Academic Journal of

Pediatrics & Neonatology

Research Article Acad J Ped Neonatol

Volume 1 Issue 3 - July 2016 Copyright © All rights are reserved by Thando P Gwetu

Anemia, Iron Deficiency and Diet Independently

Influence Growth Patterns of School Aged Children in
South Africa
Thando P Gwetu*, Meera K Chhagan, Claire J Martin, Myra Taylor, Murray Craib and Shuaib Kauchali
Department of Public health, University of KwaZulu-Natal, South Africa
Submission: May 03, 2016; Published: July 29, 2016
*Corresponding author: Thando P Gwetu, University of KwaZulu-Natal, Department of Public health, Private Bag X7, Congella, 4013, South
Africa, Tel: ; Email:

Abstract

Objective: To determine the differences that exist in the growth indicators of primary school-aged children and to estimate the burden of
disease attributed to anaemia, iron deficiency and lack of dietary diversity.

Design: This cross-sectional study assessed growth status by determining anthropometric indicators and motor development. Information
on dietary diversity and eating patterns was collected based on meals consumed at home and at school. Laboratory assays were conducted on
venous blood samples to assess haemoglobin levels and body iron status.

Setting: Children were recruited from a disadvantaged community in Kwazulu-Natal, South Africa.

Subjects: A study population of 184 children aged six to eight years was enrolled.

Results: The stunting prevalence was 8.3% for boys and 6.6% for girls. Stunted growth was significantly associated with prevalence
of parasitic infection (17.7%) (p=0.01) and prevalence of anaemia (23.4%) (p=0.03). A low prevalence of motor development impairments
was found. Anaemia and iron deficiency were significantly related with impaired fine motor skills (P>0.05). The diets of 46.7% of the study
population met the definition of minimum dietary diversity. Occurrence of nutritional deficiencies in children with low dietary diversity was
twice as high as in children with adequate dietary diversity. A significant relationship was noted between low dietary diversity (seven-day
recall) and anaemia (p=0.004).

Conclusion: These findings provide evidence of the relevance of anaemia and dietary diversity to childhood growth, reinforcing the
importance of effective actions to optimize children’s dietary intake to achieve better health outcomes.

Keywords: Anthropometry, Growth, Dietary Intake, Anemia, Iron Status

Abbreviations: IDA: Iron Deficiency Anemia; ID: Iron Deficiency; NIDA: Non-Iron Deficiency Anemia; SANHANES: SA: South Africa; HAZ: Height-
for-Age Z-scores; WAZ: Weight-for-Age Z-scores; BAZ: BMI-for-Age Z-scores; DDS: Dietary Diversity Score; SD: Standard Deviation; NSNP:National
School Nutrition Program; Hb: Hemoglobin level; CRP: C-reactive protein; SF: Serum Ferritin; s TfR: soluble Trans ferric Receptor; IDS: Iron
Deficient Stores; MA: Mixed Anemia; NA: Non-Anemic

Introduction
to be underweight, and 25% stunted [4]. The natural history of
Nutrition is a key factor in the control of many diseases of
nutritional deficiencies associated with anaemia, such as iron
public health significance. In early childhood, iron deficiency is the
deficiency in young children is not yet well defined. The high
most prevalent nutritional disorder [1]. Iron deficiency anaemia
prevalence of growth deviations and the adverse developmental
(IDA) in preschool children from the developing world has been
outcomes associated with malnutrition and anaemia highlight
estimated at 56% [1] and in South Africa (SA) this is seen more
the need for prioritization of nutrition programs. The association
commonly in children from particular ethnic groups, namely
between anaemia and psychomotor development has been
African and Coloured, as well as children disadvantaged by poor
described by various researchers with evidence suggesting that
socioeconomic circumstances [2]. The 2013 SANHANES-1 report
despite treatment the adverse consequences may not be fully
described a declining anaemia trend of 10.5% and iron deficiency
reversible [5,6]. This study was an ancillary exploration to the A
of 8.1% among South African children aged up to 14 years [3].
sense study which described high levels of anaemia prevalence
Among SA children aged less than five years 12% are estimated
(53%)[7]observed during their baseline measurements.

