Preliminary evidence suggests that a ketogenic diet may be effective for bipolar disorder.

To assess the impact of a ketogenic diet in bipolar disorder on clinical, metabolic and magnetic resonance spectroscopy outcomes.

Euthymic individuals with bipolar disorder (N = 27) were recruited to a 6- to 8-week single-arm open pilot study of a modified ketogenic diet. Clinical, metabolic and MRS measures were assessed before and after the intervention.

Of 27 recruited participants, 26 began and 20 completed the ketogenic diet. For participants completing the intervention, mean body weight fell by 4.2 kg (P < 0.001), mean body mass index fell by 1.5 kg/m2 (P < 0.001) and mean systolic blood pressure fell by 7.4 mmHg (P < 0.041). The euthymic participants had average baseline and follow-up assessments consistent with them being in the euthymic range with no statistically significant changes in Affective Lability Scale-18, Beck Depression Inventory and Young Mania Rating Scale. In participants providing reliable daily ecological momentary assessment data (n = 14), there was a positive correlation between daily ketone levels and self-rated mood (r = 0.21, P < 0.001) and energy (r = 0.19 P < 0.001), and an inverse correlation between ketone levels and both impulsivity (r = −0.30, P < 0.001) and anxiety (r = −0.19, P < 0.001). From the MRS measurements, brain glutamate plus glutamine concentration decreased by 11.6% in the anterior cingulate cortex (P = 0.025) and fell by 13.6% in the posterior cingulate cortex (P = <0.001).

These findings suggest that a ketogenic diet may be clinically useful in bipolar disorder, for both mental health and metabolic outcomes. Replication and randomised controlled trials are now warranted.

To investigate food insecurity and related coping strategies, and their associations with the risk of anxiety and depression, among South African households with children.

Nationally representative cross-sectional study. Tools for assessing food insecurity, coping strategies, risk of anxiety and depression were assessed from the Community Childhood Hunger Identification Project, Coping Strategies Index, Generalised Anxiety Disorder-7 and Patient Health Questionnaire-9, respectively. We used ordered logistic regression to test associations of food insecurity and coping strategies with the risk of anxiety and depression. Moderating effects of each coping strategy were tested in the associations of food insecurity with anxiety and depression.

South Africa, post COVID-19 restrictions, May–June 2022.

1,774 adults, weighted to 20,955,234 households.

Food insecurity prevalence was 23·7 % among households with children. All coping strategies were used to some extent, but relying on less preferred and less expensive foods was the most used strategy (85·5 % of food-insecure households). Moving to a higher level of food insecurity was associated with >1·6 greater odds of being in a higher risk of anxiety and depression. Sending a household member to beg for food was the strongest associated factor (OR = 1·7, P < 0·001). All coping strategies partly moderated (lessened) the associations of food insecurity with a higher risk of anxiety and depression.

Food insecurity among households with children was high following the COVID-19 pandemic. Collaborative efforts between government, private sector and civil society to eradicate food insecurity should prioritise poorer households with children, as these populations are the most vulnerable.

To investigate food insecurity and related coping strategies among South African households and their associations with anxiety and depression.

Cross-sectional study. Food insecurity and coping strategies were assessed using a modified Community Childhood Hunger Identification Project and the Coping Strategies Index questionnaires. The Generalized Anxiety Disorder-7 and Patient Health Questionnaire-9 were used to assess anxiety and depression risk. Ordered logistic regressions were used to test associations of food insecurity and related coping strategies with anxiety and depression.

South Africa during COVID-19, October 2021.

Nationally representative sample of 3402 adults, weighted to 39,640,674 South African households.

About 20·4 % of South African households were food insecure, with the most affected being from the lowest socio-economic groups. Shifting from ‘food secure’ to ‘at risk’ or from ‘at risk’ to ‘food insecure’ group was associated with 1·7 times greater odds of being in a higher category of anxiety or depression (P < 0·001). All coping strategies were used to some extent in South African households, with 46·0 % relying on less preferred and less expensive foods and 20·9 % sending a household member to beg for food. These coping strategies were mostly used by food-insecure households. Although the odds of moving to a higher category of anxiety and depression were observed among all coping strategies (all P < 0·001), begging for food was associated with the highest odds (OR = 2·3).

