Urban food systems for healthy diets in South Africa: Addressing the double burden of malnutrition through a coherent systems approach

Lead Research Organisation: City, University of London
Department Name: Sch of Social Sciences


In every country in the world, especially poor countries, people experience ill-health because of what they eat. Not eating enough nutritious foods, and eating too many unhealthy foods means young children do not grow properly, women do not get enough vitamins and minerals, and many more people are affected by overweight and diseases like diabetes. This is often called "malnutrition" and is especially serious for young children, including babies, many of whom are not properly breastfed or receive inadequate nutrients when they are under the age of five.

One country with a major malnutrition problem is South Africa. Most people in South Africa live in cities, where life is difficult for poor people. These people have long travel times to work and live in tiny houses. This makes it really difficult for them to store and prepare nutritious foods at home. As a result, they often rely on food that they can eat straight away or does not spoil, like fatty fried food and sugary snacks and drinks. Because they have so little money and time, they often feed babies watery, starchy foods without enough nutrients. Where they live and work, this food is readily available and cheap. In fact, the whole system of things that bring food into their neighbourhoods makes it easier and cheaper to create an environment around them that's full of the wrong types of food. This system is known as a "food system." This all means, too, that the many efforts the government has made in South Africa to help people eat better have not really reached their potential, efforts such as the extra money they give to poor families for their children, or programmes designed to help them feed their toddlers better. While South Africa has its own specific context, this is also the case in many other countries around the world.

In our project, we want to change this. We want to see a whole system of actions that will actually work for people who live in cities. This means ensuring that existing actions to help them are better aligned with and supported by that food system, as well as designing new actions within the system that recognise the challenges in peoples' lives.

We are going to provide evidence to know what this system of actions would look like. We will do this in a way that is not done very much: to actually start by listening to the people in urban settings who experience the problems we are talking about. We will talk to families who have children under the age of 5, as this is the group the evidence says needs most support, along with their mothers and other women who might have babies quite soon. We will walk with them around their neighbourhoods and find out what influences the foods they eat, and what could change that. We will talk to them about the ways the government already tries to help them and whether they know about them, or are able to respond to them. And together with them, we will design a system of actions that would actually work for them and their children. We will also talk to the government about what they can do, especially about changes further back into the entire food system, as well as in urban planning. And we will bring into a broader conversation all the people who have influenced what these people eat. Together we will work to design a system that supports children and their mothers eating foods that support their health and development.

We will do this in two communities in the fourth largest province in South Africa: the Western Cape. We have chosen that place because the local government is already committed to improving food systems to address poor nutrition in their communities, and have asked us to help them identify what could effect real change. Although we will conduct this study in South Africa, it will be relevant to the region and the whole world. So we will produce reports and other materials that help other people in other cities create a more effective response to poor diets in their communities.

Planned Impact

The long-term vision of this study is to contribute to a reduction in the double burden of malnutrition in urban settings in the Western Cape, South Africa by improving the quality of diets among women and children under 5. The realization of this vision is beyond the timeframe of the proposed work, so we seek to establish the conditions under which this vision can be met. We seek to do so by increasing knowledge and shared understanding; enhancing agency and accountability; and accelerating implementation of effective action.

We seek to benefit five groups of beneficiaries, four of whom (1-4) are directly involved in the study:
(1) Women and children under the age of 5 at risk of malnutrition in urban areas of the Western Cape. They will benefit by eating more nutritious diets and having greater capability to respond to interventions designed to address the double burden of malnutrition.
(2) The Government of the Western Cape. The study has been designed to inform and make recommendations to aid the provincial government in delivering its Nourish to Flourish food systems strategy to improve nutrition and food security.
(3) Stakeholders in the systems relevant to the double burden of malnutrition in the Western Cape and beyond. The study will include the creation of 100-Day Action plans for all stakeholders to initiate the delivery of a systems approach and create shared accountability.
(4) UNICEF and its regional and country programme offices. UNICEF will be involved in dissemination of communications outputs and benefit from a better understanding of how to take forward its new Food Systems for Children programme, especially in urban settings.
(5) The Government of South Africa and other DAC countries in the region and around the world, and the low-income urban populations at risk of the double burden of malnutrition whom they serve. We will produce communications outputs to increase knowledge and understanding of a systems approach nationally, regionally and internationally.

