly-2-million-people-now-fetch-04112018.htm">claimed the success of the programme</a>. But our study identified some gaps that should be addressed. </p>
<p>The centralised chronic medicine dispensing and distribution programme should consider revising how people with type 2 diabetes are selected. It should also include additional measures for patient empowerment and education. </p>
<p>Improving the management and care of people living with diabetes requires innovative evidence-based interventions. Strategic public-private partnerships are key to ensure that the South African government reaches its objectives in terms of providing better lives for people with diabetes. One such initiative is our <a href="https://www.diabetessa.org.za/the-tshwane-insulin-project/">Tshwane Insulin Programme</a> at the University of Pretoria.</p>
<p>Our programme is a partnership between the University of Pretoria and <a href="https://www.lilly.com/impact/lilly-foundation">the Lilly Global Health Partnership</a>. We work closely with the national, provincial and local health authorities to develop sustainable solutions to improve the management and outcomes of people living with diabetes in South Africa.</p><img src="https://counter.theconversation.com/content/160275/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Rheeder receives funding from the Lilly Global Health Partnership.</span></em></p><p class="fine-print"><em><span>Elizabeth M. Webb and Patrick Ngassa Piotie do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In 2019, 89,834 people died of diabetes. This number exceeds the capacity of Soccer City, the biggest football stadium in South Africa.Patrick Ngassa Piotie, Project Manager, Tshwane Insulin Project, University of PretoriaElizabeth M. Webb, Senior Lecturer, University of PretoriaPaul Rheeder, Project Head, Tshwane Insulin Project, University of PretoriaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1562302021-04-20T12:33:27Z2021-04-20T12:33:27ZAfrican countries must consider legal challenges to sugar taxes before pursuing policies<figure><img src="https://images.theconversation.com/files/388523/original/file-20210309-23-1lnr2vd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Sales of unhealthy foods and beverages in sub-Saharan Africa are skyrocketing. This is leading to an <a href="https://www.sciencedirect.com/science/article/pii/S2211912420301206">increase in obesity related conditons</a> such as diabetes, hypertension and cardiovascular disease. </p>
<p>These diseases are projected to become <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(19)30370-5/fulltext">the leading cause of death in sub-Saharan Africa by 2030</a>, overtaking communicable diseases like HIV and TB. The economic cost of noncommunicable diseases is immense. They result in significant disability, and can be very expensive to treat. In South Africa, the medical cost of diabetes was <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7012049/">R2.7 billion in 2018</a>. </p>
<p>But noncommunicable diseases are preventable. The economic and societal impact can be mitigated if governments take decisive action to reduce the availability of harmful products such as unhealthy food, alcohol and tobacco.</p>
<p>Sugar-sweetened beverages are among the most harmful food products to consumers. This is because <a href="https://www.sciencedirect.com/science/article/abs/pii/S1043276012001191?casa_token=mkh_7xDvoqUAAAAA:54Fjyj7MH3XZAsDWKBdWzLq9GvUIYEkYtrL1ruRSrlcE5nf3Bqf_OfhP7aenNpumeNMGtHtNfZE">liquid sugar is especially toxic</a> and these drinks have no nutritional value.</p>
<p>One of the key ways to address the growing public health impact of sugary drinks is by introducing laws, policies and regulations. These measures could limit the availability of unhealthy products and make it easier to encourage people to eat healthy food. But they must be implemented as a combined effort. </p>
<p>There are a number of <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/obr.12580">proven interventions</a> to reduce the consumption of sugary drinks. These include limiting portion sizes, banning them from schools and checkout isles of supermarkets and taxing sugar-sweetened drinks. </p>
<p>But these measures have been challenged legally and by other means by the companies that produce and sell sugary drinks. </p>
<p>In 2012, then New York City mayor Michael Bloomberg introduced a regulation limiting the portion sizes of sugar-sweetened drinks sold around the city. The beverage industry and retailers <a href="https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2015.302862">challenged this decision in court</a> and the policy was rolled back. South Africa’s efforts to introduce a tax on sugar-sweetened beverages <a href="https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-020-00647-3">faced threats of legal challenges</a>. These were based on a range of technicalities from a lack of public participation to challenging the purpose of the tax. In this case, the objections only delayed the tax rather than stopping it. </p>
<p>Even if these law suits are unsuccessful, they can have a chilling effect on other actions to prevent noncommunicable diseases. Legal challenges to government efforts to address the availability of unhealthy food and drinks can seriously undermine public health.</p>
<p>This is why countries must carefully consider the legal feasibility of an intervention before deciding how to implement it. We <a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2021.1884358">developed</a> a way in which countries can consider doing this. It involves an assessment of the potential legal barriers to, and as well as the facilitators of, the proposed intervention.</p>