Food insecurity remains a major health threat in South Africa. Public measures to address mental health should consider reductions in food insecurity as part of their strategy.

To determine whether food security, diet diversity and diet quality are associated with anthropometric measurements and body composition among women of reproductive age. The association between food security and anaemia prevalence was also tested.

Secondary analysis of cross-sectional data from the Healthy Life Trajectories Initiative (HeLTI) study. Food security and dietary data were collected by an interviewer-administered questionnaire. Hb levels were measured using a HemoCue, and anaemia was classified as an altitude-adjusted haemoglobin level < 12·5 g/dl. Body size and composition were assessed using anthropometry and dual-energy x-ray absorptiometry.

The urban township of Soweto, Johannesburg, South Africa.

Non-pregnant women aged 18–25 years (n 1534).

Almost half of the women were overweight or obese (44 %), and 9 % were underweight. Almost a third of women were anaemic (30 %). The prevalence rates of anaemia and food insecurity were similar across BMI categories. Food insecure women had the least diverse diets, and food security was negatively associated with diet quality (food security category v. diet quality score: B = –0·35, 95 % CI –0·70, –0·01, P = 0·049). Significant univariate associations were observed between food security and total lean mass. However, there were no associations between food security and body size or composition variables in multivariate models.

Our data indicate that food security is an important determinant of diet quality in this urban-poor, highly transitioned setting. Interventions to improve maternal and child nutrition should recognise both food security and the food environment as critical elements within their developmental phases.

To provide insight into the context and public health implications of the South African sugar-sweetened beverage (SSB) tax (Health Promotion Levy; HPL) by describing SSB and added sugar intakes, as well as BMI, 1 year prior to, at the time of and 1 year after implementation of the HPL.

Longitudinal dietary intake was assessed using a quantitative food frequency questionnaire (QFFQ) and BMI was measured via anthropometry.

Soweto, Johannesburg, South Africa.

Adolescents, young adults and middle-aged adults (n 617).

At baseline, median SSB intakes were 36 ml/d, 214 ml/d and 750 ml/d for those in low, medium and high consumption tertiles, respectively. SSB intake decreased by two times/week in medium consumers and seven times/week in high consumers between baseline and 12 months, equivalent to 107 ml/d and 536 ml/d reductions, respectively. These reduced levels were maintained in the following year (i.e. to 24 months). There was an overall decrease in the amount of energy consumed as added sugar in the low (−48 kJ/d), medium (−153 kJ/d) and high (−106 kJ/d) SSB consumption groups between baseline and 24 months; however, the percentage of total energy consumed as added sugar remained relatively consistent (between 10 and 11 %). There were small overall increases in BMI across low (0·6 kg/m2), medium (0·9 kg/m2) and high (1·0 kg/m2) SSB tertiles between baseline and 24 months.

These findings suggest reductions in SSB and added sugar consumption contemporaneous to the introduction of the HPL – particularly for those with higher baseline intakes.

To explore community perceptions on maternal and child nutrition issues in Sub-Saharan Africa.

Thirty focus groups with men and women from three communities facilitated by local researchers.

One urban (Soweto, South Africa) and two rural settings (Navrongo, Ghana and Nanoro, Burkina Faso) at different stages of economic transition.

Two hundred thirty-seven men and women aged 18–55 years, mostly subsistence farmers in Navrongo and Nanoro and low income in Soweto.

Differences in community concerns about maternal and child health and nutrition reflected the transitional stage of the country. Community priorities revolved around poor nutrition and hunger caused by poverty, lack of economic opportunity and traditional gender roles. Men and women felt they had limited control over food and other resources. Women wanted men to take more responsibility for domestic chores, including food provision, while men wanted more involvement in their families but felt unable to provide for them. Solutions suggested focusing on ways of increasing control over economic production, family life and domestic food supplies. Rural communities sought agricultural support, while the urban community wanted regulation of the food environment.

