Do you know what the top chronic diseases are in SA? Diabetes is one of them.

What are chronic diseases?

A chronic diseases are defined broadly as conditions that last one year or more and require ongoing medical attention or limit activities of daily living or both. They are long-term illnesses caused by a combination of genetic, physiological, environmental, and behavioural factors

Chronic diseases, also known as non-communicable diseases, are the leading cause of death and disability worldwide, accounting for nearly 60% of all deaths and 43% of the global disease burden.

Although chronic diseases are frequently associated with older age groups, evidence suggests that thousands of South Africans are dying of chronic diseases before the age of 70.

Top chronic diseases in SA 

Stroke and heart disease

The sheer number of heart disease or stroke fatalities is a growing concern in SA. According to the Heart & Stroke Foundation, 215 people die from heart disease or strokes daily. Every hour, five people have heart attacks, and 10 people have strokes. Because there is a lack of awareness about cardiovascular disease, many people go undiagnosed and untreated until it is too late.

Diabetes

One in every three adults (13 million) in South Africa has impaired fasting glucose, putting them at high risk of developing Type 2 diabetes. Diabetes is the country’s second deadliest disease, according to Statistics South Africa’s 2021 report on mortality and causes of death.

It has claimed more lives than HIV, hypertension, and other forms of heart disease combined. It’s a leading cause of blindness, kidney failure, heart attacks, stroke, and amputation of lower limbs.

Arthritis 

Osteoarthritis is the most common type of arthritis in South Africa, with a prevalence rate of 55.1% in urban areas and between 29.5% and 82.7% in adults over 65 years of age in rural areas.

As many patients are unsure how to manage their symptoms, arthritis coexists with other chronic conditions. This disease is surprisingly common among children, affecting one to four out of every 1000.

Cancer

Cancer care is expected to cost $240 billion (R4160 billion) by 2030, according to the most recent Centers for Disease Control and Prevention (CDC) and National Cancer Institute estimates, due to healthcare inflation over the previous decades.

Despite declining cancer rates, the CDC predicts that cancer will remain one of the leading causes of death in SA. It’s estimated that nearly 110 000 new cancer cases will be diagnosed in SA by 2020, with over 56 000 cancer-related deaths accounting for one-quarter of all premature non-communicable disease-related mortality.

The most effective cancer prevention measures continue to be early screenings, raising awareness about preventative techniques, and developing strategic partnerships.

Obesity

Obesity statistics in SA are concerning, with approximately 31% of men and 68% of women obese. Being overweight and obesity can lead to various lifestyle diseases, including diabetes and heart disease.

Obesity is a major issue in adults and children, with more than 13% of South African children aged 6-14 years classified as overweight or obese.

Education, promoting access to healthier foods, and providing preventive care to paediatric patients can help maintain a healthy weight.

Alzheimer’s disease 

According to the most recent World Alzheimer’s Report, SA has 4.4 million people over the age of 60 living with the disease. Around 187,000 of these people have dementia.

Alzheimer’s disease isn’t a normal part of ageing. Although most people with Alzheimer’s are 65 and older, people younger than 65 can also develop the disease. It’s the most common cause of dementia that worsens over time. In most cases, the symptoms develop gradually and become severe enough to interfere with daily activities.

Epilepsy

More than 500 000 people in SA have epilepsy. Seizures caused by epilepsy can sometimes result in death. People with epilepsy may also have poor mental health or other impairments that are difficult to detect.

Asthma

Asthma affects more than 20% of children and 10-15% of adults in SA. It’s not uncommon for those suffering from the illness to be hospitalised during an attack, which can significantly reduce their quality of life.

High blood pressure

High blood pressure, also known as hypertension, affects more than one in every three adults in SA. Because there are rarely any symptoms or visible signs that blood pressure is high, it’s referred to as a silent killer.

As a result, more than half of people with high blood pressure are unaware of their condition. Symptoms such as headaches, visual disturbances, nose bleeds, nausea, vomiting, facial flushing, and sleepiness may sometimes occur, typically with extremely high blood pressure. It would be best if you didn’t wait for symptoms to appear. High blood pressure becomes more common with age, but anyone, regardless of age, gender, fitness level, or lifestyle, can develop it.

HIV/AIDS

In SA, the overall HIV prevalence rate is estimated to be around 13.7%. In 2021, the total number of people living with HIV was expected to be approximately 8.2 million. HIV infection affects an estimated 19.5% of adults aged 15 to 49 years.

