**5. South African inequalities, poverty and compromised dietary-intake: implications on public health**

Africa is the most unequal society in the world of which South Africa is the leading unequal country, mainly due to the nation's historical injustices that were driven by colonial and the apartheid regimes. In fact, poverty and food insecurity related problems are not new in South Africa. The nation's socio-economic inequalities can be traced back to the arrival of the Europeans in the present day Western Cape province and the subsequent apartheid governance whose racialized policies disadvantaged and left the majority (black population) in chronic poverty. This increased their vulnerability to hunger and malnutrition related conditions evidenced by the 1994 demographic records which revealed that at the end of the apartheid government, about 41% of children from South Africa's impoverished households were chronically hungry and undernourished [32]. Of note is that, that during the apartheid regime, South Africa was food secure in terms of food availability. This was due to increased food production by commercial farming—a white dominated industry. However, cheap labour was sourced from the black population whose wage could not sustain their basic human needs including household food security.

Consequently, the issue of food insecurity and poverty was worsened by unjust and racialized policies that deprived the majority socially and economically [33]. More evidence of the existing inequalities such as high poverty levels among the black population is reported in several studies that were conducted during the first decade of post-apartheid South Africa. Likewise, a study [34] recounts that in 1995, in terms of annual income quantile by race, South Africans of African ancestry constituted the poorest households in terms of annual income such that an estimated 26% of them had incomes between R0. 00 and R6 839.00 per annum. This was followed by the mixed race ancestry households who constituted 12%, and only 2% of both Indian, and white households.

Additionally, in 1994, South Africa conducted its first national survey on child malnutrition whose findings revealed that one out of four children aged between 6 months and six years were malnourished. Of these 10% were underweight [35]. Having a low Body Mass Index or being underweight compromises one's immunity system, and leads in poor health. Despite that these results only linked poverty to child malnutrition, they are significant to this research as they underscore the potential correlation between lack of dietary diversity and malnutrition, and poverty or the inability to afford a good diet for a healthy living.

Similarly, research by, Woolard [9] concluded that the Africa National Congress (ANC) government inherited extremely unequal economic opportunities which saw the black population accounting for 95% of the impoverished South Africa. The prioritization of the household food security as a basic human necessity by the ANC government is evident in section 27 of the Constitution, which stipulates that "Everyone has the right to have access to (a) health care services; (b) sufficient food and water; (c) social security' [36] and that; government should "take reasonable legislative and other similar measures within the context of its available resources to achieve the progressive realization of services such as sufficient food and water, and health care" [36]. Further recognition of the right to food is enshrined in the socioeconomic policies such as the Reconstruction Development Programme (RDP) and the Broad Based Black Economic Empowerment (B-BBEE) programmes which seek to eradicate the nation's high levels of poverty and deprivation that have been compounded by relatively high level of disparities between the white population and the historically disadvantaged population. The former was favored during apartheid. The RDP is a government programme whose priority is to rectify the inequalities

**37**

per month.

*Poverty, Compromised Dietary Intake and Health Implications among South Africa's...*

which are meant to easy household poverty and vulnerability to hunger.

fabricated by the apartheid government to the majority of South Africans [37, 38]. As observed by Hendriks [39] the RDP identified household food security as a basic human necessity and food insecurity as a legacy of the oppressive apartheid laws

Despite that the apartheid government collapsed in 1994, and that the new government ushered into new policies such as the RDP of 1994 and the B-BBEE of 2003, poverty levels are still high in the country and majority of those affected are the black population and the youth. These vast populations are not only impoverished but have also been found to be food insecure [40]. Evidence of the existing poverty and poor nutrition is the government social protection policies that have been implemented through social grant financial packages and the national nutritional programmes [such as the National School Nutrition Programmes (NSNP)]

The NSNP is a fundamental government initiative that directly addresses macro and micro nutritional needs among the historically disadvantaged children in South Africa. The program is part of the National Policy on Food and Nutrition Security that enhances a broad framework for the reorientation of household food security interventions such as the nutrition programs in the country [41]. One of the aim is to address nutritional needs among the most vulnerable groups such as the school age. Adequate nutrition is essential for keeping humans healthy across their lifespan. Thus, a healthy diet helps children grow and develop properly. It also reduces their risk of chronic diseases, including obesity. Adults who eat a healthy diet live longer and have a lower risk of obesity, heart disease, type 2 diabetes, and certain cancers. Healthy eating habits can help individuals with chronic diseases to manage

