Nutrition and Dietetics

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Open Access
The effect of a combination of short-chain fatty acids on plasma fibrinogen concentrations in Westernised black men
(University of the Free State, 1999-11) De Wet, Martie; Dannhauser, A.; Veldman, F. J.
English: The incidence of the western diseases, atherosclerosis, CHD and stroke is progressively rising in black populations worldwide and in South Africa. Stroke is an important cause of death in black populations in South Africa and may increases even further if risk factor (coronary and some haemostatic risk factors) prevalence is altered by change in lifestyle and diet, westernisation and migration to an urban environment. Raised fibrinogen levels which are more prevalent in westernised black men than white men, are accepted as an important risk factor for stroke and CHD. It is believed that the possible protective effects of diet against the development of atherosclerosis and thrombosis could be mediated, in part, through haemostasis. A prudent low-fat, high-fibre diet may favourably influence haemostasis. More specifically, oat bran (soluble fibre) has been shown to have beneficial effects on some coronary risk factors and haemostasis. The physiological effects of dietary fibre are strongly related to SCFAs, which are produced by colonic fibre fermentation. According to available literature, SCFAs could possibly have a beneficial effect on lipid profiles and haemostatic risk factors. Little information is, however, available on the effect of a specific combination of SCFAs on fibrinogen levels and other haemostatic factors in human subjects. The main objective of the study was to examine the effect of a combination of SCFAs, resembling oat bran (acetate:propionate:butyrate – 65:19:16) on plasma fibrinogen levels, some haemostatic risk factors and other related risk factors for CHD and stroke in westernised black men. The study was a randomised, placebo-controlled, double-blind clinical trial. 22 subjects falling within a pre-determined set of inclusion criteria, and with higher normal fibrinogen levels were randomly selected into an experimental group (n = 11) and placebo group (n = 10). Supplementation of 12 capsules daily was sustained for five weeks. Total plasma fibrinogen, fibrin monomer concentration, fibrin network properties, factor VII and factor VIII activity, serum lipids, glucose concentrations, some metabolic indicators and fasting acetate concentrations were measured at baseline and at the end of supplementation, in all subjects. The usual dietary intake of the subjects was obtained using a food frequency questionnaire and a 24-hour recall. According to the baseline results, the subject group was homogeneous with an apparently healthy clinical and physical appearance. Although both subject groups had a favourable coronary and haemostatic risk profile, total cholesterol levels as well as factor VII and factor VIII activity were in the higher normal ranges. Furthermore, the 24-hour recall indicated a tendency towards the adoption of an atherogenic Westernised diet. Although SCFA supplementation had no effect on the fibrinogen concentrations, a significant decrease was observed in the fibrin monomer concentrations, network fibrin content, factor VII and factor VIII activity. A significant increase was observed in the compaction of the fibrin networks, as well as a tendency for the mass to length ratio of the fibrin fibres to increase. Furthermore, a statistically significant although not clinically significant increase was indicated in HDL cholesterol concentrations after SCFA supplementation. It was evident from these findings that SCFA supplementation may have a direct effect on haemostasis, especially the fibrin network characteristics, factor VII and factor VIII activities, as well as fibrin monomer concentration. This observation suggests that SCFA supplementation may have a strong protective effect against atherosclerosis and thrombosis. In conclusion, the hypothesis that soluble dietary fibre will influence fibrinogen concentrations and other haemostatic risk factors through production of SCFAs, was proven to be partially true. It was clear that, although fibrinogen concentration was not influenced by SCFA supplementation, beneficial effects on the fibrin network architecture and the positive cascade effect on haemostasis may be a direct effect of SCFAs supplementation. The study further indicated that the known protective effects of dietary fibre on CHD could partially be mediated through effects of SCFAs on fibrin networks. It is recommended that the role of fibrin networks as a risk factor for CHD and the effect of diet on haemostasis should be further investigated.
Open Access
The goitre prevalance and urinary iodine status of primary school children in Lesotho
(University of the Free State, 2000-11) Sebotsa, Masekonyela Linono Damane; Dannhauser, A.; Jooste, P. L.
