Communicable disease burden

Human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS)

The prevalence of HIV among pregnant women attending public sector clinics has been surveyed annually to monitor trends. The surveys show that prevalence has increased from 0.8 percent in 1990 to 27.9 percent in 2003, reflecting a remarkable spread of the epidemic within a decade (Figure 29). It is estimated that in 2004, about 12 percent of the total population was infected with the virus (Dorrington et al., 2004), and that by 2000 HIV/AIDS had become the biggest single cause of death in South Africa (Dorrington et al., 2004).

Prior to 2004, AIDS treatment was available only in the private sector, which restricted its use to people with medical insurance or sufficient money to pay for costly medication. In 2004, the government adopted a treatment five-year plan to roll-out anti-retroviral therapy in the public sector with the aim of meeting at least 80 percent of the need. The ASSA2002 model shows that in 2004 approximately 5 million people were HIV-positive, and 500 000 were AIDS-sick. Allowing for the impact of the treatment intervention, the number of infected people is projected to peak in 2013 and then decrease slowly, while the number of AIDS-sick people increases slowly. It is further predicted that in 2015 the number of AIDS-sick people will be about three-quarters of a million, with a projected 5.4 million-plus HIV-positive people. Currently, about 10 percent of HIV-positive people are AIDS-sick, and this will rise to just less than 13 percent.

Figure 30 shows that the projected total number of deaths increased as a result of the gradual increase in non-AIDS deaths and the rapid increase in AIDS deaths during the late 1990s. In 2004, the model estimates 389 000 non-AIDS deaths and 311 000 AIDS deaths. The total deaths in 2004 were 701 000, i.e., about 44 percent of total deaths were AIDS deaths. The proportion of AIDS deaths to total deaths is fairly constant over the time span depicted in Figure 30.

FIGURE 29
Prevalence of HIV as determined by antenatal surveys, 1990 to 2002

Source: Health Systems Trust, 2004.

FIGURE 30
Projected annual numbers of AIDS and non-AIDS deaths, 1985 to 2025

Source: ASSA2002 (ASSA, 2004).

Tuberculosis

Tuberculosis (TB) has been an important disease in South Africa for many years, affecting workers, particularly miners, and poor communities. Despite national treatment programmes, TB has been among the leading causes of death, accounting for more than 5 percent of all deaths in 2000. This has been exacerbated by the HIV/AIDS epidemic, with TB being the common opportunistic infection among HIV-positive people.

In 2002, there were an estimated 243 000 cases of TB in South Africa, making it the country with the seventh highest number of TB cases. The number of TB cases, as well as the number of new smear cases, nearly doubled between 1996 and 2002 (Figure 31). The rise in the number of reported TB cases since the inception of the National TB Control Programme in 1996 reflects a real increase in the number of cases, as well as improved case detection and reporting. The real increase in the number of cases is largely because of the rising prevalence of HIV. HIV infection is now the main single risk factor for TB, and in 2003/2004 more than half the smear-positive TB patients were HIV-positive.

FIGURE 31
Numbers of TB, pulmonary TB and new smear cases reported, 1996 to 2000

Reproduced by permission of Health Systems Trust. Originally published in Bamford, L., Loveday, M. & Verkuijl, S. 2004. Tuberculosis. In P. Ijumba, C. Day, and A. Ntuli, eds. South African Health Review 2003/04. Durban, Health Systems Trust.

Malaria

Malaria affects only the northern and northeastern regions of South Africa. Systematic control efforts introduced in the late 1940s and good access to treatment have generally kept the disease in check. In contrast to most other countries in sub-Saharan Africa, malaria is not a major cause of death in South Africa.

For the period 1976 to 1995, annual reported malaria cases ranged from 2 000 to 13 000 per year. In 1996, slightly more than 27 000 cases were reported, rising to more than 60 000 in 2000. The number of notified malaria cases decreased considerably thereafter (Figure 32). The malaria vectors’ resistance to existing pesticides, as well as antimalarial drug resistance, in part caused the dramatic increases in numbers of cases and deaths from malaria. Changes in the drugs and insecticide used contributed to the subsequent significant decrease in malaria morbidity and mortality in South Africa in subsequent years.

FIGURE 32
Annual notified malaria cases and deaths, 1971 to June 2003

Reproduced by permission of Health Systems Trust. Originally published in Moonasar, D., Johnson, C.L., Maloba, B., Kruger, P., le Grange, K., Mthembu,J. & van den Ende, J. 2004. Malaria. In P. Ijumba, C. Day, and A. Ntuli, eds.

South African Health Review 2003/04. Durban, Health Systems Trust

Diarrhoeal disease

SANBD found that diarrhoea accounted for nearly 3 percent of all deaths in South Africa in 2000. However, death rates for diarrhoeal disease vary by province, ranging from 12 per 100 000 in the Western Cape to more than 60 in Limpopo Province (Figure 33). The average rates for South Africa are about 42 per 100 000 for males and slightly fewer for females. Clearly, in some provinces deaths from diarrhoea still make a significant contribution, affecting infants, children and the elderly in particular. Serious cholera outbreaks have occurred in recent years, affecting areas where there are poor water supplies and no sanitation. However, the case fatality rates during these outbreaks have been remarkably low.

