the nutritional status of - Health Systems Trust

THE NUTRITIONAL STATUS OF
SOUTH AFRICANS
A Review of the Literature
FROM 1975-1996
By
Hester H Vorster, Welma Oosthuizen, Johann C Jerling, Frederick J Veldman & Hester M Burger
The Nutrition Research Group,
Potchefstroom University for Christian Higher Education,
Potchefstroom 2520
South Africa
For the
S
H
HEALTH SYSTEMS TRUST
T

Published by the Health Systems Trust
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T
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ISBN # 0-9584157-7-3
Date of publication: March 1997
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PREFACE
In this review, the Nutrition Research Group provides a timely and useful overview of the state of knowledge about
nutritional status and the causes of malnutrition in South Africa. The review covers a period of 21 years, from 1975
to 1996. Due to shortcomings in the data, it is unfortunately not possible to analyse trends over this period.
The review should prove useful to policy makers and programme directors, to establish the key nutritional problems
we need to address. The data shows that nutrition problems occur in specific groups and geographical areas.
Targeting interventions is therefore critical.
The review is as illuminating regarding the gaps in our knowledge. For effective policy development and planning,
researchers are challenged to focus on conducting research in these areas. Overall, there is an absence of definitive
work on the underlying causes of malnutrition in various circumstances. In depth, small scale studies, linked to
planned interventions could make an important contribution in this regard. There are gaps in our knowledge
regarding the dietary practices of certain groups, including rural black children under two years of age, and rural
adults, particularly in some provinces. The nutritional status and dietary practices of teenage girls, a potentially
vulnerable group, also appears as an area in need of study.
Nutrition researchers have an opportunity to ensure that the gaps identified in this study are filled. When a review
is done, in five or ten years time, we must have the data to be able to indicate improvements in key indicators.
Researchers should also seize the opportunity to use the available information to advocate for immediate action to
improve the nutritional status of the population.
Milla McLachlan
Chairperson: Nutrition Society.
November 1996
ACKNOWLEDGEMENTS
The research, writing and publication of this report were made possible by a grant from the Health Systems Trust.
Dr. LA Greyvenstein assisted with the language editing of the report, and Mrs. JM van Rensburg did the typing.
Dr. HM McLachlan reviewed the manuscript. Her useful recommendations were incorporated into the text with the
hope that it will contribute to a widespread application of the report in the planning of nutrition strategies and
programmes in South Africa.
We would like to thank all our colleagues (Dr. ARP Walker, Dr. AJS Benade, Prof. N Cameron and members of the
SANSS group) for assistance in the collection of the relevant literature.
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1. The problem of malnutrition
EXECUTIVE SUMMARY
As in most other developing countries, recent literature indicates that South Africa has a problem of malnutrition.
However, the exact nature and extent of this problem, as well as the vulnerability of different groups of South
Africans, are not known.
2. Ineffectiveness of present programmes
There is, at present, a perception that the few national Government programmes, and the many efforts from nongovernment
programmes and organisations aimed at addressing malnutrition are not effective. One of the main
reasons is probably because these programmes are not based on an analysis and understanding of the real
problem and are not targeted at the most needy. To design strategy, policy and programmes to tackle the problem
of malnutrition, more should be known about the nutritional status of South Africans.
3. Objectives of the review
The objective of this review is to integrate results from four national studies and a large number of ad hoc studies
by individual researchers and groups in a scientifically responsible manner, in order to evaluate and describe the
existing nutritional status of South Africans.
4. Data used
Results from published and unpublished reports which give information on the anthropometry, biochemical profiles,
dietary patterns, nutrient intakes, and clinical signs of malnutrition were used to compile 84 tables. Results are
stratified for ethnic group, age, gender, and province of domicile. Data which describes the impact of various
determinants of nutritional status (food security, poverty, urbanisation, family unity and cohesion, physical environment,
pregnancy, breast feeding and weaning practices, education, parasitic infections and alcohol intake) are summarised
in a separate chapter. A number of studies concerning the cultural influences on eating patterns of South Africans
are also included in this review.
5. Results
The results indicate that on a national level 20 - 25 % of preschool children and at least 20 % of primary school
children are stunted and therefore suffer from chronic undernutition. Prevalences of wasting and underweight in
school children are low. The vitamin A, iron and folate deficiencies observed in pre-school and primary school
children, are also seen in adolescents and adults. Rural black and coloured children are the most vulnerable
groups.
The calculated mean prevalences of stunting in pre-school and primary school children observed in a large number
of ad hoc studies, were in agreement or slightly higher for particular groups than found in the national surveys.
However, there were wide ranges reported, varying, for example, from 3-64 % in urban black preschool children to
0-12 % in white primary school children. This clearly indicates that there are pockets or areas with more serious
problems of undernutrition than others.
The dietary and nutrient intake data supported the anthropometric and biochemical observations. In addition to
low intakes of several micronutrients (calcium, iron, magnesium, zinc, riboflavin, vitamins A, B6, C and folate), the
low fibre intakes and increases in total fat intake are of concern.
An analysis of dietary patterns and determinants of malnutrition showed that, although cultural influences may
explain some differences in nutrient intakes between ethnic groups, other factors such as poverty, food insecurity,
disruption of the family unit, parasitic infections and lack of education are probably more important determinants.
In all reports which examined dietary patterns, there was consensus that the low energy density of weaning foods
and the low intake of milk (or milk products), fruits, vegetables and legumes by many South Africans are responsible
for most of the nutrient imbalances in the diets.
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6. Recommendations
It is suggested that the major findings of this review should be considered in the design of strategies, policies and
programmes to address the problem of malnutrition.
The wide range of prevalences of stunting in pre-school and primary school children indicates that programmes
should be flexible and based on real and specific needs in specific areas.
The co-existence of under- and overnutrition suggests that programmes should not only focus on adequacy of
diets, but also on prudency. Education towards “healthier” food choices should form part of all intervention
programmes.
Although some of the micronutrient deficiencies can be addressed by fortification programmes, it is suggested that
the question of iron fortification should be examined in depth by an expert committee. Fortification of weaning
foods is an option to consider.
The limited information on the nutritional status of adult South Africans, not normally regarded as a high priority
target group, indicates that their nutritional status is far from optimal. It is essential that to ensure maximum
benefit from development programmes, the nutritional status of many adults should also be improved.
A major observation in this review is the many gaps in our knowledge regarding nutritional status of specific age
and ethnic groups and also regarding specific nutrients. There is no information on how many South Africans
suffer from hunger. Very little is known about the impact of the rapid urbanisation on nutritional status and its
determinants in people living in informal housing areas. The biochemical information on nutritional status is
limited to a few nutrients in selected groups. Much more information on, for example zinc, calcium and iodine
status is needed. Clearly, all these areas require urgent research to support intervention programmes.
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PREFACE
CONTENTS
ACKNOWLEDGEMENTS
EXECUTIVE SUMMARY
CHAPTER 1
INTRODUCTION
1.1 BACKGROUND
1.2 MOTIVATION AND AIMS OF THIS REVIEW
1.3 EVALUATION OF NUTRITIONAL STATUS
1.4 STRUCTURE OF THIS REVIEW
CHAPTER 2
METHODS
2.1 COLLECTION AND SELECTION OF STUDIES/DATA
2.2 CODING OF DATA: COMPILATION OF TABLES
2.3 DIETARY DATA
2.4 UNCODED DATA
CHAPTER 3
RESULTS
3.1 ANTHROPOMETRY
3.1.1 Introduction
3.1.2 Definition and Terminology
3.1.3 Reference Population (Standards, Cutpoints)
3.1.4 Infants and Children, 0-6 years
3.1.5 Primary School Children
3.1.6 Adolescents
3.1.7 Adults
3.1.8 Comments
3.2 BIOCHEMICAL VARIABLES
3.2.1 Introduction
3.2.2 Infants and Children aged 0-6 years
3.2.3 Primary School Children
3.2.4 Adolescents
3.2.5 Adults
3.2.6 Comments
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CHAPTER 4
DETERMINANTS OF NUTRITIONAL STATUS
4.1 INTRODUCTION
4.2 CAUSES OF UNDERNUTRITION
4.3 RISK FACTORS FOR UNDERNUTRITION IN SOUTH AFRICA
4.3.1 Food Security
4.3.2 Poverty
4.3.3 Urbanisation
4.3.4 Family Unity and Cohesion
4.3.5 Physical Environment
4.3.6 Pregnancy
4.3.7 Breastfeeding and Weaning Practices
4.3.8 Education, Ignorance and Psychological Factors
4.3.9 Parasitic Infections
4.3.10 Alcohol Intake
4.4 COMMENTS
CHAPTER 5
CULTURAL INFLUENCES ON DIETARY PATTERNS
5.1 INTRODUCTION
5.2 WHITE SOUTH AFRICANS
5.3 COLOURED SOUTH AFRICANS
5.4 SOUTH AFRICAN INDIANS
5.5 BLACK SOUTH AFRICANS
5.6 COMMENTS
CHAPTER 6
DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS
6.1 LIMITATIONS OF THE REVIEW
6.2 MAIN FINDINGS: CONCLUSIONS
6.2.1 Preschool Children
6.2.2 Primary School Children
6.2.3 Adolescents
6.2.4 Adults
6.2.5 Determinations of Malnutrition
6.2.6 Dietary Patterns and Nutrient Intakes
6.3 DISCUSSION AND RECOMMENDATIONS
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INTRODUCTION
CHAPTER 1
1.1 BACKGROUND
Our health and well-being, quality of life and ability to learn, work and play depend on how well we are nourished.
Good nutrition or nutritional status is the outcome of many complex and interrelated determinants such as access
to adequate, safe, affordable and nutritious food, care and health services.
Although good nutrition is universally accepted as a basic human right, it is estimated that globally, more than 800
million people suffer from malnutrition and that in developing countries, more than 20 % of the populations are
hungry. Grant (1993) estimated that in 1990, 193 million preschool children were underweight South Africa is a
middle-income, developing country. According to the literature widespread outspoken hunger may not a major
problem, but the health and nutritional status of millions of South Africans are far from optimal. A recent comparison
of a few health indicators (infant mortality rate, life expectancy at birth and incidence of tuberculosis) and the
money spent on health services compared with those of other countries at similar levels of economic development
(McIntyre et al. 1995), indicate that we are not using our resources optimally.
The high rates of malnutrition among South African children reported by a number of authors during the past 20
years (Kotzé, 1978; Wyndham & Irwig, 1979; Hansen, 1984; Richardson, 1986; Coovadia, 1993) have motivated the
Department of Health to implement various national nutrition intervention programmes. These are the National
Nutrition and Social Development Programme (NNSDP), the Protein Energy Malnutrition Scheme (PEM) and the
Primary School Nutrition Programme (PSNP). In addition, several non-government organisations also implemented
intervention programmes.
Although the outcome of these programmes have never been evaluated in a scientific and satisfactory way, there
is a perception that they are not cost-effective and do not contribute to general improvement of nutritional status
and health. The reasons for their “failure” have been discussed in detail by McLachlan & Marshall (1995). These
include inter alia that they were designed without adequate information, that their designs reflect a limited
understanding of the problems of malnutrition, that goals were ill-defined and activities unfocused, that the emphasis
on delivering of specific services such as the handing out of food was wrong, that they were not targeted to the
most needy and that participation and involvement of communities were inadequate. However, in 1994 a nutrition
committee appointed by the Minister of Health compiled a draft report on an integrated nutrition strategy for South
Africa, which addresses these problems in a constructive and positive manner (Nutrition Committee, 1994).
1.2 MOTIVATION AND AIMS OF THIS REVIEW
It is obvious from the above that in order to design better and more effective nutrition intervention programmes
that will lead to improved nutritional status and health, we need adequate information on the existing nutritional
status and specific nutritional problems of South Africans. We also need to know which of the many interrelated
determinants of nutritional status contribute most to malnutrition in South Africa. To target programmes effectively
we need to know more about the most vulnerable and disadvantaged. In addition, we need to know where the gaps
in our knowledge are to plan more effective and relevant research in nutrition.
The main objective of this review is to provide baseline data on the existing nutritional status of South Africans.
Except for four national studies from 1980 to 1994, which provided data on the anthropometry of young children
and of which one gave information on vitamin A and iron status of preschool children, the only other available
scientific data on nutritional status are results from small regional ad hoc studies published by individual researchers.
This review therefore aims to combine, integrate and interpret the results of these studies. Because of the structure
of the South African population, as well as previous political policies, most of the above mentioned studies stratified
and reported results for specific ethnic groups. To identify the most vulnerable and needy it was thought that
further stratifications for gender, age, province and rural or urban locality in the case of Africans would be necessary,
and were therefore made in the compilation of the tables.
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1.3 EVALUATION OF NUTRITIONAL STATUS
The nutritional status of an individual depends on how well requirements for energy and more than 50 different
nutrients are met. Requirements and eating behaviour (what, where, when and how often specific foods are eaten)
are determined by a large number of physiological, pathological, psychological, cultural and socio-economic factors.
Because of this, there is no single measurement that will give comprehensive information on nutritional status.
Therefore, a combination of methods, including anthropometric measurements, biochemical analyses, nutrient
intakes and clinical signs of malnutrition is usually used. The interpretation of these variables and conclusions
reached will depend on the norms or standards used for comparison.
1.4 STRUCTURE OF THIS REVIEW
In addition to the executive summary and this introduction, (Chapter 1), the methods used to collect, select, code
and integrate the available literature are discussed in Chapter 2. In Chapter 3 the results consisting of 84 tables
and 6 figures are given. These are divided into four sections, namely anthropometry, biochemistry, nutrient intakes
and clinical signs. Data from these tables and figures are discussed briefly and salient observations highlighted.
Reports on the determinants of nutritional status which have been examined in several studies by individual
researchers and groups are given in Chapter 4. In Chapter 5, the limited information on how culture influences
eating patterns in South Africa is summarised. Cultural influences may be seen as a determinant of nutritional
status. However, it is difficult to conclude from the available literature whether it contributes to malnutrition in
South Africa. Because it probably should influence dietary recommendations, and also because it should be taken
into account in nutrition programming, the available literature on cultural influences on eating patterns is summarised
in this separate chapter. Chapter 6 consists of an integrated discussion of the results and some recommendations
on how the problem of malnutrition could be tackled. The bibliography and acknowledgements are given in
Chapters 7 and 8.
2