Another strategy in which South African government addresses poverty and household food insecurity, and vulnerability is through social grants. Social grants are a government initiative that target household food insecurity in South Africa. In particular, the grants target sub-population groups such as the impoverished, including other vulnerable groups such as people with disabilities, children and older persons above the age of 60 years. The social financial grants are distributed in form of old age pension funds, foster care grants, disability grants, care dependency grants and child support grants [32]. In 2016, 30% of the vulnerable groups were beneficiaries of social grants that translated into 44% of all households in South Africa [32]. In the same year, the Child Support Grant benefited 11, 9 million children whereby each of them was paid R350.00 per month, making it the highest form of paid social grant. On the other hand, the Older Persons Grant benefitted from an estimated R3.2 million elderly people whereby those who were aged between 60 and 74 years received R1 505.00 each per month; while R1 525.00 was granted to each beneficiary aged >75-year-old [32, 42]. A disability grant beneficiary received R1 505.00 per month, a foster Care grant received R890.00 per month; while the Care Dependency Grant beneficiary received R1 505.00

These grants are shown to have improved household food access and other basic household needs among the beneficiaries. In 2012 the Statistics South Africa [39] reported that social grants contributed to 42% of household income in impoverished families and were their major source of income. Despite such a remarkable mile stone in public spending on improving the welfare of vulnerable people, the challenge is that not all the targeted beneficiaries have access to the grants arguably due to bureaucracy in selecting those who qualify to be beneficiaries among the millions who are impoverished in the country. As a result, about 20% [43, 44] of the economically disadvantaged South Africans lack financial support from the state

*DOI: http://dx.doi.org/10.5772/intechopen.96520*

which favored the minority white race.

these conditions and prevent complications.

and are thus malnourished and live in abject poverty.

#### *Poverty, Compromised Dietary Intake and Health Implications among South Africa's... DOI: http://dx.doi.org/10.5772/intechopen.96520*

fabricated by the apartheid government to the majority of South Africans [37, 38]. As observed by Hendriks [39] the RDP identified household food security as a basic human necessity and food insecurity as a legacy of the oppressive apartheid laws which favored the minority white race.

Despite that the apartheid government collapsed in 1994, and that the new government ushered into new policies such as the RDP of 1994 and the B-BBEE of 2003, poverty levels are still high in the country and majority of those affected are the black population and the youth. These vast populations are not only impoverished but have also been found to be food insecure [40]. Evidence of the existing poverty and poor nutrition is the government social protection policies that have been implemented through social grant financial packages and the national nutritional programmes [such as the National School Nutrition Programmes (NSNP)] which are meant to easy household poverty and vulnerability to hunger.

The NSNP is a fundamental government initiative that directly addresses macro and micro nutritional needs among the historically disadvantaged children in South Africa. The program is part of the National Policy on Food and Nutrition Security that enhances a broad framework for the reorientation of household food security interventions such as the nutrition programs in the country [41]. One of the aim is to address nutritional needs among the most vulnerable groups such as the school age. Adequate nutrition is essential for keeping humans healthy across their lifespan. Thus, a healthy diet helps children grow and develop properly. It also reduces their risk of chronic diseases, including obesity. Adults who eat a healthy diet live longer and have a lower risk of obesity, heart disease, type 2 diabetes, and certain cancers. Healthy eating habits can help individuals with chronic diseases to manage these conditions and prevent complications.

Another strategy in which South African government addresses poverty and household food insecurity, and vulnerability is through social grants. Social grants are a government initiative that target household food insecurity in South Africa. In particular, the grants target sub-population groups such as the impoverished, including other vulnerable groups such as people with disabilities, children and older persons above the age of 60 years. The social financial grants are distributed in form of old age pension funds, foster care grants, disability grants, care dependency grants and child support grants [32]. In 2016, 30% of the vulnerable groups were beneficiaries of social grants that translated into 44% of all households in South Africa [32]. In the same year, the Child Support Grant benefited 11, 9 million children whereby each of them was paid R350.00 per month, making it the highest form of paid social grant. On the other hand, the Older Persons Grant benefitted from an estimated R3.2 million elderly people whereby those who were aged between 60 and 74 years received R1 505.00 each per month; while R1 525.00 was granted to each beneficiary aged >75-year-old [32, 42]. A disability grant beneficiary received R1 505.00 per month, a foster Care grant received R890.00 per month; while the Care Dependency Grant beneficiary received R1 505.00 per month.

These grants are shown to have improved household food access and other basic household needs among the beneficiaries. In 2012 the Statistics South Africa [39] reported that social grants contributed to 42% of household income in impoverished families and were their major source of income. Despite such a remarkable mile stone in public spending on improving the welfare of vulnerable people, the challenge is that not all the targeted beneficiaries have access to the grants arguably due to bureaucracy in selecting those who qualify to be beneficiaries among the millions who are impoverished in the country. As a result, about 20% [43, 44] of the economically disadvantaged South Africans lack financial support from the state and are thus malnourished and live in abject poverty.

