FACTSHEET: Child malnutrition in South Africa

Child malnutrition, a persistent problem in South Africa, became a topic of controversy during the country’s Covid-19 lockdown. 

In May 2020, Dr Glenda Gray, a leading health professional and chair of the South African Medical Research Council, claimed that child malnutrition cases were increasing after having not been seen for decades. She later clarified that she was referring to just one hospital – Chris Hani Baragwanath Academic Hospital in Johannesburg – and only for the first week of May. 

Health minister Zweli Mkhize strongly denied the claim, producing numbers that showed cases of child malnutrition at the hospital had declined in March and April 2020.

This factsheet gives an overview of child malnutrition in South Africa, now that the dust has settled. When is a child malnourished? What do national figures show? And how has it changed over time?

What is child malnutrition?

Discussions of malnutrition tend to focus on undernutrition. Undernourished children are wasted, stunted or underweight. 

Undernutrition occurs when a child takes in fewer nutrients than required for normal healthy functioning of the body, according to Joanne Katz. She is a professor in the department of international health at the Johns Hopkins Bloomberg School of Public Health in the US.

But malnutrition also includes overnutrition. This refers to children who are overweight or obese.

Child malnutrition is therefore the inadequate, imbalanced or excessive consumption of energy by children.

Statistics are normally reported for children under the age of five. This is because they have the highest burden of disease due to malnutrition, Kerstin Hanson, a paediatrician with international humanitarian organisation Doctors Without Borders, told Africa Check. 

How does a child become malnourished?

Children are at risk of becoming malnourished when they fall ill or when they take in too few or too many nutrients. These include macronutrients, which provide the body with energy and are needed in large amounts, and micronutrients such as calcium and zinc that are needed in smaller amounts but are essential for proper growth and development.

According to the UN Children’s Fund (Unicef), some of the underlying causes of child malnutrition are insufficient access to food, poor health services and a lack of safe water and sanitation. 

What do the numbers show?

The latest data on child malnutrition is collected in a global database on child growth and malnutrition, updated regularly by Unicef, the World Health Organization (WHO) and the World Bank. 

The “joint estimates”, as they are known, are calculated from nationally representative household surveys, carried out every three to five years. The current data includes 854 surveys from 152 countries, representing 90% of the world’s children aged under five. 

South Africa’s numbers are from the 2016 South African Demographic and Health Survey (DHS). 

We took a look at four key measures of malnutrition: wasting, stunting, underweight and overweight. 

• Wasting

A child is considered wasted when they are too thin for their height. It’s an acute form of malnutrition, usually the result of poor nutrient intake or disease. It can also be caused by a child rapidly losing weight or failing to gain weight. 

According to Unicef, the WHO and the World Bank, wasted children have weakened immunity and their development may be delayed over the long term. These children need urgent feeding and care.

The joint estimates show that 2.5% of South African children under five suffered from wasting in 2016. This figure has declined from 5% in 2003.  

The joint estimates also provide comparable estimates from the WHO’s Africa region and the world in 2018. (Note: The WHO Africa region includes 49 of 54 African countries. It excludes Somalia, Eritrea, Sudan, Egypt and Libya, which fall under the WHO’s Eastern Mediterranean region.)

Children under five suffering from wasting
	South Africa	WHO Africa region	World
Percentage of children	2.5%	7%	7.3%

Source: WHO joint estimates. (Note: South Africa’s figures are from 2016. The WHO Africa region and world figures are from 2018.)

• Stunting 

Stunting occurs when poor nutrition impairs the growth and development of children. A child is considered stunted if their height is lower than would be statistically expected for their age.

Stunting – particularly in the first 1,000 days of a child’s life – can lead to problems such as poor educational performance and low productivity later in life.

It is an indicator of long-standing undernutrition and, according to a systematic review conducted in 2015, remained stubbornly high in South Africa over a 20-year period. 

In 2003, 27% of South African children under five were stunted. Although it has fluctuated over the years, the figure remained at 27.4% in 2016, according to the joint estimates.

Children under five suffering from stunting
	South Africa	WHO Africa region	World
Percentage of children	27.4%	33.1%	21.9%

Source: WHO joint estimates. (Note: South Africa’s figures are from 2016. The WHO Africa region and world figures are from 2018.)

• Underweight 

According to Unicef, a child who is even slightly underweight has an increased risk of death and slower cognitive development. The problem can carry across generations as underweight women are more likely to have babies with a low birth weight.

The joint estimates show that 5.9% of South African children under five were underweight in 2016. In 2003, the figure was 12% 

Children under five who are underweight
	South Africa	WHO Africa region	World
Percentage of children	5.9%	17.1%	13.4%

Source: WHO joint estimates. (Note: South Africa’s figures are from 2016. The WHO Africa region and world figures are from 2018.)

• Overweight and obesity 

Overnutrition may cause children to be overweight. Children under five are considered overweight or obese if their weight is higher than would be statistically expected for their age. 

Overweight and obesity in early childhood increases the risk for adult obesity, as well as associated conditions such as high cholesterol, diabetes and high blood pressure. 

According to the 2019 South Africa Child Gauge, a high proportion of children eat unhealthy diets that include sugary food and drinks and salty snacks, leading to increasing levels of childhood overweight and obesity.  

The joint estimates show that 13.3% of South African children under five were overweight in 2016. Overnutrition rates are higher among boys.

The percentage of under-five children who are overweight is significantly higher in South Africa than in the Africa region, and the world. 

Children under five who are overweight
	South Africa	WHO Africa region	World
Percentage of children	13.3%	3.5%	5.9%

Source: WHO joint estimates. (Note: South Africa’s figures are from 2016. The WHO Africa region and world figures are from 2018.)

What does a healthy diet for a child look like?

South Africa has dietary guidelines for people over the age of five. A food guide, used together with the dietary guidelines, suggests the amount and kinds of foods needed. 

“For children under the age of five, the guidelines are a bit more complex,” Catherine Pereira-Kotze, registered dietitian and PhD in Public Health candidate at the University of the Western Cape, told Africa Check. 

In 2013, a set of proposed guidelines and five technical support papers were published in the South African Journal of Clinical Nutrition. 

The guidelines, which are in the final stages of testing, are divided into four age groups: zero to six months, six to 12 months, 13 to 36 months and three to five years.

They encourage exclusive breastfeeding for the first six months of a child's life. After this a variety of foods may be introduced, including meat, eggs, vegetables and fruit, dairy products and legumes, together with continued breastfeeding up until two years and beyond. Parents are advised to avoid foods high in salt, fat and sugar. 

Although the health department has not yet officially adopted the guidelines, they are already being used to guide health professionals, Pereira-Kotze said.