Secondary anthropometric data analysis of the National Food Consumption Survey in South Africa: the double burden

TFOS lifestyle: Impact of societal challenges on the ocular surface

Societal factors associated with ocular surface diseases were mapped using a framework to characterize the relationship between the individual, their health and environment. The impact of the COVID-19 pandemic and mitigating factors on ocular surface diseases were considered in a systematic review. Age and sex effects were generally well-characterized for inflammatory, infectious, autoimmune and trauma-related conditions. Sex and gender, through biological, socio-economic, and cultural factors impact the prevalence and severity of disease, access to, and use of, care. Genetic factors, race, smoking and co-morbidities are generally well characterized, with interdependencies with geographical, employment and socioeconomic factors. Living and working conditions include employment, education, water and sanitation, poverty and socioeconomic class. Employment type and hobbies are associated with eye trauma and burns. Regional, global socio-economic, cultural and environmental conditions, include remoteness, geography, seasonality, availability of and access to services. Violence associated with war, acid attacks and domestic violence are associated with traumatic injuries. The impacts of conflict, pandemic and climate are exacerbated by decreased food security, access to health services and workers. Digital technology can impact diseases through physical and mental health effects and access to health information and services. The COVID-19 pandemic and related mitigating strategies are mostly associated with an increased risk of developing new or worsening existing ocular surface diseases. Societal factors impact the type and severity of ocular surface diseases, although there is considerable interdependence between factors. The overlay of the digital environment, natural disasters, conflict and the pandemic have modified access to services in some regions.

Overweight and obesity in preschool children in Turkey: A multilevel analysis

Childhood obesity/overweight is a worldwide concern and its prevalence is increasing in many countries. The first aim of this study is to analyse the trends in overweight and obesity among children under the age of five in Turkey based on the new World Health Organization (WHO) standards, using data from the 'five-round of the Turkey Demographic and Health Surveys' (TDHSs). The second aim is to examine whether or not the maternal/household and individual-level factors are associated with overweight/obesity using TDHS 2003, 2008, and 2013 datasets. A total sample of 14,231 children under the age of five were extracted from the TDHS in 1993, 1998, 2003, 2008, and 2013 to determine the prevalence of the trend. Pooled data from 8,812 children were included in the analysis to examine factors associated with overweight/obesity. Taking into account the clustered data structure, multilevel logistic regression models were utilised. In 1993, 1998, 2003, 2008, and 2013 the prevalence of overweight children was 5.3%, 4.9%, 10.0%, 11% and 11.6%, respectively. The factors that were independently associated with overweight/obesity were as follows: living in single-parent households (adjusted odds ratio (aOR) = 2.27, 95%CI = 1.21-4.26), compared to living in dual-parent households; having an obese mother (aOR = 4.25, 95%CI = 1.73-10.44), overweight mother (aOR = 3.15, 95%CI = 1.29-7.69), and a normal-weight mother (aOR = 2.70, 95%CI = 1.11-6.59) compared to having an underweight mother; being aged between 13-24 months (aOR = 1.72, 95%CI = 1.30 to 2.27), compared to being aged 0-12 months; male gender (aOR = 1.30, 95%CI = 1.11 to 1.53); being stunted (aOR = 2.18, 95%CI = 1.74 to 2.73); high birth weight (aOR = 1.55, 95%CI = 1.08 to 2.23) compared to low birth weight. In addition, overweight was higher in children of mothers who had completed primary school (aOR = 1.21, 95%CI = 1.01 to 1.59) than children of mothers who had not completed primary school. These findings reveal that, over the years, there has been a substantial increase in obesity/overweight among children which demonstrates the importance of evaluating the overweight indicators at the maternal/household level.

The Influence of a 9-Week Movement Program on the Body Composition of 7- to 8-Year-Old Schoolchildren in the Eastern Cape of South Africa

Pediatric obesity has become a growing global epidemic which has negative health consequences, including for South African children. This study aimed to determine the immediate and sustainable influences of a 9-week movement program on the body composition of 7 to 8-year-old school children in a rural area of South Africa. A two group, pre-test, post-test and re-test after six months experimental design was used to compare anthropometric measurements of the intervention group (IG) and control group (CG). Ninety-three schoolchildren (IG = 57; CG = 36) participated in the study. A 9-week movement program was followed twice a week for 30 min during school hours with an emphasis on improving BMI. Hierarchical Linear Modelling (HLM) was used to analyze the data with time, sex and group as predictors. Effect sizes was computed based on the Cohen's d to assess the practical significance of findings. The intervention positively changed the waist circumference. The subscapular skinfold and BMI showed statistical and practically significant sustainable changes because of the intervention, although gender influenced these effects. School based movement interventions, focusing on improving fundamental movement skills (FMS), have the potential to contribute to a healthier BMI, skinfold thickness and circumferences among young children.

Is the World Health Organization’s multicentre child growth standard an appropriate growth reference for assessing optimal growth of South African mixed-ancestry children?

In South Africa (SA), it has been estimated that one-third of boys and 25% of girls under the age of 5 years are stunted, according to the World Health Organization (WHO) Multicentre Growth Reference Study. During the past decade, research in developed and developing countries has shown that the international growth standard overestimates stunting and/or wasting when compared with population-specific growth references. Population-specific growth references typically incorporate genetic and environmental factors and can therefore better inform public health by identifying children who may be at risk for malnutrition, or who may be ill. Using the universal growth standard in SA may not be accurately assessing growth. In this article, environmental and genetic factors, and their influence on growth, are reviewed. These points are illustrated through a brief history of the peopling of SA, with an understanding of the socioeconomic and political climate – past and present. We discuss the uniqueness of certain population groups in SA, with contributions regarding some of the shortest peoples in the world and a history of sociopolitical inequities, which may mean that children from certain population groups who are perfectly healthy would underperform using the universal growth standard. Therefore, we suggest that a local population-specific growth reference would serve to better inform public health policies, and address childhood health equity and physical developmental pathways to adult health risk status.  

Risk Factors for Overweight and Obesity within the Home Environment of Preschool Children in Sub-Saharan Africa: A Systematic Review

Sub-Saharan Africa (SSA) is experiencing an increasing prevalence of young children being overweight and obese. Many feeding and physical activity-related behaviours are established at home during preschool years, yet the precise factors that contribute to preschool overweight and obesity have not been fully elucidated. This review aims to identify factors in the home environment associated with overweight and or obesity in preschool children in SSA. Ovid MEDLINE, EMBASE, CINAHL, Scopus, Web of Science, Africa Journals Online (AJOL) and the African Index Medicus databases were systematically searched for qualitative and quantitative studies published between 2000 and 2021. Eleven studies (ten quantitative, one qualitative) met the inclusion criteria. Overall, the results highlight the paucity of studies exploring factors in the home environment associated with overweight and obesity in preschool children in Sub-Saharan Africa. The home food environment and maternal BMI appear to be important factors associated with overweight and obesity in preschool children; however, the information for all other factors explored remains unclear due to the lack of evidence. For successful obesity prevention and treatment interventions to be developed, more research in this area is required to understand how different aspects of the home environment contribute to overweight and obesity in preschool Sub-Saharan African children.

