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Background: Several studies have shown that South Africans consume a diet low in variety.Objective: To explore the barriers and enablers for consuming a diverse diet in resource-poor communities around Cape Town.Design: A qualitative study design was used. Data were collected from focus-group discussions (FGDs) conducted in Afrikaans, IsiXhosa, and English, using a semi-structured guide.Setting: Twelve community sites in Cape Town, South Africa.Subjects: Study participants were 24 Black and 21 Mixed-ancestry women (n = 45) with a mean age of 49.7 ± 7.8 years.Results: Fourteen FGDs were conducted with an average of three participants per FGD. Six themes were identified from the FGDs, which included nutrition knowledge, perceptions of dietary diversity and its impact on health, individual factors, and social, physical environment, and societal influences on food choices. Perceived barriers to consuming a diverse diet included financial constraints, high food prices, and family taste preferences. Perceived enablers identified were individual taste preferences, access to food stores, community food aid, and food-store specials. Proposed facilitators to achieving a diverse diet included budgeting, income-generation activities, lowering food prices, and increasing community food aid.Conclusions: The findings of this study suggest that financial constraints, high food prices, and social factors limit the ability of women from resource-poor communities to consume a diverse diet and make healthy food choices. Public health interventions aimed at promoting healthier food choices and reducing diet-related diseases should address financial barriers and the cost of food.

Abstract We investigated the incidence and duration of morbidity symptoms among infants aged 6 to 9 months from a low socioeconomic community receiving one egg daily for 6 months. This was a secondary outcome of a randomised controlled trial (RCT) of 500 infants conducted in Jouberton, South Africa. The primary outcome was linear growth. Morbidity data were collected weekly using a symptoms diary and qualitative data with focus group discussions at the endpoint. Ethical approval was obtained from the North-West University Health Research Ethics Committee. The intervention group had a ~ 5% higher incidence of gastrointestinal morbidity (17.0%) compared to the control group (11.9%). Gastrointestinal morbidity without fever tended to be 1.4 times higher in the intervention group (OR: 1.43, 95% CI: 1.03, 1.93; P = 0.058) and tended to be 4 times higher with fever (OR: 4.07, 95% CI: 0.86, 19.23; P = 0.077). The duration of total gastrointestinal and respiratory morbidity was 1.5 days longer in the intervention group (β: 1.491; 95% CI 0.064, 2.918; P = 0.041). Complementary feeding with eggs may have contributed towards an increased risk for gastrointestinal morbidity.

Abstract Objective: To conduct a comprehensive systematic review and meta-analysis of the available literature on the anthropometric nutritional status of South African infants and children, 0–18 years old and to report on trends of changes in nutritional status over the period 1997–2022. Design: Systematic review and meta-analysis. Setting: Review of the available literature on the anthropometric nutritional status of South African infants and children, 0–18 years old, over the period 1997–2022. Participants: South African infants and children, 0–18 years old. Results: Only quantitative data from ninety-five publications that described the nutritional status in terms of anthropometry were included. Most recent studies applied the WHO 2006 and 2007 definitions for malnutrition among children 0–5 years old and 5–19 years old, respectively. Meta-analysis of all prevalence data shows the highest stunting prevalence of 25·1 % among infants and preschool children, compared to 11·3 % among primary school-age children and 9·6 % among adolescents. Furthermore, the overweight and obesity prevalence was similar among children younger than 6 years and adolescents (19 %), compared to 12·5 % among primary school-age children. In national surveys, adolescent overweight prevalence increased from 16·9 % in 2002 to 23·1 % in 2011. Meta-regression analysis shows a decrease in stunting among children 6–18 years old and an increase in combined overweight and obesity in the 10–19 years age group. Conclusion: The double burden of malnutrition remains evident in South Africa with stunting and overweight/obesity the most prevalent forms of malnutrition among children.

