Has Food Security and Nutritional Status Improved in Children 1–<10 Years in Two Provinces of South Africa between 1999 (National Food Consumption Survey) and 2018 (Provincial Dietary Intake Study (PDIS))

Reviewer 1

Thanks for valuable comments

The idea and content are pretty good. However, the interpretation of the results should be carefully performed. For instance, the food security and nutritional status should include whether the freshness of the perishable foods improved. For instance, seafood spoilage will not change too much the calories but affected the quality significantly. eg., Food Control, 123, 107697;

The main food items consumed in 1999 and 2018 remained similar with the main contributors to energy intake being maize porridge, bread, salty snacks and granulated sugar. We did not examine the perishability of food items since this was not an objective of the study and intake of fish, except canned fish, fruit and vegetables was low and did not contribute significantly to energy intake as you will notice in Table 6.

Another key term should be discussed is whether more nutrient-dense foods were consumed in 2018. The low calorie does not necessarily poor but may due to some health concern. Thus another key aspect 'nutrient dense' foods should be discussed, fresh produce, seafood etc. For instance, Food Chemistry, 354, 129581.

This was an important point made by the reviewer and we have subsequently added results on energy density. See table 6 and Lines 406-423.

Energy intake increased significantly in GTG which explains some of the improvement in growth. However, many of the commonly consumed items are energy-dense, such as sugar sweetened beverages, candies and salty snacks [25].

Reviewer 2

Thank you for your valuable comments

1) the novelty of this paper is not clearly articulated. The result may be produced by any government report, but what is the value addition of this scientific work? 

Thank you we agree with this comment and have subsequently refocused the aim of the study: lines 88-93

The aim of the present study was to determine whether food security and nutritional status (diet and anthropometry) have improved in households of 1 - <10-year-old children in two provinces in since the 1999 NFCS. Furthermore, we aimed to investigate sociodemographic profiles of the households, sociodemographic predictors of food shortage in these households and relationships between household food security and child dietary and malnutrition indicators at each time point.

In order to explain the changes in food security in the two provinces we tried to evaluate all the available data to account for these changes. In order to do this, we also added additional data, namely sociodemographic factors at the two time points (Table 1), dietary changes (Table 6) and examined the association between food security and diet and anthropometry (Table 8) at the two time points. In the discussion we also described some additional factors which may have led to changes such as government initiatives introduced after 1994 when South Africa became a democracy.

2) Results from the socio-economic factors need to be highlighted broadly in the abstract and also in the conclusion

Table 1 with the socio-demographic factors has been added and in abstract lines 28-30 reflect this. In results section lines 459-475; in discussion lines 491-496; 614-617; 622-627 and in conclusion 641-644.

Reviewer 3

Thank you for your valuable comments

abstract

Line 14 -23 - reorganize percentages to be in the same order as corresponding dates - from 55% to to 29.6%.  Also use consistent number of decimal places.

This has been corrected

Line 40 - states 1999 study was on children aged 1-9 so how can comparisons be made for children older than that as stated in title?

The title had a typing error and we have corrected it

Introduction 

Line 73 - does not make sense

Corrected lines 77-79

Improvements have also been made to health services with the introduction of the Integrated School Health Program (ISHP)[13] comprising three core components, namely: health assessment and screening, on-site health services, and health promotion. Additionally, improved primary health care clinic services and free health services for children between 0-6 years and expectant and breastfeeding mothers were introduced [14]

Methods

Line 113 - repeated sentence

Corrected

Line 117 - the calculation use to obtain sample size is not clear

Lines 127-133. The sampling was done according to the USAID Household Sampling and Listing Method. This is part of the DHS survey toolkit.[16]y

Table 1: it is very confusing to put p values in one column that pertain to various columns. Reorganize the table to put the p value clearing next to relevant result.

This has been corrected in what is now Table 2

Line 305-308 this is a repeated line

The repetition has been deleted

Table 5 explanation cut off so not sure what *   **  means 

This has been corrected under Table 5.