Longitudinal Effects of Excessive Weight and Obesity on Academic Performance of Primary School Boys in Different Socio-Economic Statuses: The NW-CHILD Study

Obesity affects millions of children worldwide and can often impact their academic performance. This longitudinal study, conducted over seven years, determines the effects of excessive weight and obesity on the academic performance of primary school boys, taking into account their socio-economic status (SES). The study forms part of a seven-year (2010–2016) longitudinal study, the North-West Child-Health-Integrated-Learning and Development (NW-CHILD) study, which includes a baseline measurement and two follow-up measurements of the 181 participants from varying areas in the North West Province. Two-way frequency tables, repeated measure ANOVA’s and Spearman rank order correlations were used to analyze the data. The Body Mass Index (BMI) of the participants reported an increase from 2010–2016. Nearly all of the school subjects reported small to large correlations between BMI and academic performance (r ≥ 0.1 and r ≥ 0.3), except for Afrikaans in 2013 (r = −0.06). Only two subjects (English and Language as tested with the ANA test) reported medium effects (r ≥ 0.3), whereas the other subjects only reported small effects (r ≥ 0.1). No statistically significant relationships (p ≥ 0.05) were observed between the BMI values and academic subjects, however SES and school subject scores reported several statistically significant relationships, especially regarding Language (English and First Additional Language) and Mathematics (p = 0.02). Overweight and obese primary school boys in the North West Province of South Africa reported a higher academic performance in comparison to boys of a normal weight, even when SES was taken into consideration. Further studies are recommended to verify current findings regarding weight, obesity and academic performance.

The Relationship between Under-Nutrition and Hypertension among Ellisras Children and Adolescents Aged 9 to 17 Years

Background: Globally, under-nutrition and hypertension in children has been associated with the risk of developing cardiovascular disease (CVD) in adulthood. The main objective of this study was to investigate the relationship between under-nutrition and hypertension, furthermore, to determine the risk of developing hypertension due to under-nutrition. Methods: The study comprised of 1701 participants (874 boys and 827 girls) between the ages of 9 and 17 years old. All anthropometric and blood pressure measurements were taken according to standard procedures. Mid-upper arm circumference (MUAC), body mass index (BMI), upper arm fat area (UFA), total upper arm area (TUAA) and upper arm muscle area (UMA) of Ellisras children were compared with the National Health and Nutrition Examination Survey III reference population. The linear regression models were used to determine the relationship between under-nutrition with hypertension for unadjusted and then adjusted for age and gender. The logistic regression model was used to determine the risk of under-nutrition on developing hypertension for unadjusted and adjusted for age and gender. Results: There was a positive significant (p < 0.0001) association between all under-nutrition variables (MUAC, BMI, UFA, TUAA and UMA) and systolic blood pressure (SBP; beta ranges between 0.84 and 2.78), and diastolic blood pressure (DBP; beta ranges between 0.3 and 1.08 before adjusting and after adjusting for age and gender (SBP, beta ranges between 0.59 and 2.00 and DBP (beta ranges between 0.24 and 0.80. Conclusion: The prevalence of under-nutrition was high while the prevalence of hypertension was low in this study. The mean under-nutrition variables (BMI, UFA, UMA and MUAC) of Ellisras children were far lower compared to the NHANES III reference population. Hypertension was significantly associated with under-nutrition in this study.

Provincial Dietary Intake Study (PDIS): Micronutrient Intakes of Children in a Representative/Random Sample of 1- to <10-Year-Old Children in Two Economically Active and Urbanized Provinces in South Africa

In 1999, the National Food Consumption Survey found serious risk of dietary deficiency for a number of micronutrients in 1- to 9-year-old children in South Africa. To address these shortfalls, fortification with vitamin A, thiamine, riboflavin, niacin, vitamin B6, folic acid, iron and zinc of maize meal and bread flour was made mandatory in 2003. The aim of this study was to examine micronutrient intakes of 1- to <10-year-old children after nearly 20 years of fortification in two of the most urbanized and economically active provinces, Gauteng (GTG) and the Western Cape (WC). A multistage stratified cluster random sampling design and methodology was used. Households were visited by fieldworkers who interviewed caregivers and obtained dietary intake data by means of a multiple-pass 24-h recall. Two additional 24-h recalls were completed among a nested sample of 146 participants to adjust the single 24-h recall data of the total sample using the National Cancer Institute Method. Results show that median intake of all the fortification nutrients were above the estimated average requirement (EAR), with the only concern being folate in the WC. Between a quarter and a third of children in the WC, where maize porridge intake was significantly lower than in GTG, had a folate intake below the EAR. Nutrients that are not included in the fortification mix that remain a serious concern are calcium and vitamin D, with intake of dairy and vitamin D sources being very limited in both provinces. The improvement in micronutrient intakes of children is encouraging, however the outstanding nutrient deficiency risks need attention.

An assessment of nutritional status in children of rural, northern KwaZulu-Natal province

Background

Childhood malnutrition in South Africa is largely perceived as one of undernutrition, with the opposite end of the spectrum (overnutrition) being evidenced in the increasing prevalence of childhood obesity, demonstrated to be associated with chronic metabolic diseases in adulthood. Targeting childhood malnutrition is a potential interventional strategy to prevent non-communicable diseases amongst adults. As the prevalence of malnutrition (undernutrition and overnutrition) in rural, northern KwaZulu-Natal province, South Africa, is largely unknown, this study aimed to determine the baseline nutritional status of children attending primary healthcare facilities within the Bethesda Hospital catchment area.

Methods

This quantitative, cross-sectional study included children aged 6 weeks to 19 years, attending any primary healthcare clinics for over a 3 months period. Anthropometric measurements were obtained to categorise the children according to the World Health Organisation’s (WHO) nutritional classifications.

Results

Stunting in children aged less than 5 years was found to be lower (14%) than nationally representative studies (27%); however, 14.4% of the infants aged 6 weeks to 5 months were overweight, increasing to 32.3% in those aged 14–19 years. Males in the 6-weeks to 5-month age group were more likely to be overweight/obese and stunted than females in the same age group.

Conclusion

Undernutrition is showing a downward trend, which is a testament to initiatives to reduce food insecurity amongst the poor. However, the emerging upward trend of overweight/obesity in children of all ages, indicates the need to have a national discussion on over- and undernutrition, its causes and implications.

Social circumstances and cultural beliefs influence maternal nutrition, breastfeeding and child feeding practices in South Africa

BACKGROUND

Maternal and child undernutrition remain prevalent in developing countries with 45 and 11% of child deaths linked to poor nutrition and suboptimal breastfeeding, respectively. This also has adverse effects on child growth and development. The study determined maternal dietary diversity, breastfeeding and, infant and young child feeding (IYCF) practices and identified reasons for such behavior in five rural communities in South Africa, in the context of cultural beliefs and social aspects.

METHODS

The study used mixed methodology technique. Questionnaires were administered to 84 households, pairing mother/caregiver and a child (0-24 months old) to obtain information on maternal dietary diversity, IYCF and breastfeeding practices. Qualitative data on breastfeeding perceptions, IYCF practices, perceived eating habits for lactating mothers and cultural beliefs related to mothers' decision on IYCF and breastfeeding practices were obtained through focus group discussions.

RESULTS

Maternal dietary diversity was very low and exclusive breastfeeding for the first 6 months of life was rarely practiced, with young children exposed to poor-quality diets lacking essential nutrients for child growth and development. Social circumstances including lack of income, dependence on food purchasing, young mothers' feelings regarding breastfeeding and cultural beliefs were the major drivers of mothers' eating habits, breastfeeding behaviour and IYCF practices. Fathers were left out in breastfeeding and IYCF decision making and young mothers were unwilling to employ indigenous knowledge when preparing food (especially traditional foods) and feeding their children.