Abstract Background There is a growing body of research on local retail food environments globally in both urban and rural settings. Despite this, little research has been conducted on adult food choices, local retail environments, and healthy food access in resource-poor communities. The purpose of this study is therefore to provide an overview of the evidence on adult food choices (measured as dietary intake) in association with the local retail food environment and food access in resource-poor communities (defined as low-income communities and/or households). Methods We searched nine databases for studies published from July 2005 to March 2022 and identified 2426 records in the primary and updated search. Observational studies, empirical and theoretical studies, focused on adults ≤ 65 years, published in English peer-reviewed journals, examining local retail food environments and food access, were included. Two independent reviewers screened identified articles using the selection criteria and data extraction form. Study characteristics and findings were summarized for all studies and relevant themes summarized for qualitative and mixed methods studies. Results A total of 47 studies were included in this review. Most studies were cross sectional (93.6%) and conducted in the United States of America (70%). Nineteen (40.4%) studies assessed the association between food choice outcomes and local retail food environment exposures, and evidence on these associations are inconclusive. Associations of certain food choice outcomes with healthy food retail environments were positive for healthy foods (in 11 studies) and unhealthy foods (in 3 studies). Associations of certain food choice outcomes with unhealthy retail food environment exposures were positive for unhealthy foods in 1 study and negative for healthy foods in 3 studies. In 9 studies, some of the food choice outcomes were not associated with retail food environment exposures. A healthy food store type and lower food prices were found to be major facilitators for healthy food access in resource-poor communities, while cost and transportation were the main barriers. Conclusions More research is needed on the local retail food environment in communities in low- and middle-income countries to develop better interventions to improve food choices and access to healthy foods in resource-poor communities.

Abstract Objective: To assess the effect of daily egg consumption for six months on linear growth (primary outcome), weight-for-age, weight-for-length, mid-upper arm circumference-for-age, head circumference-for-age Z-scores, gross motor milestones development, anaemia and iron status (secondary outcomes) in a low socioeconomic community. Participants: Infants aged 6 to 9 months living in the peri-urban Jouberton area, in the Matlosana Municipality, South Africa. Design: A randomised controlled trial with a parallel design was implemented. Eligible infants were randomly allocated to the intervention (n 250) receiving one egg/day and the control group (n 250) receiving no intervention. The participants were visited weekly to monitor morbidity and gross motor development, with information on adherence collected for the intervention group. Trained assessors took anthropometric measurements, and a blood sample was collected to assess anaemia and iron status. There was blinding of the anthropometric assessors to the groups during measurements and the statistician during the analysis. Results: Baseline prevalence of stunting, underweight, wasting, overweight and anaemia was 23·8 %, 9·8 %, 1·2 %, 13·8 % and 29·2 %, respectively, and did not differ between groups. Overall, 230 and 216 participants in the intervention and control groups completed the study, respectively. There was no intervention effect on length-for-age, weight-for-age, weight-for-length Z-scores, gross motor milestone development, anaemia and iron status. Conclusions: Daily egg intake did not affect linear growth, underweight, wasting, motor milestones development, anaemia and iron status. Other interventions are necessary to understand the effect of animal-source food intake on children’s growth and development. This trial was registered at https://clinicaltrials.gov/ (NCT05168085).

Abstract Objective: To conduct a systematic review of the published peer-reviewed articles on the biochemical assessment of nutritional status of South African infants, children and adolescents in 1997–2022. Design: Online databases (Pubmed, CINAHL, EbscoHost and SAePublications) were used to identify thirty-nine papers. Setting: South Africa, 1997–2022. Participants: Infants, children and adolescents. Results: Vitamin A deficiency prevalence was 35–67 % before 2001 and mostly below 16 % after 2008. Anaemia ranged from 5·4 to 75·0 %, with 36–54 % of infants below 1 year being anaemic. Among 0- to 6-year-olds, iron deficiency (ID) was 7·2–39·4 % in rural and 16–41·9 % in urban areas. Zn deficiency remained high, especially among 0- to 6-year-olds, at 39–48 %. Iodine insufficiency (UIC < 100 µg/l) was between 0 and 28·8 %, with excessive levels in two areas. Vitamin D deficiency was 5 % for 11- to 17-year-olds in one urban study but 33–87 % in under 10-week-old infants. The 2005 national survey reported sufficient folate status among 0- to 6-year-olds, and vitamin B12 deficiency was 0–21 %. Low-grade inflammation was between 5 % and 42 % depending on the biomarker and cut-offs. Conclusions: Vitamin A status may have improved meaningfully during the last 25 years in South Africa to below 16 %, and iodine and folate deficiency appears to be low particularly among 0- to 6-year-olds. However, confirmation is needed by a national survey. Anaemia, Fe and Zn deficiencies still pose severe problems, especially among 0- to 6-year-olds. Sufficient data on vitamin D and B12 status are lacking.

