Background: The Double Burden of Malnutrition
The double burden of malnutrition has strongly been associated with countries undergoing the so-called “nutrition transition” in which case aspects of undernutrition coexist with those of overweight and obesity amongst individuals, families, and populations. The World Health Organization (WHO) (2017) recognizes the double burden of malnutrition as a global healthcare concern having been observed in both emerging and developed countries. A significant driver of this phenomenon in the last several decades has been a gradual shift from
the traditional food systems towards westernized diets that are overly energy-rich but which are significantly nutrient poor. Hawkes, Demaio, and Branca, (2017) observe that if countries can strive to maintain their traditional food systems by encouraging locals to foster the production, processing, and consumption of culturally-accepted foods, then the challenge of the double burden of malnutrition can be solved amicably. This paper will endeavor to develop an intervention strategy aimed at addressing the escalating concerns of the double burden of malnutrition amongst individuals, families, and populations in South Africa through the preservation of traditional food systems.
The double burden of malnutrition refers to the co-occurrence of undernutrition and overnutrition within individuals, households, and populations of a particular region across the life course. By “across the life course”, it literally means that there is a possibility for individuals who experienced undernutrition earlier in life to experience higher overnutrition propensities later in adulthood. This is especially the case in countries experiencing rapid development. Populations in such countries are shifting their dietary patterns from traditional food systems towards more westernized food systems. Nonetheless, the double burden of malnutrition is a global phenomenon and it affects developed countries as much as developing countries (World Health Organization, 2017).
The double burden of malnutrition has extensively been related to a spectrum of changes happening across the globe referred as nutrition transition which is often preceded by country-specific epidemiological transition and demographic transition (World Health Organization, 2017). In Low and Medium Income Countries (LMICs) intergenerational changes in diet consumption have impacted both the quality and quantity of food taken by individuals and populations effectively condensing the three transition processes. This has led to a greater coexistence of undernutrition and overnutrition.
The determinants responsible for the high escalation of nutrition transition and obesity epidemic across the globe can be categorized into four broad themes which are also crosscutting; economic/food environment factors, physical, built environment factors, health/biological environment factors, and socio/cultural environment factors (World Health Organization, 2017). With regard to the economic/food environment determinants, there has been an incredible increase in both individual wealth and food production capacities across the globe in a relatively short time span. This is as a result of initiatives such as the “green revolution”, rapid industrialization and globalization of food chains. With the global trade on food increasing by the day, global food consumption patterns are increasingly being “westernized”. As such, a lot of people are abandoning their traditional food systems (Steyn, et al., 2009).
The physical/built environment factors relate to the rapid urbanization that has denied people an opportunity to consume processed food products besides denying them an opportunity to engage in physical exercises. The health/biological determinants relate to the fast demographic and epidemiological transition happening across the globe. The world population has dramatically increased and non-communicable diseases are replacing infectious diseases as a major cause of death. The increase in population does not measure up with the increase in food production in some parts of the world thereby leading to undernutrition. Lastly, the socio/cultural landscape shapes populations food consumption patterns in many different ways. In urban areas, people are inclined at consuming processed food products which leads to overnutrition while in rural areas many people may be undernourished as a result of clinging on cultural food consumption orientations (Prentice, 2018).
Determinants of the Double Burden of Malnutrition
In the last several decades, the term malnutrition has been used to refer to undernutrition following the earlier focus of nutrition research on protein-calorie malnutrition (PCM). However, the World Health Organization defines malnutrition to mean either nutritional deficiencies or excesses. As such the etiology and epidemiology of the double burden of malnutrition is twofold since some sections of the population are malnourished (underweight) while others are overnourished (overweight) (Delisle, 2008).
Undernutrition is exhibited by stunted growth in children and underweight individuals. This is as a result of insufficient intake or poor biological use of nutrients. Undernutrition significantly impairs the functioning of vital body functions, make victims look emaciated besides impairing with growth and development especially in children. Underweight is measured through either low weight-for-age or low weight for height (wasting) as well as low length-for-age (stunting). Undernutrition is majorly caused by lack of sufficient intake of both macro and micronutrients such as iron, zinc, iodine, calcium, and vitamins. On the other hand, overnutrition results when individuals consume nutrients in excess amounts or fail to balance off their intake potentially leading to impaired body functions as well as obesity and being overweight. Overweight is deduced by measuring Body Mass Index against age or relating weight against the length/or height of an individual. Individuals are termed as being overweight when these measures are in excess amounts (Thow, et al., 2016).