CONCLUSION

The study provides comprehensive information for South African context that can be used as an intervention measure to fight against malnutrition in young children. Finding a balance between mothers' income, dietary diversity, cultural beliefs, breastfeeding and considering life of lactating mothers so that they won't feel burdened and isolated when breastfeeding and taking care of their children is crucial. Paternal inclusion in breastfeeding decisions and safeguarding indigenous knowledge on IYCF practices is recommended.

Provincial Dietary Intake Study (PDIS): Energy and Macronutrient Intakes of Children in a Representative/Random Sample of 1-<10-Year-Old Children in Two Economically Active and Urbanized Provinces in South Africa

The double burden of malnutrition is still prevalent in South Africa, hence the importance of a dietary survey to identify risks of under- and over-nutrition. A multistage stratified cluster random sampling design was applied in two economically active provinces, Gauteng (GTG) (N = 733) and Western Cape (WC) (N = 593). Field workers completed questionnaires, and a 24 h recall with children taking part aged 1–<10-years (N = 1326). Important findings were that 71% and 74%, respectively, of 3–<6-year-olds and 6–<10-year-olds had an energy intake below the estimated energy requirement (EER), while 66% 1–<3-year-olds had intakes above the EER. The percentage of children with a total fat intake below recommended levels decreased as age increased ((51%, 40% and 5%) respectively, for the three age groups). Similarly, the percentage of those who had a total fat intake above the recommendation increased with increasing age (4%, 11% and 26%, respectively, for the three age groups). Saturated fat intake above 10%E was highest in the youngest and oldest children (33% and 32%, respectively). The percentage of children with a free sugars intake above 10%E was 47%, 48% and 52% respectively, and 98–99% had a fibre intake that was less than recommended. Overall, the diet was not healthy, with the main food items being very refined, and the diet being high in salty snacks and sugary items, and low in fruit, vegetables and legumes.

Provincial Dietary Intake Study (PDIS): Prevalence and Sociodemographic Determinants of the Double Burden of Malnutrition in A Representative Sample of 1 to Under 10-Year-Old Children from Two Urbanized and Economically Active Provinces in South Africa

The objective of this study was to determine the prevalence and socio-demographic predictors of malnutrition in two urbanized economically active provinces (Gauteng N = 733, Western Cape N = 593) in South Africa. A multistage stratified cluster random sampling design was applied. Fieldworkers visited homes, measured children aged 1-<10-years old (N = 1326) and administered a questionnaire (mother/primary caregiver). In under-five year old children (N = 674) 21.6% were stunted [height-for-age z-score < −2 SD], 5.6 % underweight [weight-for-age z-score < −2 SD], 10.3% overweight (body mass index-for-age z-score) (BAZ)> +2 SD ≤ +3 SD] and 7.0% obese (BAZ > +3 SD). In 5–<10-year olds (N = 626) 6.7% were stunted, 6.8% underweight, 13.4% overweight and 6.8% obese. Stunting and overweight in the same child was present in 5.7% under-five year olds and 1.7% in 5–<10-year olds. Multiple logistic regression analyses identified having a mother with a post-grade 12 qualification (OR = 0.34) and having an obese mother (OR 0.46) as protectors and being in the under-five age group (OR = 3.73) as a risk factor for stunting. Being in the under-five age group was also a risk factor for a BAZ > 1 (OR 2.39), while being in the third wealth quintile was protective (OR = 0.62). Results indicate that stunting and overweight/obesity are still present at concerning levels, especially in the under-five age group.

Nutrition knowledge, attitudes and practices of primary school children in Tshwane Metropole, South Africa

Background

The increasing prevalence of being overweight and obesity in South African school children requires interventions that are evidence based. Nutrition knowledge, attitudes and practices (KAP) studies are thus needed to provide evidence for the planning of interventions that address and prevent nutrition problems in school children.

Aim

The aim of the study on which this article is based was to assess nutrition knowledge, attitudes and practices of grade 4–6 learners from three primary schools in a South African township. The article seeks to highlight the key results of this quantitative study.

Setting

The study took place in three primary schools in Mamelodi township, Pretoria, South Africa.

Methods

Data were collected from grade 4–6 learners using self-administered questionnaires. After coding and collating data using Epi info^TM, STATA was then used for analysis. A description of KAP results was carried out using simple descriptive statistics, while the associations were tested using a chi-square test.

Results

Learners displayed inadequate knowledge of a balanced diet (23%) as well as low knowledge of food groups. With regard to attitudes, the most liked food group was the drinks and snacks (72.9%), while the least liked food group was the fruits and vegetables (8.11%). With regard to practices, the most frequently consumed food group was the drinks and snacks (72.6%), while fruits and vegetables were the least consumed. However, 78.91% of the learners displayed very good nutrition-related practices, such as making their own breakfast and eating breakfast.

Conclusion

The inadequate knowledge displayed by learners indicates a gap with nutrition education in the curriculum. There is a need to explore innovative and novel approaches to improve nutrition knowledge of school children. Parents also need to be targeted to ensure better outcomes.

Secondary data analysis to answer questions in human biology

Despite a growing number of publicly available datasets, the use of these datasets for secondary analyses in human biology is less common compared with other fields. Secondary analysis of existing data offers an opportunity for human biologists to ask unique questions through an evolutionary and biocultural lens, allowing for an analysis of cultural and structural nuances that affect health. Leveraging publicly available datasets for human biology research is a way for students and established researchers to complement their data collection, use existing data for master's and doctoral theses, pilot test questions, and use existing data to answer interesting new questions or explore questions at the population level. Here we describe where publicly available data are stored, highlighting some data repositories and how to access them. We then discuss how to decide which dataset is right, depending on the research question. Next, we describe steps to construct datasets, analytical considerations and methodological challenges, best practices, and limitations depending on the structure of the study. We close by highlighting a number of publicly available datasets that have been used by human biologists and other datasets that may be of interest to the community, including research that has been conducted on some example datasets.

Stunting at 24 Months Is Not Related to Incidence of Overweight through Young Adulthood in an Urban South African Birth Cohort

Background

The role that childhood stunting plays in the development of overweight and obesity later in life is not well understood, particularly in adolescence and young adulthood, because most studies have only followed up through midchildhood.

Objective

The objective of this study was to examine the relation between stunting and age-specific patterns of overweight and obesity incidence from early childhood to young adulthood in the context of a country in the process of the nutrition transition while these children were growing up.

Methods

We analyzed data from 895 participants in the Birth-to-Twenty Plus Cohort (Bt20+), an urban South African birth cohort initiated in 1990. Anthropometric data were collected at multiple ages and participants were included if they provided height at age 24 mo and ≥1 measure of body mass index [BMI; weight (kg)/height (m)2] in each of the following time periods: 4-8 y, 11-12 y, 13-15 y, 16-18 y, and 22-24 y. We defined stunting at age 24 mo as height-for-age z score <2 and overweight as BMI z score (BMIZ) >1 in childhood (4-8 y) and adolescence (11-12 y, 13-15 y, and 16-18 y) and BMI ≥25 in young adulthood (22-24 y). We compared BMI, BMIZ, and the prevalence of overweight by stunting status, stratified by sex.