FIGURE 33
Mortality from diarrhoeal diseases in children, by province and sex

Source: SANBDS 2000 in Bradshaw et al., 2004.

Summary

Current burden of disease

The data presented show that South Africa has a quadruple burden of disease: 1) continuation of the infectious diseases associated with underdevelopment, poverty and undernutrition; 2) an emerging epidemic of chronic diseases linked to overnutrition and Western types of diet and lifestyle; 3) the explosive HIV/AIDS epidemic; and 4) the continued burden of injury-related deaths. In 2000, NCDs accounted for 37 percent of deaths, and HIV/AIDS and infectious diseases together for 44 percent (Bradshaw et al., 2003). CVD and diabetes together accounted for 19 percent of total deaths, and cancers for a further 7.5 percent. In contrast, nutritional deficiencies related to undernutrition accounted for 1.2 percent of deaths. In terms of mortality from chronic diseases, in 2000 IHD and stroke accounted for 123 and 124 per 100 000 deaths, respectively, while hypertensive heart disease and diabetes accounted for 68 and 54 per 100 000 deaths, respectively (Bradshaw et al., 2004).

Current nutritional status of the population

Undernutrition and its associated outcomes of stunting and underweight are still prevalent in children. In 1999, 22 percent of children aged one to nine years in South Africa were stunted, and 10 percent were underweight-for-age (Labadarios et al., 2000). However, at the same time, 17 percent of children were overweight and obese (BMI ³ 25) (Steyn et al., 2005). In adults the prevalence of obesity (BMI ³ 30) was very high in 1998, particularly in women, among whom it ranged from 21 to 31 percent in different population groups (Department of Health, SAMRC and Measure DHS+, 2002). In white males, the prevalence of obesity was 21 percent, while it was less than 10 percent in the other population groups; the prevalence of overweight (BMI ³ 25) was 20 percent in all males. Underweight (BMI < 18.5) was less than 6 percent in the adult female population and 13 percent in males (Department of Health, SAMRC and Measure DHS+, 2002). Hence, both under- and overnutrition coexist in South Africa, and sometimes even in the same household, where a child is stunted and a parent/carer overweight or obese.

Micronutrient deficiencies are also still prevalent in children; in 1994, 39 percent of 0- to five-year-olds were marginally vitamin-A deficient and 25 percent had low iron stores (SAVACG, 1995). Iodine deficiency was still found to be prevalent in some provinces in 1998 (Immelman, Towindo and Kalk, 2000). No national data on biochemical deficiencies are available for adults, but numerous localized studies have shown high prevalence of iron deficiency in women (Kruger et al., 1994; Dannhauser et al., 1999) and of VAD, particularly in HIV-infected adults (Kennedy-Oji et al., 2001; Visser et al., 2003).

Current dietary intake patterns of the population

National dietary intake data are only available for children aged one to nine years (Labadarios et al., 2000). The main findings from NFCS 1999 were that many children were deficient in energy and numerous micronutrients (vitamins A and C, niacin, vitamin B6, calcium, iron and zinc), and deficiency prevalence rates were always higher in rural areas. A few localized surveys provide some trends on dietary intake in adults. Studies in the white (Wolmarans et al., 1988), coloured (Langenhoven, Steyn and van Eck, 1988) and Indian (Wolmarans et al., 1999) populations showed that mean carbohydrate intakes were less than 55 percent of total energy, mean fat intakes more than 30 percent, and added (free) sugar intakes more than 10 percent. Rural blacks (Steyn et al., 2001) had a prudent diet with a mean fat intake of less than 20 percent of total energy, carbohydrate intake of more than 60 percent and free sugar intake of less than 10 percent. Urban blacks, on the other hand, had mean intakes that lay between the extremes of the Western diet and the rural prudent diet (Bourne et al., 1993; Steyn et al., 2001). In the urban upper-income black group (MacIntyre et al., 2002) mean fat intake was more than 30 percent of total energy. Studies on dietary trends in urban blacks showed that the mean intake of fat increased from 24 to 32 percent of total energy among those aged 19 to 44 years as the time they spent in the city increased, while mean carbohydrate intakes decreased from 61 to 53 percent (Bourne, 1996). These trends are typical of the nutrition transition that is taking place.

