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A South African perspective on preschool nutrition
N P Steyn, PhD
Director: Research Development and Administration.
Department of Human Nutrition, University of the North, P/Bag X1106, Sovenga, 0727

S A J Clin Nutr 2000 February Vol. 13 No 1.

The Government’s Reconstruction and Development Programme (RDP) has 8 main goals.1 Of these, 2 refer specifically to young children:

• Between 1995 and the year 2000, reduction of infant and under-5 child mortality rate by one-third or to 50 and 70% per 1 000 live births respectively, whichever is less.
• Between 1995 and the year 2000, reduction of severe and moderate malnutrition among under 5-year-old children by half.

Background information on the South African preschool population
In 1994 the South African population was estimated to be 40.6 million, with black South Africans accounting for 76% of the total.2 Thirty-seven per cent (14.8 million) of the population was under 5 years of age, with nearly two-thirds living in non urban areas. The highest percentage of 1 - 5-year-old children live in the Northern Province (18%), and the Eastern Cape (18%) and the lowest percentage (8%) live in Gauteng Unemployment in South Africa is very high and has been steadily increasing since the 1960s with the decline in employment generation coupled with an annual population growth rate of 2.4%. According to the Central Statistical Service (CSS) 1994 Household Survey,2 the unemployment rate is 33%. In addition, nearly 10% of those who have an income earn less than R263 per month.

The World Bank has shown that South Africa has one of the most unequal income distributions in the world.3,4 The Gini coefficient at household level is 0.61, even though the gross national product (GNP) per capita is US$2670. Most other countries with a similar GNP per capita have a Gini coefficient of less than 0.50.

South Africa also compares poorly with other middle income countries (Thailand, Poland, Chile, Brazil and Malaysia) in terms of other social indicators. It has the lowest life expectancy (63 years), the highest infant mortality rate (IMR) (70 - 100), the highest adult illiteracy rate (39%), and highest total fertility rate (4.1%). 4,5

The poverty rate in South Africa differs significantly according to race and geographical area. The poverty rate of the black population is more than 60%, compared with less than 5% for the Indian and white populations. Poverty is particularly severe in non-urban areas. In comparison with the overall poverty rate of 52.8%, the poverty rate in non-urban areas is 73.7%.6-8 An important source of income for very poor households is pensions and remittances. Pensions make up 30% of the primary source of income of these households and remittances 18%.3 The extent of poverty is most evident when one examines the IMRs as an indicator of the well-being of South African society. Although South Africa has a reasonably high GDP, its IMR and under-5 mortality rate are unacceptably high.8 The IMR for black infants is 86/1 000 live births and 94 for non-urban infants. The under-5 mortality rate for black children is 125/1 000 live births, while it is 139 in non-urban areas (Mazur RE. Demographic data in the poverty survey: Analytic perspectives and regional profiles. MRC – unpublished technical report, 1994).

Nutritional status of preschool children in South Africa
The most comprehensive survey done on the nutritional status of preschool children in South Africa was undertaken in 1994. 9 A national sample of children aged 6 - 71 months was drawn, with disproportionate stratification by province. A total of 18 219 households were included in the study, and 4 788 blood samples were drawn. Findings on nutritional status are presented in Table I.

Anthropometric findings were that 23% of children were stunted and 9% were underweight. In practical terms this means that approximately 660 000 preschool children in South Africa are underweight, and that 1 520 000 are stunted owing to chronic undernutrition. The largest numbers of malnourished children were found in the Eastern Cape, Northern Province and Kwazulu-Natal.9 One in 3 children (33.3%) had a marginal vitamin A status (< 20 µg/dl). Such a high prevalence indicates that South Africa has a serious vitamin A deficiency problem. The most disadvantaged children were those in non-urban areas with poorly educated mothers.9

One in 5 children (21.4%) was found to be anaemic (Hb < 11 g/dl). Anaemia and poor iron status were more prevalent in the urban areas, and children in the 6 - 23-month age group were the most severely affected. Children wtih marginal vitamin A status were at a significantly higher risk of being anaemic and of having iron deficiency anaemia.

