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The National Food Consumption Survey (NFCS) - Children aged 1 - 9 years, South Africa, 1999
Editor: D Labadarios. Supported by: N Steyn, E Maunder, U MacIntyre, R Swart, G Gericke, J Huskisson, A Dannhauser, H H Vorster, A E Nesamvuni
Proofreading: J Conradie

In memory of our respected colleague Fikile Shabalala, co-ordinator of the Survey in KwaZulu-Natal province.

S A J Clin Nutr 2001 May Vol 14 No 2

Preface
One of the recommendations of the 1995 national survey of children aged 6 - 71 months commissioned by the Department of Health and conducted by the South African Vitamin A Consultative Group (SAVACG), was that due consideration should be given to initiating a programme of food fortification with a view to addressing micronutrient deficiencies in the country. The Directorate of Nutrition of the Department of Health, following extensive consultation with local and overseas experts, issued a tender for a survey of the food consumption patterns of children aged 1 - 9 years, with special emphasis on children living in areas of low socio-economic status. The nine universities teaching nutrition/dietetics in the country, having formed a consortium, the National Food Consumption Survey (NFCS), were awarded the tender. Following further discussions between the Directorate of Nutrition of the Department of Health and the university consortium, the initial specifications of the tender were expanded to include the evaluation of the anthropometrical status of these children as well as their nutrient intake. This report summarises the key findings of the national survey.

In the report itself, the socio-demographic and anthropometrical findings are presented first in order to impart sufficient background to the main findings. A separate chapter is devoted to each of the components of the survey. Each chapter consists of text, with figures on selected key findings for ease of reading. More information regarding the data and findings of the survey appears in the tables at the end of each chapter. Additional information in the form of box-plots is also provided, as appropriate, in the Appendices. In view of the close interrelationship of the survey components, a separate chapter has been created (chapter 9) in which all the findings are discussed in summary form and in the order in which the components of the survey appear in the report. All recommendations have been included in this chapter and in the Executive Summary. The latter, apart from the recommendations, also includes selected key findings of the survey. The Appendices include the questionnaires that were developed specifically for use in the survey, the training manual and other selected information deemed to be of interest to the reader.

The NFCS attached great urgency to the compilation of this report with a view to making the main results of the study available as soon as possible. For this reason, the statistical analysis of the data has been limited to the most important aspects of the survey. Further detailed analysis of the data is currently being completed by some participants in the survey as part of their postgraduate studies. The results of this further analysis, however, are unlikely to have a major influence on the proposed recommendations. The directors of the NFCS have agreed that the results of the survey will also be published in peer-reviewed scientific journals.

In deciding on the proposed recommendations, the feasibility and efficacy of implementing internationally recommended plans of action within the country"s framework of health care services and the available expertise have, as far as possible, been borne in mind. However, a detailed discussion, for example, of the mechanisms for rural economic development, an essential ingredient of sustainable elimination of undernutrition, falls well outside the scope and objectives of this survey. Nevertheless, in general terms, the proposed recommendations have been made, using both the findings from the present survey and some plausible solutions suggested in other policy documents.

The Directorate of Nutrition of the Department of Health is the major sponsor for this survey. The Micronutrient Initiative, UNICEF and MOST (USAID) have also made very substantial financial contributions. This survey would not have been possible without the excellent community support it received, or without the commitment, dedication and hard work of the directors, co-ordinators, team leaders and fieldworkers of the survey, and the personnel of the Directorate of Nutrition of the Department of Health. The university consortium consisted of (in alphabetical order): the Universities of Cape Town, Free State, MEDUNSA, Natal, North, Potchefstroom, Pretoria, Stellenbosch (Chair and legal entity for the tender) and Western Cape. Other role players are duly acknowledged in the appropriate chapter.

ABBREVIATIONS/DEFINITIONS

Executive Summary
"Children are the major repository of South Africa"s potential human capital for the future. The fact that children are the workers, scientists, parents, leaders and civil society participants of tomorrow means that their survival, health, nutrition and educational progress are key issues for reconstruction and development today".
Nelson Mandela, May 1996

Against the background of prevailing undernutrition and its coexistence with micronutrient malnutrition, the Directorate of Nutrition of the Department of Health, within the scope of its Integrated Nutrition Programme (INP), has included the development of guidelines for a national micronutrient food fortification programme as part of its strategic and operational plans. However, the formulation of such a national food fortification programme requires information regarding nutrient intake as well as the identification of suitable food fortification vehicle(s) which are consumed sufficiently frequently and in sufficient quantities by the target population, and which do not pose risks for toxicity. Additionally, it is well recognised that the successful implementation of any intervention programme depends, among other factors, on appropriate nutrition education. The paucity of such data on a national basis has, therefore, necessitated the proposed survey.

1. Objectives of the survey
Primary objectives

• To determine usual food consumption of children aged 1 - 9 years (12 - 108 months) in South Africa
• To assess the usual nutrient intake of children aged 1 - 9 years in South Africa
• To identify factors impacting on food consumption
• To determine anthropometrical status

Secondary objectives
Using the baseline data obtained from the primary objectives, to propose/recommend:

• appropriate food(s) for fortification
• appropriate nutrition education material.

