Changes in diet and nutrition along with other lifestyle changes have during the last decades affected the pattern of diseases and nutrition problems in many developing countries, the phenomenon known as ‘The Nutrition Transition’. As people move into cities, their lifestyles and food supplies change leading to changes in their diets. Urban diets show trends toward greater consumption of rice and wheat, more milled and polished grains, food higher in fat, more animal products, more sugar, and more processed food. Various nutrition studies on adolescents in South Africa have shown that overweight and obesity are increasing, possibly as an outcome of the nutrition transition that is affecting the country. Researchers in South Africa have expressed a need for more studies, policies and programmes that can facilitate prevention and early diagnosis of malnutrition in all its forms including those resulting from unbalanced diets that exists among adolescents.
This thesis uses a human rights based approach as a mean of making a contribution to this need. The overall aim was to expand the knowledge of the nutrition transition processes and changes that influence adolescents in South Africa, and to explore what relevant measures exist and are/or planned for the future. Perceptions regarding adolescents’ diets, dietary pattern changes, body images and physical activity have been investigated from the selected right-holders’ as well as corresponding duty-bearers’ perspectives. Further, a conceptual framework has been used to systematise their understandings of the situation and ideas regarding possible actions and measures. The rationale behind the study was to create awareness and thus facilitate the establishment of an environment that can enable adolescents in South Africa to increasingly enjoy their right to adequate food given the challenges of the nutrition transition. The right to adequate food is laid down in international human rights law especially through the International Covenant on Economic, Social and Cultural Rights as well as the Constitution of South Africa, one of the most progressive constitutions in the world through its Bill of Rights. The right to food is realised when everybody has physical and economic access to adequate food or means for its procurement at all times. “Adequacy” refers to nutritional adequacy, food safety and cultural accessibility. Further the accessibility of such food needs to be sustainable and must not interfere with the enjoyment of other human rights. One of the major strength of a human rights based approach is that the State and other responsible actors for the realisation of the right can be held accountable for not fulfilling their duties and responsibilities.
A case study approach was chosen in the present study as it is exploratory and flexible by nature, making it well suited for investigating human rights dimensions. The data were collected through focus group discussions with the selected right-holders (grade 10 isiXhosa-speaking females from public schools in the Cape Town area), key informant interviews with the selected duty-bearers (government staff, school staff members, NGOs, research units staff and others working within the relevant fields) and review of selected government documents, in terms of relevant reports, legislation, scientific papers, regulations, statements, policies and programme plans.
Four city school and three townships school with learners residing in both formal and informal settlements in the Cape Town area were selected and invited. A total of 25 grade 10 isiXhosa-speaking females (14-16 years old) from two city schools formed three different focus groups (7, 8 and 10 learners in each group). Nineteen key informant interviews with staff members from two city schools and one township schools in the Cape Town area, the Children’s Resource, Education and Training Centre in Cape Town, the Medical Research Council Chronic Diseases of Lifestyle Research Unit and Exercise Unit and government employees at both national and provincial level working with either the School Nutrition Programme at the Department of Education or the Integrated Nutrition Programme at the Department of Health were carried out in the period between March 2006 and August 2006. The main focus of the document review was places in the leading responsible government sectors for nutrition and food which are the Department of Health and the Department of Agriculture. Other supporting sectors were also investigated, such as the Department of Sports and Recreation, the Department of Education and the Department of Social Development.
The most important nutritional and related health concerns that emerged from the data collection were related to the breakfast skipping and unhealthy tuck shop food/school lunch. In the light of human rights these findings transferred to lack of availability and access of adequate food at schools, home, and in the community. In addition, this study showed that there was lack of availability and access to physical activity opportunities during and after school hours for adolescents.
The focus group discussions revealed that traditional norms and preferences are changing both regarding the dietary habits and perceptions concerning the ideal body size/image. Social factors (social norms and a need to “fit in”) appeared to considerably affect the behaviour of the learners, something that became apparent both through the focus group discussions and key informant interviews. The traditional food seems to be losing its importance, while the fast food and more modern/Western food seem to be connected to affluence and social acceptance. Learners seem to experience pressure to buy and eat unhealthy foods in order to show that they can afford it. The conventional view that “big is beautiful” is shifting. Both traditional and more Western body perceptions co-existed among the focus group participants. For example being thin was still connected to illness and unhappiness, which may pressure this population to gain weight. On the other hand, the media was promoting thin body ideals, which in turn may pressure children and adolescents, especially females to go on a diet or develop disordered eating behaviours. Several other important issues emerged from the findings such as lack of enough and satisfactory awareness, motivation and authority to act with regard to the right to adequate food amongst both the right-holders and duty-bearers in question, poor access to and control of resources at all selected levels, and unsatisfactory internal and external communication and coordination. The document review findings showed that issues of the nutrition transition and double burden of nutrition-related disease in South Africa have not been a priority for the government up to this point. Studies show that these problems are significant and present a true health threat to the South African adolescents of all ethical groups. However, with the emerging policies and plans e.g. the school tuck shop policy and Youth Fitness and Wellness Charter, it seems that the government is trying to progressively address these matters in a serious manner.
Methodological constraints that may have biased the data collected in this study relate to language barriers (an assistant was used during the focus group data collection, who also translated and transcribed the focus group recordings); the fact that focus group participant were from city schools only and thus from somewhat better resources household than learners from township schools; limited amount of participants in each of the group and the fact that some participants may have responded in a way they thought the interviewer wanted them to respond. Despite these limitations, a strong degree of consistency was seen between the statements within each group of participants which indicates that the data collected is trustworthy and dependable. The nutrition transition in South Africa is of complex nature because of large differences that exist amongst different ethnic, gender and socio-economic groups, high HIV/AIDS prevalence and high level of poverty. The social context of young people is diverse and there exist numerous socio-cultural realities, ethnic differences and family values and structures which all need to be taken into account when designing policies and programmes in the country. A large proportion of South African youth has been very negatively affected by decades of disadvantage and disempowerment during the Apartheid. The effects are seen in the form of crime, substance abuse, disease, violence and poverty. A feeling of unity needs to be strengthened to erase and overcome the destructiveness of the former regime. Policy decisions should be based on an understanding of the existing diversity and address different needs in different parts of the country. Nutrition and related behaviour measures should try to accommodate heterogeneity that exists in South Africa without discriminating and stigmatising the people. The people need to feel that they are free to preserve their own food habits and related cultural heritage and traditions, but there should be no impediments for those who wish to identify with cultures other than their own either.
The main focus of the government sectors and other working within the field of adolescents’ nutrition and health should be placed on improving the school tuck shops and increasing the level of physical activity during school hours. Further, the media and food industry need to be encouraged to work with the government in order to influence adolescents to make healthy choices and remove the perceived link between higher social status and eating foods that are largely unhealthy. Cultural perceptions regarding food, ideal body sizes and physical activity also need to be addressed without this leading to disrespect and affecting people’s cultural pride and human dignity in a negative manner.
Last, but not least nutrition and health professionals will need to remember that adequate food for all is not just a basic need; it is also a human rights concern. No country can afford to ignore the burden resulting from unhealthy nutrition and physical inactivity, nor can it deny shared responsibility in working towards improving the current situation. It is recommended that human rights and their principles are purposively used in the future because they offer guidelines in what way matters of inadequate food and nutrition can be addressed in terms of policy formulations, implementation, evaluation and monitoring. Further, human rights create a universal platform with recognized standards where governments and national and international organisations can support and assist each other when needed. All these factors provide superior and hopefully sustainable means of counteracting the negative effects of the nutrition transition present among adolescents in South Africa.