Nutritional Status of Landfill Waste Pickers: Comparison
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Please note this is a comparison between Version 3 by Beatrix Zheng and Version 2 by Beatrix Zheng.

Waste pickers are an extremely vulnerable population from an occupational health perspective. In addition, their precarious income generation and fierce relative competition for “spots” on landfill sites to seek out a livelihood compromise their health seeking behaviour, yet they contribute to reduction of waste to landfill sites and environmental sustainability. Knowledge and understanding of the lived realities of waste pickers should guide service delivery planning by community nutrition and public health practitioners. 

  • waste pickers
  • nutritional status
  • dietary intake
  • dietary diversity
  • South Africa

1. Introduction

Nutrition is a critical component of health and development, with adequate nutrition aiding the prevention of malnutrition in all its forms, improving productivity and creating opportunities to gradually break the cycles of hunger and poverty.
South Africa is an upper-middle-income country with a culturally diverse population estimated at 59.6 million people [1]. Social, health and economic disparities remain and are aggravated by persistent high poverty, entrenched structural inequality and unemployment [2][3][4]. The country is experiencing rapid epidemiological transition, with noncommunicable diseases (NCDs) increasing to be the major cause of death, with an estimated 269,000 NCD related deaths annually [5]. This increase as well as the substantial higher burden is particularly noted among lower socioeconomic groups and obese persons [6][7][8].
The nutrition situation in South Africa is complex and typical of a country in nutrition transition. Undernutrition, notably stunting and micronutrient deficiencies, coexist with a rising incidence of overweight and obesity and the associated consequences such as NCDs [9]. The South African food system is highly commercialised with the majority of households purchasing all their food. The food system is furthermore characterised by cultural and socioeconomic diversity and high levels of income inequality, rendering vulnerable population groups at risk of food insecurity and hunger [10].
The percentage of the population that experienced hunger decreased from 29.3% in 2002 to 11.3% in 2018 and the percentage of people with limited general access to food decreased from 29.1% to 23.8% from 2010 to 2018 [10]. However, the COVID-19 pandemic foregrounded the failures of the food system to provide sufficient, healthy, nutritious food and to serve the most vulnerable people in South Africa, potentially reversing progress achieved in the reduction of hunger of the past two decades. The National Income Dynamics Survey, Coronavirus Rapid Mobile Survey (NIDS-CRAM), a monthly nationally representative panel survey conducted since May 2020, indicated immediate adverse effects on employment and food security and widening inequality. Between March and June 2020, 40% of the NIDS-CRAM sample reported the loss of employment as a result of COVID-19 and 22% of adults and 15% of children were reported to have gone to bed hungry [11][12].
Waste is an unavoidable byproduct of human activities and if accumulated in large quantities, it can lead to degradation of the environment, natural resources and health problems [13]. It is estimated that South Africa generated approximately 54.2 million tons of waste in 2017, of which an estimated 20.7 million tons were recycled. In addition, South Africa produces approximately 31 million tons of food annually, of which an estimated 10 million tons (34.3%) is lost to waste [14].
The commercialisation of waste management, coupled with an increase in recycling practices and unabated unemployment resulted in the survivalist activity of informal waste picking by the poorest and marginalised on landfill sites [15][16]. Their diversification of livelihood is an important strategy towards poverty alleviation. Waste pickers collect, sort, recycle, repurpose and/or sell materials thrown away by others; salvaging and revaluing waste through the recycling value chain [17]. While some rummage in search of necessities, others collect and sell recyclables to middlemen or businesses or work in recycling warehouses or plants owned by their cooperatives or associations [15][18]. In South Africa, there are an estimated 60,000 to 90,000 informal waste pickers operating at different levels [18].
These informal waste pickers operate at the lowest level in the hierarchy of entities that collect and dispose of waste, including municipal waste collection services and recycling structures. Yet they significantly contribute to the economy in general and the recycling economy in particular [19]. Nationally, it is estimated that waste pickers save municipalities up to R750 million per year by collecting waste at no cost and saving landfill space [20]. While waste pickers are typically scorned and treated as a nuisance, their valuable contribution towards waste management and recycling industries are increasingly being recognised and valued by the South African government and stakeholders in the waste industry; with several attempts to integrate waste pickers into formal waste and recycling structures [19]. Their contribution to the economy is in stark contrast to the meagre, and extremely variable, mean financial benefit from informal waste picking trade activities of R451.90 (less than 30 USD) per week in a case study by Schenck et al. in 2018 [21]. Considering that each waste picker in the above case study had a mean of four financial dependents, their household income would seldom exceed the poverty line of R1 268 (82 USD) per person per month [22].
Waste pickers were particularly hard hit by the initial national lockdown regulations following the outbreak of COVID-19, demonstrating their vulnerability to socioeconomic factors. As an informal sector, waste picking was not regarded as an essential service and waste pickers were dismissed for the role they play in the waste sector, resulting in income loss, hunger and reliance on food relief efforts. Reports regarding a lack of consultation and communication with stakeholders demonstrate how the impact of the pandemic extended beyond the immediate risk of infection to further adverse effects related to policy decisions [23].
Although it has been documented that waste pickers obtain food through their activities, the exact contribution of their “findings” to their dietary intake is difficult to quantify, and largely unknown. No scientifically analysed information is available on the nutritional status and dietary intake of waste pickers in South Africa.

