Discussion

This study explored how children with CP experience feeding and nutrition within the South African food environment. The findings suggest that feeding challenges for children with CP extend beyond clinical swallowing impairments and are shaped by structural conditions and knowledge that influence food availability, affordability and preparation within households. Interpreted through the dimensions of food security, availability, access, utilization and stability, the results indicate that children with CP experience distinct vulnerabilities across the food system. A food sovereignty perspective further highlights how inequalities within food systems influence which foods are produced, distributed and economically accessible, shaping children's nutritional opportunities (Moyo and Thow 2020; Pillay 2022; Weiler et al. 2015).

A key contribution of this study is demonstrating that feeding challenges are not experienced uniformly among children with CP. Children with greater functional severity (EDACS III–V) were more vulnerable to constraints across the food system. Rather than reflecting individual‐level feeding limitations alone, these differences illustrate how disability interacts with structural inequalities within food environments (Adams et al. 2024; Goh et al. 2018). In contexts where healthcare, specialized feeding services and disability‐responsive nutrition support are limited, functional severity intensifies existing household vulnerabilities (Zhao et al. 2025). Food insecurity for children with CP therefore emerges from the intersection of disability, poverty and structural inequalities within national food systems (Khan et al. 2025; Moyo and Thow 2020).

Feeding Children With CP Within a South African Food Environment

Although food was widely available within formal retail environments, this did not necessarily translate into foods suitable for children with CP. Conventional definitions of food availability focus on the physical presence of food within markets (Sabaté 2019). However, children with CP often require texture‐modified foods, thickened liquids and nutrient‐dense diets to support safe swallowing and growth (Chichevska‐Jovanova et al. 2025; Sleigh 2005). The findings in the current study showed that children's diets appeared to be dominated by staple carbohydrates, commonly available protein sources, dairy products and fruit, while consumption of some vegetables and certain traditional foods varied across participants. These patterns likely reflect the intersection of feeding abilities, caregiver adaptations and the broader household food environment (Moyo and Thow 2020). These findings suggest that children with CP in this study were exposed to a diverse but nutritionally uneven food environment, where staple foods and easily prepared items were most consumed. Dietary patterns appear to be shaped by a combination of caregiver feeding adaptations, child feeding abilities, household affordability, knowledge, equipment and broader food system factors.

Affordability emerged as a key factor shaping the foods available to children with CP. Food purchasing decisions in South African households are strongly influenced by cost (Chakona and Shackleton 2019; Tuomala and Grant 2022). For children with CP, whose diets may require higher energy and protein intake and additional vitamins and minerals due to some medications, financial constraints may limit access to nutritionally appropriate foods (Hillesund et al. 2007; Kuperminc et al. 2013). Although social grants provide important support, previous research indicates that they may not adequately offset the additional costs associated with disability‐related care (Granlund and Hochfeld 2020). Consequently, households may face persistent challenges in securing foods that meet both nutritional and feeding safety requirements. As a result, we see that economic pressures shape dietary patterns in ways that may inadvertently compromise nutritional adequacy, reinforcing what has been described as the double burden of malnutrition in South Africa (Moyo and Thow 2020).

Food utilization is particularly relevant for children with CP because safe ingestion depends on both physiological and environmental factors. Dysphagia, oral–motor impairment and gastrointestinal complications commonly affect feeding in this population (Sleigh 2005; Taylor et al. 2025). Caregivers in this study described modifying food textures and adapting feeding practices to support safe eating. Similar caregiver adaptations have been reported in other LMICs where access to multidisciplinary feeding services is limited (Adams et al. 2012; Ahmadizadeh et al. 2015; Kisinna et al. 2025; Makhoul et al. 2026). In addition, caregivers reported on prolonged mealtimes as a challenge. Previous research has shown that children with cerebral palsy, including those with milder functional impairment such as EDACS I, often demonstrate a reduced dysphagia limit per sip or bite, meaning the amount of food safely swallowed at one time is significantly smaller (Schepers et al. 2022). As a result, the total amount of food consumed within a typical 30‐min mealtime may be substantially reduced, increasing the importance of ensuring that available foods are nutrient‐dense and of high nutritional value. This highlights that food security is not only about access to food quantity but also access to foods that provide sufficient nutritional benefit within the child's swallowing and feeding capacity. These findings highlight the importance of caregiver knowledge and access to professional feeding support in promoting safe food utilization.

Food stability refers to consistent access to adequate food over time (FAO 2008). Caregivers described how rising food prices, employment instability and caregiving demands affected household food purchasing patterns. These experiences reflect broader structural conditions within South Africa, where economic inequality and unemployment contribute to persistent household food insecurity (Chakona and Shackleton 2019; Odunitan‐Wayas et al. 2018). For children with CP, disruptions in food access may have greater consequences because feeding routines often depend on consistent access to specific foods and preparation methods.

While the food security framework highlights structural barriers to nutrition, a food sovereignty perspective emphasizes issues of equity and control within food systems (Moyo and Thow 2020). Disability is rarely considered within food sovereignty discussions. The findings suggest that children with CP occupy a marginal position within current food environments, where affordability, cultural food practices and feeding safety must be negotiated simultaneously (Battersby and Crush 2014; Chakona and Shackleton 2019). In South Africa, the absence of CP‐specific nutritional guidelines and limited professional training on disability‐related food insecurity further compound these challenges (Jacobson et al. 2024; Quarmby and Pillay 2018). Addressing these gaps will require integrating disability considerations into both nutrition policy and food system planning. Without such reforms, nutritional vulnerability and caregiver burden will persist, undermining both child development and family well‐being.

A strength of this research included the use of a mixed methods research design. Nuanced caregiver narrated experiences could be explored alongside the quantitative data obtained which provided better understanding of the results for the researcher. The data collection tools (e.g., GMFCS, EDACS and HFIAS) used in this study have been used in other research studies and have been validated. Tools were also adapted for the South African context such as the food included in the FPQ. However, limitations are acknowledged. The small sample size and use of purposive sampling limit the generalizability of the findings beyond South African children with cerebral palsy and to other disability groups or contexts. As data were collected at a single point in time, the study does not capture changes in experiences over time, particularly understanding the sensitive nature of food security. Additionally, interviews were conducted in English only, which may have restricted participants' expression. Although survey and qualitative data were triangulated and piloted, variation in caregiver interpretation of survey items may have influenced responses. These limitations should be considered when interpreting the findings, which nonetheless provide useful insights to inform practice and highlight the need for further research with larger and more diverse samples across different countries.