Tuberculosis

In South Africa, tuberculosis is a significant public health concern. Every year, approximately 450,000 people contract the disease, with 270,000 also infected with HIV.

TB kills approximately 89,000 people per year, or 10 people every hour. Effective treatments are available, and the country has made significant progress in combating the disease, but much more is required to bring it under control.

This article is attributed to Affinity Health.

Header image by FreePik

The Healthy Living Alliance (HEALA) calls for urgent policy changes to prevent SA childhood obesity.

Childhood obesity in SA

Approximately 13% of South Africa’s children under five years are overweight, more than double the global average.¹ Being overweight and developing obesity in early childhood increases the risk for adult obesity, as well as associated conditions like high cholesterol, diabetes and high blood pressure. All of these conditions are increasingly prevalent in South Africa.¹

Childhood obesity is a serious medical condition that affects children and teens. It’s particularly troubling because the extra kilos often start children on the path to lifelong health problems. Childhood obesity can also lead to poor self-esteem and depression.²

The main cause of overweight and obesity among children is the consumption of high-calorie diets; those that are rich in salt, sugar and fats.¹ This is also influenced by other factors such as household poverty coupled with the high cost of healthy foods.¹

South African children’s fast-food consumption rates are high.³ In a 17-country study completed in 2014, researchers found that fast-food consumption among South African children and adolescents was more frequent than in high-income countries such as Japan and Belgium.³

“Highly processed and unhealthy foods have become increasingly accessible and affordable over the last three decades, leading to a global increase in weight issues and obesity, especially in the poorest and most vulnerable communities and households,” says Nzama Mbalati, Programmes Manager at HEALA.

Sugar consumption

One of the major factors associated with obesity is sugar consumption. South Africans are estimated to consume up to 24 teaspoons of sugar per day, double the daily WHO recommendation.⁴

South Africa passed a Health Promotion Levy (HPL) on sugary beverages in 2018.⁵ Commonly known as sugar tax, it has led to considerable reductions in the purchase and consumption of taxable drinks, proving that legislation can support consumers to reduce intake of unhealthy foods and beverages.⁵

“Currently, at least 85 countries have sugar-sweetened beverages (SSB) taxation,” says Mbalati. “Data from countries like the UK and Mexico indicates that SSB taxes successfully reduce sugar consumption. In SA, people are buying 28% fewer sugary drinks since the government implemented the HPL in 2018. In addition, the levy has slashed the South African beverage sector’s use of sugar by a third. The combination of the two has cut sugar intake in the country by nearly a third. It is now time for the sugar tax on drinks, currently at 10% of the cost per litre, to be doubled and this needs to happen soon.”

Mbalati stresses that this is critical to address the country’s raging diabetes epidemic and the high rates of obesity that fuel it. “South Africans are addicted to sugar. With more than a quarter of the population living with obesity, we are among the top 20% of the most obese nations in the world. More than 4,5 million people have diabetes, with diabetes being the second-largest cause of death after tuberculosis.”

Mbalati adds that sugary drinks should be drastically reduced in children’s diets. “Even 100% fruit juice with no added sugar contains a lot of sugar with none of the fibre you would find in a piece of fruit to help fill you up. Encourage kids to drink mostly water and plain milk. Get them to eat whole fruit, like an apple, instead of drinking apple juice.”

Visit whatsinourfood.org.za for more information.

Instagram: instagram.com/betterlabels_za

Facebook: facebook.com/betterlabelsza

References

1. Statistics on children in South Africa: Overnutrition in children, Sambu, W. Children’s Institute. University of Cape Town. [Nov 2019]. Available from:http://childrencount.uct.ac.za/indicator.php?domain=4&indicator=96
2. Childhood obesity. Mayo Foundation for Medical Education and Research (MFMER). [Dec 2022]. Available from:https://www.mayoclinic.org/diseases-conditions/childhood-obesity/symptoms-causes/syc-20354827
3. South African Child Gauge 2020: Food and nutrition security. May, J.; Witten, C.; Lake L. Children’s Institute. University of Cape Town. [2020]. Available from:http://www.ci.uct.ac.za/sites/default/files/image_tool/images/367/Child_Gauge/South_African_Child_Gauge_2020/ChildGauge_2020_screen_final.pdf
4. McCreedy, N.; Shung-King, M.; Weimann, A.; Tatah, L.; Mapa-Tassou, C.; Muzenda, T.; Govia, I.; Were, V.; Oni, T. Reducing Sugar Intake in South Africa: Learnings from A Multilevel Policy Analysis on Diet and Noncommunicable Disease Prevention. Int. J. Environ. Res. Public Health 2022, 19, 11828. Available from: https://doi.org/10.3390/ijerph191811828
5. Stacey, N; Edoka, I; Hofman, K; Swart, EC; Popkin, B; Shu Wen, N. Changes in beverage purchases following the announcement and implementation of South Africa’s Health Promotion Levy: an observational study. The Lancet. 5, 4, E200-E208. [Apr 2021]. Available from:https://www.thelancet.com/action/showPdf?pii=S2542-5196%2820%2930304-1

