title: Did HealthKick, a randomised controlled trial primary school nutrition intervention improve dietary quality of children in low-income settings in South Africa?
abstract: BACKGROUND
  Numerous studies in schools in the Western Cape Province, South Africa have shown that children have an unhealthy diet with poor diversity and which is high in sugar and fat. HealthKick (HK) was a three-year randomised controlled trial aimed at promoting healthy eating habits.
  
  
  METHODS
  Sixteen schools were selected from two low-income school districts and randomly allocated to intervention (n = 8) or control school (n = 8) status. The HK intervention comprised numerous activities to improve the school nutrition environment such as making healthier food choices available and providing nutrition education support. Dietary intake was measured by using a 24-h recall in 2009 in 500 grade 4 learners at intervention schools and 498 at control schools, and repeated in 2010 and 2011. A dietary diversity score (DDS) was calculated from nine food groups and frequency of snack food consumption was determined. A school level analysis was performed.
  
  
  RESULTS
  The mean baseline (2009) DDS was low in both arms 4.55 (SD = 1.29) and 4.54 (1.22) in the intervention and control arms respectively, and 49 % of learners in HK intervention schools had a DDS ≤4 (=low diversity). A small increase in DDS was observed in both arms by 2011: mean score 4.91 (1.17) and 4.83 (1.29) in the intervention and control arms respectively. The estimated DSS intervention effect over the two years was not significant [0 .04 (95 % CI: -0.37 to 0.46)]. Food groups least consumed were eggs, fruit and vegetables. The most commonly eaten snacking items in 2009 were table sugar in beverages and/or cereals (80.5 %); followed by potato crisps (53.1 %); non-carbonated beverages (42.9 %); sweets (26.7 %) and sugar-sweetened carbonated beverages (16 %). Unhealthy snack consumption in terms of frequency of snack items consumed did not improve significantly in intervention or control schools.
  
  
  CONCLUSIONS
  The results of the HK intervention were disappointing in terms of improvement in DDS and a decrease in unhealthy snacking. We attribute this to the finding that the intervention model used by the researchers may not have been the ideal one to use in a setting where many children came from low-income homes and educators have to deal with daily problems associated with poverty.
  
  
  CONCLUSIONS
  The HK intervention did not significantly improve quality of diet of children.
authors.affiliation: Division Human Nutrition, University of Cape Town, P/Bag X3, Observatory, Cape Town, 7925, South Africa. nelia.steyn@uct.ac.za.
authors.forename: Nelia P
authors.initials: NP
authors.lastname: Steyn
authors.affiliation: Non-communicable Diseases Research Unit, South African Medical Research Council, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa. Anniza.devilliers@mrc.ac.za.
authors.forename: Anniza
authors.initials: A
authors.lastname: de Villiers
authors.affiliation: Biostatistics Unit, South African Medical Research Council, Francie van Zyl Drive, Tygerberg, Cape Town, 7505, South Africa. Nomonde.gwebushe@mrc.ac.za.
authors.forename: Nomonde
authors.initials: N
authors.lastname: Gwebushe
authors.affiliation: Division of Exercise Science and Sports Medicine, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, 8001, South Africa. Catherine.draper@uct.ac.za.
authors.forename: Catherine E
authors.initials: CE
authors.lastname: Draper
authors.affiliation: Non-communicable Diseases Research Unit, South African Medical Research Council, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa. jillian.hill@mrc.ac.za.
authors.forename: Jillian
authors.initials: J
authors.lastname: Hill
authors.affiliation: Non-communicable Diseases Research Unit, South African Medical Research Council, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa. mdewaal@fedicsunit.co.za.
authors.forename: Marina
authors.initials: M
authors.lastname: de Waal
authors.affiliation: Division Nutrition, University of Cape Town, Cape Town, 8001, South Africa. luc1_za@yahoo.com.
authors.forename: Lucinda
authors.initials: L
authors.lastname: Dalais
authors.affiliation: BroadReach Healthcare, Park Lane Office Park, cnr Alexandra Road & Park Lane Pinelands, Cape Town, 7405, South Africa. zabrahams@brhc.com.
authors.forename: Zulfa
authors.initials: Z
authors.lastname: Abrahams
authors.affiliation: Biostatistics Unit, South African Medical Research Council, Francie van Zyl Drive, Tygerberg, Cape Town, 7505, South Africa. carl.lombard@mrc.ac.za.
authors.forename: Carl
authors.initials: C
authors.lastname: Lombard
authors.affiliation: Division of Exercise Science and Sports Medicine, Sports Science Institute of South Africa, Boundary Road, Newlands, 8001, Cape Town, South Africa. vicki.lambert@uct.ac.za.
authors.forename: Estelle V
authors.initials: EV
authors.lastname: Lambert
mesh_terms: D002648:Child; D002662:Child Health Services; D004032:Diet; D005260:Female; D006266:Health Education; D006801:Humans; D008297:Male; D044342:Malnutrition / Q000517:prevention & control*; D009752:Nutritional Status; D017063:Outcome Assessment, Health Care; D011203:Poverty; D016032:Randomized Controlled Trials as Topic; D012572:School Health Services; D012574:Schools; D013019:South Africa / Q000453:epidemiology