Current policies and strategies for addressing nutrition problems in south africa

Programmes to improve protein-calorie malnutrition and undernutrition

Since the inauguration of the democratic government in 1994, the nutritional status of children has received a great deal of attention from the new government, which made child nutrition one of the cornerstones of its Reconstruction and Development Programme. A great deal of focus was placed on the high prevalence of stunting and underweight found in preschool children, as reported by SAVACG (1995). The Nutrition Directorate of the Department of Health subsequently developed an Integrated Nutrition Programme for South Africa in an attempt to deal with some of the critical issues related to undernutrition and infectious diseases (Department of Health, 1998). As part of this strategy, certain focus areas were devoted to improving the nutritional status of children and decreasing the prevalence of PEM nationally (Nutrition Directorate, 2001).

The most crucial focus area of this strategy is contributing to household food security with the objective of alleviating short-term hunger among primary schoolchildren. A school feeding programme was introduced into schools with needy learners in 1994 and about 5 million learners a year benefit annually from this. Despite many initial problems, a qualitative survey has indicated that the programme makes a major social contribution to schools in terms of difficult-to-measure qualities such as children being more alert and benefiting intellectually (McCoy, 1997).

Additionally, there are three more focus areas in the Integrated Nutrition Programme aimed at dealing with the development and consequences of undernutrition. These are: 1) disease-specific nutrition support, treatment and counselling; 2) growth monitoring and promotion; and 3) promotion of breastfeeding. These are implemented at the primary health care level, where infants and children are brought for routine immunizations and pregnant women come for antenatal and post-natal care. The main objectives of health policy-makers are to reduce the prevalence of low birth weight from 8.3 percent nationally and to reduce the prevalence of stunting and underweight in children from 21.6 and 10.3 percent, respectively, in 1999 to 18 and 8 percent, respectively, in 2007 (Nutrition Directorate, 2001).

Another aspect of dealing with undernutrition and dietary deficiencies has been the development and promotion of food-based dietary guidelines in South Africa. The Nutrition Directorate has adopted 11 guidelines, which were developed by a national working group (Love et al., 2001) to promote healthy eating habits in the child and adult populations. Paediatric guidelines to be introduced in the near future are currently being tested.

HIV/AIDS is another focus area to receive much support in terms of promoting nutrition. Recently, the Nutrition Directorate has implemented an intervention programme aimed at people with TB and/or HIV/AIDS. The objective of this strategy is to provide an energy-dense meal and micronutrient supplements to people who qualify for the scheme. Nutritional guidelines are already available for such patients (Nutrition Directorate, personal communication, 2005).

Programmes to improve micronutrient status

The Department of Health has been successful regarding the implementation of fortification schemes to eliminate micronutrient deficiencies in the South African population. The iodization of salt became compulsory in 1995, and the fortification of maize and wheat flour in October 2003. The latter have to be fortified so as to deliver 33 percent of the RDA per serving at the point of consumption (National Food Fortification Task Group, 1998; 2002). The fortificants added are vitamin A, thiamine, riboflavin, niacin, folic acid, vitamin B6, iron and zinc. Nutrition support for women and children is provided by health care workers at primary care facilities and includes vitamin A and iron supplementation and health promotion aimed at improving diets (Nutrition Directorate, 2001). Adoption of the food-based dietary guidelines will also contribute to eliminating micronutrient deficiencies because one of the guidelines encourages dietary diversity and increased consumption of fruit and vegetables (Love et al., 2001).

Programmes to prevent and manage nutrition-related chronic diseases

The Global Strategy on Diet, Physical Activity and Health has clearly indicated that every government has a primary steering and stewardship role in initiating and developing its own national strategy for the prevention and management of chronic diseases through a strategy for diet, physical activity and health. National circumstances determine the priorities in the development of such strategies (WHO, 2004).

In 1996 the Department of Health instituted the Directorate of Chronic Diseases, Disabilities and Geriatrics, and the first director was appointed. This marked the start of a period during which NCDs were prioritized at national- and provincial-level departments of health. For the first time, provinces appointed people responsible for NCDs; this can be seen as a milestone in the organization of long-term care delivery in the South African health system (C. Kotzenberg, personal communication, 2005).

In support of this initiative, the Department of Health has embarked on a surveillance programme, incorporating health indicators such as BMI, physical inactivity and blood pressure. A nationally representative survey (SADHS) was undertaken in 1998 and repeated in 2003/2004, in order to provide a way of monitoring secular trends for these health indicators in response to the national health strategy.

The Nutrition Directorate has also supported the development of strategies for nutrition-related chronic diseases. In the late 1990s, the department initiated a consultative process to develop a series of guidelines for the prevention and management of NCDs (separate guidelines are available for the prevention and management of diabetes, hypertension, hyperlipidaemia and overweight). In this regard it has set strategic objectives aimed at reducing the prevalence rates of obesity from 9.3 percent in males and 30.1 percent in females in 2000 to 7 and 25 percent, respectively (Nutrition Directorate, 2001). To date, however, there is no clear indication of how these targets will be achieved in terms of strategies at the primary care level.