The double burden of malnutrition is fairly spread out across the globe. Undernutrition is not an exclusive phenomenon of LMICs while overnutrition is not an exception of developed countries only. According to Finuancane et al., (2011) approximately 25% of the world population is overweight currently with one-third of the same being iodine deficient. According to World Health Organization (2010), approximately 17% of preschool children worldwide are underweight and 40% of women at the reproductive age bracket are severely anemic. Perez-Escamilla, et al., (2018) observe that most of the conditions associated with the double burden of malnutrition occur simultaneously and in the same populations, households or even in the same individuals. In 2014, the World health organization estimated that 1.9 billion adults globally were overweight while another 462 million and 600 million were underweight and obese respectively. Underweight or obese children under the age of 5 in the same year were approximately 41 million while another 155 million and 52 million were affected by stunted growth and wasting respectively (World Health Organization, 2017).
At the population level, women are affected more than men by the double burden of malnutrition with most women being overweight. At the family level, obese women have been deduced to coexist with stunted children, especially in Latin America. At the individual level, the double burden of malnutrition has been deduced to be energy overnutrition with massive iron deficiency. The double burden of malnutrition posits dire consequences with early life undernutrition being a fundamental cause of young child deaths. Indeed children who survive early life undernutrition have impaired capacities of disease resistance, abilities of doing physical work and successfully progressing in school work. On the other hand, overnutrition results in obesity and overweight. The two are underlying causes of numerous non-communicable diseases such as hypertension, stroke, diabetes and heart diseases (World Health Organization, 2017). This is especially the case in South Africa where food production and dietary patterns have really transitioned.
Understanding the Etiology and Epidemiology of the Double Burden of Malnutrition
South Africa food production capacity is amongst one of the highest in Africa with the country endeavoring to produce a wide verity of food crops and many different kinds of livestock (Alliance for a Green Revolution in Africa 2017). The country produces a verity of field crops including maize, wheat, citrus fruits, sugarcane, tropical fruits, sunflower, potatoes, and vegetables. South Africa’s livestock production constitutes cattle, sheep, poultry, and pigs rearing. In the financial year 2017, agriculture contributed approximately 10% of the country’s total export earnings valued at $10.3 billion (Export, 2018). The grain industry which majorly includes maize, barley, wheat, oats, and sorghum is amongst one of South Africa’s largest agricultural production contributing approximately 30% to total agricultural output (Export, 2018). Poultry production is South Africa’s largest individual agricultural industry contributing approximately 17% of total agricultural products’ gross value (Export, 2018). Different fruits and vegetables are produced throughout South Africa. South Africa’s food production capacity has played a critical role in shaping the country’s dietary patterns over the last several decades.
South Africa has experienced a relatively steady economic transition rate over the last several decades. This has successfully increased the households’ average incomes and subsequently pushing most families to the middle income-class. At the moment approximately 70% of the South African population is in this group. This economic transition has led South Africans to significantly change their dietary patterns with many of them choosing to consume protein-filled diets. For instance, in 1995, it was estimated that an average South African eat 40 kilograms of red meet in a year. Some 20 years later, it was estimated that an average South African consumed approximately 67 kilograms of meet in a year. This represents a 70% increment over the period (Export, 2018).
Steyn, et al., (2009) observe that dietary trends and their associated risk factors in South Africa paint a grey picture worthy of the government’s attention. Steyn, et al., (2009) points out that the South Africa’s per capita energy supply rose from 2 603 kcal/day in 1962 to 2 921 kcal in 2001 while available protein, fat and carbohydrate supplies rose from 68.4 to 75.1 g, 61.2 to 79 g and 445 to 478 g respectively over the same period. The direct implication of this national food availability trend is that food is more available to South Africans which might lead to overnurition and subsequently issues of overweight and obesity.
Dietary intake significantly differs between different ethnic groups as well as between urban and rural dwellers. The Whites, Indians and urban blacks tend to take in diets with high fat content, high proteins, low carbohydrates, low fiber, and high free sugar. In the rural areas, most people take diets with high carbohydrates, high vegetables, low fat, low sugar and moderately high fiber content (Steyn, et al., 2009). The urban blacks have transitioned to consume white or Indian dietary representing the nutrition transition that has taken place within the urban environment in South Africa. While the rural population is bound to experience undernutrition, the urban dwellers are more likely to experience overnutrition, overweight, and obesity.