<h2>The landscape</h2>
<p>Our <a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2021.1884358">study</a> looked at the legal feasibility of introducing a tax on sugar-sweetened beverages in seven sub-Saharan African countries: Botswana, Kenya, Namibia, Rwanda, Tanzania, Uganda, and Zambia. We looked at four different types of sugary drinks taxes that had been introduced around the world and whether these could be introduced in each of these countries.</p>
<p>We assessed each country’s legal barriers and facilitators. These included their legal and taxation regimes. We also examined broader regional agreements and the infrastructure needed to implement such a tax. </p>
<p>We considered <a href="https://openknowledge.worldbank.org/bitstream/handle/10986/33969/Support-for-Sugary-Drinks-Taxes-Taxes-on-Sugar-Sweetened-Beverages-Summary-of-International-Evidence-and-Experiences.pdf?sequence=6&isAllowed=y">taxes implemented in various countries around the world</a> and chose to evaluate the four taxes adopted in Mexico, Colombia, the UK and South Africa under this study. The tax introduced in Mexico added a fixed amount on each litre of soft drink. The taxes in South Africa and the United Kingdom link the amount of tax payable to the sugar content of a drink. And Colombia decided to remove a value added tax exemption from sugar-sweetened beverages. With the exception of Colombia’s approach, most of these taxes are introduced as an excise tax.</p>
<p>Our research showed that all seven sub-Saharan African countries had existing excise tax legislation. And five countries already taxed sugar-sweetened beverages. However, these existing taxes worked to generate revenue for governments rather than improve public health as the taxes did not differentiate between sugary and non-sugary drinks. For example, Rwanda had a tax of 39% on carbonated beverages but sugary drinks remained a cheap beverage option.</p>
<p>In addition, countries have an obligation to introduce measures to protect the health of their citizens. These obligations are set out in treaties like the <a href="https://www.achpr.org/legalinstruments/detail?id=49">African Charter on Human and Peoples’ Rights</a> and domestic constitutions which contain rights to nutritious food or health. </p>
<p>Our research also showed that there were existing laws that could be used as a foundation to adopt a sugar-sweetened beverage tax to improve public health. For example, <a href="https://www.theguardian.com/global-development/2018/oct/26/tax-on-drinks-to-raise-funds-for-hiv-treatment-in-uganda">Uganda</a> had a dedicated HIV fund which was funded entirely by a 2% levy on drinks (including soft drinks and bottled water). Both <a href="https://www.kilimo.go.tz/index.php/en/stakeholders/view/sugar-board-of-tanzania-sbt">Tanzania</a> and <a href="http://kenyalaw.org/kl/fileadmin/pdfdownloads/bills/2019/TheSugarBill_2019.pdf">Kenya</a> had an agricultural levy on sugar, the proceeds of which were used to support sugar farmers. </p>
<p>The existence of supportive legal frameworks such as human rights could also be used to defend against potential challenges to a public health measure like this. </p>
<p>The introduction of taxes on sugar-sweetened beverages in <a href="https://www.cambridge.org/core/journals/public-health-nutrition/article/did-high-sugarsweetened-beverage-purchasers-respond-differently-to-the-excise-tax-on-sugarsweetened-beverages-in-mexico/37DBC66A6F1E19F74942888814EB1EA3">Mexico</a> and <a href="https://www.cambridge.org/core/journals/public-health-nutrition/article/abs/assessing-sugarsweetened-beverage-intakes-added-sugar-intakes-and-bmi-before-and-after-the-implementation-of-a-sugarsweetened-beverage-tax-in-south-africa/050AA9D1D8F9B12026C0F7836D1B4F09">South Africa</a> resulted in the reduced consumption of sugar and sugary drinks consumption within a year or two after the implementation of the tax. These reductions can lead to significant <a href="https://www.cambridge.org/core/journals/public-health-nutrition/article/assessing-sugarsweetened-beverage-intakes-added-sugar-intakes-and-bmi-before-and-after-the-implementation-of-a-sugarsweetened-beverage-tax-in-south-africa/050AA9D1D8F9B12026C0F7836D1B4F09">health benefits</a>, particularly in people who consume a lot of sugary drinks. In addition, these taxes are a particularly good intervention because they can help governments generate additional tax revenues. </p>
<h2>Looking ahead</h2>
<p>Our research shows that sugar-sweetened beverage taxation in the seven countries is legally feasible. Existing laws can provide a strong starting point for the introduction of a sugar-sweetened beverage tax. In addition, the adoption of such a tax is a way for governments to meet their human rights obligations without having to worry about legal challenges undermining the intervention.</p>
<p>Legal feasibility and the health impact of these interventions are only one part in the complex political economy of adopting noncommunicable disease prevention interventions. Research has shown that <a href="https://www.tandfonline.com/doi/abs/10.1080/23288604.2019.1669122">the political environment</a> and <a href="https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-020-00647-3">industry pushback</a> against measures like sugar taxation are also important hurdles that need to be overcome. </p>
