By all indications, South Africans are getting unhealthier. We are fatter, less active, and at greater risk than ever for chronic diseases. So what, if anything, can be done to reverse the trend? A hard-hitting strategy of government interventions combined with population-wide behaviour change, say researchers – and we’re running out of time to get it started.
Currently, reports a new paper by the Chronic Diseases Initiative in Africa (CDIA) and the Burden of Disease Research Unit (BDRU), South Africa is facing a quadruple burden of disease. We are improving the health and the longevity of those with HIV/Aids, but this is little use if patients survive only to die of other causes instead. The country’s incidence of chronic and non-communicable disease is increasing and the associated risk factors – generally lifestyle-related – are getting worse.
The statistics are worrying. Hypertension rates have shot up in the last ten years and diabetes and high cholesterol levels are on the rise. Physical activity is on the decrease, fat consumption is on the increase and there is still a high incidence of hazardous alcohol use. Limited policy action, for example increasing excise tax on alcoholic drinks, has not resulted in any improvements, and in terms of diet and exercise, the country is not even close to a solution.
Today, obesity is at an all-time high, with over 70% of South African women over the age of 35 being overweight or obese. In a recent study of physical activity among school learners, 60% had not had sufficient exercise in the week prior to the survey. And, as things stand, statisticians are predicting an increase in strokes and heart attacks in the years to come – owing to the inadequate prevention, diagnosis and control of raised blood pressure.
The answer lies in harder-hitting intervention programmes rather than limited legislation, believe Debbie Bradshaw and Krisela Steyn, authors of the report “Non-communicable diseases: A race against time”. According to the report, the only area to date in which there has been a positive impact on the high-risk behaviours associated with chronic disease is in the decrease of tobacco use. Extensive government interventions, including the ban on advertising, higher taxes and the compulsory health warnings on cigarette packaging, have led to a significant reduction in smoking.
Government interventions can work
The conclusion one can draw from this is mixed: on one hand, the good news is that such interventions can really work. On the other, the concern is that there are currently not enough such interventions.
The high content of salt and trans fats in manufactured foods have led medical bodies – from the National Department of Health to the CDIA and other research networks – to call for restrictions on the amount of salt that can be used in manufactured foods. Currently, South Africans are getting most of their salt intake from bread which, considering that most bread recipes call for equal amounts of salt and sugar, means they are being exposed to unacceptable levels of refined sugar as well.
And those watching their waistline have even more cause for concern: according to data from the Food and Agriculture Organisation, the fat supply in the country has leapt from 69% in 1992 to a whopping 82% in 2007.
Increasingly, South Africans are eating lots of fat, animal protein and sugar, and passing on the unrefined carbohydrates and fibre. And, despite the Food-based Dietary Guidelines developed in 2001 and the recently-implemented food labelling regulations, current food manufacturing standards mean that even health-conscious South Africans have only limited control over what they consume.
Expanding existing government interventions is critical at this stage, believe Steyn and Bradshaw, adding that these interventions should be twofold: balancing standards and regulations with behaviour change on an individual level.
“An effective chronic disease policy has two aspects,” they write, “namely, population-wide interventions and healthcare interventions. Population-wide interventions that change behaviours of the whole population can be cost-effective, but these must be combined with cost-effective primary care interventions which target individuals who are at high risk.”
Only this will result in a successful prevention strategy, they argue – and prevention is essential, as “South Africa has some way to go to provide integrated primary healthcare. As such, early diagnosis as a preventative measure is especially key as a health care intervention. Consider non-symptomatic conditions, such as high blood pressure, high blood sugar levels and high blood cholesterol levels – if caught early, these are easily treatable. At a more developed stage, where hardening of the arteries has developed, heart attacks and strokes can possibly follow. Anyone over the age of 30 should have these levels tested at least once every five years.”
“Effective management of chronic diseases, particularly focusing on managing the main risk factors – tobacco use, poor diet, lack of exercise and excessive alcohol use – is required at the primary level.”
Based on the findings of their paper, the authors’ proposals to government include:
- Strengthening tobacco control, particularly regarding young people and the exposure of children to second-hand smoke in the home;
- Supporting quitting smoking programmes;
- Promoting healthy eating patterns;
- Reducing the amount of salt and trans fats in foods;
- Restricting access to alcohol;
- Promoting physical activity, including in schools and workplaces;
- Reducing the exposure to bio-mass pollutants through electrification;
- Media and communication strategies to prevent non-communicable diseases.
They suggest various measures for strengthening primary healthcare, including implementing the integrated World Health Organisation’s chronic disease model of care; consideration of all the risk factors to identify those at highest risk chronic diseases who are the people who need treatment most urgently; introduction of realistic guidelines for managing NCDs, and training for healthcare providers and managers.
There should also be an NCD surveillance system to help monitor the quality of care, as well as an increase in evaluation capacity, the report adds.
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