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South African Journal of Science

On-line version ISSN 1996-7489
Print version ISSN 0038-2353

S. Afr. j. sci. vol.117 n.5-6 Pretoria May./Jun. 2021 



Non-communicable diseases - a catastrophe for South Africa



Ebrahim SamodienI; Yoonus AbrahamsI, II; Christo MullerI, II; Johan LouwI, III; Nireshni ChellanI, II

IBiomedical Research and Innovation Platform, South African Medical Research Council, Cape Town, South Africa
IICentre for Cardio-metabolic Research in Africa, Division of Medical Physiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
IIIDepartment of Biochemistry and Microbiology, University of Zululand, Richards Bay, South Africa





Non-communicable diseases contribute significantly to the disease burden within South Africa. In the most unequal of societies in the world, poverty and socio-economic disparity are amongst the greatest obstacles facing South Africans, impacting heavily on health care. Adverse socio-environmental factors, especially those experienced during early life, can, through neurobiological and epigenetic mechanisms, developmentally programme the outcome of obesity, diabetes, cardiovascular disease and mental health disorders in adulthood. In this narrative review, we describe the social environment experienced by South Africans and discuss the potential contribution of epigenetics to the current and future prevalence of non-communicable diseases. A large part of the population (including 60% of young children) lives in poverty and endures challenging socio-economic environments, due to high unemployment, alcohol and substance abuse, and inter-partner violence. It is imperative that socio-economic factors be considered as risk factors for strategies aimed at reducing or preventing these disorders. If the current situation is left unchecked, the disease incidences could be exacerbated, and be potentially catastrophic for future generations. The consequences can be widespread and can have a direct effect on the future health and economic development of the country. Thus, child and adolescent health requires urgent attention and should be placed at the centre of the healthcare system. Early interventions providing optimum nutrition, a secure environment, together with physical activity and education should be the cornerstones for creating a healthier population for the future.
South Africa already has a high non-communicable diseases burden. Non-communicable diseases - like cardiovascular diseases, cancer, diabetes, respiratory illnesses and mental disorders - are known to be caused by the interaction of socio-environmental factors, physiology, behaviour and genetics. About 60% of South Africa's children currently live in poverty, with adverse socio-environmental factors known to have a negative effect on development, leading to a plethora of health problems in adulthood.
The implications for the current situation are widespread: a future population with deteriorated physical and mental health, presenting with co-morbidities that render these individuals more susceptible to infectious diseases. It is important to recognise the potential repercussions on the health prognosis of future generations.
Endeavours should focus on early interventions that can provide optimum nutrition, education, and physical activity within a safe environment. These interventions can have favourable effects on children's brain development and genetics, thereby promoting their well-being and increasing their life prospects.

Keywords: biology of misfortune, child health, epigenetics, chronic illness, nutrition, social inequality




Non-communicable diseases (NCDs) are the leading cause of death worldwide, being responsible for 71% of global mortality, with an estimated 41 million people dying from NCDs each year.1 South Africa is famously known as the home of the 'Big 5' animal species, but if the current trajectory continues, it will also be the home of the big 5 NCDs. The major NCDs are cardiovascular diseases (CVDs), cancer, type 2 diabetes mellitus, respiratory illnesses (such as chronic obstructive pulmonary disease) and mental health disorders.2 NCDs are chronic illnesses that tend to be of prolonged duration and occur as the result of a combination of genetic, physiological, socio-environmental and behavioural factors.3 It is estimated that NCDs will cost the global economy USD47 trillion over the next two decades, driving millions of individuals into or further into poverty and thereby exacerbating inequalities in quality of life and longevity.4

An already poor health prognosis for South Africa has been associated with a quadruple burden of communicable diseases, NCDs, maternal and child health, as well as injury-related disorders.5,6 The country also experiences a high prevalence of inter-personal violence.7 Equally important within the South African context is the growing trend of multi-morbidity, with the combination of human immunodeficiency virus (HIV)/NCDs and tuberculosis mycobacterium (TB)/diabetes, increasing the need for resources in the treatment and management of both chronic infectious diseases and NCDs.8

Recently, socio-economic status was recognised as a major contributing factor to the development of NCDs, not only in South Africa but worldwide.9 While the role of socio-determinants of health is not new, especially with regard to NCDs, there is increased interest in understanding the influence of epigenetics in this regard.10 A better understanding of region-specific risk factors could greatly aid the development of initiatives to reduce disease incidences and lighten the burden thereof. In this narrative review, we discuss the potential contribution of the socio-environment experienced by South Africans towards the current NCDs prevalence. We describe the possible interaction of several socio-environmental factors together with epigenetics, and aim to caution against the perpetual effects thereof, which may result in an even higher disease incidence in future generations. Furthermore, several important considerations which could be useful to mitigate the detrimental epigenetic effects are proposed.


