Obesity and non-communicable diseases prevention and control

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24 May 2017
Chairperson: Ms M Dunjwa (ANC)
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Meeting Summary

The National Department of Health (NDoH) briefed the Committee on its strategic plans to prevent and control obesity and non-communicable diseases. The incidence of NCDs and obesity is rising at an alarming rate. Diseases such as cancer, diabetes, respiratory diseases are co-morbid conditions. NDoH is working towards reducing NCDs and obesity, however, lack of resources continues to be a challenge. The main drivers of NCDs and obesity are poverty, tobacco use, unhealthy diet, alcohol, poor early childhood feeding practices, lack of knowledge and insufficient physical activity. NDoH is also working towards ensuring that companies that produce and sell products that contain high sugar and salt reduce these by establishing taxation on them. Woolworths has been advised to remove these products from their ‘temptation line’ and while this is being adhered to it has not been effected at all Woolworths. It is a gradual process/war which NDoH is ready to follow and win. Tuck shops at schools will also be considered.

Members welcomed the strategies but saw a problem in their implementation. They raised concern about the effectiveness of primary health care which must be a priority as it is the first line of prevention, diagnosis and treatment for the population, but the clinics are underfunded and under-staffed. There is no data on primary health care performance because to get these numbers entails knowing what the provinces are doing. South Africa needs a national surveillance system that works and municipalities must play a role in the NDoH strategies. They pointed out that since government controls schools, the food is available at schools is within the control of government too. There was a suggestion about a policy about exercise and liaising with the Department of Sport. They felt that concentrating only on sugary beverages is not enough, it must be a holistic approach. They advised NDoH to take its monitoring and evaluation seriously.

Meeting report

Obesity and non-communicable diseases: Health Department strategies for prevention and control
Ms Jeanette Hunter, NDoH Deputy Director General: Primary Health Care, said the Primary Health Care programme has five chief directorates:
- Environmental Health
- District Health Services
- Communicable diseases except HIV and TB
- Non-communicable diseases such as diabetes, hypertension, respiratory diseases, health of the elderly, cancers, eye health, and mental health
- Health promotion, nutrition and oral health.

Ms Sandhya Singh, NDoH Director: Non-Communicable Diseases, spoke about the strategic plan of NDoH for the prevention and control of non-communicable diseases (NCDs). Non-communicable diseases are growing at an alarming rate. A study done by the Medical Research Council (MRC) shows that NCDs dominated the death profile accounting for 64.9% of deaths for persons older than 45 years of age. There are conditions that are occurring as co-morbid condition of NCDs. For HIV/AIDS, co-morbid conditions include cancer, cardiovascular disease, stroke, sensory impairment including ear conditions, deafness and hearing loss, blindness. For TB, co-morbid conditions include diabetes, hearing loss, respiratory conditions and tb spine are likely to occur. For Maternal Health, co-morbid conditions include hypertension, gestational diabetes, maternal nutrition and FAS. For Women’s Health co-morbid conditions include breast and cervical cancer. For Child Health, co-morbid conditions include diabetes type 1, cancer, cardiovascular diseases, epilepsy and asthma.

“South Africa’s health challenges are more than medical. Behavior and lifestyle also contribute to ill-health. To become a healthy nation, South Africans need to make informed decisions about what they eat, whether they consume alcohol, and their sexual behavior, among other factors”.

However, there is a link between poverty, NCDs and economic impact.

Non-Communicable Diseases Strategic Plan for Prevention and Control 2013-2017
The strategic plan was based on a National Response to the Global Call for Action (UN Political Declaration 2011) which includes:
• Implementation of multi-sectoral responses including private sector and civil society
• Reducing risk factors by creating health-promoting environments
• Strengthening of national policies and health systems
• Increasing research and development
• Strengthen Monitoring and Evaluation which has become very problematic.

The common risk factors of these diseases are: tobacco use, unhealthy diet, physical inactivity and alcohol.

A comprehensive approach to combating NCDs includes:
Sub-strategy 1: Prevent NCDs and promote health at population, community and individual levels.
Sub-strategy 2: Improve control of NCDs through health systems strengthening and reform.
Sub-strategy 3: Monitor NCDs and their main risk factors and conduct innovative research.