Discussion 

Line 387-390 : clarify years and locations you are talking about

This refers to all the children studied in both provinces (lines 485-487)

Is it not also important to note that wasting actually increased among older children in Gauteng and discuss why this could be happening?

We agree that this needs to be mentioned.

We have added this to lines 21-22 in abstract, lines 435-437 in results and lines 510-512 in discussion

Overall wasting increased from 10.3% to 14.4% in GTG and decreased from 11.8 to 10.1% in WC. It is particularly high in older children (6-<10 years) and is difficult to explain since primary school children receive school meals.

Reviewer 3

Thank you for your valuable comments

abstract

Line 14 -23 - reorganize percentages to be in the same order as corresponding dates - from 55% to to 29.6%.  Also use consistent number of decimal places.

This has been corrected

Line 40 - states 1999 study was on children aged 1-9 so how can comparisons be made for children older than that as stated in title?

The title had a typing error and we have corrected it

Introduction 

Line 73 - does not make sense

Corrected lines 77-79

Improvements have also been made to health services with the introduction of the Integrated School Health Program (ISHP)[13] comprising three core components, namely: health assessment and screening, on-site health services, and health promotion. Additionally, improved primary health care clinic services and free health services for children between 0-6 years and expectant and breastfeeding mothers were introduced [14]

Methods

Line 113 - repeated sentence

Corrected

Line 117 - the calculation use to obtain sample size is not clear

Lines 127-133. The sampling was done according to the USAID Household Sampling and Listing Method. This is part of the DHS survey toolkit.[16]y

Table 1: it is very confusing to put p values in one column that pertain to various columns. Reorganize the table to put the p value clearing next to relevant result.

This has been corrected in what is now Table 2

Line 305-308 this is a repeated line

The repetition has been deleted

Table 5 explanation cut off so not sure what *   **  means 

This has been corrected under Table 5.

Discussion 

Line 387-390 : clarify years and locations you are talking about

This refers to all the children studied in both provinces (lines 485-487)

Is it not also important to note that wasting actually increased among older children in Gauteng and discuss why this could be happening?

We agree that this needs to be mentioned.

We have added this to lines 21-22 in abstract, lines 435-437 in results and lines 510-512 in discussion

Overall wasting increased from 10.3% to 14.4% in GTG and decreased from 11.8 to 10.1% in WC. It is particularly high in older children (6-<10 years) and is difficult to explain since primary school children receive school meals.

Reviewer 4

Thank you for your valuable comments

The topic that the paper describes it is important. However, I think that the quality of the paper should be improved extensively. It seems that you mention some data and present a report of your results but you do not tell a story. Moreover, what is the importance of this paper from a scientific point of view? You start by mentioning some data about hunger levels in the introduction, present the results and then discuss about grants. What is the connection between all these things? Thus, keep in mind to tell the story. Finally, it is not very clear what is the relevance of your paper. Why scientists should read it? What is the gap that is trying to fill? You have not mentioned what the literature on this topic is about.

Thank you we agree with this comment and have subsequently refocused the aim of the study: lines 88-93

The aim of the present study was to determine whether food security and nutritional status (diet and anthropometry) have improved in households of 1 - <10-year-old children in two provinces in since the 1999 NFCS. Furthermore, we aimed to investigate sociodemographic profiles of the households, sociodemographic predictors of food shortage in these households and relationships between household food security and child dietary and malnutrition indicators at each time point.

In order to explain the changes in food security in the two provinces we tried to evaluate all the available data to account for these changes. In order to do this, we also added additional data, namely sociodemographic factors at the two time points (Table 1), dietary changes (Table 6) and examined the association between food security and diet and anthropometry (Table 8) at the two time points. In the discussion we also described some additional factors which may have led to changes such as government initiatives introduced after 1994 when South Africa became a democracy.

The title seems to start as a question but I dont see the question mark.