Poverty and socio-economic disparity

South Africa was the most economically unequal society (out of 149 countries) assessed using the Gini index.11 More than half (55%) of the population experiences poverty12, with childhood poverty affecting 63% of children.13 Early-life adversities can have a negative impact on growth and development, with childhood poverty having both short- and long-term consequences.14 Impoverished children exhibit higher rates of acute and chronic diseases, with worsened physical and mental health in adulthood.15 Prolonged exposure to early life adversity establishes a developmental 'biology of misfortune', involving neurobiological and epigenetic processes through which one's life course is steered towards diminished health, unrealised potential and reduced longevity.15 Furthermore, children who do not have access to adequate nutrition (due to malnutrition or over-consumption) are developmentally compromised, exhibit learning disabilities, and are impulsive and prone to erratic and risky behaviour.16 If poverty and inequality are not adequately addressed, vulnerable children will become adults with a heightened susceptibility to disease. In a country with an already high NCDs burden2, harsh socio-environmental conditions may contribute to a vicious cycle of unfavourable health prognosis, as is being witnessed in the current generation12, which could worsen significantly in future generations.

The failure to optimise nutrition, especially during the critical periods of development for vulnerable young children, should be avoided at all costs. There is a definite requirement for efforts directed at improving the national diet. It should be noted, however, that healthier foods are far more expensive than less healthy, nutritionally poor foods.17 Products like lean meat, fish, fruit and vegetables generally cost more than oil-heavy processed foods which contain more sugar and fat.18 This makes the promotion of a quality diet difficult, because it is simply unaffordable for many South Africans. International research has shown that the best strategies for changing the dietary environment in favour of healthier foods are those aimed at population level and are accomplished by massmedia nutrition campaigns and transparent food labelling, and, more drastically, through regulation and taxation of unhealthy foods.18 To this end, the South African government has implemented policies that ensure stricter food labelling, prohibited advertising to children, introduced mandatory salt reduction legislation in 2016 as well as sugar taxation in 2018 (with South Africa being the first African country to do so).18 While research into the effect of sugar taxation in South Africa is still underway, data from Mexico and Chile have shown taxation to be partially effective, with a reduction in sugary beverage sales.19,20 However, these policies have a greater impact on poorer households21, and offer little in reducing socio-economic inequalities in diet-related health.19,20


Cultural dynamics and educational influences

South Africa is famously known as the rainbow nation, with a rich ethnic and cultural diversity comprising a variety of population groups including African, European, Indian and others, each embracing varying beliefs and cultural practices. Yet despite this diversity, dietary diversity is ever decreasing. More nutritious traditional foods have largely been replaced by the 'Western diet', which is characterised by the consumption of energy-rich and nutrient-poor processed food, largely from animal origin22, together with increased consumption of sugar-rich beverages.18 A concomitant decrease in the consumption of fruit and vegetables, whole grains and fibre has also been observed.22 This type of food environment has been associated with the rise in chronic illnesses including CVDs, cancer and diabetes.23

More awareness about the effects of an unhealthy diet could be useful, especially to younger children. General nutrition scores for the South African population tend to increase with age and peak at 55-64 years of age.24 Initiatives to improve nutritional knowledge, such as the nutrition education programme, have been implemented, and was shown to improve both the teachers' nutritional knowledge as well as learners' nutrition attitude.25 However, in the same study, no significant improvements in dietary practice of teachers or learners were found.25 It is plausible that, even if most of the public are aware of the health risks associated with the so-called 'Western diet', the consumption of heavily processed foods is unavoidable due to economic constraints and will therefore remain widespread. Also, amongst certain ethnic groups in South Africa, the type of food consumed is a measure of economic status.26 High adiposity is considered a sign of affluence and comfortable living, while being lean may be associated with being sickly or poor (or both), or having contracted TB, HIV or cancer27, with negative stereotypes and beliefs posing a great impediment to the development and success of healthy eating campaigns.

Indeed, several studies have shown the prevention or partial reversion of NCDs through implementation of lifestyle modification therapies, such as increased levels of physical exercise together with a balanced quality diet.28,29 Such preventative approaches are heavily under-represented, are certainly not available to most South Africans, and much awareness can be created around them.28 A school environment represents a controlled system, which could be targeted with efforts aimed at promotion of such interventions. This endeavour could be aided through the implementation of the teaching of crop cultivation within the school curriculum that culminates in a food garden project. The national school nutrition programme has aimed to establish food gardens, and even though the benefits are well known, this pillar of the framework has been described as under-funded and neglected.30 Such efforts could help feed the children nutrient-rich foods, to support surrounding communities as well as to educate about the health benefits of foods in preventing disease, whilst also being therapeutic. Furthermore, it would enable knowledge transfer to the general public, with regard to health risks associated with unhealthy diets, whilst simultaneously, efforts can be aimed at breaking the negative stereotypes related to obesity/leanness, beginning with young children as the key intervention group.


