To examine power and governance arrangements in food and nutrition policy formulation and agenda-setting in South Africa

Analysis of the policy implementation environment and in-depth interviews were conducted focussing on: existing policy content and priorities across food system sectors; institutional structures for cross-sectoral and external stakeholder engagement; exercise of power in relation to food system policies; and opportunities to strengthen action on nutrition.

South Africa

Interviews were conducted with 48 key stakeholders involved in the food and nutrition policy sphere: government sectors relevant to food systems (n=21), the private sector (n=4), academia (n=10), NGOs (n=11) and farmers (n=2).

This study found that there are power dynamics involved in shaping the planning agenda that is inadvertently generating a food system that undermines the right to food. The concept of nutrition governance remains poorly defined and applied in different ways and usually based on a relatively narrow interpretation – therefore limiting policy coherence and coordination. South Africa has strong legal institutions and practices, and social policies that support public provisioning of food, but a non-interventionist approach to the food system.

The right to food and nutrition, as outlined in the South African Constitution, has not yet been effectively utilized to establish a robust normative and legal basis for tackling the dual challenges of food insecurity and malnutrition. Currently, the governance of the food system is grappling with substantial obstacles, balancing the influence of powerful stakeholders who uphold the status quo against its responsibilities for food justice.

Free school meals (FSM) are a crucial form of support for families. This study aimed to investigate whether the FSM allowance can provide what is perceived to be, healthy, sustainable and satisfying food.

A mixed methods study incorporating co-production, citizen science and participatory approaches was conducted. Citizen scientists were given a daily budget equivalent to the FSM allowance and asked to purchase a ‘tasty, healthy and sustainable’ school lunch for a week. Alongside keeping records of available and purchased foods, young people engaged in focus groups to capture information on perceptions of food offered and FSM allowance adequacy.

Secondary schools in Yorkshire, UK.

Citizen scientists (n 42) aged 11–15 years across seven schools.

Obstacles were faced in obtaining sustainable and healthful meals when restricted to an FSM allowance. Reasons included restrictions in what could be purchased due to costs, limitations in the use of allowances that restricted breaktime purchases leading to hunger, inadequate portion sizes, systemic barriers like hurried lunch breaks that encourage ‘grab and go’ options and broken water fountains that led students to purchase bottled drinks. Findings were reinforced by descriptive food record data.

Our findings suggest that schools would benefit from national policies to address the lack of funding, infrastructure issues and capacity to support optimal provision of food to those on FSM as well as provide greater flexibility in how pupils use their allowance. Young people verified these findings, which they presented to policymakers at a parliamentary event.

This study evaluated the impact of 2015/2016 prescribing guidance on antidepressant prescribing choices in children.

A retrospective e-cohort study of whole population routine electronic healthcare records was conducted. Poisson regression was undertaken to explore trends over time for depression, antidepressant prescribing, indications and secondary care contacts. Time trend analysis was conducted to assess the impact of guidance.

A total of 643 322 primary care patients in Wales UK, aged 6–17 years from 2010–2019 contributed 3 215 584 person-years of follow-up. Adjusted incidence of depression more than doubled (IRR for 2019 = 2.8 [2.5–3.2]) with similar trends seen for antidepressants. Fluoxetine was the most frequently prescribed first-line antidepressant. Citalopram comprised less than 5% of first prescriptions in younger children but 22.9% (95% CI 22.0–23.8; 95% CI 2533) in 16–17-year-olds. Approximately half of new antidepressant prescribing was associated with depression. Segmented regression analysis showed that prescriptions of ‘all’ antidepressants, Fluoxetine and Sertraline were increasing before the guidance. This upward trend flattened for both ‘all’ antidepressants and Fluoxetine and steepened for Sertraline. Citalopram prescribing was decreasing significantly pre guidance being issued with no significant change afterward.

