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Malnutrition is an imbalance between the supply of protein and energy and the body’s demand from each source, ultimately affecting optimal growth and functioning (de Onis & Blössner, 1997:3). Malnutrition can be a result of several factors often related to the poor quality of food, nutrient deficiencies, infectious diseases and diets based on inappropriate food choices and portions (de Onis & Blössner, 1997:3; Shetty, 2006:524). Malnutrition generally implies undernutrition, however, the term rather refers to both deviations above or below the adequate nutritional status (Shetty, 2006:524).

The South African National Youth Risk Behaviour Survey cross-sectional data from 2002 and 2008 indicated a substantial increase in the rates of weight gain and obesity. This suggests that South Africa is experiencing a nutritional transition, which is a key driving force behind malnutrition (Kimani-Murage, Kahn, Pettifor, Tollman, Dunger, Gómez-Olivé & Norris, 2010:159; Reddy, Resnicow, James, Funani, Kambaran, Omardien, Masuka, Sewpaul, Vaughan & Mbewu, 2012:264). Developing countries tend to go through socio-economic and nutritional transitions which can cause an increase in overnutrition and a decrease in undernutrition (Puoane, Steyn, Bradshaw, Laubscher, Fourie, Lambert & Mbananga, 2002:1046; McVeigh et al., 2004:982; Reddy et al., 2012:262). The nutritional transition typically begins in urban populations but is also known to affect lower socio-economic areas and is often accompanied by changes in diet (Popkin, 2003:518). As a result, rapid urbanisation in South Africa has caused a shift from traditional low fat, high-fibre diets to an increase in the consumption of energy-dense foods which are high in sugar, fats and carbohydrates (Kimani- Murage et al., 2010:159).

Concerns for malnutrition are not limited to adults alone as children are also largely at risk (WHO, 2017). Childhood growth largely revolves around the availability of nutritious food (the abundance or lack thereof) which is dependent on the economic status of the family (Travill, Cameron & Kemper, 2008:37). Children who are undernourished are often underdeveloped and may display reduced resistance to disease, while children who are over nourished are at a risk of NCD’s (Rossouw, Grant & Viljoen, 2012:5). Therefore, childhood malnutrition is a serious health concern. The implications of childhood undernutrition may only manifest later in life as poor nutrition during childhood may lead to adaptations which result in obesity later in life (Kimani- Murage et al., 2010:159, 168). Thus, the nutritional status of children is fundamental to their growth and development. Overnutrition and undernutrition are both considered as high risk in terms of the global burden of disease (Reddy et al., 2008:37). It becomes complex when undernutrition and overweight or obesity are found in the same household, or even affect the same child (Rossouw et al., 2012:6). In South Africa, the prevalence of overweight and obesity is higher amongst girls, while the prevalence of stunting and wasting is higher amongst boys (Monyeki, Awotidebe, Strydom, De Ridder, Mamabolo & Kemper, 2015:1167).

The following subsection describes the prevalence of overnutrition among South African children as well as factors which contribute to the incidence of childhood overweight and obesity.

2.6.2.1 Prevalence of overnutrition amongst South African children

Obesity occurs as a result of an energy imbalance in which energy intake exceeds energy expenditure (Parsons, Power, Logan & Summerbelt, 1999:S19). If this imbalance is sustained over long periods of time, the excess energy is stored in fat cells and accumulates as body fat. Obesity stems from a plethora of contributing factors which affect all backgrounds, social classes and ethnic origins.

In South Africa, an increased prevalence of overnutrition is often found among Black African women (Mvo, 1999:27; Puoane et al., 2002:1046). In Black African culture, food plays a pivitol role as it is positively associated with wealth and happiness and a lack thereof is associated with poverty (Puoane, Matwa, Hughes & Bradley, 2006:91 - 92). According to research conducted by Mvo (1999:27), weight loss and thinness is

often associated with problems and periods of anxiety within the Black African culture. It has been established that knowledge concerning nutrition is influenced by learned cultural norms and beliefs (Shisana, Labadarios, Rehle, Simbayi, Zuma, Reddy, Parker, Hoosain, Naidoo & Team, 2014:179). Therefore, a basic understanding of nutrition and knowledge about food intake and PA plays an important role in the prevention of obesity and related NCD’s (Shisana et al., 2014:177).

According to the South African National Health and Nutrition Examination (SANHNE) Survey, the prevalence of overweight and obesity for children aged between 2 and 14 years was higher amongst girls than boys (16.5% and 7.1% in comparison to 11% and 4.7% for girls and boys, respectively) (Shisana et al., 2014:204). Furthermore, higher rates of obesity were found among children from urban populations when compared to children living in rural areas (Shisana et al., 2014:204). A combined overweight and obesity prevalence of 13.5% was reported amongst schoolchildren, aged 6 to 14 years, which was higher than the global average trend of 10% (Shisana et al., 2014:211). Childhood obesity may also be a learned behaviour of bad eating habits that may be adopted from a young age (Cooke, 2009:72). Thus, the parenting practices of overweight and obese children are crucial, as parents may influence the nutritional and activity-related choices of their children. Overnutrition has adverse effects on children’s health both in short-term as well as the long-term. Children who are overweight and obese are likely to experience cardiovascular complications (increased risk factors for NCD’s) and psychosocial consequences (self-development, emotional development and social development) which may affect the child’s overall development (Reilly, Methven, McDowell, Hacking, Alexander, Stewart & Kelnar, 2003:748 - 749).

Along with the prevalence of childhood obesity, researchers have found a significant association between stunting and overweight children. This association is especially true in countries that experience nutrient transition as well as large changes in their diet (Popkin, Richards & Montiero, 1996:3009). The phenomenon is said to be the cause of inadequate nutritional adaptations during the foetal and early childhood stages which can result in obesity later in life (Kimani-Murage et al., 2010:168).

2.6.2.2 Prevalence of undernutrition amongst South African children

Undernutrition, as a result of insufficient food (or in some cases an infectious disease) may lead to wasting, thinness, underweight and stunted growth (de Onis, 2015:11). Furthermore, children who experience undernutrition may also be predisposed to infection and impaired physiological function which may reduce their work capacity (Shetty, 2006:524).

Results from the SANHNE revealed that boys were more stunted, underweight and thinner in comparison to girls (Shisana et al., 2014:211). For children from 0-to-14- years of age, the prevalence of stunting was 15.4%, 2.9% of children were wasted (thin) and 5.8% of children were categorised as underweight (Shisana et al., 2014:207). When considering geographical areas, the incidence of undernutrition was mostly prevalent in the rural areas (Shisana et al., 2014:211). The incidence of undernutrition was highest among Coloured children, followed by Black African children, the prevalence was 18.6% and 16.7% for stunting, 4.5% and 3.8% for wasting and 11.5% and 6.8% for underweight, respectively (Shisana et al., 2014:208). Overall, the prevalence of undernutrition in rural informal areas was 20.6%, 6.8% and 12.1% for stunting, wasting and underweight, respectively (Shisana et al., 2014:207).

This disparity in the undernutrition prevalence suggests that the imprint of the apartheid history is still apparent as groups suffering poverty are largely susceptible to developing nutritional disorders (Armstrong, Lambert & Lambert, 2011:835). Undernutrition is not merely a lack of food intake (quantity) but also an inadequate intake of nutritious food (quality). Thus, children from poverty-stricken areas who are not sufficiently nourished may lack concentration for school work and the energy to play and be physically active (Graham, Hochfeld, Stuart & Van Gent, 2015:12). The following section will review concerns regarding physical inactivity among South African children.