METHODS
2.1 COLLECTION AND SELECTION OF STUDIES/DATA
CHAPTER 2
Both published and unpublished data are included in this review. Published titles screened for inclusion were
obtained from several electronic data bases (MEDLINE, REPORTORIUM), as well as South African medical and nutrition
journals not included in these data bases. Articles, books and reports were obtained from the Ferdinand Postma
Library in Potchefstroom and its inter-library services. Unpublished manuscripts, dissertations, theses, research
reports and other documents (policy and briefing papers, technical reports, etc.) were obtained from the Medical
Research Council, several universities, Government Departments, the Health Systems Trust, UNICEF, WHO, FAO and
RDP offices, as well as individual colleagues and researchers. It is possible that, despite all these efforts, there may
be publications and reports with valuable information on nutritional status of South Africans that were missed.
After screening and selecting all available titles, some documents (especially postgraduate theses) could not be
traced and are therefore not included in the review. Literature that measured the nutritional status of patients or
subjects included in a study because of a specific disease or condition such as kwashiorkor, marasmus, diabetes or
hypertension, were not included in the review.
2.2 CODING OF DATA: COMPILATION OF TABLES
After collection of the literature, four researchers read the relevant sections and transferred the data to specially
designed coding forms for either anthropometry, biochemistry, nutrient intakes or clinical signs. At the same time,
short summaries of data pertaining to determinants of nutritional status and eating patterns were made. The
coding forms helped to stratify information for date of the study (or published date), province, randomisation of
subjects, ethnic group, urban/rural, gender, age, number of subjects, variables measured, means with standard
deviations or confidence intervals, percentage of subjects with abnormal values and reference range. These data
were then computerised and organised by computer into Tables 1-84.
Because of differences in study design, selection of subjects and presentation of results, it was not possible to
integrate and combine data on anthropometry, biochemistry and clinical signs of malnutrition in a meta-analysis.
These data are therefore summarized in separate tables. Available nutrient intake data were combined in a metaanalysis
by SANSS (1994) and are presented as such. For coding, urban and rural classification were used, as
reported by the authors. Where appropriate, for example in the prevalence of stunting in preschool children, means
from the different individual studies were calculated (without weighting of studies for numbers, etc.) and compared
with the recent national surveys. Data from these surveys (SALDRU/World Bank 1994; Department of Health 1994;
SAVACG, 1995) were included in the tables where appropriate, or given separately.
2.3 DIETARY DATA
Nutrient intake data depends to a large extent on methods used to obtain information on dietary habits and
intakes. The 24-hour recall method tends to measure lower intakes than, for example, the diet history and food
frequency questionnaire. A survey of the South African literature on dietary intakes (SANSS, 1995) showed that the
24-hour recall method was mostly used in larger surveys while the diet history or food frequency questionnaire
methods were used in smaller studies with limited numbers of subjects. Therefore, it was decided to present the
24-hour recall data separately, as explained in Chapter 3.3.1.
2.4 UNCODED DATA
Not all sources such as review papers, opinions, editorials and policy or briefing papers gave data in a form that
could be coded and included into the tables. If relevant, these were used in Chapters 4 and 5 to describe determinants
of nutritional status or mentioned in the brief discussions of the different tables.
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RESULTS
CHAPTER 3
3.1 ANTHROPOMETRY
3.1.1 INTRODUCTION
In this section, reported anthropometric measurements and indices of South Africans, stratified for age, gender and
ethnic group, are used as indicators to evaluate nutritional status of specific groups. Anthropometric measurements
are used to assess body size, proportions and composition. They reflect inadequate or excess food intake, insufficient
exercise, growth of children, disease, and overall health and welfare. Because anthropometry is the single most
portable, universally applicable, inexpensive and non-invasive method to obtain information on nutritional status
(De Onis & Habicht, 1996), it is often used to evaluate the outcomes of policies and nutrition intervention programmes,
or to select individuals whom should be targeted in such programmes. Therefore, repeated cross-sectional or
longitudinal measurements of anthropometry will monitor changes in nutritional indicators over time, giving
warning of impending crises and identify at risk populations.
3.1.2 DEFINITIONS AND TERMINOLOGY
The definitions of different concepts and the terminology used in this section are in agreement with recent
recommendations of an expert committee on the use and interpretation of anthropometry of the World Health
Organisation (WHO, 1995).
3.1.2.1 Measurements
The basic nutritional anthropometric measurements are weight (mass), height, body circumferences (waist, hip,
head and upper arm), as well as skinfolds.
3.1.2.2 Indices
These are combinations of measurements necessary for interpretation of the measurements. Examples are body
mass index [weight (kg)/height (m 2 )], weight-for-age (W-a), height-for-age (H-a) or weight-for-height (W-H). The
indices can be expressed in terms of Z-scores, percentiles or percent of median. These expressions can be used to
compare an individual or a group with a reference population.
* Z-scores:
This is a standard deviation score and is defined by WHO (1995) as the “deviation of the value for an individual from
the median value of the reference population, divided by the standard deviation for the reference population”.
Therefore: Z-score =
(observed value) - (median reference value)
standard deviation of reference population
* Percentiles
This is the rank position of an individual on a given reference distribution, stated in terms of what percentage of the
group is equalled or exceeded by the individual. Therefore, a child of a specific age, whose weight falls in the 10th
percentile, weighs the same or more than 10 % of the reference population of children of the same age.
* Percent of median
This is the ratio of a measured value in an individual such as weight or height to the median value of the reference
data for the same age, expressed as a percentage.
2.1.2.3 Indicators
These are applications of indices to evaluate nutritional status. In this analysis, the percentage of children below a
defined cutpoint (level) for a particular index (W-a, H-a, W-H), was used to evaluate the extent and magnitude of
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malnutrition in a particular group of children. Therefore, studies which reported percentages of subjects under a
specific cutpoint were included in the tables. Many studies did not report data in this way, but did, however, make
important observations regarding the nutritional status and anthropometry of South Africans. These studies were
also incorporated in the results and discussion sections, but not in the tables. In agreement with the World Health
Organisation’s recommendations (WHO, 1986; 1995), the anthropometric indices and indicators were used in this
analysis as follows:
* Weight-for-age (W-a)
A low W-a is indicative of underweight. If 20-40 % of a population or group is underweight, the population or group
is moderately affected. If more than 40 % is underweight, a severe problem exists.
* Height-for-age (H-a)
Low H-a is indicative of stunting, which is a result of chronic, long-term dietary inadequacy, reflecting socioeconomic
deprivation. The WHO (1986) regards a population to be moderately affected if 25-50 % of its children
under 5 years of age are stunted, and severely affected if more than 50 % are stunted.
* Weight-for-height (W-H)
A low W-H reflects wasting, a result of acute nutritional stress and severe food shortages or serious illness. A figure
of 5-10 % wasting in a population or group is regarded as a moderate prevalence and more than 10 % as a severe
problem (WHO 1986; 1995), which would need immediate nutritional support (Solarsh et al., 1994). Because one of
the main aims of this analysis is to evaluate the extent of malnutrition among South Africans, the focus in the
tables on children is on the percentage of children with low anthropometric indices. However, if data on overnutrition
(obesity) was published, this was also included in the tables.
3.1.3 REFERENCE POPULATION (STANDARDS, CUTPOINTS)
The measured frequency, magnitude or extent of malnutrition in a particular population or group will be influenced
by the anthropometric criteria employed. WHO (1995) defines a reference as a tool for grouping and analysing data
which provides a common basis for comparing populations. No inferences should be made about the meaning of
observed differences. The same source further states that a standard embraces the notion of a norm or desirable
target and thus involves a value judgement.
There has been considerable debate in the literature regarding the use of international reference data and the
desirability of national norms that would reflect growth patterns of South African black children (Walker et al., 1978;
Kotzé et al., 1982; Cameron, 1992; Cameron & Kgamphe, 1993). De Onis and Habicht (1996) maintain that although
differences of genetic origin are evident for some comparisons, these variations are relatively minor compared with
the large worldwide variation in growth related to health and nutrition. Cameron and Kgamphe (1993) state that
secular trends towards greater heights and weights and earlier pubertal development can only be assessed by
using international norms. But, if the growth of an individual child is monitored, the child should be compared with
his peers who are living under the same environmental circumstances. However, no national norms exist and
almost all the studies on children included in this analysis used the reference data collected from healthy, wellnourished
American children by the National Center for Health Statistics (NCHS) and recommended by the WHO for
international use. The cutpoints used in this analysis for children and adolescents were the percentages of children
given below:
* -2 Z-score (< 2.28th percentile)
* 3rd percentile (< 5th if the 3rd was not available)
* 80 % of the median (50th percentile) weight-for-age
* 90 % of the median height-for-age
* 90 % of the median height-for-weight
In a population with reference values following a normal (Gaussian) distribution, the -2 Z-score, 3rd percentile and
80-90 % of the median are very close to each other (WHO, 1995). To evaluate prevalence of underweight and obesity
in adults, cutpoints of < 20 kg/m 2 and > 30 kg/m 2 for body mass index were used. In children, obesity was
evaluated by using either > +2 Z -score or > 120 % of “ideal” weight as cutpoints. However, obesity results in children
should be interpreted with care. De Onis & Habicht (1996) recently observed that in the NCHS reference curves, the
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distributions of weight-for-age and weight-for-height are markedly skewed toward the higher end, reflecting a
substantial level of childhood obesity. This skewness, reflecting an unhealthy characteristic of the reference sample
may result in the misclassification of overweight children as normal.
3.1.4 INFANTS AND CHILDREN, 0-6 YEARS
The percentages of infants and children who fell under the cutpoints as discussed above regarding W-a, H-a and
W-H are given in Tables 1 to 7. The data were collected by several researchers from 1976 to 1996 from more than
60 000 children, divided into approximately 140 subgroups based on age, gender, ethnic group and geographical
location. In addition to tables for white, coloured and Indian children, there are three tables for black children,
giving data for urban and rural children separately and one (Table 6) with data from a study of Solarsh et al. (1994)
which did not distinguish between rural and urban children in the same manner as the other studies. Table 7 gives
data from national studies which did not stratify for ethnicity. This table consists mainly of data from the 1994
national study on vitamin A status of preschool children (SAVACG, 1995), which also reported on the anthropometric
status of these children. The table further includes H-a data from the SALDRU/World Bank study of 1993-1994. In
all 7 tables, the available data for the different provinces are grouped together.
Table 8 summarises some of the information in Tables 1 to 7, and also gives calculated means of percentages of
children under the given cutpoints. These means were not corrected for number of children in each subgroup. The
means given at the bottom of this table are from the SAVACG (1995) study.
From these tables it is clear that the groups most extensively researched and reported on (although not in proportion
to total numbers of South African children) are rural and urban black infants and children, while less research has
been done on Indian, white and coloured children. An important observation is that within each ethnic group there
is a wide range of percentages of children under a given cutpoint, illustrating that the prevalence and severity of
malnutrition differs from area to area and that pockets of malnourished children exist. This wide range was
especially noticeable in rural black children. A direct comparison between rural and urban black children on the
available data is not possible. The SAVACG (1995) study reported slightly higher prevalences of rural children under
the -2 Z-score of the three anthropometric indices than urban children, indicating that on a national basis and
where data is not stratified for ethnic group, the rural areas probably have a larger incidence of malnutrition than
urban areas. Except for the SALDRU and SAVACG studies, not enough comparable data were available to evaluate
the extent of malnutrition in different provinces in the under 6 year old group of children.
From Table 8 it can also be seen that both coloured and Indian children had higher prevalences of low W-a and low
H-a than black children. Unfortunately, especially in the Indian group, no recent data were available. Generally, the
percentages of children who had low W-H were small. Therefore, except for some isolated areas, wasting or acute
malnutrition was not reported as a problem. The SAVACG (1995) study confirmed these results.
In the white, coloured and Indian groups, mean prevalences of children with low W-a were higher than those with
low H-a. This indicates that in these three groups underweight was a more serious problem than stunting. In
contrast, in black children the percentages of children who were stunted exceeded those who were underweight. In
the national survey (SAVACG, 1995), the prevalence of stunting (22.9 %) was also much higher than that of underweight
(9.3 %). The same pattern of much lower degrees of underweight than underheight-for-age, in the absence of
wasting, was observed by Solarsh et al. (1994) in infants and preschool children in KwaZulu-Natal. These authors
mention that this pattern suggests that a substantial number of children are relatively overweight-for-height.
Dannhauser et al. (1996) found that approximately 10 % of the black children in their sample from a rural area in
the Free State had a Z-score of +2 and higher.
Gross & Monteiro (1989) also described differences in prevalences of stunting and wasting in infants and preschool
children in Brazil. They concluded that the high stunting (10-15 % of children) and low wasting (2-5 %) indicated
that malnutrition was caused not by hunger, but by poor sanitation and health facilities.
The growth pattern of South African infants and children has been studied in some detail by several authors on
children from different parts of the country showing very similar results. Coovadia et al. (1977) reported on 5 732
urban black children aged 0-12 years from KwaZulu-Natal. Compared to Harvard reference standards, the younger
children were generally heavier than the international standard. The heights of children aged 0-2 years were
similar to the international standard, but children older than two years were shorter (stunted). Richardson and
Sinwell (1984) monitored the growth of Tswana infants in the rural North West Province. They found that these
babies were short at birth (mean 43 cm, NCHS reference: 50 cm); but that the mean birth weight of 3.3 kg was
comparable to the international standard. Weights were maintained for 7 months but faltered thereafter, despite
continuous breastfeeding, indicating that breastmilk alone was not sufficient and that weaning practices were not
adequate.
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A direct comparison of the results from the SALDRU/World Bank and the 1994 National Survey (SAVACG, 1995; Table
8) with the compilation (calculated means) of the smaller studies done from 1976 to 1996 is not possible. Changing
circumstances over 20 years such as droughts, economic recession, improved health services, changed political
structures, as well as an absence of proper randomisation or selection bias in the smaller studies, could be
responsible for observed differences. However, looking at calculated means, the same overall pattern of low prevalence
of underweight, moderate to high prevalences of stunting in the absence of wasting, emerged. The wide range of
percentages of children under a specific cutpoint for all three indices (W-a, H-a and W-H) as summarised in Table
8 further emphasises that there are areas with high prevalences of malnutrition.
3.1.5 PRIMARY SCHOOL CHILDREN
Tables 9 to 14 give information on the anthropometric indices of primary school children, as well as percentages of
children under the 3rd or 5th percentile of these indices. Most children were between 6 and 12 years old, but some
studies included slightly older children. The data were collected from 1975 to 1996 and 34 374 children were
weighed and measured. For this analysis, the children were divided into 111 subgroups based on age, gender,
ethnicity and geographical area. The data include 20 000 children aged 6 to 9 years who were measured in the
1980 National Survey (Kotzé et al., 1982). Without this group, the anthropometry of only 14 374 primary school
children were studied by individual researchers over a period of 20 years. However, Table 15 gives data on the 1994
National Survey (Department of Health, 1994). This study included 97 790 children or 4.9 % of all school entrants
in the Republic of South Africa. These children were randomly selected from 3 300 schools using 10 schools per
magisterial district in the four Education Departments (Houses of Assembly, Representatives, Delegates and Education
and Training) of the previous Government to represent children from all four population groups. For the purpose of
this analysis, the assumption was made that these would represent the white, coloured, Indian and black children
respectively.
Table 16 summarises some of the data contained in Tables 9-15. For comparison, the mean figures obtained in the
1994 National Survey for each ethnic group are also given in this table. The mean percentages were calculated
from all studies except the 1994 National Survey. No corrections for the number or distribution of subjects in the
smaller studies were done. The data should therefore be interpreted with care. Nevertheless, the prevalences of
underweight and stunting in all population groups seemed to be higher in the smaller studies than in the 1994
National Survey. Both sets of data indicate that wasting (low W-H) is not a serious problem on a national basis,
although the wide range in prevalence reported in different studies, indicates that it is a serious problem in several
areas and in particular groups of children.
One reason for the differences in prevalences of underweight and stunting is probably that in the smaller studies
some groups of children were examined because it was suspected that they were malnourished, leading to selection
bias. For example, the Indian children studied by Van Rensburg et al. (1977) were from a socio-economically
deprived area in Durban and they were selected on a basis of scoring during aptitude tests. This study showed that
the majority of children were growth retarded and that they could be classified as “slow learners”. These authors
remarked that despite the low weights and heights of the Indian children, their skinfold thickness was close to
normal, as judged by conventional standards. The normal or “thicker” skinfolds of Indian children were also
observed in other studies (Kotzé et al., 1986; Vorster et al., 1994).
Comparing weights and heights and weight and height increases in the 6, 7, 8 and 9 year old children of the 1980
National Survey, Kotzé et al. (1982) observed that white children had the highest growth rate. Indian boys initially
had the lowest weight, and put on weight later than the coloured and black boys. But they grew faster in height
than the boys of the other two ethnic groups. Black children weighed more than the Indian and coloured children
but they had the slowest growth rate (in weight and height) over this age period.
In Table 17, the prevalences of stunting (low H-a) obtained in the three recent National Surveys on preschool
(SALDRU/World Bank 1993/1994; SAVACG 1995) and primary school children (Department of Health, 1994) are given.
On a national level, the percentages of stunted preschool children were 25.4 and 22.9, while the percentage of
stunted school entrants was 13.2. This 10 % difference is difficult to explain. It is possible that undernourished
children are kept at home and sent to school later, but both studies on preschool children had an age cutpoint (60
and 72 months). All three studies were randomised and included children from the previous Homelands. However,
differences in the provinces that did not have Homelands, such as the Western Cape, Northern Cape and Gauteng,
were smaller than the provinces that included the Transkei (Eastern Cape), Bophutatswana (Free State and North
West Province) and Venda (Northern Province). Therefore, it seems that insufficient randomisation of subjects could
be a possible reason. The prevalences of stunting obtained in the SALDRU/World Bank study for the different
provinces are generally higher than those of the SAVACG study. Due to measurement error, the body weights of
children in the SALDRU/World Bank study could not be used (Harrison, 1995). The possibility that heights and ages
were not accurate cannot, therefore, be ruled out.
8