<p>Governments must take urgent action to prevent noncommunicable diseases from becoming an uncontrollable epidemic in sub-Saharan Africa. Sugar-sweetened beverage taxation offers a potential solution.</p><img src="https://counter.theconversation.com/content/156230/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Safura Abdool Karim is supported by the South African Medical Research Council Centre for Health Economics and Decision Science - PRICELESS SA. The research referenced in this article was supported by the International Development Research Centre, Canada.</span></em></p><p class="fine-print"><em><span>Karen Hofman is supported by the South African Medical Research Council Centre for Health Economics and Decision Science - PRICELESS SA. The research referenced in this article was supported by the International Development Research Centre, Canada.</span></em></p>Governments must take urgent action to prevent noncommunicable diseases from becoming an uncontrollable epidemic in sub-Saharan Africa. Sugar-sweetened beverage taxation offers a potential solution.Safura Abdool Karim, Senior researcher, University of the WitwatersrandKaren Hofman, Professor and Programme Director, SA MRC Centre for Health Economics and Decision Science - PRICELESS SA (Priority Cost Effective Lessons in Systems Strengthening South Africa), University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1562162021-04-20T12:32:08Z2021-04-20T12:32:08ZWhy African countries need reliable local data on sugary drinks taxes<figure><img src="https://images.theconversation.com/files/388205/original/file-20210308-18-779b17.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Appropriately designed taxes on sugar-sweetened beverages would result in proportional reductions in consumption.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Diets in sub-Saharan Africa are <a href="https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.12433">changing</a> as more countries advance from low-income to middle-income status. People’s eating habits are shifting from food rich in starchy staples, vegetables and fruits to a more <a href="https://theconversation.com/whats-driving-sub-saharan-africas-malnutrition-problem-55579">westernised diet</a> high in sugar, saturated fats and oils. This shift to unhealthy foods is <a href="https://www.who.int/news-room/fact-sheets/detail/healthy-diet">fuelling</a> obesity related chronic, noncommunicable conditions such as heart disease, diabetes and cancer.</p>
<p>Preventive measures are more critical than ever to curtail this tsunami that is overwhelming health systems.</p>
<p>One area that must adjust is the food and beverage sector in sub-Saharan Africa. The processed food industry is promoting the region as a <a href="https://www.mdpi.com/2071-1050/11/16/4306/htm">growth market</a> for its products. </p>
<p>To discourage consumption and reduce health risks, an increasing number of low- and middle-income countries have imposed <a href="https://openknowledge.worldbank.org/bitstream/handle/10986/33969/Support-for-Sugary-Drinks-Taxes-Taxes-on-Sugar-Sweetened-Beverages-Summary-of-International-Evidence-and-Experiences.pdf?sequence=6">taxes on sugar-sweetened drinks</a>. Across the globe and especially in <a href="https://www.healthaffairs.org/doi/10.1377/hlthaff.2016.1231">Latin America</a> and the <a href="https://www.sciencedirect.com/science/article/pii/S0091743517302608?via%3Dihub">Caribbean</a>, taxing sugary drinks to reduce consumption has been effective.</p>
<p>The World Health Organisation (WHO) has <a href="https://africa-health.com/news/world-health-organization-wants-sugar-taxes/">called on</a> African governments to follow this example, and to ease the burden of noncommunicable diseases. </p>
<p>In <a href="https://www.who.int/dietphysicalactivity/publications/fiscal-policies-diet-prevention/en/">2015</a>, a WHO panel of public health experts found that: </p>
<blockquote>
<p>appropriately designed taxes on sugar-sweetened beverages would result in proportional reductions in consumption, especially if aimed at raising the retail price by 20% or more. </p>
</blockquote>
<p>Some African countries such as South Africa, Botswana and Zambia already tax sugary drinks. But others have been slow to act. The <a href="https://www.who.int/dietphysicalactivity/publications/fiscal-policies-diet-prevention/en/">WHO</a> attributes this, in part, to evidence gaps. </p>
<p>Credible local data are essential to determine what taxes can and cannot achieve. </p>
<p>We wanted to get an understanding of what data are available to support the design, implementation, monitoring and evaluation of a sugary drinks tax. We focused on seven sub-Saharan African countries: Botswana, Kenya, Namibia, Rwanda, Tanzania, Uganda, and Zambia. These economies are growing and their marketing industries are low-cost. Regulation of unhealthy commodities is also weak. </p>
<p>In combination, these factors represent a growth opportunity for the industry. They will also fuel diet-related noncommunicable diseases.</p>
<p>Our <a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2020.1871189">research</a> highlighted the urgent need for new indicators on unhealthy diets, including sugary drinks consumption and purchase patterns. Without this evidence, countries might underestimate the consumption figures. They might then miss the potential of sugar-sweetened drinks taxation as a public health intervention.</p>
<h2>Our research</h2>
<p>We interviewed stakeholders such as representatives from government agencies, including those in health, commerce, development, agriculture, education and academia. All individuals underscored the importance of local evidence on sugary drinks consumption and purchasing behaviours, as well as fiscal evidence to compare the cost and benefits of a tax. This is because policymakers need to take into account evidence for coherent economic arguments to discuss sugar-sweetened drinks taxes in policy circles.</p>
<p>The potential health benefits, the revenue of such a tax, as well as the monitoring and evaluation of its implementation, requires appropriate baseline data at the outset particularly across income levels, and age groups. </p>
