Theses and Dissertations (Human Nutrition)

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Postnatal growth and body composition up to two years of age of term and preterm infants with placental insufficiency and/or small size for gestational age at birth
(University of Pretoria, 2024-05-31) Wenhold, Friedeburg Anna Maria; Feucht, Ute Dagmar; nel.sanja@gmail.com; Nel, Sanja
Background: Growth in the first thousand days can affect lifelong health, yet joint clinical management between prenatal, perinatal and postnatal healthcare providers is often limited. Preterm birth and/or foetal growth restriction (FGR), often presenting as small-for-gestational age (SGA), affect short- and long-term outcomes. Placental insufficiency affects foetal growth and body composition (BC) even in appropriate-for-gestational age (AGA) newborns. Preterm birth, SGA and placental insufficiency are prevalent in South Africa. Aims: This thesis aimed to (a) develop an integrated framework for foetal/infant growth assessment, (b) compare the predictive value of two commonly used preterm infant growth charts, (c) describe one-year growth and its early life predictors in preterm infants with/without SGA (d) describe two-year growth and BC, and early-life predictors thereof, in term infants with/without placental insufficiency. Methods: Framework development (objective a): An interdisciplinary (obstetricians, paediatricians and dietitians) iterative think-tank approach, supported by published literature, was used for framework development. Cohort 1, a preterm historical cohort (objectives b and c), utilised patient records (N=321, 111 SGA, 310 AGA) from the kangaroo mother care follow-up clinic at a tertiary South African hospital. Using anthropometric data up to 12 months, z-scores were calculated with the Fenton Growth Chart (FGC), INTERGROWTH-21ST Newborn Size Standards (IG-NBSS), and INTERGROWTH-21ST Postnatal Growth Standards for Preterm Infants (IG-PPGS). Birth weight z-score (BWZ, FGC vs. IG-NBSS) and weight gain up to 50 weeks postmenstrual age (ΔWZ, FGC vs. IG-PPGS) were compared (Cohen’s Kappa) for association with one-year anthropometry (malnutrition). Cohort 2, the UmbiBaby cohort (objective d), included 81 term-born infants with Doppler-derived umbilical artery resistance index (UmA-RI) assessed at 28-34 weeks’ gestation (55 normal, 26 abnormal UmA-RI). During eight follow-up visits over two years, anthropometric measurements were taken, and fat-free mass (FFM) and fat mass (FM) assessed using deuterium dilution. Z-scores were calculated for FM (FMZ), FFM (FFMZ), FM index (FMIZ) and FFM index (FFMIZ). For both cohorts, z-scores were calculated for weight-for-age (WAZ), length-for-age (LAZ), weight-for-length (WLZ), BMI-for-age (BMIZ), MUAC-for-age (MUACZ) and HC-for-age (HCZ) using WHO Anthro (age-corrected for preterm infants). Underweight (WAZ< 2), stunting (LAZ< 2), wasting (WLZ< 2) and overweight (BMIZ>+2) rates were calculated at last visit. Outcomes were compared for SGA (birth weight-for-GA <10th percentile) vs. AGA (birth weight-for-GA ≥10th - ≤90th percentile) infants (preterm cohort), and normal vs. abnormal UmA-RI (UmbiBaby cohort). Longitudinal growth was characterised using latent class trajectory modelling (LCTM). Multivariable analysis investigated early-life predictors of growth trajectories (both cohorts) and one-year malnutrition (preterm cohort). Results: Objective a: An integrated framework of measurements, indices and indicators used by various health care providers in antenatal, perinatal and postnatal care and research informed all subsequent investigations. Objective b (preterm cohort): FGC and IG-PPGS produced similar ΔWZ (IG-PPGS= 0.26±1.23, FGC= 0.11±1.14; P=0.153) and performed similarly in multivariable analysis. Using ΔWZ<-1, FGC predicted more underweight (42.0% vs. 36.0%), more wasting (43.5% vs. 39.1%), and equal stunting (33.3%), while ΔWZ>+1 on FGC predicted more overweight (57.1% vs. 38.1%). There was substantial agreement between the charts in terms of number of infants with ΔWZ<-1, 1≤ΔWZ≤+1 and ΔWZ>+1 (Κ=0.647) and the association between these classes and malnutrition outcomes (Κ=0.734 to 0.627) Objective c (preterm cohort): At one year, SGA infants had lower anthropometric z-scores and more stunting (34.2% vs. 9.1%; P<0.001), underweight (31.2% vs. 7.2%; P<0.001) and wasting (12.6% vs. 4.3%, P=0.012), despite larger first-year WAZ gains (+0.70±1.30 vs. +0.05±1.30, P<0.001). In multivariable analysis, birth weight z-score (BWZ) predicted one-year undernutrition better than being born SGA. LCTM identified three WAZ and LAZ trajectories (faltering, gradual gain, catch-up), and two WLZ trajectories (faltering, gain). Lower BWZ was associated with WAZ and LAZ catch-up but WLZ faltering. Larger ΔWZ was associated with WAZ catch-up and gradual LAZ gain. WAZ and WLZ faltering were associated with more underweight (49.1%, 22.4%), stunting (45.5%, 23.5%) and wasting (21.8%, 10.3%), while WAZ catch-up and WLZ gain were associated with more overweight (24.4%, 17.6%; all P<0.001). Gradual LAZ gain was associated with the least underweight (2.0%), stunting (2.1%) and wasting (2.1%, all P<0.001). Objective d (UmbiBaby cohort): Infants with abnormal UmA-RI had lower WAZ up to 18 months (mean±SD [ 0.6±0.82 to 0.2±1.12] vs. [0.1±1.18 to 0.6±1.09]; P=0.037-0.017 for measurements at different ages), LAZ up to 14 weeks ([ 1.3±1.25 to 0.9±0.87] vs. [ 0.2±1.04 to 0.1±1.00]; P=0.004-0.021); and FFMZ up to 9 months ([ 0.1±0.82 to 0.7±0.71] vs. [0.7±1.00 to 1.3±0.85]; P=0.002-0.028). LCTM identified three WAZ, LAZ, WLZ, BMIZ, HCZ and FFMZ trajectories, and two MUACZ, FMZ, FMIZ and FFMIZ trajectories. While FMZ and FMIZ trajectories converged around 2 years, FFMZ and FFMIZ trajectories