Snack consumption frequency of children and adults in the Vaal region of Gauteng, South Africa

Background Energy-dense, nutrient-poor snacks are associated with an increased risk of non-communicable diseases (NCDs) and the double burden of malnutrition, especially among poor communities. Aim To determine and compare the snacking preferences and consumption frequency of children and adults from a low SES community in South Africa. Setting A preschool, primary school, and an elderly centre in Gauteng. Methods A cross-sectional study with a convenience sample of 90 children (3–8 years) and 100 adults (≥ 18 years) to assess snack consumption frequency and preferences of children and adults by means of a snack survey. Mann-Whitney U test was used to determine the differences in preferences and snack consumption frequency of children and adults. Results The most preferred and consumed snacks included fruits, potato chips, corn chips, sweets, and cookies. Children frequently ate more potato chips (p < 0.001), corn chips (p < 0.001), cheese curls (p < 0.001), and muffins (p = 0.024) than adults. In contrast, adults frequently consumed more peanuts or nuts (p = 0.024), savoury biscuits (p = 0.048) and biltong (p < 0.001) than children. Conclusion Apart from fruits, the most preferred and frequently consumed snacks by the sample were highly processed snacks, which are low in fibre and high in added sugars, saturated fat, and sodium. Contributions Findings from this study highlight current snack trends and can guide future nutrition education interventions on healthy snacking and in developing nutritious snacks for the South African community


Introduction
Over the last decades, snack consumption has been rising in South Africa (Hassanally, Naicker & Singh 2020;Ronquest-Ross, Vink & Sigge 2015).This increase in snack consumption is of public concern because of the connection to the double burden of malnutrition (DBM) -the coexistence of undernutrition and overweight or obesity in the same population, community, household or person (Mkhize, Napier & Oldewage-Theron 2013;Moyo, Egal & Oldewage-Theron 2022;Popkin, Corvalan & Grummer-Strawn 2020).In a 2020 Lancet series, the consumption of cheap snacks and beverages was identified as the leading risk factor for DBM, particularly among low-and middle-income countries (LMICs) such as South Africa (Popkin et al. 2020;Wells et al. 2020).
Interestingly, South Africa is facing the DBM.The latest South African Health and Demographic Survey (SADHS) 2016 reported that although undernutrition was still prevalent in 27% of children under 5 years (U5) being stunted -with 10% severely stunted -overweight was also prevalent in 13% of U5 children (National Department of Health [NDoH], StatsSA & SAMRC 2019;StatsSA 2017).Among older children and adolescents (5-19 years), 29.4% of girls and 20.2% of boys are overweight, while 3.4% of girls and 6.0% of boys are underweight.The prevalence of obesity among older children and adolescents is 12.8% among girls and 9.8% among boys.Likewise, the prevalence of obesity in South African women is almost four times that in men, while underweight in men is three times higher than in women (McHiza et al. 2019).There is thus a trend that the Background: Energy-dense, nutrient-poor snacks are associated with an increased risk of non-communicable diseases (NCDs) and the double burden of malnutrition, especially among poor communities.

Snack consumption frequency of children and adults in the Vaal region of Gauteng, South Africa
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prevalence of being overweight is increasing with age in the country.
South Africa has been experiencing a nutritional transition over the last two decades (Vorster, Kruger & Margetts 2011;Wrottesley et al. 2019;Zingoni et al. 2009).In particular, this transition has been characterised by increased consumption of sugary drinks, sweets, savoury snacks, and ultra processed and packaged snack foods that are lower in fibre and high in salt, sugar and saturated fats (NDoH 2022).
Although some snacks can provide essential nutrients, majority of the consumed snacks in South Africa are nutrient-poor and energy-dense.Taste, affordability and availability are the most common factors leading to the continuous increase in snack consumption in South Africa (Govender et al. 2018;Wrottesley et al. 2020).The healthier snacks are generally more expensive than most available snacks (Govender et al. 2018;Herforth et al. 2020).This high cost, coupled with the country's low socioeconomic status (SES), makes inexpensive, energy-dense, nutrient-poor snacks the preferred choice among the South African population (Hassanally et al. 2020;Steyn, Labadarios & Nel 2011).
With the onset of COVID-19, the affordability and availability of foods have been affected (Litton & Beavers 2021)

Study design and participants
This study was conducted in the Vaal region of South Africa -located approximately 70 km south of Johannesburg in the Gauteng province.With about 800 000 people, Vaal is a densely populated region in the province of Gauteng (Oldewage-Theron, Kruger & Egal 2014).Gauteng is the country's financial hub and the most populated province, with 15.5 million people, about 26% of the country's total population (Statistics South Africa 2020).
Participants (children 3-8 years and adults ≥18 years) were recruited for this study via a convenient sampling method and completed a snack consumption frequency and preference survey.The investigators visited a preschool, a primary school and an elderly home in the Vaal region and obtained permission to undertake the study from the school principals and coordinator of the elderly home.Children were recruited from a preschool and a primary school in the region, whereas adults were recruited in various ways.Firstly, parents of preschool and primary school students were recruited.Secondly, attendees of an elderly care centre were recruited as adult respondents.All interested adult participants and parents of children were approached, and those who gave consent or parental consent for their children completed the questionnaire between 15 June 2021 and 23 June 2021.