<p>Our study highlights that such information is missing in all seven countries.</p>
<p>We looked at a range of publicly available data sources to establish the rate of sugary drinks consumption and the impact on people’s health. </p>
<p>We found that national survey data does not adequately track either the intake of sugar-sweetened drinks, or household spending. Fiscal data is lacking regarding sugary drinks tax revenue, value added tax from sugary beverage sales, and the corporate income tax and customs duty revenue.</p>
<p>Accurate information on the soft drinks industry was not easily accessed either. Unlike in countries such as Mexico, it was difficult to find information on a number of fronts. The number of companies in industry sectors, beverage industry forecasts, drinks prices, package sizes, number of low- or no-calorie beverages, and sugar content were unavailable. </p>
<p>Kenya, Zambia, Rwanda, Tanzania and Uganda had taxes on non-alcoholic beverages. But only Zambia had a differential sugar-sweetened beverages tax – 3% on imported beverages and 0.5% on local drinks. Botswana recently introduced a tax that is very similar to the health promotion levy in South Africa.</p>
<h2>Going forward</h2>
<p>Timely, easily understood, concise, and locally relevant evidence is needed to inform policy development on sugary drinks. The relevant data are drawn from multiple sectors. Cross-sector collaboration is, therefore, needed. </p>
<p>Indicators to measure sugar-sweetened drinks and added sugar consumption should be developed. These must be included in current data collection tools such as national income dynamics studies. This would ensure monitoring and evaluation of taxation. </p>
<p>There’s no consensus on how best to capture data for new indicators. But a useful point of departure would be to complement existing data sources. These include population-based surveys that ask questions related to sugary drinks taxation. This would lead to improvement in tracking the intake of sweet drinks, and the effectiveness of taxation.</p>
<p>Establishing robust, accurate baseline data to inform evidence could enable governments to accelerate political and public support for sugar-sweetened beverage taxation and related policies. Finally, greater transparency of industry data is essential.</p><img src="https://counter.theconversation.com/content/156216/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Agnes Erzse receives funding from the South African Medical Research Council/Centre for Health Economics and Decision Science PRICELESS SA, University of Witwatersrand School of Public Health, Faculty of Health
Sciences, Johannesburg South Africa (D1305910-03). The research was supported by the International Development Research Center grant (#108648-001)</span></em></p><p class="fine-print"><em><span>Karen Hofman is supported by the South African Medical Research Council Centre for Health Economics and Decision Science - PRICELESS SA. The research referenced in this article was supported by the International Development Research Centre, Canada.</span></em></p>Without reliable, local and timely data, countries will miss the potential of sugar-sweetened beverage taxation as a public health intervention.Agnes Erzse, Researcher, SAMRC/Centre for Health Economics and Decision Science- PRICELESS SA, University of the WitwatersrandKaren Hofman, Professor and Programme Director, SA MRC Centre for Health Economics and Decision Science - PRICELESS SA (Priority Cost Effective Lessons in Systems Strengthening South Africa), University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1551452021-04-20T12:30:44Z2021-04-20T12:30:44ZHow Rwanda can use fiscal policies to improve health outcomes<figure><img src="https://images.theconversation.com/files/384477/original/file-20210216-17-19uobba.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Rwanda’s health sector has seen many reforms over the past <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60574-2/fulltext?rss=yes">two decades</a>, which have greatly improved public health indicators. Communicable diseases have declined and the <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-017-1581-4">maternal mortality</a> rate fell from 1,071 deaths per 100,000 live births in 2000 to 210 in 2015.</p>
<p>But noncommunicable diseases are a <a href="https://www.who.int/ncds/surveillance/steps/Rwanda_2012_STEPS_Report.pdf">growing problem</a>. Overweight, obesity and associated nutrition related diseases are becoming <a href="https://www.who.int/nmh/countries/rwa_en.pdf?ua=1">more prevalent</a> in Rwanda. </p>
<p>Globally, the rapid increase in consumption of <a href="https://www.who.int/elena/titles/bbc/ssbs_adult_weight/en/">sugar sweetened beverages</a> has been identified as a major contributor to the rise of obesity and noncommunicable disease such as type 2 diabetes. </p>
<p>In several countries taxation on sugar sweetened beverages has <a href="https://www.tandfonline.com/doi/full/10.1080/23288604.2019.1669122">emerged</a> as a cost-effective strategy to combat obesity and noncommunicable diseases. <a href="https://pubmed.ncbi.nlm.nih.gov/29531419/">Research</a> has shown that people buy and consume sugary drinks less when their price is increased through taxation.</p>
<p>Rwanda has an excise tax of <a href="https://taxsummaries.pwc.com/rwanda/corporate/other-taxes#:%7E:text=Excise%20taxes&text=Soda%20and%20lemonade%3A%2039%25.">39%</a> on soft drinks. Its main purpose is to generate revenue. Because it applies to all soft drinks, irrespective of sugar content, the tax as it stands is unlikely to reduce consumption of sugary drinks. </p>
