South Africa has a quadruple burden of disease, with high prevalence of HIV/AIDS and TB; high maternal and child mortality; high levels of violence and injuries; and a growing burden of non-communicable diseases (NCDs), according to the Council for Medical Schemes (CMS) discussion document, ‘Development of Low-Cost Benefit Options within the Medical Schemes Industry’.
Of note is the number of NCDs in the top 10 causes of deaths, which together account for approximately 23% of deaths.
In sub-Saharan Africa, the document states, South Africa has among the highest prevalence of obesity and corresponding NCDs, with increasing deaths from hypertensive disorders and diabetes. Socio-cultural, environmental and behavioral factors including socio-economic status are likely to explain this rapid epidemiological transition to increasing obesity and NCDs.
Conditions driving NCDS
At the Actuarial Society of South Africa (ASSA) Convention, key experts discussed the social and structural conditions driving NCDs.
“Perceptions of NCDs is that they are not infectious, yet highly social creatures would be susceptible to social epidemics; NCDs are due to ageing, yet 44% are premature deaths, 85% of that in low and middle-income countries; and last but not least, is that it is an urban/wealth problem, yet the Eastern Cape Karoo has a high prevalence,” said Yageshree Moodley, Consulting Actuary.
“Over half of all deaths are from NCDs, with high proportion of women dying from diabetes. Poorer black men are at high risk with worst access to/seeking of care,” emphasised Moodley.
Breaking this cycle
“According to the National Income Dynamics Study (NiDS), Central Karoo has a high age-standardised hypertension prevalence. Yet, you would think an area like this would be low in disease because it is an open natural region, with clean air etc. A place where decoctions are made of plants for the treatment of colds and coughs etc,” said Beth Vale, an Independent Researcher and Writer.
“The transition from infectious to non-infectious diseases is more like a collision. This is not just about an individual’s willpower or geographical location. NCDs are forcing us to reevaluate economic externalities and socio-political constructs,” added Vale.
Poverty drives and is driven by NCDs, but financial protection from high medical costs can break this cycle; price policies and taxation can reduce NCD risk factors and inequalities; and investment in NCD control results in increased economic growth, according to the Lancet Taskforce on NCDs and economics, 2018.
Health and disease
“Sugar consumption has steadily increased over the past 200 years. High carbohydrate intakes increase glucose levels and insulin levels in humans. Glucose is converted to fats and raises triglyceride levels and fatty liver develops. Through multiple pathways (including genetic predispositions) the fatty liver overproduces glucose, which is initially suppressed by increasing insulin levels, (shown by insulin responses to glucose challenges), but this response decreases with time. However, as glucose levels rise damage to β-cells starts to play a role and insulin levels either in relative terms or absolute levels reduce. Diabetes then ensues,” said Dr Neville Wellington, a Cape Town based family practitioner who specialises in diabetes management.
“Logically we need to reduce the intake of excessive carbohydrates. Reversal studies from bariatric surgery and low-calorie diets confirm that liver fat reduces, and pancreatic islet cell fat reduces, glucose levels improve and insulin responses improve. Many low carbohydrate studies have also shown this response and recent Virta Health studies in patients with diabetes have confirmed significant benefits,” added Dr Wellington.
The modern industrial diet
“The modern industrial diet is likely to lead to full blown insulin resistance resulting in obesity, type 2 diabetes, hypertension, coronary heart disease, dementia and cancer. So, what should we be eating? Whole food fats, non-starchy green vegetables, low sugar fruits, high fat dairy etc. We should be avoiding bread, pastas, sugar, milk etc,” said Professor Tim Noakes, a scientist.
“Government and private sector should unite to make nutritious, sugar free, carb free foods widely available. Critical is widespread behavior changes through consistent messaging, diabetic self-management, education and support and creating an enabling environment,” added Noakes.
A “high road” scenario for diabetes in South Africa
“The vision is that everyone will know their status when it comes to insulin resistance in exactly the same way that everyone will know their HIV status. Treating doctors, specialists and dieticians will be aligned in dietary advice given to those with insulin resistance facilitated by organisations like Nutrition Network,” said Noakes.
“The prevalence of chronic disease (measured by those registered for chronic medication) will reduce – not only for diabetes but for all other conditions relating to insulin resistance. Society and big business will support those with insulin resistance by making sugar and carbohydrates less ubiquitous. Diabetic admissions will be substantially reduced through proper management of the disease,” added Noakes.
“A Low Carbohydrate High Fat (LCHF) diet will be a recognized, generally accepted treatment regime in South Africa, as recognized by the ADA guidelines. The National Health Insurance fund and medical schemes will facilitate widespread behavior change through Alternative Reimbursement Models and Active Disease Risk Management,” said Noakes.
“How involved should the Actuarial Profession be in diabetes and treatment like LCHF? We need to be involved to some extent to design products, price and reserve correctly. Actuaries should be influencing behavior change in product design/modelling the epidemic. Actuaries should be actively campaigning government to promote healthy eating,” said Sarah Bennett, a health care actuary.
Writer’s Thoughts:
We can only hope that LCHF becomes a mainstream dietary requirement. As Noakes said, the government and private sector should unite to make nutritious, sugar free, carb free foods widely available. Behaviour change and education is also critical. Do you agree? If you have any questions please comment below, interact with us on Twitter at @fanews_online or email me - myra@fanews.co.za.
Get the latest issue of FAnews
Comment on this post