Visible goitre was noted in 1% of children nationally. However, the authors stress that this figure should be interpreted cautiously owing to the subjective nature of goitre assessment.9

Table I. Summary of nutritional indicators for children aged 6 - 71 months (SAVACG Study 1994)9

Nutrient intakes of preschool children
To date there has not been a national food consumption survey in South Africa. However, in 1995 a meta-analysis of dietary surveys was undertaken by the South African National Nutrition Survey Study (SANNSS) Group.10 The results of surveys using the 24-hour recall methodology for 2 - 6-year old children will be presented here. It should be borne in mind that the 24-hour recall method may underestimate dietary intake when compared with the dietary frequency method.11 The data presented here should be interpreted cautiously as it represents the results of three studies only.12-14 One study was conducted in the Northern Province (black non-urban children),12 one in Gauteng (white, coloured and black urban children)13 and one in the Western Cape (black urban children).14 These studies were not representative of the provinces, and in certain groups (white and coloured) the sample sizes were small. No data were available on Indian children for this age group.

Table II indicates that non-urban black children had the lowest energy and macro-nutrient intakes. Although mean protein intake met the requirement of the RDA, 15 fat intake was very low and could have contributed to the low energy intake of this group. The low energy intake of non-urban children explains the high prevalence of stunting in black children.

Mean calcium and zinc intakes were very low in black children compared with the RDA(Table III). Mean iron intake of urban black children was half the recommended amount. This would explain the higher prevalence of anaemia found in urban black children. Mean intakes of B vitamins were generally found to be greater than the RDA, with the exception of vitamin B 6 and folate in non-urban black children (Table IV). Mean intakes of vitamin C were found to be low in non-urban black children (Table V).

Results of the meta-analysis indicate that the dietary intake of black children is inadequate for many nutrients, the most problematic being a low energy intake and low intakes of micronutrients such as calcium, iron, zinc, vitamin C, B6 , folate and vitamin A.

Table II. Energy and macronutrient intakes of 2 - 6-year-old African children (SANNSS 1995)10

Table III. Micronutrient intakes of 2 - 6-year-old South African children (SANNSS 1995)10

Table IV. B vitamin intakes of 2 - 6-year-old South African children (SANNSS 1995)10

Table V. Vitamin intakes of 2 - 6-year-old South African children (SANNSS 1995)10

Causes of malnutrition in preschool children
One of the most commonly used conceptual frameworks of malnutrition cites inadequate dietary intake as one of the three immediate causes of malnutrition.16 Inadequate dietary intake is the outcome of underlying causes that are closely interlinked, namely poor household food security and inadequate maternal and child care.16

Poor household food security
Household food security is linked to numerous factors, which are presented in Fig. 1 and which are reflected by a family's standard of living. For the majority of South Africans, food security is primarily a matter of income security.8 Food security at household level depends on the power relationships within the household. If these are unequal, small children may be poorly fed even in middle income homes.8

According to Latham 17 the three most important requisites of household food security are: an adequate local food supply, and stability and accessibility of the food supply. Poor food security is frequently the result of a shock that has delivered a blow to an already impoverished resource-poor household. May 18 has indicated that short-term shocks in the South African. context have frequently led to poor household food security. He cites the most devastating and common ones as drought fire, loss of employment and death of family members. However, long-term trends influence the ability of the family to survive such shocks.19 These include ‘being born in, or marrying into resource poor households and gender discrimination, the erosion of resource base through continuous pregnancies, illness, long term unemployment and the long term impact of repeated drought’.

May 20 has found that among poor non-urban households, 31% can be considered to be food insecure. Numerous factors have led to a situation where subsistence farmers are limited to production for home consumption; this is generally low and does not meet consumption needs. This is usually a consequence of periodic drought, the composition of households and lack of access to alternative sources of income. As a result, non-urban households frequently rely on wages and remittances generated by family members in the urban areas or supplied in the form of old age pensions.20

Inadequate maternal and child care
Care in this context refers to the practices of caregivers, which translate food security and health care resources into a child's growth and development.21 These practices include care for women, breast-feeding and complementary feeding, adaptation to family diet, food preparation and hygiene practices.

In the South African context, household food security is directly related to the burdens placed on women. As a result of the large migration of men to urgban areas in search of work, female-headed households have become the norm, particularly in non-urban areas. This has placed additional responsibilities on women, particularly with regard to child care. Lack of time may prevent proper and frequent feeding of infants, resulting in poor nutritional outcomes.8

In South Africa growth faltering usually sets in during the weaning period, and the eventual outcome is stunting.9,22 One of the main reasons for this is the fact that small children are not fed food that is sufficiently energy-dense often enough to meet their energy requirements. Lack of food per se is not necessarily the primary cause, rather lack of information and access to energy-dense foods.

Numerous studies in South Africa have indicated that supplementary foods are introduced early in life and that exclusive breast-feeding is not the most common practice.23-26 These practices cause decreased frequency of suckling, with a consequent decline in breast-milk production and intake.22 The SAVACG study 9 found that 37% of urban women breast-fed for periods of less than 6 months, compared with 26% of non-urban women (Table VI).