<p>We <a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2021.1883911">looked at</a> what might influence the ability of the government to use the soft drinks tax to achieve public health goals.</p>
<p>We found that competing priorities stand in the way of imposing a sugary drinks tax. The government has progressive, cross-sectoral policies to address the growing burden of noncommunicable diseases. But other <a href="https://www.newtimes.co.rw/section/read/51017">policies</a> support the growth of local sugar production and the sugary drinks industry. And the country’s <a href="http://www.rwandafda.gov.rw/web/fileadmin/national_food_and_nutrition_policy_.pdf">food policies</a> generally focus more on food production to make sure people have livelihoods and enough quality food.</p>
<h2>Existing taxes</h2>
<p>The existing excise tax of 39% on soft drinks is well above the 20% tax rate <a href="https://www.who.int/dietphysicalactivity/publications/fiscal-policies-diet-prevention/en/">recommended</a> by the World Health Organisation. But it hasn’t had a significant impact on the price or consumption of sugar sweetened drinks compared to non-sugary beverages. This is likely because it applies equally to sugary and non-sugary carbonates. </p>
<p>Still, the tax is a good starting point for policies that put public health first.</p>
<p>The position and economic importance of the sugar sweetened beverage industry in Rwanda is likely to be a barrier to the adoption of such taxation. This has been the case in many <a href="https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-019-0495-5">low- and middle-income countries</a>. Concerns about the economic and job implications of a sugary drinks tax may hinder or delay the adoption of such a policy. Opponents of a sugary drinks tax in <a href="https://theconversation.com/how-south-african-food-companies-go-about-shaping-public-health-policy-in-their-favour-143368">South Africa</a> argued that it would result in significant job losses – despite evidence to the contrary. The country increased taxes on sugar-sweetened beverages in 2018. </p>
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Read more:
<a href="https://theconversation.com/how-south-african-food-companies-go-about-shaping-public-health-policy-in-their-favour-143368">How South African food companies go about shaping public health policy in their favour</a>
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<p>The East African Community can influence markets and companies through trade mechanisms and coordinated regulations. Its secretariat has a <a href="https://ideas.repec.org/p/pot/fiwidp/60.html">technical working group</a> on excise tax coordination. So, interventions at a regional level could be another way of achieving the public health goals. </p>
<p>The policy landscape related to sugary drinks taxation in Rwanda is influenced by many factors and is evolving. The existing policy landscape, at domestic and regional levels, provides opportunities to strengthen sugary drinks taxation. But these are matched by a complex political landscape with competing priorities. Action must be taken to improve support for this intervention and the successful adoption of a policy. </p>
<h2>Recommendations</h2>
<p>We believe the government could use soft drinks tax more effectively as a <a href="https://www.who.int/dietphysicalactivity/publications/fiscal-policies-diet-prevention/en/">public health tool</a> without undermining employment and national development. Producers could redesign their production or invest in more healthy products.</p>
<p>It will need the cooperation of government ministries, regulatory authorities, civil society and consumer organisations, as well as academia and research institutions. The East African Community could also play a part by adopting regional regulations. </p>
<p>The role of private actors, such as the beverages industry, in the development of nutrition-related health policies should remain limited to avoid undue influence.</p>
<p>Rwanda should amend the excise tax to target sugar content so that people reduce their consumption of sugary drinks and turn to healthier options. </p>
<p>Different taxes linked to the sugar content of beverages should be adopted such as the ones adopted in countries like Mexico, the United Kingdom and South Africa. These <a href="https://gh.bmj.com/content/4/4/e001317">resulted</a> in increased prices of sugary drinks and encouraged producers to reformulate their products to reduce the sugar content.</p><img src="https://counter.theconversation.com/content/155145/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ruhara Mulindabigwi Charles does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Rwanda’s food policies focus on production to make sure people have livelihoods and enough nutritious food. Not much attention is given to overnutrition.Ruhara Mulindabigwi Charles, Coordinator of Postgraduate Programmes, School of Economics, University of RwandaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1563162021-04-20T12:27:18Z2021-04-20T12:27:18ZZambia must find a way to balance the economy and public health in tax policy<figure><img src="https://images.theconversation.com/files/394740/original/file-20210413-17-9xp7jr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The burden of noncommunicable diseases is <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(19)30374-2/fulltext">growing rapidly</a> across sub-Saharan Africa. The conditions, which include obesity and diabetes, are now <a href="https://www.who.int/nmh/countries/2018/zmb_en.pdf">leading causes</a> of premature deaths. In Zambia, noncommunicable diseases account for <a href="https://www.who.int/nmh/countries/2018/zmb_en.pdf">29% of all deaths</a>.</p>