Acad J Ped Neonatol 1(3) : AJPN.MS.ID.555565 (2016) 001

 Academic Journal of Pediatrics & Neonatology

Nutritional status is assessed by measuring clinical health Both questionnaires were assessed for content validity by a
status, dietary adequacy, anthropometric and biochemical professional nutritionist, familiar with locally available foods,
indicators. These measurements are essential for health screening and for face validity in a pilot sample of 10 community members.
and for monitoring the response to interventions. Population The questionnaires were interviewer administered by trained
level growth monitoring is valuable for evaluating group nutrition research nurses, to the children’s caregivers. For the 24 hour-recall,
status within the community as well as for identifying the caregivers were asked to recall all foods and beverages consumed
determinants and burden of disease attributable to malnutrition. by the children in the previous 24 hours, starting with the most
Our study describes the variations in nutritional status of school- recent meal and working backwards. Additional information on
aged children living in a rural community and explores the dietary diversity was obtained from a seven-day recall of foods
relation to anaemia and iron status. This study also describes the consumed in the preceding week. Each food was assigned to one
contribution of family meals and the school nutritional program to of 9 food groups used to evaluate the diet quality index: 1. Cereal,
nutritional status and dietary adequacy. The information obtained White roots and tubers; 2. Vitamin A rich vegetables and fruit; 3.
from this study can contribute to addressing the nutrition-related other vegetables; 4. other fruits; 5. Meats; 6. Eggs; 7. Legumes,
problems existing in this school-age population and for planning nuts and seeds; 8. Milk and milk products; 9. Oils and fats; and
interventions aimed at overcoming these challenges. sweets. A dietary diversity score (DDS) was calculated by adding
the total number of different food groups consumed. A DDS < 4
Materials and methods
was a reflection of poor dietary diversity [12].
Growth analyses
School diet: Study participants were enrolled at eight local
Anthropometry measurements were conducted by trained schools that provided a meal within the National School Nutrition
research nurses. Under-nutrition in childhood is characterized Program (NSNP) and therefore, to obtain a complete picture of
by growth failure. Height and weight measurements were their daily food intake necessitated the collection of information
used as indicators of nutritional status [8]. Height and weight about meals consumed at home and at school. To obtain insight into
were measured according to standard procedures [9]. Weight the food consumed at each school, 20 randomly selected children
measurements were read to the nearest 0.1kg on a portable were discretely observed during a meal. Meals were described in
Philips® digital bathroom scale - model HF340/00. Body height terms of foods offered, ingredient availability as well as the served
measurements were read to the nearest 0.1cm using a Scales® versus consumed portion per child. The information collected was
2000 moveable stadio meter. Height-for-Age, Weight-for-Age and related to program guidelines and recommendations.
BMI-for-Age Z-scores for each child were computed using the
Anaemia analysis: Venous blood samples were analysed
WHO Child Growth Standards [10]. Anthropometric indices were
at an accredited local laboratory. Tests for haemoglobin level
expressed in the form of z-scores; Height-for-Age Z-scores (HAZ),
(Hb), C-reactive protein (CRP), serum ferritin (SF) and soluble
Weight-for-Age Z-scores (WAZ) and BMI-for-Age Z-scores (BAZ).
transferrin receptor (s TfR) were conducted to assess anaemia and
Underweight was defined as below minus two standard deviations
iron status. The body iron assessment was based on the ratio of
(SD) from the median weight for age of the reference population,
sTfR to SF as defined by Cook et al. in the equation: body iron (mg/
while severe underweight was defined as below -3 SD from the
kg) = - [log10 (sTfR * 1000/SF) -2.8229)]/0.1207). The limits for
median weight-for-age of the reference population. A deficit in
the outcome measures were: (a) anaemia: Hb<11.5g/dl [13] (b)
height (stunting) was defined as below -2 SD from median height-
ID: body iron stores <0mg/kg [14]; and (c) inflammation: CRP≥5
for-age of the reference population and severe stunting as <-3 SD.
[15]. The children were categorized into five groups based on
A deficit in weight-for-height (wasting) was defined as less than -2
anaemia and iron status; iron deficiency anaemia (IDA) - anaemia
SD from the median weight for height, of the reference population,
and low body iron stores; non-iron deficiency anaemia (NIDA) -
while severe wasting was defined as < -3 SD [10]. BMI-for-Age
anaemia in the presence of inflammation in a child with normal
Z-scores >1 SD were categorized as overweight, >2 SD as obesity
body iron stores; iron deficient stores (IDS) - depleted iron stores
while children with BMI values in the range 0 - 1 SD were at risk of
in a non-anaemic child; mixed anaemia (MA) for participants with
becoming overweight [11].
anaemia in the presence of both iron deficiency and inflammation
Motor development was evaluated by a medical doctor who and non-anaemic non-iron deficient (NA) – where the child had
carried out a gross motor skills’ examination and a fine motor skills’ normal haemoglobin concentration and normal iron status. Stool
examination. Motor abilities were characterised into 3 groups: and urine samples were also collected and sent to a local academic
Locomotor, Body manipulation and Object control. Abilities were laboratory for microscopy and analysis for parasites.
recorded on a log with a pass or fail mark. Each individual’s overall
Statistical considerations: Data were entered daily into a
assessment was then categorised as normal, suspect or delayed.
predesigned electronic database using SPSS version 22 software
Dietary intake assessment package and cleaned regularly. The differentiation between
genders was conducted for anthropometric outcomes, because
Home diet: Two structured questionnaires were used to
of expected differences between boys and girls. Z-scores and
describe intake patterns and dietary diversity of food consumed
standard deviations (SD) were used as reference standards
at home; a non-quantified 24-hour-recall and a 7-day-recall.