Table 17 shows that the Northern Cape, Eastern Cape and Northern Province have the highest stunting prevalences,
followed by the North West Province, KwaZulu-Natal, Free State and Mpumalanga. Gauteng and the Western Cape,
the two most urban provinces, had the lowest prevalences.
3.1.6 ADOLESCENTS
The anthropometric indices of adolescent boys and girls measured by several authors from 1978 to 1993 are given
in Tables 18-22. No national study of a representative group of adolescents has been done, probably because they
are not generally seen to be a vulnerable group for malnutrition. The data in Tables 18-22 are from children of
different ages and different variables were measured. It is, therefore, difficult to compare the different population
groups or to obtain an indication of the general level of nutritional status. However, three groups of researchers
including Walker, Richardson and Cameron, studied the anthropometry and secondary sexual development of
South African adolescents. Walker et al. (1982) compared 16 year old children from all four population groups and
found that Afrikaans speaking white boys and girls were the tallest and heaviest (also taller than English speaking
and Jewish boys and girls), while rural black boys and Indian girls were the shortest and lightest. In another study,
Walker et al. (1980) demonstrated that 16 and 17 year old rural black children were on average 1 cm shorter and 2
kg lighter than urban black children. However, in a series of studies Cameron (1992) and Cameron et al. (1991;
1992; 1993; 1994) found that rural children of farm labourers and subsistence farmers had superior growth
compared with average urban children. They concluded that “black children of good socio-economic status have
growth patterns similar to those of NCHS norms”.
The same authors consistently found that rural black children were delayed in the age at which they entered events
of puberty, but that urban black children from good socio-economic backgrounds were slightly ahead of European
children. Richardson & Pieters (1977) and Richardson et al. (1983) described the same pattern of late menarche in
rural black girls despite normal breast development and adequate body fat composition. Their average weight-forheight
was, in fact, greater than the average minimum required for white girls to menstruate. Cameron et al. (1991;
1992; 1993; 1994) observed a secular trend of a decrease in age of menarche in black girls since 1943 of 0.34 years
for rural girls and 0.73 years for urban girls.
Cameron et al. (1994) also described the fat patterning of rural black children. The girls showed a rapid gain in
fatness after peak height velocity which differed from male centralised patterning. They hypothesised that this fat
gain may be a physiological adaptation to an environment of suboptimal energy availability to buffer the energy
cost of reproduction.
3.1.7 ADULTS
Tables 23 to 26 give anthropometric indices of South African adults. Table 27 summarises reported heights of the
men and women from the different population groups. Table 28 gives an analysis which Walker (1995) made of the
prevalences of obesity among adult men and women, stratified for age and ethnic group. The data used to compile
this table came from four large studies on whites (CORIS: Jooste et al., 1988), coloureds (CRISIC: Steyn et al., 1990),
Indians (Seedat et al., 1990) and blacks (BRISK: Steyn et al., 1991).
Table 27 indicates that black and coloured men and women are on average shorter than white men and women.
Woods et al. (1978) also showed that coloured primigravidas delivering at term in the Western Cape, were shorter,
lighter and thinner than white primigravidas. They related this phenomenon to childhood undernutrition and an
inadequate diet during pregnancy. But Cameron and Kgamphe (1993) maintain that heights of African men and
women (except the Pygmy and Bushmen) fell within or above European standards, showing that catchup growth
took place where children were short for their age. Tobias (1989) examined secular trends in heights (statures) of
Africans. He showed that no increase in height of Africans in Johannesburg took place from 1919 to 1950.
However, the Kalahari San (Bushmen) has a secular trend towards increased adult mean stature.
Table 28 shows that obesity (BMI > 30 k/g/m2) is common among South A frican women. The highest prevalence
of 59 % was observed among black women aged 45-54 years in the BRISK study. Coloured women of the same age
had a prevalence of 42.6 %, Indian women 40 % and white women 23.8 %. The black women aged 15-64 also had
the highest mean prevalence of 34.4 %. The prevalences for men are much lower. The group with the highest
prevalence was the black men aged 55 to 64 years (28.6 %), but the white men had a higher mean prevalence
(14.7 %) than the other ethnic groups.
3.1.8 COMMENTS
The trends or patterns observed from the nutritional anthropometry are that although only moderate prevalences
of stunting, relatively low levels of underweight and low levels of wasting exist on a national level, there are pockets
9

of high prevalences, indicating that there are areas where undernutrition is a severe and serious problem. Rural
black and coloured children seemed to be the most vulnerable. At the same time, relatively high prevalences of
obesity, especially among black and coloured women were observed. This coexistence of under and overnutrition
in developing countries has been described by several authors (Gross & Monteiro, 1989; Popkin, 1994). It has also
been observed in the same families. Steyn et al. (1994) examined the caretakers of 57 underweight Pedi preschool
children. They found that 4 % of the caretakers were underweight, 20 % overweight and 11 % were obese. More
than 50 % of siblings were stunted. It seems that in these families there was enough diet energy available, but that
it was difficult for young children to eat enough food to meet energy needs. The low energy density of the diet was
therefore a contributing factor to the high prevalence of underweight. Steyn et al. (1994) also mention that parasitic
infections in the children, as well as unhygienic feeding practices which lead to illness, may be responsible for the
undernutrition of children, despite the availability of enough food and energy.
There are other hypotheses that try to explain the coexistence of under and overnutrition in the same communities
or families. The one is the “Barker” hypothesis (Barker, 1992) which states that foetal nourishment will influence
health in later life. The other is the thrifty gene hypothesis, recently reviewed by Swinburn (1995). This hypothesis
maintains that a process of natural selection of survivors of hunger, famine and starvation is responsible for the
high incidence of obesity in developing populations. Both are beyond the scope of this report, but are mentioned
to make the point that many mysteries and problems in the field of community nutrition will only be solved
through research on a genetic and molecular level.
3.2 BIOCHEMICAL VARIABLES
3.2.1 INTRODUCTION
The concentration of many variables in body fluids (blood, plasma, serum, urine) or tissues (blood cells, muscle,
adipose, etc.) can give useful information on the dynamics of a particular physiological or pathological process and
also on nutritional status. Unfortunately, no single biochemical variable will reflect total nutritional status and a
number of variables are generally used in conjunction with other measures of nutritional status (anthropometry,
nutrient intakes and clinical signs of deficiencies). It should be kept in mind that the concentration of a specific
nutrient variable will be influenced not only by intakes, but also by all factors which influence turnover (absorption,
transport, metabolism and excretion). Moreover, several homeostatic mechanisms are responsible for maintaining
many blood variables within narrow ranges. The blood (plasma or serum) concentration of a particular variable
therefore does not necessarily reflect body stores.
Another problem in the interpretation of biochemical variables is often their poor correlations with other measures
of nutritional status. For example, Badenhorst et al (1993) found in 296 rural black children that, while 25 % were
underweight and 23 % stunted according to anthropometric indices, none had serum albumin or glucose values
outside the reference range, only 3 % had low phosphorus values, but 38 % had abnormal alkaline phosphatase
levels. In a group of primary school black children from a remote rural area in the North West Province, Schmidt &
Vorster (1995) also found that, although more than 50 % of the sample were stunted, total protein, albumin, prealbumin,
retinol, ß-carotene and several other vitamins and minerals fell within normal ranges. Poor dietary
intakes are often better reflected by anthropometry than by biochemical measurements. However, the opposite can
also be true. Jooste et al. (1994) demonstrated in a group of 380 black primary school children in the Caprivi that,
although 43.9 % of the girls and 33.7 % of the boys were biochemically anaemic, less than 1 % showed clinical
signs of anaemia. The above emphasises the fact that while anthropometric measurements reflect growth and
total nutritional status, biochemical measurements should be used to evaluate specific nutrient deficiencies.
In this section, mean biochemical variables and in some instances, percentages outside normal ranges, reported
during the past 10 years on South Africans stratified for age and ethnic group, are given in Tables 30 to 43. The
“normal” reference ranges used to evaluate these variables are given in Table 29.
3.2.2 INFANTS AND CHILDREN AGED 0-6 YEARS
The data obtained from 8 different studies in six provinces and in 1947 coloured and black children are given in
Tables 30 to 33. The only national study in which biochemical variables were measured is the SAVACG (1995) study
and it did not stratify for ethnic group. Data from this study are given in Table 33.
The mean values reported for groups of coloured children (Table 30) were all within normal ranges, except for mean
serum phosphorus values which were slightly raised and haemoglobin concentrations which were in the low
normal range.
10