<p>The consumption of <a href="https://www.sciencedirect.com/science/article/abs/pii/S0140673612620893">unhealthy commodities</a> – tobacco, alcohol and ultra-processed foods high in sugar, salt and fats – is a major risk factor for these conditions. </p>
<p>To regulate the availability of unhealthy commodities, the World Health Organisation (WHO) recommends cost-effective, evidence-based interventions. One such measure is a <a href="https://www.who.int/dietphysicalactivity/publications/fiscal-policies-diet-prevention/en/">tax on sugar-sweetened beverages</a>. Sweetened beverages are associated with a number of <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/obr.12868">health complications</a>. These include an increased risk of <a href="https://www.bmj.com/content/351/bmj.h3576">type 2 diabetes</a>, <a href="https://pubmed.ncbi.nlm.nih.gov/26869455/">cardiovascular diseases</a> and other obesity‐related diseases.</p>
<p>The aim of such a tax is to discourage people from buying these drinks. </p>
<p>Zambia is one of the African countries that has acted to regulate the environment for products linked to obesity. In January 2019 the country introduced an excise tax on all non-alcoholic beverages except water. A <a href="https://extranet.who.int/nutrition/gina/sites/default/filesstore/ZMB%202018%20Customs%20and%20Excise%20%28amendment%29%20%20Act%20No.%2019%20of%202018.pdf">tax rate</a> of K0.30 (US$ 0.02) per litre was levied. This 3% tax is well below the <a href="https://gh.bmj.com/content/bmjgh/5/4/e001968.full.pdf">recommended rate</a> of 20% required to reduce noncommunicable disease risk factors like obesity. Because of the low rate, health sector stakeholders are suggesting that the tax no longer focuses on public health. Instead, it’s a general source of government revenue. </p>
<p>In our recent <a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2021.1872172">study,</a> my colleagues and I looked for opportunities to strengthen this tax policy in Zambia. Our focus was on sugar-sweetened beverage taxation. We reviewed policy documents and spoke to nutrition advocates, industry representatives and policymakers. We wanted to understand the context in which policies about nutrition-related diseases are developed. We also wanted to explore the potential use of revenue from tax on sugary drinks to support improved nutrition.</p>
<p>Our findings showed tension between the government’s economic and public health priorities. The government has <a href="https://health-policy-systems.biomedcentral.com/articles/10.1186/s12961-017-0195-7">intentions of regulating</a> production of harmful food products like sugar-sweetened beverages. But it also <a href="https://www.mcti.gov.zm/?page_id=5176">commits to growing the economy</a> by investment in the manufacturing sector, which includes the food and beverage sub-sector. </p>
<p>This has prevented stronger fiscal measures to address noncommunicable diseases related to nutrition. But we believe the tension need not hurt the public health objectives. There are opportunities to strengthen existing taxation of sugary drinks by ensuring policies take local economic context into account.</p>
<h2>Our research</h2>
<p>The policy <a href="https://extranet.who.int/ncdccs/Data/ZMB_B3_NCDs%20Strategic%20plan.pdf">documents</a> we <a href="https://www.mndp.gov.zm/wp-content/uploads/2018/05/7NDP.pdf">reviewed</a> and stakeholder interviews we conducted recognised the increasing problem of noncommunicable diseases in Zambia. </p>
<p>The diseases were linked to lifestyle factors such as physical inactivity and unhealthy diet. But none of the policies we reviewed identified sugary beverages as a driver of noncommunicable diseases in Zambia. </p>
<p>Our interviews also highlighted existing misperceptions. The people we interviewed linked affluence to sugary drinks consumption. They believed wealthier populations were more affected by nutrition-related diseases. But <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-9-465">research suggests</a> it’s poorer populations who tend to consume more unhealthy food. Unhealthy foods, including processed foods high in salt, fat and sugar, are cheaper than healthier food options but have attracted high status. </p>
<p>Nutrition advocates and government representatives suggested that the lack of diversity in people’s diets could be a contributor to the rise of noncommunicable diseases. Maize porridge – <em>nshima</em> – is a staple in the country and is consumed several times a day. But there’s a lack of evidence in this regard. </p>
<p>Policymakers felt the government was well prepared to address the health problem. They pointed to policies such as the strategic plan for nutrition-related noncommunicable diseases and related <a href="https://extranet.who.int/ncdccs/Data/ZMB_B3_NCDs%20Strategic%20plan.pdf">risk factors</a> as an example. The <a href="https://www.lusakatimes.com/2019/02/02/exercise-is-best-health-practice-president-lungu/">president’s active engagement</a> in promoting healthy lifestyles in mainstream media was seen as good leadership. </p>
<p>In contrast, respondents representing civil society felt that the current leadership and policies were insufficient. Marketing of unhealthy food products remained unregulated and nutrition programmes were poorly funded. They also felt the sugar-sweetened beverage tax was inadequate to curb consumption and hence noncommunicable diseases. </p>