Header image supplied

Dr Paula Diab sheds light on the physiological mechanism of weight loss and gain then looks at the methodologies that can assist in achieving and maintaining the desired weight.

Did you make any New Year’s resolutions for planned weight loss, go on diet, spend more time in the gym or start some new type of exercise? Have you kept up with any of those goals as yet?

Don’t feel alone or despondent about these goals. In this fast-paced, instant-gratification world in which we live, such goals are extremely common. However, the rewards aren’t as easy to achieve as we think they are.

Obesity as a chronic disease

Obesity has recently been recognised by the international healthcare community as a chronic disease. What this means is that the mechanisms that cause obesity are persistent and long-lasting and various complications may be associated with the condition as well.

The European Medicines Agency states that “Obesity is recognised as a chronic clinical condition that usually requires long-term therapy to induce and maintain weight loss and is considered to be the result of complex interaction of genetic, metabolic, environmental and behavioural factors, which are associated with increases in both morbidity and mortality.”

The World Health Organization has recognised obesity as a threat to both developed and developing countries and estimates that over 650 million people worldwide are affected by it.

The Canadian Medical Association has declared “obesity to be a chronic medical disease requiring enhanced research, treatment and prevention efforts.”

The bottom line is that treating obesity is more complicated than cutting out sweets and going to gym more often.

What is obesity?

Many people and healthcare institutions consider a body mass index (BMI), a simple height to weight ratio, as the only indicator of being over or underweight. In addition, it’s suggested that all types of people from all races and ethnic backgrounds be subject to the same parameters. Some exceptions have been made but generally a BMI of > 25 is considered overweight and > 30 is obese.

This is also changing. I’m not a big follower of action movies but my teenage son tells me that Dwayne Johnson (aka The Rock) is 1.96m tall and weighs 118kg. That gives him a BMI of 34; very soundly in the obese category. I’ll certainly be last in the queue of people to go up to him and tell him he’s overweight.

More recently, we have started looking at a multitude of other factors to determine if someone is overweight and how this may or may not affect their health. Some of the factors we consider are:

• Medical co-morbidities – cardiac disease, arthritis, fertility problems, diabetes, etc
• Mental concerns – depression, social isolation, etc.
• Functional ability – can the person continue their desired daily activities without limitation?

These are all important indicators that will guide as to how we should approach the management of obesity. Few would argue that The Rock has any limitations on his functional abilities.

Complications of obesity

Does this mean that we can ignore a higher BMI and allow people to choose their desired weight as they please? Not really. Research indicates that people with a higher BMI are definitely prone to developing a range of complications and that obesity has a significant impact on life expectancy. People with a BMI over 40 have a predicted only 50% chance of reaching the age of 70 compared to those with a BMI < 30 who have an 80% chance.

Complications range from other metabolic diseases, such as diabetes, which has a significant impact on other health concerns in itself, to cardiovascular disease and some types of cancers.

Gout, arthritis and bone disease also become more prevalent due to the mechanical strain on joints and muscles and mental health complications, such as depression, also are more frequent.

Weight loss improves complications

Whilst this may sound like a very negative situation, the reality is even a modest weight loss will have an enormous effect on reducing these complications.  

What causes obesity?

It’s probably fair to say that most people think that weight gain is due to an imbalance between energy intake and energy expenditure. People who are overweight, either eat too many calories or do too little activity. Losing weight therefore requires more activity or fewer calories. This is not true.

It has now been scientifically proven that weight gain or loss is far more complex than this and that the main organ responsible for controlling weight is our brain.Genetics play a vital role in regulating this control; if your family is overweight, it’s very likely that you have similar genes that will dictate how your body responds. Other organs in the body such as the pancreas, gut and adipose tissue (fat tissue) also influence your metabolism and how you process energy in the body.

