Why better food regulations will help fight obesity

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About one in four South African adults are obese, and almost as many are overweight. 

Someone is considered heavily overweight when their body mass index is 25 or higher, and obese when this number reaches 30 or more.

Body mass index is a number that tells you how your weight (in kilogrammes) relates to your height (in metres). 

But the problem with weighing much more than you should is about more than just what the scale says. Obesity is a huge public health problem — affecting more than 650 million people worldwide — because it also leads to other health problems such as diabetes, high blood pressure (also called hypertension) and heart disease.

In South Africa, about 15% of people have type 2 diabetes, an illness that develops when your body can no longer make enough of the hormone insulin to control your blood sugar levels. Almost nine out of 10 cases of this type of diabetes among South Africans can be linked to obesity and overweight, research has shown.

Injectable medicines such as Ozempic (registered to treat type 2 diabetes in South Africa, but which also leads to weight loss) and Wegovy (a medicine meant specifically to help people lose weight) may help us curb this growing illness. But the jabs are expensive  and may not be a realistic solution for people who use the public health sector.

The country would need to weigh up whether the long-term health benefits from cutting obesity rates using these medicines will justify using money meant for preventing other diseases, such as through childhood vaccinations for example, Susan Goldstein, a public health researcher at Priceless SA told Mia Malan in the latest episode of Health Beat, Bhekisisa’s monthly TV programme. 

She explains why regulating the sale and advertising of highly processed foods (which can make us fat) and making it easier for people to buy healthy food at low prices are as crucial as finding medicines to fight obesity. 

Mia Malan (MM): What kind of burden does obesity put on the health system?

Susan Goldstein (SG): The burden on our public health system [was] between R30 billion and R36 billion [in 2020]. [In 2020, South Africa’s health budget was R55.5 billion. This means obesity-related issues could have taken about 60% of the budget. (The public health budget for 2023/24 is R60.1 billion)]. But the burden is also on individuals and families, because obesity [can lead to] diabetes, hypertension and cardiac [heart] disease. Then people end up not being able to work, [for example] because they had a stroke or an amputation from diabetes.

MM: South Africa implemented a sugar tax a few years ago. What is that?

SG: The sugary beverage tax is now called the Health Promotion Levy. Sugary beverages have no nutritional value, but drinking them [too often] can cause obesity. [A drink is] allowed [to have] four grams of sugar [per 100ml] before it is taxed. [For example, a 440ml bottle of Coca-Cola has about 47g of sugar, which works out to 10.6g per 100ml. This means there’s 6.6g taxable sugar per 100ml — and a total of 29g per bottle. For every gram above the exempted amount, the manufacturer has to pay 2.1c. So, in total this is 61c per bottle.]

MM: Is the tax working? 

SG: Yes and no. [Although] the government didn’t implement the full tax that was [originally] recommended, it is working to a certain extent. People have stopped buying as many sugary drinks. Poor people, especially, are doing better because they’re having less of these drinks.

MM: If we look at foods and snacks such as crisps and slap chips, should they be regulated? 

SG: Absolutely. We talk about [these as] ultra-processed foods. [This means they have added chemicals such as preservatives and artificial colourants and flavourants, to make them last long and so that they can be eaten straight from the packet.] Anything that comes in a box is usually processed in a way that makes us want to eat it, by adding sugar, salt and fat. [Too much of] these things are bad for us. We are encouraging people to rather buy and cook food or eat more [fresh] foods [because they are better for our health]. Ultra-processed foods have created a massive obesity problem in South Africa.

MM: How do we regulate them?

SG: The first way is to stop advertising these foods, especially to children. Children are advertised these foods all the time, not only on television and radio but also through things like [sponsored youth sport development], for example, or having cartoon characters on cereal, which has a lot of sugar. Banning advertising of these things to children is a start. However, doing this has been complicated, because the government will ask: how can you tell the good foods from the bad ones? Therefore, [public health experts] have asked for regulations that will label the packets of these particular foods, to show [which ones have] too much salt, sugar or fat. The idea is that anything with [such] a label cannot be marketed to a child.

MM: The health department has published draft regulations for this and we could have these labels from 2025. Is there evidence from other countries that this labelling works?

SG: Chile and Mexico have done it, and they show quite good evidence that it decreases the amount of packaged foods that people buy [which are often high in added fat, sugar or salt]. It does wear off somewhat after a while. But what is encouraging is that the producers reformulate foods in order to avoid the labelling, trying to decrease the amount of sugar or salt or fat. 

MM: In the South African situation a lot of these foods don’t come packaged. They’re sold in informal markets or on the street, like vetkoek [a deep-fried dumpling] or kotas [a hollowed-out quarter loaf of bread stuffed with fries]. How do you regulate that?

SG: You can’t. But what [we] should be doing is looking at improving the food system. We have a food system that’s dominated by big, multinational companies. What we need is a food system where people farm and sell their produce locally, and that produce will be healthier. We need to rethink how we have food in our society.

MM: The United Kingdom’s public health system recently recommended the weight loss injection Wegovy, which has the same ingredient (semaglutide) as Ozempic [the type 2 diabetes product that also leads to weight loss]. Should South Africa follow suit once Wegovy is registered here? 

SG: Obesity, like any illness, needs to be treated. People who are obese need help to decrease their weight. We know diets don’t work for some people in the long term. But the problem with it is the opportunity costs. For every [Wegovy] injection we buy, which is going to be very expensive, we will lose the chance [for example] to immunise children against measles or [offer] treatments against hypertension. We have to decide what is most important in our context.

MM: You’ve mentioned that we need to weigh up buying injections to treat weight loss against spending money on immunisations. But shouldn’t we also look at what we would save by preventing people from getting diabetes? 

SG: We need to look at the cost of this new injection and at equity. Who is going to be able to get it? I suspect it’s going to be only the wealthier people, and poorer people may end up not getting it. But we need to look at what the savings [in terms of the public health burden] would be against what the actual cost [of the injection] would be. 

MM: The Competition Commission has found that, in 2022, prices consumers paid for basic foods such as sunflower oil, brown bread and maize meal rose unjustifiably — increasing by more than if only the cost of making the products was taken into account. How should we regulate grocery stores so that ultra-processed foods aren’t cheaper than essential foods?

SG: At the moment, the food system and the whole supply chain are controlled by big [companies], from the farmer to the grocery store. We need to open this up and make sure food [supply] isn’t controlled [by only a few players]. We need to rethink the whole food system.

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.