There are also initiatives within the Ministries of Sport (Sport and Recreation South Africa) and Education, which provide a policy and programme framework that supports the strategic priorities for health care. Sport and Recreation South Africa is responsible for devising and implementing sport and recreation policy in South Africa, specifically targeting increased mass participation and sports development. This mandate is reflected in the theme of the ministerial White Paper on Sport and Recreation in South Africa, which is "getting the nation to play".

The Directorates of Health Promotion and Chronic Diseases have also recognized the need to encourage physical activity, in particular among older adults, and have initiated guidelines for promoting "active ageing" (1999). More recently, in November 2004, the Directorate of Health Promotion in the Department of Health launched an intersectoral strategy aimed at promoting healthy lifestyles and change from risky behaviour, particularly among youth. This forms part of a plan for comprehensive health care in South Africa, and is one of the strategic priorities for the period 2004 to 2009 (Nutrition Directorate, 2001).

Future policy needs to address the nutrition transition

The rising prevalence of obesity in South Africa gives cause for grave concern because of the increased risk of diabetes and CVD (WHO/FAO, 2003). As well as direct costs, which may be as high as 6.8 percent of total health care costs, there are also indirect costs such as workdays lost, doctor visits, impaired quality of life and premature mortality (WHO/FAO 2003). Over the last three decades, many chronic diseases have featured significantly in terms of overall morbidity and mortality. This is particularly so for IHD, hypertensive disease, stroke, diabetes, chronic obstructive pulmonary diseases, lung, oesophageal, breast and colorectal cancers.

In addition, communicable diseases are still major causes of mortality and morbidity in South Africa, and should remain priorities on the health agenda. The death rates from infectious diseases such as HIV/AIDS, TB and diarrhoeal disease are still high, and in the case of HIV and TB increasing. In addition, both under- and overnutrition are coexisting. It is important that health care policy-makers do not neglect any of these areas of concern and, despite the immediate pressure for relief against infectious diseases, the government should also be looking for long-term solutions for chronic diseases. The first step in this regard will be prevention, and it is most feasible that prevention efforts should be aimed mainly at children.

Children are important targets for health interventions. It is increasingly recognized that the occurrence of adult chronic diseases is influenced by factors operating throughout the life course (Kuh and Schlomo, 2004). Increased risk may start in infancy, or even before birth, and continues to be influenced by health-related behaviours during childhood. Hence, future policies should focus on inculcating healthy behaviours in children, where feasible. Some recommendations for policies that can be adopted and implemented are presented in the following paragraphs.

Fiscal policies and levies

Swinburn et al. (2004) highlighted the importance of introducing fiscal policies that influence the food supply in order to ensure that the population has access to safe and affordable foods that discourage the intake of high-fat/-sugar products. Another option in this regard would be for the government to introduce small levies on certain high-fat/-sugar foods, including such items as soft drinks and crisps.

School-based intervention programmes

Schools are an established setting for health promotion activities and have the advantage of influencing health-related beliefs and behaviours early in the "health career" so that they become established as adult patterns. Children in schools also represent a large population who are present and accessible over prolonged periods in a setting that is relatively sheltered and where education and learning are the norm. Influencing children in their formative years is a potential mechanism for influencing the emerging culture and health beliefs of society.

An additional potential benefit of school-based health promotion is that by improving the health of schoolchildren, educational performance and learning may be enhanced. A large body of evidence indicates that positive educational outcomes are closely linked to good health in schoolchildren. These positive outcomes include classroom performance, school attendance, participation in school activities and student attitudes (Symons et al., 1997).

The importance of school health promotion programmes for the prevention of chronic diseases was underlined in a recent scientific statement by the American Heart Association (Hayman et al., 2004), which recommended that: "All schools should implement: evidence-based, comprehensive, age-appropriate curricula about cardiovascular health, methods for improving health behaviours, and the reduction of CVD risk; and age-appropriate and culturally sensitive curricula on changing students’ patterns of dietary intake, physical activity, and smoking behaviours." An intervention programme to prevent smoking in adolescents is currently being tested at some schools in South Africa (P. Reddy, personal communication, 2005). It is hoped that this may lead to the introduction of similar strategies aimed at diet and physical activity.

Food labelling and claims

Food labelling is currently being revised by the Department of Health, and new regulations are expected for the end of 2005 (Booyzen, Directorate of Food Control, personal communication, 2005). These new regulations are more informative than the present ones, and will provide consumers with detailed nutrition information. In future, consumers will be able to determine whether the products they purchase and consume comply with recommendations for a healthy diet, particularly in terms of fats, free sugars and sodium. Furthermore, the regulatory framework will minimize misleading food, health and nutrition claims. However, consumers need to be educated about these regulations and about how to select healthy foods accordingly. Clearly, the Nutrition Directorate of the Department of Health, together with the Directorate of Food Control, will need to plan and implement specific strategies to do this.

Marketing and advertising standards

To date there have been no regulations regarding the marketing of energy-dense foods to children. Ideally it is hoped that in the near future there will be bans on the television advertising of energy-dense, high-fat and high-sugar foods to young children, particularly because this has been shown to be an effective way of persuading children to make undesirable and unhealthy choices (Swinburn et al., 2004).