*Lifestyle and Epidemiology - The Double Burden of Poverty and Cardiovascular Diseases...*

**implications on public health**

2% of both Indian, and white households.

**5. South African inequalities, poverty and compromised dietary-intake:** 

Africa is the most unequal society in the world of which South Africa is the leading unequal country, mainly due to the nation's historical injustices that were driven by colonial and the apartheid regimes. In fact, poverty and food insecurity related problems are not new in South Africa. The nation's socio-economic inequalities can be traced back to the arrival of the Europeans in the present day Western Cape province and the subsequent apartheid governance whose racialized policies disadvantaged and left the majority (black population) in chronic poverty. This increased their vulnerability to hunger and malnutrition related conditions evidenced by the 1994 demographic records which revealed that at the end of the apartheid government, about 41% of children from South Africa's impoverished households were chronically hungry and undernourished [32]. Of note is that, that during the apartheid regime, South Africa was food secure in terms of food availability. This was due to increased food production by commercial farming—a white dominated industry. However, cheap labour was sourced from the black population whose wage could not sustain their basic human needs including household food

Consequently, the issue of food insecurity and poverty was worsened by unjust and racialized policies that deprived the majority socially and economically [33]. More evidence of the existing inequalities such as high poverty levels among the black population is reported in several studies that were conducted during the first decade of post-apartheid South Africa. Likewise, a study [34] recounts that in 1995, in terms of annual income quantile by race, South Africans of African ancestry constituted the poorest households in terms of annual income such that an estimated 26% of them had incomes between R0. 00 and R6 839.00 per annum. This was followed by the mixed race ancestry households who constituted 12%, and only

Additionally, in 1994, South Africa conducted its first national survey on child malnutrition whose findings revealed that one out of four children aged between 6 months and six years were malnourished. Of these 10% were underweight [35]. Having a low Body Mass Index or being underweight compromises one's immunity system, and leads in poor health. Despite that these results only linked poverty to child malnutrition, they are significant to this research as they underscore the potential correlation between lack of dietary diversity and malnutrition, and

Similarly, research by, Woolard [9] concluded that the Africa National Congress (ANC) government inherited extremely unequal economic opportunities which saw the black population accounting for 95% of the impoverished South Africa. The prioritization of the household food security as a basic human necessity by the ANC government is evident in section 27 of the Constitution, which stipulates that "Everyone has the right to have access to (a) health care services; (b) sufficient food and water; (c) social security' [36] and that; government should "take reasonable legislative and other similar measures within the context of its available resources to achieve the progressive realization of services such as sufficient food and water, and health care" [36]. Further recognition of the right to food is enshrined in the socioeconomic policies such as the Reconstruction Development Programme (RDP) and the Broad Based Black Economic Empowerment (B-BBEE) programmes which seek to eradicate the nation's high levels of poverty and deprivation that have been compounded by relatively high level of disparities between the white population and the historically disadvantaged population. The former was favored during apartheid. The RDP is a government programme whose priority is to rectify the inequalities

poverty or the inability to afford a good diet for a healthy living.

**36**

security.

Some empirical studies [45] have reported about caregivers of child support grants citing forgery of more birth certificates including having multiple children so that they could secure more grants as safety nets. Similarly, there are also reports of increased teenage pregnancy in households particularly in rural areas as strategy to secure more child grant support. In turn, this increases poverty and unemployment among such households because the young mothers are likely to drop out of school and stay unemployed; in cases where they fail to secure their child support grants, such families find it difficult to cope with the cost of maintaining large households. Alcohol abuse is another identified risk factor for poverty and compromised healthy lifestyle in South Africa. Some studies revealed that some grant caregivers do not utilize the money for the intended purposes but divert a portion of it on alcohol consumption [46].

Furthermore, it is reasoned that poverty levels in South Africa are also escalated by undocumented immigrants in the country. For instance, given that the grants are exclusive to documented persons or citizens (vulnerable groups) of South Africa, this leaves the resource-poor undocumented or illegal immigrants in the country to fend for themselves. Of note is that, South Africa has the highest number (>4 million) of immigrants legal and undocumented (mostly from low income countries), in Africa [47] most of whom are highly vulnerable to poverty and hunger.