declined. In multivariable analysis, lower BWZ (or SGA) predicted lower WAZ, WLZ, BMIZ, FMZ and FFMZ trajectories, while higher (or abnormal) UmA-RI predicted lower LAZ and FFMZ trajectories. Conclusions and recommendations: The complex associations of prenatal and early postnatal growth with growth and BC outcomes at 1-2 years underscore the importance of an integrated approach to growth in the first thousand days. Careful documentation on the Road-to-Health Booklet of pregnancy conditions (including UmA-RI screening results, when available) and accurately measured birth anthropometry can facilitate interdisciplinary communication. For preterm infants, FGC and IG-PPGN perform similarly, as long as the change in z-score (rather than an absolute z-score) is used to assess growth. Abnormal UmA-RI predicts lower LAZ and FFMZ trajectories up to 24 months, while lower BWZ predicts lower WAZ, LAZ and WLZ at 12 months in preterm infants (accompanied by higher rates of underweight, stunting and wasting), and at 24 months in term infants. Though the cause of the high observed rates of abnormal UmA-RI in the South African population is currently unknown, interventions to support healthy pregnancies and foetal growth should be prioritised. Early and ongoing assessment of WAZ, LAZ and WLZ can guide nutrition interventions for optimal longer-term growth; faltering growth in any anthropometric index should prompt further assessment of health conditions and nutrition status, followed by appropriate caregiver counselling, referral or other interventions.
Association of nutritional and environmental risk factors with Asthma among rural and urban Pre-schoolers in Mpumalanga province, South Africa
(University of Pretoria, 2024-07-01) Shirinde, Joyce; Voyi, Kuku; rodney.mudau@up.ac.za; Mudau, Thabelo Rodney
Abstract Background: Asthma is a significant global public health issue and one of the most common non-communicable diseases. The disease affects both young children and adults, with the majority being children in both affluent and poor nations, with the latter experiencing particularly severe consequences. The literature suggests that the disease is a complex multifactorial disorder and is largely attributed to the interactions between genetic susceptibility, characteristics of an individual and environmental exposures. The genetic factors include asthma susceptibility and genes, the characteristics of an individual include, nutritional factors including, infections and allergic sensitisation, while environmental factors include air pollution, pollens, moulds and other aeroallergens and weather. To establish recommendations to reduce the burden of asthma in this demographic group, it was necessary to evaluate its potential risk factors. Previous studies on asthma amongst preschool children have shown that there is a limited understanding of epidemiology, incomplete risk factor analysis and a lack of comprehensive environmental assessment. Therefore, this thesis presents an observational study that examined the prevalence and risk factors associated with asthma and related symptoms among pre-schoolers. Aim: The primary aim of this study was to observe the prevalence of asthma and its symptoms among pre-schoolers living in rural and urban areas of Mpumalanga Province, South Africa. Furthermore, the study aimed to examine the relationship between nutritional and environmental risk factors with asthma among cases and controls. Methods: The present study was carried out in two distinct phases, namely phase one and phase two. Phase 1: An analytical cross-sectional study described and compared the prevalence of asthma and its symptoms in rural and urban Mpumalanga pre-schoolers. Parents/caregivers of preschool children (n=3145) completed a modified International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire. Data were analysed using multiple logistic regression models. Phase 2 assessed two components (personal and environmental factors). An unmatched case-control study consisted of 189 pre-schoolers (63 with asthma, 126 controls) recruited from Phase 1. Firstly, the researcher identified primary dietary patterns by conducting a Principal Component Analysis (PCA) on reported food consumption data from the Quantitative Food Frequency Questionnaire (QFFQ). Anthropometric data were collected for the anthropometric status assessment using Seca scales and a stadiometer for height. Secondly, Radiello passive air samplers were utilized to measure Nitrogen Dioxide (NO2) and Sulphur Dioxide (SO2) levels at preschools to assess the indoor and outdoor air quality. Dietary patterns were analysed using PCA and were associated with asthma using multiple logistic regression. Moreover, multiple logistic regression and chi-square analysis were used to link anthropometric data to asthma. Lastly, the Wilcoxon paired signed rank test was used to compare the in/out (I/O) ratios of SO2 and NO2. Gert Sibande District Municipality is located in Mpumalanga province and forms part of the highveld priority area, which was declared an air pollution hot spot because of poor air quality and this affects the health of communities in the area, with children being the most vulnerable group. Results: Phase 1: The overall prevalence of wheeze ever was 15.14%, with a higher prevalence in urban pre-schoolers than rural pre-schoolers (20.71% vs 13.30 %, P<0.000). Moreover, the total prevalence of asthma ever was 2.34%. The prevalence was greater in urban pre-schoolers than in rural pre-schoolers (3.92% vs 1.81%, P<0.001). Phase 2: The results identified four primary dietary patterns that defined the dietary preferences of the pre-schoolers: meat general and dressings pattern, healthy dietary pattern, sugary and /or sweetened