The importance of an optimal nutritional status for health and normal functioning of the immune system has already been mentioned repeatedly in this text. To improve Table III. Percentage prevalences of weight status of adult South Africans19
Population Group
Men Women
Under- weight Normal weight Over- weight Obesity Over- weight plus obesity Under- weight Normal weight Over- weight Obesity Over- weight plus obesity
BMI <18.5 18.5-25 25-30 >30 >25 <18.5 18.5-25 25-30 >30 >25 African
(Black) 12.9 61.7 19.4 6.0 25.4 4.8 36.7 26.7 31.8 58.5
Coloured
(mixed) 12.1 57.1 23.1 7.7 30.8 10.5 37.3 25.9 26.3 52.2
Indian 16.9 50.3 24.0 8.7 32.7 14.9 36.1 27.8 21.1 48.9
White 5.0 40.4 36.6 18.2 54.5 3.1 47.8 26.5 22.7 49.2
the nutritional status of both children and adults in South Africa, the multiple, inter- related factors associated with the development of malnutrition should be addressed by concerted efforts in multidisciplinary and integrated policies and programmes from all of the involved sectors: health, agriculture, housing, economics, etc. Some of these risk factors and their inter-relationships will now be briefly discussed:
Poverty and underdevelopment
The multifactorial and inter-related causes of malnutrition are illustrated in Figure 2, showing that the consequences of undernutrition often aggravate the causes. It is difficult for undernourished individuals to escape this vicious cycle: they have low energy levels and micronutrient deficiencies, associated with an inability to optimally benefit from education and development programmes to sufficiently create a healthy socio-economic environment for their families to prevent undernutrition. Poverty is a fundamental or Figure 2. The vicious cycle of undernutrition causes and consequences16
Undernutrition
Disease
Lack of care
Household food security
Political-, economical- and ideological
structures
Potential resources
Poverty Uneducated
mothers Overcrowding
Unbalanced and inadequate Intakes
Inadequate physical-, mental-, social development
Health and sanitation services
Infant mortality
Incentives, Health, Productivity, Edutcation Disease
Compensatory birthrate
Requirements Absorbtion
Taboos Tradition Culture
Family disruption
root cause of undernutrition, because it is associated with unemployment, inability to pay for food, health care and basic services, disintegration of family life, inability to care for children, vulnerability, homelessness and despair. Figure 2 further illustrates that to address undernutrition these interrelated factors should be mitigated in community- based, intersectorial programmes, with a focus on alleviating poverty and development of “human capital”. Undernutrition increases the sk of infectious diseases. It is clear how the HIV/AIDS pandemic contribute to this vicious cycle of undernutrition and poverty.
Food and nutrition insecurity
Lack of access to adequate, affordable, safe and nutritious food is a major determinant of malnutrition. Although South Africa is food secure on a national basis, and is even in a position to export food, many households experience hunger and food and nutrition insecurity because of all the factors contributing to poverty and underdevelopment. The HIV/AIDS pandemic, often associated with children becoming head of households and main “breadwinners”, also contributes to food insecurity.
Increased vulnerability for obesity: the double burden within individuals There is an increasing awareness that maternal malnutrition, foetal undernutrition (low birth weight) as well as infant and childhood undernutrition (stunting) may be related to an increased risk of obesity and other chronic diseases of lifestyle in adulthood.
Levitt et al21 recently reviewed South African studies that examined this hypothesis (or phenomenon) and concluded that an association between adverse early life exposures and propensity to obesity has been observed in several of these studies, which could explain the high prevalence of obesity, especially amongst black South African women.
The quality of diets which consist of cheaper energy-dense, but micronutrient-deficient foods, probably contributes to adult obesity combined with “hidden hunger” in poor households. The mandatory micronutrient fortification of maize meal and bread flour in South Africa aims to address this problem.
The nutrition transition
As mentioned earlier, urbanisation, modernisation, acculturation or westernisation of black South Africans is characterised with changing dietary intakes that increase the risk of overweight and obesity without rectifying micronutrient undernutrition. In all population groups, increased exposure to cheaper energy-dense, high-fat and sweet foods, are leading to food choices that contribute to overnutrition in respect of macronutrients, and undernutrition in respect of micronutrients in many individuals. In addition, many poor households are characterised by undernutrition in children and overweight or
obesity in the mothers (caregivers). This co-existence of under- and overnutrition can be addressed by ensuring food security, education regarding healthy food choices, and creating an environment where these choices are available and affordable. Cooperation of the media and industry is essential for attaining this environment. Promotion of traditional and indigenous foods, emphasising their value in healthy diets, can also help to improve nutritional status and decrease disease risk.
Physical environment
The standard of housing, occupational density, access to clean safe water and sanitation, as well as the availability of adequate cooking and refrigeration facilities combine to determine the risk of malnutrition. Much has been done during the past years to improve housing conditions in South Africa. Many South Africans in transition, however, still reside in informal settlements in conditions not conducive to optimal nutrition18. Family unity and cohesion
Several studies have shown that disruption of family units and broken homes, with less support from fathers as heads of households, are associated with malnutrition19. In the past, migrant workers were probably a main contributor to this situation. At present, the HIV/AIDS pandemic is one of the main reasons for the disruption of family life with resultant malnutrition.
Pregnancy, lactation and weaning
Repeated pregnancies may jeopardise the nutritional status of both mother and child.
Pregnant women have a high risk of developing iron-deficiency anaemia. Urban women are known to breastfeed for shorter periods (if at all). Several South African studies have indicated that one of the major reasons for childhood undernutrition is inappropriate weaning practices16,with possible long-term consequences in adulthood21.
Alcohol consumption
The excessive consumption of alcoholic beverages may influence nutritional status directly and indirectly: directly, by providing energy without micronutrients (diluting micronutrient density of the diet), and indirectly, as a result of psycho-social problems affecting household resources to buy food. Alcohol consumption may also influence sexual behaviour and risk of HIV transmission. The World Health Organizationrecently published data which showed that although South Africans drink less than 43 other populations, those that do drink consume very large amounts, and binge drinking is a serious problem22. Policies that address malnutrition should also include strategies that will promote healthy drinking behaviours.