Table 31 indicates that urban black children had normal mean levels of most variables measured, but that mean
serum retinol and iron were low, with borderline low haemoglobin levels. It seems that the micronutrient status of
these children may be low, especially vitamin A and iron.
The low mean levels of serum vitamin A, ß-carotene, iron and haemoglobin in many (but not all) groups of rural
preschool children (Table 32) confirm that vitamin A and iron deficiencies are present in black children. Table 32
also shows that, although mean levels of a particular biochemical variable may be within normal ranges, a large
percentage of children within that group could have abnormal low levels.
For example, mean folate levels in serum and red blood cells appear to be normal, but between 8.7 and 25.7 % of
children within particular groups had low folate status. Unfortunately, not all studies reported these percentages.
The moderate to high prevalences of multiple micronutrient (vitamin A, iron and folate) deficiencies, coupled to
chronic low energy intakes in many black children as was gleaned from the high rates of stunting (see Section 3.1),
suggest that single nutrient fortification or supplementation programmes will be less successful in addressing the
problem than increases in energy and micronutrient density of the total diet, especially in areas with inadequate
sanitation and safe water. This point is illustrated by the results of Steyn et al. (1994). These authors examined
biochemical profiles of 57 underweight Pedi children from an original sample of 659 preschoolers. They found that
many of these underweight children had concentrations below the age-specific cutpoints for red blood cell count
(15 %), haemoglobin (22 %), haematocrit (24 %), ferritin (51 %), transferrin (25 %) and folate (6 %), indicating that the
energy deficiency was accompanied by several micronutrient deficiencies. There are indications (Tichelaar et al.,
1995a) that the omega-6/omega-3 fatty acid ratios in formula fed stunted infants are abnormal, indicating that
other macronutrients are also deficient in undernourished children.
Table 33 summarises the results from the SAVACG (1995) study. In addition to anthropometric measurements and
coverage of immunisation status of a random sample of 11 430 South African children aged 0.5 to 5.9 years, serum
vitamin A, blood haemoglobin, and serum ferritin concentrations of a subsample of 4 788 children were measured
in this study.
On a national level, 33 % of the children had a vitamin A concentration below 20 µg/dL, indicative of a marginal
vitamin A status. Those living in rural areas and with poorly educated mothers were the most disadvantaged. The
study further showed that 3 to 3.9 year old children and those from the Northern Province and KwaZulu-Natal had
the highest prevalence of vitamin A deficiency.
The iron status of the children was evaluated by measuring full blood counts, haemoglobin and serum ferritin. To
diagnose mild iron deficiency anaemia, haemoglobin levels between 10 and 11 g/dL and ferritin levels below 12
µg/L were used. For moderate anaemia, respective cutpoints were 7-10 g/dL and below 10 µg/L and for severe
anaemia, haemoglobin values under 7 g/dL and ferritin below 10µg/L. Based on haemoglobin values the results
showed an overall prevalence of anaemia of 21 %, with the lowest prevalence in KwaZulu-Natal (10 %) and the
highest in the Northern Province (34 %). No differences between rural and urban or boys and girls were observed.
The mean serum ferritin concentration was 34.6 (CI : 33.3-36.0). Children from urban areas had a significantly
lower concentration than those from rural areas and the highest prevalence of low concentrations was seen in the
Western Cape (16 %). On a national level, 9.8 % of the children had values below 12 µg/L. Based on haemoglobin
concentration 0.2 % of children were severely anaemic and based on serum ferritin 5.8 %.
3.2.3 PRIMARY SCHOOL CHILDREN
The biochemical variables measured in four studies in Gauteng and the Western Cape in a total of 267 white
children are given in Table 34. Mean values fell within normal ranges, although one study found that 11,3 % of the
children had low haemoglobin and 16.9 % low red blood cell folate concentrations. Serum vitamin A (retinol) was
not measured in any of the studies, but retinol binding protein (RBP) concentrations were normal where measured.
These results indicate that iron and folate deficiencies also exist in some white primary school children.
A total of 683 coloured children in the Western Cape and Gauteng were biochemically examined in four different
studies (Table 35). Mean values of most variables were within normal ranges, but two groups of children had a
16.7 % and 18.4 % prevalence of low haemoglobins, one group had a 34.6 % prevalence of low red blood cell folate
and another group an 11.7 % prevalence of low serum ferritin. Therefore, it seems that many coloured primary
school children also have iron and folate deficiencies.
Only three studies reported biochemical variables of Indian primary school children (Table 36). A total of 631
children from Gauteng and KwaZulu-Natal were examined. Again, although mean values of the different groups
fell within normal ranges, some groups had low levels and a wide range especially of serum ferritin, illustrating that
11

iron deficiency is a problem in these children.
The biochemical variables of urban black primary school children are shown in Table 37. Four studies from four
different provinces reported on a total of 1 975 children. Again, although mean values for the different groups were
within normal reference ranges, high prevalences of low haemoglobin, serum ferritin and red blood cell folate were
observed in some groups.
The rural black children (Table 38) is the group most extensively studied. Data from 11 studies, covering seven of
the nine provinces (KwaZulu-Natal and Free State being the exceptions) obtained from 2 326 children are summarised
in Table 38. The general pattern in this group was high prevalences of low haemoglobin, ferritin, iron, vitamin A, ß-
carotene, red blood cell folate, vitamin E, retinol binding protein and vitamin B6, indicating multiple micronutrient
deficiencies. Interestingly, vitamin B12 concentrations were within normal ranges in all subjects where measured.
In addition to the above mentioned micronutrients, calcium and vitamin D status of rural black children have been
studied in some detail. Pettifor et al. (1979) compared 761 rural and urban black primary school children and found
that 13.2 % of the rural children were hypocalcaemic compared with none of the urban children. Of the rural
children, 41.5 % had elevated alkaline phosphatase concentrations. The authors estimated that the rural children
took in only 125 mg calcium per day, compared to the 337 mg of the urban group. Van Rensburg et al. (1983) also
reported a high prevalence of hypocalcaemia (35 %) in rural black subjects from the Transkei. However, in their
sample, serum alkaline phosphatase concentrations were normal. Although rickets is rarely diagnosed in South
Africa, the low serum calcium values are indicative of suboptimal micronutrient status in rural black children.
3.2.4 ADOLESCENTS
Very little information and no recent studies on the biochemical profiles of whites, coloureds and Indians are
available (Table 39). Mean concentrations of iron status variables of the Indian children were low, which is an
indication of possible iron deficiency in this group. The mean values of the variables measured in urban black
adolescents (Table 40) were all in the normal ranges. One study reported high prevalences (14.8 to 31.4 %) of low
red blood cell folate. The rural black adolescents (Table 41) showed high prevalences of low serum phosphorus
(25 %), red blood cell folate (4.2-19.3 %) haemoglobin (5-30 %), ferritin (14-20 %), and iron (26-27 %) in some
groups. Clearly, the iron and folate micronutrient deficiencies seen in younger children are still present in adolescents.
3.2.5 ADULTS
The data from 20 different studies, on 5 421 adult subjects from six provinces are summarised in Tables 42 and 43.
Many other studies reported on lipid and lipoprotein profiles, as well as other risk factors of chronic diseases of
lifestyle of adults. These were not included since many factors other than nutrition influence them. Unfortunately,
no data on the nutritional status of Indian adults and very little on the other ethnic groups, especially the coloured
group, could be found.
Mean values of most variables fell within normal ranges. However, a small group of 20 year old white women had
a 23 % prevalence of low iron status. Mean concentrations of iron status variables in both men and women of the
coloured and black groups were low-normal or below normal, indicating that iron deficiency anaemia is present in
many adult South Africans. The group of 100 elderly white men and women included in Table 42 is not representative
of all elderly whites. They were included in the study of Kruger (1990) because they were healthy. Nevertheless, the
data show that healthy elderly people have biochemical variables which are in the normal ranges for younger
adults. Although vitamin B12 values were normal to high in all groups measured, one study (Johnson & Van der
Westhuizen, 1989) found that 21 % of the women and 33 % of the men in a sample of 100 elderly rural blacks had
low circulating vitamin B12 concentrations.
3.2.6 COMMENTS
The limited number of studies which reported on the biochemical variables of nutritional status focused mainly on
iron, vitamin A and folate status. A few studies gave information on other vitamins and some minerals.
The biochemical data revealed high prevalences of vitamin A, iron and folate deficiencies in pre- and primary
school children. These micronutrient deficiencies were also seen in adolescents and iron deficiencies were found
in adult men and women. There were indications that the status of other micronutrients (vitamin B6, E and also
calcium) may be low in many groups. Clearly, more information on specific micronutrients on a national level is
needed, but at this stage, it seems that vitamin A, iron and folate deficiencies in many South Africans need
immediate attention.
12

3.3 NUTRIENT INTAKES
3.3.1 INTRODUCTION
Measurements of what people eat and analyses of their diets to obtain nutrient intakes, can give valuable information
on nutritional status. Nutrient intake data can be used to evaluate the adequacy of diets, to establish nutrient goals,
for food and nutrition policy decisions and to study the relationship between nutrient intakes and health and
disease.
There has never been a national survey of food and nutrient intakes of South Africans. However, several authors
have published intake data obtained in studies throughout the country. Much of this data published between 1979
and 1994 has been combined in a meta-analysis by the South African Nutrition Survey Study group (SANSS group).
The SANSS (1995) analysis consists of two sets of tables, compiled from 55 studies which met inclusion criteria
regarding randomisation, numbers of subgroups, data base used for nutrient analysis and specific age and ethnic
groupings. The first set (a) represents studies in which the 24-hour recall method was used and the second set (b)
represents data obtained from using other dietary assessment techniques, such as food frequency questionnaires,
diet histories or weighed records. In the present analysis, a third set of tables (c) are included. These were compiled
from nine separate studies representing data published in 1995 and 1996, as well as a few studies that were not
included in the meta-analysis, mainly because age groupings differed and no distinctions were made between the
sexes. The tables are numbered and presented according to nutrients. Intakes are stratified for gender (sex), age
and ethnic group and are compared with the USA recommended dietary allowances (RDA’s) of the Food and
Nutrition Board (1989), as well as with the South African dietary guidelines (Health Matters Advisory Committee,
1992), where appropriate. In a few instances, WHO, British and European recommendations (Garrow & James, 1993)
were also used for comparison.
3.3.2 ENERGY INTAKES
Tables 44 (a), (b) and (c) give the mean energy intake of the different age and ethnic groups. Energy intakes of
infants 0 to 2 years old were adequate in all population groups, but fell in 2-6 years old rural black children to
between 83 and 60 % of the RDA’s. The intakes of the other groups, except for rural black children, all seem
adequate. The 24-hour recall method measured low intakes in adult women, except for one group of 95 rural
African women from KwaZulu-Natal which reported a mean intake of 10 148 kJ which was high compared with the
RDA of 9 240 kJ. These low intakes were not supported by studies which used other assessment techniques nor by
the 24-hour recall studies included in Table 44(c). The 24-hour recall method tends to give lower intake data than
other methods (Bingham, 1987). However, a survey of nutrient intakes of adults in Britain in which weighed records
were used, also found low mean energy intakes of 7 231 and 6 730 kJ for 35 to 49 and 60 to 64 year old women
(Gregory et al., 1990). It is difficult to meet micronutrient intakes on such low energy diets. Therefore, if intakes are
kept low to maintain ideal body weight, advice should be aimed at increasing activity and energy expenditure. In
general, except for rural black children aged 2 to 6 years, mean energy intakes of South African groups of children,
adolescents and adults from all ethnic groups seem to be adequate.
3.3.3 PROTEIN INTAKES
Tables 45 (a), (b) and (c) indicate that intakes of total protein in all groups either met or exceeded recommended
intakes. Figures 1 to 4 show, however, that especially in rural blacks, almost two-thirds of the protein came from
plant sources. Therefore, unless legumes and grains are carefully balanced in meals, it is possible that not enough
essential amino acids are taken in for protein synthesis and growth. Additionally, in low energy diets as seen in the
rural black children, dietary proteins could be used as an energy source and not for protein synthesis. Steyn et al.
(1992, 1993) showed that rural black children ate enough portions from the meat and cereal groups, but had
inadequate intakes of milk, fruits and vegetables. Therefore, although total protein intakes exceeded the RDA’s, the
quality of protein in the diets of rural black children can be improved by increased milk intakes.
The diet history and food frequency methods tended to measure higher protein intakes than the 24-hour recall
method.
3.3.4 FAT INTAKES
Total fat intakes are given in Tables 46 (a), (b) and (c). The percentages of total energy provided by fat (calculated
from the means in Tables 44 and 46 (a) and (b)) are given in Table 47. Table 47 (c) contains data from studies not
included in the meta-analysis. The pattern that emerges from these tables is that rural blacks have a low-fat diet
and urban blacks already follow a diet much higher in fat than the rural diet, but still more prudent than the diets
13