How to cite this article: Thando PG, Meera KC, Claire JM, Myra T, Murray C. Anemia, Iron Deficiency and Diet Independently Influence Growth Patterns
002
of School Aged Children in South Africa. Acad J Ped Neonatol. 2016; 1(3): 555565.
 Academic Journal of Pediatrics & Neonatology

indicating deviation from the mean. WHO anthropometric tables Table 1: Descriptive statistics for child anthropometric indicators, n=184.
for adolescents aged 5-19 years were used to analyse growth HAZ WAZ BAZ
indicator data and to determine impairment of growth by assessing Mean ± SD -1.07 ± 1.03 -0.55 ± 1.03 -0.13 ± 0.96
the relationship of the Z-score to the mean. Dietary intake data
n below –2 SD,
were analysed by the principal investigator (TPG) and verified by 13/184 (7.1%) 3/184 (1.6%) 1/184 (0.5%)
(%)
a registered dietician. Nutrient intakes were reported as means (95% CI)
(4.2, 11.7) (0.6,4.7) (0.6, 4.7)
and SD. Frequencies were used to determine the percentage of
n below –3 SD, 1/184 (0.5%) 1/184 (0.5%) 1/184 (0.5%)
subjects with nutrient intakes < 100% of the dietary reference
(%) (95% CI) (0.1,3.0) (0.1, 3.0) (0.1, 3.0)
intakes. The Student’s t-test was performed to test the gender
difference in HAZ, WAZ and BAZ. Analysis of variance (ANOVA) HAZ: Height-for-Age Z-scores; WAZ: Weight-for-Age Z-scores; BAZ:
BMI-for-Age Z-scores
test was performed to assess the differences in mean values of
anthropometric indices by age. Correlation analysis (r) was also Motor skills
conducted to evaluate the strength of the relations between
A low prevalence of motor impairments was noted. One
variables such as anaemia prevalence by age and gender. Poisson
child was identified as having an abnormal gait which occurred
regression with robust standard error analyses was conducted to
during both walking and running (ICF b770). Poor control and
examine associations between anaemia and various covariates
coordination of voluntary movements (ICF b760) was identified
of interest, such as dietary diversity and growth characteristics.
in 7/184 (3.8%) of the sampled population. Fine motor evaluation
Results were reported as point estimates with 95% confidence
showed that 7/184 (3.8%) of sampled children experienced
intervals.
difficulties with fine motor hand use including the manipulation of
Results fingers and hands when handling small objects (ICF d4402). The
presence of anaemia was significantly associated with impaired
Population characteristics
fine motor skills (p=0.009). An iron deficient status was also
In total n=184 children participated in this study. The children significantly associated with impaired fine motor skills (p=0.023).
were aged 6.5 ± 0.55 years. More males participated 108/184 However, due to the small quantities of affected children with the
(58.7%) than females 76/184(41.3%). The difference in age outcome variables such as gross motor development, conclusions
between the boys and girls was not statistically significant. The could not be drawn concerning the relationship between motor
children were all asymptomatic for anaemia, iron deficiency or development and anaemia, diet and iron deficiency as this was
any ill-health, but 5/181 (2.8%) of the children tested positive for inadequate for drawing statistical conclusions.
HIV infection.
Dietary intake
Child growth
Dietary diversity had a significant association with stunting
Anthropometry as a main effect (r=0.185, p<0.05), and was associated with less
The mean BMI for boys was 16.0 ± 1.40kg/m2, for girls dietary diversity using the seven day recall.
16.45 ± 2.06kg/m2 and overall for the study population 16.21
Home diet: dietary diversity and eating patterns
± 1.71kg/m2. The overall prevalence for stunting was 14/184
(7.6%), underweight 4/184 (2.1%) and wasting 2/184 (1.1%). The children consumed mainly cereals. The consumption of
More boys 9/108 (8.3%) were stunted than girls 5/76 (6.6%) protein-rich foods both of plant and animal origin was low. Food
Severe stunting was observed in 1/184 (0.5%) boy and stunting items such as organ meat, legumes, nuts, seeds, fish and seafood
in 13/184 (7.1%) of which 5/76 (6.6%) were girls and 8/108 were consumed by less than 15% of the study group. Vegetables
(7.4%) boys. Underweight was observed in 2/108 (1.9%) boys were consumed more frequently than fruits. The consumption of
and 2/76 (2.6%) girls. Severe underweight for age was identified vitamin-A rich fruits and vegetables was much lower than that of
in a boy 1/184 (0.5%). Wasting results showed 1/184 (0.5%) non-vitamin-A-rich fruits and vegetables. Consumption of dark
boy who was severely wasted and 1/184 (0.5%) girl who was green leafy vegetables was low although 60% of the children had
wasted. Of note is that the same boy who was severely wasted this at least once in seven days.
was also severely stunted and severely underweight. This child The 24-hour dietary diversity score (DDS) was generally low
was HIV negative, non-anaemic, body iron stores were normal, with a maximum score of 7/9 food groups in 2/184 (1.1%), 95%CI
inflammatory markers were not elevated and had no parasitic (0.3, 3.9%) and a minimum of 1/9 food groups in 2/184 (1.1%)
infection detected. Conversely, 34/184 (18.5%) of these children 95% CI (0.3, 3.9%) children. The diversity scores were normally
had a high risk of becoming overweight. 4/184 (2.2%) children distributed with a mean score of 3.70 (SD 1.13). Feeding patterns
were overweight and 2/184 (1.1%) were obese - one girl and one for the seven-day recall were comparable to the 24-hour recall
boy. The majority of children 87/184 (90.7%) were of normal though higher food frequency scores were documented. The range
weight. (Table 1): Descriptive statistics for child anthropometric was wider with a minimum score of 1/9 food groups consumed
indicators, n=184. for 23/184 (12.5%), 95% CI (8.5, 18.1%) and a maximum 8/9