drinks pattern, and mixed dietary pattern. The consumption of sugary and sweetened drinks, (adjusted odds ratio (OR) 7.0, 95% CI: 2.3 -21.1; p=0.00) as well as a mixed dietary pattern, (adjusted OR 1.9, 95% CI: 1.1-3.6; p=0.03) were positively associated with a higher probability of developing asthma. In addition, being overweight was significantly linked to high chances of presenting with asthma [unadjusted Body Mass Index for Age with Z-scores (BAZ) OR 8.15 (3.97-16.71), Weight-for-age with Z- scores (WAZ) OR 5.33 (2.54-11.26), and adjusted BAZ OR 5.83 (1.21-27.89), WAZ OR 5.83 (1.21-27.89)]. The mean levels of NO2 indoors and outdoors were within the recommended criteria outlined by the World Health Organization (WHO), specifically target levels 1 (40μg.m-3) to 3 (20μg.m-3). Additionally, these values were also below those in the air quality guides outlined by South Africa, both for yearly and one-hour mean measurements. Nevertheless, both of these levels remained above the suitable threshold of 10 µg.m-3 outlined by the World Health Organization Air Quality Guidelines (WHO AQG). Conclusion: This cross-sectional study revealed that the prevalence of wheezing and asthma was high in pre-schoolers, particularly in urban areas compared to rural areas. The case-control study further demonstrated that the consumption of sugary and sweetened drinks, as well as a mixed dietary pattern, were positively associated with a higher probability of developing asthma. Conversely, a healthy dietary pattern was found to offer protective benefits against the risk of developing asthma. The finding highlights the importance of promoting healthier eating habits for respiratory health. A comprehensive approach to asthma management is imperative, encompassing pharmacological and non-pharmacological interventions, education, and self-management components. Healthcare professionals can help children with asthma and obesity manage their condition through a combination of preventive strategies and therapeutic interventions. Some key recommendations include: prevention and lifestyle changes, medication management, weight loss through multidisciplinary intervention, nutritional counselling, routine exercise and recognition and treatment. Future research should explore the combined impact of both home and school environmental tobacco smoke (ETS), NO2 and SO2 levels on children's asthma risk and severity. This could help in understanding the overall exposure patterns and their effects on asthma development. Keywords Air quality, Dietary patterns, Anthropometric status, Overweight, Obesity, SO2, NO2, Asthma, Pre-schoolers
Development of a staffing norm framework for dietitians at South African central and tertiary public hospitals
(University of Pretoria, 2024) Legodi, Heather; Muchiri, Jane Wanjiku; nolene.naicker1@gmail.com; Naicker, Vertharani Nolene
Background: The global human resources for health strategy indicates the necessity to prioritise human resources to improve health care and overall health outcomes. South Africa`s (SA) double burden of malnutrition, the core of the quadruple burden of diseases stresses the need for nutrition action. The absence of a national workforce planning tool to address nutrition workforce challenges impacts on the implementation of nutrition interventions and the aligned outcomes. The registered dietetic professional plays a significant role in the provision of appropriate and quality nutrition services. Hence, the need for an investment in an evidence-based workforce planning tool to determine the staffing needs of the cadre. Aims and Objectives: This study aimed to develop a staffing norm framework to determine the needs of dietitians at South African central and tertiary public hospitals using the Workload Indicators of Staffing Need (WISN). Design and Methods: A three phased developmental study based on the World Health Organisation Workload indicators for staffing (WISN) was conducted. In Phase 1 (preparatory phase) the distribution of permanently employed dietitians at South African public hospitals was mapped. The job descriptions of dietitians at central and tertiary public hospitals were analysed to inform a baseline of current dietetic practices for phase two of the study. In phase 2 (consensus phase) an online Delphi exercise was conducted to determine a standardised list of workload components and activity standards as per the WISN methodology. In phase 3 (finalisation phase) the eight step WISN methodology was applied to: 1) To conduct a case study at 21 central and tertiary public hospitals to determine the staffing needs of dietitians. 2) To develop a staffing norm framework and implementation tool for dietitians at the same level of care. Results: Findings from the preparatory phase indicated a total of 844 permanently employed dietitians and 189 available dietetic vacancies at SA`s public hospitals. This first phase also provided a baseline of the work activities of dietitians for the Delphi consensus phase. The online Delphi resulted in a 92% agreement rating on all proposed and newly added workload components. A total of 45 workload components together with aligned activity standards was finalised. The application of WISN in the finalisation phase indicated extreme understaffing with high work pressures at the 21 hospitals. The lack of support staff and managerial posts compounded staffing needs often resulting in unnecessary overtime. WHO recommends the use of WISN as part of periodic reviews to allow for long-term forecasting of staffing needs. Hence, this last phase developed a context and cadre specific staffing norm framework. In addition, a South African WISN based excel tool was also developed to support implementation of the framework, allowing for automation and user-friendliness. The validation of the tool against the WHO WISN supported its use in the South African central and tertiary hospital setting. Conclusion and Recommendations: WISN appears to be a beneficial tool in determining the needs of the cadre. The versatility of WISN has resulted in the development of a context specific tool to assist policy makers in prioritising the needs, future planning and forecasting of dietitians at South African central and tertiary public hospitals. It is recommended that similar tools be researched to prioritise the needs of dietitians at regional, district and specialised hospitals. Keywords: Delphi, Dietitian, Framework, Human resources, Hospital, South Africa, Staffing, Staffing Needs, Tools, WISN
