Comment: Childhood nutrition and social support

Abstract

The three papers discussed all deal with aspects of the causation of undernutrition in the Agincourt sub-district. Previous work has highlighted kwashiorkor as an important cause of under-5-year-old mortality [1] in a region that has relatively low infant and under-5 mortality rates when compared with other regions in sub-Saharan Africa. In a casecontrol study, Saloojee and colleagues [2] found that many of the usually accepted factors contributing to severe malnutrition in rural communities were also responsible in Agincourt, namely poor weaning practices and higher birth order, as well as HIV. Diversity of food intake and the family being a recipient of a state child support grant proved protective. Of interest is the finding of a high prevalence of stunting (45%) in the control group of children, which is far higher than that found in a national survey (,20%) [3], but similar to that found in another region of Limpopo Province [4]. It is possible that the prevalence found in the Agincourt study does not reflect the actual prevalence in the region as the control children lived in the same villages as the malnourished study children – thus they may not reflect children living throughout the area – but we have no other information on nutritional status among children from this setting. It is clear that child-support grants do make a significant difference to the lives of families living in impoverished circumstances and these, together with pensions that are available to many of the grandparents of children, are often the only income that families in rural areas have to purchase food and other essentials. Despite the importance of these grants to families, Twine and co-researchers [5] document that barriers prevent the poorest families from gaining optimal access (only a third of South African families living in Agincourt in the lowest socioeconomic stratum had applied), while it is the less impoverished families who make better use of such grants. The most important barriers to obtaining grants include the lack of necessary documentation (such as identity documents), the distance to service offices (which reflects the lack of money for transportation), and the educational level of the household head. The study by Madhavan and Townsend [6] deals with the social interactions within and between families that might prevent or contribute to the development of undernutrition in children (v22 years of age). Not surprisingly, undernutrition is associated with the lack of the mother within the house either through death or non-co-residence, and with the lack of financial support from the father. None of the findings from these studies should surprise health workers who have spent time in the impoverished rural areas of South Africa. Subsistence farming, which in many countries provides at least a minimum nutrient intake for members of poor families, occurs to a very limited extent due to the lack of agricultural land and regular and reliable rains. Poor unemployed families in many parts of South Africa depend on food or money being remitted on an irregular basis – by family members often working hundreds of kilometres away – in order to survive. It is clear that the small but regular income derived from the government social security programme is of considerable benefit to poor families in the region but efforts are needed to improve access to these grants. Several questions remain unanswered: what is the true prevalence of undernutrition (and obesity) among the childhood population in the area; what are the most feasible and practical methods with