Estimating the healthcare cost of overweight and obesity in South Africa

The association between the health promotion levy and employment in South Africa: an interrupted time series analysis

BACKGROUND

The production and consumption of sugar-sweetened beverages (SSBs) have been increasing over the past years, globally. However, there is overwhelming evidence linking SSBs to the rising prevalence in obesity and its comorbidities. In South Africa, the prevalence of overweight and obesity is high and is among the highest in Sub-Saharan Africa. In response to rising prevalence in obesity and its comorbidities, on 1 April 2018 the South African government introduced an SSB tax, known as the Health Promotion Levy (HPL). However, the levy has been opposed by the sugar industry, claiming that it leads to jobs losses. Against this backdrop, this study seeks to investigate the association between the HPL and employment in the sugar industry.

METHODS

We employed single-group interrupted time series analyses using the Quarterly Labour Force Survey data from Statistics South Africa.

RESULTS

Our results show that the HPL has not been associated with job losses (or generation) in the sugar-related industries in South Africa. These findings are consistent with the findings on the effects of SSB taxes on employment in other jurisdictions.

CONCLUSIONS

Considering that the HPL does not impede employment, and the overwhelming evidence on the effectiveness of SSB taxes, together with the relatively low tax burden, it is imperative that the government raises the HPL from the current 8% of the retail price to the WHO-recommended 20% threshold. The government should also consider expanding the HPL to fruit juices. Such strategies are important in encouraging people to reduce the intake of SSBs, while enabling the government to raise additional revenue for the fiscus.

Unraveling the Causal Relationship Between Non-Communicable Diseases, Obesity, and Health Expenditure: Insights from the Toda-Yamamoto Approach

BACKGROUND/OBJECTIVES

Understanding the relationship between non-communicable diseases (NCDs), obesity, and health expenditure is crucial for developing effective public health policies, particularly in light of the rising global burden of NCDs and obesity. Therefore, this study aimed to investigate the causal relationships between NCDs, obesity, and health expenditure in Turkiye.

METHODS

Data were collected from the World Health Organization and Our World in Data. Time series econometric analysis was performed using the Toda-Yamamoto causality approach. A model was designed to regularly capture causal relationships to ensure robust and consistent findings.

RESULTS

The analysis revealed four significant results. First, a causal relationship was observed between obesity and the prevalence of NCDs, indicating that higher obesity rates lead to an increase in NCDs within the population. Second, obesity had a direct impact on health expenditures, as rising obesity levels drove up healthcare costs. Third, the burden of NCDs contributed to increased health expenditure. Finally, the combined effect of obesity and NCDs on health expenditure was statistically significant at the 0.05 level.

CONCLUSIONS

These results highlight the need for policymakers to develop more effective strategies to address both obesity and NCDs. Recommended policies include the implementation of public health programs aimed at preventing obesity, strengthening early diagnosis and treatment methods, and increasing awareness campaigns focused on NCDs. These measures would be crucial steps in improving public health and controlling healthcare expenditures.

Modelling the potential impact of a tax on fruit juice in South Africa: implications for the primary prevention of type 2 diabetes and health financing

BACKGROUND

South Africa is experiencing a persistent growth in non-communicable diseases. Diabetes is among the top ten causes of mortality, especially among women, which is partly driven by high levels of added sugar consumption and obesity. To reduce obesity rates and the incidence of diabetes, South Africa introduced a tax on sugar sweetened beverages (also known as the Health Promotion Levy (HPL)) in 2018. The tax is applicable to sugar-sweetened beverages but excludes 100% fruit juice. The government is currently considering extending the tax to include fruit juices. This study models the potential health and economic impact of taxing fruit juices at 20% of the retail price of one liter.

METHODS

To analyze the distributional impact of the tax, this study uses extended cost-effectiveness analysis methodology. Data on price elasticities, healthcare cost, income, fruit juice consumption were sourced from the literature and representative national surveys. The potential impact of the tax on diabetes incidence, prevalence, mortality, and financial benefits were estimated for each income group (lowest, quintile 1 to highest, quintile 5).

FINDINGS

We estimate that a 20% tax on fruit juice would avert 156,640 incident cases of type 2 diabetes mellitus over 20 years, with most disease averted occurring among the first- and fifth-income groups. Averted deaths from diabetes would average 2,000 deaths per quintile (for quintiles 1 to 4) and about 2,800 in quintile 5. The improved health resulting from averted incidence and deaths will reduce overall healthcare expenditure by R7.5 billion over 20 years, of which R2.3 billion will occur in the fifth quintile. The South African government will also save about R300 million in subsidizing diabetes-related healthcare cost as a result of prevention; and would raise R8.6 billion in tax revenues per annum. Out-of-pocket expenditure savings will be R303 million and a financial risk protection (money-metric value of insurance) of R4.6 billion over the 20-year period.