Question mark has been added

Lines 14 to 17 not very clear. Try to divide the sentence

Corrected as requested also by another reviewer.

Introduction:

1. This part is a bit confusing. The paper seems to be for children, but you also mention adults. The paragraphs seems disconnected. Probably you should start by mentioning the general conditions of food security and then explain how it is reflected to children. Remember, you are telling a story. 
2. line 33, in children should be written among children
3. line 34: You start talking about children and then you mentioned women 15-49 years old. Even though you might have mentioned it to illustrate the situation, I find it confusing. Stick to children.

1. Unfortunately there was a typing error in the title which has been corrected to children under 10 years old.

2. Correction made

3. The statistics on overweight/obesity in South African women were included to illustrate the finding that the double burden of malnutrition exists in South Africa. However, the reviewer makes an important point hence we have removed this sentence

In the methodology's part, it is not very clear if the regions are the same for both, 1999 and 2018. Explain this.

Random EAs were drawn in 1999 and 2018 keeping the domains the same, namely urban formal, urban informal and rural EAs. Every attempt was made to keep the repeated survey as similar as possible to that of 1999.

Conclusion: Here you are talking extensively about grants and their impacts but you do not mention results of your study. Moreover, in the introduction you do not mention grants. Subsequently, it is not very clear from where grants come out. Remember that in this section you should explain the implications that your results have.

Grants are mentioned in the introduction in lines 71-81:

To combat poverty and food insecurity the South African Government has introduced numerous social benefits and programs, including a social grants (cash transfers) such as the childcare and foster care grants [10]. Furthermore, a National School Nutrition Program (NSNP) has been introduced to provide hungry children with a daily meal at school [11], community food garden initiatives and a national fortification program was introduced to combat micronutrient deficiencies [12]. Improvements have also been made to health services with the introduction of the Integrated School Health Program (ISHP)[13] comprising three core components, namely: health assessment and screening, on-site health services, and health promotion. Additionally, improved primary health care clinic services and free health services for children between 0-6 years and expectant and breastfeeding mothers [14].

We have also refocused the aim:

The aim of the present study was to determine whether food security and nutritional status (diet and anthropometry) have improved in households of 1 - <10-year-old children in two provinces in since the 1999 NFCS. Furthermore, we aimed to investigate sociodemographic profiles of the households, sociodemographic predictors of food shortage in these households and relationships between household food security and child dietary and malnutrition indicators at each time point.

In order to explain the changes in food security in the two provinces we tried to evaluate all the available data to account for these changes. In order to do this, we have added additional data, namely sociodemographic factors at the two time points (Table 1), dietary changes (Table 6) and examined the association between food security and diet and anthropometry (Table 8) at the two time points. In the discussion we also described some additional factors which may have led to changes such as government initiatives introduced after 1994 when South Africa became a democracy.

Conclusion: In contrast with 1999, no predictors of risk of food security remained in GTG and only one in the WC (living in an informal area). Protectors against food shortage remained similar over time and mostly involved having better educated and employed parents. The improvement in food security may have contributed to the increase in energy intake of children in GTG and subsequent improvements in nutritional status.  However, it is a concern that the improvement in food security has been accompanied by increased overweight and obesity, especially in the younger children in both provinces. It is not possible to say conclusively that the government initiatives led to the improvements in food security but evidence from the South African literature has indicated that many of these initiatives have been successful, particularly the child support grant and the NSNP.

Reviewer 5

Thank you for your valuable comments

This is an interesting paper with a great deal of data. The authors conducted adequate analysis and conclusions are supported by the data. Methods used are simple but sound. I have only minor comments regarding the paper.

1. The tile talks about "children 1-<20years" but the paper present data about children 1-10 years.
2.  Table 1 could have separate columns for the p-values, just as table 2. It would be easier to understand.
3. Table 4 "gauteng" panel shows "total protein g" twice. 

1.The title had a typing error which has been corrected to children <10 years

2. Table 1 (now 2) has been simplified.

3. This has been corrected.