Results

Our sample was 93% black and 51% female. The prevalence of stunting at 24 mo was 26% in males and 19% in females. In young adulthood, the prevalence of overweight and obesity was 15.5% (men) and 47.5% (women). Among both males and females, neither mean BMI nor a combined measure of overweight and obesity in any subsequent period differed by stunting status at 24 mo (P ≥ 0.05).

Conclusion

Stunting at 24 mo was not related to the risk of overweight or obesity in this cohort. Stunting may not be an important contributor to the increasing obesity rates in urban South Africa.

Patterns of Growth, Body Composition, and Lipid Profiles in a South African Cohort of Human Immunodeficiency Virus-Infected and Uninfected Children: A Cross-Sectional Study

BACKGROUND

Prior research in sub-Saharan Africa reports dyslipidemia in perinatally human immunodeficiency virus (HIV)-infected children receiving ritonavir-boosted lopinavir (LPV/r) compared with efavirenz; however, interpretation of findings is limited by lack of comparison data from HIV-uninfected children.

METHODS

We conducted a cross-sectional analysis of lipid profiles and growth within a larger longitudinal cohort study of perinatally HIV-infected and HIV-uninfected children aged 4-9 years in Johannesburg, South Africa. At enrollment, anthropometrics, viral load, CD4, total cholesterol (TC), high-density lipoprotein, low-density lipoprotein (LDL), and triglycerides were measured. Weight-for-age Z-score (WAZ), height-for-age Z-score (HAZ), and body mass index-for-age Z-score (BAZ) were calculated. United States pediatric thresholds for dyslipidemia were used.

RESULTS

Five hundred fifty-three HIV-infected and 300 HIV-uninfected children (median age 6.9 years) of similar demographic characteristics were enrolled. Of the HIV-infected children, 94.8% were on combination antiretroviral therapy (cART) (65.4% on LPV/r- and 28.6% on efavirenz-based regimens). Among the treated, 94.3% had a viral load <200 copies/mL. Median CD4% was 34.4. The HIV-infected children had lower mean WAZ (-0.7 vs -0.3, P < .01) and HAZ (-1.1 vs -0.7, P < .01) compared with HIV-uninfected children. A lower proportion of HIV-infected children were overweight (BAZ >1) compared with HIV-uninfected children (14.4% vs 21.7%, P = .04). Whether on LPV/r or efavirenz, a higher proportion of HIV-infected children had borderline/elevated TC or abnormal triglycerides than HIV-uninfected children, although a higher proportion of those on LPV/r had borderline/elevated TC, borderline/elevated LDL, or abnormal triglycerides than those on efavirenz.

CONCLUSIONS

In a South African cohort of HIV-infected children and population-appropriate HIV-uninfected children, unfavorable alterations in lipid profiles were detected in HIV-infected children regardless of treatment regimen compared with HIV-uninfected children. The HIV-infected children were of smaller size than HIV-uninfected children, but there was a high prevalence of overweight in both groups. Strategies for optimizing growth and early life management of lipid alterations may be warranted.

Household Food Insecurity along an Agro-Ecological Gradient Influences Children's Nutritional Status in South Africa

The burden of food insecurity and malnutrition is a severe problem experienced by many poor households and children under the age of five are at high risk. The objective of the study was to examine household food insecurity, dietary diversity, and child nutritional status in relation to local context which influences access to and ability to grow food in South Africa and explore the links and associations between these and household socio-economic status. Using a 48-h dietary recall method, we interviewed 554 women from randomly selected households along a rural-urban continuum in three towns situated along an agro-ecological gradient. The Household Dietary Diversity Scores (HDDS) and the Household Food Insecurity Access Scale (HFIAS) tools were used to measure household dietary diversity and food insecurity, respectively. Anthropometric measurements with 216 children (2-5 years) from the sampled households were conducted using height-for-age and mid-upper arm circumference (MUAC) as indicators of stunting and wasting, respectively. The key findings were that mean HDDS declined with decreasing agro-ecological potential from the wettest site (8.44 ± 1.72) to the other two drier sites (7.83 ± 1.59 and 7.76 ± 1.63). The mean HFIAS followed the opposite trend. Stunted growth was the dominant form of malnutrition detected in 35% of children and 18% of children were wasted. Child wasting was greatest at the site with lowest agro-ecological potential. Children from households with low HDDS had large MUAC which showed an inverse association among HDDS and obesity. Areas with agro-ecological potential had lower prevalence of food insecurity and wasting in children. Agro-ecological potential has significant influence on children's nutritional status, which is also related to household food security and socio-economic status. Dependence on food purchasing and any limitations in households' income, access to land and food, can result in different forms of malnutrition in children. Responses to address malnutrition in South Africa need to be prioritized and move beyond relying on food security and nutritional-specific interventions, but rather on nutrition-specific and sensitive programs and approaches; and building an enabling environment. Land availability, agriculture (including climate-smart agriculture especially in drier areas), and wild foods usage should be promoted.

Determinants of overweight with concurrent stunting among Ghanaian children

Background

Malnutrition (undernutrition and overnutrition) is a major public health problem in Ghana –affecting growth and development of individuals and the nation. Stunting and overweight are of particular interest, as recent national surveys show a rising trend of overnutrition and stubbornly high burden of stunting among Ghanaian children. There are currently no data on the simultaneous occurrence of overweight and stunting within individuals in Ghana. This paper presents the burden, the individual-level, and contextual determinants of overweight with concurrent stunting among Ghanaian children.

Methods

This study analyzed data set of the fourth round of the Ghana Multiple Indicator Cluster Survey (MICS4). Bivariate analyses were used to describe selected characteristics of survey respondents and their children. Hierarchical modelling approach facilitated identification of significant distal, intermediate and proximal factors/determinants of concurrent stunting and overweight. Both crude and adjusted prevalence ratios via a multivariable Poison regression model with their corresponding 95% Confidence Intervals (CI) are reported. Variables with p ≤ 0.25 at the bivariate level were included in the multivariable analysis. An alpha value of 5% was used to indicate significance.

Results

Of 7550 cases (children) analyzed, the prevalence of stunting was 27.5%; underweight was 17.3%; and wasting was 7.7%. The prevalence of overweight and concurrent overweight and stunting were respectively 2.4% and 1.2%. Children who belonged to the fourth wealth quintile, were more likely to be overweight and concurrently stunted as against children belonging to the poorest quintile (aPR = 1.010; 95% CI, 1.003–1.017). Compared to religious (Christians/Muslim/Traditionalist) household heads, children whose household heads did not belong to any religion had 2 times the rates of the Overweight with concurrent stunting (PR = 2.024; 95% CI, 1.016–4.034). Children with mothers aged 20–34 and 35–49 had an increased though insignificant prevalence ratio of association (aPR = 1.001; 95% CI, 0.994–1.005) and (aPR = 1.001; 95% CI, 0.998–1.012) respectively.

Conclusion

This analysis determined the prevalence of concurrent stunting and overweight among Ghanaian children to be 1.2%. Four contextual variables (breastfeeding status, religion, geographic region, and wealth index quintile) were associated with overweight with concurrent stunting. We conclude that, only contextual factors are predictive of DBM among children under five living in Ghana.

