Strategy for the Prevention and Control of Obesity in South Africa 2015-2020

Objectives

South Africa’s strategy seeks to enable a long and healthy life by empowering people to make healthy choices through environments that promote healthy eating and physical activity, preventing and controlling overweight and obesity as major risk factors for non-communicable diseases.[1]It aims to improve quality of life, reduce obesity-related ill health, stigma and marginalisation, and strengthen people’s capacity to make informed choices.[2][3]The strategy adopts a population-based, life-course framework focused on policy, environmental and contextual change rather than relying only on individual behaviour or isolated interventions.[4][5]

• Achieve obesity-prevalence targets of no increase by 2016, a 3% reduction across all age groups by 2017, and a 10% reduction by 2020.[1]
• Establish an institutional framework for inter-sectoral engagement and leadership for the national overweight and obesity response.[5][1]
• Improve the availability, affordability and accessibility of healthy food choices, including fruit and vegetables, healthier school and workplace food environments, nutrition labelling, food standards, responsible marketing and fiscal measures affecting sugar-sweetened beverages.[1][6][7]
• Increase participation in physical activity through safe active transport, walkable communities, recreational facilities, school physical education, community activity groups and physical-activity-friendly workplaces.[8][9]
• Prevent obesity from pregnancy through early childhood and age 12 by improving maternal nutrition, exclusive breastfeeding, complementary feeding, child growth monitoring, healthy weight gain and early childhood development services.[5][9][10]
• Communicate with, educate and mobilise communities, implementers and stakeholders on healthy eating, regular physical activity, obesity risks and access to weight-status services.[5][11]
• Establish surveillance and strengthen monitoring, evaluation, implementation research and evidence-based policy development.[5][12][13]

The strategy aligns with the Strategic Plan for the Prevention and Control of Non-Communicable Diseases 2013–17, the Health Promotion Policy and Strategy, relevant World Health Organization strategies and the initiative to end childhood obesity.[2]It recognises that obesity is shaped by poverty, unequal wealth distribution, education, urbanisation, the built environment, unhealthy food environments, limited physical activity and inappropriate early-childhood feeding.[14][15][16]It also identifies gendered risks, including lower physical activity among women, greater obesity prevalence and disproportionate caregiving burdens.[17][18]

Implementation

Implementation is designed as a phased, systems-based, multi-sectoral and multidisciplinary effort across national, provincial and local levels, requiring leadership, resources and joint ownership from government and wider society.[18][5][1]Delivery combines regulatory and fiscal measures, supportive environments, health-service interventions, settings-based programmes and public mobilisation across healthcare facilities, early childhood development centres, schools, workplaces and communities.[5][19][1]

• Coordinate action through a national inter-sectoral structure or forum with leadership and ownership for research priorities, intervention implementation, evaluation and outcome monitoring.[5][13]
• Engage the Department of Health, Department of Basic Education, Department of Sports and Recreation, Transport, Public Service and Administration, municipalities, other government departments, civil society, non-governmental organisations, academia, research institutions, international organisations, industry and the private sector.[20][17][18][6]
• Develop sectoral micro-plans with specific targets and incorporate obesity prevention and control into inter-sectoral and departmental plans, with participating departments allocating and advocating for resources.[1][6]
• Strengthen schools through the Care and Support Teaching and Learning Programme, Health Promotion, Sport in Education, the National School Nutrition Programme, curriculum and co-curricular activities, physical education, Life Skills, Life Orientation and school meals.[20]
• Improve healthier food environments through legislation, nutritional standards for sugar and fat in ultra-processed foods, advertising codes, front-of-pack and restaurant labelling, food gardens, local markets, dietary guidelines and school and workplace nutrition initiatives.[6][7]
• Promote active travel and physical activity by improving public transport, maintaining safe and well-lit footpaths and pavements, expanding recreational facilities, enabling school-community access arrangements and embedding activity in employee wellness programmes.[8][9]
• Integrate prevention into maternal and child health services, including breastfeeding support, complementary-feeding guidance, growth monitoring and healthy eating and activity messages in early childhood development policies and materials.[5][9][10]
• Use media campaigns, champions, community dialogues, consumer and social-activism groups, and public information to build demand for healthier lifestyles and services.[11]
• Expand screening, body mass index assessment, counselling and referral systems through healthcare settings, private-sector campaigns, employers and wellness services; assess body mass index alongside waist circumference where appropriate.[3][12]

The strategy envisages a comprehensive intervention package in which fiscal measures, restrictions on food marketing to children, food labelling, industry reformulation, worksite and school interventions, mass media campaigns and primary-care counselling reinforce one another.[19][1]Fiscal measures, food advertising regulation, food labelling, worksite interventions, mass media campaigns, school-based interventions and physician counselling were assessed in 2010 South African rand, with fiscal measures identified as the most cost-effective intervention.[19]No overall implementation budget, funding source, financing plan or quantified funding gap is specified.[1][12][13]

Monitoring should use an obesity surveillance system covering exposure to unhealthy lifestyles and risk factors, health outcomes, and health-system capacity, access and intervention quality.[13]It should build on the District Health Information System, Statistics South Africa, the South African Demographic and Health Survey, the South African National Health and Nutrition Examination Survey, targeted surveys and research.[13]Key measures include obesity trends, screening and referral access, healthy-food and physical-activity implementation indicators, breastfeeding and complementary-feeding practices, media reach, departmental initiatives, research outputs and establishment of monitoring frameworks.[6][7][8][9][10][11][12]Regular reporting through an inter-sectoral forum, a national repository of South African interventions, and health-systems and implementation research are intended to identify barriers, assess impact and scale effective context-specific interventions.[12][13]

