BackgroundDuring the last century we have seen wide-reaching changes in diet, nutritional status and life expectancy. The change in diet and physical activity patterns has become known as the nutrition transition. At any given time, a country or region within a country may be at different stages within this transition. This paper examines a range of nutrition-related indicators for countries in Sub-Saharan Africa (SSA) and attempts to develop a typical model of a country in transition.MethodsBased on the availability of data, 40 countries in SSA were selected for analysis. Data were obtained from the World Health Organisation, Demographic and Health Surveys and the Food and Agriculture Organisation of the United Nations. Multiple linear regression analysis (MLRA) was used to explore the determinants of infant mortality. A six point score was developed to identify each country's stage in the nutrition transition.ResultsMLRA showed that underweight-for-age, protein and the percentage of exclusively breastfed infants were associated with the infant mortality rate (IMR). The majority of countries (n = 26) used in the analysis had nutrition transition scores of zero and one. Most of them had a high prevalence of infant mortality, children that were stunted or underweight-for-age, small percentages of women that were overweight and obese, and low intakes of energy, protein, and fat. Countries with the highest scores include South Africa, Ghana, Gabon, Cape Verde and Senegal which had relatively low IMRs, high levels of obesity/overweight, and low levels of underweight in women, as well as high intakes of energy and fat. These countries display classic signs of a population well established in the nutrition-related non-communicable disease phase of the nutrition transition.ConclusionsCountries in SSA are clearly undergoing a nutrition transition. More than half of them are still in the early stage, while a few have reached a point where changes in dietary patterns are affecting health outcomes in a large portion of the population. Those in the early stage of the transition are especially important, since primordial prevention can still be introduced.

PurposeFood insecurity has been linked with maternal depression in low-income settings. Few studies have looked at factors associated with both food insecurity and maternal depression as outcomes. This study aimed to assess factors associated with food insecurity and depression in a sample of pregnant South African women.MethodsWe conducted a cross-sectional study at a Midwife Obstetric Unit in a low-income suburb in Cape Town. Pregnant women attending the clinic for their first antenatal visit were invited to participate. The shortened form of the US Household Food Security Survey Module was used to measure food insecurity. The Expanded Mini-International Neuropsychiatric Interview was used to diagnose depression, anxiety, alcohol and drug dependence, and assess for suicidal ideation and behaviour. Logistic regression modelling was conducted to explore factors associated with food insecurity and depression in separate models.ResultsWe found that 42% of households were food insecure and that 21% of participants were depressed (N = 376). The odds of being food insecure were increased in women with suicidal behaviour (OR = 5.34; 95% CI 1.26–22.57), with depression (4.27; 1.43–12.70) and in those with three or more children (3.79; 1.25–11.55). The odds of depression was greater in women who were food insecure (5.30; 1.63–17.30), substance dependent (15.83; 1.31–191.48) or diagnosed with an anxiety disorder (5.04; 1.71–14.82).ConclusionsFood insecurity and depression are strongly associated in pregnant women. The relationship between food insecurity and depression is complex and requires further investigation. Interventions that improve both food security and mental health during the perinatal period are likely to benefit the physical and mental well-being of mothers and children.

BackgroundThis study evaluated the primary school environment in terms of being conducive to good nutrition practices, sufficient physical activity and prevention of nicotine use, with the view of planning a school-based health intervention.MethodsA sample of 100 urban and rural disadvantaged schools was randomly selected from two education districts of the Western Cape Education Department, South Africa. A situation analysis, which comprised an interview with the school principal and completion of an observation schedule of the school environment, was done at all schools.ResultsSchools, on average, had 560 learners and 16 educators. Principals perceived the top health priorities for learners to be an unhealthy diet (50%) and to far lesser degree, lack of physical activity (24%) and underweight (16%). They cited lack of physical activity (33%) and non-communicable diseases (NCDs; 24%) as the main health priorities for educators, while substance abuse (66%) and tobacco use (31%) were prioritised for parents. Main barriers to health promotion programmes included lack of financial resources and too little time in the time table. The most common items sold at the school tuck shops were crisps (100%), and then sweets (96%), while vendors mainly sold sweets (92%), crisps (89%), and ice lollies (38%). Very few schools (8%) had policies governing the type of food items sold at school. Twenty-six of the 100 schools that were visited had vegetable gardens. All schools reported having physical activity and physical education in their time tables, however, not all of them offered this activity outside the class room. Extramural sport offered at schools mainly included athletics, netball, and rugby, with cricket and soccer being offered less frequently.ConclusionThe formative findings of this study contribute to the knowledge of key environmental and policy determinants that may play a role in the health behaviour of learners, their parents and their educators. Evidently, these show that school environments are not always conducive to healthy lifestyles. To address the identified determinants relating to learners it is necessary to intervene on the various levels of influence, i.e. parents, educators, and the support systems for the school environment including the curriculum, food available at school, resources for physical activity as well as appropriate policies in this regard.