of whites, Indians and coloureds. Young adult men and women (aged 16-24.9 years) had the highest fat intakes.
The mean ratios between saturated, mono-unsaturated and polyunsaturated fats are illustrated in Figures 1 to 4.
The diet of whites had the lowest P/S ratio, while those of the Indians and rural blacks exceeded 1.0, indicating the
liberal use of plant oils in the cooking of food.
3.3.5 CHOLESTEROL INTAKES
Information obtained by the 24-hour recall method (Table 49(a)) showed that except for white and coloured adult
men, all groups had cholesterol intakes which fell within the dietary guidelines. Studies which used other methods
found high (> 300 mg/day) intakes also in Indian men and white and coloured women.
3.3.6 TOTAL CARBOHYDRATE INTAKES
Mean total carbohydrate intakes (Tables 5 (a), (b), (c)) and percentage contribution to total energy intake (Figures 1 to
4) of blacks and coloureds were higher than those of the Indians and whites. In all age and gender groups, where
comparative data were available, rural blacks had relatively greater carbohydrate intakes, illustrating the expected
change in intake during urbanisation (Gross & Monteiro, 1989; Popkin, 1994). No data on starch and other saccharides
are available. It is suspected that traditional preparation and cooking methods of maize, the staple food of black
and some coloured groups, could result in formation of resistant starch, which has putative beneficial health effects
(Venter et al., 1990).
3.3.7 DIETARY FIBRE INTAKES
The fibre hypothesis states that high fibre intakes help to protect against the development of chronic diseases of
lifestyle. The hypothesis was formulated after observations that Africans with high fibre intakes had low prevalences
of these diseases (reviewed by Vorster, 1994). Tables 51 (a), (b) and (c) show that many of the urban and rural black
groups had relatively low fibre intakes compared to those of whites, coloureds and Indians. It seems, therefore, that
present differences in prevalences of specific chronic diseases of lifestyle in the different ethnic groups could not
have been caused only by differences in fibre intakes.
Except for the one study on 95 rural Zulu women (De Villiers, 1988), the 24 hour recall method gave lower intakes
than the “other” methods. With these “other” methods, intakes which met dietary guidelines of 25 to 30 g/day, were
measured in several groups, while with the 24-hour recall only one of the 35 groups met these guidelines. Clearly,
many South Africans are following fibre deficient diets.
3.3.8 SUGAR INTAKES
Mean sugar intakes appear in Tables 52 (a) and (b). Rural blacks had the lowest intakes. Young white men, urban
black men and women, as well as adult coloured men and women had the highest intakes. The value of 155 g
measured with “other” methods in coloured men aged 25 to 64.9 years, would mean approximately 30 teaspoons
(5 g) of added sugar per day!
3.3.9 CALCIUM INTAKES
Tables 53 (a), (b) and (c) compare calcium intakes with the USA RDA’s for calcium. The United Kingdom (Department
of Health) revised their Dietary Reference Values (DRV’s) in 1991. Their lower reference nutrient intakes (LRNI), which
are 2 SD below the estimated average requirement (EAR) which assumes normal distribution of variability (Garrow
& James, 1993), are also given in the tables. Both LRNI and EAR are much lower than the RDA’s. If compared with
the RDA’s, only the children between 0 and 1.9 years and white, coloured and Indian children 2 to 5.9 years met
their calcium requirements. If compared to the LRNI, data collected with the 24-hour recall method show that all
the rural black groups as well as black, coloured and Indian women did not even reach these lowest recommendations.
The low calcium intakes are in agreement with many reports on low milk intakes of South Africans, especially
Africans. Possible reasons are influences from previous cultural habits and taboos regarding milk consumption,
lactose intolerance (which is high in Africans), as well as price. Milk and milk products are relatively expensive
commodities. Despite these low intakes, the prevalence of osteoporosis in black women is still much lower than in
white women (Walker, 1981).
14

FIGURE 1:
ENERGY DISTRIBUTION OF THE DIET OF SOUTH AFRICAN CHILDREN
100
PERCENTAGE ENERGY
80
60
40
20
N
o
a
v
a
i
l
a
b
l
e
d
a
t
a
N
o
a
v
a
i
l
a
b
l
e
d
a
t
a
Total protein
Animal protein
Plant protein
Carbohydrate
Polyunsaturated fat
Monounsaturated fat
Saturated fat
Total fat
0
W B C I RB W B C I RB
Age: 2-5.9 years Age: 6-10.9 years
W=whites; B=blacks; C=coloureds; I=Indians(Asians); RB=rural blacks
FIGURE 2: ENERGY DISTRIBUTION OF THE DIET OF SOUTH AFRICAN BOYS AND GIRLS AGED 11-15.9 YEARS
100
Protein
PERCENTAGE ENERGY
80
60
40
20
Carbohydrate
Fat
0
W B C I RB W B C I RB
Boys
Girls
W=whites; B=blacks; C=coloureds; I=Indians(Asians); RB=rural blacks
15

FIGURE 3 : ENERGY DISTRIBUTION OF THE DIET OF SOUTH AFRICAN MEN
100
PERCENTAGE ENERGY
80
60
40
20
N
o
a
v
a
i
l
a
b
l
e
d
a
t
a
N
o
a
v
a
i
l
a
b
l
e
d
a
t
a
Animal protein
Plant protein
Carbohydrate
Polyunsaturated fat
Monounsaturated fat
Saturated fat
0
W B C I RB W B C I RB
Age: 16-24.9 years Age: 25-64.9 years
W=whites; B=blacks; C=coloureds; I=Indians(Asians); RB=rural blacks
FIGURE 4 : ENERGY DISTRIBUTION OF THE DIET OF SOUTH AFRICAN WOMEN
100
PERCENTAGE ENERGY
80
60
40
20
N
o
a
v
a
i
l
a
b
l
e
d
a
t
a
Animal protein
Plant protein
Carbohydrate
Polyunsaturated fat
Monounsaturated fat
Saturated fat
0
W B C I RB W B C I RB
Age: 16-24.9 years Age: 25-64.9 years
W=whites; B=blacks; C=coloureds; I=Indians(Asians); RB=rural blacks
16

3.3.10 IRON INTAKES
Tables 54 (a), (b) and (c) compare iron intakes with the USA RDA’s and the British LNRI and EAR. Because vulnerable
groups may suffer from parasitic infections (Schutte, 1995; Fincham, 1996a) which may increase iron requirements,
the higher RDA’s are used here to evaluate adequacy in Table 55.
From Table 55 it can be seen that the vulnerable groups with intakes less than 67 % (two thirds) of the RDA were
urban black infants, a small group of rural black children, girls aged 11 to 15.9 years, and adult women, aged 16 to
64.9 years. The low intakes of the girls and women are relative because their requirements are higher than those
of boys and men.
The low intake of iron is a serious, but complicated problem. An iron deficient state may be responsible for arrested
cognitive development of children. But in later life, it may possibly protect against coronary heart disease and iron
overload in genetically susceptible individuals (MacPhail & Bothwell, 1989). An iron fortification or supplementation
programme should therefore be targeted at young children and iron deficient women of childbearing age.
3.3.11 MAGNESIUM INTAKES
Magnesium intakes are related to the plant content (fruits, vegetables, legumes) of the diet. Table 56 (a) shows that
adult men and women, except for the group of rural black women, tended to have low magnesium intakes. The
data obtained by methods other than the 24-hour recall (tables 56 (b) and (c)), show adequate intakes, except for
coloured men and women. Therefore, there may be borderline magnesium deficiencies in some adult groups,
which could be rectified by inclusion of more fruit, vegetables and legumes in the diet.
3.3.12 POTASSIUM INTAKES
From Tables 57(a) and (b) it seems that in all groups for whom potassium intakes were calculated, the USA RDA’s for
potassium were met.
3.3.13 ZINC INTAKES
Zinc is a constituent of many enzymes in the body. It, therefore, plays an important role in metabolism. Unfortunately,
diagnosis of the consequences of low intakes, as well as zinc requirements, are not well understood. The richest
sources of zinc in the diet are lean meats and wholegrain cereal foods. Tables 58 (a) and (b) show that regardless
of which method was used, many groups had low intakes compared to the RDA’s. It seems that zinc may be one
of the micronutrients in the diet of South Africans that needs immediate attention.
3.3.14 PHOSPHORUS INTAKES
Tables 59 (a), (b) and (c) indicate that mean intakes of phosphorus in almost all groups were adequate, the exception
being black children when diets were assessed by the 24-hour recall method.
3.3.15 SODIUM INTAKES
All groups measured had higher mean intakes than the estimated safe and adequate daily dietary intakes of the
Food and Nutrition Board (1989), as can be seen in Tables 60 (a) and (b). High sodium intakes are associated with
hypertension which is one of the major chronic diseases of lifestyle in South Africa (Opie, 1995). A shift in the diet
to include more unprocessed foods and uncooked fruits and vegetables could reduce sodium consumption.
3.3.16 THIAMIN INTAKES
Mean intakes of thiamin (vitamin B1 or anti-beriberi factor) of all groups were adequate when compared to the RDA
(Tables 61 (a), (b) and (c)). From the available data it, therefore, seems that the mean intake of thiamin is not a
problem in the South African diet.
3.3.17 RIBOFLAVIN INTAKES
From Tables 62 (a), (b) and (c) it seems that coloured, Indian and rural black groups had inadequate riboflavin
(vitamin B2)) intakes. Dairy products are principle sources of riboflavin and increases in milk or sour milk consumption
could rectify this dietary deficiency.
17

3.3.18 NIACIN INTAKES
Niacin (vitamin B3) deficiency may develop in individuals who follow a maize based diet or with an impaired
absorption of the amino acid, tryptophan, which is a precursor for niacin. Tables 63 (a) and (b) indicate that mean
intakes of niacin of all groups were adequate. Intakes varied between 70 and 140 % of the RDA. However,
Dannhauser et al. (1996) (Table 63(c)) reported low intakes in rural black children from the Free State. Some groups
took in less than 67 % of the RDA. These results illustrate that, although mean intakes of groups stratified for age
and gender may be adequate, intakes of a specific group may be deficient. Therefore, although there may not be
a national deficiency problem with a specific nutrient, there may be a regional one, as seems to be the case for
niacin.
3.3.19 VITAMIN B6 INTAKES
Tables 64 (a), (b) and (c) give mean vitamin B6 (pyridoxine) intakes. In Table 65 the mean intakes are expressed as
a percentage of the RDA. Fourteen of the 27 groups, mainly black, coloured and Indian, had intakes less than 67 %
of the RDA. Vitamin B6 intake reflects the variety in the diet since this vitamin is found in several foods from both
animal and plant origin. Clearly, many South Africans lack variety in their diet.
3.3.20 FOLATE INTAKES
Tables 66 (a), (b) and (c) show the mean folate intakes of the different age and gender groups while Table 67
compares intakes of females in µg with different recommendations. From these tables it seems that Indian and
rural black women of child bearing age have low mean folate intakes. Unfortunately, no data for pregnant and
lactating women could be found. In addition to its protective effect against macrocytic anaemia, folate also protects
the foetus against neural tube defects. The low intakes of rural black and Indian women are, therefore, of concern
and should be addressed in nutrition programmes.
3.3.21 VITAMIN B12 INTAKES
From Tables 68 (a), (b) and (c) it is clear that vitamin B12 intakes were more than adequate in all groups measured.
The main reason is probably the adequate to high intakes of foods from animal origin. However, in a remote rural
area in Venda, subjects who followed a plant food-based diet, had normal to high blood levels of vitamin B12
(Vorster et al., 1994). This suggests that microbial production of B12, either in fermented foods and beverages, or in
the human colon, contributes to vitamin B12 “intakes”. It therefore seems that, at present, on a population level,
vitamin B12 status is sufficient. However, it is possible that individuals or specific groups, such as vegetarians or
the poorest of the poor, could have low intakes and low B12 status because of insufficient intakes of animal foods.
3.3.22 VITAMIN C INTAKES
Table 69 (a) shows that vitamin C or ascorbic acid intakes, when measured by the 24-hour recall method, were
inadequate in most of the black and Indian groups and in coloured girls aged 11 to 15.9 years. Data obtained by
other methods, showed adequate intakes (Table 69 (b)), except for rural black children aged 2 to 5.9 years who took
in 69 % of their RDA. The study of Dannhauser et al., (1996) on rural black infants and children under 6 years of
age in the Free State (Table 69 (c)) confirmed these low intakes. Vitamin C is the water soluble antioxidant provided
by fresh fruits and vegetables. The RDA’s are based on its anti-scurvy properties and early turnover studies (Food
and Nutrition Board, 1989). Taking the antioxidant properties into account, the RDA for smokers has been increased
from 60 to 100 mg per day. It is not known at what level of intake vitamin C will protect against chronic diseases
of lifestyle such as cancer, but it will probably be at higher levels than the existing RDA’s. Therefore, the low intake
of many South Africans is a matter of concern. These results emphasise the importance of increasing fruit and
vegetable intake of all South Africans.
3.3.23 VITAMIN A INTAKES
Tables 70 (a), (b) and (c) summarise vitamin A intakes of the different groups. Intakes measured by the 24-hour
recall method were low in 9 of the 20 groups, ranging from 37 to 86 % of the RDA’s. Data obtained by other
methods showed adequate intakes in most groups with black children being the exception.
Measurements and evaluation of vitamin A (retinol) intakes, are important. In addition to its essential functions in
normal growth and eyesight, vitamin A status is necessary for children to survive the consequences of respiratory
and gastrointestinal infections (reviewed by McLaren et al., 1993). There is no doubt that a high prevalence of
vitamin A deficiency among children in developing countries is a serious public health problem (Grant, 1994;
18