Table VI. Percentage of children aged 36 - 47 months who were breastfed for various durations (adapted from SAVACG study, 1994) 9

Lack of education and information
The rate of illiteracy in South Africa, particularly in non-urban areas, is still very high. In 1993, only 54% of the black population was regarded as being literate.27 Added to this are factors related to inappropriate nutrition education, agricultural extension and training.

According to May,18 nutrition education needs to be dealt with as a cross-sectoral issue whereby the whole family is educated, not only the women, particularly in instances where women do not have control over their own income. Many of the factors leading to poor household food security and consequent malnutrition in young children are probably the

With regard to agricultural education, the current extension system is still largely focused on men and on the use of fertilizers. It does not take into consideration the fact that women perform most of the agricultural activities, and that input supplies (e.g. fertilizers and implements) may be lacking or non-existent.18 Because subsistence farming provide about half of the income of the poorest 5% of non-urban housholds, it is absolutely essential that such education is available and relevant.20

Recommendations
There can be little doubt that the nutritional status and related health of preschool children is the outcome of many complex interactions. No one department, discipline, or profession can solve the problem of poor nutrition in preschool children. The approach should be multisectoral and interdisciplinary.

Nutrition education should focus on the family and pay specific attention to: within-household food distribution, encouraging exclusive breast-feeding, encouraging frequent feeding of small children, discouraging complementary foods before 4 months of age, and encouraging ways of making staple foods more energy-dense, such as adding peanut butter to maize porridge.

• Agricultural extension should focus on women and should teach farming methods relevant to local conditions.
• Policymakers should investigate the possibility of making energy-dense supplements available to families with preschool children. Food supplements could be dispensed at routine clinic visits.
• Policymakers need to investigate micronutrient fortification and/or supplementation programmes which would benefit preschool children. This could be done at routine immunisation visits, as has been done successfully in other countries.28,29

References

1. Government of National Unity. Reconstruction and Development Programme (RDP) White Paper Discussion Document. Pretoria : Government Printer, 1994.
2. Central Statistical Service. October Household Survey. Pretoria: Government Printer, 1994.
3. Project for Statistics on Living Standards and Development. South Africans Rich and Poor: Baseline Household Statistics. Washington, DC: World Bank, 1994.
4. World Bank. Reducing Poverty in South Africa: Options for Equitable and Sustainable Growth. Washington, DC: World Bank, 1994.
5. Whiteford A, McGrath M. Income distribution, inequality and poverty in South Africa: preliminary findings from the Project on Living Standards and Development. Paper presented at the SALDRU Conference on Poverty, 1995.
6. World Bank. Health Expenditure and Finance in South Africa . Durban: World Bank and Health Systems Trust, 1995.
7. Government of National Unity. Reconstruction and Development Programme (RDP) White Paper Discussion Document. Cape Town: CTPBook Printers, 1995.
8. Reconstruction and Development Programme (RDP) Office. Children, Poverty and Disparity Reduction. Pretoria: Government Printer, 1996.
9. Labadarios D, ed. The South African Vitamin A Consultative Group (SAVACG). Children aged 6 to 71 months in South Africa, 1994: Their anthropometric, vitamin A, iron and immunisation coverage status. Isando: SAVACG, 1995.
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24. Steyn NP, Badenhorst CJ, Nel JH, Ladzani R. Breast-feeding and weaning practices of Pedi mothers and the dietary intakes of their preschool children. S Afr J Food Sci Nutr 1993; 5(1): 10-13.
25. Richter L. The early introduction of solids: an analysis of beliefs and practices among African women in Soweto. Paper presented at the South African Paediatric Association Conference, Skukuza, April 1994.
26. Ladzani R, Steyn NP, Nel JH. Infant feeding practices of Pedi women in six semi-rural areas of Northern Province. South Afr J Epidemiol Infect 1998; 13(2): 63-65.
27. South African Institute for Race Relations. RaceRelations Survey, 1993/94. Johannesburg: South African Institute for Race Relations, 1994.
28. Diene SM, Sanghvi T, Ndiaye M, Ly CW, Combest C. Integrating vitamin A interventions in health services : The PAIN program in Senekal. Poster presentation at the XIXth IVACG Meeting, Durban, March 1999.
29. Awwal AA, Hoque A, Hafiz MA, Rahman KM, Begum SA, Nahar S. Vitamin A supplementation along with immunization: Strategies and success in Bangladesh. Poster