English: Iodine deficiency has been called the world's most significant cause of mental retardation. Studies conducted since 1960 have indicated iodine deficiency as public health problem in Lesotho. The ICCIDD has been instrumental in focusing the world's attention on 100 and the goal of virtual elimination of 100 as a public health problem by the year 2000 was accepted by the united systems in 1990. This goal was reaffirmed by the e" World Health Assembly in 1993, which also provided a strategic guidance including emphasis on salt iodisation. The main objective of this study was to estimate the current 100 situation in Lesotho 5 years after the 1993 National Micronutrient Survey which was followed by iodised oil capsule supplementation as a short term intervention and the introduction of the legislation on universal salt iodisation as a long term intervention. This was a cross sectional study where stratified random sampling was used to select 5 schools in each of the 10 districts of Lesotho. All children aged 8 to 12 years from the selected schools participated in the study. The size of the thyroid gland was determined by palpation and graded according to the Joint criteria of the WHO/UNICEF/ICCIDD (1994). Casual urine samples were obtained from 10 children in each school in the morning during school hours and frozen until they were analysed for urinary iodine level using the Sandell-Kolthoff reaction involving alkaline ashing at the National University of Lesotho. Using a structured questionnaire, iodised oil supplementation coverage was determined. Salt samples brought by children were also analysed for the presence of iodine using the rapid (spot) test kits. The SAS package was used for statistical analysis of the results at the University of Orange Free State. 4071 primary school children were palpated and responded to the questionnaire, 4071 salt samples and 500 urine samples were analysed. The median urinary iodine concentration of 26.3IJg/l, which ranged from 22.3IJg/1to 47.91Jg/l and from 25.7IJg/1 to 27.2IJg/1 in the different districts and ecological zones respectively, indicated moderate 100. The prevalence of goitre, which increased with age and was higher in females than males, ranged from 2.2 to 8.8 percent and from 2.3 to 6.3 percent in the different districts and ecological zones respectively indicating mild to normal iodine deficiency. The adjusted prevalence of goitre for the whole country was 4.9 percent, indicating the absence of 100. 94.2 percent of salt samples were iodised. Coverage on iodised oil capsules supplementation, which was 55.1 percent, was not adequate. Lesotho was found in this study as having mild to moderate 100, which is still of public health concern according to WHO/UNICEF/ICCIOO (1994). Iodine deficiency was higher in the Mountains than in the Lowlands. However there is an improvement in controlling 100 in Lesotho as observed from the results of the present study and those of the previous studies. The use of iodised salt and iodised oil capsules has most likely contributed to a decrease in the 100 prevalence. Similar studies using ultrasonography and the titration method need to be conducted in the future. More iodised oil supplementation is recommended in the Mountains and in schools, which never received the capsules and this needs to be coupled with efficient awareness programs. An effective monitoring program needs to be initiated to ensure that the entire population use adequately iodised salt.
Open Access
Effects of a low-insulin-response, energy-restricted diet on weight loss and endocrinological parameter in obese, anovulatory women in their reproductive years
(University of the Free State, 2002-12) Lusardi, Liz-Mare; Slabber, M.; Meyer, G. M.
