Stellenbosch University: South Africa’s hunger problem is turning into a major health crisis

One in ten South Africans go hungry every day. As a result malnutrition levels are high. Malnutrition has three simultaneous dimensions: undernourishment, micronutrient deficiencies and over-nutrition.

These can manifest in stunting – being short for one’s age because of long-term undernutrition. In 2016 it was estimated to be 27% among South African children. This is high. Africa is currently the only continent where stunting rates continue to rise, with 27% of African children classified as stunted in 2018.

Another consequence of malnutrition is overweight and obesity. There has been a dramatic increase in both among adults in the country from 29.6% in 1998 to 39.8% in 2016 in women aged 15–24 years. In women aged 45–54 years it increased from 72% in 1998 to 81.9% in 2016. Obesity and overweight increased in men too.

The number of overweight children in South Africa has also grown. It increased from 10.6% in 2005 to 13.3% in 2016. This is more than twice the global prevalence of 5.6%.

Lifestyle diseases related to nutrition such as diabetes, heart disease, stroke and some cancers are among the top causes of death in the country. Together these conditions account for about 40% of total deaths.

The main reasons for the rise in obesity and overweight are urbanisation and the “nutrition transition” – the move away from typical traditional diets to a “western” diet and lifestyle. Changes in diet are toward less unrefined foods and carbohydrates, accompanied by an increase in animal protein, saturated fat, and sugar. This lifestyle pattern is also associated with lower energy expenditure.

Dietary and lifestyle changes can be seen in patterns of consumption of food, alcohol and tobacco, reduction in physical activity, and a shift to a diet high in sugar, salt and saturated fat.

Several environmental factors also affect what people eat. Highly palatable, energy dense food is increasingly available. And powerful food stimuli (like commercials, vending machines, school tuck shops and fast food) are present in urban environments.

Affordability also plays a big role in food choices, with profound health implications.

There are solutions. For example, efforts should be made to encourage people to eat pulses and legumes. They are affordable sources of good quality protein, carbohydrates, dietary fibre, vitamins and minerals and phytochemicals. They are low in energy, fat and salt. They can improve diet quality and protect against lifestyle diseases.

Why it’s a worry

A 2016 survey showed that the majority of women in all ethnic groups were overweight and obese. Also of concern is the increase in prevalence among younger women see above

These high proportions in are overweight and obese is of particular concern. Raised BMI is a major risk factor for non-communicable diseases such as cardiovascular disease and diabetes.

When it comes to children, the prevalence of zinc deficiency appears to be high in South African children, ranging from 39.3% to 47.8%. Zinc deficiency can lead to loss of appetite, growth retardation and impaired immune function.

A typical feature of the nutrition transition both maternal overweight and child malnutrition are found in the same household or community in South Africa.

In South Africa just over a quarter of the population are still food insecure despite sufficient food being produced at national level, according to the South African National Health and Nutrition Examination Survey.

The World Health Organisation has set nutrition targets which, if met, would reduce malnutrition in the country.

What are the solutions?

In 2003 the South African government introduced legislation for the mandatory fortification of bread flour and maize meal with vitamin A, zinc, iron, folic acid, thiamine, riboflavin, niacin and pyridoxine.

Since then, increased folic acid intake by pregnant women has resulted in a 30% decline in the incidence of neural tube defects in babies. Neural tube defects are birth defects of the brain, spine, or spinal cord. They happen in the first month of pregnancy, often before a woman even knows that she is pregnant. The two most common neural tube defects are spina bifida and anencephaly.

However, studies have shown that deficiencies of vitamin A, iron, and zinc still exist in adults.

There are other interventions that could, and should be taken, to ensure that the WHO nutrition targets are met by 2025.

The targets include achieving:

40% reduction in the number of children under-5 who are stunted;
50% reduction of anaemia in women of reproductive age;
30% reduction in low birth weight
no increase in childhood overweight.
South Africa is on track to meet some of them, but there is a need to accelerate the work. The following steps would make a major contribution:

Ensure there’s a focus on the first 1000 days of a baby’s life (from conception to 24 months). Receiving good nutrition in the womb and through early life is essential for a child’s future health. Research has shown that what a mother eats, her weight and her lifestyle habits can influence how the baby’s metabolism, immune system and organs develop. Poor nutrition during pregnancy and early life can lead to obesity, heart disease and stroke later on.
address micronutrient deficiency such as anaemia. One important step would be to screen and treat all pregnant women with anaemia.
reduce obesity. This particularly important when it comes to adolescent girls, to optimise nutrition later in life.
increase coverage of exclusive breastfeeding in the first six months. Breastfeeding protects against obesity and non-communicable diseases such as type-2 diabetes, cardiovascular disease and certain cancers later in life. In South Africa, the exclusive breastfeeding rate in infants under six months increased from 8% in 2003 to 32% in 2016. The WHO global nutrition target to be accomplished by the year 2025, is increasing exclusive breastfeeding among infants younger than 6 months to 50% by the year 2025.
provide supplements for those experiencing food insecurity through the Integrated Nutrition Programme. This was introduced in 1994 to address malnutrition in South Africa. Approximately 11% (6.5 million) of South Africa’s population is hungry and food insecure.
provide iron, folic acid and calcium supplements to all women at antenatal care sites and through community health workers.
food supplementation by the Integrated Nutrition Programme together with counselling of caregivers to reduce stunting of children under two years old in food insecure settings.
Regulate, monitor and strengthen the fortification of maize meal and wheat flour to ensure compliance with fortification standards.
Continued support of the National School Feeding Programme to address malnutrition in South Africa. Over 9 million children are fed under the scheme every day.
Introduce additional laws and taxes to curtail advertising and the distribution of unhealthy food and drinks. South Africa implemented legislation on salt in 2016 and sugar taxes in 2017.
Provide education on nutrition to counter the effect of urbanisation on obesity rates. People need guidance to make the best possible food choices with the money they have available. They should, for example, be encouraged to choose foods that are adequate in energy but are also relatively rich in nutrient content. The South African Food Based Dietary Guidelines were developed to provide nutrition education in South Africa.
Encourage plant-based diets.