South African Child Gauge tackles the slow violence of malnutrition

The Children’s Institute at the University of Cape Town (UCT) publishes the South African Child Gauge annually to review the status of children in South Africa and to inform policy and programming.

The South African Child Gauge 2020 was launched on 18 February in partnership with the Department of Science and Innovation-National Research Foundation (DSI-NRF) Centre of Excellence in Human Development based at Wits University, the DSI-NRF Centre of Excellence in Food Security at the University of the Western Cape, the Standard Bank Tutuwa Community Foundation, the DG Murray Trust, and UNICEF South Africa.

South Africa’s First Lady, Dr. Tsepho Motsepe opened the high-profile launch event and called on all South Africans to take action: “Let us become that society that ensures that no child goes to bed hungry.”

Children stunted, obese, malnourished

The nutritional status of South Africa’s children is deteriorating. One in four children under the age of five are stunted, a sign of chronic undernutrition that has remained stubbornly unchanged for 20 years. And over the same period, South Africa has seen a steady increase in childhood overweight and obesity (one in eight children under the age of five) which is now double the global average.

This double burden of malnutrition can occur in the same household or even the same individual. For example, children who are stunted early in life are at greater risk of becoming obese—with prevalence rising across the life course especially amongst adolescent girls (28%) and adult women (64%). This increases their risk of developing non-communicable diseases such as diabetes, heart disease and certain cancers—and severe COVID-19 infection.

“Malnutrition is not simply a threat to child survival. It robs them of health and development. The 2020 issue of the South African Child Gauge focuses attention on and identifies points of leverage to improve children’s nutrition outcomes, calling for the strong leadership and concerted action from government, civil society and the private sector to ensure children’s rights are upheld,” said Professor Shane Norris, director of the DSI-NRF Centre of Excellence in Human Development at Wits.

Poverty and malnutrition

South Africa’s burden of child malnutrition remains unacceptably high for a middle- income country, placing it as an outlier among countries of similar wealth. The roots of the problem lie in our apartheid past and our on-going failure to uproot poverty and inequality. Twenty-five years since the advent of democracy, South Africa remains the most unequal country in the world. Poverty has a profoundly damaging effect on children’s care, health and development—with young children in the poorest of households three times more likely to be stunted than those in the richest 20% of households.

Thirty percent of South Africa’s children live below the food poverty line in households with a per capita income of less than R571 per month. These households do not have enough money to meet the nutritional needs of children. While frequent infections caused by overcrowding and poor access to water, sanitation and health care services further compromise children’s nutritional status. It is therefore not surprising that, according to the National Department of Health Ministerial Committee for the Morbidity and Mortality of Children under five years, severe acute malnutrition is one of three leading causes of child deaths in South Africa.

The slow violence of malnutrition

“Child malnutrition is a slow form of violence that lingers largely unseen until the child’s health is seriously compromised. It slowly eats away at children’s potential, eroding their physical health and cognitive development and undermining their education and economic prospects—and it drives an intergenerational cycle of poverty, malnutrition and ill-health that comes at a huge cost for individual children, their families and the South African economy,” says lead editor Professor Julian May, the director of the DSI-NRF Centre of Excellence in Food Security at the University of the Western Cape.

Professor Mamokgethi Phakeng, Vice-Chancellor of UCT, concurs: “Children who manage to survive malnutrition continue carrying the harm in their bodies, minds and spirits for the rest of their lives. And it doesn’t stop there: by attacking our children, malnutrition erodes our national development. The nation that starves its children is also starving itself.”

The devastating impact of COVID-19

COVID-19 has intensified these challenges– with rising unemployment and food prices driving a dramatic increase in child hunger and disrupting children’s access to essential safety nets such as school feeding, early childhood development programs and health services. Food prices rose dramatically—before, during and post-lockdown—with the Pietermaritzburg Economic Justice and Dignity Project reporting a 14.4% annual increase in the cost of basic Household Food Basket in November 2020.

Three million jobs were lost between February and June 2020—with women accounting for 60% of jobs lost during the first wave. Yet they are less likely than men to benefit from UIF and the COVID-19 relief grant.

The introduction of the COVIDD-19 relief grants, and top-ups to the old age pension and Child Support Grant (CSG) provided welcome relief for poor households. Yet the removal of the caregiver and top-up grants at the end of October precipitated a dramatic rise in child hunger with 1 in 6 households reporting that a child went hungry in November/December 2020—with CSG beneficiaries most likely to run out of money to buy food.

The impact of (lack of) income

While the physical environment in which food is obtained and prepared has an impact on the nutritional status of children, as do their feeding patterns and access to health care, research has shown that the driving factor behind both stunting and obesity is income. Poor households deal with the loss of income by eating less, and eating less nutritious food.

Although mothers buffer children at the cost of their own health, the implication is that children will go hungry, and their risk of stunting increases, as will the likelihood that their consumption of cheap, but empty calories, and their propensity to become overweight or obese.

The withdrawal of a lifeline grant such as the COVID-19 top-up grant, and reduced incomes due to job and livelihood losses, have served to exacerbate South Africa already excessive double burden.

These challenges were compounded by the closure of schools and early childhood development programs that made it more difficult for women to return to work and prevented children from accessing school meals. While the disruption of routine maternal and child health services and delays in care-seeking behavior have made it harder to prevent, identify and treat children at risk of severe acute malnutrition.

Global estimates by a multidisciplinary consortium of nutrition, economics, food, and health systems researchers projected a 14.3% increase in the global prevalence of severe acute malnutrition during the first 12 months of the pandemic with 80% of the burden concentrated in sub-Saharan Africa.