To be acceptable and effective, interventions to improve maternal and child nutrition need to take account of communities’ perceptions of their needs and address wider determinants of nutritional status and differences in access to food reflecting the stage of the country’s economic transition. Findings suggest that education and knowledge are necessary but not sufficient to support improvements in women’s and children’s nutritional status.

To obtain a community perspective on key nutrition-specific problems and solutions for mothers and children.

A qualitative study comprising nine focus group discussions (FGD) following a semi-structured interview guide.

The township of Soweto in South Africa with a rising prevalence of double burden of malnutrition.

Men and women aged ≥18 years (n 66). Three FGD held with men, six with women.

Despite participants perceived healthy diet to be important, they felt their ability to maintain a healthy diet was limited. Inexpensive, unhealthy food was easier to access in Soweto than healthier alternatives. Factors such as land use, hygiene and low income played a fundamental role in shaping access to foods and decisions about what to eat. Participants suggested four broad areas for change: health sector, social protection, the food system and food environment. Their solutions ranged from improved nutrition education for women at clinic visits, communal vegetable gardens and government provision of food parcels to regulatory measures to improve the healthiness of their food environment.

South Africa’s current nutrition policy environment does not adequately address community-level needs that are often linked to structural factors beyond the health sector. Our findings suggest that to successfully address the double burden of malnutrition among women and children, a multifaceted approach is needed combining action on the ground with coherent policies that address upstream factors, including poverty. Further, there is a need for public engagement and integration of community perspectives and priorities in developing and implementing double-duty actions to improve nutrition.

To (i) describe the infant feeding practices of South African women living in Soweto and (ii) understand from the mothers’ perspective what influences feeding practices.

Semi-structured focus group discussions (FGD) and in-depth interviews (IDI) were conducted, and data were analysed using thematic analysis.

Soweto, South Africa.

Nineteen mothers were stratified into three FGD according to their baby’s age as follows: 0–6-month-olds, 7–14-month-olds and 15–24-month-olds. Four mothers from each FGD then attended an IDI.

Although mothers understood that breast-feeding was beneficial, they reported short durations of exclusive breast-feeding. The diversity and quality of weaning foods were low, and ‘junk’ food items were commonly given. Infants were fed using bottles or spoons and feeding commonly occurred separately to family meal times. Feeding practices were influenced by mothers’ beliefs that what babies eat is important for their health and that an unwillingness to eat is a sign of ill health. As such, mothers often force-fed their babies. In addition, mothers believed that feeding solid food to babies before 6 months of age was necessary. Family matriarchs were highly influential to mothers’ feeding practices; however, their advice often contradicted that of health professionals.

In South Africa, interventions aimed at establishing healthier appetites and eating behaviours in early life should focus on: (i) fostering maternal self-efficacy around exclusive breast-feeding; (ii) challenging mixed feeding practices and encouraging more responsive feeding approaches and (iii) engaging family members to promote supportive household and community structures around infant feeding.

In the past decade, South Africa’s obesity epidemic has increased in both children and adults, and being overweight is becoming the norm. Several contributing factors lead to the normalisation of obesity. One of these is the culturally entrenched likeness of larger body sizes or shapes within a milieu of easily accessible unhealthy food and beverages. This qualitative study advances knowledge about the influence of socio-cultural norms and obesogenic environments on weight under estimation and ‘obesity normalisation’ amongst black South Africans living in an urban setting.

A theory-based qualitative study used focus group discussions (FGDs) with a semi-structured interview guide. FGDs were transcribed verbatim and analysed thematically using a constant comparison method.

Soweto, Johannesburg, South Africa, is a setting which has undergone rapid urbanisation and nutrition transition with ubiquitous availability of processed and fast-foods.

Adults older than 18 years living in Soweto (n 57).

