The triple burden of malnutrition that haunts South Africa and stunts development

I find an email from a big food company in my inbox. The subject line reads: “Eat Less, Move More, Live Better” I click on the email to read it in full.

“Dear Health Professional”, it starts. It then goes on to describe how nearly 20 million adults in South Africa are struggling with being overweight and obese, stating that, in fact, we are one of the countries with the highest obesity occurrences in the world (according to the World Obesity Federation we rank 25th for females and 131st for males). “A concerning fact,” they write, “that can partly be attributed to cultural misperceptions and uninformed lifestyle decisions”.

The second paragraph goes on to say how they would now like to share information “to help patients understand the relationship between obesity and the choices they make every day”. And that last part — the word “choices” — unsettles me.

The word “choice” implies the ability to select between two or more options. It involves decision-making where a person typically has the freedom, power and agency to choose based on their needs or preferences.

Now consider this: over half of adults in South Africa are overweight or obese, costing our strained economy over R33-billion per year in public healthcare costs alone, yet paradoxically, nearly three out of 10 children under five are stunted (short for their age), a tell-tale sign of chronic malnutrition.

The reality is that these seemingly opposite nutritional outcomes have overlapping drivers, and are often found in the same households, and sometimes even in the same individuals.

These two expressions of poor nutrition, along with hidden hunger (referring to micronutrient deficiencies) are all part of the triple burden of malnutrition that haunts our country and is in a large part responsible for preventing human development and economic progress.

Read more in Daily Maverick: Government must take action against double burden of malnutrition

As my colleague and I have argued in another article, when 20% of households are food insecure and child support grants have only marginally increased despite escalating food prices, the choices many families have are hardly choices at all, especially where ultra-processed foods are not only cheaper but more accessible. Often, it is easier for people to buy unhealthier foods close to where they live than to travel to markets selling fresh produce and less processed foods.

When you are poor, the cost of electricity and cooking fuels can also be a reason why you are eating foods that require little to no cooking and don’t require refrigeration, further encouraging reliance on foods such as instant noodles, maize meal, bread, local fast foods (such as fat cakes) and instant porridge.

To add to this, aggressive marketing of unhealthy food drives demand for sugary and salty snacks and sugar-sweetened beverages, creating a perception that these products are desirable or even necessary. This type of advertising disproportionately targets vulnerable populations, including children, influencing dietary preferences from a young age. This is further compounded by the hyper-palatable nature of these foods, making them satisfying to eat.

Referring to this reality that millions of South Africans have as “choices” is out of touch. Even the directive to “move more” (quoting the email) — often in areas where roads have no pavements, walkers have to negotiate litter and human waste and safety on the street is an ongoing concern — is not aligned with the lived experiences of the majority of South Africans.

Moving towards change

The Indian economist and philosopher Amartya Sen’s concept of “unfreedoms” — the idea that poverty involves not just a lack of income but a deprivation of capabilities — resonates here. Sen (who is also a Nobel Laureate) suggests that poverty limits an individual’s ability to make meaningful choices, as illustrated with the above scenarios.

So how can we move towards less poverty and a more equitable food landscape as a step towards increased human health, economic development and a more realistic notion of freedom of choice?

Warren Buffett’s late business partner, billionaire Charlie Munger, famously said that if you want to know the outcome, know the incentives. Government, civil society and the private sector must work together to make nutritious foods more accessible and affordable by providing the various incentives each group requires to effect change — for example government subsidies or rebates to benefit producers and retailers to grow and sell more nutritious foods; and industry discounts to benefit the public (specifically vulnerable groups), incentivising the purchasing of these foods.

In addition, these actors can collaborate to create demand for more nutritious foods through national public awareness campaigns, which can further encourage the food industry to supply these products at competitive prices.

Currently, it is government and civil society that are driving nutrition education initiatives (such as the National Nutrition Week, Grow Great and Heala campaigns) which aim to shift consumer knowledge, behaviour and perceptions about healthy food. Unfortunately, they can’t compete with the multi-million-rand marketing machines of the food industry.

We, as the public, are often unaware of the effect of industry and retailers on our choices, especially since they work hard at winning our favour and that of NGOs, often through corporate social responsibility (CSR) investments. Though these CSR investments may be significant and certainly have benefits for several communities and civil society organisations, they do not address the underlying causes of malnutrition. There is thus an urgent need for them to make different commitments that allow more real “choice”.

Similarly, government also has an important role to play in unlocking more freedoms. By addressing structural barriers (for example, access to water, transportation and electricity, as alluded to earlier), increasing the Child Support Grant to above the food poverty line, and creating mechanisms through which nutritious foods can be made more affordable, are just some of the levers they can pull.

By shifting the incentives for industry, government and civil society, South Africa can create a more supportive environment for healthy eating, ultimately leading to better child developmental outcomes — and economic prosperity — for all South Africans. DM

Liezel Engelbrecht is a registered dietitian. She is an Innovation Manager at the DG Murray Trust (DGMT) focused on nutrition and stunting.