Policies aimed at improving the environment

Intersectoral action is required in order to modify the environment so that physical activity and a healthy diet are promoted and enhanced in schools, workplaces and communities. This should include limiting the exposure of young children to heavy marketing of energy-dense, micronutrient-poor foods, which can be done by introducing school policies that prohibit the presence of vending machines and unhealthy food sales in schools, crèches and after-school centres. Furthermore, it is essential that food items that are included in the primary school meal programme are healthy. It is also important to ensure that children have safe and adequate space at school and in the community for playing sports and games that promote physical activity. The onus rests with employers to make workplaces encouraging of physical activity and to provide healthy foods and meals.

Nutrition health logos

In South Africa the Heart Foundation and the Cancer Association provide their logos to food products that meet certain specified health and nutrition standards. In doing so, these associations are raising the awareness of consumers and manufacturers about the value of using healthy foods. The Department of Health should encourage this trend in an effort to persuade the food industry of the benefits of producing healthier food and meal options.

Nutrition education programmes at primary health care facilities

It is important that the food-based dietary guidelines initiated by the Nutrition Directorate be given priority as a tool for nutrition education, and be incorporated into primary health care programmes and school curricula. As these guidelines also cater for overnutrition and promote healthy eating habits for all South Africans, they need to be implemented by all departments and district health authorities, with an important emphasis on avoiding both over- and undernutrition.

Furthermore, it has been found that health professionals working at the primary care level have inadequate knowledge about nutrition and lifestyle modification regarding NCDs; their basic training therefore needs to be updated in this regard (Talip et al., unpublished data, 2005).

Conclusions

The following important findings regarding nutrition and chronic diseases need to be kept high on the health agenda. First, it should be recognized that malnutrition (both under- and overnutrition) is prevalent in all ethnic groups in South Africa, and poor diet - together with other unhealthy behaviours - leads to the development of a substantial (and growing) burden of chronic diseases. Second, it should be recognized that many children and adults in South Africa have unhealthy lifestyles with high intakes of energy, total fat and added sugar, and low intakes of fruit and vegetables. Many people are inactive, smoke cigarettes and have high intakes of alcohol. In order to reduce the burden of chronic diseases over the next few decades these unhealthy behaviours need to be addressed now.

References

Archer, S., Bromberger, N., Nattrass, N. & Oldham, G. 1990. Unemployment and labour market issues - A beginner’s guide. In N. Nattrass and E. Ardington, eds. The political economy of South Africa. Cape Town, Oxford University Press.

ASSA. 2004. ASSA AIDS and Demographic Models: AASA2002. AIDS Committee of ASSA. Available at: www.assa.org.za/. Actuarial Society of South Africa.

Blaauw, D. & Gilson, L. 2001. Health and poverty reduction policies in South Africa. Johannesburg, Centre for Health Policy.

Bourne, L.T. 1996. Dietary intake in an urban African population in South Africa - with special reference to the nutrition transition. University of Cape Town. (Ph.D. thesis)

Bourne, L.T., Langenhoven, M.L., Steyn, K., Jooste, P.L., Laubscher, J.A. & van der Vyver, E. 1993. Nutrient intake in the urban African population of the Cape Peninsula, South Africa. The Brisk study. Cent. Afr. J. Medical, 39(12): 238-247.

Bradshaw, D., Dorrington, R.E. & Sitas, F. 1992. The level of mortality in South Africa in 1985 - what does it tell us about health? S. Afr. Med. J., 82: 237-240.

Bradshaw, D., Bourne, D., Schneider, M. & Sayed, R. 1995. Mortality patterns of chronic diseases of lifestyle in South Africa. In J. Fourie and K. Steyn, eds. Chronic diseases of lifestyle in South Africa, pp. 5-23. MRC Technical Report. Cape Town, SAMRC.

Bradshaw, D., Groenewald, P., Laubscher, R., Nannan, N., Nojilana, B., Norman, R., Pieterse, D. & Schneider, M. 2003. Initial burden of disease estimates for South Africa, 2000. S. Afr. Med. J., 93(9): 682-688.

Bradshaw, D., Nannan, N., Laubscher, R., Groenewald, P., Joubert, J., Nojilana, B., Norman, R., Pieterse, D. & Schneider, M. 2004. South African National Burden of Disease Study, 2000: Estimates of Provincial Mortality. Tygerberg, SAMRC.

Cole, T.J., Bellizzi, M.C., Flegal, K.M. & Dietz, W.H. 2000. Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ, 320: 1240-1243.

Cook-Mozaffari, P., Azordegan, F., Day, N.E., Ressicaud, A., Sabai, C. & Aramesh, B. 1979. Oesophageal cancer studies in the Caspian Littoral of Iran: Results of a case-control study. Br. J. Cancer, 39: 293.