Socio-environmental factors and epigenetics

Socio-environmental conditions, even before we are born, are extremely important and can fundamentally affect our biological physiology31, and thereby activate or deactivate specific genes, with experiences of parental hardship in early childhood leading to alterations in chromatin structure, which are detectable a decade and a half later32. Epigenetic modifications - which include DNA methylation, micro-RNA circulation, histone modification and chromatin remodelling - have been implicated in the pathophysiology of obesity and several NCDs33, including diabetes, CVDs, cancers, and neurodegenerative and mental health disorders. Epigenetic markers constitute a biological 'memory' of early life experience, even more so in experiences of misfortune, poverty and stress.32 Epigenetic alterations can have long-lasting effects, spanning across generations, as observed in the Dutch famine cohort34 and the seasonal famines of Gambia.35 The same holds true for children suffering maltreatment, who exhibit long-lasting mental health perturbations and behavioural problems, which persist into adulthood.36

It is conceivable that the interaction between epigenetic changes arising from challenging socio-economic conditions are partially responsible for the high prevalence of NCDs in South Africa. The interplay between socio-environmental factors and epigenetics (Figure 1) must be considered and taken seriously when developing strategies to attenuate disease progression. The high genetic diversity together with varying socio-economic factors, although complex, offers a unique milieu of conditions for clinical investigations, and due to the paucity of research, calls for programmes to be initiated for this purpose, not only in South Africa but within Africa too.37



Obesity has been described as a normal response to an abnormal environment38; however, the social and environmental factors contributing to disease aetiology are often underappreciated.39 While South Africa is the most food secure nation on the African continent, more than half of the population are at risk of hunger.12,24 Despite high levels of food insecurity and elevated risk of starvation, the country remains one of the top 20 overweight and obese nations in the world.12

An estimated 27% of the population is obese, with South African women being amongst those with the highest rates of obesity worldwide, with a prevalence of 42%.40 This can partially be explained by high levels of physical inactivity amongst women, which is estimated to be 48%.2

Physical inactivity is also prevalent amongst children and youth, with levels deemed insufficient to promote health and prevent NCDs.41 Obesity in young children in South Africa is also rapidly increasing, which is intriguing as a large proportion of children are at risk of starvation.12,24 The prevalence of overweight and obesity in 2013 was reported to be 19% and 7%, respectively, for boys, and 26% and 10%, respectively, for girls within urban areas.40 In 2008, these figures were reported at 11% and 3% for boys, and 29% and 8% for girls within a nationally representative cohort.42 The country experiences what has been described as the double burden of malnutrition. A large number of children have been found to be developmentally stunted and thereby are at an increased risk of becoming overweight and obese, with a higher likelihood of developing NCDs in adulthood.43 Not only do obese individuals have an elevated risk of developing metabolic diseases, but offspring born to obese women are increasingly vulnerable to chronic disease development later in life.44 It has been estimated that more than 90% of type 2 diabetes mellitus, 68% of hypertensive, 45% of ischaemic stroke and 38% of ischaemic heart disease cases in South Africa occur as a result of excess body weight.45 The sub-Saharan African region is undergoing rapid demographic and epidemiological transition, which is believed to be the driving factor behind the increased risk, prevalence and burden of CVDs, diabetes and neurodegenerative diseases.46

It is worthy of mention that obesity is an underlying and re-occurring theme within the development of several major NCDs and thus represents a pivotal preventative and/or therapeutic target. Therefore, strategies aimed at addressing obesity could go a long way in reducing the prevalence of NCDs. In this regard, strategies should target young children, particularly through providing adequate nutrition together with education that facilitates their growth and development. Additionally, specific policies that address physical inactivity amongst children and young adults in both rural and urban settings across diverse socioeconomic status are also required.47 It is notable to mention that the prescription of exercise is a specialist therapy and the importance of having biokineticists in the public sector in the fight to reduce NCDs should be recognised.48


Stress, anxiety and depression

The in utero environment is increasingly being recognised as important in determining our future health prognosis.32 An adverse in utero environment can contribute to altered epigenetic and gene expression profiles as well as compromised growth and development. Individuals enduring such challenging environments may suffer emotional and cognitive impairment, with an increased likelihood of adopting risky behaviours (Figure 1). Additionally, such circumstances can also contribute to an increased susceptibility for developing metabolic diseases as well as psychological mood disorders.