2. Survey methodology

• A cross-sectional survey of a nationally representative sample of children aged 1 - 9 years in South Africa using the census 1996 data (see also Appendix: Protocol).
• The survey population comprised all children aged 1 - 9 years in South Africa. The initial survey sample was adapted by means of 50% over-sampling to allow for a defined dropout rate, an overrepresentation of the children living in high-risk areas as well as the defined requirements for the dietary questionnaires employed in the survey. A total of 156 enumerator areas (EAs) were included in the survey, 82 of which were urban and 74 non-urban. A total of 3 120 children were included in the survey.
• Validated questionnaires (Socio-Demographic, 24-Hour Recall (24-H-RQ), Quantitative Food Frequency (QFFQ), Food Procurement and Household Inventory (FPHIQ) in every high-risk household (HH) as well as one randomly selected HH in all other EAs) were developed specifically for the survey and were administered by trained fieldworkers. The Hunger Scale Questionnaire (HSQ) was completed by the mother/caregiver of the child.
• A training manual, a video and food models were developed and employed, as appropriate, for the administration of the questionnaires.
• Anthropometric status assessment included height, weight as well as mid- upper arm and head circumference (the latter two are not presented in this report).
• Quality control measures were employed throughout the survey.

3. Main findings
Socio-demographic data - Findings

• Of the 3 120 children originally included in the survey, data were obtained for a total of 2 894 children, which amounted to a 93% response rate.
• Information for completion of the questionnaires was in the majority of cases provided by the mother or a grandparent of the child and can therefore be considered reasonably reliable, within the specifications of the methodology employed. The same majority of household members were responsible for feeding the child.
• In 1 out of 10 HHs the mother was the head of the HH; this tended to be more often the case in HHs in formal and informal urban areas. One out of 10 mothers of children in all age groups had no formal education. In almost 1 out of 5 HHs the head of the HH was unemployed. Unemployment was overall higher in rural, tribal and informal urban areas. One-third of the HHs in the survey had a monthly income of between R100 and R500. This income range was characteristic of HHs in rural, tribal and informal urban areas as well as of HHs on commercial farms.
• One out of 4 and 1 out of 5 HHs at national level spent respectively between R0 and R50 and R 50 and R100 on food weekly.
• Approximately 6 out of 10 HHs nationally obtained water from their own tap, whereas 1 out of 4 HHs obtained their water from a communal tap.
• One out of 2 HHs had both a radio and a television set in working order, with the radio being the most common means of receiving information.
• A very significant percentage of the country"s population still lives under adverse socio-economic conditions. Although a trend towards an improvement in some of these conditions appears to be taking place, it is only the long-term socio-economic upliftment of the population that is likely to ensure the improvement of the nutritional status of the community at large.
  Recommendations

3.1 Government should accelerate and expand its current policies and programmes on job creation. This is seen as one of the most crucial recommendations in this report, which must be afforded the greatest priority.

3.2 The Welfare Department should consider immediate steps to increase the income in low-income HHs in the country, especially in rural areas and particularly on commercial farms. This could be achieved in close consultation with farmers and take the form of income-generation activities rather than "hand outs". The latter, however, should be considered, at least in the short-term, as part of any such programme in order to achieve a measure of immediate relief. Due consideration should, for instance, be given to making special loans available to these groups or to developing the social capital aspects related to increased economic growth and consumption.

3.3 Social security programmes aimed at female-headed HHs should be developed, which should incorporate development.

3.4 Families, but particularly mothers/caregivers and grandparents, should be targeted for any relief and education programmes. Particular emphasis should be placed on the education and empowerment of women.

3.5 The radio should primarily be used, together with television, for disseminating information on expanded/new relief programmes and nutrition education as well as quality child care programmes.

3.6 The achievement of these aims should be addressed within the current framework of the INP of the Directorate: Nutrition.8 The Directorate should also re-evaluate its current programmes on development in terms of definition and goals in relation to its core business of nutrition and expertise.

4. Anthropometric status
Findings

• One out of 10 children aged 1 - 9 years was underweight and just more than 1 in 5 was stunted. Furthermore, younger children (1 - 3 years of age) were most severely affected, as were those who lived in rural areas and on commercial farms in particular. The level of maternal education was an important determinant for these nutritional disorders.
• In contrast, 1 out of 13 children was overweight in the formal urban areas, a prevalence that was higher among children (1 out of 8 children) of well-educated mothers.
• At national level the nutritional status of younger children (12 - 71 months of age) has not improved but does also not appear to have deteriorated when compared with the South African Vitamin A Consultative Group (SAVACG) national data of 1995. In this regard, however, it should be borne in mind that the present survey placed particular emphasis on the high-risk segments of the population and as such it has captured data for a greater percentage of HHs of lower socio-economic status than the SAVACG survey.

Recommendations
4.1 Stunting should be addressed within the current framework of the INP, which is based on an integrated nutrition strategy for South Africa. It is also strongly recommended that the Directorate of Nutrition is provided with the necessary, additional and needed resources to attain the aims and objectives of the INP.

4.2 The findings of the present survey clearly identify the younger child (1 - 3 years of age) as a prime target for intensified nutritional intervention, and the mother/caregiver for nutrition promotion (i.e. facilitation of healthy feeding practices including complementary feeding, quality child care and decision making) as well as education. At present, both these aims should be concurrently achieved within the existing health facility-based and community- based nutrition programmes.

4.3 The supplementary foods that are provided by ongoing programmes should be re-evaluated/modified and should not simply concentrate on energy content but also on dietary quality and micronutrient composition. The provision of supplementary foods is seen as an interim, but crucially essential measure, in view of the extent of the prevailing poverty and food insecurity. In the longer term, the need for continued supplementary feeding must be weighed against socio-economic development.