Dannhauser, A., Bam, R., Joubert, G. et al. 1999. Iron status of pregnant women attending the antenatal clinic at Pelonomi Hospital, Bloemfontein. S. Afr. J. Clin. Nutr., 12: 8-16.

Day, N.E. 1984. The geographic pathology of cancer of the oesophagus. Br. Med. Bull., 40: 329-334.

Department of Health. 1998. Integrated Nutrition Programme for South Africa. Summary of broad guidelines for implementation. Pretoria.

Department of Health, SAMRC & Measure DHS+. 2002. South Africa Demographic and Health Survey 1998. Full report. Available at: www.doh.gov.za/facts/sadhs-f.html and www.doh.gov.za/facts/1998/sadhs98/.

Department of Labour. 2002. Sectoral Determination 7: Domestic Worker Section of the Basic Conditions of Employment Act, No. 75 of 1997. Government Gazette No. 23732. Pretoria.

Dorrington, R.E., Bradshaw, D., Johnson, L, & Budlender, D. 2004. The demographic impact of HIV/AIDS in South Africa. National indicators for 2004. Cape Town, Centre for Actuarial Research, SAMRC and ASSA.

Ewing, J.A. 1984. Detecting alcoholism. The CAGE questionnaire. JAMA, 252: 1905-1907.

FAO. 2004. Food balance sheets. Available at: www.fao.org/faostat.

FAO/WHO. 2002. Human vitamin and mineral requirements. Report of a Joint FAO/WHO Expert Consultation. Rome.

Gelderblom, D. & Kok, P. 1994. Urbanisation: South Africa's challenge. Volume 1: Dynamics. Pretoria, HSRC Publishers.

Hayman, L.L., Williams, C.L., Daniels, S.R., Steinberger, J., Paridon, S., Dennison, B.A. & McCrindle, B.W. 2004. Cardiovascular health promotion in the schools. AHA Scientific Statement. Circulation, 110: 2266-2275.

Health Systems Trust. 2004. South African Health Review, 2003/4. Durban.

HSRC. 2003. Synthesis report on social and economic impacts of government programmes since 1994. Prepared for the Policy Coordination and Advisory Services, Office of the President. Pretoria, Human Sciences Research Council (HSRC) Publishers.

IARC. 1988. Alcohol drinking. IARC Monographs on the Evaluation of the Carcinogenic Risk of Chemicals to Humans No. 44. Lyon, France, WHO, International Agency for Research on Cancer (IARC).

Immelman, R., Towindo, T. & Kalk, W.J. 2000. Report of the South African Institute for Medical Research (SAIMR) on the Iodine Deficiency Disorder Survey of Primary School Learners for the Department of Health, South Africa. Johannesburg, SAIMR.

Jooste, P.L., Steenkamp, H.J., Benadé, A.J.S. & Rossouw, J.E. 1988. Prevalence of overweight and obesity and its relation to coronary heart diseases in the CORIS study. S. Afr. Med. J., 74: 101-104.

Kennedy-Oji, C., Coutsoudis, A., Kuhn, L., Pillay, K., Mburu, A., Stein, Z. & Coovadia, H. 2001. Effects of vitamin A supplementation during pregnancy and early lactation on body weight of South African HIV-infected women. J. Health Popul. Nutr., 19(3):167-176.

Kok, P., O’Donovan, M., Bouare, O. & Van Zyl, J. 2003. Post-apartheid patterns of internal migration in South Africa. Pretoria, HSRC Publishers.

Kruger, M., Dhansay, M.A., Van Staden, E. et al. 1994. Anaemia and iron deficiency in women in the third trimester of pregnancy receiving selective iron supplementation. S. Afr. J. Food Sci. Nutr., 6: 132-137.

Kuh. D.J.L. & Schlomo, B.Y. 2004. A life course approach to chronic disease epidemiology. Oxford, UK, Oxford University Press.

Kustner, H.G.V. 1987. First RHOSA Nutrition Study: Anthropometric assessment of nutritional status in black under-fives in rural South Africa. Epidemiological Comments, 14(3): 1-32.

Labadarios, D., Steyn, N.P., Maunder, E., MacIntyre, U., Swart, R., Gericke, G., Huskisson, J., Dannhauser, A., Vorster, H.H. & Nesamvuni, E.A. 2000. The National Food Consumption Survey (NFCS): Children aged 1-9 years, South Africa, 1999. Pretoria, Department of Health.

Langenhoven, M.L, Steyn, K. & van Eck, M. 1988. The food and meal pattern in Cape Peninsula coloured population. Ecol. Food Nutr., 22: 107-116.

Love, P., Maunder, E., Green, M., Ross, F., Smale-Lovely, J. & Charlton, K. 2001. South African food-based dietary guidelines: Testing of the preliminary guidelines among women in KwaZulu-Natal and the Western Cape. S. Afr. J. Clin. Nutr., 14: 9-19.