Monitoring & Evaluation

The strategy establishes surveillance, monitoring, evaluation and research as a core goal, linking measurement to implementation oversight, evidence generation and continuous improvement of obesity-prevention interventions.[5][1][12]It combines population-level outcome monitoring with tracking of risk factors, health-system response and delivery across sectors.[13]

• Establish a comprehensive obesity surveillance system covering exposure to unhealthy lifestyles and other risk factors; health outcomes including morbidity and cause-specific mortality; and health-system capacity, access and intervention quality.[13]
• Build surveillance on existing data sources, including the District Health Information System, Statistics South Africa, the South African Demographic and Health Survey, the South African National Health and Nutrition Examination Survey, specific surveys and research.[13]
• Monitor obesity and weight-related risk using body mass index and waist circumference, while interpreting body mass index in children against age- and sex-specific population reference data.[3]
• Use evidence from sources such as the National Income Dynamics Study, the 2012 South African National Health and Nutrition Examination Survey and the 2008 Youth Risk Behaviour Survey to understand obesity prevalence and related behaviours.[2]
• Track outcome targets to prevent any increase in obesity prevalence by 2016, achieve a 3% reduction across all age groups by 2017, and achieve a 10% reduction by 2020.[1]
• Develop and agree monitoring indicators and reporting tools with stakeholders, including national and provincial departments, the National Obesity Forum and academia.[12]
• Report regularly through an inter-sectoral forum using a tool that tracks activities across sectors.[13]
• Measure access to screening, body mass index assessment and counselling; obesity referrals; availability of monitoring and evaluation frameworks; obesity data and trends; development of an intervention repository; and peer-reviewed research outputs.[12]
• Track implementation of food-environment actions through measures such as establishment of an inter-sectoral structure, departmental resource allocation, adoption of sugar-related legislation, food and beverage compliance with nutritional standards, nutrition information in restaurants, healthy meal provision, healthier retail practices, labelling tools, fruit and vegetable consumption, school nutrition compliance and workplace initiatives.[6][7]
• Monitor physical-activity actions through the number of sub-districts with facilities, the proportion of people using active transport or participating in physical activity, learner participation, implementation of physical-activity guidelines and the number of orientation sessions.[8][9]
• Measure early-life prevention through exclusive breastfeeding rates at 14 weeks and six months, complementary-feeding practices, childcare facilities in government departments, updated child-growth-monitoring materials and integration of healthy-eating messages into early-childhood-development policies and guidelines.[9][10]
• Evaluate intervention effectiveness using disability-adjusted life-years averted and the capacity of interventions to delay non-communicable disease onset.[19]
• Maintain a national repository of South African obesity interventions, communicate evidence-based information and implement a prioritised research agenda incorporating capacity building and knowledge transfer.[12]
• Undertake health-systems and implementation research to assess delivery, identify barriers, understand context-specific social determinants and inform the scale-up of effective interventions.[13]
• Use the World Health Organization framework as guidance for monitoring and evaluating implementation of key actions.[1]

The supplied material identifies broad monitoring functions, indicators and an inter-sectoral reporting mechanism, but does not specify indicator definitions, data-collection frequency, reporting schedules, evaluation designs, public disclosure requirements or formal sanctions for non-performance.[1][12][13]

Costing & Financing

The strategy recognises obesity as an economic and health-system burden, but does not provide a national implementation budget, funding gap, costed workplan, financing source or resource-mobilisation plan.[15][12][13]It requires participating departments to advocate for and allocate resources through their plans, alongside leadership and commitment from government, private-sector and civil-society stakeholders.[1][6]

• Recognise direct and indirect costs from healthcare expenditure, lost productivity, disability and economic disenfranchisement, alongside additional pressure from obesity-related diseases on health systems.[15]
• Note the estimated global economic impact of obesity of approximately US$2.0 trillion, equivalent to 2.8% of global gross domestic product.[15]
• Recognise estimates that high body mass indices drive 2% to 7% of global healthcare spending and that obesity-related diseases account for up to 20% of healthcare spending.[15]
• Prioritise fiscal measures, including taxation of unhealthy foods and sugar-sweetened beverages, as part of a combined intervention package; a 20% sugar-sweetened beverage tax was modelled for its potential effect on obesity in South Africa.[16][19]
• Classify salt reduction, taxes on unhealthy foods and subsidies for fruit and vegetables as low-cost and very cost-effective, while classifying physician counselling as high-cost but very cost-effective.[19]
• Rank fiscal measures as the most cost-effective intervention in 2010 South African rand, followed by food advertising regulation; the assessment also includes food labelling, worksite interventions, mass media campaigns, school-based interventions and physician counselling.[19]
• Recognise that fiscal measures are cost-saving in low- and middle-income settings under the stated model assumptions, while restrictions on food advertising are associated with reduced obesity among young people.[19]
• Explore expansion of rebates for healthy food purchases, although no value, financing mechanism or implementation detail is provided.[11]

Financial and economic context includes poverty, financial pressures, volatile food and energy prices, food-security concerns and unequal access to healthier choices, but the supplied material does not quantify their budgetary implications.[17][18]