CONCLUSION

We conclude that an HPL that significantly raises the retail price of fruit juices would reduce consumption and diabetes-related morbidity and mortality. The tax will also provide significant financial benefits in the form of reduced healthcare costs for both government and households as well as providing financial risk protection to individuals. Health taxes are win-win policies that improve population health and generate revenue for governments to fund public health services delivery and thus improve overall health financing activities of the government. Therefore, population level disease prevention measures such as health taxes are important for achieving universal health coverage.

Pregnant women's dietary patterns and knowledge of gestational weight gain: A cross-sectional study

OBJECTIVE

Excess gestational weight gain (GWG) is a risk factor for various unfavorable maternal and neonatal outcomes that may be preventable. Maintaining a healthy lifestyle while pregnant can help prevent uncontrollable weight gain. The aim of this study was to assess pregnant women's knowledge on weight, GWG, diet, and knowledge of obesity-related complications among women who seek care at our semi-urban, regional setting.

METHODS

A prospective observational study was conducted at the prenatal clinic at Kalafong Academic Hospital. Prospective participants completed a questionnaire on their perception of GWG, attitudes toward GWG, knowledge of GWG, associated complications of obesity, and food choices. Data analysis was performed using SAS version 9.4.

RESULTS

The majority of the 500 individuals were overweight or obese prior to pregnancy. By the end of the third trimester, this increased by 10.1% (n = 420; 86.1%). Nearly half (n = 240; 48.78%) of the overweight and obese women underestimated their weight. Only 26.53% (n = 26) of women who checked their body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) gained weight according to recommendations. However, less than half (n = 96; 30.5%) gained weight within the recommended range, despite the fact that the majority of them (n = 315; 64%) were aware of the harmful effects of obesity on the cardiovascular system and the effects of high calories on weight gain (n = 321; 65%).

CONCLUSION

Despite basic knowledge of the impact of high-caloric intake on weight gain and cardiovascular complications, less than half of the study population gained weight within the recommended range.

Establishment of a novel obesity mouse model: the induction of intestinal microbiota dysbiosis

To establish and evaluate an intestinal microbiota dysbiosis-induced obesity mouse model. 50 C57BL/6 J male healthy mice were randomly divided into an obesity model group and the control group. The body weight, body length, and Lee's index of the two groups of mice at week 1 and week 10 were compared. Serum glucose (GLU), total cholesterol (TC) and triglyceride (TG) were measured by enzyme-labeled colorimetric methods. Illumina HiSeq 16S rDNA high-throughput sequencing technology was used to characterize intestinal microbiota in feces. The success rate of model establishment in obese mice was 52%. The body weight, body length, Lee's index, and abdominal fat (wet weight) in the obese model group were all higher than those in the control group, and the differences were statistically significant (P < 0.01). Serum GLU and TC levels in the obesity model group were higher than those in the control group (P < 0.05), and there was no difference in TG levels between the two groups (P > 0.05). The control group contained more abundant intestinal microbiota phyla and genera than did the obesity model group; the differences between the two groups were significant (FDR ≤ 0.05, P ≤ 0.05). Intestinal microbiota dysbiosis can be used to generate an obesity model in mice.

Potential health and economic impact of achieving Kenya's overweight and obesity reduction target: a modelling study

Introduction

Kenya has adopted the WHO target of halting the rise of overweight, including obesity, by 2025. This paper assesses the potential impact of achieving the set target on health, healthcare cost and productivity.

Methods

We used a proportional multistate life table model (Kenya Obesity Model) to simulate the 2019 population of Kenya over their lifetime. We compared a scenario in which body mass index (BMI) distributions stabilise in 2025 against one whose BMI distributions stabilise in 2044, and quantified changes in disease-specific health outcomes, healthcare costs and productivity. We searched the literature to identify the best estimates of the total and disease-specific healthcare costs in Kenya. We used the Human Capital Approach to estimate productivity gains.

Results

If BMI distributions stabilised in 2025, an estimated 6.8 million health-adjusted life years (HALYs) (95% uncertainty interval (UI) 5.8-7.9 million) would be saved over the lifetime of the 2019 Kenyan population (135 HALYs per 1000 persons). A total of US$755 million in body mass-related healthcare costs could be saved by 2044 (US$15 per capita). For context, this equates to 16% of Kenya's annual healthcare expenditure. Over the lifetime, ~US$3 billion healthcare costs could be saved (US$62 per capita). By 2044, the total productivity gain resulting from a reduction in high BMI-related mortality and morbidity (combined) was ~US$5.8 billion (~US$237 per capita).