Childcare often subjects parents to anxiety, stress and depression. Both antenatal and postnatal depression affects an estimated one-third of all mothers. This is indeed worsened by a lower socio-economic status with such conditions affecting 39% and 47% of pregnant mothers in informal settlements and rural areas, respectively.49,50 Maternal depression during infancy has been associated with dysregulation of the child's biological stress response.51 Furthermore, alcohol and substance abuse during pregnancy is also rife, with South Africa having one of the highest occurrences of foetal alcohol syndrome in the world.52 Another alarming matter is the high prevalence of intimate partner violence, with approximately 20% of pregnant women being affected.53 Half of female homicides in South Africa are perpetrated by intimate partners54,55, with violence against women being a significant problem that profoundly affects the physical and mental well-being of the individuals involved.55

Early-life adversity and struggles are linked to pro-inflammatory shifts in cytokine expression and increased CVDs risk56, whilst also increasing an individual's vulnerability to developing depressive disorder in adulthood.57

In South Africa, we are witnessing an ever-increasing rate of depression, and perhaps due to the stigma associated with mental health disorders, many incidences are unreported.58 Depression induced by HIV-stressors is also prevalent.59 It is estimated that one in three South Africans will experience a depressive episode at least once in their lifetime.60 Interestingly, substance and alcohol abuse are also significant public health problems in South Africa, which are inadvertently linked with increased violence and injury.61,62 Furthermore, there is a considerable loss of life due to self-harm, with 70% of individuals who had attempted suicide shown to be suffering from a mental health disorder.63 A high lifetime prevalence of substance abuse is also rife within the country, and with these disorders known to have an early age of onset, it provides an important indication in regard to which demographic to target when planning mental health initiatives and services.64


Food for thought

Unhealthy diets high in fat and sugar negatively affect the brain65 and contribute to 1 in 5 deaths worldwide.23 Diet-induced hypothalamic inflammation is one of the first symptoms to occur in the development of obesity and metabolic diseases.65 Increased neuronal Inflammation is also a commonality for several neurodegenerative diseases like Parkinson's and Alzheimer's, as well as in psychological mood disorders such as depression.66 With diet being intertwined with emotions, cognition and behaviour67, close attention should be paid to nutrition in order to prevent the induction of metabolic and inflammatory perturbations.

There are dietary regimens, particularly those high in polyphenols, which confer beneficial health effects. Dietary polyphenols are plant compounds found in tea, chocolates, herbs and spices, fruit, vegetables and nuts. Several polyphenols have been shown to be able to attenuate metabolic disease pathologies partially through preventing oxidative stress and inflammation in the brain.68 These plant compounds are regarded as exercise mimetics and have shown synergistic effects in combination therapies.69 Interestingly, like exercise, polyphenols hold the potential to positively modulate the epigenetic machinery and thereby restore normal gene expression.70,71 Furthermore, South Africa sits on a botanical 'goldmine' of indigenous medicinal plants that exhibit anti-obesity, anti-cancer, anti-diabetic as well as anti-ageing properties amongst others72, and more efforts are required in order to develop such natural therapeutics.

Finally, while the benefits of breastfeeding for both mother and child have long been known,73 South Africa, like most countries, is still not doing enough to support mothers to breastfeed, despite the immense economic implications.74 For mothers, breastfeeding decreases stress and promotes positive affect, while improving maternal compassion and care.75 According to the World Health Organization, all babies should ideally be breastfed exclusively from birth up to 6 months of age. Breastfeeding has positive effects on epigenetics76 and is critical for the establishment of optimal reference intake values for specific nutrients during lactation. This in turn creates a personalised pattern of nutrition, programming a healthy phenotype in early childhood that will continue into adulthood.77 Interestingly, there are reports that extended breastfeeding has been positively associated with increased childhood consumption of vegetables, even amongst obesity-prone young children.78,79 Just as the consumption of vegetables and exercise is important for boosting physical and mental wellness, breastfeeding has been associated with enhanced cognitive performance and socio-affective responses in children, promoting positive affect and social behaviour, while relieving stress and anti-social behaviour.75 An early investment into a child's health, education, development, security and well-being, provides benefits that compound during their lifetime, and increases prospects for their future and for that of their children and, thus, society as a whole.80



South Africa has a high prevalence of NCDs namely, obesity, diabetes, CVDs, cancer and mental health disorders. A large part of the population (including many young children) lives in poverty and under challenging socio-economic environments due to high unemployment, alcohol and substance abuse, and inter-partner violence, amongst others. It is plausible that adverse socio-environmental conditions together with modified epigenetic mechanisms are responsible for amplified disease susceptibility and diminished health outcomes, as is witnessed in the current generation, and if left unchecked can persist to worsen the situation in future generations. The plight of young poverty-stricken children requires urgent attention and should be prioritised and placed at the centre of the country's sustainable developmental goals. It is imperative in South Africa, as well as in countries experiencing similar socio-economic challenges, that children's health and well-being is improved in order to circumvent an impending catastrophe.