How to cite this article: Thando PG, Meera KC, Claire JM, Myra T, Murray C. Anemia, Iron Deficiency and Diet Independently Influence Growth Patterns
003
of School Aged Children in South Africa. Acad J Ped Neonatol. 2016; 1(3): 555565.
 Academic Journal of Pediatrics & Neonatology

food groups, for 7/184 (3.8%), 95% CI (1.9, 7.6%) children. A consumed by the child was generally high 80-100%. Second
higher mean score of 4.07 (SD 1.96) was observed over the seven- servings were infrequently observed 19/160 (11.9%) 95%
day recall period. (Table 2): Diversity in feeding practices. CI (7.7, 17.8%). The school menu guidelines were not strictly
followed though used as a guide, as some ingredients listed on
Table 2: Diversity in feeding practices.
the menu were missing. The food observed was rich in cereals
24 hours 7 days and tubers (100%), non-vitamin-A-rich vegetables 7/8 (87.5%)
FOOD GROUPS 95% CI (52.9, 97.8%), meat 5/8 (62.5%) 95% CI (30.6, 86.3%)
Mean SD Mean SD as well as legumes, nuts and seeds 4/8 (50.0%) 95% CI (21.5,
78.5%). No eggs, milk or milk products were observed at the time
Cereal, White roots and
1. 1.00 0.00 1.00 0.00 of the study in any of the schools. All schools assessed provided
tubers
Vitamin A rich vegetables and
meals during weekdays and not on weekends, school holidays or
2. 0.28 0.45 0.55 0.50 public holidays. No take-home rations were given to children in
fruit
the observed schools.
3. Other vegetables 0.76 0.43 0.60 0.49
Biochemical measurements: serum iron concentrations
4. Other fruits 0.03 0.18 0.12 0.33
The mean Hb level for this sample was 12.17 ± 1.2g/dl.
Anaemia was detected in 43/184 (23.4%) 95% CI (17.8, 30.0%)
5. Meat 0.66 0.47 0.52 0.50
children. The severity of anaemia was mostly mild 24/43 (55.8%)
6. Eggs 0.11 0.32 0.29 0.45
95% CI (38.9, 67.5%) and moderate 18/43 (41.9%) 95% CI (28.4,
56.7%), only 1/43 (2.3%) 95% CI (0.4, 12.1%) child had severe
7. Legumes, nuts and seeds 0.40 0.49 0.14 0.34 anaemia. Of the children sampled, 13/184(7.1%) 95% CI (4.2,
11.7%) had tissue iron depletion and of these 9/13 (69.2%)
8. Milk and milk products 0.17 0.38 0.39 0.49 95% CI (42.4, 87.3%) were anaemic. Stunting and underweight
were noted to be worse in children who were iron deficient and
9. Oils and fats 0.28 0.45 0.45 0.50 anaemic but was not statistically significant (p>0.05). Table 3 -
Relationship of mean anthropometric indicators with children’s
*Sweets 0.39 0.49 0.67 0.47 anaemia and iron status.