4.4 The correct management of infectious diseases, especially diarrhoea and HIV/AIDS, should form an integral part of any such supplementary feeding programmes.

4.5 In terms of priorities, all children who are stunted or overweight should be targeted according to prevalence and prevailing provincial priorities.

4.6 Due consideration should be given to accelerating the creation of créche (child care) facilities within the community and at the work place, especially in provinces with a high prevalence of stunting as well as in disadvantaged communities, which have a high prevalence of stunting.

4.7 Similarly, the creation of health facility-based rehabilitation centres should be accelerated for the intensive treatment, supervision and follow-up of severely malnourished children.

4.8 Mothers/caregivers should be educated according to the prevailing needs of their environment. Both aspects of malnutrition, namely under- and over- nutrition, as well as the importance of micronutrients in child growth should form part of any education programme. In particular, the mothers/caregivers of malnourished children, apart from being educated, should also concurrently have access to and engage in income-generating programmes. Additionally, they should be trained in the rehabilitation of their children, as home-based rehabilitation is considered to be more cost-effective than facility-based rehabilitation.

4.9 The Directorate of Nutrition should engage both universities and research organisations to conduct research on the monitoring and evaluation of any such schemes that are implemented. In this regard, particular attention should be given to the long-term benefits afforded to children by such schemes.

4.10 The Directorate of Nutrition should establish a consultative group, such as the National Food Consumption Survey Group, specifically mandated to monitor growth as well as the prevention, identification and treatment of malnutrition.

4.11 An anthropometric assessment of children in the age range of the present survey should be repeated in 3 - 5 years with a view to assessing progress achieved.

4.12 In terms of nutrition surveillance, the Directorate of Nutrition should reassess/re-evaluate the parameters currently monitored since these do not include parameters that reflect progress in the commonest nutritional disorder in the country, namely stunting. Repeated assertions that such measures are difficult to implement are largely based on personal attitudes and the limitations of proposed international policies, which may be inappropriate in relation to the specific needs of the country. Initially, monitoring for stunting should be introduced gradually and selectively for children living in the high-risk areas identified in the present survey.

4.13 The findings of the present survey should be disseminated as soon as possible to all health workers and regional staff.

5. Nutrient intake (24-H-RQ and QFFQ)

• In general terms, 1 out of 2 children had an intake of approximately less than half of the recommended level for a number of important nutrients.
• The great majority of children consumed a diet deficient in energy and of poor nutrient density to meet their micronutrient requirements.
• The nutrient intake of children living in rural areas was overall considerably poorer than that of children living in urban areas.
• All variables associated with HH food insecurity were associated with poorer dietary intake and poorer anthropometric status, particularly stunting and underweight.
• For South African children as a whole, the dietary intake of the following nutrients was less than 67% of the RDAs:
  • Energy
  • Calcium
  • Iron
  • Zinc
  • Selenium
  • Vitamin A
  • Vitamin D
  • Vitamin C
  • Vitamin E
  • Riboflavin
  • Niacin
  • Vitamin B6
  • At national level, the five most commonly eaten foods included maize, white sugar, tea, whole milk and brown bread. With a few exceptions, this pattern, rather than the actual frequency, appears to be fairly consistent in all provinces.
• A significant correlation was found at national level between energy intake and stunting.
• The consumption of animal products (milk and dairy products, eggs, meat, fish) was significantly correlated with stunting and underweight. This was the case overall for children in all age groups in five of the nine provinces and for children living in formal urban areas.
• Overall and within the limitations of the two methodologies employed, the findings on nutrient intake obtained by the 24-H-RQ and the QFFQ are largely in good agreement and mutually supportive of the respective findings.

Recommendation
5.1 The need to improve the dietary and nutrient intake of children should be addressed within the current framework of the INP, which is based on an integrated nutrition strategy for South Africa. It is also strongly recommended that the Directorate of Nutrition is provided with the necessary, additional and needed resources to attain the aims and objectives of the INP.

5.2 Food fortification is a trusted and tested solution to improve the micronutrient status of children and the population at large and should be implemented as soon as possible.

5.3 The current menus of the Primary School Nutrition Programme, the protein energy malnutrition scheme as well as those of créches should be reviewed with a view to improving dietary variety and the quality of the foods used.

5.4 The data of the present survey should be used for the purpose of targeting families for, in the short-term at least, supplementing the diet of preschool children. Specific weaning foods should be made available to high-risk families with young children.

5.5 The introduction of a comprehensive nutrition education programme, which together with socio-economic development will impart practical knowledge and sustainable means of improving dietary intake and quality of life, is considered mandatory. It is also recommended that additional finance be made available for this purpose.

5.6 Nutrition education messages must be tailored to the currently prevailing consumption patterns and the desired changes therein, including the improvement of the nutrient density of children"s diets as well as food hygiene and feeding practices, and, when appropriate, home-grown crops and the use of foods of animal origin from domestic animal production.

5.7 The creation of preschool facilities for children in poor areas is strongly recommended. State facilities for children from low-income families should provide day care, including meals, especially to children with working mothers in rural and high risk peri-urban areas of the country.

5.8 The key findings of this survey need to be widely disseminated to the public and health care workers in order to increase awareness of the level and nature of food and micronutrient insecurity together with their effect on the health and wellbeing of individuals and the economic, educational and health care costs to the nation.