Objective: To identify and describe factors associated with food shop (known as tuck shop in South Africa) and lunchbox behaviours of primary-school learners in South Africa. Design: Analysis of data collected in 2008 from a cross-sectional survey. Setting: Sixteen primary schools in the Western Cape, South Africa. Subjects: A total of 717 grade 4 learners aged 10-12 years. Results: A 24 h recall established that 69 % of learners carried a lunchbox to school and 49 % had consumed at least one item purchased from the school food shop/ vendor. Most lunchboxes contained white bread with processed meat, whereas the most frequent food shop/vendor purchase comprised chips/crisps. Learners who carried a lunchbox to school had significantly lower BMI percentiles (P 5 0?002) and BMI-for-age (P 5 0?034), compared with their counterparts. Moreover, they were younger, had higher standard-of-living and dietary diversity scores, consumed more meals per day, had greater self-efficacy and came from predominantly urban schools, compared with those who did not carry a lunchbox to school. Learners who ate food shop/vendor purchases had a lower standard-of-living score and higher dietary diversity and meal scores. Only 2 % of learners were underweight, whereas 19 % were stunted and 21 % were overweight/obese (BMI $ 25 kg/m 2 ). Conclusions: Children who carried a lunchbox to school appeared to have greater dietary diversity, consumed more regular meals, had a higher standard of living and greater nutritional self-efficacy compared with those who did not carry a lunchbox to school.

Unsuppressed viral load (VL) in patients on antiretroviral therapy (ART) occurs when treatment fails to suppress a person's VL and is associated with decreased survival and increased HIV transmission. The objective of this study was to evaluate factors associated with unsuppressed VL (VL > 400 copies/ml) in patients currently in care on first-line ART for ≥ 6 months attending South African public healthcare facilities. We analysed electronic medical records of ART patients with a VL result on record who started ART between January 2004 and April 2016 from 271 public health facilities. We present descriptive and multivariable logistic regression for unsuppressed VL at last visit using a priori variables. We included 244,370 patients (69% female) on first-line ART in April 2016 for ≥ 6 months. Median age at ART start was 33 years (7% were < 15 years old). Median duration on ART was 3.7 years. Adjusting for other variables, factors associated with having an unsuppressed VL at the most recent visit among patients in care included: (1) < 15 years old at ART start (adjusted odds ratio [aOR]=2.58; 95% CI = 2.37, 2.81) versus 15-49 years at ART start, (2) male gender (aOR = 1.29; 95% CI = 1.25, 1.35), (3) 6-12 months on ART versus longer (aOR = 1.34; 95% CI = 1.29, 1.40), (4) on tuberculosis (TB) treatment (aOR = 1.78; 95% CI = 1.48, 2.13), and (5) prior ART exposure versus none (aOR = 1.20; 95% CI = 1.08, 1.32). Approximately 85% of the ART cohort who were in care had achieved viral suppression, though men, youth/adolescents, patients with prior ART exposure, those with short duration of ART, and patients on TB treatment had increased odds of not achieving viral suppression. There is a need to develop and evaluate targeted interventions for ART patients in care who are at high risk of unsuppressed VL.