The pathways to this impact would be by:
(i) Involving ultimate beneficiaries in to research as part of the co-creation of knowledge. Women with children under the age of 5 will actively participate in knowledge generation through community-based participatory research methods. This process of activating citizenship is known to be a crucial capacity development strategy to increase impact for community members.
(ii) Involving the government of the Western Cape in the design of the study and throughout the proposed work. The Department of the Premier has participated in the design of this proposal, expressed commitment to the project and is anticipating it will provide recommendations and guidance which they can implement. We will work together throughout the project as part of the research team, feeding back through Steering Committee meetings and informal discussions whenever necessary.
(iii) Involving the ultimate beneficiaries, government partners and food system and other relevant stakeholders in a process of co-production. The process of co-producing what a systems approach would look like will enable all beneficiaries to come to collective agreement of the transformative actions needed, and to generate shared accountability for initiating action.
(iv) Carefully crafting communications outputs and a dissemination strategy to reach beneficiaries at a provincial level and nationally and internationally. Different outputs will be crafted to target different beneficiaries, and disseminated at influencing opportunities.

These impact activities will take place throughout the study with a budget of approximately £60,000.


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Title 'WhatsApp' Protocol (Transect Walk adaptation) 
Description The purpose of this methodological tool is to generate participant dialogue (in the form of a text or voice note exchange between the participants on WhatsApp) to "make meaning" of how and why key aspects of their local food, infrastructure, and social systems shape their (and their children's') food consumption and health. The framing of this methodological tool is informed by the project's existing intervention scan that sought to understand how programmes and policies of the state could impact these three systems and participants' experiences of them. This new tool is an adaptation of the originally proposed Transect Walk approach. The change was made due to local COVID-related lockdown restrictions. 
Type Of Material Improvements to research infrastructure 
Year Produced 2021 
Provided To Others? No  
Impact We are now able to still meet our originally proposed study aims as a result of this new approach. 
Description Presentation at one of 4 founding meetings of the Provincial Government of the Western Cape Food and Nutrition Systems Working Group (PF&NSWG) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Policymakers/politicians
Results and Impact The purpose of the presentation to the PF&NSWG was threefold; firstly it was to truth the NIS and to ask if there were components missing from the scan. Secondly, this presentation was intended to support the wider development of the PF&NSWG and to concretise the identified need of the leaders of the PF&NSWG stressing that food and nutrition was intersectoral and transversal in nature and as a result, this drove the needed responses, approaches and governance actions. Finally, the presentation sought to introduce the PF&NSWG to the Nourished Child project and to offer support and create a collegial space for engagement, testing the receptiveness from the different departments to the approaches applied in the project.
Year(s) Of Engagement Activity 2021
Description Presentation of the Nutrition Intervention Scan (NIS) to the lead author of the provincial food and nutrition strategy, Nourish to Flourish, and strategy head in Department of the Premier of the Provincial Government 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Policymakers/politicians
Results and Impact The online and virtual presentation (given Covid19 protocols) served three key purposes: The first was to update the Head of Strategy in the DotP on the NIS and to present the key findings and observations. Secondly, the presentation was to serve as a truthing exercise to identify gaps in the NIS, but at the same time identify areas where innate internal knowledge of these intersecting systems require an alternative perspective or approach. Finally, given the nature of the NIS, the presentation also served to inform the head of strategy about this work, but in doing so, offer spaces for this work to be used to support ongoing DotP food and nutrition system activities.
Year(s) Of Engagement Activity 2021
Description Presentation to the Principal Resilience Officer at City of Cape Town, introducing and truthing the Nutrition Intervention Scan (NIS). 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Policymakers/politicians
Results and Impact The Resilience Department in the City of Cape Town is one of the few City scale departments who focus explicitly on the urban food system as one of their active areas of work, research focus and policy engagement. In the initial stages of the NIS work, an early draft was submitted to the City Resilience Department for comment and review. Feedback from this initial review was later used to refine the NIS. Given this process, a feedback and presentation session to the Resilience Department principal officer formed part of a longer run strategic engagement with the city. Also given the leading role that the Resilience Department has played in urban food system related issues, this presentation was also used as a means to not only test the NIS, but also to collaboratively strategize, in a manner that was mutually beneficial, how other presentations and engagement with a wider collection of city officials would best be run. Additionally, after presenting the NIS, the principal resilience officer has asked that this work be presented to the City Food System Working Group, a city scale transversal working group led by the Resilience Department, trying to better understand and engage in food system issues at the urban scale.
Year(s) Of Engagement Activity 2021