McLaren et al., 1993). In South Africa, the 1994 National Survey (SAVACG, 1995) found that approximately 30 % of
young children had a marginal vitamin A status, indicating that South Africa also faces a serious public health
problem of Vitamin A deficiency.
Therefore, although mean intakes of some groups were adequate, many children were vitamin A deficient. It is of
concern that groups of older children and adults, not included in the SAVACG-study, had even lower relative intakes
than the under 6 year old children. Marginal vitamin A deficiency may be an even greater health problem than
indicated by the SAVACG study.
3.3.24 VITAMIN D INTAKES
Mean intakes of vitamin D for some groups are given in Tables 71 (a), (b) and (c). This data should, however, be
interpreted with care. The vitamin D content of some South African foods is not known and not given in the MRC
Food Composition Tables (Langenhoven et al., 1992). Intakes may, therefore, be higher than reported here.
3.3.25 COMMENTS
Tables 44 to 71 clearly demonstrate that nutrient intake data depend to a large extent on the methodology employed
to assess dietary intakes, as well as the quality of food composition data. Nutrient intakes should, therefore, be
interpreted with care, and always in combination with other variables of nutritional status. For example, although
the South African Composition Tables have no or very little data on trace element contents of foods, the prevalence
of goitre could give information on iodine status.
Another factor that should be considered in using nutrient intakes to evaluate nutritional status is that means of a
population or particular group do not necessarily reflect individual or majority intakes. From the anthropometric
data as well as the individual nutrient intake studies used to compile Tables 44 to 70, it was clear that pockets of
malnutrition exist, especially in the rural areas among inhabitants of the former “Homelands” or TBVC-states.
In summary, the nutrient intake data indicate that energy intakes in some rural children were inadequate, while
several adult groups had excessive energy intakes. Micronutrient intakes of many groups were far from optimal.
Furthermore, it seems as if there is an increasing tendency towards higher fat and lower fibre intakes which
indicates a westernisation of traditional diets. Unfortunately, almost no information on the diet of pregnant and
lactating women and the elderly in all ethnic groups could be found. It is, therefore, not possible to prioritise the
most vulnerable groups. However, from existing data it is clear that rural black children may be the most vulnerable
group regarding nutrient intakes.
3.4 CLINICAL SIGNS OF MALNUTRITION
3.4.1 INTRODUCTION
The clinical signs of malnutrition are mostly used to help in the diagnosis of ill children and to distinguish between
primary and secondary malnutrition and specific nutrient deficiencies. Very few studies in South Africa have
examined the prevalence or frequency of clinical signs in specific groups of people. Available data are summarised
in Tables 72 to 74.
3.4.2 INFANTS AND CHILDREN 0-6 YEARS
The SAVACG (1995) study reported prevalences between 5.3 and 26.5 % of clinical abnormalities of the eyes of
preschool children in the different provinces (Table 72). The Free State had the highest prevalence. On a national
level, this study found that 12 % of the children possibly suffered from nightblindness, 0.4 to 0.8 % had Bitot’s spots,
0.2 to 0.7 % corneal xerosis and 0.1 % keratomalacia. A recent study of rural black children in the Free State
(Dannhauser et al., 1996) supported the high prevalence of clinical eye abnormalities (17 and 23.1 %) and also
reported high frequencies of skin, hair, nail, mouth and muscle (legs) abnormalities (Table 72) in these children.
Coutsoudis et al. (1993) warn that some clinical tests could correlate poorly with biochemically diagnosed deficiencies.
These authors tested 169 3 to 6 year old children in an informal housing area near Durban in KwaZulu-Natal. Of
these children, 5 % were vitamin A deficient (serum retinol < 0.35 µmol/L) and 44 % had low vitamin A concentrations
(< 0.7 0 µmol/L). Conjunctival impression cytology revealed that 18.9 % had poor vitamin A status as defined by two
abnormal conjunctival specimens. There was a poor correlation between this test and serum retinol threshold
values of vitamin A deficiency.
19

3.4.3 PRIMARY SCHOOL CHILDREN
Table 73 indicates that two of the three studies which reported on clinical variables of nutritional status also found
high prevalences (11-40 %) of eye abnormalities in primary school children. Other abnormalities of hair, gums, skin
and muscle wasting were also seen.
3.4.4 ADOLESCENTS AND ADULTS
Table 74 shows low prevalences in those groups where clinical signs were reported, except for a group of elderly
white men and women. In these subjects, the signs were probably related to age rather than nutritional deficiencies
(Kruger, 1990).
3.4.5 COMMENTS
Traditionally, clinical signs are not used to evaluate prevalences of the consequences of overnutrition such as
obesity and hypertension resulting from excess energy and salt intakes. The high prevalences of obesity in South
African women has been mentioned (see. 3.1.7). It has been known since the 1950’s that urbanisation in South
Africa is accompanied by increases in blood pressure, especially among black (Seedat et al., 1978; Opie, 1995) and
coloured (Steyn et al., 1986) ethnic groups. These diseases, as well as other chronic diseases of lifestyle are related
to nutritional status and should be considered in strategies, policies and programmes to address malnutrition.
20

CHAPTER 4
DETERMINANTS OF NUTRITIONAL STATUS
4.1 INTRODUCTION
To understand malnutrition and to address the problems of undernutrition effectively, it is important that the root
causes should be identified. In this section, the internationally accepted causes of undernutrition will be briefly
illustrated, using a model developed from the UNICEF conceptual framework (Grant, 1994). The available information
on risk factors for and determinants in South Africans will then be discussed.
4.2 CAUSES OF UNDERNUTRITION
Figure 5 illustrates the vicious cycle of the causes and consequences of undernutrition. It indicates that, because
of the consequences, malnourished communities and individuals cannot benefit fully from developmental actions.
It is extremely difficult to escape from this vicious circle of poverty and undernutrition. The multifactorial model
further illustrates why it is so important that community based, intersectorial programmes aimed at all possible
causes are necessary to address undernutrition in a sustainable way.
Undernutrition develops when nutrient intakes do not meet nutrient requirements. Intakes are inter alia determined
by household food security defined as access to adequate, affordable, safe and nutritious food. Clearly, many
economic, social and cultural factors will influence household food security. In addition, political and ideological
factors, coupled with availability and access to potential resources, will also influence food security on a national as
well as household level.
Nutrient requirements may be increased by infectious diseases and malabsorption. Access to adequate health and
other services such as clean, safe water, sanitation and refuse removal is therefore a major determinant of nutritional
status. Small children cannot feed themselves. Care, and all factors influencing the care of young children, as well
as of the old and the infirm, will also influence nutritional status.
The figure further illustrates that the consequences of undernutrition directly aggravate the causes. Inadequate
physical, mental and social development of people will lead to chronic ill-health, decreased incentives, low productivity
and lack of education. All these factors could contribute to poverty and, therefore, to household food insecurity, lack
of care and decreased access to health and other services. Because the causes of undernutrition are so interrelated
and further aggravated by the consequences, it can be expected that they will not occur in isolation within a
community or household. Usually, a combination of factors, all associated with poverty, will collectively be responsible
for undernutrition.
Because the causative factors of undernutrition are all interrelated, it is difficult to isolate and classify them. With
the available data it is not possible to evaluate the precise contribution of a specific factor to the prevalence or
extent of undernutrition in South Africans. The factors that will be discussed here are those that have been
examined in different South African ethnic groups. Because it is not possible to conclude from the available
literature whether cultural practices contribute to malnutrition, the cultural influences an eating pattern will be
discussed in a separate chapter (5).
4.3 RISK FACTORS FOR UNDERNUTRITION IN SOUTH AFRICA
4.3.1 FOOD SECURITY
Food insecurity or lack of access to adequate, affordable, safe and nutritious food, is a major determinant of
undernutrition. There is general agreement that we have national but not household food security in South Africa.
The first is relatively easy to assess by comparing and combining data on population demographics and statistics,
production, import and export of food. The latter is more difficult and is often measured by the incidence of poverty
and undernutrition, although “poor access to health services and sanitation may be more significant causes of
malnutrition than inadequate food access” (Land and Agriculture Policy Centre, 1994). Nevertheless, it is generally
accepted (Health Systems Trust, 1995) that inequalities to access of land and other resources and specific agricultural
land use and urbanisation policies of the past has led to household food insecurity and has contributed significantly
to undernutrition, especially in rural areas and the previous Homelands (TBVC-States) where agriculture currently
contributes very little to household income.
21

FIGURE 5: THE VICIOUS CYCLE OF THE CAUSES AND CONSEQUENCES OF UNDERNUTRITION
unbalanced
inadequate
INTAKES
UNDERNUTRITION
inadequate
physical
mental
social
DEVELOPMENT
DISEASE
requirements
absorption
DISEASE
LACK OF CARE
HEALTH AND
SANITATION
SERVICES
OVERCROWDING
INFANT MORALITY
compensatory
Household
Food
Security
BIRTHRATE
taboos
tradition
{ culture
Political-
Economical-
Ideological
Structures
UNEDUCATED
MOTHERS
family disruption
POVERTY
Incentives
Health
Productivity
Education
Potential resources
22

Not many studies examined the direct relationship between food availability and undernutrition. Booth (1982)
found that protein-energy malnutrition in children under 5 years in Lebowa was inter alia caused by inadequate
local food production. Westcott and Stott (1977) reported that, in addition to low incomes, lack of agricultural
resources was a strong contributor to undernutrition in the Transkei. The extent to which food insecurity contributes
to undernutrition is, therefore, not known.
Many factors influence both national and household food security. They are dependent on a stable and effective
enabling economic and political environment with good governance at all levels. At present, food subsidies,
international trade, price controls and stabilisation, protection of staple food production, rural development, land
reform, agricultural marketing, education and training, drought relief, protection of the environment and natural
resources, as well as other strategies and policies to ensure national and household food security are under
discussion in several briefing, working and policy papers (see for example those from the Land and Agriculture
Policy Centre, 1993; 1994; 1995). In this regard, Heydorn (1996) recently pointed out that South Africa should move
to an approach which will promote optimal and long-term regional development, which will fulfil economic,
environmental and all-embracing human requirements in order to prevent economic collapse and exhaustion of
our natural resources. In addition, population growth and stabilisation should form an integral part of policies to
establish household food security.
4.3.2 POVERTY
As shown in Figure 5, poverty is universally accepted as a fundamental cause of undernutrition. In South Africa, it
is associated with high unemployment, inability to pay for food, health care and basic services, disintegration of
families, vulnerability, risk of homelessness, and despair (RDP, 1995). It is also accepted that South Africa has a very
serious poverty problem with a strong race, rural, and regional dimensions (RDP, 1995; May et al., 1994, 1995). For
example, 95 % of the poor in South Africa are African, 5 % are coloured and less than 1 % are Indian and white.
Although there is not an uniformly agreed poverty line for South Africa, using a minimum per capita caloric intake
at 2000 Kcal/day and a minimum per capita adult equivalent caloric intake at 2500 Kcal/day, it is estimated that
39-42 % of the people of South Africa are poor (RDP, 1995). Most of the poor (75 %) live in rural areas, and about
two-thirds of the poor live in only three provinces: Eastern Cape (24 %), KwaZulu-Natal (21 %) and Northern Province
(18 %). The Eastern Cape and Northern Province also have the highest poverty rates of 78 and 77 % (percentage of
population who are poor). The rates for the other provinces are: Western Cape (23 %), Northern Cape (57 %),
KwaZulu-Natal (53 %), Free State (66 %), Mpumalanga (52 %), North West (57 %) and Gauteng (19 %).
Although there is no doubt that poverty is a root cause of undernutrition, it should be realised that not all poor
people are undernourished. Figure 6 compares poverty rates (percentage people of a given group that are poor) in
the different provinces with the prevalence of stunting (low height-for-age) among preschool and primary school
children (Table 7). The provinces with the highest poverty rates (Eastern Cape and Northern Province) have lower
prevalences of stunted children than the Northern Cape which had the highest figure of stunted children. Table 7
also indicates that the prevalences of stunting among school entrants measured in the National Survey of 1994
were equal in coloured and black children. This is despite the much higher poverty rate of Africans (65 %) than that
of coloureds (33 %). Also, relatively high obesity prevalences have been reported for African and coloured women
(Walker, 1995). Clearly, other factors such as climate, household ability to produce food, expenditure patterns and
social support networks will influence the impact of poverty on the extent of malnutrition within communities.
4.3.3 URBANISATION
The process of urbanisation is often associated with improved economic circumstances, better access to medical
care and an increased availability of a wider variety of foods. However, in developing countries, urbanisation is also
accompanied by changes in family structures, decreased activity, abrupt changes in cultural norms and social
safety nets, exposure to chemical contamination and noise pollution, stress, increased demands on available
money and possibly extreme poverty, homelessness and destitution (Gross & Monteiro, 1989; Solomon & Gross,
1995). All these factors could lead to undernutrition.
Little is known about the effect of urbanisation on nutritional status of South Africans. In KwaZulu-Natal, Margo et
al. (1978) found a higher prevalence of nutritional anaemia in urban children from a “city slum” area than in rural
control children. Byarugaba (1991) examined the effect of urbanisation on the health of black preschool children in
the Umtata district in the Eastern Cape. Urbanisation was associated with several risk factors for undernutrition,
such as increased poverty, overcrowding, decreased availability of clean water, diarrhoeal disease, less breastfeeding
and the replacement of “mother-care” with “maid-care”. In this study, urbanisation was associated with
less underweight and stunting, but with more wasting (acute malnutrition).
23