Usability and validity of a dairy intake screener as a web-based mobile application for South African adults
(University of Pretoria, 2023) Wenhold, F.A.M. (Friedeburg Anna Maria); White, Zelda; monique@nutritionalsolutions.co.za; Piderit, Monique Cruz
Background Paper-based dietary assessment tools such as food frequency questionnaires (FFQs) and especially dietary screeners are making way for versions that use technology. Amidst low intakes of dairy and dairy-related nutrients in South Africa and to increase public awareness thereof, this research aimed to develop and evaluate the usability of an application (app), namely the Dairy Diary, to screen for dairy intake in higher income South African adults. Thereafter, the screener was evaluated in terms of test-retest reliability and comparative validity. Methods Development and usability: In a consultative process, a dairy intake screener (Dairy Diary) was developed as an eight-item quantitative FFQ with four types of commonly consumed local dairy product, namely milk, maas (fermented milk), yoghurt, and cheese. For each dairy product, the usual frequency of consumption and portion size per eating occasion were scored (product serving score; PSS) and summed, resulting in a daily serving score (DSS) as a continuous variable with three risk classes, namely < 1 serving daily; 1 to < 2 servings daily; ≥ 2 servings daily. Digitalisation included product- and portion-specific graphics with linkage to risk class-relevant preliminary dairy-related guidance as part of a web-based mobile app. For the evaluation of the usability, the 26-item user-friendly end-user version of the Mobile Application Rating Scale (uMARS) was used in an online cross-sectional survey (Qualtrics, April 2020) of conveniently sampled adult respondents. Items were scored on a five-point Likert-type scale resulting in three scores made up of six subscales. Descriptive statistics summarised the findings, with mean scores ≥ 3.0 considered acceptable. Reliability and validity: In a diagnostic accuracy study, purposefully recruited undergraduate dietetics/nutrition student volunteers from three South African universities completed three non-consecutive days of weighed food records (reference standard) within a seven-day period (comparative validity), followed by two administrations, two weeks apart, of the screener (index test) (reliability). Dairy intake from the food records was converted to be comparable to dairy intake in the screener. For the reliability and validity assessment, statistical analyses included mean differences, paired t-tests and Pearson rank correlations for continuous data, and Kappa statistic for categorical data. For test-retest reliability, McNemar’s test for symmetry was performed on categorised DSSs. For the validity assessment, agreement between the DSSs of the first administration of the Dairy Diary and mean DSSs of the three food records was verified with Bland–Altman plots. Sensitivity , specificity , predictive values, odds ratios and receiver operating characteristics (ROC) were used to quantify the diagnostic ability of the categorised DSSs of the Dairy Diary. Results Development and usability: From 1 102 respondents, 703 (64%; 81% female; mean age 29.8 ± 11.0 years) were retained for analysis. The uMARS mean app quality score (objective) (3.9 ± 0.85), app subjective quality score (3.5 ± 0.77), app-specific score (3.6 ± 0.94), and the additional question on the e-portion (4.3 ± 0.78) exceeded minimum acceptability. For the subscales, the mean score for aesthetics was the highest (4.4 ± 0.82), followed by information (4.3 ± 0.90) and functionality (4.0 ± 1.33). Engagement scored the lowest (3.0 ± 1.55). Reliability and validity: Participants included a purposefully recruited sample of 79 (100% female; mean age: 21.6 ± 3.8 years). For reliability, mean PSSs and DSSs did not differ significantly (P > 0.05) between the screener administrations. Mean PSSs were strongly correlated: milk (r = 0.69; P < 0.001), maas (fermented milk) (r = 0.72; P < 0.001), yoghurt (r = 0.71; P < 0.001), cheese (r = 0.74; P < 0.001). For DSSs, Kappa was moderate (κ = 0.45; P < 0.001). Non-agreeing responses suggest symmetry (P = 0.334). For validity, the PSSs of the screener and food records were moderately correlated [milk (r = 0.30; P = 0.0129), yoghurt (r = 0.38; P < 0.001), cheese (r = 0.38; P < 0.001)], with κ = 0.31 (P = 0.006) for DSS. Bland–Altman analyses showed acceptable agreement for DSSs (bias: −0.49; 95%CI: -0.7 to −0.3). Categorised DSSs had high sensitivity (81.4%) and positive predictive value (93.4%), yet low specificity (55.6%) and negative predictive value (27.8%). The area under the ROC curve (0.7) was acceptable. Conclusion The Dairy Diary is a user-friendly screener for dairy intake, with high aesthetic appeal and low engagement. Furthermore, it is test-retest reliable and has moderate potential to be a comparatively valid tool to screen for dairy intake of groups of higher income South Africans.