*Tea 0.36 0.48 0.75 0.43 Table 3: Relationship of mean anthropometric indicators with children’s
anaemia and iron status.
Most 91/184 (49.5%) 95% CI (42.3,56.6%) children had HAZ mean WAZ mean BAZ mean n (%)
a flexible meal plan and often missed meals, although 41/184 ± SD ± SD ± SD (95%CI)
(22.3%) 95% CI (16.9, 28.8%) ate three meals plus a snack, 7 (3.8%) (1.8,
IDA -1.57 ± 0.79 -0.71 ± 0.49 0 ± 0.58
28/184 (15.2%) 95% CI (10.8, 21.1%) had three meals without 7.6%)
snacks and 12/184 (6.5%) 95% CI (3.8, 11.1%) had two meals
34 (18.5%)
plus snacks. Of the children sampled 2/184 (1.1%) 95% CI (0.3, NIDA -1.15 ± 1.18 -0.62 ± 1.07 -0.09 ± 0.87
(13.5, 24.7%)
3.9%) had gone without food for at least 24 hours in the week
2 (1.1%) (0.3,
preceding the interview. Most children 168/184 (91.3%) 95% CI MA -2.0 ± 0.0 0.5 ± 0.71 1.50 ± 0.71
3.9%)
(86.2, 94.6%) ate the same food as that prepared for the rest of
the family. Only 94/184 (51.1%) 95% CI (43.9, 58.2%) caregivers 4 (2.2%) (0.8,
IDS -0.50 ± 1.29 -0.75 ± 0.96 -0.75 ± 0.5
5.5%)
acknowledged that their children ate food from a school feeding
scheme. Whether or not the children ate food at the school 137(74.5%)
NA -1.02 ± 1.0 -0.54 ± 1.04 -0.15 ± 0.99
(67.7,80.2%)
feeding scheme no differences were observed with stunting or the
presence of anaemia. IDA: Iron Deficiency Anaemia; NIDA – Non-Iron Deficiency Anaemia;
IDS: Iron- Deficiency Syndrome; NA: Non-Iron Deficient Non-Anaemic;
School meals MA: Anaemia With Iron Deficiency + Inflammation; HAZ: Height-For-
Age Z-Scores; WAZ: Weight-For-Age Z-Scores; BAZ: BMI-For-Age
There were 160 children from eight schools who participated
Z-Scores
in the school sub-survey. The schools generally selected children
to be fed in the program and did not feed all learners. The food HAZ values in children with NIDA ranged widely as did those
was served inside a classroom during break time and children for non-anaemic, non-iron deficient children (Figure 1). Moreover,
chose whether or not to come there. Serving sizes were mostly the prevalence of stunting was surprisingly high among non-
predetermined and did not vary according to children’s needs, anaemic non-iron deficient children (NA). Despite the trends
age or size. A uniform serving potion was used, usually a large noted, the iron status of the children did not indicate any significant
dishing spoon 3/8 (37.5%) or a cup 5/8 (62.5%). The proportion associations with growth status. A significant relationship was
however noted between low dietary diversity from the seven day

How to cite this article: Thando PG, Meera KC, Claire JM, Myra T, Murray C. Anemia, Iron Deficiency and Diet Independently Influence Growth Patterns
004
of School Aged Children in South Africa. Acad J Ped Neonatol. 2016; 1(3): 555565.
 Academic Journal of Pediatrics & Neonatology

recall and anaemia (p=0.004) Figure 1 - Distribution of height-for-

age in different anaemia and iron status groups.

Figure 2: Study profile of children with parasite infestation and

growth impairment.