Lubbe, A.M. 1973. Nutritional status of Pretoria schoolchildren from four racial groups. S. Afr. Med. J., 47: 679-688.

MacIntyre, U.E., Kruger, H.S., Venter, C.S. & Vorster, H.H. 2002. Dietary intakes of an African population in different stages of transition in the North West Province, South Africa: the THUSA study. Nutr. Res., 22: 239-256.

Martin, G., Steyn, K. & Yach, D. 1992. Beliefs about smoking and health and attitudes toward tobacco control measures. S. Afr. Med. J., 82: 241-245.

May, J. 1998. Poverty and inequality in South Africa. Summary report. Available at: www.polity.org.za/html/govdocs/reports/poverty.html.

May, J. 2004. Poverty, social policy and the social wage. Paper presented at a conference on The Politics of Socio-Economic Rights in South Africa: 10 years after Apartheid. Oslo, 8 to 9 June.

McCoy, D. 1997. An evaluation of the Primary School Nutrition Programme. Durban, Health Systems Trust.

Mostert, W.P., Hofmeyr, B.E., Oosthuizen, J.S. & Van Zyl, J.A. 1998. Demography: Textbook for the South African student. Pretoria, HSRC Publishers.

Moultrie, T.A. & Timæus, I.M. 2003. The South African fertility decline: Evidence from two censuses and a Demographic and Health Survey. Population Studies, 57(3): 265-283.

Mqoqi, N.P., Kellett, P., Madhoo, J. & Sitas, F. 2004. Cancer in South Africa: Incidence of histologically diagnosed cancer in South Africa, 1996-1997. Johannesburg, National Cancer Registry Report, National Health Laboratory Service.

National Food Fortification Task Group. 1998 and 2002. Reports. Pretoria, Department of Health.

Nel, J.H. & Steyn, N.P. 2002. Report on South Africa food consumption studies undertaken amongst different population groups (1983-2000): Average intakes of foods most commonly consumed. Available at: www.sahealthinfo.org/nutrition/scientific.htm.

Nojilana, B., Norman, R., van Blerk, L. & Dhansay, A. in press. Estimating the burden of vitamin A deficiency in South Africa.

Nutrition Directorate. 2001. Integrated Nutrition Programme Strategic Plan 2001/02 to 2006/7. Pretoria, Department of Health, Nutrition and Provincial Nutrition Units.

Parkin, D.M., Ferlay, J., Hamdi-Chériff, M., Sitas, F., Thomas, J.O., Wabinga, H. & Whelan, S.L. 2003. Cancer in Africa: Epidemiology and prevention. IARC Scientific Publication No.153. Lyon, France, IARC Press.

Popkin, B.M. 2001. The nutrition transition and obesity in the developing world. J. Nutr., 131(3): 871S-873S.

Reddy, S.P., Panday, S., Swart, D., Jinabhai, C.C., Amosun, S.L., James, S., Monyeki, K.D., Stevens, G., Morejele, N., Kambaran, N.S., Omardien, R.G. & Van den Borne, H.W. 2003. The 1st South African National Youth Risk Behaviour Survey 2002. Cape Town, SAMRC.

Reddy, P., Meyer-Weitz Abedian, I., Steyn, K. & Swart, D. 1998. Implementable strategies to strengthen comprehensive tobacco control in South Africa: Towards an optimal policy intervention mix. MRC Policy Brief. Cape Town, SAMRC.

Richardson, B.D. 1977. Underweight - a nutritional risk. S. Afr. Med. J., 51: 42-48.

Rossouw, J.E., du Plessis, J.P., Benadé, A.J.S., Jordaan, P.C., Kotze, J.P., Jooste, P.L. & Ferreira, J.J. 1983. Coronary risk factor screening in three rural communities. S. Afr. Med. J., 64: 430-436.

SAVACG. 1995. Children aged 6-71 months in South Africa, 1994: Their anthropometric, vitamin A, iron and immunization coverage status. Stellenbosch, University of Stellenbosch and South African Vitamin A Consultative Group (SAVACG).

Seedat, Y.K., Mayet, F.G.H., Khan, S., Somer, S.R. & Joubert, G. 1990. Risk factors for coronary heart diseases in the Indians in Durban. S. Afr. Med. J., 78: 447-454.

Statistics South Africa. 2003. Census 2001: Census in brief. Report No. 03-02-03 (2001). Pretoria.

Steyn, K., Jooste, P., Langenhoven, M.L., Benadé, A.J., Rossouw, J.E., Steyn, M., Jordaan, P.C. & Parry, C.D. 1985. Coronary risk factors in the coloured population of the Cape Peninsula. S. Afr. Med. J., 67: 619-625.

Steyn, K., Jooste, P.L., Bourne, L., Fourie, J., Badenhorst, C.J., Bourne, D.E., Langenhoven, M.L., Lombard, C.J., Truter, H., Katzenellenbogen, J., Marais, M. & Oelofse, A. 1991. Risk factors for coronary heart diseases in the black population of the Cape Peninsula. S. Afr. Med. J., 79: 480-485.