Factors related to resting energy expenditure and physical activity of 6–9-year old children in two primary schools in the City of Tshwane metropolitan area
(University of Pretoria, 2020-12) Wenhold, F.A.M. (Friedeburg Anna Maria); Wood, Paola; Legodi, Heather; adeline.pretorius@up.ac.za; Pretorius, Adeline
A lower resting energy expenditure (REE) has been suggested to partially explain the disproportionate prevalence of overweight/obesity among black African women, yet no studies have investigated the REE of South African (SA) children. Similarly, physical activity (PA) as a modifiable factor related to childhood energy expenditure is under-researched in the local context. The study determined the relationship between sex and population group (determinant factors), on the one hand, and REE and PA (outcomes) of 6–9-year-old SA children attending two primary schools in the City of Tshwane metropolitan area, on the other, taking phenotypic characteristics as confounders (mediating factors) and the study context into account. In a cross-sectional study with quota sampling, the REE of 6–9-year-old children attending two urban schools in SA was measured with indirect calorimetry (IC), and PA with a pedometer. Multifrequency bioelectrical impedance analysis was used to assess body composition (BC) (fat-free mass [FFM], FFM index, fat mass [FM] and FM index). Multivariate regression was used to calculate REE and PA adjusted for phenotypic confounders (z-scores of weight-for-age, height-for-age and body mass index-for-age, and BC). Sex and population differences in REE and PA (measured and adjusted) were determined with two-way ANOVA. Ninety-four healthy children (59.6% girls; 52.1% black African) with similar socio-economic status and access to PA participated in the study. Despite variations in BC, sex differences in REE were not significant (41 kcal/day ≈ 172 kJ/day; P = 0.375). The REE in black African participants was significantly lower than in their white counterparts (146 kcal/day ≈ 613 kJ/day; P = 0.002). When adjusting for BC, population differences in REE declined, especially after adjustment for FFM (91 kcal/day ≈ 382 kJ/day; P = 0.039), but remained clinically significant. Average steps/day in girls (10212 [9519;10906]) was lower than in boys (11433 [10588;12277]) (P = 0.029), and lower in black African (9280 [8538;10022]) than in white (12258 [11483;13033]) (P < 0.001) participants. No significant relationship (r = 0.05; P = 0.651) was observed between REE and PA. Within the context of a similar SES and PA environment, the REE and PA of black African children was lower than white. Differences in REE between sexes were not significant, but girls had a lower PA than boys.
In-hospital growth of very low birth weight preterm infants : comparative effectiveness of two human milk fortifiers
(University of Pretoria, 2020) Wenhold, F.A.M. (Friedeburg Anna Maria); Nakwa, Firdose; kemridge@absamail.co.za; Kemp, Johanna Elizabeth
The protein content of the only human milk fortifier available in South Africa was increased in 2017. The Original fortifier (OF) and the Reformulated fortifier (RF) provided similar energy. This study aimed to prospectively compare in-hospital growth during the intermediate stage of nutrition support of very low birth weight (VLBW) preterm infants receiving human milk fortified with these two formulations in a tertiary South African hospital. Intake of VLBW infants receiving exclusively human milk plus one of two fortifiers (OF 0.2gprotein/g powder; RF 0.4gprotein/g powder) was calculated. Change in Z-scores (Fenton, 2013) from start to end of fortification of weight, length and head circumference (HC) for age was calculated as primary outcomes. Additionally, weight gain velocity (g/kg/d) and gain in length and HC (cm/wk) were calculated. Fifty eight infants (52% female; gestational age: 30±2wk; birth weight: 1215±187g) received OF (2016 to 2017) and 59 infants (56% female; gestational age: 29±2wk; birth weight 1202±167g) received RF (2017 to 2018) for 15 days. Protein intake of RF (3.7±0.4g/kg/d) was significantly higher (p<0.001) than of OF (3.4±0.2g/kg/d). Protein-to-energy ratio of RF (2.6±0.2) was significantly higher (p<0.001) than of OF (2.3±0.1g/100kcal). No adverse effects were noted. In both groups Z-scores of weight and length dropped; Z-scores for HC showed slight improvements. There were no significant differences between the two groups in terms of Z-scores, weight gain velocity, length gain or HC gain. Analysed human milk from preterm infants’ mothers’ protein levels was higher than published values. In-hospital growth was not statistically different between groups, even though calculated protein intake and protein-to-energy ratio were significantly higher in RF group.