<p>The sugary drinks tax in Zambia was initiated and championed by the Ministry of Health. Initially, a tax rate of 20% was proposed. But this met strong pushback from the government’s economic sector and industry stakeholders. They argued this would contribute to a high cost of doing business. Industry <a href="http://zam.co.zm/download/zam-submission-proposed-regulatory-reform-to-improve-nutrition/">attempted</a> to discredit evidence supporting the tax. Some suggested that the Zambian government was bowing to international pressure without considering the implication of the tax in the domestic context. Such strong lobbying against the tax likely contributed to the low rate of 3% that was eventually adopted.</p>
<p>Respondents suggested that revenues from the tax should finance nutrition and noncommunicable disease prevention programmes. These would include health promotion and education, regulation of the marketing of unhealthy foods, improved food labelling, and incentives for production of healthy foods. </p>
<p>These suggestions reflected a perception among all respondents that the population was largely unaware of causes, prevention and impact of nutrition related noncommunicable diseases. Therefore, raising awareness should be an immediate priority for Zambia.</p>
<h2>Way forward</h2>
<p>Our findings show that there is an opportunity to strengthen policies addressing noncommunicable diseases in African countries through measures like sugar-sweetened beverage taxes. But policy measures should be contextualised to the needs of the country. The priority of most African governments is economic growth. This is evident in policies that encourage growth of industries that produce unhealthy commodities. This context should not be ignored as it bears on the success of policy measures that protect population health. </p>
<p>A differential tax that distinguishes between international and local producers and manufacturers may be a feasible starting point to balance economic interest with public health objectives.</p>
<p>Taxation could also support public health by providing subsidies for fruit and vegetables, or the provision of safe drinking water. To achieve this, the revenues from the tax could be earmarked for health promotion.</p>
<p>Health problems have their origins and consequently solutions outside the health sector. This is why consultation must expand beyond the health sector during the development of policies addressing noncommunicable diseases. </p>
<p>Such consultation will go a long way to improve policy coherence between the health and economic sectors of governments. Policy measures should be contextualised to strike a balance between public health and the economic needs of countries.</p><img src="https://counter.theconversation.com/content/156316/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mulenga Mary Mukanu, received support for this work from International Development Research Centre, Ottawa
Canada under grant number 108648-001. </span></em></p>Tension between the government’s economic and public health priorities is preventing stronger fiscal measures to address nutrition-related noncommunicable diseases.Mulenga Mary Mukanu,, PhD Candidates, University of the Western CapeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1579082021-04-20T08:08:01Z2021-04-20T08:08:01ZKenya doesn’t have a stand-alone tax on sugary drinks: we set out to find out why<figure><img src="https://images.theconversation.com/files/395266/original/file-20210415-20-r25nse.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The consumption of a lot of soft drinks is linked to increased obesity. </span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Kenya is <a href="https://www.health.go.ke/wp-content/uploads/2016/04/Steps-Report-NCD-2015.pdf">experiencing a rise</a> in obesity. Overweight and obesity among women increased from 25% in 2008 to 33% in 2014. An estimated one in four Kenyan urban children are <a href="https://www.dhsprogram.com/pubs/pdf/sr227/sr227.pdf">overweight or obese</a>. At the same time there has been a rise in associated <a href="https://globalnutritionreport.org/resources/nutrition-profiles/?country-search=kenya">noncommunicable diseases</a>. These include diabetes, cardiovascular diseases and cancer. Noncommunicable diseases now account for over <a href="https://www.health.go.ke/wp-content/uploads/2016/04/Steps-Report-NCD-2015.pdf">50% of hospital admissions</a> in the country.</p>
<p>Globally, the rise in noncommunicable diseases has been attributed to the growing consumption of unhealthy foods such as sugar-sweetened beverages. Between 2018 and 2019 Kenya registered a 30% spike in <a href="https://apps.fas.usda.gov/newgainapi/api/report/downloadreportbyfilename?filename=Sugar%20Annual_Nairobi_Kenya_4-12-2018.pdf">sugar production</a> and an <a href="http://www.parliament.go.ke/sites/default/files/2019-08/Report%20on%20the%20Crisis%20Facing%20the%20Sugar%20Industry%20in%20Kenya%20%28%20Annexures%29.pdf">increase</a> in sugar consumption from the growth of retail, industrial and food service sectors. </p>
<p>To control the rising burden of obesity and noncommunicable diseases the World Health Organisation (WHO) <a href="https://www.who.int/dietphysicalactivity/publications/fiscal-policies-diet-prevention/en/">recommends</a> a tax on sugar-sweetened beverages. It views such taxes as a population-level, cost-effective measure to discourage consumption of sugar-sweetened beverages. </p>
<p>The approach has been widely used in several countries including South Africa. However, to date, Kenya has no standalone sugar-sweetened beverage tax policy.</p>
<p>We undertook <a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2021.1902659">research</a> into the possibility of implementing a sugar-sweetened beverage tax in Kenya. </p>