5.9 Within the framework of health care services, exclusive breast-feeding for 4 - 6 months should be promoted and implemented. Furthermore, the introduction of complementary feeding together with breast-feeding for up to 2 years should form the cornerstone in the nutrition of young children. The factors responsible for the documented tendency for younger children to be breast-fed for periods shorter than 3 months should be identified and addressed. In South Africa, these goals should be achieved in close partnership with all relevant role players and with due consideration to and respect for the choice of an informed mother regarding the feeding of her child. The prevalence of exclusive breast-feeding for 4 - 6 months in the country is largely unknown and should be defined. Breast-feeding practices, including exclusive breast-feeding, should form part of the national surveillance system in order to monitor progress and take corrective steps as appropriate.

5.10 Food consumption surveys of the nature of the present survey should be repeated every 3 - 5 years and be extended to cover the whole population for the purpose of establishing baseline data and for monitoring and evaluation.

6. Food procurement and hunger

• The findings of the survey on procurement patterns are substantially supportive of maize and sugar being the two most frequently and consistently consumed foods in the country, followed by tea, whole milk and brown bread. It is equally important to note that these same food items were also the ones found most frequently in the HHs.
• Most HHs procured these items by purchasing them, primarily in supermarkets and to a much lesser extent in small shops.
• Subsistence agriculture was not a major source of these foods in the country.
• HH income would appear to be a decisive factor in the consumption and procurement of foods.
• At national level, 1 out of 2 HHs experienced hunger, 1 out of 4 were at risk of hunger and only 1 out of 4 HHs appeared food-secure.
• In the rural areas a significantly higher percentage of HHs experienced hunger when compared with HHs in the urban areas.
• There was an overall consistent association between the hunger risk classification and anthropometric status. A similar association was found with energy intake and the intake of micronutrients.
• HHs at risk of hunger or experiencing hunger procured a smaller number of food items and had a similarly smaller number of food items in the HH inventory. Additionally, HHs at risk of hunger or experiencing hunger tended to be of the informal dwelling type, had the lowest monthly income and spent the lowest amount of money weekly on food. The mothers of such HHs also had a lower standard of education.
• Food insecurity was, on average, experienced nationally by 2 out of 3 HHs, 5 out of 10 individuals and 4 out of 10 children respectively at the HH, individual and child hunger level.
• It would appear that women sacrifice the quality of their diets and limit the amount of food eaten by the adults in a HH in order to preserve the amount of food available to their children.
• The findings of the FPHIQ and the HSQ are largely supportive of the poor nutrient intake as obtained by the 24-H-RQ and the QFFQ.

Recommendation
6.1 Food and micronutrient insecurity should be addressed within the current framework of the INP,8 which is based on an integrated nutrition strategy for South Africa. It is also strongly recommended that the Directorate of Nutrition is provided with the necessary, additional and needed resources to attain the aims and objectives of the INP.

6.2 The creation of employment opportunities should rank among the highest priorities of the government.

6.3 The data of the present survey should be analysed more extensively with a view to identifying parameters that can be used to target HHs at the highest level of food insecurity.

6.4 The data of the present survey should also be communicated to other relevant sectors within government, especially the agricultural sector, in order to highlight the importance and extent of the food and micronutrient insecurity in the country.

7. Food fortification

Against the outlined background of the findings of the present survey, the following recommendations are made:

Recommendations
7.1 Maize (sifted, special, super), white and brown wheat flour and white retail sugar should be the vehicles for fortification on a mandatory basis, henceforth collectively referred to as food vehicles.

7.2 The micronutrients that should be used for fortification should be:

• Vitamin A
• Thiamin
• Riboflavin
• Niacin
• Folic acid
• Vitamin B6
• Iron
• Zinc
• Calcium

7.3 The food vehicles should be fortified at the level designed to deliver 33% of the current RDAs per serving at the point of consumption, taking into account the inherent content of these micronutrients in the food vehicles, the anticipated losses of these micronutrients during production, distribution and food preparation as well as the limitations that may arise from organoleptic considerations of such additions, especially with regard to riboflavin, folic acid, iron, zinc and calcium.

7.4 Sugar should be fortified with vitamin A only at the level of 50 IU/g, and the portion size for calculation purposes for maize and wheat flours should be 200 g.

7.5 Encompassing legislation, which must include all aspects of the necessary monitoring and evaluation of a fortification programme, should be enacted and implemented.

7.6 Ongoing discussions with the relevant sectors of the food industry should be continued and expanded with a view to reaching mutually acceptable solutions on issues relating to costs, product quality and acceptability as well as any other related issues likely to impact on the proposed fortification programme.

7.7 The current food fortification task group within the Directorate of Nutrition should be transformed into a permanent committee on food fortification with a clear mandate to monitor and co-ordinate all aspects of the proposed food fortification programme.

7.8 Current voluntary practices regarding the addition of fat-soluble vitamins to margarines should be retained.

7.9 The current component of the INP regarding vitamin A supplementation should be retained and should target children at highest risk of vitamin A deficiency.

7.10 The current component of the INP regarding multi-micronutrient supplementation (other than vitamin A) should be retained and should target children at highest risk of such deficiencies. All such supplements should be reassessed in terms of composition and posology.

7.11 Foods, especially those consumed by children older than 6 months of age, which are currently fortified on a voluntary basis, should be re-assessed with a view to harmonising the proposed framework of fortification. The necessary negotiations with the relevant manufacturers should be concluded before the enacting of legislation on fortification. Additionally, any fortified products currently used in the PSNP and PEM schemes should be re-evaluated.

7.12 Any future proposals by food manufacturers regarding the fortification of additional food vehicles on a national basis with vitamin A and/or iron should first be discussed with and agreed upon by the Directorates of Nutrition and Food Control with a view to assessing their impact and safety within the framework of the proposed fortification programme.