Food Accessibility and Nutrition Status of Tenant Women of Reproductive Age and Under-Five Children on Smallholder Tobacco Farms in the Northern Malawi
(University of Pretoria, 2017) Gericke, Gerda J.; Muchiri, Jane Wanjiku; u15005730@tuks.co.za; Munthali, Justice
Introduction: Lack of evidence-based information is an impediment to improve the food security and nutrition status of vulnerable tobacco tenant women and their children on smallholder farms in Malawi. Aim: To assess and describe the food accessibility and nutrition status of the tobacco tenant women of reproductive age and their under-five children on smallholder farms, as well as to determine and report correlational relationships amongst demographic and socio-economic factors, food accessibility measurements and nutrition status indicators. Design: Quantitative cross-sectional descriptive correlational study. Setting: Bwengu, Engucwini and Njuyu Extension Planning Areas, Mzimba North district, Malawi. Sample: 110 women of reproductive age sampled through a proportional systematic random sampling technique, and their 139 under-five children. The sample size was calculated using nQuery version 7 software based on 47% prevalence of malnutrition among under-five children in Malawi, estimated at 95% CI to the accuracy of 10%. Methodology: Data were captured through face-to-face interviews during the hunger season. Food accessibility was captured using the Household Food Insecurity Access Scale (HFIAS), Household Hunger Scale (HHS), Months of Adequate Household Food Provisioning (MAHFP) and Individual Dietary Diversity Scale (IDDS). Nutrition status was measured using anthropometry according to standard protocol. WHO Anthro software was used to compute Z-scores (W/A, H/A, W/H and BMI/A) for children, based on WHO standards. Microsoft Excel was used to calculate BMI for women, based on WHO cut-off points. Stata software was used to compute regression analyses to establish correlational relationships between independent and dependent variables. Ethical approval was obtained from the University of Pretoria, Natural and Agriculture Science Committee (Number EC151215- 028), as well as from the Mzuzu Agriculture Development Division in Malawi. Results: Mean age of the women was 27.3 ± 6 years and 28.8 ± 15 months for the children. The experience of food insecurity access was severe for 75% of the households. Nearly onefifth of households were severely hungry, and had adequate food for only about eight months of the year. The women and their children consumed a mean of two food groups in the previous 24 hours. For the women, 21% were malnourished. For the children, 20% were wasted, 31.3% were stunted and 34% were underweight. More male children were malnourished. For food accessibility measurements, the multivariable linear regression analysis was used. The significant factors influencing the severity of the experience of food insecurity access were loan access (P = 0.015) and household size (P = 0.000). For the prevalence of hunger, the significant factors were food security and nutrition training (P = 0.046), marital status (P = 0.045) and household size (P = 0.000). For the annual prevalence of hunger, the significant factors were labour (P = 0.038), income (P = 0.008) and household size (P = 0.001). For the dietary diversity, the significant factors were labour (P = 0.001), food security and nutrition decisions (P = 0.004), mother’s age (P = 0.033) and income (P = 0.000). Using the multivariable IV regression analysis, the significant factors influencing the BMI of the women were their age (P = 0.054), loan access (P = 0.004), HFIAS scores (P = 0.007) and HHS scores (P = 0.001). For the children’s weight-for-age, the significant factors were the mother’s BMI (P = 0.014), child’s sex (P = 0.005), assets (P = 0.014), mother’s age (P = 0.001) and child’s age (P = 0.015). Using the multivariable random-effects GLS regression analysis, the significant factors influencing the children’s height-for-age were the mother’s age (P = 0.004), child’s sex (P = 0.005), assets (P = 0.028) and HFIAS scores (P = 0.006). For the children’s weight-forheight, the significant factors were the mother’s BMI (P = 0.032), MAHFP scores (P = 0.029), child’s age (P = 0.008) and income (P = 0.001). For the children’s BMI-for-age, the significant factors were the mother’s BMI (P = 0.030), mother’s age (P = 0.029), income (P = 0.002) and assets (P = 0.047). Conclusion: The food accessibility and nutrition status of the tobacco tenant women and their children were seriously poor. The significant factors influencing food accessibility and nutrition status were loan access, household size, food security and nutrition training, marital status, labour, income, assets, food security and nutrition decisions, mother’s BMI, mother’s age, child’s age, child’s sex, HFIAS scores, HHS scores and MAHFP scores. The study findings offer clues to policy makers on where to direct interventions to improve food accessibility and nutrition status of the tobacco tenant women and their children in Malawi.