Assessment of the Dietary Intake of Schoolchildren in South Africa: 15 Years after the First National Study

There has not been a national dietary study in children in South Africa since 1999. Fortification of flour and maize meal became mandatory in October 2003 to address micronutrient deficiencies found in the national study in 1999. The purpose of this review was to identify studies done after 1999 in schoolchildren, 6–15 years old, in order to determine whether dietary intakes reflected improvements in micronutrients, namely: iron, zinc, vitamin A, folate, thiamine, riboflavin, vitamin B6, and niacin. An electronic and hand search was done to identify all studies complying with relevant inclusion criteria. The search yielded 10 studies. Overall, there is a paucity of dietary studies which have included the fortified nutrients; only four, of which only one, reported on all micronutrients; making it difficult to determine whether fortification has improved the micronutrient intake of schoolchildren. This is further complicated by the fact that different dietary methods were used and that studies were only done in three of the nine provinces and thus are not generalizable. The results of these studies clearly point to the importance of doing a national study on the dietary intake of schoolchildren in order to confirm the outcomes of the fortification process.

Urbanicity Gradients Are Associated with the Household- and Individual-Level Double Burden of Malnutrition in Sub-Saharan Africa

BACKGROUND

The nutrition transition is advancing throughout sub-Saharan Africa (SSA). However, the nutritional risk across urbanicity gradients associated with this transition is not clear.

OBJECTIVES

We aimed to determine 1) the extent to which overweight and anemia in women of childbearing age (WCBA) and stunting in preschool-age children (PSC) are spatially correlated within countries of SSA; and 2) the association of urbanicity with the individual-level nutritional double burden (i.e., concurrent overweight and anemia within an individual WCBA), the household-level double burden (i.e., overweight WCBA and stunted PSC in the same household), and the 3 components of these double burdens (i.e., overweight, anemia, and stunting).

METHODS

We used Demographic and Health Surveys (DHS) data for 30 countries in SSA from 2006-2012. We calculated overweight [body mass index (BMI; in kg/m(2)) ≥25] and anemia (hemoglobin concentration <120 g/L) in WCBA, and stunting in PSC aged 12-59 mo (height-for-age z score <-2). We used population density, measured using a high-resolution population distribution dataset, to define gradients of urbanicity. We used geolocated DHS data to calculate cluster-level mean population densities and the Moran's I statistic to assess spatial autocorrelation.

RESULTS

Cluster-level BMI values and hemoglobin concentrations for WCBA were spatially correlated. The odds of overweight in WCBA were higher in periurban and urban areas than in rural areas (periurban, OR: 1.08; 95% CI: 1.01, 1.16; urban, OR: 1.26; 95% CI: 1.18, 1.36), as were the odds of stunting in PSC in periurban areas (OR: 1.13; 95% CI: 1.06, 1.22). The odds of both double burden conditions were higher in periurban and urban areas than in rural areas (individual-level-periurban, OR: 1.18; 95% CI: 1.05, 1.33; urban, OR: 1.43; 95% CI: 1.27, 1.61; household-level-periurban, OR: 1.24; 95% CI: 1.06, 1.44; urban, OR: 1.24; 95% CI: 1.06, 1.46).

CONCLUSION

Urban and periurban areas in SSA may be particularly vulnerable to the nutritional double burden compared with rural areas. Clearly differentiating urban environments is important for assessing changing patterns of nutritional risk associated with the nutrition transition in SSA.

Added Sugar, Macro- and Micronutrient Intakes and Anthropometry of Children in a Developing World Context

OBJECTIVE

The objective of this study was to determine the relationship between added sugar and dietary diversity, micronutrient intakes and anthropometric status in a nationally representative study of children, 1-8.9 years of age in South Africa.

METHODS

Secondary analysis of a national survey of children (weighted n = 2,200; non weighted n = 2818) was undertaken. Validated 24-hour recalls of children were collected from mothers/caregivers and stratified into quartiles of percentage energy from added sugar (% EAS). A dietary diversity score (DDS) using 9 food groups, a food variety score (FVS) of individual food items, and a mean adequacy ratio (MAR) based on 11 micronutrients were calculated. The prevalence of stunting and overweight/obesity was also determined.

RESULTS

Added sugar intake varied from 7.5-10.3% of energy intake for rural and urban areas, respectively. Mean added sugar intake ranged from 1.0% of energy intake in Quartile 1 (1-3 years) (Q1) to 19.3% in Q4 (4-8 years). Main sources of added sugar were white sugar (60.1%), cool drinks (squash type) (10.4%) and carbonated cool drinks (6.0%). Added sugar intake, correlated positively with most micronutrient intakes, DDS, FVS, and MAR. Significant negative partial correlations, adjusted for energy intake, were found between added sugar intake and intakes of protein, fibre, thiamin, pantothenic acid, biotin, vitamin E, calcium (1-3 years), phosphorus, iron (4-8 years), magnesium and zinc. The prevalence of overweight/obesity was higher in children aged 4-8 years in Q4 of %EAS than in other quartiles [mean (95%CI) % prevalence overweight 23.0 (16.2-29.8)% in Q4 compared to 13.0 (8.7-17.3)% in Q1, p = 0.0063].

CONCLUSION

Although DDS, FVS, MAR and micronutrient intakes were positively correlated with added sugar intakes, overall negative associations between micronutrients and added sugar intakes, adjusted for dietary energy, indicate micronutrient dilution. Overweight/obesity was increased with higher added sugar intakes in the 4-8 year old children.

Socio-economic position as an intervention against overweight and obesity in children: a systematic review and meta-analysis

Studies that investigated the association between socio-economic position (SEP) and obesity in children suggest inconsistent results. The aim of this study is to summarize and quantify the current evidence on SEP and risks of overweight and obesity in children aged 0–15 years. Relevant studies published between 1990 to Sep 4, 2014 were searched in Medline, Web of Science, Embase, and the Cochrane Database of Systematic Reviews. Risk estimates from individual studies were pooled using random-effects models, according to lowest vs the highest SEP category. A total of 62 articles were included in the meta-analysis. The odds of both overweight risk and obesity risk were higher in the children with lowest SEP than in those with highest SEP (OR, 1.10, 95% CI: 1.03–1.17, and OR, 1.41, 95% CI: 1.29–1.55, respectively). Sub-group analyses showed that the inverse relationships between SEP and childhood overweight and obesity were only found in high-income countries and in more economic developed areas. In conclusion, our study suggests that children with lower SEP had higher risks of overweight and obesity, and the increased risks were independent of the income levels of countries.

Has the prevalence of stunting in South African children changed in 40 years? A systematic review

BACKGROUND

In the last 20 years, South Africa has experienced political, economic, and demographic transitions accompanied by an epidemiological transition. Like several sub-Saharan countries, the South African population is facing both under-and over-nutrition, and nutrition and lifestyle related chronic disease while the burden of infectious disease remains high. It is critical to understand these trends overtime in order to highlights the pitfalls and successful measures initiatives taken in the efforts to tackle malnutrition. The objective of this systematic review is to investigate the changes in the prevalence of stunting, a chronic form of undernutrition, in South Africa over 40 years, and to derive lessons from the South African experience, a country in an advanced process of transition in sub-Saharan Africa.

METHODS

We undertook a systematic review of publications selected from PubMed, Science Direct and Scopus. We included studies and surveys published between 1970 and 2013 if they reported the prevalence of stunting (low height-for-age) in children under-6 years of age living in South Africa. We excluded studies conducted in health facility outpatients or hospital wards, or children with known chronic and acute infectious diseases. We extracted Date of data collection, study setting, ethnicity, age, sex, sample size, growth references/standards, diagnostic criteria for stunting and prevalence of stunting from each study.