2. Current Insights

While dietary intake of the research participants varied greatly, the total energy consumption was below the recommended intake range. With regards to macronutrient distribution, most participants had an excessive consumption of carbohydrates, adequate intake of proteins and inadequate intake of fats. None of the participants met the recommended intake for fibre. Micronutrient intake was mostly adequate according to the recommended dietary intake, except for potassium, vitamin C and vitamin D. While the sodium intake for the research population was at an acceptable level, a proportion of the population had a very high sodium intake due to the type of foods found at the sites where they worked. The overall dietary diversity among research participants was very low, with little variation between sites.
Consumption of a variety of foods is required to ensure adequate nutrient intake. The availability and affordability of highly processed foods are considered important drivers of poor nutrition [24]. On the other hand, dietary patterns characterised by higher intakes of unprocessed foods are linked to more positive health outcomes [25]. However, for the most vulnerable groups, nutrient-rich foods such as animal-source foods, fruits and vegetables are not affordable [26][27].
The quarterly labour force survey of the fourth quarter of 2020 reports the official unemployment rate in South Africa at 32.5% [28]. Many individuals and households, therefore, rely on social support as a source of income, with 31% and 44.3% respectively being dependent on social grants in 2018 [10]. Thirty-four per cent of participants benefitted from social grants with either themselves or other household members receiving a grant [29].
Waste picking is not a choice or preference, but rather a source of income for those desperate to make a living, and in some instances also a source of food. People with a low income may consume a less healthy diet due to energy-dense foods being relatively cheap sources of energy, but with a low nutrient density. A healthy diet remains unaffordable for most South Africans [26][27]. Waste pickers are regarded as vulnerable to economic instability. A high level of food insecurity—not having physical and/or economic access to sufficient food to meet dietary needs for a productive and healthy life at all times—was measured among the waste pickers included in this research and reported elsewhere [21]. Overall, 20% of the participants reported going to bed hungry at night and a further 18% reported going for a whole day and night without eating. In this study, two participants reported not eating or drinking anything during the previous day. Food sources included food brought from home, bought as ready meals, found on the landfill site or shared by other waste pickers [21].
The morbidity and mortality rates related to obesity and NCDs are higher among people from socioeconomically disadvantaged groups, due to poor food choices which mostly include energy-dense foods and low nutrition density [30]. The prevalence of obesity among the adult population in South Africa is increasing alarmingly, with more than a quarter of the female adult population estimated to be overweight and almost a third obese [31]. The prevalence of overweight and obesity in women has increased by 21% between 1998 and 2016 [9][31]. In addition, 31% of adult men are overweight or obese, an increase of 2% since 1998 [9][31]. In contrast to the burden of overweight and obesity, 3% of the South African female adult population and 10% of the male adult population are underweight and a dual burden of child undernutrition and adult obesity exists with 27% of children under the age of 5 years being stunted—a sign of chronic undernutrition [31].
The BMI of more than half of the waste pickers in this research was within the normal range. Underweight and overweight/obesity of female and male waste pickers were statistically significantly different. Of concern, the prevalence of underweight among male participants was double that of the national male population [31]. As illustrated in Table 1, underweight in both males and females were higher than the lowest wealth quantile in the national SADHS, 2016 [32]. Overweight and obesity was low in males, but in the female research population it was comparable to the lowest wealth income quantile of the SADHS 2016 albeit lower compared to the general South African population [31]. It is known that the prevalence of overweight and obesity varies among different population groups and the severity of obesity increases with increasing wealth [31], although overweight and obesity is very high in South African females regardless of wealth quantile. The lower prevalence of overweight and obesity among the research population, compared to the national population is therefore potentially attributed to their socioeconomic status. The prevalence of overweight and obesity however remains a concern, due to the association with NCDs, the leading cause of death in South Africa [2]. Access to public health services for NCD related treatment for waste pickers may be limited especially given the high opportunity cost as their daily survival is based on their engagement at the landfill sites at critical times of waste deposits.
Table 1. Comparison of BMI of waste pickers with 2016 SADHS* findings.
  Sex Underweight Overweight/Obese
Severely Thin ≤17 Mildly Thin (>17<18.5) Total Thin (≤18.5) Total Overweight (≥25) Overweight (>25<30) Obese (≥30)
Waste pickers 2015/16