7.13 With regard to cow"s milk and in view of the findings of the present survey, negotiations should be initiated with the relevant sectors of the dairy industry in order to investigate the feasibility of fortifying milk with selected fat-soluble micronutrients.

7.14 The inclusion of milk in the menus of the PSNP and in créches should be seriously considered and implemented.

7.15 No health claims other than those approved by the Directorate of Food Control should be allowed for any of the food fortification vehicles.

7.16 With regard to trade considerations, negotiations should be initiated with neighbouring countries with a view to achieving regional standards for fortified food items for import/export purposes.

7.17 The impact of the proposed fortification programme on the country"s population should be evaluated during the programme"s third/fifth year of implementation. Such an evaluation should form an integral part of the regular evaluation of the "monitoring and evaluation" component of the programme.

8. Nutrition education
Against the outlined background of the findings of the present survey and in terms of nutrition education, the following recommendations are made:

Recommendations
8.1 An in-depth analysis of the economic implications and needs for a national nutrition education programme should be conducted before finally selecting the most cost-effective and appropriate nutrition education strategy on fortification and/or supplementation.

8.2 A national consultative group on nutrition education should be constituted in order to ensure that nutrition messages and nutrition education/promotion campaigns are consistent and globally supportive, that duplication is prevented and that the targeting of such messages/campaigns is prioritised in relation to the findings of the present survey. This consultative group must of necessity include government (all sectors) as well as industry and NGOs involved in providing nutrition and nutrition-related information to the public. Alternatively, a smaller consultative group could co-ordinate activities in the different sectors.

8.3 All relevant role players (families, communities, health, social, agricultural, educational workers, policy makers and politicians) should be informed that the critical dietary inadequacies, in terms of dietary variety and nutrient intake in general and micronutrients in particular, affect the majority of the child population in the country and impact severely and adversely on their growth and overall development.

8.4 A government-food industry partnership must be established and should work in unison in enhancing the already favourable perception of the public at large regarding the benefits of consuming fortified foods. The primary guide of such a crucial partnership must be for the benefit of the people rather than for market gain.

8.5 Families and communities, especially mothers/caregivers, must be informed that micronutrient deficiencies can be prevented by consuming fortified foods as well as by consuming, within their financial means, a variety of foods especially legumes, fruits, vegetables and, when possible, foods of animal origin. In this regard, the concept of "budgeting for good nutrition" should be introduced and disseminated as should "nutrition wise", "good value for money" food choices.

8.6 Health- and community-based facility programmes should become more specifically involved in educating mothers/caregivers on the importance of micronutrients and correct nutrition in the growth of their children. Health- facility based programmes should also educate mothers/caregivers on the importance of compliance when micronutrient supplements are dispensed.

8.7 Families, mothers/caregivers should be educated on the importance of regular clinic visits to ensure that their children grow adequately because of the subtle nature of stunting. The concept that many children who look apparently healthy may not be growing to their full potential needs to be highlighted and emphasised.

8.8 Health workers involved in feeding schemes should be educated on the choice of micronutrient-rich foods and should also be made the conduit for strengthening messages on the importance of micronutrients. This should also be the case for all personnel working in day care facilities, especially in relation to purchasing and preparation of food for young children.

8.9 The importance of exclusive breast-feeding for the first 4 - 6 months of life in ensuring an adequate micronutrient intake early in life, as well as the important contribution breast-milk can make for up to 2 years of life in meeting micronutrient requirements, should be included and should be more emphasised as part of the programme on promotion and protection of exclusive breast-feeding. However, one should guard carefully against creating a feeling of false security in the mother in relation to breast-milk being adequate to meet the nutrient requirements of the older child, which is clearly not the case.

8.10 Families, mothers/caregivers, and health workers should be educated on the importance of and need for younger children to have small and frequent meals for adequate growth. Monitoring and evaluation should specifically focus on the facilitating factors and barriers to improving young child feeding with energy- and nutrient-dense foods.

8.11 The important slogan of "clean hands, clean food and a clean home protect children against diseases and ensure optimal child growth" should be promoted and disseminated to all individuals concerned with the care of young children.

8.12 In dealing with malnourished children (under- and over-weight), their mothers/caregivers should be provided with nutrition information relevant to the prevailing needs of their environment and in relation to home-based rehabilitation.

8.13 The concept of "child health begins before birth" in relation to planned parenthood (age, child spacing, nutritional and prenatal care), the importance of micronutrient supplementation during pregnancy (iron, folate) and preparation for choice of infant feeding (breast-feeding promotion) should be promoted to all women of child-bearing age.

8.14 In rural or other appropriate settings, the important contribution that home-based crops and livestock can make to the child"s diet should be strengthened and promoted as feasible and appropriate.

8.15 The recommended nutrition education activities should, when applicable to children older than 5 years of age, follow the FBDG as follows:

• Enjoy a variety of foods
• Be active!
• Make starchy foods the basis of most meals
• Eat plenty of fruits and vegetables every day
• Eat legumes regularly
• Foods from animals can be eaten every day
• Use fat sparingly
• Use salt sparingly
• Drink lots of clean, safe water
• If you drink alcohol, drink sensibly.

8.16 Dietary guidelines for children younger than 5 years of age should be developed.

8.17 The proposed Nutrition Education Programme should be specific and sensitive to provincial differences with regard to available household appliances, prevailing circumstances and cultural requirements. Equally, nutrition education materials on the chosen topics should be relevant to prevailing environmental circumstances. Such a programme should capitalise on existing good practices.