Development and evaluation of a nutrition education programme for adults with type 2 diabetes mellitus in a resource limited setting of the Moretele sub-district, North West Province (South Africa)
(University of Pretoria, 2013) Rheeder, Paul; Gericke, Gerda J.; rahabmuchiri@yahoo.com; Muchiri, Jane Wanjiku
Background: Diabetes self-management education, including nutrition education (NE) is an essential component of diabetes management. Effective NE can assist individuals with type 2 diabetes mellitus (DM) in resource limited settings to improve their dietary self-care; an area cited among the most difficult with consequent improvement in health outcomes. Aim: To develop a NE programme that is tailored to the needs of adults with type 2 DM in a resource limited setting and to evaluate the programme's effectiveness on health outcomes. Setting: Makapanstad and Mathibestad community health centres in the Moretele sub-district, North West Province (South Africa). Methods: The study was done in three phases employing mixed methods research. Qualitative methods, using focus group discussions with 31 diabetic patients (a convenience purposive sample), and an open ended self-administered questionnaire with ten health professionals serving them, assessed the NE needs and preferences (phase 1). The data were analysed according to the framework approach. The results from the needs assessment were used to plan a tailored NE programme (phase 2). A randomised controlled trial (quantitative) with a sample of 82 patients (with HbA1c ≥ 8), allocated to either intervention or control groups, evaluated the effect of the NE programme (phase 3). Outcomes [HbA1c, dietary behaviours, blood lipids, blood pressure, body mass index (BMI), diabetes knowledge and attitudes towards diabetes and its treatment] were assessed at baseline, six months and 12 months respectively. An analysis of covariance (ANCOVA) compared the groups on measured outcomes using baseline values, age, gender, and clinic as covariates. Rank ANCOVA was used for dietary intake. The level of significance for all tests was set at α < 0.05 for a two-tailed test. Results: Needs assessment Diabetes related knowledge deficits and inappropriate dietary practices, including food portion control problems, inadequate intake of vegetables and fruits and unbalanced diets, were observed. Eight barriers and two facilitators to dietary adherence were identified. Financial constraint was the major barrier while social support was the major facilitator. NE recommendations included content related to the disease and diet, group education at the clinic, a competent educator, provision of education materials and inclusion of family members. The planned NE programme consisted of eight weekly training sessions and six follow-up sessions (monthly and bi-monthly), vegetable gardening demonstrations and education materials. Nutrition education programme effects: Seventy six participants (38 per group) completed the study. The differences in HbA1c (primary outcome) between the intervention and control groups were -0.62% (p=0.15) at six months and -0.67% (p=0.16) at 12 months. Few participants, four from the intervention group and one from the control group, achieved HbA1c target (<7%) at both six and 12 months, [(p=0.20), (p=0.36)] respectively. There were no significant between group differences in BMI, lipid profile and blood pressure at six months and 12 months. Starchy foods intake (median servings) were significantly lower in the intervention group compared to the control group, 9.3 vs. 10.8 (p=0.005) at six months and 9.9 vs. 11.9 (p=0.017) at 12 months. The proportion of participants growing own vegetables significantly increased in the intervention group compared to the control group 17/41 vs. 5/40 (p=0.003) at six months and 16/38 vs. 5/38 at 12 months. No significant group differences in the intake of energy, macronutrients, vegetable and fruits, sodium, cholesterol and fibre were observed at six and 12 months. Diabetes knowledge improved in the intervention group +0.95 (p=0.033) and +2.2 (p=0.000) when compared with the control group at six and 12 months respectively. There were no significant group differences in the attitudes towards diabetes and its treatment. Conclusions: The qualitative needs assessment provided insight for planning a tailored NE programme. The NE improved some dietary behaviours (starchy foods portion control and growing own vegetables) and diabetes knowledge. A non-significant lowering of HbA1c was observed.
A comparison of the glycemic index (GI) results obtained from two techniques on a group of healthy and a group of mixed subjects
(University of Pretoria, 2008-04-24) Gericke, Gerda J.; liesbet@gifoundation.com; Delport, Elizabeth
Please read the abstract in the dissertation
Development and comparative validation of a dietary fat screener for grade six children
(University of Pretoria, 2006-11-03) MacIntyre, Una Elizabeth; Rheeder, Paul; upetd@ais.up.ac.za; Wenhold, Friedeburg Anna Maria
Background Risk factors for chronic non-communicable diseases have been shown to track from childhood into adulthood. Cost-effective intervention starts with valid screening. The aim of this research was development and comparative validation of a dietary fat screener in grade six learners. Methods A pictorial, quantitative food frequency questionnaire type, scored dietary fat screener (test method), consisting of ten food categories associated with high fat intakes, was developed and subjected to developmental evaluations in the target group. Subsequently the test method was administered to learners of an urban middle-class school (Pretoria, South Africa). Test-retest reproducibility was checked in a random sub-sample. Two reference methods were used for comparison: Parental completion of the screener and a three-day food record by the children. Reliability testing of the test method involved measuring internal consistency and test-retest reproducibility. Credibility of energy intakes in the food record was checked. Mean cholesterol intake and percentage fat and saturated fat energy were determined. Comparative validation was based on correlations, mean differences