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South African Journal of Child Health

versão On-line ISSN 1999-7671
versão impressa ISSN 1994-3032

S. Afr. j. child health vol.13 no.3 Cape Town Set. 2019 



Results from the Healthy Active Kids South Africa 2018 Report Card



C E DraperI, II; S A TomazII; S H BassettIII; J HarbronIV; H S KrugerV; L K MicklesfieldI, II; A MonyekiVI; E V LambertII, VII

IPhD SA MRC Developmental Pathways for Health Research Unit, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
IIPhD Division of Exercise and Sports Medicine, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, South Africa
IIIPhD; Department of Sport, Recreation and Exercise Science, Faculty of Community and Health, University of the Western Cape, Cape Town, South Africa
IVPhD; Division of Human Nutrition, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, South Africa
VPhD; Centre of Excellence for Nutrition, Faculty of Health Sciences, North-West University, Potchefstroom, South Africa
VIPhD; Physical Activity, Recreation and Sport Sciences Research Focus Area, Faculty of Health Sciences, North-West University, Potchefstroom, South Africa
VIIPhD; Health through Physical Activity, Lifestyle and Sport Research Centre, Faculty of Health Sciences, University of Cape Town, South Africa





BACKGROUND. Healthy Active Kids South Africa (HAKSA) Report Cards were produced in 2007, 2010, 2014 and 2016.
OBJECTIVE. The 2018 Report Card aims to report on the latest available evidence relating to the physical activity (PA), nutrition and body
composition of South African (SA) children and adolescents.
METHODS. A review was conducted using the following databases: PubMed; Africa Journals Online; and Africa-Wide (EBSCOhost). Articles published from January 2016 to September 2018 were included for review by the HAKSA scientific advisory group. Data were extracted, and a grade for each indicator was assigned based on the available evidence and the consensus of the scientific advisory group. This included 12 PA indicators, 6 nutrition indicators and 3 body composition indicators.
RESULTS. There was no evidence of a significant change in any of the indicators since the 2016 Report Card. Grades for certain indicators have been downgraded (from 2016) to bring these to the attention of relevant stakeholders and industry. These include food insecurity and grades that relate to the implementation of policy on PA and nutrition in the school environment, and on advertising and media relating to nutrition.
CONCLUSION. Key priorities for action include: safe opportunities for physical activity; minimising the gap between policy and implementation (school culture and environment, and government strategies); and the double burden of over- and undernutrition, which relates to the continuing concern about food insecurity in SA. There is a need for further research, including surveillance, on all indicators, for future Report Cards.



Physical activity (PA) is beneficial for the physical and mental health of children and adolescents (0 - 17 years old),[1,2] while higher levels of sedentary behaviour (particularly screen time) are associated with unfavourable health outcomes.[3,4] Nutrition has been recognised as a factor contributing to the development of overweight/obesity in children and adolescents.[5]A nutrient-dense diet and regular PA are beneficial for overall child growth, health and wellbeing.[6] Healthy lifestyle behaviours also play a role in cognitive development and school achievement in children and adolescents.[7]

The Healthy Active Kids South Africa (HAKSA) Report Card reviews the most current evidence on the PA, nutrition and body composition of South African (SA) children and adolescents. This evidence provides the basis from which to guide policy, develop interventions and programmes and strengthen advocacy to create healthy environments and support healthy nutrition and PA, and discourage sedentary behaviours in SA children and adolescents. Children and adolescents (0 - 19 years old) make up 39% of the total population of SA (~52 million people in total).[8] Although this proportion of children and adolescents is relatively high, it is lower than those in some other African countries: the proportion of children and adolescents 0 - 14 years old (a narrower age range) is also 39% in Zimbabwe (population ~13.8 million), and in Nigeria the proportion of 0 - 14 year olds is 43% (population ~190.6 million).[9-Results from the HAKSA 2016 Report Card indicated that more than 50% of SA children were meeting PA recommendations, and government policies for the support of sport and PA in children and adolescents were evident. Areas of concern were high amounts of screen time and sedentary behaviour, as well as low fruit and vegetable consumption, and high intake of sugar-sweetened beverages (SSBs) and fast foods. Undernutrition and overweight/obesity were highlighted as a concern, as overweight prevalence was increasing,[10] and the HAKSA 2016 Report Card highlighted the persistence of the double burden of under- and over-nutrition across South Africa.[11] The HAKSA 2018 Report Card is the fifth in the series (since 2007),[10-12] and aims to report on the available evidence relating to PA, sedentary behaviours, nutrition and body composition of SA children and adolescents (3 -18 years old) published since the 2016 Report Card. In addition, we consider the related environmental and ecological factors that may be barriers to or facilitators for healthy eating and PA in SA children and adolescents.