The work herein was made possible through funding by the South African Medical Research Council's Biomedical Research and Innovation Platform and the Division of Research Capacity Development under the Intra-mural Post-doctoral Programme. The content hereof is the sole responsibility of the authors and does not necessarily represent the official views of the South African Medical Research Council or the funders. We acknowledge the support of colleagues at the Biomedical Research and Innovation Platform, and Corporate and Marketing Communications, South African Medical Research Council.


Competing interests

We declare that there are no competing interests.


Authors' contributions

E.S. conceptualised and produced the original draft. All authors contributed to the paper, with N.C., C.M. and J.L. providing overall guidance. E.S. and Y.A. finalised the manuscript based on comments and feedback from other authors.



1. World Health Organization (WHO). Global status report on noncommunicable diseases 2014. Geneva: WHO; 2014.         [ Links ]

2. World Health Organization (WHO). Noncommunicable diseases country profiles 2018. Geneva: WHO; 2018.         [ Links ]

3. Silvaggi F, Leonardi M, Guastafierro E, Quintas R, Toppo C, Foucaud J, et al. Chronic diseases & employment: An overview of existing training tools for employers. Int J Environ Res Public Health. 2019;16:718.        [ Links ]

4. Allen LN, Feigl AB. What's in a name? A call to reframe non-communicable diseases. Lancet Glob Health. 2017;5:129-130.        [ Links ]

5. Mayosi BM, Flisher AJ, Lalloo UG, Sitas F, Tollman SM, Bradshaw D. The burden of non-communicable diseases in South Africa. Lancet. 2009;374:934-947.        [ Links ]

6. Pillay-van Wyk V Msemburi W, Laubscher R, Dorrington RE, Groenewald P Glass T, et al. Mortality trends and differentials in South Africa from 1997 to 2012: Second National Burden of Disease Study. Lancet Glob Health. 2016;4:642-653.        [ Links ]

7. Norman R, Schneider M, Bradshaw D, Jewkes R, Abrahams N, Matzopoulos R, et al. Interpersonal violence: An important risk factor for disease and injury in South Africa. Popul Health Metr. 2010;8:32.        [ Links ]

8. Berkowitz N, Okorie A, Goliath R, Levitt N, Wilkinson RJ, Oni T. The prevalence and determinants of active tuberculosis among diabetes patients in Cape Town, South Africa, a high HIV/TB burden setting. Diabetes Res Clin Pract. 2018;138:16-25.        [ Links ]

9. Stringhini S, Carmeli C, Jokela M, Avendano M, Muennig P Guida F, et al. Socioeconomic status and the 25 χ 25 risk factors as determinants of premature mortality: A multicohort study and meta-analysis of 1·7 million men and women. Lancet. 2017;389:1229-1237.        [ Links ]

10. Notterman DA, Mitchell C. Epigenetics and understanding the impact of social determinants of health. Pediatr Clin North Am. 2015;62:1227-1240.        [ Links ]

11. Sulla V Zikhali P. Overcoming poverty and inequality in South Africa: An assessment of drivers , constraints and opportunities (English). Washington DC : World Bank Group; 2018.         [ Links ]

12. Hall K, Richter L, Mokomane Z, Lake L. Families and the state collaboration and contestation [document on the Internet]. c2018 [cited 2021 Apr 09]. Available from:        [ Links ]

13. Hall K, Sambu W, Berry L, Giese S, Almeleh C, Rosa S. South African early childhood review 2016. Cape Town: Children's Institute, University of Cape Town and Ilifa Labantwana; 2016 [cited 2021 Apr 09]. Available from:        [ Links ]

14. Sun J, Patel F, Rose-Jacobs R, Frank DA, Black MM, Chilton M. Mothers' adverse childhood experiences and their young children's development. Am J Prev Med. 2017;53:882-891.        [ Links ]

15. Boyce TW. A biology of misfortune. Focus. 2012;29:1-6.         [ Links ]

16. De Lannoy A, Swartz S, Lake L, Smith C. Broad overview of the South African Child Gauge 2015 [document on the Internet].c2015 [cited 2021 Apr 09] Available from:        [ Links ]

17. Temple NJ, Steyn NFP Fourie J, De Villiers A. Price and availability of healthy food: A study in rural South Africa. Nutrition. 2011;27:55-58.        [ Links ]

18. Igumbor EU, Sanders D, Puoane TR, Tsolekile L, Schwarz C, Purdy C, et al. 'Big food,' the consumer food environment, health, and the policy response in South Africa. PLoS Med. 2012;9(7), e1001253.        [ Links ]

19. Colchero MA, Rivera-Dommarco J, Popkin BM, Ng SW. In Mexico, evidence of sustained consumer response two years after implementing a sugar-sweetened beverage tax. Health Aff. 2017;36:564-571.        [ Links ]