Abstract This study aimed to investigate the association between maternal postpartum depressive symptoms, household demographic, socioeconomic, and infant characteristics with infant physical growth, and how these factors correlate to determine latent factors. This study was based on the baseline data of a 6-month randomised controlled trial aimed at providing an egg a day to infants aged 6 to 9-months from a low socioeconomic community in South Africa. Information collected on household demographic, socioeconomic, and infant characteristics was by face-to-face structured interviews, and trained assessors took anthropometric measurements. The Edinburgh Postnatal Depression Scale (EPDS) was used to assess maternal postpartum depressive symptoms. The analysis was based on 428 mother-infant pairs. Total EPDS score and its subscales score were not associated with stunting or underweight risk. However, a three- to four-fold increased risk of stunting and underweight, respectively was observed for premature birth. Low birthweight was associated with an estimated six-fold increased risk of underweight and stunting. Being female was associated with about 50% reduced risk of stunting and underweight. In conclusion, more robust studies are needed to substantiate these findings, with more awareness creation on the consequences of LBW and prematurity on the physical growth of infants from resource-limited settings.

Abstract Background Recommended breastfeeding practices contribute to improved health of infants, young children, and mothers. Access to comprehensive maternity protection would enable working women to breastfeed for longer. Women working in positions of non-standard employment are particularly vulnerable to not accessing maternity protection entitlements. The objective of this scoping review was to determine the current research conducted on maternity protection available and accessible to non-standard workers in low-and-middle-income countries and any potential implications for breastfeeding practices. Methods Nine databases were searched using search terms related to maternity protection, non-standard employment, and breastfeeding. Documents in English published between January 2000 and May 2021 were included. The approach recommended by the Joanna Briggs Institute was used to select sources, extract, and present data. The types of participants included in the research were female non-standard workers of child-bearing age. The core concept examined by the scoping review was the availability and access to comprehensive maternity protection entitlements of pregnant and breastfeeding women. Research from low-and-middle-income countries was included. The types of evidence sources were limited to primary research. Results Seventeen articles were included for data extraction mainly from research conducted in Africa and Asia. Research on maternity protection for non-standard workers mostly focused on childcare. Components of maternity protection are inconsistently available and often inaccessible to women working in non-standard employment. Inaccessibility of maternity protection was described to disrupt breastfeeding both directly and indirectly, but certain characteristics of non-standard work were found to be supportive of breastfeeding. Conclusions Published information on maternity protection for non-standard workers is limited. However, the available information indicates that non-standard workers have inadequate and inconsistent access to maternity protection rights. The expansion of comprehensive maternity protection to all women working in positions of non-standard employment could encourage significant social and economic benefits.

Objective: A study was undertaken to determine the energy and nutrient contribution of different food groups to the dietary intake of 6- to

Abstract Background Many women work in positions of non-standard employment, with limited legal and social protection. Access to comprehensive maternity protection for all working women could ensure that all women and children can access health and social protection. This study aimed to describe the maternity protection benefits available to women in positions of non-standard employment in South Africa, using domestic workers as a case study. Methods A qualitative descriptive study design was used. National policy documents containing provisions on maternity protection were identified and analysed. Interviews were conducted with purposively selected key informants. Data extracted from published policy documents and information obtained from interviews were triangulated. A thematic analysis approach was used for evaluation of policy content and analysis of the interviews. Results Twenty-nine policy and legislative documents were identified that contain provisions on maternity protection relevant to non-standard workers. These documents together with three key informant interviews and two media releases are used to describe availability and accessibility of maternity protection benefits for non-standard workers in South Africa, using domestic workers as a case study. Maternity protection is available in South Africa for some non-standard workers. However, the components of maternity protection are dispersed through many policy documents and there is weak alignment within government on maternity protection. Implementation, monitoring, and enforcement of existing maternity protection policy is inadequate. It is difficult for non-standard workers to access maternity protection benefits, particularly cash payments. Some non-standard workers have unique challenges in accessing maternity protection, for example domestic workers whose place of work is a private household and therefore difficult to monitor. Conclusion The heterogeneity of non-standard employment makes it challenging for many women to access maternity protection. There are policy amendments that could be made and improvements to policy implementation that would enhance non-standard workers’ access to maternity protection. Potential long-term benefits to women and children’s health and development could come from making comprehensive maternity protection available and accessible to all women.