UN Summit targets
• Reduce by at least 25% the relative premature mortality (under 60 years of age) from NCDs by 2020;
• Reduce by 20% tobacco use by 2020;
• Reduce by 20% the per capita consumption of alcohol by 2020;
• Reduce mean population intake of salt to <5 grams per day by 2020;
• Reduce by 10% the percentage of people who are obese and/or overweight by 2020;
• Increase prevalence of physical activity by 10% (150 minutes of moderate-intensity activity per week)
• Reduce prevalence of raised blood pressure by 20% by 2020 (through lifestyle and medication);
• Every woman with sexually transmitted diseases to be screened for cervical cancer every 5 years, otherwise every woman to have 3 screens in a lifetime.
• Increase percentage of people controlled for hypertension, diabetes and asthma by 30% by 2020;
• Increase number of people screened and treated for mental disorders by 30% by 2030.

Key Achievements linked to the Strategy
Policies/ Models of Care:
• Scale up of the Integrated Clinical Services Management Model through the Ideal Clinic programme
• Roll out of training – July 2017
• NCD strengthening in Primary Care: Adult
• Development of Health Promotion Tool for Primary Care: Adult
• NCD Integration in Adherence Guideline and Follow Up Plan
• Training of PHC nurses on Diabetes Guideline
• Approved Strategic Framework on Disability and Rehabilitation
• Approval of National Policy Framework and Strategy on Palliative Care
• Regulation of the Compulsory Registration on Cancer strongly supported updating the National Cancer Register since 1999
• Cervical cancer screening coverage is moving toward meeting target: 2016/17 61.2 and the target is 63
• Policies on Breast and Cervical Cancer approved by the NHC
• 9-Year-old girls receiving HPV vaccine to date – approx. 1 million, considered best practice globally
• Regulation on the Reduction of Sodium Content in certain foods
• Dates on which Sodium reduction becomes effective; 2016 and 2019
• There has been established taxation on Sugar Sweetening Beverages
• Establishment of the National Health Commission (NHC).

The Tobacco Products Control Act is currently being amended to align with the WHO Framework Convention on Tobacco Control (WHOFCTC). The proposed amendments are completed. The draft Tobacco Bill is to be presented to the National Health Council Technical Committee on 8 June for onward approval of the NHC and the parliamentary process will follow.

Alcohol regulation is dealt with by the Department of Trade and Industry as lead department. It coordinates the inter government policy on alcohol production, trade, and use. In this regard, DTI produced a liquor policy that was approved by Cabinet. The Liquor Act is being reviewed to implement the policy changes. DTI is in the process of finalising the Liquor Amendment Bill. Among other things, the Bill deals with reducing access, curbing alcohol advertising and marketing, and the legal age for purchasing alcohol.

• Measurement of achievement was compromised due to lack of initial baselines
• Limited access to data collection tools, poor data quality, compromised access to collecting parameters
• Demand for data at all levels varied
• Poor data resulting in exclusion from key programmes such as Central Chronic Medicine Dispensing and Distribution Programme (CCMDD)
• Extent of priority allocated to implementation varied
• Reported access to limited resources, stock outs
• Extent of coordination of prevention and control varied
• Extent of buy in from relevant stakeholders varied
• Reported poor “integration “with Programmes.

Post 2017
- Note achievements of linked policies and strategies
- Obtain estimates or actual data and identify new sources of data
- Overcome impact of not having baseline data for effective management
- Continuum of care, life course integrated approach
- Focus on prevention without forgetting those with diagnosed conditions who need to be managed
- Consult relevant programmes and stakeholders right from outset of planning with civil society,
- Strive toward: all of government; all of society commitment to prevention and control plan

Opportunity: Sustainable Development Goals
The biggest opportunity presented to the country is that while NCDs were excluded in the Millennium Development Goals, they are included in the Sustainable Development Goals (Goal 3.4: By 2030 one-third premature mortality from NCDs should be reduced through prevention and treatment, and promote mental health and wellbeing). These goals cannot be considered in isolation but together with other goals such as addressing poverty, education of women and children, gender equality, environmental conditions.

Proposed New Policy Framework
This is an overarching Policy Framework on Prevention and Control of NCDs which is why it is very important to acknowledge the multi-program, multi-sectoral approach to developing the policy framework. The policy must be read together with relevant Strategies and Implementation Plans such as the obesity strategy. What has come up as urgent is management and control of NCDs to ensure compliance, continuity of care, how to get its approval by March 2018.