Restricting energy intake (eating less) is also not an effective means of weight loss as hormones, such as leptin, are downregulated as energy restriction occurs. Low leptin levels cause the body to conserve energy and trigger a response in the brain that you are hungry and need to eat. This is not a will-power issue but a genuine lack of energy in the body which causes weight to regain as your body adapts to the feeling of hunger and desire to eat.

The role of the brain in controlling appetite

Until recently, the impact of the brain in appetite has been largely overlooked. Homeostatic eating is eating for hunger. This is what we generally don’t do. It is, however, what most animals do. They hunt when they are hungry and eat until they have gained enough calories to survive.

Hedonic eating

Hedonic eating is eating for pleasure and is under control of the mesolimbic system. This is the eating that happens at Christmas lunch or at a wedding or when we eat out at a restaurant with friends. It’s mediated by feelings of wanting or liking to eat and not by satiety or hunger.

A want-to-eat is mediated by dopamine, a hormone implicated in reward-behaviour system. The more we eat, the more we reward our brain and drive future such behaviours. Liking-to-eat is associated with pleasure derived from eating and is mediated through opioid and cannabinoid receptors. No one would dream of hosting a celebration and serving just a small amount of food to allow your guests to survive and combat starvation. We like tasting different foods, we like socialising while we eat, we like food that tastes good.

We have the privilege of being able to indulge in hedonic eating and not just eat when we are hungry. It’s the executive functioning in the pre-frontal cortex of our brains that decides when we are hungry. Over years of over-riding the need to eat and the want to eat, our brains develop alternate pathways.

In addition, each time we gain weight, our brains use that as a new set-point, a new normal to which it governs our weight regain. Many of us will relate to the experience of going on a diet, eating fewer calories but as soon as you go into a maintenance phase again, you regain the weight to where you were initially.

How do medications work?

Some older weight loss preparations have a more short-term effect and aim to speed up metabolism; these generally work very well in the short-term but have little effect on the underlying problem.

Others act on energy wastage and bind fat in the gut to reduce calories absorbed. Again, this can work well in the short-term but aside from some negative side effects, do very little to address the pathways in the brain.

Newer formulations of medications to manage weight have recently been developed and licenced for use and are much more effective at addressing the chronic underlying pathology that results in weight gain.

What we need is a drug that acts on the pathways in the brain to reset the weight set-point and override the feelings of hunger and desire to eat as well as improve metabolism in the gut, pancreas and other metabolic organs.

By reducing gastric emptying, you feel fuller for a longer period of time thus decreasing the desire to eat. Within the liver, metabolism is also affected reducing glucose production and enhancing glucose sensitivity.

Such drugs also have a positive effect on cardiac function, but the most significant effect is the action directly on the brain which results in decreased food intake, improved satiety and sustained weight loss.

Patient feedback

There has been great success using these drugs with my patients and some of the comments talk directly to the mechanisms in which they work. Comments relating to how their focus shifts away from food and they can get on with normal daily activities without being fixated about their next meal or how little they should be eating.

Other comments relating to the ability to sit at a table and eat what they feel they need to eat rather than what they want to eat and actually feel full and satisfied at the same time. The medication also has a significant effect on combatting the cravings that people feel in between meals and the extra snacks that we have just because they taste nice.

Summary

Shifting from a BMI-centric approach of treatment where we are purely trying to target a number to a more complication-centric focus where the multiple co-morbidities associated with obesity are addresses as well as the often unseen mental complications will certainly result in better outcomes in managing weight and obesity.

Counselling, self-monitoring, physical activity and diet are most certainly vital aspects of weight management achieved through interaction with a holistic multi-disciplinary team. This includes dietitians to address the obvious aspects of diet and a doctor skilled in obesity management to know which drugs and possible surgical options suit each patient as well as multiple other practitioners as individual patient needs dictate.

Our healthcare system is perhaps not ideally suited to deliver obesity management in such a way, but it will be a great leap forward if we can shift our focus from thinking that weight loss is a quick-fix that requires more activity and fewer calories to one of understanding the chronic nature and multi-faceted cause of weight gain.

Accurate and effective pharmacological treatment is the future of weight management and treating obesity as a disease and not a lack of will power and poor decision-making will go a long way to helping those who need medication to access it.

Header image by Adobe Stock