There is consistent evidence that obese women are less fertile than women of normal body weight. Obesity, in particular android obesity, is associated with several sex steroid abnormalities in premenopausal women including: increased free estrogen and androgen fractions, reduced sex hormone-binding globulin and increased bioactive estrogen delivery to target tissue. The state of insulin resistance with secondary hyperinsulinemia is commonly observed in obese, infertile women whereas the gonadotrophic effects of insulin on ovarian steroid hormone synthesis have been indicated in vivo and in vitro. Insulin can directly and indirectly stimulate ovarian androgen production. The exaggerated insulin action on ovarian tissues may present the pathological mechanism for disturbances in the endocrine profile and menstrual cycle and infertility in some obese women. Due to certain limitations we did not diagnose anovulation whereas only a certain percentage of the subjects in each group were hyperinsulinemic. One of the problems experienced was the drop outs in each group. Weight loss is associated with a significant improvement in menstrual abnormalities, ovulation and fertility rates with a reduction in hyperandrogenism and hyperinsulinemia. It is suggested that weight loss should be the first option in the treatment of overweight infertile women. Intervention studies suggest that reducing weight and/or hyperinsulinemia either by diet alone or a combination of diet and drug therapy should be investigated. This study was undertaken to evaluate the effects of a low-insulin-response, energyrestricted diet (LID) on anthropometric and endocrinological parameters in obese women with menstrual abnormalities. For the purpose of this study we compared the effects LID to a normal balanced-energy restricted diet. The principles for the LID were based on the available literature regarding the insulin response to foods and their combinat ions. At baseline 37 candidates were randomly assigned into two groups. Group A followed the LID and consisted of 19 candidates whereas Group B followed the NO and consisted of 18 subjects. The inclusion criteria were: obese (BMI > 30kg/m2), premonopausal, insulin resistance, anovulation and between the ages of 18 and 04 years of age whereas the exclusion criteria included increased fasting and stimulated glucose concentrations, cigarette-smokers, and the presence of any chronic medical condition. Subject fasted for a 10 to 12 hour period after following a 250 g carbohydrate diet for three-days prior to baseline blood sampling. Blood samples were collected at baseline and at the end of the 16-week trial and analyzed for fasting insulin and glucose, testosterone (T), luteinizing hormone (LH), follicle stimulating hormone (FSH), estrogen (E), prolactin, thyroid stimulating hormone (TSH), thyroxine (FT4), leptin and progesterone. Insulin resistance were defined as a glucose-to-insulin ratio < 4.5. Stimulated 30 and 120-minute insulin and glucose were collected after subjects consumed 82.5g of monohydrate glucose powder diluted in 300ml water. Due to certain limitations we did not diagnose anovulation whereas only a certain percentage of the subjects in each group were hyperinsulinemic. One of the problems experienced was the drop outs in each group. Results form this trial indicated a significant reduction in fasting and JO-minute stimulated insulin, LH, and testosterone and leptin concentrations in the NO group whereas only leptin concentrations reduced significantly in the LID group. A significant reduction occurred in mean weight, BMI, body fat percentage, waist and hip circumference in both groups. Numerous studies evaluated the effects of weight loss on fertility but to our knowledge this is the first trial of its kind to evaluate the effects of two different test diets on fertility parameters. Results from this trial confirm the positive effects of weight loss on endocrinological and anthropometric parameters in obese women, however, the LID showed no beneficial effects over the NO. Future research is needed to evaluate the effect of diet manipulation on fertility parameters with specific regard to diet manipulation in combination with drug therapy. This trial, however, serves as a good pilot study for future research of this kind.
Open Access
The effect of a combination of short-chain fatty acids on glycometabolic control in men
(University of the Free State, 2002-12) Van Onselen, Annette; Dannhauser, A.; Veldman, F. J.