RESULTS

Over the last decade, the national prevalence of stunting has decreased. However, between and within provincial, age and ethnic group disparities remain. Unlike other countries in sub-Saharan Africa, no sex or rural/urban differences were found in preschool children. However, the analysis of long-term trends and identification of vulnerable groups is complicated by the use of different growth references/standards and sampling methods.

CONCLUSION

Despite economic growth, political and social transitions, and national nutritional programs, stunting remains stubbornly persistent and prevalent in South Africa. A multi-sectoral and public health approach is needed to: (i) better monitor stunting over time, (ii) combat malnutrition during the first thousand days of life through continued efforts to improve maternal nutrition during pregnancy and infant feeding practices.

Evidence of nutrition transition in Southern Africa

Nutrition transition is characterised by shift to highly refined diets high in fat, salt and caloric sweeteners and low in fibre in rapidly growing economies. Dietary shifts occur almost concurrently with demographic and epidemiologic shifts, urbanisation and industrialisation and together contribute to increased prevalence of nutrition related (NR)-non-communicable disease (NCR). The emergence of nutrition transition in Southern Africa countries (SAC) was examined using anthropometric, NCD prevalence, and food consumption data. The findings reveal growing prevalence of overweight and obesity (OWOB) across SAC, with national prevalence estimated between 30 and 60 % in all but two SAC. Overweight prevalence in excess of 60 % has been reported in some sub-population groups. Hypertension prevalence of at least 30 % has also been reported. Further, the prevalence of OWOB and hypertension in many SAC exceeds that of HIV and is often at par with stunting in children. NCD are equally serious public health problems as stunting and HIV. Collectively, NR-NCD explain 20-31 % of mortality for Botswana, South Africa, Swaziland, Mozambique and Zambia. At least 72 % of adults in SAC have fewer servings of fruit and vegetable servings daily than recommended. Additionally, adults in SAC do poorly in physical activity; 31-75 % do not exercise regularly. Not surprisingly, 15-40 % of adults in SAC have at least three risk factors of CVD. SAC are grappling with NR-NCD which threaten to surpass infectious diseases burden. SAC are at various levels in interventions for moving their populations to stage 5, but there is room for much improvement.

Which dietary diversity indicator is best to assess micronutrient adequacy in children 1 to 9 y?

OBJECTIVES

The aim of this study was to determine the best dietary diversity indicator to measure dietary diversity and micronutrient adequacy in children.

METHODS

A national representative cross-sectional survey of children ages 1 to 9 y (N = 2,200) was undertaken in all ethnic groups in South Africa. A 24-h recall was done with the mother or caregiver of each child. A dietary diversity score (DDS), the number of food groups consumed at least once in a period of 24 h, was calculated for each child in accordance with 6-, 9-, 13-, and 21-food group (G) indicators and compared with a mean adequacy ratio (MAR). The nutrient adequacy ratio (NAR) was calculated for 11 micronutrients by comparing the distributions of estimated intakes with the Estimated Average Requirements for that micronutrient. The MAR was the average of all NARs. Correlations were done between MAR and DDS and sensitivity and specificity calculated for each group indicator.

RESULTS

Pearson's correlations between food group indicators and MAR indicate that r values were all highly significant (P < 0.0001). There were no consistent or large differences found between the different group indicators although G13 and G21 appeared to be marginally better. Sensitivity and specificity values in the current study lay between DDS of 3 and 5, suggesting one of these as the best indication of (low) micronutrient adequacy.

CONCLUSIONS

Overall results seem to indicate that any of the four G indicators can be used in dietary assessment studies on children, with G13 and G21 being marginally better. A cut-off DDS of 4 and 5, respectively, appear best.

Determinants of Stunting and Overweight among Young Children and Adolescents in Sub-Saharan Africa

Background

Stunting and overweight are nutritional problems affecting most of sub-Saharan Africa. The region now has the world's highest rate of stunting among children (43%), while overweight and obesity are becoming a global epidemic, and Africa is not spared. The past two decades have seen a dramatic increase in obesity in sub-Saharan Africa.

Objective

The purpose of this systematic review is to explore the determinants of stunting and overweight in sub-Saharan Africa.

Methods

A literature search was conducted in PubMed using the key words stunting, overweight, obesity, Africa, sub-Saharan Africa, determinants, and prevalence. Limits were set to include articles published between 1990 and 2012. The systematic review resulted in 38 studies, and after selection based on title, content, and country of the study, 18 studies were eligible for this review. Data were analyzed by the chi-square test.

Results

The prevalence rates of stunting and over-weight were dependent on socioeconomic, demographic, and environmental factors. Many studies indicate that male children and those living in a rural setting are more likely to be stunted, whereas overweight among children depends more on age, household composition, occupation of the mother, and the mother's body mass index. Stunting occurred together with overweight among both boys and girls from 1 to 5 years of age. Stunting was more prevalent among boys than among girls. Indicators of socioeconomic status, such as mother's education, mother's occupation, and household income, were some of the determinants directly linked to stunting, whereas environmental factors, such as rural or urban setting and sanitation, influenced both stunting and overweight. Concurrent stunting and overweight is influenced by maternal and household factors, such as maternal height, age, and education, large household size, and lower socioeconomic status.

Conclusions

Although socioeconomic, demographic, and environmental factors were significant in determining stunting and overweight, other factors, such as nutrition and lifestyle, were important risk factors. Stunting in childhood is a risk factor that may result in overweight and obesity later in adolescence and adulthood, indicating the need to screen children below 1 year of age to identify stunting early in life. Promoting exclusive breastfeeding is reported to be important in preventing both stunting and overweight among children. More research is needed to explore the relationship between stunting and overweight and to explore policy guidelines to address the phenomenon.

Correlates of objectively measured overweight/obesity and physical activity in Kenyan school children: results from ISCOLE-Kenya

BACKGROUND

Childhood overweight/obesity and inadequate physical activity burden Western countries, and now, pose a growing threat to the health of children in low and middle income countries. Behavioural transitions toward more sedentary lifestyles coupled with increased consumption of high calorie foods has resulted in rising proportions of overweight/obesity and decreasing levels of physical activity in school-aged children. The objective of this study was to determine the prevalence and to investigate factors associated with overweight/obesity and physical activity in Kenyan children aged 9 to 11 years.

METHODS

Body composition and physical activity measures of participating children were accomplished by anthropometric assessment, accelerometry, and administration of questionnaires related to diet and lifestyle, and the school and neighbourhood environments. Data collection was conducted in the city of Nairobi as part of a larger International Study of Childhood Obesity, Lifestyle and Environment.

RESULTS

A total of 563 participants (46.5% boys, 53.5% girls) were included in the analyses. Of these, 3.7% were underweight, 14.4% were overweight, and 6.4% were obese based on WHO cut-points. Mean daily sedentary time was 398 minutes, time spent in light physical activity was 463 minutes, and time spent in moderate-to-vigorous physical activity was 36 minutes based on activity cut-points developed by Treuth et al. Only 12.6% of participating children were meeting the recommendation of ≥ 60 minutes of daily moderate-to-vigorous physical activity, and 45.7% of participants used active transportation to/from school. Increasing parental education level, total annual household income, and attending a private rather than public school were associated positively with being overweight/obese and negatively with meeting physical activity guidelines.