and the Bland Altman method for continuous variables. Percentage agreement, kappa statistics and the McNemar tests were determined for categorical data, as were sensitivity, specificity and predictive values. Receiver operating characteristic curves were plotted. Results Sample: Out of 108 children, 39 (100%) were re-tested, 93 (86%) provided usable food records and 78 (72%) parents responded. Mean age was 148±4.4 months. Reliability: The test method was internally consistent. Test-retest reproducibility of portion size and frequency of intake estimates depended on the food category. No systematic error between administrations was noted as mean category and final score differences between the two administrations did not differ significantly from zero. A significant (r=0.36, P=0.02) correlation existed between administrations, but boys were characterised by random error and a lack of reproducibility (r=0.26, P=0.29), whilst for girls reproducibility could be established (r=0.58, P=0.01). Comparison to screener by parents: Children and parents did not agree in respect of reported portion size and frequency of intake. Parents had lower values for all scores. Correlation between children’s and parents’ final scores was 0.23 (P=0.04) (boys: r=0.13, P=0.46; girls: r=0.33, P=0.04), but the mean difference in final scores differed significantly from zero (P=0.0001). Classification was identical in 74% of cases, but when corrected for chance this agreement was also poor. Comparison to food record: The food record appeared to be a plausible reflection of energy intakes during the recording period. For girls a significant (P<0.05) correlation between test method final score versus cholesterol intake and energy from total and saturated fat was found. The sensitivity of the test method was very high (over 90%). Chance corrected agreement between test method classification and measures of fat intake from the food record was poor. Changing the cut-off of the test method final score could not achieve high sensitivity and high specificity simultaneously. Conclusion The dietary fat screener cannot yet be used as sole indicator of high fat intake in grade six learners. Until the discriminatory abilities have been improved, its value lies in creating awareness of high fat intakes and providing a food-based starting point for anticipatory guidance.
Assessing HIV lipodystrophy syndrome : a comparison of different methods to an objective case definition
(University of Pretoria, 2009) Wenhold, F.A.M. (Friedeburg Anna Maria); elmarie.vanwyk@gmail.com; Van Wyk, Elmarie Charlotte
Background: Morphological changes of Human Immunodeficiency Virus lipodystrophy syndrome (HIV LDS) are said to be the new face of HIV / Acquired Immune Deficiency Syndrome (AIDS) which may negatively influence the adherence to Highly Active Antiretroviral Therapy (HAART). Methods of assessing HIV LDS vary among researchers and practitioners who make it difficult to compare incidence and prevalence figures among clinics in South Africa. Instruments available in other countries to assess HIV LDS are costly and time consuming for the clinical setup. A standard, objective and practical instrument is needed for the South African clinical setup to address this problem. Objectives: The primary objective of the study was to assess the agreement between methods routinely used to classify HIV LDS in the clinical setup (i.e. National Cholesterol Education Programme [NCEP] criteria, subjective self-reporting and routine anthropometry) to a published, objective case definition using diagnostic testing. The secondary objective was to develop and cross-validate a classification instrument for HIV LDS utilising parameters from the studied test methods. Design and sample: The study was a cross-sectional, analytical and non-experimental analysis of 1421 HIV positive adult patients (69% female) enrolled on HAART. Of the 283 subjects who met the inclusion criteria, 253 consented to participate. Purposeful sampling was performed dividing the study population into a case (n=79) - and control (n=73) group according to a screening process. The dichotomous outcome (HIV LDS (+) or – Ө) of the tests – and reference method was statistically analysed by means of diagnostic testing. The new classification instrument was developed using logistic regression on all the variables and validated with a cross-validation technique. Setting: Outpatient clinic at Kalafong Hospital, Gauteng Province, South Africa. Results: Primary objective: The diagnostic properties (sensitivity, specificity, Kappa coefficient and p-value for McNemar’s test respectively) of the test methods were as follows: NCEP criteria: (45%, 83%, 0.29 and 0.54); subjective self-reporting (74%, 59%, 0.26 and 0.00); Kotler anthropometry (71%, 52%, 0.18 and 0.00); routine anthropometry (62%, 54%, 0.12 and 0.00); and Dong&Hendricks anthropometry: (10%, 88%, 0.00 and 0.00). Secondary objective: A new, simple classification instrument (with limited blood samples) had the following diagnostic properties: (sensitivity 81% [71% validated], specificity 79% [75% validated], Kappa 0.54 [0.41 validated], McNemar’s test of symmetry p=0.00, and the area under the receiver operating curve [AUC] was 0.88). A classification instrument without blood samples had a sensitivity of 69%, specificity of 67%, Kappa = 0.310, McNemar’s p= 0.00 and AUC= 0.75). Conclusion: In a resource limited setting the NCEP criteria appears to be the “best” among the methods tested for identifying HIV LDS. Two newly developed instruments showed even better diagnostic properties. Use of these might lead to an accurate, consistent detection of HIV LDS in the typical South African setting. However, practical implications to the individual and the health care system still need to be investigated further. The results can also be used in longitudinal studies.
Feeding practices and nutritional status of children (aged 0 to 3 years) in two clinics in the Moretele district
(University of Pretoria, 1999) Gericke, Gerda J.; upetd@up.ac.za; Kruger, Rozanne
Please read the abstract in the section 00front of this document

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