English: Dietary fibre has revealed benefits for health maintenance and disease prevention and as a component of medical nutrition therapy. Dietary fibre forms an important part of the Westemised diet, which is characterised by low-fat, low-carbohydrate and low-fibre intake. A high-fibre diet may favourably influence glycometabolic control. It is believed that short-chain fatty acids (SCF As) may partially be responsible for some of the beneficial effects of dietary fibre on metabolism. These SCFAs namely, acetate, propionate and butyrate arc the major products of colonic fibre fermentation. Some of the SCFAs have been shown to improve blood glucose and insulin levels. However, the effect of a combination of SCFAs on glycometabolic control is still unclear. The main aim of the study was to determine the effect of a combination of SCFAs (acetate: propionate: butyrate in the ratio of 70: 15: 15, respectively) and (acetate & propionate: in the ratio of 50:50, respectively) on glycometabolic control in men. The study was a randomised, placebo-controlled, double-blinded clinical trial. Voluntary subjects were recruited for this study using a very strict set of inclusion criteria. All subjects received a placebo for a period of one week following the collection of baseline blood samples and other information. A second baseline blood sample was collected from each individual at the end of this period to ensure accurate reflection of the variables and a stable baseline. Subjects were randomly assigned to three different intervention groups and consumed the different mixtures of either placebo, acetate-propionatebutyrate or acetate-propionate supplement for a period of four weeks following the second baseline blood collection. Supplementation of eight capsules daily was sustained for four weeks. Metabolic indicators (serum glucose, serum insulin, serum albumin, total protein, total cholesterol (TC), high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, non-esterified fatty acids (NEF A), anthropometric status and blood pressure were measured at baseline two (day 8) and after supplementation (day 36). A wash-out period of one week following the supplementation period measured any changes in the metabolic indicators (day 43). The usual dietary intake of the subjects was obtained using a food frequency questionnaire (FFQ) at baseline one (day 0) and after supplementation (day 36). Anthropometric status included body mass index (BMI) and waist-to-hip ratio (WHR), which were measured by means of standardised methods (on days 1, 8 and 36). The BMI and WHR fell within the normal range, and remained within the normal range during the study. This indicated that the subjects were apparently healthy. The study group was also of homogeneous nature, mainly as a result of the strict inclusion criteria applied at the time of recruitment of the subjects. The fasting serum glucose levels were within the higher normal range (5.1 - 5.7mmollL). No statistically significant changes were observed in any of the glycometabolic parameters following supplementation with the different SCFAs regimens (acetate, propionate and butyrate; acetate and propionate). Total cholesterol (TC) levels of the subject group as a whole fell within the normal range of the population (3.0 - 5.2mmollL). However, the observed levels fell in the higher normal range (4.1 - 4.8mmol/L). The HDL-C levels increased slightly in group three (acetate and propionate) and slightly decreased in group two (acetate, propionate and butyrate), however not significantly. The LDL-C significantly decreased in group two (acetate, propionate and butyrate). The observed decreased in systolic blood pressure were statistically significant after the intervention period in group two (acetate, propionate and butyrate). However, observed changes in LDL-C and systolic blood pressure were of no clinical importance. The FFQ indicated a tendency towards the adoption of an atherogenic Westenised diet. This study could not shown that a combination of short chain fatty acids have a beneficial effect on glycometabolic control. The findings of this study are supported by other studies, which indicate that acetate, propionate and butyrate do not improve glucose metabolism in healthy subjects. In contrast, other studies indicated a decrease in fasting serum glucose concentration from propionate (Todesco et aI., 1991) and acetate (Jenkins et aI., 1991) as well as from a combination of acetate, propionate and butyrate (De Wet, 1999). The controversial results regarding the effect of short chain fatty acids on glucose metabolism emphasize the importance of further investigation about the association between physical characteristics and formation of SCFAs, as well as the different combinations of SCFAs over a longer period of time.
Open Access
Evaluation of the iodine deficiency disorders control program in Lesotho
(University of the Free State, 2003-05) Sebotsa, Masekonyela Linono Damane; Dannhauser, A.; Jooste, P. L.
