In general, the study findings showed that participants had a low energy intake, low fruit and vegetable consumption, high prevalence of stunting, overweight and iron deficiency. The importance of nutrition in early childhood development and the effects of inadequate nutrition beyond childhood has been well established (19). Results in this study show that the energy, fibre, calcium, iron and zinc intake were lower than the recommended amount in all the age groups, similar to findings in a study conducted in Durban in South Africa (20). Furthermore, the majority of the children consumed less than the recommended EAR for vitamin A, except for girls between 24–47 months. In contrast, there was generally a high protein intake in all groups, and none of the participants consumed less than the recommended intake. Given that the food intake results are similar to findings reported in the National Food Consumption Survey conducted in 1999 and a more recent study at an ECD centre in a similar context (4, 20), and despite national interventions, various reasons can be attributed to the current results. Nutritional status is influenced by several environmental factors and, as such, in countries like South Africa where the prevalence of HIV infection is high, HIV infection has both a direct impact on the nutritional status of women and children who are infected and an indirect effect through changes in household food security and inappropriate choices of infant-feeding practices to prevent mother-to-child transmission of HIV (21).
It has been well established that adequate fruit and vegetable consumption is crucial for child health. Globally and nationally, most children do not meet the guidelines for adequate fruit and vegetable intake. The results from this study are no different; the mean fruit and vegetable intake for all participants between 24–47 months and 48–60 months was less than the recommended 320 to 480 g per day and 400 to 480 g per day respectively. These findings of low fruit and vegetable intake compare with the SANHANES-1 study. Cost is the major constraint prohibiting daily consumption of fruits and vegetables (22). Given that 65% of young children in South Africa live below the poverty line, affordability is related to the low fruit and vegetable intake (23). Although initiatives such as food gardens have been amplified and promoted as a nutrition intervention strategy, its impact is seldom measured. Moreover, the dislike of fruit and vegetables among children and the habit of eating fruits and vegetables at an early age is another possible reason. According to Raggio & Gambaro, (2018) the sensory characteristics of vegetables and the habits of consumption in the family environment play an important role in acceptance or rejection of vegetables by children (24).
Anthropometric results show that over and undernutrition coexists within the study population, which reflects similar trends in developing countries (25). The incidence of stunting was noted in girls and boys between 48–60 months, with severe stunting being more pronounced among girls. The high prevalence of stunting in this study population is similar to other studies in South Africa (26, 27). While wasting was only observed in boys aged 48–60 months, the risk of overweight was high in all age groups, especially in girls between 48–60 months. The more recent South African Demographic Health Survey in 2016 found a decline in wasting and underweight, yet stunting remained high, affecting 27% of children under five (28). Stunting is an indicator of chronic malnutrition compromising children’s cognitive development, education and employment prospects, and increases their risk of overweight and obesity (21). While South Africa has experienced a rapid nutrition transition characterised by an increase in the prevalence of obesity and non-communicable diseases, the South African pattern of transition differs in that stunting persists (29). To effectively direct public health initiatives, an understanding of the long-term dynamics of stunting in the South African context is required in conjunction with the interplay of the obesogenic food environment.
In children, vitamin A is essential to support rapid growth and help to combat infections (WHO). The findings in this study show that a small percentage of participants had low serum retinol levels. In the SAHANES study at the national level, the prevalence of vitamin A deficiency was 43.6%. South Africa introduced routine periodic high-dose vitamin A supplementation in 2002 to reduce childhood mortality, however, there is no evidence from the past two decades, with changing disease profiles, increased use of vaccines and reduced morbidity from diarrhoea and pneumonia, that a high-dose programme is nearly as effective today as it was in some countries 20–30 years ago (30). Moreover, it has been found that there may also be pockets where, due to unique eating patterns, vitamin A deficiency may not be present at all (31).
Iron deficiency can have a serious impact on children’s health and later development through alteration of the immune status, adverse effects on morbidity and delayed behavioural and mental development (32). In this study, the prevalence of anaemia was high contrary to the findings of the SAHANES study where the overall prevalence of anaemia was 10.7%, mild anaemia 8.6% and moderate anaemia 2.1% (5). It was also found that children in the 24–47 months age group had lower Hb levels. Likewise, the prevalence of anaemia was highest in children in the 24–35 months (15.2%) age group and decreased to 3.0% in the 48–59 months age group in the SAHANES study (5). A possible reason for the low Hb levels in this study population could be alluded to the fact that top five foods consumed were carbohydrate-rich foods, with meat being the eight food item consumed, bearing in mind that the 24-food recall, showed a high protein content which is attributed to the high consumption of legumes which is typically consumed in South African rural areas. Co-morbid anaemia and stunting among young children are highly prevalent in low- and middle-income countries (6). Hence a syndemic framework approach is encouraged integrating the co-occurrence of health problems with social and environmental factors.