8.18 The primary target groups for the proposed Nutrition Education Programme should not only be all the mothers/caregivers of children and the children themselves (depending on age), but also their grandparents, and specifically the poor (limited financial and other resources) with relative low formal educational levels in rural areas, especially on commercial farms. Furthermore, the same nutrition programme/messages need to be extended to the urban areas in view of the high rates of urbanisation, and also to pregnant women.

8.19 The secondary target groups should include day care workers, the food production and marketing sector, teachers and schools (pre-primary, primary and secondary), as well as all health workers, including all private health practitioners. The low schooling level of mothers, also part of the regression analysis, suggests additional secondary targets for information, i.e. schoolchildren.

8.20 The tertiary target groups should include decision-makers, administrators and politicians at national, provincial and community level. This group needs to be involved in a number of alternative strategies such as advocacy, regulation (food labelling, food fortification, supplementation), organisational change (health-promoting schools and healthy cities), and legislation (input on minimum wages of farm workers from the nutrition sector).

8.21 The multiple causality of nutritional disorders demands that any nutrition education programme (like all other nutrition-relevant activities) must be of a multisectoral nature. The primary target groups should be reached where they "work, live and play", as well as through the education and health system, and agriculture.

8.22 The radio and/or television should be the primary communication medium for the Nutrition Education Programme but not at the exclusion of other means and modes of communication such as printed material, the broader media, and, importantly, face-to-face activities at every possible opportunity.

8.23 The content of the education material must be sensitive to the prevailing low level of education of the primary target groups and cater for language and cultural prerequisites.

8.24 Any education material must be developed within the current framework and all components of the Integrated Nutrition Programme of the Directorate of Nutrition of the Department of Health.

8.25 The overall monitoring and evaluation of the proposed Nutrition Education Programme should form an integral component of the programme. This should be achieved by establishing the level of knowledge of the public at large on basic nutrition issues in any future national surveys.

8.26 The findings of the present survey should be made available to all health workers, the media and the public at large in order to increase awareness of the scale and nature of the most prevalent nutritional disorders in the country.

9. Recommendations of a general nature
9.1 Since very significant delays were encountered and considerable time was spent on designing and drawing a national probability sample of children, every effort should be made in future health surveys to share sampling resources with other organisations conducting national health surveys. An example of such an organisation is the Central Statistical Service, which conducts annually the October household survey. Given that the current emphasis of the Directorate of Nutrition is correctly placed on the improvement of child health, it is recommended that the Directorate should investigate the feasibility of establishing and maintaining a national valid sampling frame for children.

9.2 Socio-economic upliftment is considered essential to sustainable reduction of micronutrient deficiencies and undernutrition in general. A detailed discussion of this subject falls outside the scope of this report. Nevertheless, it is important to note that these particular deficiencies, because of their intimate link with socio-economic status, may be used as medium-term indicators in assessing the success of the currently implemented national nutrition programmes. Such findings should be incorporated into the national health information system.

9.3 The findings of the present survey indicate that the four most seriously affected provinces are the Eastern Cape, the Northern Cape, the Northern Province and Mpumalanga. The Directorate of Nutrition should establish whether further assistance, other than fund allocations, would be required in terms of expertise to ensure the capability to implement the recommendations in this report in these provinces.

9.4 In order to achieve a sustainable solution in the reduction of micronutrient deficiencies and other dietary inadequacies, it is essential to develop a comprehensive strategy that will address such issues in the immediate- and medium-term, i.e. until such time that socio-economic upliftment can achieve sustained reduction. For an immediate- and medium-term solution to be effective, several different aspects of adequate micronutrient intake need to be addressed at a national level, which should include campaigns to:

• increase consumer awareness of adequate micronutrient intake
• increase awareness of the importance of breast-feeding
• improve health worker training with regard to stunting, micronutrients, and breast-feeding. Finally, the findings of the present survey are largely confirmatory of those of the recently published report on poverty in the country in terms of the socio- economic determinant of malnutrition, including income. Importantly, and in relation to HIV/AIDS, nutritional status is considered of the utmost importance in delaying the progression of the disease, reducing the incidence of complications related to the disease, reducing overall health care costs and improving quality of life. On these and other considerations, therefore, it can be argued strongly that the nutritional rehabilitation of those at risk must be given the highest priority. In conclusion, we believe that this has been a very successful and much-needed survey in both providing baseline data for future reference and also in formulating policy on a number of aspects of food fortification in the country. The directors of the survey wish to express their sincere gratitude to all those who made the study possible and successful. They are all acknowledged in the appropriate chapter.

NATIONAL FOOD CONSUMPTION SURVEY MEMBERSHIP
Directors
Eastern Cape Mrs E C Swart, Department of Human Ecology and Dietetics, University of the Western Cape. Free State Professor A Dannhauser, Department of Human Nutrition, University of the Orange Free State. Gauteng Mr A E Nesamvuni, Department of Human Nutrition, MEDUNSA. KwaZulu-Natal Professor E Maunder, Department of Dietetics and Community Resources, University of Natal. Mpumalanga Miss G Gericke, Division of Human Nutrition, Faculty of Medicine, University of Pretoria. Northern Cape Mrs J Huskisson, Nutrition and Dietetics Unit, University of Cape Town. Northern Province Professor N P Steyn, Director: Research Administration, University of the North. North West Professor H H Vorster (Este), Lipid Clinic, Nutrition Research Group, School for Physiology and Nutrition, Potchefstroom University for Christian Higher Education, Potchefstroom. Western Cape (Director and elected Survey Chairperson) Professor D Labadarios, Department of Human Nutrition, University of Stellenbosch and Tygerberg Hospital, Tygerberg.
Validation and Standardisation of the Quantitative Food Frequency Questionnaire
U MacIntyre, Department of Paediatrics and Child Health, MEDUNSA.
Co-ordinators
Eastern Cape Mrs A De Villiers Free State L Theron Gauteng A E Nesamvuni T C Tau KwaZulu-Natal Vicky Marsh Fikile Shabalala Mpumalanga L Theron Northern Cape Ansie van der Walt Northern Province S Howard North West E Wentzel Western Cape R Saitowitz