The time to act is now

“But all is not lost,” says Professor Shanaaz Mathews, director of the Children’s Institute, UCT. “There is much that the state can and must do, and the 2020 South African Child Gauge outlines a range of opportunities for double-duty actions to address the double burden of malnutrition—starting early during the antenatal period and extending across the life course.”

Build a strong foundation

Women’s need for energy, protein and micronutrients increases during pregnancy so it is important to optimize maternal nutrition. This includes strengthening the focus on nutrition and education counseling during antenatal care to address with the threat of undernutrition, obesity and gestational diabetes. And intervening even earlier through schools and adolescent and youth-friendly health services to help young women optimize their health, micronutrient status and weight before they become pregnant.

Improve infant and young child feeding practices

“Exclusive breastfeeding helps build a healthy immune system, enhances cognitive development and protects against NCDs in the adult years. While 80% of women initiate breastfeeding, only 32% of infants 0-6 months are exclusively breastfed, and only 23% of children 6—23 months receive a minimum acceptable diet, reflecting the low dietary diversity and the nutrient-dense dietary pattern,” says Chantell Witten, chairperson of the Child Health Priorities Association and the Nutrition Lead for the South African Civil Society for Women’s, Adolescent’s and Children’s Health.

Greater efforts are therefore needed to scale up nutrition interventions to promote optimal infant and young child feeding, and to identify and respond proactively to signs of malnutrition.

Expand social protection

Health care services need to be coupled with social assistance to support the efforts of families and caregivers in the context of rising hunger and unemployment. Poverty not only limits women’s food choices. It increases the risk of domestic violence and common mental disorders such as anxiety and depression that further compromise their capacity to feed and care for young children.

The Child Support Grant provides an essential lifeline to poor households, yet at R450 a month (or R15 a day) it is not enough to protect children from malnutrition. Take up also remains low with 19% of young children from poor households not receiving the CSG.

Increasing the value of the CSG to the food poverty line and extending social assistance to pregnant women is an essential first step in helping to close the gaps in the social protection system and improving child and maternal health and nutrition.

Increase investment in early childhood development programs

Early learning programs provide another important opportunity to provide nutritional support. Zanele Twala, Chief Executive Officer, of the Standard Bank Tutuwa Community Foundation agrees: “It’s proven beyond doubt that proper nutrition with exclusive breastfeeding through six months of age (where possible) and adequate micronutrient content diet, and regular growth monitoring and immunization is the greatest contribution we can make in the early years of a child’s life. For this reason, I believe food and nutrition programs at ECD level should be supported at scale.”

While 70% of 0-2-year-olds are cared for at home, two-thirds (69%) of older children (3-5 years) attend an early learning program. Registered Early Childhood Development (ECD) centers qualify for an ECD subsidy of R15 per child per day—40% of which should be used to provide nutritious food for children. Yet many centers serving the poorest communities are excluded from the subsidy because they are unable to meet the registration requirements.

These barriers need to be urgently addressed as less than 10% of young children benefit from the subsidy—which is in marked contrast with the National School Nutrition Program which supports 77% of learners.

Use schools as a platform to improve the nutrition of older children

Schools are an important platform for improving the nutritional status of older children and adolescents. The National School Nutrition Program (NSNP) provides a daily meal to over 9 million learners (77%) and improves learners’ punctuality, attendance and concentration. Yet it took concerted effort and legal action from civil society to uphold children’s right to basic nutrition and a court order to ensure the Department of Basic Education honored its obligation to provide school meals even when learners are unable to attend school due to COVID-19.

Create a healthier more equitable and child-centered food system

It is also essential to intervene outside of schools to create a healthy food environment. Children’s individual food choices are shaped in powerful ways by their immediate food environment and the broader food system. This includes all the elements involved in taking food from the producer to the consumer including food production, processing, packaging, distribution, marketing and retail.

The food system is increasingly dominated by commercial interests that are driven by profit rather than creating foods that are good for the health of people and the planet. Big food corporations are expanding into the global South, targeting children as consumers, and flooding local markets with cheap ultra-processed foods. These foods—low in nutrients, high in sugar, salt and fat—are helping to fuel the rapid rise in obesity and NCDs, with many children trapped in obesogenic food environments where healthy foods are increasingly unaffordable.

Scott Drimie, Director of the Southern Africa Food Lab and a Professor in the Nutrition Division, Department of Global Health, Stellenbosch University, argues that “direct intervention by the state is therefore needed to create a healthy food environment for South Africa’s children.” This can be achieved through introducing regulations to protect children from the marketing of harmful foods (those that are high in sugar, salt and fat), the judicious use of taxes (such as the ‘sugar tax’) to protect children from foods that are harmful to their health, subsidies to make healthy foods more affordable, and through the procurement and provision of healthy food in public schools, ECD programs and health care services.

A call for leadership and collaboration

“There is much that we can do as individuals to protect and promote our own health and nutrition and that of our children, but we cannot do this in isolation,” says Lori Lake, Communication and Education Specialist at the Children’s Institute, UCT. “Safeguarding children’s health and nutrition requires intervention at every stage in the life course and collective action from a range of government departments, civil society and the private sector.”

The National Food and Nutrition Security Council, first gazetted in 2014, needs to be established as a matter of urgency to provide political leadership at the highest level in the Presidency with the authority to hold government departments accountable and to drive concerted and consolidated action for children across a range of sectors from Health, Education and Social Development to Trade and Industry.

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