Obesity Prevention and Control strategies
Ms Lynn Moeng-Mahlangu, Chief Director: Health Promotion, Nutrition & Oral Health, said that obesity is one of the key contributors or risk factors for NCDs. South Africa is among the top three over-weight / obese countries in Africa and amongst the top ten in the world. Over time there has been an increase rather than a decrease. The World Health Organisation (WHO) recommends that national governments should develop policies to create equitable, safe and sustainable environment to prevent and control obesity. Expert bodies also recommend that government engage all societal sectors to successfully reduce NCDs.

The strategy recognises the need for a multi-disciplinary approach which includes;
Goal 1: Creating an institutional framework to support inter-sectoral engagement
Goal 2: Creating an enabling environment that support availability and accessibility to healthy food choices
Goal 3: Increasing percentage of the population engaging in physical activity
Goal 4: Supporting obesity prevention in early childhood
Goal 5: Communicating with, educating and mobilising communities
Goal 6: Establishing a surveillance system and strengthening monitoring, evaluation and research.
It must be noted that the strategy is not addressing the issue of treatment but prevention and control.

The target is to reduce the prevalence of being overweight and obesity by 10% in children and adults by 2020 by adopting a multi-sectoral life course approach.

The drivers of overweight and obesity include poor diet, poor early childhood feeding practices, lack of knowledge and insufficient physical activity.

NDoH is engaging with Department of Sport and Recreation, Department of Basic Education, DPSA, Department of Transport, Department of trade and Industry, medical aid schemes, research institutions and academia.

Dr W James (DA) thanked NDoH for the presentation. No country comes to mind which has un-health burden that can be a good comparison with South Africa unless Mexico. NCDs are rising more than infectious diseases. The question is to avoid repeating the mistake of last year and rather budget properly. There is a mismatch in terms of priorities when it comes to primary health care (PHC). What can be achieved by PHC with its 90% coverage, as the first line of diagnosis and treatment for the population, is not being achieved. As a country, having more clinics will be helpful but it is not the solution. The major problem is that clinics are underfunded and under-staffed. It is not clear how much is spent on primary health care. There is no data on the performance of the system when it comes to primary health care in the country. To get these numbers entails knowing what the provinces are doing. Primary health care is not a priority considering its budget and its performance.

What government can do is to provide expertise and infrastructure for early diagnosis; then see the health system is primed with treatment to deal with the diseases. There are two priorities to this: the first is what happens to moms and maternal health conditions such as maternal mortality which is now increasing. This can be helped by having proper and functional ambulances. The second priority is children. This is not present in the budget.

There is no surveillance data in this country. Any Minister of Health must have a national surveillance system that works. Municipalities and cities must play a role in whatever strategy NDoH has. Working with the Department of Cooperative Governance and Traditional Affairs (COGTA) is not good enough. About the food available at schools, the government control schools and so what happens there is within the control of government. There are vending machines dispensing Coke in some schools. These vending machines should be removed and quality drinks sold to kids.

Ms C Ndaba (ANC) welcomed the good presentation which needs time for one to read and digest. Insufficient physical activity calls to mind the study tour to Cameroon organised by the Committee. Cameroon has days where everybody does exercises including children, adults and the aged. Sports is a culture in Cameroon. Having a policy or legislation which obliges everybody to exercise would be useful. The Cameroonian model is a good one and should be taken up by NDoH. It must be serious about doing health inspections in Early Childhood Development (ECD) centres and check what activities children are engaging in and what they are eating. NDoH should also advise the Department of Basic Education to come up with a standard practice on what needs to happen. It also involves advising people especially the aged on healthy lifestyles. Sugar testing is good but concentrating on sugary beverages is not enough. If sugar must be eliminated it must be considered holistically without targeting only on one. Special K breakfast cereal has a lot of sugar, why is NDoH not considering that?

On purchasing power, most people in SA are poor and they buy what is cheap. Frozen chicken has high salt levels and it is not healthy for people. People eat it every day. What is the plan around this? It seems that some people are targeted whilst the other ones killing people with unhealthy foods are not targeted but allowed to get away with the murder. They should all be dealt with collectively and not piece-meal.

