Dietary and lifestyle practices in rural and urban South African adolescents

Sedibe, Modiehi Heather
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Introduction: Among adolescents, the occurrence of overweight and obesity has become a crucial public health challenge, in high-income and low- and middle-income settings. It is a phenomenon that has been strongly associated with environmental factors, particularly modifiable lifestyle factors and behaviours linked to diet and physical activity. Dietary practices and habits developed in childhood and usually maintained into adulthood, are said to predispose individuals to obesity and increased risk of metabolic diseases. South Africa is also undergoing rapid nutrition transition, which is associated with changes in dietary and physical activity patterns. Recent national findings have shown onsets of obesity among African children as early as 2-5 years of age, and the combined prevalence of overweight and obesity of 22.3% and 10.2% among 10-14 year old female and male adolescents, respectively. Not much is known about dietary, eating and physical activity practices of urban and rural South African adolescents, and the social factors that influence these practices within the home, community, and school environments. Research is needed to help inform interventions that curtail the burgeoning obesity epidemic among South African adolescents. Aims: This thesis aimed to explore and compare dietary practices, eating practices, and lifestyle practices of adolescents across various levels of social influences including the household, school and community in rural vs urban adolescents. Methods: This study employed a mixed methods study design, using both qualitative in-depth interviews and retrospective cross-sectional data. There are four studies to the thesis, with study components one, two, and three employing qualitative research, in both an urban and rural setting. Firstly a qualitative exploratory multiple case study approach was used to explore eating patterns, friendship and social interactions around dietary habits among 58 female adolescents (29 friend pairs) still in high school (mean age =18 years) in an urban Soweto setting; secondly narratives pertaining to dietary and physical activity practices among 58 female adolescents (29 friend pairs) still in high school (mean age =18 years) in an urban Soweto setting; thirdly semi-structured duo-interviews to explore perceptions, attitudes, barriers and facilitators related to healthy eating and physical activity practices among 22 female adolescents (11 pairs) still in high school (aged 16-19 years) in rural Agincourt Health and Socio-demographic Surveillance System (AHDSS); lastly a cross-sectional quantitative assessment and comparison of dietary habits, eating practices, and anthropometric measurements were performed on rural (n=392, mean age=13 years) and urban (n=3098, mean age=14 years) South African adolescents. Results: In study 1, among urban female friends, food sharing and money pooling was common. Joint food choices at school were mostly unhealthy, influenced by availability, prices and quality. Within shopping malls, food preference influenced joint food choices. In study 2, which was conducted on the same sample as study 1, majority of the urban girls were purchasing locally prepared convenience foods from school vendors instead of home-prepared breakfast, and most preferred to purchase food from the school tuck shop instead of using lunch boxes. ―Kotas‖, ―fat‖ cakes and snacks were popular lunch choices because of their affordability, convenience, and popularity. Respondents engaged in minimal active recreational activities due to lack of facilities and safety concerns. Findings of study 3, among rural adolescent girls, majority of participants considered locally grown and traditional foods to be healthy, but their consumption was limited due to availability. Female caregivers and school meal programmes were the main promoters of healthy eating practices. Limited food within the household was a barrier to eating breakfast before going to school, majority cited limited accessibility to healthy foods as a major barrier to healthy eating, and noted the increasing intake of ―convenient and less healthy foods‖. Girls were aware of the benefits of physical activity and engaged in various physical activities within the home, community, and schools. According to study 4 findings, there were differences in dietary habits and eating practices by gender and between urban and rural adolescents within the home, community, and school. After adjusting for gender, and site, irregular and regular frequency of consuming family meals, and irregular frequency of consuming breakfast on weekdays were all associated with increased risk of being overweight or obese. For mid-adolescent participants, irregular frequency of consuming breakfast on weekends within the home environment was associated with increased risk of being overweight and obese. For both early- and mid-adolescent participants, being male and residing in a rural setting were associated with reduced risk of being overweight and obese. Conclusion: In conclusion, interventions aimed at reducing the increasing prevalence of overweight and obesity among adolescents in particular, have to be sensitive to socio-cultural contexts and specific realities within the different settings. Our findings suggest that future research aimed at addressing the increasing risk of overweight and obesity among rural, and especially urban adolescents; should investigate interventions to: (i) improve the availability and access to healthier breakfast options within the home; (ii) healthier and affordable fast food options within the community; (iii) subsidising good quality food, with the involvement of school vendors and tuck shops within school environments and (iv) improving dietary habits and eating practices within the home environment in order to reduce the risk of being overweight and obese among adolescents.
A THESIS Submitted to the Faculty of Health Sciences, University of the Witwatersrand, in fulfilment of the requirements for the degree of Doctor of Philosophy JOHANNESBURG, SOUTH AFRICA 2016