Targeted intervention is needed to address rising rates of depression in children. Practitioners are partially adhering to local and national guidance. The decision-making process behind prescribing choices is likely to be multi-factorial. Activities to support implementation of guidance should be adopted in relation to safety in prescribing of antidepressants in children including timely availability of talking therapies and specialist mental health services.

The adoption of policies promoting healthier restaurant food environments is contingent on their acceptability. Limited evidence exists regarding individual characteristics associated with restaurant food environment policy acceptability, especially health-related characteristics. This study examined associations between health characteristics and restaurant food environment policy acceptability among urban Canadians.

Links between health characteristics and complete agreement levels with selected policies were examined using data in the cross-sectional Targeting Healthy Eating and Physical Activity survey study, that is, a large pan-Canadian study on policy acceptability. For each policy, several logistic multilevel regression analyses were conducted.

Canada’s seventeen most populated census metropolitan areas.

Urban Canadian adults responded to the survey (n 27 162).

Body mass index was not associated with acceptability after adjustments for other health and sociodemographic characteristics were made. Across all policies and analyses, those reporting excellent or very good health statuses were more likely to be in complete agreement with targeted policies than those with good health statuses. For selected policies and analyses, those reporting poor health statuses were also more likely to be in complete agreement than those describing their health status as good. For all policies and analyses, both those consuming restaurant-prepared foods daily and those never consuming these foods were more likely to be in complete agreement than those consuming these foods once per week.

More research is needed to explain discrepancies in acceptability according to health characteristics. Bringing this study’s findings to the attention of policymakers may help build momentum for policy enactment.

In response to increasing hypertension rates, South Africa implemented a regulation which set a maximum total sodium content for certain packaged food categories. We assess changes in reported sodium intake among 18-39 year old adults living in one township in the Western Cape as a result of the implementation of the regulation in 2016.

By linking one set of 24 hour dietary recall data to two versions of the South Africa Food Composition Database which reflect the pre-regulation and post-regulation periods, we calculated changes in sodium intake due to reformulation of food products, not behavior change. We statistically tested differences in mean consumption in this sample with paired t-tests.

Langa, Western Cape, South Africa

Surveyed participants were residents of Langa between 18-39 years old (n=2,148)

Before and after the implementation of the regulation there was a statistically significant decrease in the estimated sodium intake among adults of 189.4 mg (137.5, 241.4; p=0.00). Reported sodium from cured meat (such as Russians) and certain types of soup powder, cereals, and salted peanuts had a 9 to 33 percent lower calculated sodium consumption.

Our conclusions show that independent of any behavioral changes on the part of consumers, it is possible to lower sodium intake by using regulations to induce food manufacturers to lower the sodium levels in their products. As countries explore similar regulatory strategies, this work can add to that body of evidence to inform policies to improve the food system.

To examine underlying political economy factors that enable or impede the integration of nutrition considerations into food system governance.

Comparative political economy analysis of data collected through (1) value chain analyses of selected healthy and unhealthy commodities and (2) food system policy analyses, using a theoretical framework focused on power, politics, interests and ideas.

Ghana and South Africa.

Value chain actors relevant to healthy and unhealthy foods (Ghana n 121; South Africa n 72) and policy stakeholders from government (Health, Agriculture, Trade and Industry, Finance), academia, civil society, development partners, Civil Society Organization (CSO) and private sector (Ghana n 28; South Africa n 48).

Nutrition was a stated policy priority in both countries; however, policy responsibility was located within the health sector, with limited integration of nutrition into food system sectors (including Agriculture, Trade and Industry). Contributing factors included a conceptions of policy responsibilities for nutrition and food systems, dominant ideas and narratives regarding the economic role of the food industry and the purpose of food system policy, the influence of large food industry actors, and limited institutional structures for cross-sectoral engagement and coordination.

Integrating nutrition into multi-sectoral food policy to achieve multiple food system policy goals will require strategic action across jurisdictions and regional levels. Opportunities included increasing investment in healthy traditional foods, strengthening urban/rural linkages and informal food systems, and strengthening institutional structures for policy coherence and coordination related to nutrition.