FIGURE 6: COMPARISON OF POVERTY RATES WITH PREVALENCES OF STUNTING
E. Cape
N. Province
Free State
80
70
60
50
40
30
20
10
0
RDP - 1995 (Poverty rate)
SALDRU/WORLD BANK STUDY (Prevalence of stunting)
1994 National Survey (Prevalence of stunting)
SAVACG Study - 1995 (Prevalence of stunting)
N. West
N. Cape
KwaZulu-Natal
Mpumalanga
W. Cape
Gauteng
Poverty rates: % of population who are poor
24

The complexity of the effects of urbanisation on nutritional status is further demonstrated by Bourne et al. (1993)
who showed in the BRISK study (n=983 adult Africans, aged 15-64 years from the Cape Peninsula) that although the
subjects followed a prudent diet regarding fat and carbohydrate intake, their diet was low in fibre, vitamins and
minerals. Compared with rural Africans, their diet was in a transition phase towards a progressively atherogenic
diet. The study of Jooste et al. (1990) described the same trends.
Ndlovu (1983) identified the disrupting effect of urbanisation on the family unit and family life as a contributing
cause of malnutrition. Urbanisation, and especially migration of men from the rural areas to earn money in urban
areas, has led to broken homes and destitution with consequent malnutrition in the rural areas (Westcott & Stott,
1977). Gericke et al. (1987) in their studies on urban and rural Vendas, found that urbanisation with its accompanying
westernisation and acculturation is a two-way process during which urban influences also spread into the rural
areas.
4.3.4 FAMILY UNITY AND COHESION
As mentioned above, urbanisation and migration, but also other factors, could lead to changes in family structures.
The impact of the low social status of many South African women has not been studied, but several studies have
identified family unity to be a major contributor to undernutrition, especially in children. Westcott & Stott (1977),
Fincham (1982), Ndlovu (1983), Krynauw et al. (1983), Molteno & Kibel (1989), Howard (1990) and Sive et al. (1993) all
found that children who came from disrupted family units and broken homes with less support from the father and
exposed to more social problems were more likely to be undernourished than children from stable, cohesive
families. It seems that the extended families often seen in some communities provide a social support network
that contributes to prevention of undernutrition. Child care competencies and arrangements are major determinants
of nutritional status and sharing these responsibilities obviously influences the nutritional status of children.
4.3.5 PHYSICAL ENVIRONMENT
The standard of housing, occupational density, access to clean and safe water and sanitation, and easy cooking and
refrigeration facilities have been identified in several studies as contributors to malnutrition (Fincham, 1982; Krynauw
et al., 1983; Molteno & Kibel, 1989; Howard, 1990; Sive et al., 1993). However, two of these studies (Howard, 1990; Sive
et al., 1993) found that the number of people in the household and displacement by a younger sibling did not
necessarily contribute to risk of malnutrition.
4.3.6 PREGNANCY
Repeated pregnancies may jeopardise nutritional status of both mother and child, but especially of the mother. The
total fertility rate in South Africa is high at 4.1 (RDP, 1995). It can therefore be expected that repeated pregnancies
could play a role as determinant of nutritional status in South African women.
Pregnant women have a high risk for developing iron deficiency anaemia. The global prevalence is 51 % and the
World Health Organisation, therefore, advocates the use of iron supplements in developing countries during the
second half of pregnancy (De Mayer et al., 1989). The need for this has, however, been questioned (Ross et al., 1981).
Table 75 summarises reported prevalences of iron deficient anaemia in pregnant coloured and African women.
Kruger et al. (1994) found that in the coloured women, primigravidas of 18-22 years of age who were unemployed,
single and not related to the household head, were at the greatest risk for developing anaemia.
Except for the study on the Gazankulu women (Baynes et al., 1986) which showed a higher prevalence of folate than
iron deficiency, the other studies reported adequate folate and vitamin B12 status.
Most authors agree that blanket iron supplements are justified during pregnancy, especially in the 3rd trimester in
women from a poor socio-economic background. Baynes et al. (1986) also recommend folate supplementation in
the form of the fortification of maize meal with folic acid. Vitamin A fortification may also be indicated. Fairney et
al. (1987) reported that vitamin A status of rural black mothers and their babies was low. Vitamin D status,
measured as 25-hydroxy-vitamin D, was adequate, suggesting that actinic synthesis maintained Vitamin D status.
25

4.3.7 BREASTFEEDING AND WEANING PRACTICES
The growth pattern of children from disadvantaged communities (Molteno et al., 1991; Delport & Bergh, 1994; Tables
1-7) clearly indicates that undernutrition often develops at the time of weaning. Tables 78 to 83, which describe
dietary patterns, show that breastfeeding and weaning practices in many groups are far from optimal. The studies
of Krynauw et al. (1983), Lazarus & Bhana (1984), Househam & Elliot (1985), Molteno & Kibel (1989) and Sive et al.
(1993) all identified insufficient breastfeeding and inappropriate weaning practices as major contributors to
undernutrition in South African children. The risks of unhygienic bottle feeding, infections and diarrhoea with
consequent undernutrition in deprived communities are well known.
Whitehead (1994) recently pointed out that textbook dietary recommendations for young babies overestimate energy
requirements. New research from the Dunn Clinical Nutrition Centre in the UK indicates that an infant of 1 month
needs 483 kJ/kg daily, at 4 months 399 kJ/kg and at 6 months 357 kJ/kg. Accepting that human milk output peaks
around 850 mL/day, breastfeeding would cover energy needs of a child growing along the 50th weight percentile
until 4 months. For a typically developing (3rd) world child tracking the 25th percentile, exclusive breastfeeding
would be sufficient for 6 months. However, infections would increase energy needs. Brink & Boshoff (1984)
reported that in urban blacks, supplementary feeding of some babies started at 1 month and is common at 3 to 6
months, confirmed by Cleaton-Jones (1991). Zöllner & Carlier (1993) found that 60 % of rural black mothers in their
study introduced solid foods before 3 months. Both Gericke et al. (1987) and Odendaal (1988) reported that urban
black children are less breastfed and weaned earlier than rural controls. Richter (1994) inteviewed 100 urban black
mothers and their babies and mentions that the early introduction of supplementary food could be due to a
perception that crying infants are hungry.
4.3.8 EDUCATION, IGNORANCE AND PSYCHOLOGICAL FACTORS
The impact of education status and/or knowledge of nutrition of the mother or care givers (child minder) of children,
has been examined in some studies. Lack of education and ignorance were found by Molteno & Kibel (1989),
Howard (1990) and Sive et al. (1993) to be risk factors. In other studies (Fincham, 1982; Krynauw et al., 1983)
education did not appear to be a significant variable, especially in rural circumstances. However, Lazarus & Bhana
(1984) describe ignorance and lack of nutritional knowledge, exchange of misconceptions by housewives and
passing on of harmful traditions as part of a vicious circle of poor nutritional practices in rural communities,
leading to undernutrition. Richter (1993) found that “emotional unavailability” of stressed care givers, together with
socio-political inequalities and physical deprivation, plays an important role in the development of protein-energy
malnutrition and disruption of the “life ecology” of young children.
4.3.9 PARASITIC INFECTIONS
Helmintic infections can affect health and nutritional status. Rapid urbanisation and increases in population
density in informal settlements with inadequate sanitation increase the risk of parasitic infections (Fincham et al.,
1996; 1996(a)). Walker & Walker (1994) reviewed the burden and prevalence of these infections in South African
populations, particularly in schoolchildren. Approximately 1 000 million people world-wide suffer from ascariasis,
900 million from hookworm, 750 million from trichuriasis, 400 million from amoebiasis and about 200 million
from schistosomiasis (Walker & Walker, 1994). It is estimated that 4 million people in South Africa may suffer from
schistosomiasis infection (Schutte et al., 1995). From Table 76 it can be seen that high prevalences of infections
have been observed in certain areas. Unfortunately, the contribution of a particular infection to loss of appetite and
food intake, nutrient losses (blood loss), undernutrition, growth, intelligence, and physical activity is not well described
(Walker & Walker, 1994). Fincham et al. (1996) showed that whipworm (Trichuria trihiuria) infection was associated
with anaemia and iron depletion in children. They also showed that antihelminthic treatment, without extra food,
resulted in improved growth and less anaemia in these children. Haycock & Schutte (1983) examined 834 children
in KwaZulu and 1 219 in Tongaland and found that children infected with schistosoma haematobium showed
slower progress through school. From the available literature, it is clear that treatment of heavily infected children
improves appetite, growth, general health and physical fitness.
Because parasitic infestation is associated with poverty and substandard hygienic practices, reinfection is a constant
hazard (Schutte, 1994). Therefore, long-term control of helminthic infections has proven to be practically impossible
(Schutte, 1994). For example, when whipworm infestation is predominant, treatment should be continued for 3
years at intervals of 4 months (Fincham et al., 1996a). It is advised that treatment should be targeted at areas with
prevalences > 30 % and that it should be coupled to improvements in sanitation, water supply, waste disposal and
education to improve hygienic practices.
26

4.3.10 ALCOHOL INTAKE
Moderate drinking is associated with beneficial effects on coronary heart disease risk factors (reviewed by Oosthuizen
et al., 1996), but excessive alcohol intakes lead to bio-psychosocial problems in individuals and families (Rocha-
Silva, 1985; 1987; 1988). It is possible that high intakes could replace food in the diet, or consume money that could
have been spent on food, thereby jeopardising nutrient intakes and nutritional status.
From available data it is difficult to judge whether alcohol consumption patterns, total intake or attitudes towards
drinking play a significant role in determining nutritional status of South Africans. Certainly, it can be suspected
that in poor families and with abuse it could have a significant influence. However, overall, the available South
African data indicate that alcohol intake is not a serious problem. Table 77 summarises percentages of current
drinkers and abstainers in the different population groups, provided by publications on consumption patterns from
1962 to 1992. The literature shows that whites have the larger proportion of drinkers and also the largest proportion
who consume wine and spirits with a comparatively high absolute alcohol content. But with regard to total annual
intake in the past, by far the majority of South African drinkers fell within the comparatively low category of intake
of < 36.5 litres absolute alcohol per annum (Rocha-Silva, 1985). Compared to the international literature, Oosthuizen
et al. (1996) also found that alcohol intakes of whites from two industrial towns (Vanderbijlpark and Witbank) were
low. Table 77 shows that Indian/Asian women was the group with the lowest intakes. Generally, more men than
women were drinkers. Africans preferred home brewed beverages and beer, although African women showed an
increased consumption of wine. A study conducted on pregnant women in Soweto (Patel et al., 1992) indicated that
45 % consumed alcohol, of which 80 % preferred traditional brews. Mean consumption was 19 g alcohol/day.
Baker (1986) examined the relationship between alcohol intake and iron status in black men recruited from outpatient
waiting areas of two large hospitals. No association between amounts consumed and serum ferritin was found.
In summary, more information on present consumption patterns is needed before the effect of drinking or alcohol
intake on nutritional status of South Africans can be evaluated.
4.4 COMMENTS
We need more information on the prevalence of the many determinants of malnutrition in some communities,
especially information on the effects of urbanisation. No recent literature on the nutritional status and factors
influencing nutritional status of people living in the fast growing peri-urban and urban informal housing areas
(squatter areas) are available. Clearly, this is an area that needs urgent research.
27

CHAPTER 5
CULTURAL INFLUENCES ON DIETARY PATTERNS
5.1 Introduction
In addition to availability and affordability of food, culture, tradition and religion influence the eating patterns of
many South Africans. Knowledge of these influences and of specific taboos are necessary to analyse the adequacy
of nutrient intakes and also to ensure that dietary recommendations and food choices for specific nutritional aid
programmes are culture sensitive. In this section, a short description of the major features of the dietary patterns
of some of the different South African groups and what is known about their possible impact on nutritional status
is given. This is followed by Tables 78 to 83 which summarise information on existing dietary patterns observed
during several epidemiological and clinical studies during recent years. Table 84 describes some of the traditional
foods and dishes of different African groups.
5.2 White South Africans
Van Heerden (1983) and MacDonald (1991) describe the diet of most whites in South Africa as a typical western diet.
The food culture which developed during the past 300 years was based on a European culture with strong Dutch,
French Huguenot, German and later, English, Irish and Scottish influences. One of the strongest influences was that
of the Malayan culture which introduced strongly flavoured foods and dishes and a variety of spices and condiments,
resulting in typically traditional dishes such as bobotie, curried fish, sosaties and blatjang. Traditionally the Afrikaner
ate three meals. Mealtimes were important occasions. Grace was said and at least one but often two meals were
combined with devotions (huisgodsdiens). Snacking (tea or coffee with baked products) between meals was common.
With time and urbanisation, meal patterns changed and broadened under the influence of British, Italian, Greek,
Portuguese, Indian and also African cultures. South Africa has a strong Jewish community, of which many follow
the traditional dietary prescriptions of the Torah. Seven-day Adventists follow a vegetarian diet.
5.3 Coloured South Africans
The Malayan culture, with strongly flavoured hot and spicy foods, contributed to the rich cooking culture of the
coloured people. The Muslim influence is also very strong in the lifestyle and eating patterns of many coloureds.
Some African influences, such as using maize meal as a staple food have been observed (summarised by MacDonald,
1991). In urban communities, typical western diets, with a variety of foods rich in animal protein and fat with
refined starchy foods and relatively large intakes of sugar, jams and other sweet items are followed (Vorster et al.,
1988; Steyn et al., 1990). Walsh (1995) studied coloured respondents in the Free State and reported a meal pattern
of three meals/day although many families in both rural and urban areas ate only two meals/day. She found that,
in most areas, children ate breakfast before school. A study on elderly coloured subjects in Cape Town (Charlton &
Arries, 1994) revealed a diet low in energy and micronutrients, but high in animal protein and fat.
5.4 South African Indians
The Indian housewife and mother perceives her cooking of traditional Indian meals as an art, a privilege and an
expression of her love for her family (Mia, 1983; Mia, 1992). Most South African Indians are either Muslim or Hindu.
The Islamic prescriptions regarding religion, lifestyle, eating patterns and hygiene are followed faithfully by many
Muslims. Special dishes are prepared for the many feasts. A wide variety of foods, strongly flavoured with many
spices including chillies and ginger, are eaten. Meat must be Halaal, and pork is not allowed. Foods are very
thoroughly washed before cooking, often finely cut and cooked for long periods. Many foods, including vegetable
dishes are fried either in ghee (clarified butter) or in sunflower oil. The result is a diet high in fat and possibly low
in vitamins and fibre (Mia, 1992). An interesting feature is the belief that the stomach should be one third filled with
food, one-third with liquid and one third with air. This belief could protect against overeating and obesity! The
Hindu religion prescribes vegetarianism in several forms. If Hindus are not vegetarian, pork and lamb, but not beef
are allowed. Many Hindus “fast” one day a week, a period during which no pulses, cereals or legumes are eaten,
but milk, root vegetables and fruit are allowed (Richardson & Cleaton-Jones, 1986).
29

