This study presents the results of a co-creation of an IF diet for children under five in ECD centres. Stakeholders shared their knowledge and perceptions of IF types to co-created an IF diet to be implemented in ECD centers. Experts perceived it suitable to address poor eating habits to improve health and nutritional outcomes of children. This diet will help achieve SGD 3 and 4 that seek to promote improved nutrition and ensuring healthy lifestyles for all ages (19). A menu was designed with fruits, vegetables and mixed dishes in line with the South African FBDG (6). Our findings reveal that stakeholders perceived an IF diet as essential in achieving 2030 agenda to end malnutrition, stunting and wasting for children under five. Stakeholders shared pre-populated types of IF suitable and acceptable for use by children under five.
An IF diet menu was co-created with consideration of important factors such as frequency of use for the prioritized IF, the type of meal, how they should be prepared and served. Furthermore, stakeholders co-created the IF diet with the types of food that are suitable and acceptable for consumption for children under five. IF such as ditokomane, oranges, mabele soft porridge, dinawa were prioritized for inclusion in the menu. The prioritized food to be served not less than twice a week whereas the least prioritized food can be served once a week. Stakeholders expressed the need to consider IF preparation, the quality of IF and the feeding practices during implementation of the diet.
In our study, stakeholders perceived the use of an IF diet as a strategy to address poor eating habits at an early age. This is backed by a report on IF and their contribution to nutritional requirements which states that IF play a major role in enhancing quality diets (20). Stakeholders perceived that IF can be cooked alone and some mixed to made one dish. This findings support a previous study which highlights that combination of fruits and vegetables have more potential benefits rather than single fruits and vegetable (21). Furthermore, sufficient intake of fruits and vegetables has been related with reduced risk of many non-communicable diseases (21). Challenges were reported that may affect implementation of IF diet were reported elsewhere (4, 22). Similar challenges were reported from a study conducted on the role of fruits and vegetable in delivering healthy diets challenges on accessibility and acceptability of IF (22). Stakeholders expressed the need for early introduction of IF diet for children’s health and development. However, a study conducted on rural parent support on child health behavior reveal that children are being fed food that does not support their growing bodies and brains (23). Early exposure to overall unhealthy diets low in nutrients dense food negatively impact children’s cognitive development (24).
An IF diet was co-created by stakeholders and reviewed by experts to ensure that it is suitable and acceptable for use by children under five. Stakeholders perceive the IF diet as an initiative to promote healthy eating, barriers that emerges to impede the implementation of the diet need to be addressed. The current co-created diet includes fruits, vegetables and mixed dishes, this correlates well with the findings of the previous study conducted on consumption intensity of leafy indigenous vegetables which reports that diversity in IF consumption is necessary for healthy diet(8). In addition, FBDG recommends that different colored, textured, and tasting fruits and vegetables, both fresh and cooked should be frequently offered to children(6). Stakeholders emphasized the frequent consumption of both fruits and vegetables such as oranges, banana, spinach and beetroot on daily basis. Okop,2019 reports that adequate intake of fruits and vegetables is considered an essential for optimum growth(25). However, in the current study amounts of IF to be consumed were not indicated. This is contrary to the study by Ramsay, 2017 which reports that children should be fed specific amounts of fruits and vegetables to optimize growth(26).
Nutrition interventions targeting ECD centres need to be strengthened to promote and encourage early introduction of an IF diet as part of healthy eating for improved nutritional outcomes. Future studies should focus on nutritional values of IF to ensure that the diet address the nutritional status of children under five. Government should strengthen collaborations to ensure accessibility, acceptability and affordability in ECD centres.
The strength of this study is that all stakeholders involved in the co-creation of an IF diet work with ECD centres and children under five. The participants comprised of different age groups and gender shared different perceptions regarding the diet which is suitable and acceptable for children under five. Limitation of this study was that only stakeholders from other settings limiting knowledge and expertise from other settings towards the study findings. There is a need for further research with stakeholders from different settings were there are different types of IF available and preferred for children under five.