From lifestyle disease to food systems disease

Obesity among children in South Africa has increased from approximately 1 in 20 children in 2005, to 1 in 8 children in 2015. If we continue on this trajectory, it is estimated that at least 3 in 5 children will be obese by 2030.

These were some of the shocking figures shared by Prof Rina Swart, senior researcher at the University of the Western Cape (UWC) as part of a webinar hosted by the Dullah Omar Institute at UWC on the link between the access to safe and nutritious foods and noncommunicable diseases (NCDs).

Swart is also an advisory committee member of the Nourished Child project, a study currently underway to investigate what a systems approach to improving the quality of diets among children under five and women of childbearing age would look like in an urban setting to address under- and overnutrition. For the webinar she was joined by Assoc Prof Jane Battersby, Nourished Child-project researcher at the African Centre for Cities at the University of Cape Town, and Dr Vicki Pinkney-Atkinson, director of the South African Noncommunicable Disease Alliance.

Swart says the child obesity estimates are of particular concern as research also shows that treating obesity through weight loss is extremely difficult, and an estimated 7 out of 10 overweight adolescents will grow up to be obese adults. Obesity is a major risk factor for developing NCDs. Approximately 51 per cent of all premature deaths in South Africa can be attributed to NCDs. Pinkney-Atkinson noted that the leading underlying cause of natural deaths among women in South Africa is diabetes.

“So prevention is better than cure,” Swart says.

Rina Swart

Why the increase?
According to Swart, the increase in overweight and obesity makes sense in the context of the ‘nutrition transition’, a term that refers to “the type of food consumed by people, the way in which thy acquire and consume foods, and the subsequent consequences in terms of ill-health and disease”. For South Africa, Swart produced data  by Euromonitor showing the significant increase in sugar containing drinks and breakfast cereals (which are often higher in sugar and lower in fibre than alternatives) between 2005 and 2019, which is indicative of the change in the types foods and beverages consumed that contribute to obesity.

This, she says, is also partially due to the obesogenic food environment, thus where we choose our foods. “The obesogenic environment refers to the physical environment, the economic conditions within that, the policy actions and the socio-cultural norms that contribute to obesity,” Swart explains. “In South Africa there are however very few policies and regulations that would benefit our environments and norms.”

Packaged foods in a shop in Masiphumelele. PHOTO | Samantha Reinders

Battersby, an urban social geographer working in the urban food security space, agrees about the lack of policies, and sees the potential especially within local governments to change this. In her presentation, she used a time series map to demonstrate the rapid expansion of supermarkets across Cape Town between 1994 and 2013 alone, to illustrate what she calls “a fundamental shift in the food system.” In a more recent joint research study by German and South African researchers on the role of Big Food and fast food on South Africa’s obesity epidemic, it was found that, though not necessarily the main drivers, the proximity to fast food outlets supermarkets are significantly associated with overweigh and obesity.

Battersby notes there may be a case for supermarkets’ contribution to the quality and diversity of food in certain areas, but also to remember that supermarkets increase the availability of ultra-processed foods (UPFs). “We should ask what is being sold, and why are people consuming what they are consuming, and why things are located where they are.”

She says with mapping, one can see a proliferation of fresh produce markets close to supermarkets, signifying the relationship between supermarkets and trade. But whether this is health promoting or health demoting is debatable. Regardless, however, she says this should be recognised as an important component of the food system, which is in many ways under the control of the local government.

“There are many interventions the local government can make that would perhaps crowd healthier foods in these environments.”

Jane Battersby

Can obesity and NCDs be prevented?
Though NCDs are widely referred to as “diseases of lifestyle”, Battersby, Swart and Pinkney-Atkinson emphasised that the development of obesity and NCDs is far more nuanced than an individual lifestyle choice. Poverty, unemployment, food insecurity, inequality and commercial factors are among some of the underlying drivers. The discussion highlighted the food system and food environment, and not the individual, as key in providing safe and nutritious food for curbing NCD prevalence.

According to Battersby decision makers who are influencing the food system often have no awareness of food system outcomes. “If you look at the rhetoric around mall development, it’s about job creation, creating a modern retail environment, brand identity, and capital flow that comes in from the infrastructure. It’s not about food.” Likewise, she says, there have been informal trader policies that make no mention of food or what types of food may be sold by traders and how one might be able to intervene. “These all fall within municipal mandates, so they are things that municipalities could act on if they were to adopt a food sensitive lens.”

Battersby also highlighted transport planning and what it does for people’s mobility and food interactions, as well as delivery, design and maintenance of critical infrastructure as part of local governing bodies’ mandates that have a major impact on health outcomes.

Battersby is currently doing remote fieldwork in Masiphumelele in Cape Town for the Nourished Child project. As part of this work, they are talking to people to understand how the food environment, infrastructure environment and social services all interact to shape how they feed themselves.

“Some people may prepare slow cooked, nutritionally dense meals only in winter because electricity is too expensive – in winter they can at least also use the heat generated from cooking to warm their houses. And what does it mean for your food consumption if the tap runs out of water? All these things shape food environment people occupy, but also their ability to purchase and use food effectively.”

A resident from Masiphumele prepares food in her home. PHOTO | Samantha Reinders

She says that, as a result of the current pandemic, there are now more points of leverage where key changes can be made to address the obesity epidemic. “Covid has shown us just how vulnerable our food systems are, and how costly NCDs are.” Dr Vicky Pinkney-Atkinson, director of the South African Noncommunicable Disease Alliance, agrees. She says though funding for NCD interventions have been grossly inadequate, especially when compared to that awarded to communicable diseases, such as HIV/Aids, COVID-19 opened a new window of opportunity for policy around NCDs.

The way forward?
“We have to rethink not only the food that we choose, but also our food environments at large,” says Swart. “What kinds of foods do we want farmers and manufacturers to produce for us? What kinds of food do we want to see promoted to our children? What kinds of information do we want to have on a product when we have to make the choice? And what information on food and nutrition do we want our children to receive at places of care such as schools?”

Battersby believes this can be addressed through transversal and inclusive governance, where national scale policies are integrated with local scale policies and programmes.

“Food systems policies can be central as our cities seek to rebuild the economies and improve public health post-pandemic outcomes,” she says.

Jane Battersby

“The levers are there, and they can be powerful.”