In the past 20 years, researchers have linked the increase of obesity and chronic diseases like diabetes and hypertension in low- and middle-income countries to urbanisation, changing diets and less active lives.
The spread of big retail food chains and fast food has also had an impact – increasing the availability of processed, high-energy, nutrient-poor foods and making them more affordable than fresh, healthy food.
Though this is accurate, it does not entirely capture the realities of the rural, agrarian poor people and the nutrition challenges they face.
Most South Africans’ food energy needs are adequately met and extreme hunger is a thing of the past. This is thanks, in part, to one of the largest cash-based social welfare programmes on the continent.
But the reality is that rural poor people are among the most disempowered among food citizens. Most poor rural South Africans cannot afford a healthy, balanced diet with adequate fruits, vegetables and legumes. Where these are not locally produced, supermarkets supply them with hefty price tags that are often higher than city prices. As a result, poor people living in rural areas may suffer from malnutrition.
For children, malnutrition comes as chronic under-nutrition. It translates into stunting or growth faltering. This often occurs simultaneously with obesity. For adults, it means a higher risk of obesity.
If the current trajectory continues, the costs of treating obesity-related chronic diseases could be staggering, let alone for a health system that already heaves under the burden of HIV.
And the social and economic costs of childhood stunting due to nutritional deficiencies are even higher, robbing children of quality of life and nations of potential.
Why rural poor face particular problems
Industrialised and highly urbanised developed countries have been leading the charge in the global obesity epidemic, but the world’s poorest countries are rapidly catching up.
Researchers refer to this as nutrition transition. This is explained as shifts in food consumption, physical activity levels and increasing urbanisation.
But this does not explain why obesity is also on the rise among rural people. It challenges a common argument around obesity: it is caused by unhealthy lifestyle choices, including inactivity and eating junk food.
Clearly the phenomenon of obesity in poor rural communities has little to do with an addiction to drive-through burgers. But it is no less related to food environments.
Food environments are the ways in which food is produced, distributed and consumed. These are determined largely by global trade policies, national food production and distribution patterns, agriculture and nutrition policies and, increasingly, the unfolding crisis of climate change.
And although nutrition transition is linked to changing food preferences, it is also linked to changing rural livelihoods, land and water entitlements, agricultural diversity and urbanisation. The dynamics of these push and pull factors are complex.
The South African case
Livelihoods and food environments – rather than personal choices – often determine the consumption of healthy or unhealthy food. In South Africa, for example, the particular challenge is that most rural people buy, rather than produce, their own food. This is because the country has an underdeveloped smallholder and subsistence-farmer sector and a weak culture of home food production. As a result their choices are severely limited by income, the retail environment and their capacity to produce their own food.
Producing their own food, in turn, is constrained by the high costs of inputs, land and water shortages, and the lack of support for subsistence and small food producers and marketers.
So instead of vibrant local production and markets, rural people rely mainly on processed foods – refined carbohydrates like maize meal, white sugar, mass-produced vegetable oils and, occasionally, processed animal products – bought largely from big retail chains, because these are the cheapest and most prolific.
Food security in rural South Africa is heavily reliant on cash incomes, which, in turn, are boosted considerably by social grants. But, unlike food prices, these do not increase in response to frequent price hikes.
Rural people are often trapped in cycles of chronic food insecurity. Although they get enough calories, they suffer from hidden hunger. This results in micronutrient deficiencies and obesity due to poor food quality, perpetual anxiety about future food supplies and unstable livelihoods.
There are answers
Malnutrition in rural communities cannot be addressed through manufacturing more food and trucking it to rural areas or sending more food charity. What is needed is a systemic approach that considers the underlying causes of hunger and malnutrition and the the whole food system.
Researchers, civil society groups and activists are increasingly highlighting the fact that food systems that primarily generate profits not only fail to deliver adequate nutritious food, but also contribute to environmental damage, biodiversity loss and climate change – and a global obesity epidemic.
South Africa produces enough food for local consumption. It also has the natural resources and technology to do this in more sustainable, nutritious and culturally appropriate ways. The key to this is diversification.
The retail sector is critical when most people rely on food purchased with cash. But like ecosystems, when food systems rely too heavily on one component, it makes for weakness and vulnerability. Relying heavily on purchased food from too few sources is making rural people vulnerable.
One solution may be to improve small-scale farming and household production. With the right support, small-scale, diverse and ecologically sustainable farming need not be a struggle for survival.
But small producers need access to land, water and inputs, vibrant local markets and protection against corporate and charitable dumping. This is but one suggestion. There is much wider scope for innovation in food and agricultural policies.
Addressing current nutrition and health challenges will require improved access to good quality, diverse diets – ending malnutrition is no longer about delivering enough calories to prevent starvation.