BackgroundNumerous studies in schools in the Western Cape Province, South Africa have shown that children have an unhealthy diet with poor diversity and which is high in sugar and fat. HealthKick (HK) was a three-year randomised controlled trial aimed at promoting healthy eating habits.MethodsSixteen schools were selected from two low-income school districts and randomly allocated to intervention (n = 8) or control school (n = 8) status. The HK intervention comprised numerous activities to improve the school nutrition environment such as making healthier food choices available and providing nutrition education support. Dietary intake was measured by using a 24-h recall in 2009 in 500 grade 4 learners at intervention schools and 498 at control schools, and repeated in 2010 and 2011. A dietary diversity score (DDS) was calculated from nine food groups and frequency of snack food consumption was determined. A school level analysis was performed.ResultsThe mean baseline (2009) DDS was low in both arms 4.55 (SD = 1.29) and 4.54 (1.22) in the intervention and control arms respectively, and 49 % of learners in HK intervention schools had a DDS ≤4 (=low diversity). A small increase in DDS was observed in both arms by 2011: mean score 4.91 (1.17) and 4.83 (1.29) in the intervention and control arms respectively. The estimated DSS intervention effect over the two years was not significant [0 .04 (95 % CI: −0.37 to 0.46)]. Food groups least consumed were eggs, fruit and vegetables. The most commonly eaten snacking items in 2009 were table sugar in beverages and/or cereals (80.5 %); followed by potato crisps (53.1 %); non-carbonated beverages (42.9 %); sweets (26.7 %) and sugar-sweetened carbonated beverages (16 %). Unhealthy snack consumption in terms of frequency of snack items consumed did not improve significantly in intervention or control schools.DiscussionThe results of the HK intervention were disappointing in terms of improvement in DDS and a decrease in unhealthy snacking. We attribute this to the finding that the intervention model used by the researchers may not have been the ideal one to use in a setting where many children came from low-income homes and educators have to deal with daily problems associated with poverty.ConclusionsThe HK intervention did not significantly improve quality of diet of children.

BackgroundA number of metabolic abnormalities, such as dysglycaemia, insulin resistance, lipodystrophy and dyslipidaemia, are associated with the use of antiretroviral drugs. We aimed to assess the effects of long-term antiretroviral exposure on blood pressure, glycaemia, insulin secretion and anthropometric measures in black South African women.MethodsA convenience sample of HIV-infected women on first-line ART for a median of 16 months at baseline, had the following evaluations twice, at baseline and after approximately 5 years: anthropometry, including skin fold thicknesses, blood pressure, oral glucose test, and insulin. Insulin sensitivity and secretion (HOMA-IR, IGI and DIo) were estimated.ResultsAt baseline more than half the 103 women were using stavudine and efavirenz. The median interval between baseline and follow-up evaluation was 66 months. Weight, waist circumference, and waist-hip ratio increased over time, while limb skinfold thickness decreased over time. Systolic and diastolic blood pressure increased significantly and the proportion of participants with hypertension increased from 3.9 to 15.5% (p < 0.001). There were increases from baseline in plasma glucose concentrations at 30 and 120 min; insulin concentrations at 0 and 30 min; and IGI and DIo. The proportion of participants with diabetes increased from 1 to 7.5% (p = 0.070).ConclusionIn black South African women with long-term exposure to ART, increases in hypertension and possibly diabetes were observed. Participants experienced an increase in central fat and a decrease in peripheral fat distribution. Early identification and management of these metabolic changes are important, especially in a region with the highest HIV-infected population in the world.

BackgroundThe burden of non-communicable diseases, including type 2 diabetes, is growing in South Africa. This country has a complex mix of over- and under-nutrition, especially in low-income communities, and concerning levels of physical inactivity in children and youth. This paper describes HealthKick, a school-based nutrition and physical activity intervention in primary schools in these settings aimed at reducing diabetes risk factors.Methods/DesignThis study includes schools within historically disadvantaged, low-income communities from an urban area close to the city of Cape Town and from two rural areas outside of Cape Town, South Africa. The three Educational Districts involved are Metropole North, Cape Winelands and the Overberg. The study has three phases: intervention mapping and formative assessment, intervention development, and outcome and process evaluation. Sixteen schools were purposively selected to participate in the study and randomly allocated as intervention (eight schools) and control (eight schools).The primary aims of HealthKick are to promote healthful eating habits and increase regular participation in health-enhancing physical activity in children, parents and teachers, to prevent overweight, and reduce risk of chronic diseases (particularly type 2 diabetes); as well as to promote the development of an environment within the school and community that facilitates the adoption of healthy lifestyles.The components of HealthKick are: action planning, toolkit (resource guide, a resource box and physical activity resource bin), and an Educators' Manual, which includes a curriculum component.DiscussionThis study continues to highlight the key role that educators play in implementing a school-based intervention, but that developing capacity within school staff and stakeholders is not a simple or easy task. In spite of the challenges experienced thus far, valuable findings are being produced from this study, especially from Phase 1. Materials developed could be disseminated to other schools in low-income settings both within and outside of South Africa. Owing to the novelty of the HealthKick intervention in low-income South African primary schools, the findings of the evaluation phase have the potential to impact on policy and practice within these settings.