Objectives: A study was undertaken to determine whether benefits gained by providing small-quantity lipid-based nutrient supplements (SQ-LNS) from age 6–12 months were maintained at age 18 months compared with a delayed intervention. Design: Children who completed a randomised controlled trial were enrolled at age 12 months (n = 392) and followed-up until age 18 months (n = 252; dropout rate 35.7%). Two previously exposed (PE and PE-plus) groups (received SQ-LNS from 6–12 months, but no supplement from 12–18 months) were compared with the delayed intervention (DI) group (received no supplement from 6–12 months, but received SQ-LNS from 12–18 months). Methods and outcome measures: At age 12 and 18 months, weight, length, haemoglobin (Hb) and psychomotor development were measured. Setting: The study was carried out in peri-urban Jouberton area, Klerksdorp, South Africa. Subjects: Children aged 12–18 months. Results: Compared with DI, negative effects (either a trend or statistically significant) were observed for PE and PE-plus for length-for-age Z-scores (LAZ) (p = 0.091 and p = 0.075, respectively), PE-plus for weight-for-age Z-scores (WAZ) (p = 0.027), and PE and PE-plus for Hb (p = 0.080 and p = 0.033, respectively); and a positive effect for PE-plus for eye–hand coordination (p = 0.086). The odds for anaemia were higher for PE-plus compared with DI (OR = 1.68; 95% CI 0.91, 3.09). Regardless of group, prevalence of anaemia and stunting increased from age 12 to age 18 months. Conclusions Benefits of providing SQ-LNS from age 6–12 months were not sustained at age 18 months, compared with providing SQ-LNS from age 12–18 months. Studies to determine the optimum supplementary period to achieve sustainable benefits of SQ-LNS on linear growth and iron status are warranted.

Abstract Background Studies have investigated dietary attributes associated with cardiovascular disease (CVD) risk in Africa. However, there has been no effort to critically assess the existing evidence. This systematic review examined available evidence on the association between plant-based dietary exposures and CVD risk profile in Africa. PROSPERO registration number: CRD42020159862. Methods We conducted a literature search for observational studies reporting on plant-based dietary exposures in relation to CVD risk profile in African populations. PubMed-Medline, Scopus, EBSCOhost, and African Journals Online platforms were searched up to 19 March 2021. Titles and abstracts of the identified records were screened independently by two investigators. The quality of the studies was also assessed independently. Results Of 458 entries identified, 15 studies published between 2002 and 2020 were included in this review. These studies originated from 12 sub-Saharan Africa (SSA) countries. Sample sizes ranged from 110 to 2362, age from 18 to 80 years; and majority of participants were females (66.0%). In all, four plant-based dietary exposures were identified across SSA. Sixty percent of the studies reported a significant association between a plant-based dietary exposure with at least one CVD risk factor such as hypertension, diabetes mellitus, dyslipidaemia, overweight/obesity, and metabolic syndrome. Conclusions The few available studies suggest that there may be a protective effect of plant-based dietary exposures on CVD risk profile in the African setting. Nonetheless, more elaborated studies are still needed to address plant-based diet (PBD) adherence in relation with CVD risk in African populations.

Food-based dietary guidelines promote consumption of a variety of nutritious foods for optimal health and prevention of chronic disease. However, adherence to these guidelines is challenging because of high food costs. The present study aimed to determine the nutrient density of foods relative to cost in South Africa, with the aim to identify foods within food groups with the best nutritional value per cost. A checklist of 116 food items was developed to record the type, unit, brand and cost of foods. Food prices were obtained from the websites of three national supermarkets and the average cost per 100 g edible portion was used to calculate cost per 100 kcal (418 kJ) for each food item. Nutrient content of the food items was obtained from the South African Food Composition Tables. Nutrient density was calculated using the Nutrient Rich Food (NRF9.3) Index. Nutrient density relative to cost was calculated as NRF9.3/price per 100 kcal. Vegetables and fruits had the highest NRF9.3 score and cost per 100 kcal. Overall, pulses had the highest nutritional value per cost. Fortified maizemeal porridge and bread had the best nutritional value per cost within the starchy food group. Foods with the least nutritional value per cost were fats, oils, foods high in fat and sugar, and foods and drinks high in sugar. Analysis of nutrient density and cost of foods can be used to develop tools to guide low-income consumers to make healthier food choices by identifying foods with the best nutritional value per cost.