20. Nakamura R, Mirelman AJ, Cuadrado C, Silva-Illanes N, Dunstan J, Suhrcke M. Evaluating the 2014 sugar-sweetened beverage tax in Chile: An observational study in urban areas. PLoS Med. 2018;15, e1002596.        [ Links ]

21. Okop KJ, Lambert EV Alaba O, Levitt NS, Luke A, Dugas L, et al. Sugar-sweetened beverage intake and relative weight gain among South African adults living in resource-poor communities: Longitudinal data from the STOP-SA study. Int J Obes. 2019;43:603-614.        [ Links ]

22. Steyn NP Bradshaw D, Norman R, Joubert JD, Schneider M. Dietary changes and the health transition in South Africa: Implications for health policy. FAO Food Nutrition Paper. c2006 [cited 2021 Apr 09] Available from:        [ Links ]

23. GBD 2017 Diet Collaborators. Health effects of dietary risks in 195 countries, 1990-2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2019;393:1958-1972.        [ Links ]

24. Shisana O, Labadarios D, Rehle T, Simbayi L, Zuma K, Dhansay A, et al. South African National Health and Nutrition Examination Survey (SANHANES-1). Cape Town: HSRC Press; 2014.         [ Links ]

25. Kupolati MD, MacIntyre UE, Gericke GJ, Becker P. A contextual nutrition education program improves nutrition knowledge and attitudes of South African teachers and learners. Front Public Health. 2019;7:258.        [ Links ]

26. Venter FC, Walsh CM, Slabber M, Bester CJ. Body size perception of African women (25-44 years) in Mangaung. J Family Ecol Consumer Sci. 2009;37:12-23.        [ Links ]

27. Okop KJ, Mukumbang FC, Mathole T, Levitt N, Puoane T. Perceptions of body size, obesity threat and the willingness to lose weight among black South African adults: A qualitative study. BMC Public Health. 2016;16:1-13.        [ Links ]

28. Ezzati M, Riboli E. Can noncommunicable diseases be prevented? Lessons from studies of populations and individuals. Science. 2012;337:1482-1487.        [ Links ]

29. Arena R, Berra K, Kaminsky L, Whitsel L, Berra K, Lavie CJ, et al. Healthy lifestyle interventions to combat noncommunicable - A novel nonhierarchical connectivity model for key stakeholders: A policy statement from the American Heart Association, European Society of Cardiology, European Association for Cardiovascu. Eur Heart J. 2015;36:2097-2109.        [ Links ]

30. Devereux S, Hochfeld T, Karriem A, Mensah C, Morahanye M, Msimango T, et al. School feeding in South Africa: What we know, what we don't know, what we need to know, what we need to do [document on the Internet]. c2018 [cited 2021 Apr 09]. Available from:        [ Links ]

31. Hertzman C. Putting the concept of biological embedding in historical perspective. Proc Natl Acad Sci USA. 2012;109(suppl):17160-17167.        [ Links ]

32. Essex MJ, Boyce WT, Hertzman C, Lam LL, Armstrong JM. Epigenetic vestiges of early developmental adversity: Childhood stress exposure and DNA methylation in adolescence. Child Dev. 2014;84:58-75.        [ Links ]

33. Kubota T. Epigenetic alterations induced by environmental stress associated with metabolic and neurodevelopmental disorders. Environ Epigenet. 2016;2, dvw017.        [ Links ]

34. Heijmans BT, Tobi EW, Stein AD, Putter H, Blauw GJ, Susser ES, et al. Persistent epigenetic differences associated with prenatal exposure to famine in humans. Proc Natl Acad Sci USA. 2008;105:17046-17049.        [ Links ]

35. Waterland RA, Kellermayer R, Laritsky E, Rayco-Solon P Harris RA, Travisano M, et al. Season of conception in rural Gambia affects DNA methylation at putative human metastable epialleles. PLoS Genet. 2010;6, e1001252.        [ Links ]

36. Gilbert R, Widom CS, Browne K, Fergusson D, Webb E, Janson S. Burden and consequences of child maltreatment in high-income countries. Lancet. 2009;373:68-81.        [ Links ]

37. Hobbs A, Ramsay M. Epigenetics and the burden of noncommunicable disease: A paucity of research in Africa. Epigenomics 2015;7:627-639.        [ Links ]

38. Hoffman SJ, R0ttingen J-A. A framework convention on obesity control? Lancet. 2011;378:2068.        [ Links ]

39. Lee A, Cardel M, Donahoo WT. Social and environmental factors influencing obesity. In: Feingold KR, Anawalt B, Boyce A, Chrousos G, de Herder WW, Dhatariya K, et al., editors. Endotext [Internet]. South Dartmouth (MA):, Inc; 2000.         [ Links ]