In 2010–2011, South Africa drafted a National Development Plan-2030 (NDP-2030) as a broad strategic framework for a more prosperous and equitable South Africa, where poverty and its related conditions such as individual food insecurity and non-communicable diseases will be adequately addressed by enhancing socialeconomic opportunities such as health care, education, social security and safety nets [48]. The implementation and success of the plan would depend on every South African taking responsibility for the NDP, led by the head of state and the Cabinet. However, several years after the implementation of the program whereby, less than a decade is remaining to reach the year 2030, the problem of social-economic inequalities persistent common in South Africa. Likewise, a report on South African household poverty as proxy for household food insecurity revealed that in 2015, some 13,8 million individuals were vulnerable to hunger because they lived below the national food poverty line of R441.00 per person per month [49]. This was an increase from 11 million people in 2011. The most affected were the historically disadvantaged, single-parent households, and the rural households.

Consequently, most recent research shows that poverty, vulnerability to hunger, and compromised health lifestyle are still common in South Africa. Accordingly, the 2019 Statistics South Africa report showed that, 11.3% or 6.5 million people by head count experienced hunger while vulnerability to hunger by households was 9.7%. In terms of food access inadequacy, 15.7% of the households that lived in metropolitan areas had experienced inadequate or severely inadequate access to food during the preceding year [50]. At the same time, severe inadequate food access affected 5.2% of the households. Moderate food access inadequate stood at 15.0%. In the same study, it was reported that inadequate food access was influenced by rising economic challenges or poverty in the country. More so, rural poverty areas remained much poorer, despite that the urban–rural economic gap has narrowed.

Another research [51] revealed that in South Africa, chronic malnutrition coexisted in increasing cases of obesity and overweight whereby compromised diet often caused high levels of malnutrition. As such, high food prices, high poverty levels and socio-economic inequalities meant that many households were unable to consume a diverse diet. In the same study, socio-economic status was measured using income and relative asset index. The study concluded that a consistence of pro-rich Socio Economic Status (SES) influenced dietary intake among high income households. Of note is that, although, consumption of starch and energy dense food (high

**39**

*Poverty, Compromised Dietary Intake and Health Implications among South Africa's...*

sugar) was common in both categories of the surveyed, low income households had a low intake of fruit, vegetable, and meat than their high SES counterparts whose households also consumed food rich in vitamins, minerals and protein. The findings also concluded that inequality in both dietary diversity and the frequency of consuming all food categories favored high income households whose dietary intake resonated with both the South African national and the WHO. On the same subject, a different research [27] shows that an intake of fruits and vegetables reduces the risk of non-communicable diseases such as diabetes, obesity, cancer and cardiovascular mortality and all cause of mortality among resource-poor communities.

This chapter concludes that in a developing country like South Africa, poverty is one of the influencers of compromised-dietary intake and vulnerability not only to cardiovascular diseases such as stroke, heart attack and heart failure, but also to other non-communicable diseases, malnutrition and undernutrition, and type 2 diabetes. This is evident in the majority of the historically disadvantaged group in

A comprehensive public health approach is needed to curb the inequality and ignorance which are the main source of compromised dietary intake among vulnerable groups. The problem associated with malnutrition related diseases cannot be left in the hands of government alone. It requires multi sectorial approach from civil society actors, researchers and the public itself; the approach that requires public

As the world continues to nurse its latest public health disaster—COVID-19 pandemic which infected >62 million people and claimed >1.5 million lives in 2020 [52, 53], individuals with pre-existing unhealthy conditions such as malnutrition, cardiovascular disease, and diabetes are highly vulnerable to succumbing to the virus. Deliberate policies that promote household food security are critical in foster-

Furthermore, global extreme poverty is expected to rise in 2020/2021 for the first time in over two decades. This is due to the disruption of the COVID-19 pandemic that has worsened the pressures of conflict and climate change, which were already slowing poverty reduction progress in Sub-Saharan Africa. As a result of the COVID 19 pandemic, Sub-Sahara Africa's fragile economy, will negatively affect the vulnerable groups who are dependent on government handouts for their livelihood

ing dietary diversity, and health lifestyle such as physical exercises.

*DOI: http://dx.doi.org/10.5772/intechopen.96520*

**6. Conclusions and recommendations**

South Africa.

awareness.

as is the case in South Africa.

*Poverty, Compromised Dietary Intake and Health Implications among South Africa's... DOI: http://dx.doi.org/10.5772/intechopen.96520*

sugar) was common in both categories of the surveyed, low income households had a low intake of fruit, vegetable, and meat than their high SES counterparts whose households also consumed food rich in vitamins, minerals and protein. The findings also concluded that inequality in both dietary diversity and the frequency of consuming all food categories favored high income households whose dietary intake resonated with both the South African national and the WHO. On the same subject, a different research [27] shows that an intake of fruits and vegetables reduces the risk of non-communicable diseases such as diabetes, obesity, cancer and cardiovascular mortality and all cause of mortality among resource-poor communities.