Multivariate analysis - anaemia association

The presence of anaemia was significantly more likely to
Figure 1: Distribution of height-for-age in different anaemia and be associated with iron deficiency (RRR<0.005 [0.968, 2.584])
iron status groups.
and the presence of inflammation/infection (RRR< 0.05 [-0.04,-
0.003]) than with biological, dietary and nutrition indicators such
Parasitic infection as worm presence (RRR>0.05 [-0.81, 0.92]), poor dietary diversity
Samples of urine and stool were collected from 181/184 (RRR>0.05 [-0.51, 1.02]) or growth stunting (RRR>0.05 [-1.59,
(98.4%) children. Positive microscopy findings were identified 1.31]).
in 49/181 (27.1%) 95% CI (21.1, 34.0%) of children although Discussion
pathologic infections were present in 32/181 (17.7%) 95%
This study provided supplementary evidence of a relationship
CI (12.8, 23.9%). The pathologic organisms identified were
between the growth indices and anaemia, diet and iron deficiency.
presented in (Table 1). None of the sampled children had Taenia or
The children’s growth patterns were affected by the levels
Entamoeba histolyticainfection. Stunted growth was significantly
of nutritional risk in the sampled population. The children’s
associated with parasitic infection (p=0.01) Figure 2 and anaemia
growth in the presence of anaemia and iron deficiency varied
(p=0.03). Table 4- Parasitic prevalence and the association with
independently of the dietary diversity. The small numbers of
anaemia and stunting. Figure 2- Study profile of children with
children identified with some of the outcome variables however
parasite infestation and growth impairment.
meant that conclusions on motor development could not be
Table 4: Parasitic prevalence and the association with anaemia and drawn.
stunting.
This current study identified high rates of stunting among
Positive the sampled children. The stunting rates were similar to, though
Parasite Anaemia Stunting
microscopy lower than stunting rates reported in other findings for South
4/11 (36.4%)
African children of the same age group. Anaemia was significantly
1/11(9.1%)
11/181 associated with low dietary diversity as well as stunting and
Ascarislumbricoides 95% CI (15.2, 95% CI (1.6,
(6.1%)
64.6%) 37.7%) underweight. Dietary diversity was significantly associated with
stunting. This study did not any observe significant differences in
2/181 growth or dietary diversity for children with IDA and those with
Enterobiusvermicularis 0 No difference
(1.1%)
NIDA. The motivation for this study was the high mortality globally,
1/3 (33.3%) attributed to under-nutrition. According to the 2013 report by
Schistosoma 3/181 the Maternal and Child Nutrition study group, under-nutrition
95% CI (6.2, No difference
haematobium (1.7%)
79.2%) accounted for 45.0% of children’s deaths which was equivalent
7/18 to more than three million deaths annually. An estimated 165
1/18 (5.5%)
Giardia lamblia
18/181 (38.9%) 95% million children had stunted growth resulting in compromised
(9.9%) 95% CI (1.0, CI (20.3,
26.9%) intellectual and physical development [16].
61.4%)
2/7 (28.6%) Growth indicators
8/181
Entamoeba coli 95% CI (8.2, No difference Anthropometric findings from this study were compared to
(4.4%)
64.1%) outcomes from the South African National Health and Nutrition

How to cite this article: Thando PG, Meera KC, Claire JM, Myra T, Murray C. Anemia, Iron Deficiency and Diet Independently Influence Growth Patterns
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of School Aged Children in South Africa. Acad J Ped Neonatol. 2016; 1(3): 555565.
 Academic Journal of Pediatrics & Neonatology