Statistical Support
Dr J H Nel Theunis J Van Wyk Kotze (Directorate of Nutrition, Department of Health) N Dladla C Mjigima M de Hoop D Boshoff J Booysen

ACKNOWLEDGEMENTS
The invaluable contribution of the colleagues mentioned hereunder as well as many other contributors to the successful implementation of the survey is hereby gratefully acknowledged and presented in the format received from the provinces. The survey would not have been possible without the support and co-operation of the families that willingly participated in the survey, most particularly that of their children.
Eastern Cape
Director Mrs E C Swart, Department of Human Ecology and Dietetics, University of the Western Cape
Co-ordinator Mrs A De Villiers
Team Leader Ms N Soguala
Fieldworkers S Nobatana V Rathenam D M Seema
Sampling N Siqhaza N Siwisa S Tshona Ms M Beeforth: Principal Dietitian, Port Elizabeth Transitional Local Council and Department of Health Mr F Bese: Chief Agricultural Officer, Engcobo district Mrs Capa: Member of Parliament, Bizana Chief Ngxangane: Engcobo district Chief S Mdutshana: Flagstaff Mr Witbooi: Middelburg: Transitional Local Council Mr Fitz: Mayor, Dordrecht Other contributors Dr E R Rajeev, Medical Superintendent, Frere Hospital, East London. Border Technikon (School of Tourism and Hospitality), Eastern Cape, for use of facilities and infrastructure for fieldwork. Drivers Mr Msimang Mr Viljoen
Initial validation exercise (Western Cape)
J Humphries F Jamalie E Kunneke H Ntsabiso M Saban
Free State
Director Professor A Dannhauser, Department of Human Nutrition, University of the Orange Free State Co-ordinator L Theron Team leader L Silingile Fieldworkers M Sebotza M Sekwena M Mokapane C Moahlodi
Gauteng
Director Mr A E Nesamvuni, Department Of Human Nutrition, MEDUNSA Co-ordinators A E Nesamvuni T C Tau Team leaders M Mathews V M Moremi T Moyana L Theron (from the Free State) Fieldworkers E Bruwer M Damons S Dockrat N Horn M Malaza I Manganye A Manyuha M Maphanga M Marutha C Matamane T Mfolo T Moetlwa T Mpete I Ngwenya N M Petersen (from the Western Cape) G Sepeng H Shiri A Sieberts (from the Western Cape) T Sono C van Zyl A Van Aswegen (from the Western Cape) M Vermuelen South African Police Service Commissioner Bhettha (Soweto) Director Marx (Soweto) Captain Mabaso (Etwatwa) Inspector Marweshe (Etwatwa) Inspector Mosuwe (Etwatwa) Superintendent Daveyton police station Sergeant Mabatha (Daveyton) Dube Anti Crime Unit Tsakane police station Academic Dr U MacIntyre Dr E Albertse MEDICOS (Medunsa Institute of Community Services) Medunsa Transport section and Catering Mr A D Matsaneng (Health Promotion: Vaal) Community organisations SANCO Kagiso (Krugersdorp) Munsiville (Krugersdorp) Ceruiteville (Nigel) Popo Molefe Informal Settlement Mamelodi Bapong ba Mogale Ga-rankuwa Joe Slovo Informal Settlement Election Park Barcelona Etwatwa Tsakane
KwaZulu-Natal
Director Professor E Maunder, Department of Dietetics and Community Resources, University of Natal Co-ordinators Vicky Marsh Assistant co-ordinator Fikile Shabalala Elsie Corriea Hilda Esteves Rajan Padayachee Team leaders Phumeleli Buthelezi Marcelle Holesgrove Zanele Khanyile Daphney Tindemweba Susan Wells Fieldworkers Duduzile Cele Benedicta Dladla Hlengiwe Gwala Nokuthula Hlongwane Lindiwe Kuzwayo Sanelisilwe Makhanya Thulile Mbuyisa Nosindiso Nteyi Nomagugu Shange Tozi Sigaqa Gugu Zulu Sampling Busi Ndlovu-Khumalo Tanqiso Moso Lincoln Nzama Other contributors Fiona Ross, Marie Paterson and Lettie Grobler for assistance in discussing and formulation of the questionnaires. Fikile Shabalala and Dolly Mchunu for translation of the questionnaires into Zulu. The Department of Dietetics and Community Resources for providing assistance and facilities and coping with the extra work generated during training and during the survey. Brenda Roberts for organising car hire. Mrs Cheryl Pratt, Finance Division, University of Natal, Pietermaritzburg, for administering finances. Mr Moletsane, Statistics, KwaZulu-Natal, for providing information and assistance regarding enumerator areas (EAs). Mr Wiseman Mkhona, Department of Local Government and Housing KwaZulu-Natal provincial government for assistance in providing maps of EAs and surrounding areas. Surveyor General"s Office, Pietermaritzburg Street, Pietermaritzburg, for providing geographic information systems (GIS) maps of the EAs. Mrs Ningi Ncobo, Mrs Penny Cambell, Ms Dolly Mchunu, Nutrition Sub-Directorate, Department of Health, KwaZulu-Natal, for the loan of anthropometrical equipment and translation of questionnaires into Zulu. Ms Vasanthie Naidoo, Student Housing, University of Natal for providing assistance with accommodation of fieldworkers. Drivers Raymond Mdlesthe Tholi Mpoolfu Musi Ntembu Sakhiwe Zuma
Mpumalanga