<p>The study entailed a desk review of existing evidence on noncommunicable diseases and sugar-sweetened beverages. We also conducted interviews with a wide range of experts to explore the policy and political context as well as the enablers of and barriers to such a policy.</p>
<p>We identified a number of barriers to adopting a tax on sugary drinks in Kenya. These included limited evidence on sugar-sweetened beverages as a risk factor for noncommunicable diseases in Kenya. We also found industry interference in the development of sugar-sweetened beverage taxation policy. </p>
<p>But we also found that existing policies provided an opportunity to pursue a sugar tax in the country. These include the <a href="http://publications.universalhealth2030.org/uploads/kenya_health_policy_2014_to_2030.pdf">Kenya Health Policy</a> and the <a href="https://www.who.int/nmh/ncd-task-force/kenya-strategy-ncds-2015-2020.pdf?ua=1">National Strategy for Control and Prevention of Noncommunicable diseases</a>. </p>
<h2>Barriers</h2>
<p>A number of factors accounted for the fact that Kenya hasn’t pursued a tax on sugar-sweetened beverages.</p>
<p>The first was a dearth of up-to-date publicly available information on sugary drinks sales and consumption in Kenya. Data are essential to guide the decisions and process of development and adoption of a stand alone sugar-sweetened beverage tax. </p>
<p>Interviewees also cited lack of information in the general population about sugar-sweetened beverages and how they affect health. They attested to the fact that tobacco and alcohol are widely recognised risk factors for noncommunicable diseases. Not so with sugar-sweetened beverages.</p>
<blockquote>
<p>An important barrier when we are dealing with sugar-sweetened beverages is the fact that the public does not appreciate that this is a problem. What do respectable old men and women in the village, church elders, take when they go for a meeting? It is tea, Coca-Cola, Sprite, Fanta. I think it presents a subtle challenge that we don’t have when we are dealing with tobacco or alcohol. Nobody argues about the adverse consequences of tobacco or of alcohol.</p>
</blockquote>
<p>A second barrier we identified was that government ministries held different and sometimes opposing interests. </p>
<p>For instance, the ministry of health was interested in improving health and discouraging the trade, production and marketing of sugary drinks. But the ministry of industry, trade and cooperatives promoted the sugar and food processing industries as major revenue for government. </p>
<p>Our key informants felt that these opposing priorities might get in the way of a sugar-sweetened beverage taxation policy being developed. </p>
<p>A third factor we identified was industry lobbying against sweet drinks taxation. The sugar-sweetened beverage companies were described by key informants as having major influence over government decision making. This was because of the power they wielded in terms of their operations, and their contribution to the government revenues. They also use industry alliances and formations to fight sugar-sweetened beverage taxes, which may overwhelm an under-resourced government like Kenya’s. </p>
<p>As one interviewee put it: </p>
<blockquote>
<p>… unfortunately, there’s a lot of industry interference with policy (on sugary drinks). This is a big industry; very big in terms of capital and also in terms of influence. They pay a lot of tax to government and they have a lot of leverage … An industry like that of course has a lot of policy interference because they have big money they can compete with us.</p>
</blockquote>
<p>Kenya does charge an excise tax on all soft drinks of 10 Kenya shillings (0.10 USD) per litre. This includes sugar-sweetened beverages. And in <a href="http://kenyalaw.org/kl/fileadmin/pdfdownloads/bills/2018/FinanceBill__2018.pdf">2018</a> an excise tax of 20 shillings (0.20 USD) per kilogram was imposed on sugar confectionery and chocolate. </p>
<p>But these taxes were introduced as a revenue generation strategy, not as a means to manage noncommunicable diseases. They are likely to have only a minimal impact on the consumption of sugary drinks.</p>
<h2>Going forward</h2>
<p>We made a number of recommendations on how a sugar-sweetened beverage tax could be developed and implemented in Kenya.</p>
<p>First, public and policymaker education is critical to challenge the prevailing attitudes to sugary drinks.</p>
<p>Second, strategies to develop industrial growth should be critically examined to understand how they could undermine the government’s commitment to addressing noncommunicable diseases. This will require wide stakeholder engagement beyond the ministry of health in policy development.</p>
<p>Third, civil society needs to be involved in sustained advocacy to ensure that Kenyans understand the issues at hand.</p>
<p>And more research evidence is needed to support an explicit sugar-sweetened beverage taxation policy. Kenya also needs to gather local and regional or international evidence to inform and guide its decisions in the development and adoption of a standalone tax on sugary drinks.</p><img src="https://counter.theconversation.com/content/157908/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>This work was carried out with support from the International Development Research Centre (IDRC),Ottawa Canada (grant number 108648-001)</span></em></p><p class="fine-print"><em><span>Gershim Asiki does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Between 2018 and 2019 Kenya registered a 30% spike in sugar production and an increase in sugar consumption.Milka Wanjohi, Research officer, African Population and Health Research CenterGershim Asiki, Research Scientist, African Population and Health Research CenterLicensed as Creative Commons – attribution, no derivatives.