Ethical consideration
Ethics approval for this study was sought from the Institutional Review Board (IRB) at the University of the Free State (UFS) (ethical clearance number -UFS-HSD2021/0821/22).The snack preference questionnaire was developed from a previously used and validated snack pattern questionnaire in the Vaal region (Du Plessis 2009).All questionnaires were completed by participants, while parents of children ≤ 5 years completed the questionnaire on their behalf.Survey respondents were asked to indicate how much they liked the typical snacks consumed in South Africa, how often they are consumed and how much is typically spent on snacks per week.For this study, snacks were defined as foods consumed between regular meals.

Data analyses
The

Study participants' characteristics
A total of 204 completed questionnaires were retrieved.Fourteen respondents who did not include their age and completed less than 20% of the survey were removed.
Resultantly, 190 respondent data -90 children aged 3-8 years and 100 adults aged ≥ 18 years -who completed the questionnaire were analysed.Among the children, 49% of the respondents were boys, while 51% were girls.The mean age of children was 5.77 years (SD 1.77).Among adult participants, 69% were women, 31% were men and the mean age of adults was 34.96 years (SD 13.10).More

Snack consumption frequency
The mean consumption frequency score shows that the five most frequently consumed snacks by children included fruits, potato chips, corn chips, sweets and cookies.The most frequently consumed snacks among adults included fruits, sweets, freshly fried chips, cookies and corn chips (Table 2).Children consumed more potato chips, corn chips, cheese curls and muffins than adults.In contrast, adults consumed more peanuts, savoury biscuits and biltong than children (Table 2).These differences between adults and children were statistically significant (p < 0.05).
More than one-third of children reported they consumed corn chips, potato chips and fruits daily.In comparison, 17% of adults consumed freshly fried chips, potato chips and cookies daily.Four out of 10 adults and more than half of the children reported the consumed fruits daily.

Snack preferences
Children's five most preferred snacks were potato chips, ice cream, muffins, fruits and corn chips.At the same time, adults' five most preferred snacks were potato chips, fruits, freshly fried chips, corn chips and cookies (Table 3).More than two-thirds of children indicated they 'really liked' ice cream, potato chips, fruits, cakes and chocolates, whereas more than half of adults indicated that they 'really liked' fruits, freshly fried chips, ice cream, potato chips, biltong, cookies and chocolates.Table 3 compares the preference for snacks among children and adults.Children indicated they statistically significantly liked potato chips, cheese curls, sweets, chocolates, snack bars, ice cream, cakes and muffins more than adults.In contrast, adults significantly liked savoury biscuits, condensed milk and biltong more than children (Table 2).

Association between snack consumption frequency and preferences
There was a moderate to strong positive association between the consumption frequency and liking of most snacks, including fruits, snack bars, potato chips and corn chips (Table 4).However, a weak positive relationship between the liking and consumption frequency of cakes, scones or muffins and ice cream among participants was found.Snacks with a strong positive association between consumption frequency and liking by participants were rusks, high-protein snacks and peanuts or nuts.