There is a wide misperception about obesity amongst black Africans living in an urban setting in Soweto. Participants who admitted to being fat or overweight did not view themselves as such. This could be attributed to unchanging socio-cultural factors that reinforce the acceptability of bigger bodies and living in obesogenic environment.

Without addressing socio-cultural norms that attribute bigger bodies to beauty and wealth, motivating individuals to address weight gain will prove difficult especially for populations living in obesogenic environments. A multi-faceted strategy is required to address obesity in urban South African settings.

To: (i) understand facilitators and barriers to healthy eating practices and physical activity in younger and older urban adolescent South African boys and girls; and (ii) understand how the views of caregivers interact with, and influence, adolescent behaviours.

Semi-structured focus group discussions (FGD) were conducted in July 2018. Data were analysed using thematic analysis.

Soweto, Johannesburg, South Africa.

Seventy-five participants were stratified into eight FGD as follows: two for young boys and girls (10–12 years); two for older boys and girls (15–17 years); two for caregivers of young adolescents (boys and girls); and two for caregivers of older adolescents (boys and girls).

Unlike their caregivers, adolescents were not motivated to eat healthily and failed to appreciate the need to develop consistent patterns of both healthy eating and physical activity for their long-term health. Although adolescents gained independence with age, they commonly attributed unhealthy food choices to a lack of autonomy and, thereby, to the influence of their caregivers. Adolescents and caregivers perceived their engagement in physical activity according to distinct siloes of recreational and routine activity, respectively. Both similarities and differences in the drivers of healthy eating and physical activity exist in adolescents and caregivers, and should be targeted in future interventions.

Our study identified a complex paradigm of eating practices and physical activity in South African adolescents and their caregivers. We also highlighted the need for a new narrative in addressing the multifaceted and interrelated determinants of adolescent health within urban poor settings.

A tax on sugar-sweetened beverages (SSB) was introduced in South Africa in April 2018. Our objective was to document perceptions and attitudes among urban South Africans living in Soweto on factors that contribute to their SSB intake and on South Africa’s use of a tax to reduce SSB consumption.

We conducted six focus group discussions using a semi-structured guide.

The study was conducted in Soweto, Johannesburg, South Africa, 3 months before South Africa’s SSB tax was implemented.

Adults aged 18 years or above living in Soweto (n 57).

Participants reported frequent SSB consumption and attributed this to habit, addiction, advertising and wide accessibility of SSB. Most of the participants were not aware of the proposed SSB tax; when made aware of the tax, their responses included both beliefs that it would and would not result in reduced SSB intake. However, participants indicated cynicism with regard to the government’s stated motivation in introducing the tax for health rather than revenue reasons.

While an SSB tax is a policy tool that could be used with other strategies to reduce people’s high level of SSB consumption in Soweto, our findings suggest a need to complement the SSB tax with a multipronged behaviour change strategy. This strategy could include both environmental and individual levers to reduce SSB consumption and its associated risks.

The study aimed to investigate the relationship between physical activity, gross motor skills and adiposity in South African children of pre-school age.

Cross-sectional study.

High-income urban, and low-income urban and rural settings in South Africa.

Children (3–6 years old, n 268) were recruited from urban high-income (n 46), urban low-income (n 91) and rural low-income (n 122) settings. Height and weight were measured to calculate the main outcome variables: BMI and BMI-for-age Z-score (BAZ). Height-for-age and weight-for-age Z-scores were also calculated. Actigraph GT3X+ accelerometers were used to objectively measure physical activity; the Test of Gross Motor Development (Version 2) was used to assess gross motor skills.

More children were overweight/obese and had a higher BAZ from urban low-income settings compared with urban high-income settings and rural low-income settings. Being less physically active was associated with thinness, but not overweight/obesity. Time spent in physical activity at moderate and vigorous intensities was positively associated with BMI and BAZ. Gross motor proficiency was not associated with adiposity in this sample.

The findings of this research highlight the need for obesity prevention particularly in urban low-income settings, as well as the need to take into consideration the complexity of the relationship between adiposity, physical activity and gross motor skills in South African pre-school children.