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The National food consumption survey, 1999
Alexander R P Walker

The National Food Consumption Survey, of 10 chapters and 1210 pages, is a truly outstanding contribution on the present situation regarding anthropometry/dietary patterns/nutrient intakes in South African children aged 1 - 9 years, principally black children.1 The subject is a highly important one. Many authorities have stressed that investment in interventions aimed at improving children's physical growth and mental development can be expected not only to decrease the prevalence of stunting, but also to prevent its negative functional consequences throughout the life cycle.2 hence there is increasing need, especially in developing populations, for policy makers to focus attention on the nutritional status of children as one of the main indicators of health development, and as a factor in the socio-economic advancement of societies in the long term. In the Survey, information on various socio-demographic aspects is followed by chapters giving detailed attention to children's anthropometric status, dietary patterns and nutrient intakes, as measured by both 24-hour recall and qualitative food frequency questionnaire methods, dietary intake, food procurement patterns, results of a household food inventory, a hunger scale, and food fortification, the latter being a primary purpose of the Survey. These results are used to give direction for nutrition education. In the Executive Summary of the Survey1 the conclusions reached on each of these topics in turn, based on the results of the national random sample recruited, are summarised briefly and are then followed by series of recommendations, all put forward in a very concise manner.

Understandably, numerous questions arise on this important subject. Have there been meaningful improvements in anthropometric indices and food consumption patterns among the young, compared with such prevailing in the past? To what extent are the numerous recommendations made, nutritional and other, likely to be implemented in the near future? Will the costs involved be the primary limiting factor? Of the aims, how much will depend on the extent of the help provided by the State and local authorities? Closely linked, what are likely to be the extents of the responses, following educational advice, of the mothers or other caregivers of the young children? Of major importance regarding the magnitude of the problem, what is the present situation regarding morbidity and mortality rates in the young? Further, how do the local rates compare with those of other child populations in sub-Saharan Africa - indeed, in other Third-World populations?

As regards the latter questions, to provide perspective, in most developing populations there has in general been a decline in child mortality in recent years.3 Unfortunately, however, in southern African countries such decreases are now being lessened, indeed perhaps reversed, owing to the devastating spread of the HIV/AIDS epidemic. And, according to the World Health Organisation, despite the falls in mortality rate described one-third of the world's children remain undernourished - almost all being those living in developing countries..4 In a recently published perspective on preschool nutrition in black South african children, two of the Government's goals listed were 'Between 1995 and the year 2000, reduction of infant and under-5 child mortality rates by one third to 50 and 70 per 1 000 live births, respectively'; and 'to reduce severe and moderate malnutrition among under-5-year-old children by half'.5 In the tackling of these endeavours, it was emphasised that no one department, discipline or profession can solve the problem of poor nutrition in preschool children; the approach must be multisectorial and interdisciplinary. As regards the current level of mortality, according to the South African Health Review for 1999, the mean infant mortality rate for black infants in 1998 was 47/1 000 live births and the under-5 mortality rate 66/1 000.6 It is therefore gratifying that both of these levels are within the goals cited. These rates are far lower than those in most African countries; in Nigeria, for example, corresponding rates are 73 and 106/1 000 live births, respectively.7 However, the desired reduction in the prevalence of malnutrition has yet to be attained. Of the numerous situations discussed in the Survey, it is noteworthy that in the final recommendations made, the need for a rise in socio-economic state was stressed. Unfortunately, the likelihood of a meaningful rise in general is remote. Both in First- and Third-World populations the rich are becoming richer and the poor poorer,8,9 so for the near-impoverished masses in African countries, little improvement seems likely to occur.

In the recommendations made with regard to the remedying of nutritional inadequacies, three aims were listed. The first concerns the need for an improvement in education on social awareness of nutrient needs. This, of course, is a universal need. It must be appreciated that there can be improvement not only if there is a listening to nutritional and other health recommendations, but, when possible, if there is acting upon them.10 Here it must be faced that the general response world-wide has been disappointing, for even in Western populations, with their greater understanding, urges to adopt particular nutritional guidelines are almost wholly disregarded. As an example, in a recent study it was found that about 50% of Belgian adolescents ate neither fruit nor vegetables daily,11 never mind the five helpings that are recommended. Equally to the point, concerning non-nutritional health recommendations, there have been rises in smoking and alcohol consumption in young adults.12,13 In South Africa, what a benefit it would be to health education if a simplified version of the book Child to Child,4 with its splendid illustrations, could be made available to health and educational workers.