CONCLUSIONS

This study provided the evidence for an existing prevalence of childhood overweight/obesity in Nairobi. Children were spending a considerable amount of time in sedentary and light intensity physical activity, with few meeting physical activity guidelines. Higher socioeconomic status and parental education attainment were associated with a higher likelihood of children being overweight/obese and a lower likelihood of children meeting the physical activity recommendations. Interventions and strategies should be attentive to the potential health consequences of lifestyle transitions resulting from urbanisation and economic prosperity.

Stunting, adiposity, and the individual-level "dual burden" among urban lowland and rural highland Peruvian children

Background

The causes of the “dual burden” of stunting and obesity remain unclear, and its existence at the individual level varies between populations. We investigate whether the individual dual burden differentially affects low socioeconomic status Peruvian children from contrasting environments (urban lowlands and rural highlands), and whether tibia length can discount the possible autocorrelation between adiposity proxies and height due to height measurement error.

Methods

Stature, tibia length, weight, and waist circumference were measured in children aged 3–8.5 years (n = 201). Height and body mass index (BMI) z scores were calculated using international reference data. Age-sex-specific centile curves were also calculated for height, BMI, and tibia length. Adiposity proxies (BMI z score, waist circumference-height ratio (WCHtR)) were regressed on height and also on tibia length z scores.

Results

Regression model interaction terms between site (highland vs. lowland) and height indicate that relationships between adiposity and linear growth measures differed significantly between samples (P < 0.001). Height was positively associated with BMI among urban lowland children, and more weakly with WCHtR. Among rural highland children, height was negatively associated with WCHtR but unrelated to BMI. Similar results using tibia length rather than stature indicate that stature measurement error was not a major concern.

Conclusions

Lowland and rural highland children differ in their patterns of stunting, BMI, and WCHtR. These contrasts likely reflect environmental differences and overall environmental stress exposure. Tibia length or knee height can be used to assess the influence of measurement error in height on the relationship between stature and BMI or WCHtR.

Evidence of an overweight/obesity transition among school-aged children and youth in Sub-Saharan Africa: a systematic review

BACKGROUND

Prevalence of childhood overweight/obesity has increased considerably in recent years. The transition to higher rates of overweight/obesity has been well documented in high income countries; however, consistent or representative data from lower income countries is scarce. It is therefore pertinent to assess if rates of overweight/obesity are also increasing in lower income countries, to inform public health efforts.

OBJECTIVE

This systematic review aimed to investigate the evidence for an overweight/obesity transition occurring in school-aged children and youth in Sub Saharan Africa.

METHODS

Studies were identified by searching the MEDLINE, Embase, Africa Index Medicus, Global Health, Geobase, and EPPI-Centre electronic databases. Studies that used subjective or objective metrics to assess body composition in apparently healthy or population-based samples of children and youth aged 5 to 17 years were included.

RESULTS

A total of 283 articles met the inclusion criteria, and of these, 68 were used for quantitative synthesis. The four regions (West, Central, East, and South) of Sub Saharan Africa were well represented, though only 11 (3.9%) studies were nationally representative. Quantitative synthesis revealed a trend towards increasing proportions of overweight/obesity over time in school-aged children in this region, as well as a persistent problem of underweight. Weighted averages of overweight/obesity and obesity for the entire time period captured were 10.6% and 2.5% respectively. Body composition measures were found to be higher in girls than boys, and higher in urban living and higher socioeconomic status children compared to rural populations or those of lower socioeconomic status.

CONCLUSIONS

This review provides evidence for an overweight/obesity transition in school-aged children in Sub Saharan Africa. The findings of this review serve to describe the region with respect to the growing concern of childhood overweight/obesity, highlight research gaps, and inform interventions.

PROSPERO REGISTRATION NUMBER

CRD42013004399.

Socio-cultural, environmental and behavioural determinants of obesity in black South African women

South Africa (SA) is undergoing a rapid epidemiological transition and has the highest prevalence of obesity in sub-Saharan Africa (SSA), with black women being the most affected (obesity prevalence 31.8%). Although genetic factors are important, socio-cultural, environmental and behavioural factors, as well as the influence of socio-economic status, more likely explain the high prevalence of obesity in black SA women. This review examines these determinants in black SA women, and compares them to their white counterparts, black SA men, and where appropriate, to women from SSA. Specifically this review focuses on environmental factors influencing obesity, the influence of urbanisation, as well as the interaction with socio-cultural and socio-economic factors. In addition, the role of maternal and early life factors and cultural aspects relating to body image are discussed. This information can be used to guide public health interventions aimed at reducing obesity in black SA women.

Residential mobility, socioeconomic context and body mass index in a cohort of urban South African adolescents

Adolescents who are changing residence, as well as their social and economic circumstances may experience lifestyle changes that have an effect on body composition outcomes such as undernutrition, overweight or obesity. This paper uses data from Birth to Twenty, a birth cohort of South African urban children, to determine the relationship between residential mobility and body mass index (BMI) amongst Black adolescents aged 15 (n=1613), and to examine the role of changes in household socioeconomic status (SES). The prevalence of overweight and obesity in the sample was 25% in females and 8% in males. Amongst the females, a strong positive association between residential mobility and BMI was observed for those who also experienced an increase in household SES between birth and 15 years (β=0.42, SE=0.13), while no effect was identified for males. The study shows the potential for environmental change and increased resources to influence the risk for obesity. It also highlights the value in considering the range of social environmental factors and changes across the early life course that might play a part in evolving nutritional patterns in urban transitioning environments.

Investigation into longitudinal dietary behaviours and household socio-economic indicators and their association with BMI Z-score and fat mass in South African adolescents: the Birth to Twenty (Bt20) cohort

Objective

The present study aimed to assess the relationship between dietary habits, change in socio-economic status and BMI Z-score and fat mass in a cohort of South African adolescents.

Design

In the longitudinal study, data were collected at ages 13, 15 and 17 years on a birth cohort who have been followed since 1990. Black participants with complete dietary habits data (breakfast consumption during the week and at weekends, snacking while watching television, eating main meal with family, lunchbox use, number of tuck shop purchases, fast-food consumption, confectionery consumption and sweetened beverage consumption) at all three ages and body composition data at age 17 years were included in the analyses. Generalized estimating equations were used to test the associations between individual longitudinal dietary habits and obesity (denoted by BMI Z-score and fat mass) with adjustments for change in socio-economic status between birth and age 12 years.

Setting

Birth to Twenty (Bt20) study, Soweto-Johannesburg, South Africa.

Subjects

Adolescents (n 1298; 49·7 % male).

Results

In males, the multivariable analyses showed that soft drink consumption was positively associated with both BMI Z-score and fat mass (P < 0·05). Furthermore, these relationships remained the same after adjustment for socio-economic indicators (P < 0·05). No associations were found in females.

Conclusions

Longitudinal soft drink consumption was associated with increased BMI Z-score and fat mass in males only. Fridge ownership at birth (a proxy for greater household disposable income in this cohort) was shown to be associated with both BMI Z-score and fat mass.

Stunting and obesity in childhood: a reassessment using longitudinal data from South Africa

BACKGROUND

A series of cross-sectional studies have found a relationship between stunting and obesity in childhood. Because height appears in both the numerator of indices of stunting and the denominator of indices of obesity, random errors made by fieldworkers measuring heights can produce negative bias in estimates of this relationship.