Maternity protection enables women to combine reproductive and productive roles. Domestic workers are a vulnerable group due to heterogeneous non-standard employment relationships and are unlikely to have access to comprehensive maternity protection. This study aimed to explore the knowledge, understanding and perceptions of key stakeholders in government, trade unions, non-governmental organisations and other relevant organisations of the maternity protection entitlements that should be available and accessible to female domestic workers in South Africa. This qualitative cross-sectional study included in-depth interviews with fifteen stakeholders working in different sectors in South Africa and mainly at a national level involved in maternity protection availability and access. Results show that stakeholders appear to have limited understanding of comprehensive maternity protection. Many challenges related to accessing cash payments while on maternity leave were described and suggestions were provided for how this could be improved. Participants described how certain labour-related characteristics unique to the domestic work sector were barriers in accessing maternity protection. Ensuring greater awareness of all components of maternity protection and improving implementation of existing labour legislation intended to guarantee maternity protection for non-standard workers in South Africa is important to improve access to maternity protection for this vulnerable group. Improved access to maternity protection would contribute to optimal maternal and new-born health and ensure economic security for women around the time of childbirth.

Undernourishment, low food quantity and poor dietary quality are common among smallholders in rural communities of Uganda. A cross-sectional study of rural smallholder farming households (n = 174) with children under five in Kiboga district, Uganda used a structured questionnaire to assess household food security status, frequency of household food consumption, and dietary diversity for children. Children's height and weight measurements were taken, and Z-scores calculated as indicators for nutritional status. Household typologies were created using principal component analysis. Households had adequate food supply for 7.6 ± 0.2 months a year; and a total of 35% were food secure. Over 7 days, starchy staples and legumes were consumed by all households; other food groups consumed were dark green leafy vegetables (43%), orange and dark-yellow foods (72%), and animal source foods (53%–60%). Roots, tubers, cooking bananas; vitamin A-rich vegetables, and legumes were sourced mainly from on-farm production, while animal source foods were mainly from the market. 76% of children consumed ≤3 food groups the previous day and 33% were stunted. Four household typologies were generated, 1st (29% households) and 2nd (23%) had more food secure households, 3rd (28%) had mild food insecurity and 4th (20%) had severe food insecurity. The 3rd and 4th typologies had the lowest dietary diversity. In summary, limited diversity of crops grown, low consumption of micronutrient-rich foods, child stunting, and household food insecurity were observed, while own production and markets were the main sources of food. The four household typologies can be used to develop context specific strategies to improve dietary diversity.

Abstract Background High rates of food insecurity, obesity and obesity-related comorbidities in ageing South African (SA) women may amplify the risk of developing sarcopenic obesity. This study aimed to investigate the prevalence and correlates of sarcopenic obesity and its diagnostic components [grip strength, appendicular skeletal muscle mass (ASM) and body mass index (BMI)] in older SA women from a low-income setting. Methods This cross-sectional study recruited black SA women between the ages of 60–85 years (n = 122) from a low-income community. Testing included a fasting blood sample (markers of cardiometabolic risk, HIV), whole body and regional muscle and fat mass (dual-energy absorptiometry x-ray), anthropometry, blood pressure, functional movement tests, current medication use, demographic and health questionnaires, physical activity (PA; accelerometery), household food insecurity access scale, and a one-week quantified food frequency questionnaire. Foundation for the National Institutes of Health (FNIH) criteria (grip strength and ASM, adjusted for BMI) were used to classify sarcopenia. Participants with sarcopenia alongside a BMI of > 30.0 kg/m2 were classified as having sarcopenic obesity. Prevalence using other criteria (European Working Group on Sarcopenia in Older People, Asian Working Group for Sarcopenia and the International Working Group for Sarcopenia) were also explored. Results The prevalence of sarcopenia was 27.9%, which comprised of sarcopenia without obesity (3.3%) and sarcopenic obesity (24.6%). Other classification criteria showed that sarcopenia ranged from 0.8–14.7%, including 0.8–9.8% without obesity and 0–4.9% with sarcopenic obesity. Using multivariate-discriminant analysis (OPLS-DA) those with sarcopenic obesity presented with a descriptive profile of higher C-reactive protein, waist circumference, food security and sedentary time than women without sarcopenic obesity (p = 0.046). A similar profile described women with low BMI-adjusted grip strength (p