In the second point listed in the Survey it was stressed that there should be increased awareness of the importance of breast-feeding to health of the very young. The practice, however, is not improving in countries in sub-Saharan Africa. Indeed, according to the United Nations Children's Fund, the situation in 1995 - 2000 revealed barely significant improvements compared with that in 1990 - 1996.15,16 In South Africa it has been stated that adequate documentation of national trends in breast-feeding is not available.17 On this very important subject, it will be appreciated that the highly practical current issue is the need for clarification regarding the avoidance of HIV infection, for, unfortunately, there are differences of opinion on the breast-feeding procedures that should be followed.18,19 The HIV/AIDS infection situation is a national calamity. At Hlabisa Hospital, KwaZulu-Natal, 47% of black women were found to be infected in 1995.20 It has been stated that half of black children are likely to die from the infection,21 and that life expectancy is likely to fall from the average of 63 years in 1998 to 45 years in 2005.22

The third point raised concerns the need for a good level of training for health care workers in respect of stunting, micronutrients and breast-feeding. With regard to the latter, too early a recommendation for the use of breast-milk substitutes by some carers has been severely criticised.23

While other aspects of the Survey call for comment, there is one highly practical question - what is the likelihood of reaching the primary goal of improving the health of 1 - 9-year-old children?

First the negative side. Understandably, the HIV/AIDS epidemic will have far- reaching consequences, especially with regard to sickness and death among the young. Next, the cost of the recommendations made in the Survey in respect of actions on the part of the State and the public will be large, bearing in mind the present limited health budget and the largely impoverished masses of the black population, among whom, in any case, only the small proportion who are better off are likely to benefit meaningfully.9 A further problem is the current patient overcrowding at hospitals and clinics,24 which means that there is limited time for the giving of advice on the upbringing of the young, despite the services rendered to pregnant women and the young being free. It is interesting that in a recent report from a village in Nigeria, stunting in the young was stated still to be common despite the advice given at a local public health centre,25 thereby re-emphasising the near overwhelming disadvantage of widespread poverty.

On the positive side, as already mentioned, are the present relatively favourable vital statistics for the young compared with those in other African countries. Indeed, in the Birth to Ten Study, still being carried out in the large city of Soweto (3 - 4 million inhabitants), it was found that the infant mortality rate had fallen to 20/1 000 live births in 1998,26 a rate lower than that in any other African city in sub-Saharan africa. Next, with the increase in urbanisation, now affecting about half of South Africa's black population, goes a higher level of education and appreciation regarding the health needs of the young in town dwellers. Another positive point is the gratifying fact that the State, through the Department of Health, is showing increasing interest in the well-being of the public, as evidenced by the annual publication of the South African Health Review (the 2000 review has 516 pages 27), in which there are rigorous analyses of the various health problems and in which forceful recommendations are made. Additionally, on the positive side, various studies have revealed procedures that need to be followed in interventions,28 and that enquiries, in the main, indicate that the prevalence of stunting in the young becomes lessened in their later years;29 in large measure this also applies to increases in cognitive scores.30 Concerning the fortification of foods recommended, chiefly affecting maize meal, bread, and sugar, the procedures are comparatively inexpensive and the beneficial results are undoubted, as already shown in respect of the iodisation of salt locally31 and additions made to cereal products in some countries overseas.32,33 Not least, should the Primary School Nutrition Programme mentioned in the Survey be implemented nationally it could result in a substantial lessening of the occurrence of malnutrition.

How rewarding it would be if, in 5 years' time, a further survey were to reveal that real progress had been made in bettering the health of 1 - 9-year-olds, especially in respect of anthropometric indices. However, as will have been readily apparent, this will only take place with substantial co-operation from health authorities, child advisors and school authorities, as well as co- operation from parents and the children themselves.

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