Examination Survey-one (SANHANES-1), six to nine year-old KZN [24]. Subsequently, poorer households spend more money
children [3]. Anthropometric indicators for children in this on staple foods, mainly maize meal and less on costly fruits and
study were similar though marginally lower when compared vegetables [24]. A major concern about this population’s diet
to the national estimates for children of the same age. Stunting was the low intake of fruits and vegetables (Table 2). In the
prevalence, boys (8.3%) and girls (6.6%) were lower than the week reviewed, more than 40.0% did not consume any fruits or
national rates of 10.0% for boys and 8.7% for girls of the same age. vegetables. Additionally, the dietary diversity scores as well as the
Wasting (1.0%) and underweight (2.1%) were also lower than the school dietary data collected suggest a low dietary intake of iron-
national prevalence of 2.4% and 9.4% respectively. For boys in this rich foods from plant and animal sources. While inaccurate recall
study, the mean weight (23.6kg) and height (118.3cm) was lower and underreporting are factors, it is unlikely to explain this trend.
than the national mean for six to nine year old boys of 24.4kg, Lack of knowledge and poor food choices, inadequate storage
123.2cm respectively. The mean BMI for boys was comparable, facilities and far distances in rural areas are also considerations.
being 16.0kg/m2 in this study and 15.9kg/m2 nationally. These In some food insecure families though, as food becomes scarcer,
differences were similar to findings for girls where the mean more dire measures are taken, such as the omitting of meals. A
weight (23.2kg) and height (118.3cm) were also lower than the 2008 survey confirmed that 25.1% of children’s meals were cut,
national mean for six to nine year old girls of 25.4kg and 123.9cm while 16.2% of children went to bed hungry [18]. In this study
respectively. Girls’ mean BMI for this study was 16.45kg/m2 2/184 (1.1%) children had gone without food for at least 24 hours
while the national estimate was 16.40kg/m2. The difference in the preceding week.
between genders has been observed in other comparable studies, Poor eating practices raise the risk of micronutrient
reporting stunting for boys (19.1%) and girls (7.5%) [17]. Growth deficiencies. Promotions to encourage subsistence farming may
impairment was more prevalent in males than females. enable increased consumption of fruits, vegetables and animal-
The trends in under-nutrition in this study are in accordance source food [26,27]. This study area was rural and had very
with those observed in previous national surveys that consistently low levels of subsistence farming [24]. In South African a staple
identified stunting as the most prevalent form of under-nutrition; food fortification program has also been implemented to help
followed, to a lesser extent by underweight and wasting [3,18- reduce the threat of micronutrient deficits in the population [28].
21]. While it is encouraging that there is an overall decline in However, it has been argued that the continued, albeit reduced
stunting, our results show little difference from a 2001 study of prevalence of stunting may indicate that the food fortification
eight to ten year olds, also in rural KwaZulu-Natal, that reported a initiative has had little influence on dietary diversity [18].
7.3% prevalence of stunting [22]. Apart from infections, stunting The National School Nutrition Program (NSNP) is a further
and under-nutrition are issues of chronic poor feeding practices public health initiative to address food insecurity and relieve
[23] and poor food accessibility [18]. This study provided insights short term hunger [25]. In this study, only 51.1% of the children
into both these factors through measures of dietary diversity and ate food provided by the school feeding scheme. Encouragingly,
eating habits. some researchers have shown improvements in dietary intake
Dietary diversity and diversity [25], though there have also been some reports
of challenges at some schools [29]. Likewise, in this study, the
The seven-day DDS was higher than the 24-hour DDS,
challenges that schools faced were mostly regarding limited food
highlighting the importance of multiple assessments versus a
supply and restricted availability of prescribed menu foods. Few
single day recall, in order to account for day to day variability.
schools had an adequate food variety score. A previous report
Nevertheless, the mean seven-day dietary diversity was still low
also highlights that the NSNP aims to improve long term feeding
(4.07 ± 1.96), although somewhat higher than that of the 1999
practices through nutrition education in schools [25]. This is
National Food Consumption Survey (NFCS) of children aged
targeted at improving long-term dietary habits by improving food
one to eight years who had a mean DDS of 3.58 ± 1.37 [18]. In
choices and combating negative eating practices such as high
the NFCS, the DDS was related to stunting, underweight and
intakes of sweets and missing of meals seen in this study.
wasting, whereas in this present study a significant association
was only identified between dietary diversity (seven-day recall) Anaemia and iron status
and stunting. A similar finding was reported by an 11-country The results of this study show that anaemia remains a common
demographic survey [24]. problem in school-aged children (23.4%). Iron deficiency was
Dietary diversity is an indication of food accessibility, identified in 7.1% of the sampled children and was a significant
providing a perspective on food security of the child’s household contributor to the prevalence of anaemia. These iron status
[18]. National food surveys revealed an overall trend of improved findings were comparable to the 2012 SANHANES-1 survey
food security from 1999 to 2008. However, food insecurity and where the national prevalence for iron deficiency was 8.1% [3].
hunger still prevail, with rural households being at a higher risk The high anaemia prevalence reported in this study was however
[18, 25]. Recently it was shown that 17.0% of SA households have in contrast to the SANHANES-1 report which showed a declining
restricted food access with a greater number (20.9%) affected in trend in anaemia (10.5%) for children aged up to 14 years.