The broad range of disorders in a population caused by an inadequate dietary supply of iodine was denoted as iodine deficiency disorders (JDD), which include endemic goitre, hypothyroidism, cretinism and congenital anomalies. When iodine deficiency is widespread, mental retardation impedes national human resource development. Despite the known effective control measures, 130 WHO member states have a significant JDD problem. Severe to mild JDD have been reported in Lesotho since 1960. The most cost-effective and sustainable intervention to eliminate JDD is the iodisation of all edible salt. However, several countries with long standing salt iodisation programs have reported declining levels of urinary iodine. In Lesotho, the legislation on universal salt iodisation was promulgated in 2000. Therefore the aim of the study was to evaluate the salt iodisation program in Lesotho in terms of process, impact and sustainability indicators. A 30 cluster national survey was conducted where the proportion to population size method was administered. In each cluster, 30 women aged 15 to 30 years, and 30 primary school children aged 8 to 12 years, were randomly selected. The selected women and children were palpated and thyroid size graded according to WHOIUNICEFIICCJDD (2001) criteria and urine samples collected. 30 salt samples were collected from these selected women, 6 samples from 2 randomly selected retailers in each cluster, and 107 samples collected from all the commercial entry points in the country. The salt samples were analysed using the iodometric titration method while urine samples were analysed using the method using ammonium persulfate according to WHOIUNICEFIICCJDD (2001) recommendations. This analysis was performed at the Medical Research Council in Cape Town (South Africa) where the Coefficient of Variation for urinary iodine analysis was 7.7 at a concentration of IOug/l, and was 2.7 at a concentration of 70ppm for titration method of salt analysis. The statistical analysis was done using the SAS program at the University of the Free State (South Africa). A total of927 children and 930 women who were palpated, and 912 children and 924 women who gave urine samples, were included in the analysis of the results. 930 salt samples from household level, 186 from retail level and 107 from entry point level were analysed. 3 salt samples from entry point, 18 and 6 data sheets for urinary iodine of women and children respectively were not included during statistical analysis. The median iodine concentration of salt was 36.2ppm (ranging from 30.5-55.4ppm in the different entry points), 37.3ppm (ranging from 12.4-50.2ppm in the different districts) and 38.5ppm (ranging from 29.2-43.2ppm in the different districts) at entry point, retail level and household level respectively. At household level only 1.6 percent used non iodised salt and 86.9 percent used adequately iodised salt. The analysis of the urine samples showed that the median urinary excretion was 214.7flg/1 (ranging from 62.9flg/1 to 302.6flg/l in the different districts) for the children and 280.1flg/ (ranging from 124.8flg/1 to 381.6flg/l in the different districts) for the women, indicating more than adequate iodine intake according to the WHOIUNICEFIICCIDD (2001) report. The median iodine concentration was higher in boys (219.3flg/l) than in girls (212.6flg/I), higher in the Lowlands (256.0 flg/l in children and 329.9 ug/l in women) than in the Mountains (99.30flg/l for children and 182.6flg/1 in women) and higher in non-pregnant women (283.0 ug/l) than in pregnant women (212.1 ug/l). In the whole country, the prevalence of goitre was 10.7 percent (ranging from 6.6% to 22.6 % in the different district) in children and 19.4 percent (ranging from 6.7% to 36.7% in the different districts) in women, which indicates mild IDD (WHOIUNICEFIICCIDD, 2001). IDD were observed more in females (14.0%) than in males (7.0%) and was less (4.3%) in children aged 8 than in children aged 12 years (12.9%). In women IDD increased with age from the age group of 15 to 19 (17.3%) to the age group of 20 to 25 (22 %) and decreased in the age group of 26 to 30 (18.4%). Similar to urinary iodine results, IDD was observed more in the Mountains (17.7% for women and 18.1% for children) than in the Lowlands (14.3% for women and 6.7% for children). Only the urinary iodine excretion reached the WHOIUNICEFIICCIDD (2001) sustainability goals. At household level, 86.9 percent of the households, which is slightly lower than the recommendation of at least 90 percent, use adequately iodised salt. Out of 10 programmatic indicators of sustainability, only 4 indicators have been attained by the salt iodisation program in Lesotho. According to the WHOIUNICEFIICCIDD (2001) at least 8 of the programmatic indicators should be attained for sustainable elimination ofIDD. The study demonstrates a major achievement in the household use of iodised salt and adequately iodised salt. However, salt is not iodised according to the legislation on universal salt iodisation in Lesotho due to under iodisation and non- uniformity of salt iodisation at the production site. Iodine deficiency has been eliminated as a public health problem in Lesotho and this is due to the introduction of the legislation on universal salt iodisation. This study highlighted the effectiveness of iodised salt in increasing urinary iodine concentration. Iodine deficiency increased with age and was higher in girls than in boys, and higher in the Mountains than in the Lowlands. IDD elimination in Lesotho will be sustainable if more than 90 percent of the households use adequately iodised salt and the programmatic indicators such as commitment to reassessment, political commitment, implementation of social mobilization program and reqular monitoring are achieved by the IDD control task force. The administrative structure and activities of the IDD control task force need to be revised and strengthened for the sustainable elimination ofIDD. The terms of reference of the committee should be revised, budgets for the activities be drawn, new members added and trained and responsibilities given to each member. Awareness campaigns, which will start at policy makers' level, should be initiated. Law enforcement should be an integral part of the salt iodisation program. Effective regular monitoring of salt iodine content at all levels with special attention to iodisation of coarse salt is recommended together with periodic evaluation of the iodisation program.