TV watching by children is a serious issue since it contributes to obesity. Children like chips just like adults, people go to Nando’s to buy grilled chicken, chips with tomato sauce. Tomato sauce has a lot of sugar. Tomato sauce should be identified as another contributory factor to obesity. Sugar content must be unpacked so that people know what is what - so that it will not be viewed as dismissing people from their jobs especially those at the sugar cane farms.

The strategy is good but the implementation is the problem. What is the roll out plan? Communities should be educated on this matter. Other departments should be involved in the implementation of this strategy. How can people be advised not to buy braai packs when there is no money to get healthy food. The main challenge is lack of coordination amongst departments.

Mr D Khosa (ANC) stated that cigarette packets indicate that cigarette smoking is dangerous to health. At Nando’s, KFC, and McDonalds nothing indicates that the food is dangerous. There are no health inspectors in municipalities who inspect spaza shops in the villages. Is NDoH working towards ensuring that health inspectors check food stuffs in spaza shops and the food sold to children at school tuck shops.

On physical education (PE), has NDoH engaged with the Department of Education. Children no longer walk to school. They are driven to and from school and then they sit down and watch TV. Physical education in schools is no longer compulsory. In every school, those participating in physical education are fewer than 10% and that is seasonal, when they do athletics.

Ms L James (DA) said that the strategy is very good but its implementation may be a problem. There are challenges to the implementation of the strategy which includes lack of facilities. Other departments should be engaged such as Safety and Security. The reason for driving children to and from school is because of security. It is not safe to walk these days.

People have no knowledge about NCDs, their causes and what to do. People should be educated on how to check themselves and where to go for check-ups. This then points to primary health clinics. Private schools are even worse with regards to selling and buying of unhealthy food. There is no PE time in schools. How will NDoH get the budget? There is lack of staff in the clinics, what plan does NDoH have?

Mr P Maesela (ANC) said it is good to talk about these issues and raise awareness but it would not amount to anything because of poverty. Poverty is the biggest driver of ill-health. These diseases are more prevalent in the low and middle income countries. People buy junk food to survive because they do not have the means of production. This is engineered by colonisation. The majority of people do not have land. It is not enough to give tablets. It is about food and ways of preventing poverty should be considered.

Obesity is caused by malnutrition and malnutrition is because people cannot afford good nutrition. People cannot afford good nutrition because there is no land to grow food hence they buy junk food. Yet they cannot even buy the junk food because there is no employment. The root cause of NCDs should be considered and that is poverty. The national nutritional supplementation at schools is a scandal. It is supposed to be done by the Department of Health but is done by Department of Education which does not know what it entails.

Is there wellness in Parliament to start with? A poor person does not have time for all this information, the information is for the rich who can afford food. A poor person who is hungry cannot be expected to be running in the name of exercising. They are only interested in how to get food. The rich people who have money do not eat at McDonalds, they call it junk food but the poor do not care whether it is junk or not. 90% of people who die of NCDs die because of poverty, not by chance but design.

The Chairperson welcomed the report, saying this is a very serious situation. The broader ideological debate is needed to ascertain and access the situation. Has NDoH checked the soup kitchen/nutrition centres in Social Development to check the quality of food being prepared? The high rate of employment is going up. Are there strategies to empower people so that they can do the right thing and understand why? Are the vegetables sold in outlets consumable?

On monitoring people, it must be noted that NDoH is understaffed in terms of its human resources. The presentation is good but the implementation is the problem. Are the community health workers empowered to empower the people? NDoH must consider what is in the lunch boxes of children, not only the tuck shops. Communities should also be empowered and educated. How is NDoH engaging with Department of Sports? Even though NDoH has praised Woolworths, some of the food is salty. It should however not only be Woolworths, but Shoprite, Pick n Pay and other shops.

Ms Hunter said there are environmental health officers working in local government. NDoH works closely with them. However, the work is not done to the degree that one expects it to be and it is not happening everywhere. This relates to the resources available. Primary health is not properly resourced now. NDoH is working on a program with the Director General, Chief Financial Officer, National Treasury and Provincial Treasuries. Within National Treasury there is a lot of competition amongst departments for a bigger slice of the pie. What National Treasury colleagues expect from NDoH is to have a well-developed business case to show why the country should invest in this. The NDoH also work with universities to assist with quantitative analysis. NDoH is working with National Treasury to get a bigger slice for health and primary health care.