The HAKSA 2018 Report Card has been developed and produced by a scientific advisory group consisting of 29 academics and/or content experts, with group leaders for physical activity, nutrition, body composition and early childhood content (in the context of this article, 'early childhood' refers to preschool-aged children, or those aged between 3 and 5 years old). Comprehensive searches on PubMed, Africa Journals Online, Africa-Wide Information (hosted by EBSCO) databases for evidence published from January 2016 - September 2018 on PA, nutrition and body composition in SA children and adolescents (3 - 18 years old) were conducted. Exclusion criteria were (i) review articles; (ii) studies in which the participants were exclusively over 18 years old; (iii) studies conducted outside of SA; and (iv) articles included in previous Report Cards. The HAKSA 2018 Report Card comprises 3 categories of indicators: PA, nutrition and body composition (Table 1). The PA indicators are aligned to a larger, international initiative, the Active Healthy Kids Global Alliance, which involves 49 countries.[13] Data from these countries are harmonised for comparison.

The search yielded 805 titles, of which 62 were extracted for consideration (35 PA, 14 nutrition, 7 body composition and 9 early childhood (covering PA and body composition), with some overlap between different indicators). In addition, hand-searching was conducted by members of the scientific advisory group. Members of the group were each assigned between 2 and 4 full manuscripts to critically appraise.[14] Key study methods and findings relevant to the indicators were extracted and submitted to group leaders, who then summarised the findings for their theme. Where necessary, cross-checking of extracted data was done by the group leaders and first author of the present article. Content groups were asked to compile a summary report and to propose grades (with justification) for each indicator, taking into consideration the grades assigned in the HAKSA 2016 Report Card, to assess whether any improvements had occurred.[10] These grades were then discussed in order to reach consensus within each group, and all groups were provided with an opportunity to comment on them so that there was consensus on all grades within the scientific advisory group.

Meetings were held in person and online to reach consensus on the grade assignment. Grades were assigned to each indicator within each of the four categories, ranging from A to F (Table 2), and a rationale for each grade was constructed.



Most of the indicators were informed by smaller regional studies, as the only national data available for the past 2 years related to active transportation, the National School Nutrition Programme (NSNP), food security and body composition. Tables 3 - 5 provide the grade and a rationale for each indicator within the categories of PA, nutrition and body composition, respectively. A full reference list is available on request from the authors. Table 6 presents grades assigned for the 2014, 2016 and 2018 Report Cards, to indicate progress or lack thereof.




There was no evidence of improvements or declines since 2016 in any of the PA, nutrition and body composition indicators included in the HAKSA 2018 Report Card. The only indicators that seem positive are early childhood PA and gross motor proficiency (specifically in preschool-aged children), although further research is required to establish whether these levels are maintained as preschool-aged children transition into formal schooling. Furthermore, since a grade was not previously included for these early childhood indicators, it is not possible to state that this is an improvement. All indicators would benefit from additional research, and particularly research that is able to provide a national perspective, considering the heterogeneity that was identified for some indicators, particularly across different income settings. There are challenges in measuring and reporting on the prevalence of certain behaviours and activities, e.g. active play, organised sports participation and PA at school. It was also challenging to obtain accurate data on SA children and adolescents' online exposure to food and beverage marketing, specifically SSBs and fast food. As electronic media become increasingly accessible to this age group in SA, along with increased uptake and use of social media and the global shift towards digital forms of marketing, it is more important than ever to track this exposure and its potential impact on behaviour.

Despite the absence of new evidence of improvements or declines in any of the PA, nutrition and body composition indicators between 2016 and 2018, certain indicators have been downgraded (as described in Tables 3 and 4) since the 2016 Report Card. These include PA indicators for school and government, and nutrition indicators for the NSNP, food security and advertising and media. The purpose of downgrading these indicators was to highlight the lack of progress in these areas, in the hope that relevant stakeholders and industry would take necessary action. In particular, the development and implementation of policies on PA and nutrition in the school environment, and on advertising and media relating to unhealthy eating, are needed. The food insecurity indicator was also downgraded, to highlight the lack of sufficient effort to improve access to food of adequate quality for those living in the poorest of circumstances in SA. For children and adolescents specifically, failure to act could have significant consequences for cognitive development and academic outcomes.[7] The worsening of food insecurity is particularly concerning in light of the growth of the fast food industry and increases in SSB sales.