Director Miss G Gericke, Division of Human Nutrition, Faculty of Medicine, University of Pretoria Co-ordinator L Theron (from the Free State) Team leaders (from the Northern Province) N E Mabuela E M Masenya Fieldworkers (from the Northern Province) D D Chauke M A Leolo B F Magoai M M Magoai B V Mamaregane V A Matlakeng R I Mokgopha K D Monyeki L N Mukwevho A C Nenswenda M J Nong C M J Phasha M T Xivuri
Northern Cape
Director Mrs J Huskisson, Nutrition and Dietetics Unit, University of Cape Town Co-ordinator Ansie van der Walt Fieldworkers A Heneke W Brits C September S Sekgwelo D Fredericks M Mclean R Musabi Other contributors The generous professional support of Ms Lizeka Magwenchu and Ms Marietha le Roux of the Department of Health, Kimberley; the advice of the staff of the National Defence Force, Smidtsdrif; and the financial management and administrative help of Mrs Dot Bransby, University of Cape Town are all much appreciated.
Northern Province
Director Professor N P Steyn, Director: Research Administration, University of the North Co-ordinator S Howard Team leader K D Monyeki Assistant team leaders M E Masenya H Maanaka L Fernandez Fieldworkers M R Magampa L N Mukwevho D V Mmamaregane P Molekoa M T Xhivuri V A Matlakeng F Magoai M C Dikgale A C Nengwenda D D Chauke C M J Phasha R I Mokgopha A Leolo P Molekwa
North West
Director Professor H H Vorster (Este), Lipid Clinic, Nutrition Research Group, School for Physiology and Nutrition, PU for CHE, Potchefstroom Co-ordinator E Wentzel Team leader Mr T A Nell Fieldworkers S M Legoete M M Maki A M Mokele N W Motswasele D Setlhako
Western Cape
Director (and elected Survey Chairperson) Professor D Labadarios, Department of Human Nutrition, University of Stellenbosch and Tygerberg Hospital, Tygerberg Co-ordinator R Saitowitz Team leaders C Broek T Kelly J Russel (Queen Margaret University College, Scotland, UK) Fieldworkers C Baguley G Beukes C Duncan T Matoti N Petersen M Prince A Sieberts N Steinbach A Van Aswegen
Other major contributors
Central Statistical Services Mr P Bossert and Professor A Stoker for expert advice and prompt help in designing the sample frame of the survey. Directorate of Nutrition, Department of Health M De Hoop, N Dladla and C Mjigima for general support and constructive discussions regarding the scope and finalisation of the aims and objectives of the survey, and A Boshoff and J Booysen for financial and administrative support respectively. Questionnaire design (Quantitative Food Frequency Questionnaire) Dr U MacIntyre for the design of and training for the questionnaire. Statistical services Dr J H Nel for the excellent and punctual support and the meticulous care in the analysis of the data. Theunis J Van Wyk Kotze, Centre for Statistical Consultations, University of Stellenbosch, for expert advice on the design of the survey. Liezl Jordaan, dietician, for helping with the cleaning of data. Elna Schoeman, for data proofreading. Bernardus Niehaus for transport and communication. Data typists Muriel van Oudshoorn Jackie Rudman Cathy Fischer Carin Parsons Wynn Henderson
University of Stellenbosch
A very special word of appreciation to Mr N Basson, Chief Director Finance, who released University finances to overcome cash flow problems during the implementation phase of the survey and thus made the completion of the survey possible. The expert help and support of Mr R Phillips, Deputy Director Finance, Faculty of Medicine and Dr R Blaauw, Department of Human Nutrition, for assistance in the financial management of the survey. The most able and meticulous assistance of Miss J Conradie, Department of Human Nutrition, in proofreading the report. Mr J Kistner, Information Technology, for the excellent, meticulous and very punctual support in national and international communications. Professors J De V Lochner, Dean, Faculty of Medicine, and W L Van Der Merwe, Associate Dean, Faculty of Medicine, for institutional support and encouragement. Dr A K M M Rahman, Chief Executive, Tygerberg Hospital, for institutional support and special leave arrangements. Mrs Portia Permall and Mr F G Van Wyk for excellent secretarial and administrative support respectively. All the personnel of the Department of Human Nutrition, for their support and understanding throughout the implementation of the survey.
The Medical Research Council
For support to the Department of Human Nutrition, Faculty of Medicine, University of Stellenbosch.

The National Food Consumption Survey (NFCS), Stellenbosch, South Africa, 2000.

Copyright: Directorate of Nutrition, Department of Health, NFCS. All comments and queries emanating from this report should be directed to:

The National Food Consumption Survey
PO Box 19063
c/o Department of Human Nutrition
University of Stellenbosch and Tygerberg Hospital
Tygerberg 7505
South Africa
Tel: 27 21 938 9259
Fax: 27 21 933 2991