Drivers and levers of the double burden of malnutrition in Cape Town, South Africa: insights from in-depth interviews with multi-sectoral stakeholders

South Africa faces a high burden of malnutrition, including undernutrition, overweight, obesity, and diet-related non-communicable diseases. This coexistence and interaction of multiple forms of malnutrition within individuals and communities across the life-course is referred to as the double burden of malnutrition (DBM) and has complex, interrelated causes that need to be concurrently addressed. This qualitative study explored the drivers and potential leverage points of the DBM at individual, household, community, and (local) policy level in the Cape Town Metropolitan region. From November 2023 to April 2024, 35 in-depth, semi-structured interviews were conducted with community health workers (CHWs) and CHW coordinators, researchers, civil society representatives, and government employees. Interviews were conducted in isiXhosa or English, and transcribed and translated into English where necessary. Coding and analysis drew from grounded theory and complex systems thinking. Across the individual, household, community, and local policy level, four central drivers of the DBM emerged: financial constraints, other resource constraints, food and nutrition literacy, and food quality of informal food business. At the individual and household level (micro-level), two additional barriers were identified: abuse of alcohol and other drugs and a lack of individual accountability. At the community and local policy level (meso-level), additional challenges included the power of the formal food industry, political inertia, and a siloed government approach. Leverage points at the micro-level included government social support programs and food gardens. At the meso-level, leverage points included an emphasis on the first 1000 days of life, food sensitive urban planning, strengthening networks, and adopting a systems response. This study revealed drivers of the DBM at the micro- and meso-level in Cape Town, as well as potential leverage points. By understanding the lived realities of those experiencing and working with the DBM, researchers can better understand the interconnected drivers and how these drivers manifest in everyday life. Local solutions to address the complex issue of the DBM require multi-sectoral stakeholder perspectives.