Call for action to address malnutrition in all its forms

The nutrition challenges facing South Africa are complex and underpinned by historical and current inequalities. Undernutrition co-exists with the rising incidence of overweight and obesity (frequently in the same household) and resultant non-communicable diseases (NCDs) such as type 2 diabetes mellitus and hypertension. The availability and affordability of highly processed foods are considered  important drivers of poor nutrition (1). On the other hand, dietary patterns characterised by higher intakes of unprocessed foods are linked to more positive health outcomes (2).

In South Africa more than a quarter of the female adult population is overweight and more than a third obese, with the highest prevalence (42%) among urban women (3–6). Moreover, it is estimated that 269,000 NCD related deaths occur in the country annually (7). Obesity and NCDs are regarded as major risk factors for Covid-19 hospital admissions and complications (8). While the prevalence of overweight among children is increasing (13% of children under the age of five years) and of concern, child undernutrition persists, with stunting rates of children under 5 years of age (an indicator for chronic undernutrition and lack of food) showing no reduction (27% stunted children <5 years in 2016), mostly affecting poor and rural communities (6,9,10). In this context it is concerning that South Africa has a lower ratio of nutrition professionals per 100 000 people (5.4 professionals) than other African countries (8.4 professionals) (11,12).

The United Nations recognises the threat of the Covid-19 pandemic to food security and nutrition of millions of people and warns of a looming global food emergency unless immediate coordinated action is taken (13). Nationally, efforts to contain the spread of Covid-19 have resulted in worsening of food shortages, nutrition deficits, and an interruption of social and other nutrition support services on which the most marginalised groups of our country rely (14). The lockdown also poses challenges with regard to the accessibility and affordability of healthy food which has increased the chances of food secure households becoming food insecure.

While hunger has been reduced and food access in South Africa has improved over the past 15 years, 1.7 million households still experienced hunger in 2017, and the pace of addressing inadequate food access has been too slow to achieve the goal of zero hunger by 2030 (15). Early indications now suggest a rapid rise in hunger prevalence since the lockdown was imposed, with up to 24% of residents not having money to buy food (16). In addition, in this context, food prices have increased by as much as 30% over the past two months, further adding to the financial strain on households (17). It is anticipated that maternal and child mortality is likely to increase directly and indirectly as a result of the Covid-19 outbreak (18).

Tackling malnutrition in all its forms requires political commitment and actions across multiple sectors that goes beyond the Covid-19 pandemic. We are therefore calling on government to:

• Prioritise nutrition on policy agendas related to health and social security, including a regulatory framework to support access to healthy and affordable foods.
  
• Provide strategic direction and ensure coordinated and aligned programming to address food and nutrition security, in collaboration with other sectors including civil society organisations.
  
• Coordinate an adequate and targeted food and social relief approach, prioritising the most vulnerable and needy for short term mitigation.
  
• Focus on delivery of preventive nutrition services as part of the transformation and strengthening of the health system, integrating nutrition into universal health coverage as an indispensable prerequisite for longer term mitigation.
  
• Prioritise the challenges faced by specific populations, including the elderly, women (especially women of childbearing age), children and those with pre-existing medical conditions (most notably HIV/AIDS, TB and NCDs).
  
• Implement well-funded coordinated strategies to actively address the main drivers of malnutrition; paying attention to food, nutrition and health, backed up by responsive social protection mechanisms.
  
• Improve access to quality nutrition care through investment in human resources to increase the number of qualified nutrition professionals as well as education opportunities for other cadres of workers that provide nutrition services in primary care settings.
  
• Promote nutrition education of the public through targeted nutrition messaging and communication campaigns.

Contact details:

Nutrition Society South Africa
President: Prof Corinna Walsh
www.nutritionsociety.co.za

Association for Dietetics in South Africa
President: Dr Christine Taljaard-Krugell

http://www.adsa.org.za

Dietetics-Nutrition is a Profession
President: Mr Tshilidzi Nageli
moc.liamg@as.gropid
az.oc.aledahk@tilegan

References:

1. Popkin BM, Adair LS, Ng SW. Now and then: The global nutrition transition: The pandemic of obesity in developing countries. Nutr Rev. 2012 Jan;70(1):3–21.

2. Wrottesley S V., Pisa PT, Norris SA. The influence of maternal dietary patterns on body mass index and gestational weight gain in urban black South African women. Nutrients. 2017 Jul;9(7):e732.

3. Cois A, Day C. Obesity trends and risk factors in the South African adult population. BMC Obes. 2015;2(1):1–10.

4. Shisana O, Labadarios D, Rehle T, Simbayi L, Zuma K, Dhansay A, et al. The South African National Health and Nutrition Examination Survey, 2012 (SANHANES-1). Cape Town; 2014.

5. World Health Organization. Global status report on noncommunicable diseases 2014. Vol. 53, World Health Organization. Geneva; 2014.

6. South African National Department of Health. South Africa Demographic Health Survey 2016. Pretoria: Department of Health, South Africa; Statistics South Africa; South African Medical Research Council; 2019.

7. Statistics South Africa. Mid-year population estimates 2018. 2019.

8. Kassir R. Risk of Covid-19 for patients with obesity. Obes Rev. 2020;21:313034.

9. Said-Mohamed R, Micklesfield LK, Pettifor JM, Norris SA. Has the prevalence of stunting in South African children changed in 40 years? A systematic review. BMC Public Health. 2015;15(1):1–10.

10. Shung-King M, Lake L, Sanders D, Hendricks M. Child and adolescent health Leave no one behind. 2019.

11. World Health Organization. Nutrition Landscape Information System [Internet]. Available from: https://apps.who.int/nutrition/landscape/report.aspx?iso=ZAF&rid=1620&goButton=Go

12. World Health Organization. Global nutrition policy review 2016-2017 - country progress in creating enabling poilcy environments. Geneva; 2018.

13. United Nations. Policy Brief: The Impact of Covid-19 on Food Security and Nutrition, June 2020. United Nations; 2020.

14. Vermeulen H, Muller C, Schonfeldt HC. Food aid parcels in South Africa could do with a better nutritional balance [Internet]. The Conversation. 2020. Available from: https://theconversation.com/food-aid-parcels-in-south-africa-could-do-with-a-better-nutritional-balance-136417

15. Statistics South Africa. Towards measuring the extent of food security in South Africa. Pretoria: Statistics South Africa; 2019.

16. Engaging communities regarding their knowledge, beliefs, practices and attitudes in response to the Covid-19 outbreak in South Africa. 2020.

17. Abrahams M, Smith J. Covid-19: Families living on low incomes may be spending 30% more on food than they did two months ago. Pietermaritzburg; 2020.

18. Roberton T, Carter ED, Chou VB, Stegmuller AR, Jackson BD, Tam Y, et al. Early estimates of the indirect effects of the Covid-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study. Lancet Glob Heal. 2020 May;e30229.