Steyn, N.P., Senekal, M., Brits, S. & Nel, J.H. 2000. Urban and rural differences in dietary intake, weight status and nutrition knowledge of black female students. Asia Pacific J. Clin. Nutr., 9(1): 11-16.

Steyn, N.P., Burger, S., Monyeki, K.D., Alberts, M. & Nthangeni, G. 2001. Variation in dietary intake of the adult population of Dikgale. S. Afr. J. Clin. Nutr., 14(4): 140-145.

Steyn, N.P., Labadarios, D., Maunder, E., Nel, J. & Lombard C. 2005. Secondary anthropometric data analysis of the National Food Consumption Survey in South Africa: The double burden. Nutrition, 21: 4-13.

Swinburn, B.A., Caterson, I., Seidell, J.C. & James, W.P.T. 2004. Diet, nutrition and the prevention of excess weight gain and obesity. PHN, 7(1A): 123-146.

Symons, C., Cincelli, B., James, T.C. & Groff, P. 1997. Bridging student health risks and academic achievement through comprehensive school health programs. Journal of School Health, 6: 220-227.

Terreblanche, S. 2004. A history of inequality in South Africa, 1652-2002. Pietermaritzburg, University of Natal Press and KMM Review Publishing Company.

Terreblanche, S. & Nattrass, N. 1990. A periodization of the political economy from 1910. In N. Nattrass and E. Ardington, eds. The political economy of South Africa. Cape Town, Oxford University Press.

Tuyns, A.J., Pequinot, G. & Jensen, D.M. 1979. Role of diet, alcohol and tobacco in oesophageal cancer, as illustrated by two contrasting high-incidence areas in the North of Iran and West of France. Front. Gastrointest. Res., 4: 101-110.

UNDP. 2001. Human Development Report 2001. New York.

UNDP. 2003. South Africa Human Development Report 2003. The challenge of sustainable development in South Africa: unlocking people’s creativity. Cape Town, Oxford University Press.

Van Rensburg, S.J. 1981. Epidemiologic and dietary evidence for specific nutritional predisposition to oesophageal cancer. J. Natl. Cancer Inst., 67: 243.

Van Walbeek, C. 2005. The economics of tobacco control in South Africa. Cape Town, University of Cape Town, Department of Economics. (Ph.D. thesis)

Visser, M.E., Maartens, G., Kossew, G. & Hussey, G.D. 2003. Plasma vitamin A and zinc levels in HIV-infected adults in Cape Town, South Africa. Br. J. Nutr., 89(4): 475-482.

Vorster, H.H., Oosthuizen, W., Steyn, H.S., Van der Merwe, A.M. & Kotze, J.P. 1995. Nutrient intakes of white South Africans - a cause for concern: The VIGHOR Study. S. Afr. J. Food Sci. Nutr., 7(3): 119-126.

Walker, A.R.P., Adam, A. & Küstner, H.G.V. 1993. Changes in total death rate and in ischaemic heart disease death rate in interethnic South African populations, 1978-1989. S. Afr. Med. J., 83: 602-605.

WHO. 2003. The World Health Report 2002. Reducing risks, promoting healthy life. WHO Technical Report Series No. 916. Geneva.

WHO. 2004. Global strategy on diet, physical activity and health. Fifty-Seventh World Health Assembly. Agenda item 12.6, 17 April. Geneva.

WHO/FAO. 2003. Diet, nutrition and the prevention of chronic diseases. Report of a Joint WHO/FAO Expert Consultation. WHO Technical Report Series No. 910. Geneva.

Wolmarans, P., Langenhoven, M.L., Benadé, A.J.S., Swanepoel, A.S.P., Kotze, T.J.W. & Rossouw, J.E. 1988. Intake of macronutrients and their relationship with total cholesterol and high-density lipoprotein cholesterol. The Coronary Risk Factor Study, 1979. S. Afr. Med. J., 73(9): 12-15.

Wolmarans, P., Langenhoven, M.L., van Eck, M. & Swanepoel, A.S.P. 1989. The contribution of different food groups to the energy, fat and fibre intake of the Coronary Risk Factors Study (CORIS) population. S. Afr. Med. J., 75: 167-171.

Wolmarans, P., Seedat, Y.K., Mayet, F.G.H., Joubert, G. & Wentzel, E. 1999. Dietary intake of Indians living in the metropolitan area of Durban. Public Health Nutr., 2(1): 55-60.

Yach, D. & Townshend, D. 1988. Smoking and health in South Africa: The need for action. Centre for Epidemiological Research in Southern Africa Technical Report No. 1. Cape Town, SAMRC

Annexes

ANNEX 1: FAO FOOD BALANCE SHEETS FOR SOUTH AFRICA, 1962 TO 2001

* Divide this amount by 365 to obtain the daily per capita availability.