Discussion
This study aimed to assess snacking preferences and frequency of children and adults snack consumption to guide the development of nutrient-dense and healthy snacks.This study identified important trends in snack consumption among a community of low SES in South Africa.Our findings showed that more than two-thirds of children consume snacks at least once a day, with nearly half of adults consuming snacks daily.
In our study, the most frequently consumed snacks by survey respondents included fruits, potato chips, corn chips, sweets and cookies.This trend is similar to the reported snack consumption pattern in South Africa.In a snack survey among 200 school children in Grades 4-7, Govender et al. (2018) reported sweets, chips, soft drinks and chocolates are the most consumed snacks.Similarly, in a randomised controlled trial to improve healthy snacks among primary school children in the Western Cape province, Steyn et al. (2015) found that the most consumed snacks by children between the age of 8-10 years were potato chips, sweets and sugar-sweetened beverages.Aside from fruits, the snacks mostly consumed by our study respondents, particularly among children, are nutrient-poor, energy-dense snacks that are either high in added sugar or sodium or low in fibre and micronutrients.Our study findings showed that children significantly consumed more potato chips, corn chips, cheese curls and muffins than adults.The intake of energy-dense, nutrient-poor snacks has been associated with obesity, cardiovascular diseases, non-communicable diseases (NCDs) and the DBM (Barrington & Beresford 2019;Popkin, Adair & Ng 2012;Popkin et al. 2020).In a 5-year Adult Prospective Urban and Rural Epidemiology (PURE) study among South Africans, increased consumption of added sugars was associated with higher waist circumference, body mass index (BMI) and lower HDL-cholesterol levels (Vorster et al. 2014) When considering the relationship between snacks liked and frequently consumed, a weak positive association between snack consumption frequency and liking was found for ice cream scones or muffins and cakes (Table 4).Fruits and most snacks had a moderate positive association, while peanuts and rusks had a strong positive association.Furthermore, our findings indicate that children and adults in this community may not frequently be consuming the snacks they like.While some snacks were highly preferred, they were not frequently consumed.For instance, 80.7% of children indicated they liked ice cream.However, the mean frequency consumption score of ice cream was lower than 1.
Similarly, 67% of children liked cakes, but it had a mean frequency consumption score of 1 ( This study found that fruits are children's and adult's most frequently consumed 'snacks'.This finding is in contrast to several studies that have reported a low intake of fruits and vegetables in South Africa compared to snacks (McHiza et al. 2015;Ronquest-Ross et al. 2015).This could be because this study did not determine the portion sizes of snacks consumed.The study aimed to determine the frequency and predilection of specific snacks.However, it could not account for portion sizes consumed or if a pack or a snack serving was consumed at more than one sitting.Consuming sugary and salty snacks is a cause of public concern in South Africa and is not part of the recommendations for healthy eating.
The food-based dietary guidelines for South Africans (FBDG-SA) recommends consuming five servings of fruits and vegetables daily and limiting foods high in added sugars and salt (Vorster, Badham & Venter 2013).While it is applaudable that fruits were highly preferred and frequently consumed by our study respondents, the cost of fruits is generally higher than highly processed snacks and not easily accessible or affordable by low-income individuals and households in South Africa (FAO et al. 2022;Herforth et al. 2020;Temple et al. 2011).Snacking is often defined differently, as there is no generally accepted definition or classification of snacks.A significant strength of this study is that it defined the term 'snacks' and identified major snacks consumed by respondents in each subcategory of children and adults.However, it was not without limitations.The study was conducted within a specific population in a particular region in South Africa.Hence, the snacking preferences and consumption patterns may not be generalisable for all children and adults in South Africa.

Conclusion
In line with similar studies, this study reported that adults and children in low SES communities in South Africa prefer energy-dense snacks such as ice cream, potato chips, corn chips, muffins and cookies.Similarly, the most frequently consumed snacks are fruits, potato chips, corn chips, cookies and sweets.Apart from fruits, the most popular snacks consumed by the population are high in added sugars, saturated fat and sodium, which are against the South African dietary guidelines for healthy eating.
The findings of this study could guide effective nutrition education interventions and programmes on healthy snacking.In addition, the results and findings of this study could be pivotal for snack food producers and manufacturers in developing nutrient-dense snacks that are acceptable to individuals from a low SES community without compromising on taste and affordability.Nutrientdense snacks low in sugar and sodium should be developed as a substitute for potato chips, corn chips, sweets and cookies.Future research and nutrition education programmes should include teaching households how to prepare nutrient-dense snacks, especially those with little or no added sugar, sodium and low saturated fat content.
These popular snacks in the South African market, such as chips, puffs, corn bites, toffees and chocolates, are high in added sugars and sodium, which is inconsistent with healthy dietary recommendations to combat obesity and undernourishment (NDoH et al. 2019 al. 2015)& Ferguson 2019).In 2017, maize, potato chips and puffs dominated the South African snack industry with 40%, 20% and 10% of the market sector, respectively; whereas jellies and gums dominated the sugar confectionery industry(Eagle 2019).The South African savoury snacks market is projected to grow by 31.6% from 2019 to 2026(Statista 2021).Such snacks, high in added sugars, saturated fat and sodium, are usually cheaper than nutritious foods and thus widely consumed by children and adults.A review of food consumption patterns from 1994 to 2012 in South Africa indicates an increase in sugar confectionery consumption of 16.7%.Total biscuit (cookie) consumption increased by 57.1%, while sweet and savoury snacks increased by 53.3%(Ronquest-Ross et al. 2015).In 2016, SADHS reported that 41.0% of children consumed salty snacks while 35.0%consumed sugary snacks(NDoH et al. 2019).

TABLE 1 :
Characteristics of participants.

How often do you eat snack food items
two-thirds of the children (68.2%) consumed snacks at least once a day, while 46% of adults consumed snacks at least once a day (Table1).The majority of children (58%) and adults (54%) spent up to ZAR50 (South African Rand) on snacks weekly.More than one-third of children and adults (39.1% and 32.6%, respectively) snacked most when watching television (TV).Similarly, about one-third (32%) of adults and 18% of children snacked most when bored.Table1presents the complete age and gender distribution, snacking frequency and amount spent on snacks by the participants.
ZAR, South African Rand; TV, television; s.d., standard deviation.than Table 2 presents participants' snack consumption of specific snacks.

TABLE 2 :
Snack frequency of participants reported in percentage.

TABLE 3 :
Indication of likeness by participants.

TABLE 4 :
Relationship between snacks frequently consumed and liked by participants.