CORRESPONDENCE

Response to 'Obesity is South Africa's new HIV epidemic'

To the Editor: Recognition that obesity is a medical condition and that it is not deserving of its prevalent Stigmatisation is important. Obesity is now recognised, along with the other non-communicable diseases (NCDs) as chiefly metabolic and inflammatory responses to poor nutrition, lack of physical activity and environmental influences.

We can thank the COVID-19 pandemic and the pharmaceutical industry for sharpening attention to obesity. COVID-19 infection was evidently associated with higher morbidity and mortality among the obese and overweight.^[1] Two pharmaceutical companies have now researched, produced and marketed glucagon-like peptide-1 receptor agonists (GLP-1s), again putting obesity in the spotlight. The April 2024 editorial by Dr Chandiwana et al.^[2] introduced a comprehensive set of very necessary interventions. However, an emphasis on the efficacy and importance of lifestyle approaches and healthy nutrition was not adequately addressed.

Nutrition is complex, and each of the 8.1 billion humans^[3] on the planet has unique dietary requirements for optimal health. Human nutrition is a highly contested space, but there is general consensus within lifestyle medicine that optimal health is related to higher proportions of vegetable and whole plant foods, the lowest proportions of processed and ultra-processed foods, with less animal produce, along with adequate sleep, rest, physical activity, appropriate stress management, avoidance of unhealthy substances and healthy social relationships.^[4]

HIV activism showed us that social change starts from the bottom. In a similar vein, the Western Cape Government has introduced the Western Cape on Wellness (WOW) initiative, a community-based nutrition and wellness programme that is rapidly developing into a social movement, with patients leading their own paths to wellness and potentially greatly reducing their dependency on health services and professionals. The North West Provincial Health Department's NOW, based on the WOW, and the National Cheka Impilo are similar important wellness initiatives. The Physicians Association for Nutrition South Africa (PAN South Africa) and the South African Lifestyle Medicine Association (SALMA) are demonstrating that food can be prescribed as medicine within our SA context.^[4,5] There is no doubt that GLP-ls have an important role to play in the management of obesity. However, side-effects, lack of evidence for long-term efficacy, safety relative to benefit and cost considerations/ pharmaceutical profiteering are among the concerns that require that they must only be considered as an adjunct to a fundamental shift in access and provision of healthy food, adequate nutrition, and lifestyle and attitudinal changes to food in SA.

The scepticism that food can be equated to medicine among health professions largely stems from the fact that we received very little formal training indeed on nutrition. For example, an informal 2023 PAN South Africa social media survey of our SA medical school students^[6] showed that 74% of students feel that they do not receive enough nutrition education. This skills gap is a global phenomenon among the medical and health professions; paradoxically, all eyes are on the health professions to 'fix' the obesity and nutrition crisis, globally and locally.

Success in reversing and halting the obesity and related NCD pandemic lies with enabling individuals to navigate their own healthy lifestyles. Lifestyle interventions such as WOW, dramatic dietary change and, perhaps most importantly, radical changes to our obesogenic food environment must remain at the core of NCD and obesity reduction. Nutritional solutions are already known about and need to be harnessed. It is widely accepted that NCDs barely existed on the African continent before the mass import and adoption of Western-style food production and consumption. This was well documented in Dr ARP Walker and Dr Denis Burkitt's work in Africa from the 1950s.^[7,8] Promotion of a traditional plant-orientated, wholegrain diet, widely consumed not more than a few generations back throughout SA and beyond, needs to be urgently prioritised, promoted and restored.

Our experience in managing addiction to tobacco products shows that the need to persistently address the role of deep-pocketed industries in maintaining the status quo must be addressed. To add to the comprehensive list of interventions recommended in the editorial could be:

• banning of vending machines dispensing ultra-processed foods

• addressing food choices in hospitals

• offering culinary medicine in medical and allied curricula

• encouraging training in healthy, regenerative food growing and preparation at grassroots level

• encouraging industries to offer whole-food options at cafeterias

• a public awareness campaign to define the role of energy-dense foods in promoting obesity.

The recommendations of Dr Chandiwana et al.^[2] are commendable. However, we must also take care that nutrition remains central to initiatives to reduce NCDs and obesity, and is not merely peripheral or an add-on to pharma industry-led 'quick-fixes'.

Andrew K L Robinson, Chairperson: Physicians Association for Nutrition (PAN) South Africa; former deputy-director general, North West Provincial Health Department; professor, Faculty of Health Sciences, North-West University. andrew.robinson@pan-sa.org

David R Glass, Chairperson: South African Lifestyle Medicine Association; vice-president: African Lifestyle Medicine Council

Acknowledgements. Contributions from Helen Robinson and Dr Nanine Wyma towards the writing and editing of this letter are acknowledged.

References

1. Srivastava S, Rathor R, Singh S, Kumar B, Suryakumar G. Obesity - a risk factor for COVID-19. Adv Exp Med Biol 2021:1352:195-210. https://doi.org/10.1007/978-3-030-85109-5_12        [ Links ]

2. Chandiwana N, Venter F, Manne-Goehler JM, et al. Obesity is South Africa's new HIV epidemic. S Afr Med J 2024;114(4):e1927. https://doi.org/10.7196/SAMJ.2024.v114i4.1927        [ Links ]

3. Worldometer. Current World Population. Worldometer, 2024. https://www.worldometers.info/world-population/ (accessed 25 March 2024).         [ Links ]

4. Sagner M, Katz D, Egger G, et al. Lifestyle medicine potential for reversing a world of chronic disease epidemic: From cell to community. Int J Clin Pract 2014;68(11):1289-1292. https://doi.org/10.1111/ijcp.12509        [ Links ]

5. Wyma N, Niesling C, Robinson AKL, Bester P. A plant-based dietary approach to the management of type 2 diabetes mellitus in South Africa: Short communication of a multiple-case study. South Afr J Clin Nutr 2024;1-5. https://doi.org/10.1080/16070658.2023.2295514        [ Links ]

6. Physicians Association for Nutrition. Student survey report. PAN, 2024. https://pan-int.org/branches/south-africa/student-survey-report/ (accessed 25 March 2024).         [ Links ]

7. Cummings JH. Denis Burkitt: A cancer, the virus, and the prevention of man-made diseases. New York: Springer, 2022.         [ Links ]

8. Cummings JH, Engineer A. Denis Burkitt and the origins of the dietary fibre hypothesis. Nutr Res Rev 2018;31(1):1-15. https://doi.org/10.1017/S0954422417000117        [ Links ]