40. Ng M. Global, regional and national prevalence of overweight and obesity in children and adults 1980-2013: A systematic analysis. Lancet. 2014;384:766-781.         [ Links ]

41. Van Biljon A, McKune AJ, DuBose KD, Kolanisi U, Semple SJ. Physical activity levels in urban-based South African learners: A cross-sectional study of 7 348 participants. S Afr Med J. 2018;108:126-131.        [ Links ]

42. Reddy SP Resnicow K, James S, Funani IN, Kambaran NS, Omardien RG, et al. Rapid increases in overweight and obesity among South African adolescents: Comparison of data from the South African National Youth Risk Behaviour Survey in 2002 and 2008. Am J Public Health. 2012;102:262-268.        [ Links ]

43. Tydeman-Edwards R, Van Rooyen FC, Walsh CM. Obesity, undernutrition and the double burden of malnutrition in the urban and rural southern Free State, South Africa. Heliyon. 2018;4, e00983.        [ Links ]

44. Glastras SJ, Chen H, Pollock CA, Saad S. Maternal obesity increases the risk of metabolic disease and impacts renal health in offspring. Biosci Rep. 2018;38(2), BSR20180050.        [ Links ]

45. Joubert J, Norman R, Bradshaw D, Goedecke JH, Steyn NP, Puoane T et al. Estimating the burden of disease attributed to excess weight in SA. S Afr Med J. 2007;97(8 Pt 2):683-690.         [ Links ]

46. NCD Risk Factor Collaboration (NCD-RisC) - Africa Working Group. Trends in obesity and diabetes across Africa from 1980 to 2014: An analysis of pooled population-based studies. Int J Epidemiol. 2017;46:1421-1432.         [ Links ]

47. Malambo P Kengne AP Lambert EV De Villiers A, Puoane T. Prevalence and socio-demographic correlates of physical activity levels among South African adults in Cape Town and Mount Frere communities in 2008-2009. Arch Public Health. 2016;74:54.        [ Links ]

48. Evans RW, Smith T, McWade D, Angouras N, Van Aarde RF, Kay P et al. The need for biokineticists in the South African public health care system. S Afr J Sport Med. 2016;28:85-86.        [ Links ]

49. Hartley M, Tomlinson M, Greco E, Comulada WS, Stewart J, Le Roux I, et al. Depressed mood in pregnancy: Prevalence and correlates in two Cape Town peri-urban settlements. Reprod Health. 2011;8:9.        [ Links ]

50. Rochat TJ, Tomlinson M, Newell ML, Stein A. Detection of antenatal depression in rural HIV-affected populations with short and ultrashort versions of the Edinburgh Postnatal Depression Scale (EPDS). Arch Womens Ment Health. 2013;16:401-410.        [ Links ]

51. Essex MJ, Klein MH, Cho E, Kalin NH. Maternal stress beginning in infancy may sensitize children to later stress exposure: Effects on cortisol and behavior. Biol Psychiatry. 2002;52:776-784.        [ Links ]

52. Olivier L, Curfs LMG, Viljoen DL. Fetal alcohol spectrum disorders: Prevalence rates in South Africa. S Afr Med J. 2016;106(6 suppl):S103-S106.        [ Links ]

53. Groves AK, Moodley D, McNaughton-Reyes L, Martin SL, Foshee V Maman S. Prevalence, rates and correlates of intimate partner violence among South African women during pregnancy and the postpartum period. Matern Child Health J. 2015;19:487-495.        [ Links ]

54. Abrahams N, Mathews S, Martin LJ, Lombard C, Jewkes R. Intimate partner femicide in South Africa in 1999 and 2009. PLoS Med. 2013;10(4), e1001412.        [ Links ]

55. Lopes C. Intimate partner violence: A helpful guide to legal and psychosocial support services. S Afr Med J. 2016;106:966.        [ Links ]

56. Miller AH, Maletic V, Raison CL. NIH Public access. Psychiatry Interpers Biol Process. 2009;65:732-741.        [ Links ]

57. Plant DT, Pariante CM, Sharp D, Pawlby S. Maternal depression during pregnancy and offspring depression in adulthood: Role of child maltreatment. Br J Psychiatry. 2015;207:213-220.        [ Links ]

58. Shilubane HN, Ruiter RAC, Van den Borne B, Sewpaul R, James S, Reddy PS. Suicide and related health risk behaviours among school learners in South Africa: Results from the 2002 and 2008 national youth risk behaviour surveys. BMC Public Health. 2013;13:926.        [ Links ]

59. Van Coppenhagen B, Duvenage HS. Prevalence of depression in people living with HIV and AIDS at the Kalafong Provincial Tertiary Hospital Antiretroviral Clinic. S Afr J Psychiatry. 2019;25, art. #1175.        [ Links ]