Smallholder farmers produce majority of food in developing countries yet continue to be vulnerable to poverty, food insecurity, limited diet quality and diversity, malnutrition, and face various production challenges. Though quantitative studies have explored determinants of dietary diversity among farmers, this data can be further enriched with farmer experiences and perspectives of whether and how these factors affect dietary diversity to inform intervention design and implementation. A qualitative study was conducted among rural smallholder farmers in Kiboga district, Central Uganda with 28 participants in eight focus group discussions (four groups with men and four groups with women). The results showed that both men and women were concerned about food security and dietary diversity and viewed household food production as pivotal to food security. Purchase of food was affected by prices, household income, distance to markets and food diversity in the accessed markets. Major determinants of dietary diversity included household food production, agricultural and nutrition knowledge and awareness, information access and use, household income, and time. Poor perception towards meetings, insufficient nutrition information, skills and training were also noted. Gender influences and differences noted were concerned with allocation and use of harvested food and income within the household; more men than women having a poor perception towards meetings/trainings; and women having limited time for agricultural and nutrition practices that support dietary diversity. From the results, efforts to improve dietary diversity should address the food security and production challenges faced; support income generation whether on- or off-farm and market access to diverse foods; use designs that address gender issues and are labor and time sensitive; and include capacity building in nutrition and practices that support access to and utilization of diverse food baskets, and social behavior change strategies.

Abstract Background Correcting anemia during pregnancy often requires integrating food and non-food-based approaches. Nonetheless, little is known about specific dietary diversity (DD) cutoff values predicting risk of anemia during the different trimesters of pregnancy. Objective We aimed to determine the lowest possible DD cutoff values associated with risk of maternal anemia at mid and term of pregnancy in a rural resource limited setting of Ethiopia. Design A multi-center prospective cohort study was conducted enrolling 432 eligible pregnant women from eight rural health centers selected from four districts in Arsi zone, Central Ethiopia. Women were classified into exposed (n = 216) and unexposed (n = 216) groups, based on Women’s Individual Dietary Diversity (WIDD) score, and were followed from mid to term of pregnancy. The cutoff values for WIDD corresponding to the lowest risk of anemia were defined by receiver operating characteristic (ROC) curve analysis. Logistic regressions were also fitted to identify food groups associated with low anemia risk during pregnancy. Results The overall prevalence of anemia increased from 28.6 to 32.4% between mid and term of pregnancy. Calculatedly, using the ROC curve analysis, the minimum WIDD score associated with lower risk of anemia was three and four respectively at these periods. Not consuming animal source foods [adjusted odds ratio (AOR), 2.36; 95% confidence interval (CI), 1.35–4.14], pre-existing anemia (AOR 28.56; 95% CI, 14.33, 56.79), and low DD during pregnancy (AOR, 2.22; 95% CI, 1.09–4.52) were associated with risk of anemia at term. Conclusion The cutoff for WIDD score predicting risk of anemia varied significantly, increasing from three to four, between mid and term of pregnancy. Additional population-based observational and experimental studies validating the metrics are needed before policy level recommendations. Trial registration This trial was registered at clinicaltrials.gov as NCT02620943.

Introduction The local retail food environment influences dietary patterns and food choices, as suggested in the literature. The lack of access to healthy food within this environment may result in unhealthy food choices which may lead to obesity and the development of non-communicable diseases. Evidence suggests that resource-poor communities may have unhealthy food environments, therefore, preventing residents from making healthy food choices. A systematic scoping review will be conducted to provide an overview of the evidence on adult food choices in association with the local retail food environment and food access in resource-poor communities.Methods and analysis This protocol for the scoping review was developed following the Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines and the framework process by Arksey and O’Malley. Observational studies, published from July 2005 to January 2021, will be searched and screened. Keywords and medical subject headings (MeSH) terms will be used to search several multidisciplinary databases. Two independent reviewers will screen identified articles using the selection criteria and extract data using the PRISMA-ScR checklist. Descriptive numerical and thematic analysis will be performed to evaluate and categorise quantitative and qualitative data.Ethics and dissemination Ethical approval will not be required for the review, as data from published studies will be used. The results of this scoping review will form part of a PhD thesis that will be submitted to the University of the Western Cape, South Africa. The review findings will also be presented at conferences and published in a peer-reviewed journal.Open science framework registration number https://osf.io/shf93.