Conclusion

Achieving Kenya's overweight and obesity reduction target could improve health outcomes and also yield substantial healthcare cost savings and productivity gains.

Comparison of low-dose maximal-intent versus controlled-tempo resistance training on quality-of-life, functional capacity, and strength in untrained healthy adults: a comparative effectiveness study

Lack of physical activity is a global issue for adults that can lead to sedentary behaviour and a higher prevalence of health complications and chronic diseases, resulting in reduced quality-of-life (QoL) and functional capacity (FC). A potential strategy to mitigate this inactivity is low-dose resistance training (RT); however, physiological, and psychological responses are limited in evidence. Twenty untrained participants aged 30-60 years old (mean ± SD age 42 ± 7 years, mass 77 ± 13 kg, stature 166 ± 8 cm; 18 females and two males) were recruited and randomly assigned to maximal velocity-intent (MI, n = 10) or controlled-tempo (CT, n = 10) RT according to CONsolidated Standards of Reporting Trials (CONSORT) guidelines. Participants attended one training session per week for 6 weeks, consisting of five sets of five repetitions at 60% of one-repetition maximum (1RM) leg press. The interventions differed only during the concentric phase, with MI group pushing with maximal intent, and CT group pushing in a time-controlled manner (3 s). Outcome measures assessed pre- and post-RT included body mass, body mass index (BMI), strength-to-mass ratio, bipedal balance, 6-minute walk test (6MWT), 30-second sit-to-stand (30s-STS), timed up and go (TUG), and leg press 1RM. Time effects were observed for all demographics and FC-related outcomes, such as identical reductions in mass and BMI (- 2%), improvements in strength-to-mass ratio (25%) leg press 1RM (22%), 6MWT (3%), and 30s-STS (14%), as well as a 9% improvement in both TUG-clockwise and anticlockwise. Results show low-dose once-weekly RT is effective in improving QoL, FC, and strength in untrained healthy adults, regardless of modality. Positive responses from participants suggest an increased likelihood of consistent participation for low-dose once-weekly RT over more intense modalities. Retrospective ClinicalTrials.gov ID (TRN): NCT06107855, 24/10/2023.

Weight Gain After HIV Therapy Initiation: Pathophysiology and Implications

Rapid advances in the potency, safety, and availability of modern HIV antiretroviral therapy (ART) have yielded a near-normal life expectancy for most people living with HIV (PLWH). Ironically, considering the history of HIV/AIDS (initially called "slim disease" because of associated weight loss), the latest dilemma faced by many people starting HIV therapy is weight gain and obesity, particularly Black people, women, and those who commenced treatment with advanced immunodeficiency. We review the pathophysiology and implications of weight gain among PLWH on ART and discuss why this phenomenon was recognized only recently, despite the availability of effective therapy for nearly 30 years. We comprehensively explore the theories of the causes, from initial speculation that weight gain was simply a return to health for people recovering from wasting to comparative effects of newer regimens vs prior toxic agents, to direct effects of agents on mitochondrial function. We then discuss the implications of weight gain on modern ART, particularly concomitant effects on lipids, glucose metabolism, and inflammatory markers. Finally, we discuss intervention options for PLWH and obesity, from the limitations of switching ART regimens or specific agents within regimens, weight-gain mitigation strategies, and potential hope in access to emerging antiobesity agents, which are yet to be evaluated in this population.

Economic costs of obesity: a systematic review

INTRODUCTION

Obesity is a growing public health problem leading to substantial economic impact. This study aimed to summarize the economic impact of obesity and to critically analyze the methods used in the cost-of-illness (COI) studies on obesity.

METHODS

We conducted systematic search in PubMed and Scopus from September 1, 2016, to July 22, 2022. Original COI studies estimating the economic cost of obesity and/or overweight in at least one country, published in English were included. To facilitate the comparison of estimates across countries, we converted the cost estimates of different years to 2022 purchasing power parity (PPP) values using each country's consumer price index (CPI) and PPP conversion rate.

RESULTS

Nineteen studies were included. All studies employed a prevalence-based approach using Population Attributable Fraction (PAF) methodology. About half of the included studies (53%) were conducted in high-income countries while the others (47%) were conducted in middle-income countries. The economic burden of obesity ranged between PPP 15 million in Brazil to PPP 126 billion in the USA, in the year 2022. Direct medical costs accounted for 0.7% to 17.8% of the health system expenditure. Furthermore, the total costs of obesity ranged from 0.05% to 2.42% of the country's gross domestic product (GDP). Of the seven studies that estimated both direct and indirect costs, indirect costs accounted for the largest portion of five studies. Nevertheless, a variety in methodology across studies was identified. The number of co-morbidities included in the analysis varied across studies.