How to cite this article: Thando PG, Meera KC, Claire JM, Myra T, Murray C. Anemia, Iron Deficiency and Diet Independently Influence Growth Patterns
006
of School Aged Children in South Africa. Acad J Ped Neonatol. 2016; 1(3): 555565.
 Academic Journal of Pediatrics & Neonatology

Two studies conducted in Kwazulu-Natal reported an anaemia 6. Lozoff B, Jimenez E, Hagen J, Mollen E, Wolf AW (2000) Poorer
prevalence of 16.5% and 22.0% in school age children [30,31]. The Behavioural and Developmental Outcome More Than 10 Years after
Treatment for Iron Deficiency in Infancy. Paediatrics 105: E51.
persistently high anaemia prevalence in this study population may
be attributed to anaemia of inflammation resulting from chronic 7. Davidson LL, Kauchali S, Chhagan M, Kvalsvig J, Arpadi S, et al. (2015)
The A sense Study of Neuro-disability in Preschool Children in
poorly managed infections. KwaZulu-Natal, South Africa. SONA Meeting, Durban, South Africa.
Limitation 8. WHO (1995) Physical Status: The Use and Interpretation of
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This investigation had a cross-sectional study design hence Ser 854: 1-452.
trends over time and the temporal sequence between exposure
9. WHO (1976) WHO technical report series 53. WHO, Geneva.
(anaemia, iron deficiency and dietary diversity) and outcome
(growth) could not be evaluated. Hence the cause-effect 10. WHO (2006) Child Growth Standards: Length/Height-for-Age, Weight-
for-Age, Weight-for-Length, Weight-for-Height, and Body Mass Index-
relationship could not be determined. This cross-sectional study for-Age: Methods and Development. Geneva.
measured prevalence and not incidence which could result in
11. WHO (2007) Growth reference data for 5-19 years.
prevalence-incidence bias as long-standing cases of anaemia and
dietary insufficiency may have been over-represented while short- 12. Steyn NP, Maunder EMW, Labadarios D, Nel JH (2006) Food variety and
dietary diversity scores in children: Are they good indicators of dietary
lived cases may be under-represented. Current exposure and adequacy? Publ Health Nutr 9(5): 644-650.
outcome were measured simultaneously; hence recent changes to
13. WHO (2011) Haemoglobin Concentrations for the Diagnosis of
the anaemia status or dietary pattern in growth impaired children Anaemia and Assessment of Severity. Vitamin and Mineral Nutrition
were overlooked. The proportion of children no longer affected Information System. WHO, Geneva.
by growth impairment, anaemia or iron deficiency could not be 14. Cook JD, Flowers CH, Skikne BS (2003) The Quantitative Assessment of
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Responses to Inflammation. N Engl J Med 340(6): 448-454.
The overall findings from this study provide evidence of the
16. Maternal and Child Nutrition Study Group (2013) Maternal and child
benefits of a diverse overall diet and suggest the improvements nutrition: building momentum for impact.
required to enhance the children’s growth pattern. Interventions
17. Oldewage-Theron W, Napier C, Egal A (2011) Dietary fat intake and
providing dietary support and iron supplementation need to nutritional status indicators of primary school children in a low-income
be complemented with attempts to improve the general health informal settlement in the Vaal region S Afr J ClinNutr 24(2): 99-104.
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interventions and policies which target individual, community, (2011) Food security in South Africa: a review of national surveys. Bull
and national levels are needed. These may comprise providing WHO 89(12): 891-899.
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feeding programs and providing behavioural modification
South African Vitamin A Consultative Group (SAVACG) 335.
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20. Labadarios D, Swart R, Maunder EMW, Kruger HS, Gericke GJ, et al.
the local cultural practices and financial restrictions. Community
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with secondary prevention by screening and providing treatment
21. Labadarios D, Steyn N, Maunder E, MacIntyre U, Swart R, et al. (2000)
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How to cite this article: Thando PG, Meera KC, Claire JM, Myra T, Murray C. Anemia, Iron Deficiency and Diet Independently Influence Growth Patterns
007
of School Aged Children in South Africa. Acad J Ped Neonatol. 2016; 1(3): 555565.
 Academic Journal of Pediatrics & Neonatology

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How to cite this article: Thando PG, Meera KC, Claire JM, Myra T, Murray C. Anemia, Iron Deficiency and Diet Independently Influence Growth Patterns
008
of School Aged Children in South Africa. Acad J Ped Neonatol. 2016; 1(3): 555565.