Open Access
Application of the current dietary guidelines for people with diabetes mellitus by dieticians and nurses
(University of the Free State, 2004-04) Taljaard, Hilana; Slabber, M.
English: Intensive diabetes management resulting in control of blood glucose concentrations will delay the onset and significantly impede the progression of complications from diabetes. Healthcare professionals such as dieticians and nurses are increasingly challenged to help patients with diabetes achieve a desirable body weight, and maintain good metabolic control. Therefore, a clear understanding of current dietary goals and skills to implement these goals when counselling patients with diabetes, is needed. A Position Statement was compiled by an expert group of dieticians in South Africa in 1997 to encourage a uniform approach to the nutritional management of diabetes mellitus. However, application of these dietary recommendations by health professionals has not been established. The main aim of this study was to assess the current practice trends of dieticians and nurses regarding application of the goals of the Position Statement in the Free State province (FS) and the North West province (NW). To accomplish this aim, dieticians and nurses were asked open-ended questions regarding the dietary goals. The study was a comparative, multi-centre study. A total of 18 dieticians (n=8 from the FS and n=10 from the NW), registered as Private Practicing Dieticians (PPDs), as well as a randomized, stratified sample of 150 registered nurses (n=100 from the FS and n=50 from the NW) working in all primary health care clinics, were included in the study. The researcher obtained informed consent from each participant. After the researcher telephonically scheduled appointments with all participants who gave permission to take part in the study, structured personal and telephonic interviews were conducted with dieticians and nurses, respectively. A standardized questionnaire was used to gather the necessary information. Answers were evaluated by scores preset to each answer, classifying them from the most to the least acceptable answer. High scores (from 75% to 100%) gave an indication of good application of the dietary goals, while lower scores (from 65%-74%) indicated that the dietary goals were not properly applied. The lowest scores (below 65%) indicated poor application of the dietary goals. All dieticians that were included in the study, as well as 64 and 31 nurses in the FS and NW, respectively, received formal letters from the researcher, requesting a copy of nutrition education material (NEM). Total scores were also determined for each NEM. High scores (from 75%-100%) indicated that the information was comparable to the dietary goals, while lower scores (from 65%-74%) gave an indication that part of the information was outdated. The lowest scores (below 65%) indicated that the information was unacceptable or completely outdated. Eighty-eight percent of the FS PPDs and 70% of the NW PPDs, as well as 87% and 96% of the FS and NW nurses, respectively, gave permission to take part in the study. Although dieticians obtained higher scores than nurses in both the FS and NW, total scores obtained by all health professionals were below 65%. No statistically significant differences were found between the scores obtained by nurses in the FS (mean 28%) and nurses in the NW (mean 29%). Dieticians in the FS and NW obtained mean scores of 64% and 61%, respectively. Although scores obtained by the FS dieticians were 3% higher, no statistically significant differences were found between the scores of dieticians in the two provinces. Mean scores obtained by NEMs from all health professionals were below 65%. No statistically significant differences were found between the scores for NEM from dieticians (mean 35%) and scores for NEM from nurses (mean 33%). It can be concluded that dieticians and nurses in the FS and NW poorly apply the current dietary recommendations for people with diabetes. Furthermore, most of the NEMs used by both dieticians and nurses in their respective practice settings do not correlate with the 1997 dietary goals. These results indicate that there is a dire need to focus on better education of health professionals who counsel patients with diabetes. More research is needed to identify the possible barriers to effective application of current dietary recommendations by health professionals.