Ms Hunter noted that Ms Moeng had started the crusade of ‘temptation lines’ with Woolworths. There are so many Woolworths in SA but the changes are not in all the Woolworths. Woolworths reported on the radio some time back that they are taking the lines away and this was based on Ms Moeng interaction with Woolworths. Now that Woolworths is working on it; other shops are coming on board. Ms Moeng is also looking at fast foods joints. This war cannot be fought one-dimensionally. It cannot be only about regulation, education but also intervention within the environment to make it conducive for exercise. There is regulation in terms of smoking and more recently on the reduction of salt. A deadline has been given to reduce salt by 2019. The salty chicken is due to the brine. This does not concern chicken alone but marinated chicken which has a high salt content. They have been earmarked for salt reduction.

The lack of exercise deals with people’s perception about how safe they are.

Concentrating more on liquid sugar relates to limited resources. The Director General will be informed on how to broaden the scope of regulating other areas. Fights must be picked one by one. Research has shown that reducing sugar in liquids such as beverages will make a significant impact.

People have been conditioned to eat wrongly, especially pouring salt onto food from childhood. Yoghurt states if it is low or fat free but does not say the amount of sugar in it.

The implementation of the plan is what is going to make the difference. There is a lot happening in terms of the implementation. NDoH has appointed an agency to put out health education materials on radio and TV in order to get the health education out to people in all languages of the country. NDoH is not yet visible. NDoH is working towards completing its investment case and getting the funding to become more visible and run more programmes for the different stages of the human from uterus to the aged. NDoH had tried to get as many signatures and the commitment of Ministers in other sectors, as is possible. The Minister of Basic Education was one of the signatories and this is good going forward because Basic Education is the strongest ally in this crusade.

Creation of employment is however the determinant factor on whether this war on NCDs can be won or not.

On the budget, the NDoH is working with its Chief Financial Officer to get provinces to be more specific about what they spend on primary health care in order to have a good baseline. This will also help to provide evidence for budget growth. The CFO in his monthly forum is working with provincial CFOs to know what is spent on primary health care.

Ms Moeng replied about the issue of the ideological debate, saying that policies within departments and government which allow some companies to invest in SA will be reviewed. For example, where is a KFC in front of a school where children have their breakfast before going to class.

On regulating brine in chicken, the Department of Agriculture (DoA) is working on this and has already published regulations to reduce the brine. In some products, sugar is being reduced such as in yoghurt.

On coordination, most of what NDoH has in the obesity strategy tries to incorporate a plan whereby all of government can report. The focus is on malnutrition and food security. Malnutrition means both over and under nutrition.

Initially, the expected outcomes of the school nutrition programme were to ensure that hungry children who are fed will be more attentive and come to school because there is something to expect. After a few years, when it was moved to Education, came the realisation of strengthening the nutrition outcomes within the programme. The main challenge is around implementation. Menus can be set but some schools are not implementing these. This concern means that monitoring needs to be strengthened.

NDoH has not visited community nutrition centres to inspect the quality of foods. Recently the Department of Social Development invited NDoH to guide it in setting up menus in the community nutrition centres.

On the quality of vegetables sold in open places, Ms Moeng replied that the involvement of municipalities to establish centres or shelter where people can sell vegetables in a protected environment will be a welcome strategy. Establishment of local markets will improve the quality and cost of vegetables.

It is a welcome suggestion that NDoH regulate what food is sold in schools. The main challenge is that what is sold in school is controlled by the school governing body. NDoH will engage with the school governing bodies to improve the situation. Implementation has started but only with available resources.

The Chairperson said that the presentation is not for the mere sake of presenting. The Committee will monitor all processes for reducing obesity despite the challenges raised. It is very important to understand the role of the municipalities and local government. The presentations that follow should not be general anymore, it must show specifics such as places where work has been done, schools visited and what was observed. People are perishing because of NCDs. Empowerment of people must be seriously considered.

She mentioned that it is frustrating sometimes to request information from NDoH only for NDoH to take its time before responding. All questions and information must be responded to timeously.

She then thanked NDoH and adjourned the meeting.

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