METHODS

With longitudinal data, height can be instrumented with its lagged value in a two-stage probit regression model, purging the estimated association between the probability of being obese or underweight and the height-for-age z-score of this errors-in-variables bias. Such a model is fitted to a cohort of 1110 primary-school-age children measured in 1993-2004 in a panel study in KwaZulu-Natal, South Africa. The study also collected detailed data on households' demographic and socio-economic characteristics.

RESULTS

Risk factors for stunting, wasting and obesity differed in this population. Stunting was not associated with childhood obesity in either the cross-sectional or two-stage models. In the cross-sectional analysis, however, random measurement errors masked a negative association between children's height-for-age and their probability of being underweight or wasted that emerged in the two-stage instrumental variable models. This association was further amplified, rather than attenuated, by controlling for children's household income, racial group, residence and mother's education.

CONCLUSIONS

The validity of the findings of earlier cross-sectional studies of the association between stunting and obesity in childhood is dependent on the precision with which they measured height. Random measurement error can also mask an association between being stunted and underweight in cross-sectional studies.

Sobrepeso e obesidade em crianças de cinco a dez anos de idade beneficiárias do Programa Bolsa Família no estado de Sergipe, Brasil

OBJETIVO: Estimar a prevalência de sobrepeso e obesidade em crianças beneficiárias do Programa Bolsa Família (PBF) durante os anos de 2008 a 2010, de acordo com o sexo e com as regionais de saúde do estado de Sergipe. MÉTODOS: Estudo epidemiológico descritivo, conduzido com banco de dados secundário do Datasus/Sisvan. Foram obtidos 79.795 registros de crianças de cinco a dez anos de idade beneficiárias do PBF no estado de Sergipe, sendo 20.338 de 2008 (9.848 do sexo feminino e 10.490 do masculino), 27.106 de 2009 (13.092 do sexo feminino e 14.014 do masculino) e 32.351 de 2010 (15.963 do sexo feminino e 16.388 do masculino). Foram mensuradas as variáveis de massa corporal e estatura, calculando-se o índice de massa corpórea (IMC), o qual foi analisado por meio dos valores do escore Z das tabelas normativas da Organização Mundial de Saúde. RESULTADOS: A prevalência de sobrepeso nos sexos feminino e masculino, respectivamente, no ano de 2008 foi de 12,2 e 12,4%; em 2009, de 13,2 e 13,2% e em 2010, de 13,1 e 13,3%. A prevalência de obesidade em 2008 foi de 11,0 e 13,5%; em 2009, de 11,9 e 15,1%; e em 2010, de 11,2 e 14,5%, respectivamente, para o sexo feminino e masculino. O sobrepeso e a obesidade foram mais prevalentes em crianças de municípios com menor Índice de Desenvolvimento Humano. CONCLUSÕES: Recomenda-se a criação de uma política nacional nutricional que dê subsídios para os beneficiários do PBF se alimentarem com qualidade.

Overweight among children decreased, but obesity prevalence remained high among women in South Africa, 1999-2005

OBJECTIVE

The aim of the present study was to assess anthropometric status in South African children and women in 2005 in order to document temporal trends in selected anthropometric parameters.

DESIGN

Heights and weights were measured in a cross-sectional study of children aged 1-9 years and women aged 16-35 years. The WHO reference values and BMI cut-off points were used to determine weight status.

SETTING

South Africa, representative sample based on census data.

SUBJECTS

Children (n 2157) and women (n 2403).

RESULTS

Stunting was the most common nutritional disorder affecting 21·7% of children in 1999 and 20·7% in 2005. The difference was not statistically significant. Underweight prevalence remained unchanged, affecting 8·1% of children, whereas wasting affected 5·8% of children nationally, a significant increase from 4·3% of children in 1999. Rural children were most severely affected. According to the international BMI cut-off points for overweight and obesity, 10% of children nationally were classified as overweight and 4% as obese. The national prevalence of overweight and obesity combined for women was 51·5%. The prevalence of overweight in children based on weight-for-height Z-score did not change significantly (8·0% to 6·8%, P = 0·138), but the combined overweight/obesity prevalence based on BMI cut-off points (17·1% to 14·0%, P = 0·02) decreased significantly from 1999 to 2005.

CONCLUSIONS

The double burden of undernutrition in children and overweight among women is evident in South Africa and getting worse due to increased childhood wasting combined with a high prevalence of obesity among urban women, indicating a need for urgent intervention.

What's in the lunchbox? Dietary behaviour of learners from disadvantaged schools in the Western Cape, South Africa

OBJECTIVE

To identify and describe factors associated with food shop (known as tuck shop in South Africa) and lunchbox behaviours of primary-school learners in South Africa.

DESIGN

Analysis of data collected in 2008 from a cross-sectional survey.

SETTING

Sixteen primary schools in the Western Cape, South Africa.

SUBJECTS

A total of 717 grade 4 learners aged 10-12 years.

RESULTS

A 24 h recall established that 69 % of learners carried a lunchbox to school and 49 % had consumed at least one item purchased from the school food shop/vendor. Most lunchboxes contained white bread with processed meat, whereas the most frequent food shop/vendor purchase comprised chips/crisps. Learners who carried a lunchbox to school had significantly lower BMI percentiles (P = 0·002) and BMI-for-age (P = 0·034), compared with their counterparts. Moreover, they were younger, had higher standard-of-living and dietary diversity scores, consumed more meals per day, had greater self-efficacy and came from predominantly urban schools, compared with those who did not carry a lunchbox to school. Learners who ate food shop/vendor purchases had a lower standard-of-living score and higher dietary diversity and meal scores. Only 2 % of learners were underweight, whereas 19 % were stunted and 21 % were overweight/obese (BMI ≥ 25 kg/m2).

CONCLUSIONS

Children who carried a lunchbox to school appeared to have greater dietary diversity, consumed more regular meals, had a higher standard of living and greater nutritional self-efficacy compared with those who did not carry a lunchbox to school.

The benefit of supplementary feeding for wasted Malawian adults initiating ART

Food insecurity is considered to be an important contributor to HIV associated wasting in sub-Saharan Africa. Low body mass index (BMI) is a strong risk factor for early mortality during antiretroviral therapy (ART). Nutritional supplementation has become standard of care in wasted patients starting ART in many countries in the region, but there is no unequivocal evidence base for this intervention. Against this background, we performed a retrospective study to compare food supplementation versus no nutritional intervention in wasted adults starting ART in Blantyre, Malawi. All patients received free nevirapine, lamivudine, and stavudine. Participants in an effectiveness trial of two food supplements received either corn-soy blend (CSB) or ready-to-use food spread (RUFS) during the first 14 weeks of ART. Results were compared with a historical control group receiving no food supplement that was part of an observational cohort study of outcomes of the same ART regimen. Characteristics on initiation of ART were similar in the three groups, except the use of cotrimoxazole prophylaxis which was more frequent in the food-supplemented groups. Linear regression analysis showed that increase in BMI was greatest in the RUFS group and better in the CSB group than in those receiving no food supplementation at 14 weeks. These differences were no longer significant at 26 weeks. Lower BMI, CD4 count and hemoglobin, WHO clinical stage IV, male gender, and not receiving cotrimoxazole prophylaxis were independent risk factors for mortality at 14 and 26 weeks in the logistic regression analysis. Supplementary food use was not directly associated with improved survival.