60. Jack H, Wagner RG, Petersen I, Thom R, Newton CR, Stein A, et al. Closing the mental health treatment gap in South Africa: A review of costs and cost-effectiveness. Glob Health Action. 2014;7:23431.        [ Links ]

61. Trangenstein PJ, Morojele NK, Lombard C, Jernigan DH, Parry CDH. Heavy drinking and contextual risk factors among adults in South Africa: Findings from the International Alcohol Control study. Subst Abuse Treat Prev Policy. 2018;13:43.        [ Links ]

62. Peltzer K, Phaswana-Mafuya N. Drug use among youth and adults in a population-based survey in South Africa. S Afr J Psychiatry. 2018;24:1139.        [ Links ]

63. Khasakhala L, Sorsdahl KR, Harder VS, Williams DR, Stein DJ, Ndetei DM. Lifetime mental disorders and suicidal behaviour in South Africa. Afr J Psychiatry. 2011;14:134-139.        [ Links ]

64. Stein DJ, Seedat S, Herman A, Moomal H, Heeringa SG, Kessler RC, et al. Lifetime prevalence of psychiatric disorders in South Africa. Br J Psychiatry. 2008;192:112-117.        [ Links ]

65. Guillemot-Legris O, Muccioli GG. Obesity-induced neuroinflammation: Beyond the hypothalamus. Trends Neurosci. 2017;40:237-253.        [ Links ]

66. Gomez-Pinilla F, Nguyen TTJ. Natural mood foods: The actions of polyphenols against psychiatric and cognitive disorders. Nutr Neurosci. 2012;15:127-133. https://doLorg/10.1179/1476830511Y0000000035        [ Links ]

67. Ahima RS, Antwi DA. Brain regulation of appetite and satiety. Endocrinol Metab Clin North Am. 2008;37:811-823.        [ Links ]

68. Samodien E, Johnson R, Pheiffer C, Mabasa L, Erasmus M, Louw J, et al. Diet-induced hypothalamic dysfunction and metabolic disease, and the therapeutic potential of polyphenols. Mol Metab. 2019;27:1-10.        [ Links ]

69. Lambert K, Hokayem M, Thomas C, Fabre O, Cassan C, Bourret A, et al. Combination of nutritional polyphenols supplementation with exercise training counteracts insulin resistance and improves endurance in high-fat diet-induced obese rats. Sci Rep. 2018;8:2885.        [ Links ]

70. Fang M, Chen D, Yang CS. Dietary polyphenols may affect DNA methylation. J Nutr. 2007;137:223S-228S.        [ Links ]

71. Voisin S, Eynon N, Yan X, Bishop DJ. Exercise training and DNA methylation in humans. Acta Physiol. 2015;213:39-59.        [ Links ]

72. Van Wyk B-E. The potential of South African plants in the development of new medicinal products. S Afr J Bot. 2011;77:812-829.        [ Links ]

73. Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane database Syst Rev. 2012; CD003517.        [ Links ]

74. Walters DD, Phan LTH, Mathisen R. The cost of not breastfeeding: Global results from a new tool. Health Policy Plan. 2019;34(6):407-417.        [ Links ]

75. Krol KM, Grossmann T. Psychologische Effekte des Stillens auf Kinder und Mütter [Psychological effects of breastfeeding on children and mothers]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2018;61:977-985. German.        [ Links ]

76. Verduci E, Banderali G, Barberi S, Radaelli G, Lops A, Betti F, et al. Epigenetic effects of human breast milk. Nutrients. 2014;6:1711-1724.        [ Links ]

77. Palou M, Picó C, Palou A. Leptin as a breast milk component for the prevention of obesity. Nutr Rev. 2018;76:875-892.        [ Links ]

78. Soldateli B, Vigo A, Giugliani ERJ. Effect of pattern and duration of breastfeeding on the consumption of fruits and vegetables among preschool children. PLoS ONE. 2016;11, e0148357.        [ Links ]

79. Specht IO, Rohde JF, Olsen NJ, Heitmann BL. Duration of exclusive breastfeeding may be related to eating behaviour and dietary intake in obesity prone normal weight young children. PLoS ONE. 2018;13, e0200388.        [ Links ]

80. Clark H, Coll-Seck AM, Banerjee A, Peterson S, Dalglish SL, Ameratunga S, et al. A future for the world's children? A WHO-UNICEF-Lancet Commission. Lancet. 2020;395:605-658.        [ Links ]



Ebrahim Samodien

Received: 15 July 2020
Revised: 06 Nov. 2020
Accepted: 18 Jan. 2021
Published: 28 May 2021



Editors: Pascal Bessong; Sandiswa Mbewana
Funding: South African Medical Research Council

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