the nutritional status of - Health Systems Trust

CHAPTER 4
DETERMINANTS OF NUTRITIONAL STATUS
4.1 INTRODUCTION
To understand malnutrition and to address the problems of undernutrition effectively, it is important that the root
causes should be identified. In this section, the internationally accepted causes of undernutrition will be briefly
illustrated, using a model developed from the UNICEF conceptual framework (Grant, 1994). The available information
on risk factors for and determinants in South Africans will then be discussed.
4.2 CAUSES OF UNDERNUTRITION
Figure 5 illustrates the vicious cycle of the causes and consequences of undernutrition. It indicates that, because
of the consequences, malnourished communities and individuals cannot benefit fully from developmental actions.
It is extremely difficult to escape from this vicious circle of poverty and undernutrition. The multifactorial model
further illustrates why it is so important that community based, intersectorial programmes aimed at all possible
causes are necessary to address undernutrition in a sustainable way.
Undernutrition develops when nutrient intakes do not meet nutrient requirements. Intakes are inter alia determined
by household food security defined as access to adequate, affordable, safe and nutritious food. Clearly, many
economic, social and cultural factors will influence household food security. In addition, political and ideological
factors, coupled with availability and access to potential resources, will also influence food security on a national as
well as household level.
Nutrient requirements may be increased by infectious diseases and malabsorption. Access to adequate health and
other services such as clean, safe water, sanitation and refuse removal is therefore a major determinant of nutritional
status. Small children cannot feed themselves. Care, and all factors influencing the care of young children, as well
as of the old and the infirm, will also influence nutritional status.
The figure further illustrates that the consequences of undernutrition directly aggravate the causes. Inadequate
physical, mental and social development of people will lead to chronic ill-health, decreased incentives, low productivity
and lack of education. All these factors could contribute to poverty and, therefore, to household food insecurity, lack
of care and decreased access to health and other services. Because the causes of undernutrition are so interrelated
and further aggravated by the consequences, it can be expected that they will not occur in isolation within a
community or household. Usually, a combination of factors, all associated with poverty, will collectively be responsible
for undernutrition.
Because the causative factors of undernutrition are all interrelated, it is difficult to isolate and classify them. With
the available data it is not possible to evaluate the precise contribution of a specific factor to the prevalence or
extent of undernutrition in South Africans. The factors that will be discussed here are those that have been
examined in different South African ethnic groups. Because it is not possible to conclude from the available
literature whether cultural practices contribute to malnutrition, the cultural influences an eating pattern will be
discussed in a separate chapter (5).
4.3 RISK FACTORS FOR UNDERNUTRITION IN SOUTH AFRICA
4.3.1 FOOD SECURITY
Food insecurity or lack of access to adequate, affordable, safe and nutritious food, is a major determinant of
undernutrition. There is general agreement that we have national but not household food security in South Africa.
The first is relatively easy to assess by comparing and combining data on population demographics and statistics,
production, import and export of food. The latter is more difficult and is often measured by the incidence of poverty
and undernutrition, although “poor access to health services and sanitation may be more significant causes of
malnutrition than inadequate food access” (Land and Agriculture Policy Centre, 1994). Nevertheless, it is generally
accepted (Health Systems Trust, 1995) that inequalities to access of land and other resources and specific agricultural
land use and urbanisation policies of the past has led to household food insecurity and has contributed significantly
to undernutrition, especially in rural areas and the previous Homelands (TBVC-States) where agriculture currently
contributes very little to household income.
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