The HAKSA 2018 Report Card findings highlight a number of key priorities that require action. Firstly, safety remains a concern for SA children and adolescents, particularly in low-income communities: it was raised as an issue for three of the PA indicators: 'active play', 'active transportation' and 'community and environment'. There is an apparent lack of a systematic approach to deal with this issue. While further research is required to fully understand the nature of the impact of safety concerns on children's PA and play, children's safety and vulnerability should be a priority on a far broader agenda than this.

Secondly, there remains a significant gap between policy and implementation, particularly with regard to the school environment and government strategies to promote PA and healthy nutrition among children and adolescents. It appears that there is little accountability for lack of implementation, and that what has been implemented has not been rigorously evaluated.

Thirdly, the double burden of under- and over-nutrition persists among SA children and adolescents. Overweight/obesity continues to be high (especially among girls), despite the presence of food insecurity, which again highlights the need for better access to food of good quality, rather than merely food of high caloric content. However, this will remain challenging as the fast food industry grows, and if the sale of SSBs continues to rise. Furthermore, it is essential to consider the broader food environment and the food and beverage industry as a whole, and the impact that these may have on the nutrition and body composition of SA children and adolescents. The competitive nature of multinational food companies, their rapid penetration of markets in low- and middle-income countries and their targeting of children and parents in an effort to develop taste preferences early in life warrant consideration.[66] There is a broader need in SA to address food environments, and how these can be adapted to support children and adolescents to make healthy food choices, in order to improve overall child health and support growth.[67]

In terms of limitations of the present review article, certain data that have been included should be interpreted with caution. These include self-report PA data, which are likely to be less reliable than objective measures. They also include the body composition data presented by the SA Demographic and Health Survey (SADHS)[56] for adolescents, which used adult BMI cut-offs. Furthermore, the early childhood body composition data from the SADHS present much lower levels of overweight (9.1%) than the SA National Health and Nutrition Examination Survey (SANHANES; 18.2%),[68] which used International Obesity Task Force cut-offs,[65] for this age group. In addition, owing to limited prevalence data, conclusions have mostly been drawn based on smaller, regional studies.



The HAKSA 2018 Report Card provides an evidence-based call to action for all those with a vested interest in the health, development and wellbeing of SA children and adolescents. With the rising prevalence of overweight/obesity and non-communicable diseases in SA adults,[56] the need to establish healthy lifestyle behaviours and promote environments that support healthy choices among children and adolescents is more important than ever. A healthier generation of young South Africans could contribute to the progress and development of our country.

Acknowledgements. In addition to the listed authors, the HAKSA 2018 Report Card Scientific Advisory Group consists of: C Burnett (University of Johannesburg), CJ Christie (Rhodes University), CJ Cook (University of Cape Town), C Cozett (University of the Western Cape), M de Milander (University of the Free State), H Dugmore (Rhodes University), M Faber (SA Medical Research Council), S Krog (University of South Africa), T Liebenberg (Sports Science Institute of SA), Z Mchiza (University of the Western Cape), K McQuaide (Sports Science Institute of SA), ST Meltzer (Sports Science Institute of SA), N Naidoo (University of Cape Town), R Naidoo (University of KwaZulu-Natal), A Prioreschi (University of the Witwatersrand), AE Pienaar (North-West University), T Puoane (University of the Western Cape), B Tromp (SA Heart and Stroke Foundation), M van Gent (University of Fort Hare), C Walter (Nelson Mandela University), E Watson (University of the Witwatersrand).

Author contributions. CED and EVL were co-leaders of the HAKSA 2018 Report Card. CED co-ordinated the scientific advisory group and the compilation of the final lay report, and drafted the manuscript. SAT conducted the literature searches and helped to co-ordinate the review process. In the Scientific Advisory Group, SHB and AM were leaders of the PA group; JH led the nutrition group; and HSK and LKM co-ordinated the body composition group. All authors edited and commented on the manuscript and approved the final version.

Funding. None.

Conflicts of interest. None



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C E Draper

Accepted 20 May 2019

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