CONCLUSIONS

Although there was a variety of methodologies across studies, consistent evidence indicated that the economic burden of obesity was substantial. Obesity prevention and control should be a public health priority, especially among countries with high prevalence of obesity.

Roles of Marine Macroalgae or Seaweeds and Their Bioactive Compounds in Combating Overweight, Obesity and Diabetes: A Comprehensive Review

Obesity and diabetes are matters of serious concern in the health sector due to their rapid increase in prevalence over the last three decades. Obesity is a severe metabolic problem that results in energy imbalance that is persistent over a long period of time, and it is characterized by insulin resistance, suggesting a strong association with type 2 diabetes (T2D). The available therapies for these diseases have side effects and some still need to be approved by the Food and Drug Administration (FDA), and they are expensive for underdeveloped countries. Hence, the need for natural anti-obesity and anti-diabetic drugs has increased in recent years due to their lower costs and having virtually no or negligible side effects. This review thoroughly examined the anti-obesity and anti-diabetic effects of various marine macroalgae or seaweeds and their bioactive compounds in different experimental settings. According to the findings of this review, seaweeds and their bioactive compounds have been shown to have strong potential to alleviate obesity and diabetes in both in vitro and in vivo or animal-model studies. However, the number of clinical trials in this regard is limited. Hence, further studies investigating the effects of marine algal extracts and their bioactive compounds in clinical settings are required for developing anti-obesity and anti-diabetic medicines with better efficacy but lower or no side effects.

Beverage industry's advertising expenditures and airtimes in South Africa from 2013 to 2019 target children and families

With the growing burden of non-communicable diseases (NCDs), countries across the globe are finding ways to reduce the consumption of ultra-processed food and drinks including sugar-sweetened beverages (SSBs). South Africa implemented a health promotion levy (HPL) in April 2018 as one strategy to reduce sugar intake. Such efforts are frequently countered or mitigated by industry action in various ways, including through marketing and advertising strategies. To better understand trends in the extent of advertising, this paper analyses advertising expenditures and exposure of children to SSB advertisements in South Africa. Using Nielsen's monthly data on advertising expenditure before and after the introduction of the HPL, for the period January 2013 to April 2019, the results show that manufacturers spent ZAR 3683 million to advertise their products. Advertising expenditure on carbonated drinks accounted for over 60% (ZAR 2220 million) of the total expenditure on SSBs. The results also show that companies spend less in advertising powdered SSBs (an average of ZAR 0.05 million per month). Based on expenditure patterns, television (TV) was the preferred medium of advertisements, with companies prioritizing what is often considered children's and family viewing time. Urgent mandatory regulations are needed to prevent child-directed marketing.

Estimation and predictors of direct hospitalisation expenses and in-hospital mortality for patients who had a stroke in a low-middle income country: evidence from a nationwide cross-sectional study in Iranian hospitals

OBJECTIVE

Stroke is the second most prevalent cardiovascular disease in Iran. This study investigates the estimation and predictors of hospitalisation expenses and in-hospital mortality for patients who had a stroke in Iranian hospitals.

SETTING

Patients who had a stroke in Iran between 2019 and 2020 were identified through the data collected from the Iran Health Insurance Organization and the Ministry of Health and Medical Education. This study is the first to conduct a pervasive, nationwide investigation.

DESIGN

This is a cross-sectional, prevalence-based study. Generalised linear models and a multiple logistic regression model were used to determine the predictors of hospitalisation expenses and in-hospital mortality for patients who had a stroke.

PARTICIPANTS

A total of 19 150 patients suffering from stroke were studied.

RESULTS

Mean hospitalisation expenses per patient who had a stroke in Iran amounted to US$590.91±974.44 (mean±SD). Mean daily hospitalisation expenses per patient who had a stroke were US$55.18±37.89. The in-hospital mortality for patients who had a stroke was 18.80%. Younger people (aged ≤49 years) had significantly higher expenses than older patients. The OR of in-hospital mortality in haemorrhagic stroke was significantly higher by 1.539 times (95% CI, 1.401 to 1.691) compared with ischaemic and unspecified strokes. Compared with patients covered by the rural fund, patients covered by Iranian health insurance had significantly higher costs by 1.14 times (95% CI, 1.186 to 1.097) and 1.319 times (95% CI, 1.099 to 1.582) higher mortality. There were also significant geographical variations in patients who had a stroke's expenses and mortality rates.

CONCLUSION

Applying cost-effective stroke prevention strategies among the younger population (≤49 years old) is strongly recommended. Migration to universal health insurance can effectively reduce the inequality gap among all insured patients.