5.5 Black South Africans
Traditional eating patterns and taboos of the different black groups in South Africa have been described by Becker
(1975), Beyers (1979), Coetzee (1982), Vorster et al. (1987), and Gresse (1991). Although there are several unique
features and taboos of individual groups, there are also common habits and patterns. One is that traditionally, only
two meals were eaten daily. Breakfast was eaten late in the morning and originally consisted only of sour milk
(amazi), especially in the South Nguni’s. Later, a thin porridge cooked from cereal (sorghum, millet or maize meal)
and served with sour milk was added. Wolmarans et al. (1995) found, however, that present day urban African
children have breakfast consisting mainly of bread before school. Only 14 % of grade 1 pupils and 17 % of standard
3 pupils in their sample did not eat breakfast. The main meal was usually served after dusk and consisted of two
dishes. The first was the main cereal dish such as a thick porridge or a cereal and vegetable mix (maize meal
cooked with pumpkin or samp and beans). The second was a side dish of meat, meat gravy or a vegetable stew, in
which the cereal (eaten by hand) could be dipped in. It was believed that the side dish should “ease the swallowing”
of the main cereal dish. Snacking between meals was common and a fermented cereal beverage (or beer with a
low alcohol content) was consumed in huge quantities to quench thirst and to still hunger pangs. Even small
children could drink this home brewed beverage.
Another common feature is that a bitter and sour musty taste is the favourite taste in African cuisine. To create this
taste, gall from slaughtered animals was sprinkled over food. The stomach content or some bitter plants were also
used for this purpose. Sweetening agents were not added to foods, although honey and sugar cane were eaten as
snacks.
Milk was a favourite food. However, its consumption was influenced by numerous taboos and rituals. It was usually
used as sour milk. Only small children and the elderly drank fresh milk. Milk consumption indicated kinship. A
man could only drink milk in his own household or in that of a paternal of maternal relative. A woman could only
drink milk obtained from her husband’s herd, and then only when she was accepted by her new family. An
“impure” women, as during menstruation or after a miscarriage, had to avoid milk and all milk containers. Milk
played a purification role and was sprinkled around a house (as was bile from a slaughtered animal), to “purify” the
house. It is possible that some of the older taboos regarding milk may be responsible for the low milk intake of
present day Africans. Pettifor et al. (1979) found that rural black children drank even less milk than urban children
and that this led to hypocalcaemia in the rural children.
Other taboos which could jeopardise nutritional status were that pregnant women were not allowed to eat vegetables
or sweet or hot foods and that during the last month of pregnancy, very little could be eaten to avoid big babies and
difficult deliveries. Women were also not allowed to eat eggs because it was believed that it would either make
them infertile, or let them acquire extra lovers. Religious beliefs, based in an ancestor cult where ancestral spirits
were guarding over the descendants, influenced consumption of certain foods and particular customs during
several ceremonies. Nutritionally, some of these beliefs and practices could also limit intakes of certain foods by
specific people, while it would favour intakes of others. For example, in the Pedi culture, only the men of the tribe
were allowed to eat the “funeral meat” obtained from an ox or goat slaughtered for a funeral feast.
It is possible that in the past the traditional attitude towards cattle (Fox, 1979) as well as the land tenure custom
contributed to food insecurity and low nutritional status of some Africans.
5.6 Comments
It is not known how many of these older customs still influence eating patterns of the modern African. Ramphele
& Heap (1991) found that hostel dwellers in urban areas of the Western Cape ate more frequently and regularly than
when they were “home-based” in their rural area. Lazarus and Bhana (1984) are of the opinion that lack of
nutrition knowledge, exchange of nutritional misconceptions by housewives and traditional practices passed on to
the next generation are major causes of community malnutrition.
Tables 78 to 83 clearly illustrate that nutrient intakes of all South Africans may be improved by including more milk,
milk products, fruits and vegetables in the diet. The dietary (nutrient) intake results shown in Section 3.3 also
demonstrate how dietary patterns have changed during urbanisation and that urban Africans now follow a much
more westernised diet with more fat and less fibre. In addition, Tables 81 and 82 show that inadequate weaning
practices were associated with a deterioration of nutritional status of black infants. The availability of an inexpensive
nutrient dense weaning food and knowledge on the correct use of such a food, or increasing energy density of
maize porridge by adding oil, sugar or peanut butter could be one way to address the problem of undernutrition in
these infants.
30

CHAPTER 6
DISCUSSION, CONCLUSIONS AND
RECOMMENDATIONS
6.1 LIMITATIONS OF THE REVIEW
By definition, in addition to four unrelated National Surveys, data gathered in many small ad hoc studies by a large
number of individual researchers and groups, employing different designs and methods, had to be used in this
review. Therefore, care should be taken in the integration and interpretation of the results. Conclusions drawn
should take into account that results from small studies may be biased and not representative of the total population.
A major observation from these studies is that some groups that are perceived as being the most vulnerable to
malnutrition, such as children in disadvantaged communities, have been studied in much more detail than other
possible groups, such as pregnant and lactating women and the elderly. The data in Tables 1 to 84 show that there
are many gaps in our knowledge, not only regarding specific groups, but also regarding specific nutrients.
Another observation is that except for the four National Surveys, very little research has been done in some provinces,
notably in the Northern and Eastern Cape and in Mpumalanga. The Western Cape and Gauteng have the most
comprehensive data. This may be related to the distribution of universities, medical schools, academic hospitals,
departments of nutrition/dietetics, MRC laboratories and funding of research projects. Therefore, it is not possible
to compare and prioritise the most needy provinces or districts on the available data.
6.2 MAIN FINDINGS: CONCLUSIONS
6.2.1 PRESCHOOL CHILDREN
The most important observation is that, on a national basis, between 20 and 25 % of preschoolers are stunted and
therefore suffer from chronic undernutrition.
Black and coloured children have the highest prevalences (25 and 17 % respectively), with rural black children the
most vulnerable group.
The most vulnerable age is approximately 2 years and there is substantial evidence that inadequate weaning
practices are a major determinant of undernutrition in this age group.
It seems that wasting is not a problem, but that in white, Indian and coloured children, underweight is a more
serious problem than stunting. There are indications that even in rural black children, overweight could be an
emerging problem.
The mean prevalences of malnourished children (diagnosed on anthropometric variables) from different studies
are in agreement with the one National Survey on preschoolers. However, the ad hoc studies reported a wide range
of undernutrition, indicating that there are pockets or areas which have a very serious problem in malnutrition.
This is an extremely important finding, because it indicates that intervention programmes will probably have to
differ in different areas.
Biochemical analyses show that preschool children, especially black children, had high prevalences (up to 20 %) of
iron deficiency anaemia, as well as vitamin A and folate deficiencies. The high prevalence of parasitic infections
reported by a number of researchers, probably contributes to the iron deficiency problems.
The dietary intake data supports the anthropometric and biochemical observations. Rural black children have low
mean energy intakes and although total protein intakes seem adequate, the quality of the protein may be jeopardised.
The clinical data on eye abnormalities confirms a high prevalence of vitamin A deficiency on a national level
among preschoolers.
31

6.2.2 PRIMARY SCHOOL CHILDREN
Prevalences of wasting and also of underweight are low in primary school children. However, it is estimated that on
a national basis, at least 20 % of primary school children are stunted and suffer from chronic malnutrition.
The mean prevalence of stunting calculated from results of the ad hoc studies is higher than in the 1994 National
Survey. The wide range of results indicate that pockets of extreme malnutrition exist in some areas.
The growth pattern of children from different ethnic groups differs and there is not enough evidence to attribute
this to dietary intake patterns only. Clearly, other environmental determinants also play a role.
The same micronutrient deficiencies observed in the preschoolers, namely iron, vitamin A and folate are also
present in primary school children. There are indications that low calcium intakes could also be a problem.
6.2.3 ADOLESCENTS
Much less research has been done on this age group.
Iron and folate deficiencies are common amongst all ethnic groups and black children seem to have low vitamin
A, E, B6 and also calcium status.
6.2.4 ADULTS
Indications are that the same differences between ethnic groups observed in children are present in adults.
Obesity (and associated diseases of lifestyle) is common among South African adults. From the limited data
available it seems that especially black women have a very high prevalence of obesity.
The iron and folate micronutrient deficiencies observed in children are also present in adults.
6.2.5 DETERMINATIONS OF MALNUTRITION
All the complex, interrelated socio-economic determinants described in the international literature were observed
by a number of authors in South African subjects. Broken family units seem to emerge as an important roleplayer.
Although poverty is identified as a major underlying cause, it is clear that not all poor people are malnourished. It
is suspected that social-support networks within poor communities could play an important role in preventing
undernutrition. This strength, together with the existence of extended families within communities could be
utilised in preventive and intervention programmes. Of concern is the lack of information on the impact of changes
in determinants of nutritional status during urbanisation. To address possible problems of malnutrition in the fastgrowing
informal housing areas and throughout South Africa, much more research on these changes are necessary.
6.2.6 DIETARY PATTERNS AND NUTRIENT INTAKES
The available data on dietary patterns showes that cultural influences could explain some of the differences
observed in the different ethnic groups. However, it is suspected that poverty, household food insecurity and other
factors dictated by socio-economic realities, are more important determinants of nutrient intakes. It is clear that
low energy density of weaning foods and of the diets of rural black primary school children, coupled to a low intake
of fruits, vegetables, legumes and milk by many individuals of all ethnic groups, are the main deficiencies in the
South African diet.
The nutrient intake data supports these observations. There are adequate intakes of protein, total fat, sodium
chloride (table salt), potassium, phosphorus, thiamin, riboflavin and vitamin B12. All other nutrients are deficient in
the diet of many groups. The low intakes of dietary fibre, calcium, iron, magnesium, zinc, riboflavin, vitamin B6,
vitamin C, folate and especially vitamin A by many groups, is a matter of serious concern, as is the increasing
tendency towards westernisation of prudent traditional diets. The latter is associated with higher fat and lower fibre
intakes, increasing the risk of chronic diseases of lifestyle.
32

6.3 DISCUSSION AND RECOMMENDATIONS
The aim of this discussion is not to consider all possible solutions to South Africa’s nutritional problems, but only to
highlight the major findings of this review and how they should influence our thinking in the design of future
nutrition policy and programmes.
Firstly, with a quarter of South Africa’s children stunted, coupled to high prevalences of micronutrient deficiencies
across all age groups, as well as very high prevalences of obesity, we clearly have the double burden of both under
and overnutrition. This means that our strategies to address undernutrition should not lead directly to overnutrition
in later life. The nutrition “message” of adequacy should be accompanied by one of prudency. While addressing
energy deficiency in vulnerable groups and micronutrient deficiencies in the total population, education on healthier
food choices should be a focus point.
The second important observation is that, within a specific age and ethnic group, wide ranges in prevalences of
undernutrition were seen. This means that although national strategies and policies are extremely important in
addressing the problem, specific programmes should be based on the real need in a specific area or group.
Programmes should be flexible and adaptable. For example, children in a Gauteng school could only need education
on how to choose healthy snacks from a tuckshop, while children in a remote rural school could need a total school
meal programme.
The third observation of importance is that some (vitamin A and folate), but not all (iron) of the micronutrient
deficiencies could be addressed by a fortification programme. The danger of iron overload should be considered.
It is suggested that to address the iron problem, an expert committee should advise Government on both the
advantages and disadvantages of fortification and that targeting of inexpensive weaning foods should be considered.
In conclusion, although malnutrition on a national level may only be a mild problem of coexisting under and
overnutrition, it may be a serious problem of outspoken undernutrition and even hunger in specific areas. Our
strategies, policies and programmes to address this problem should take these differences into account and be
flexible enough to adapt to specific needs.
33

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