(Chi-square p < 0.001)		 Male

(n = 110)		 10 (4.6%) 26 (11.9%) 36 (16.5%) 19 (8.7%) 16 (7.3%) 3 (1.4%)
Female

(n = 190)		 3 (1.8%) 8 (4.8%) 11 (6.7%) 84 (50.9%) 38 (23.0%) 46 (27.9%)
TOTAL

(n = 300)		 13 (3.4%) 34 (8.9%) 47 (12.2%) 103 (26.9%) 54 (14.1%) 49 (12.8%)
SADHS 2016 *              
Lowest wealth quantile # Male 2.9% 7.0% 9.9% 17.4% 14.1% 3.3%
Total 2.1% 7.4% 9.5% 31.3% 20.3% 11.0%
Lowest wealth quantile # Female 0.6% 2.4% 3.0% 57.3% 27.8% 29.5%
Total 0.5% 2.1% 2.6% 67.7% 26.6% 41.0%
* South African Demographic and Health Survey, 2016 [26]. # The wealth quantile was based on a wealth index that scores households on the number and kinds of consumer goods owned using principal component analyses. Lowest wealth quantile represents 20% of SADHS 2016 [26] population that has fewest assets including those of lowest value.
Representing the leading cause of mortality worldwide (71% of all deaths), the prevalence of NCD multimorbidity is exploding in low- and middle-income countries, and substantially increasing in sub-Saharan Africa, particularly among lower socioeconomic groups and obese persons [9][10][11]. A large study (n = 1025) amongst waste pickers in the largest dumpsite in Latin America found 32.6% to be overweight and 21.1% obese, with a 24.2% prevalence of hypertension 24.2% and 10.1% of diabetes [33]. Another study from Brazil established that 29.5% of 253 male-dominant (86.2%) pushcart waste pickers in the city of Santos were overweight or obese [34]. Auler et al. (2014) reported a much higher prevalence of overweight (51.1%) and obesity (25.7%) with hypertension (32.8%) and diabetes (11.4%) among 268 waste pickers in southern Brazil [35].
In the absence of national data on the dietary intake of adult South Africans, a recent review of dietary surveys in the adult South African population from 2000 to 2015 [36] concluded that energy intake varied from low intakes in informal settlements to very high intakes in urban centres. Macronutrient intake varied similarly to energy intakes but remain within acceptable minimum distribution ranges [36]. Overall, food consumption patterns in the country have dramatically shifted towards a concerning overall increase in daily energy intake, a diet of sugar-sweetened beverages, an increase in the proportion of processed foods and animal source foods, added sugar and a shift away from vegetables [37].
Many low-income households consume monotonous, low-quality diets, typically cereal-based and lacking in vegetables, fruit and animal-source foods [38]. Monotonous diets and a lack of dietary diversity is closely associated with food insecurity [39]. The risk of micronutrient deficiencies also increases when dietary diversity is low [40] although it should be noted that mandatory fortification of maize meal, wheat flour and bread [41] is assumed to have contributed to the micronutrient content of diets of the waste pickers. Dietary diversity is a proxy for nutrient adequacy [42]. National food diversity was evaluated in 2009 as a proxy for food security, with a dietary diversity score below 4 regarded to reflect poor dietary diversity and poor food security [43]. Overall, a national level dietary diversity score of 4.02 reflects that the majority of South Africans consumed a diet low in dietary variety, albeit with significant provincial differences. Low dietary diversity correlated with socioeconomic status, lower-income groups having the lowest dietary diversity score of 2.93 [43]. At 2.465, the average dietary diversity score of waste pickers included in this research is lower than the average score of low-income groups in the national evaluation; implying that waste pickers are at explicit risk of food insecurity and micronutrient deficiencies due to inadequate diets.