Background: In human immunodeficiency virus (HIV)-infected individuals, smoking increases both HIV-related and non-related negative health outcomes. Objectives: To determine the prevalence and associations of smoking in HIV-infected adults receiving antiretroviral therapy at public healthcare facilities in the Western Cape province, South Africa. Methods: Participants comprised 827 HIV-infected patients, who were 18 years old and randomly selected from 17 HIV healthcare facilities. Self-reported smoking was defined as smoking tobacco daily or occasionally. Serum cotinine levels confirmed smoking status. Results: Participants included 653 women and 174 men. The overall mean (standard deviation [SD]) age was 38.9 (9.0) years, 41.1 (8.9) years in men and 37.7 (8.9) years in women (p ˂ 0.001). The median diagnosed duration of HIV infection was 5 years. Smoking prevalence was 22% overall, and 26% in men and 21% in women (p = 0.022). The prevalence of former smoking was 14%. About a quarter of participants (185/751; 24.6%) had serum cotinine levels 100 mg/mL with similar prevalence of high levels across smoking status (current smokers: 27.2%, former smokers: 29.6% and never smokers: 22.7%, p = 0.564) and did not vary by age, gender, cluster of differentiation 4 count or known duration of HIV. There was no agreement between self-reports and cotinine levels at ranking smoking exposure. Conclusions: Prevalence of current tobacco smoking in HIV-infected patients on care is within the range of that in the general population. This highlights the potential missed opportunity or challenges of co-addressing smoking cessation in individuals already in regular contact with the health system.

Objectives: To assess knowledge, perceptions and practices on food production amongst learners and educators, gardening activities and management of school food gardens in schools participating in the National School Nutrition Programme. Design: Cross-sectional survey. Setting: Ten purposively selected primary schools in each of the nine provinces of South Africa (total: n = 90). Subjects and outcome measures: Questionnaire data were collected from the garden administrators (n = 66), garden workers (n = 55), educators (n = 687) and learners (n = 2 547). A checklist was completed for the school garden (n = 66) by observation. Results: Sixty-six (73%) schools had a food garden, varying in size (100 m2 – 6 000 m2). A variety of vegetables, but few fruit, were grown. Problems experienced with gardens were mostly lack of funds (59%), tools and infrastructure (47%), garden workers (53%) and technical support (50%). Few schools received external funding for food gardens. In 50% of gardens, crops were growing for > 6 months, and 30% of gardens provided fresh produce for school meals more than twice a week. Fifty-four percent (54%) of learners were involved in school gardens, and 67% had food gardens at home. Attitudes of learners and educators towards both food gardening and eating vegetables and fruit were generally positive; 68.4% of learners and 86.4% of educators indicated they like to eat vegetables every day. Conclusions: School food gardens as a vehicle for improving nutrition should be strengthened through training of educators and garden personnel, and support by external role players and policy directives are needed to enhance sustainability.

It can be postulated that schools have an ethical responsibility to protect children from an unhealthy food environment. Against the backdrop of stunting, overweight and micronutrient deficiencies prevalent in South African children, the aim of this scoping study is to review information available on foods sold to school children within an ethical framework. While some schools have a formal tuck shop, at other schools, food vendors sell food either on or outside the school premises. Ten studies, of which two were national, fit the selection criteria for this study. Available data show that mostly unhealthy food options are sold to South African school children; with low-nutrient energy-dense foods (e.g. chips, sweets) and sugar sweetened beverages being the most popular. The Integrated School Health Policy provide a policy framework for achieving healthy school food environments in South Africa, and several guidelines are available in South African to assist school tuck shops to sell healthier options. Children’s preference for unhealthy foods, the cost of healthier food options and a lack of proper facilities may however be barriers for implementing healthy tuck shops. An action stronger than merely providing guidelines may therefore be needed. Cognisance needs to be taken of conflicting value based arguments within ethical perspectives. Given these conflicts, the authors argue that an Ethics of Responsibility contributes to the debate of the best and supports the notion that society at large has a responsibility to protect vulnerable communities of which school children are part. Presently an ethical vacuum exists in terms of rights and responsibilities which this study hopes to address.