Traditional Food Systems and the Double Burden of Malnutrition
From the foregoing, solving South Africa’s dual burden of malnutrition calls for formidable intervention strategies that would not only meet the current underlying nutritional demands but also meet future nutritional needs of South Africans. The rapid food transition witnessed especially in urban centers pose a grey picture for South Africa’ s nutritional requirements now and in the future. The move to consume westernized food diets pose the risk of overnutrition, overweight, and obesity while lack of adequate access to critical nutrients in the rural areas pose the risk of undernutrition and stunted growth and development especially in children (Malik, Willett, & Hu, 2013).
A formidable strategy to solve the double burden of malnutrition in South Africa lies with need to encourage local communities to embrace the production, processing, and consumption of a variety of traditional food crops (Dubé, Webb, Arora, & Pingali, 2014). However, processing should instead assume traditional systems of processing different food products. This will allow most food products to retain their original nutritional composition, unlike the highly synthesized western food products. To this end, the government needs to emphasize the production of a wide variety of traditional food products using traditional farming methods and where modern food production methods are involved; they must conform to the tenets of traditional farming (Finney Rutten, Yaroch, Patrick, & Story, 2012). Moreover, South Africans should endeavor to consume animal products in moderation to minimize instances of contracting non-communicable diseases that come about due to overconsumption of fats and proteins.
While most African countries have taken food-sufficiency to mean the sufficient production of staple food products especially cereals like rice, maize, and sorghum, this is not always adequate to meet the nutritional requirements of the populace. Indeed such a policy has the potential to lead to massive undernutrition if the production of other traditional food crops is not emphasized (Kimani-Murage, et al., 2010). Staple food crops such as maize, potatoes, rice, and sorghum contributes only carbohydrates to the body. As such, staple food crops in South Africa need to be reinforced by encouraging farmers to produce other traditional food products necessary at meeting the other nutritional requirements of South Africans. This includes the production of different types of leaf, fruit, stem and root vegetables; tropical fruits; and root crops (Uusiku, Oelofse, Duodu, Bester, & Faber, 2010).
Moreover, the government should continue emphasizing the importance of producing a variety of animal products including milk, eggs, honey, and meat by encouraging farmers to give importance in rearing farm animals that produce these products. Animal products are critical at supplying the body with vital nutrients not found in food crops. Milk and eggs, for instance, are critical at supplying the body with calcium critical for bone formation while white meat from poultry and fish is considerably safe from healthcare problems posed by red meat such as arthritis and heart diseases. Moreover, animal products are important sources of proteins, and both macronutrients and micronutrients. Animal products ought to be consumed to supplement the nutritional deficits left by food crop products.
Intervention Strategy to Address Double Burden of Malnutrition
By and large, integrated farming systems are critical at meeting the requirements of traditional food systems. South Africa must endeavor to tap from the synergies posed by livestock keeping, field crop production, aquaculture, horticulture, and fruits production to sufficiently meet the requirements of its nutritional demands (Baiphethi, & Jacobs, 2009). Since the double burden of malnutrition is double edged, such farming approaches are significant enough to suffice the nutritional requirements of either groups in South Africa. At household level in rural setups, subsistent farmers must endeavor to practice traditional intercropping practices, fruit production together with animal rearing to meet the households’ nutritional needs. Such practices will subsequently avert the possibilities of undernutrition. In urban setups, households must endeavor to embrace traditional food crops sold in the open air market as opposed to purchasing already processed westernized food products (Tzioumis, & Adair, 2014). Such practices will remove the possibilities of being overweight and obese.
The South African government must endeavor to train and educate its people on the importance of producing and consuming a variety of traditional food products to meet their nutritional needs. This can be effected by conducting subsistence farmer training and education forums, consumer education, and having demonstration farms from where farmers can learn best practices in traditional farming. This is in a bid to strengthen local food systems to produce food products that are macro and micronutrient-rich. Farmers must also be trained on best practices relating to food storage, handling, transportation and processing in a bid to minimize the loss in different foods’ nutritional quality and quantity (Valbuena, et al., 2012)
Indeed, the dual burden of malnutrition poses as a critical global healthcare concern and therefore world nations must devise strategies to avert the same. Besides increasing the burden of healthcare to families and the government, the dual burden of malnutrition pose as a potential cause of death in different populations. This is especially the case for populations undergoing nutrition transition like South Africa where there is a gradual shift from the traditional food systems towards Westernized diets. As such, governments across the globe ought to profile the determinants, etiology, and epidemiology of the double burden of malnutrition in their respective countries to inform best strategies of combating the same. Moreover, governments ought to profile the food production capacities and dietary patterns of their countries to enable them further come up with the appropriate approaches of solving the vice.
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