Food groups most commonly consumed, according to the evaluation of national dietary diversity [43], included starchy staples, meat and fish, dairy and vegetables other than vitamin A rich food. Eggs, legumes and vitamin A-rich fruits and vegetable were the least consumed among the national population. Similarly, the most commonly deficient food groups observed in a recent review of dietary surveys in South Africa included vegetables and fruits, and milk and milk products [36]. Based on reported intake over the past 24 h, 49% and 59% of participants in the 2016 Demographic and Health Survey reported consuming fruit and vegetables respectively, with variations between population groups and according to income status [31]. It is a global trend for low-income households to spend less on fresh produce than higher-income households [44]. Of further concern, the consumption of fresh vegetables in South Africa declined whilst consumption of ultra-processed foods increased dramatically between 1994 and 2012 [37].
Fruit and vegetable consumption amongst waste pickers in this research is much lower than the reported national consumption and confirms that these foods are not accessible and/or affordable to socially vulnerable populations. A low intake of fruits and vegetables are of particular concern in relation to micronutrient deficiencies. Meat was the food most commonly collected on landfill sites [21]. This would explain why most of the waste pickers consumed foods from the meat and fish group, contrary to what would be expected due to their socioeconomic status as it was sometimes obtained from the sites and not bought with household income. The variation in overall dietary intake among waste pickers in this research is likely an indication of varied access to food retrieved from the landfill site.
Frequent consumption of food products not beneficial to health, such as sugary drinks, is of concern. According to the 2016 South African Demographic Health Survey [31], 36% of participants reported drinking any sugar-sweetened beverage (607 mL on average) and 14% reported drinking fruit juice (304 mL on average). A similar proportion of waste pickers in this research reported consuming sweetened beverages. The absence of access to water on the landfill sites [29] may be contributing to the consumption of sugary beverages.
With food production, processing and marketing being driven by profit, ultraprocessed food is becoming increasingly available and affordable [45]. At the same time, food security and the nutritional status of the most vulnerable population groups are likely to deteriorate further due to the health and socioeconomic impacts of the COVID-19 pandemic [38]. In South Africa, it is estimated that 9.34 million people faced high levels of acute food insecurity by the end of 2020 with projections of a further increase with regards to the number of people affected.
Particular attention should be paid, through policy interventions, to curb increasing food prices and the energy cost of food preparation. Access to and the affordability of nutrient-dense foods, by the most vulnerable and marginalised populations, including waste pickers as a particularly vulnerable group, should be improved. This may include, but are not limited to, policies to make healthy food options more affordable with consideration of a subsidy for the vulnerable, increased targeted social protection including food relief, and an extension of the health promotion levy to tax other unhealthy food items.

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