Abstract Background Collection of reliable and comparable individual food consumption data is of primary importance to better understand, control and monitor malnutrition and its related comorbidities in low- and middle-income countries (LMICs), including in Africa. The lack of standardised dietary tools and their related research support infrastructure remains a major obstacle to implement concerted and region-specific research and action plans worldwide. Citing the magnitude and importance of this challenge, the International Agency for Research on Cancer (IARC/WHO) launched the “Global Nutrition Surveillance initiative” to pilot test the use of a standardized 24-h dietary recall research tool (GloboDiet), validated in Europe, in other regions. In this regard, the development of the GloboDiet-Africa can be optimised by better understanding of the local specific methodological needs, barriers and opportunities. The study aimed to evaluate the standardized 24-h dietary recall research tool (GloboDiet) as a possible common methodology for research and surveillance across Africa. Methods A consultative panel of African and international experts in dietary assessment participated in six e-workshop sessions. They completed an in-depth e-questionnaire to evaluate the GloboDiet dietary methodology before and after participating in the e-workshop. Results The 29 experts expressed their satisfaction on the potential of the software to address local specific needs when evaluating the main structure of the software, the stepwise approach for data collection and standardisation concept. Nevertheless, additional information to better describe local foods and recipes, as well as particular culinary patterns (e.g. mortar pounding), were proposed. Furthermore, food quantification in shared-plates and -bowls eating situations and interviewing of populations with low literacy skills, especially in rural settings, were acknowledged as requiring further specific considerations and appropriate solutions. Conclusions An overall positive evaluation of the GloboDiet methodology by both African and international experts, supports the flexibility and potential applicability of this tool in diverse African settings and sets a positive platform for improved dietary monitoring and surveillance. Following this evaluation, prerequisite for future implementation and/or adaptation of GloboDiet in Africa, rigorous and robust capacity building as well as knowledge transfer will be required to roadmap a stepwise approach to implement this methodology across pilot African countries/regions.

Background:Plant-based diets (PBDs) are characterised as healthy dietary patterns that emphasise the intake of plant foods and limit the intake of animal foods. The Mediterranean and Dietary Approaches to Stop Hypertension (DASH) diets are common examples of healthy dietary patterns that are mainly plant based. There are different dietary pattern analysis approaches and scoring systems available to construct indices that measure adherence to a dietary pattern. Nutritional epidemiology studies necessitate the use of appropriate dietary indices when investigating diet-disease associations. This protocol is for a review that will: 1) evaluate how a PBD has been defined in studies published globally; and 2) assess the methods used to construct dietary indices that measure adherence to a PBD; with a focus on studies that have assessed the association between adherence to a PBD and CVD risk. Methods:This protocol was developed according to the Preferred Reporting Items for Systematic reviews and Meta-Analysis Protocols guidelines. PubMed–Medline, Scopus and biomedical databases within EBSCOhost will be searched up to August 2021. Two reviewers will independently screen the identified records and review the eligible full texts for inclusion. Discrepancies will be resolved by consensus or through discussion with a third reviewer. Meta-analysis will be performed where possible and consistency of the findings checked through subgroup analysis. Heterogeneity across studies will be assessed and quantified, and publication bias investigated. Relevant sensitivity analyses will be performed to substantiate the robustness of the study findings. Conclusion:Currently, there is some inconsistency in defining and measuring adherence to a PBD across study populations. Moreover, a lack of global data on the association between adherence to a PBD and CVD risk. This systematic review could aid in promoting the worldwide uptake of these findings for policy and practice purposes. This research will use previously published studies; and therefore, will not require ethical approval.

Background: Plant-based diets (PBDs) are characterised as healthy dietary patterns that emphasise the intake of plant foods and limit the intake of animal foods. The Mediterranean and Dietary Approaches to Stop Hypertension (DASH) diets are common examples of healthy dietary patterns that are mainly plant based. There are different dietary pattern analysis approaches and scoring systems available to construct indices that measure adherence to a dietary pattern. Nutritional epidemiology studies necessitate the use of appropriate dietary indices when investigating diet-disease associations. Methods: This systematic review protocol was developed according to the Preferred Reporting Items for Systematic reviews and Meta-Analysis protocols (PRISMA-P) guidelines. PubMed–Medline, Scopus and relevant biomedical databases within EBSCOhost will be searched up to August 2021 using relevant key words. Two reviewers will independently screen the identified records and review the eligible full texts for inclusion. Discrepancies will be resolved by consensus or through discussion with a third reviewer. Appropriate meta-analysis will be performed where possible and consistency of the findings checked through subgroup analysis. Heterogeneity across studies will be assessed and quantified, and publication bias investigated. Relevant sensitivity analyses will be performed to substantiate the robustness of the study findings. Conclusion: Currently, there is some inconsistency in defining and measuring adherence to a PBD across study populations. In addition to this, a lack of global data on the association between adherence to a PBD and CVD risk. This systematic review could aid in promoting the worldwide uptake of these findings for policy and practice purposes. This research will use previously published studies; and therefore, will not require ethical approval.