Open Access
Anthropometric measurements and biochemical parameters in black women at the unit for reproductive care at Universitas Hospital, Bloemfontein
(University of the Free State, 2004-11) Motseke, Lucia; Slabber, M.; Nortjé
English: The prevalence of infertility in Africa is overshadowed by the high population growth rate in this continent. The number of infertile black African women seeking treatment is on the increase due to the fact that more black women are concentrating on their careers and postponing having children. The desire to reproduce is a highly motivating factor in most marriages and failure to do so places a lot of stress on the couple. Infertile women in most parts of Africa are treated as outcasts due to their infertile status. In most cases these women are either abused or divorced by their husbands. In sub-Saharan Africa, sexually transmitted diseases are the most common causes of infertility. Other causes of infertility in women include endometriosis, anovulation, tubal diseases, cervical factors and unexplained infertility. Anorexia and bulimia nervosa, as well as obesity, produce alterations in the reproductive system of women. Obesity has an effect on ovulation and on the outcomes of in vitro fertilization and assisted reproduction therapy. Anorexia nervosa on the other hand, has also been associated with amenorrhoea and oligoamenorrhoea. Insulin resistance is another factor that is linked to polycystic ovarian syndrome and infertility. Insulin resistance has also been shown to be prevalent in obese individuals, especially those with android fat distribution. Lowering insulin resistance by weight loss, results in spontaneous ovulation. The main objective of this study was to determine the anthropometrical and biochemical parameters in infertile black South African women. A total of sixty participants attending the Unit for Reproductive Health, Universitas Hospital, Bloemfontein were included in the study. Anthropometrical data measured included: body mass index; waist-to-hip ratio; waist circumference; neck circumference and body fat percentage. Blood samples were also obtained to determine the levels of fasting insulin, glucose, thyroid-stimulating hormone, luteinizing hormone, follicle-stimulating hormone, leptin, prolactin, progesterone, testosterone and C-reactive protein. The results of this study show that tubal factor infertility was the most prevalent cause of infertility and the second highest cause of infertility was male factors. The median age of the subjects of this study was 32 years. Sixty percent of the subjects had a gynoid fat distribution. More than a third of the subjects had a body mass index of more than 25 kg/m² and none of the subjects in this study had a body mass index of less than 18.5 kg/m². Eighty five percent of the subjects had a body fat percentage of more than 32 percent. These results indicate that obesity is a problem among these subjects. Biochemical parameters indicate that the median concentrations of the reproductive hormones were normal. Only 35 percent of the subjects had hyperinsulinaemia. Almost all of the subjects (83.6%) had leptin concentrations above normal. Median C-reactive protein level was also normal. No association was found between body mass index and C-reactive protein and insulin. An association was established between leptin concentrations and body mass index and the correlation between these two parameters was very strong. An association was also found between android fat distribution and hyperinsulinaemia. The high rate of obesity among the subjects of this study, places the subjects of this study at a risk of developing metabolic syndrome and other obesity-related factors. Their obesity status may also be a contributory factor to their infertile status. There should, be increased awareness of the impact of obesity on infertility and on their general health. Increased physical activity and healthy food choices should be encouraged among black infertile women. Black women should still be made aware of the fact that there are facilities available for treatment of infertility.
Open Access
Causes of malnutrition in Mangaung
(University of the Free State, 2005) Pienaar, Michelle; Walsh, C. M.; Dannhauser, A.
English: Malnutrition is often a silent and invisible problem and its persistence has profound and devastating implications for children, society and the future of humankind. While good nutrition is extremely important for a healthy lifestyle and quality of life, the effects of poor nutrition are devastating. Before interventions can be implemented however, it is essential to determine the specific causes of malnutrition in a community. The community of Mangaung is a rapidly urbanizing community where the double burden of malnutrition and diseases of lifestyle occur simultaneously. The causes of malnutrition are seen as deeply rooted in environmental factors, such as poverty and lack of education. In any attempt to improve nutritional status it is therefore important to assess the relationship between certain environmental factors and nutritional status indicators. The aim of this study was to assess nutritional status (anthropometric status and dietary intake) and household resources (household and parent/caregiver particulars), in an attempt to identify specific issues that play a role in the development of malnutrition. The main objective of this study was thus to provide baseline data on causes of malnutrition in two areas of Mangaung, namely JB Mafora and Namibia. Household information and socio-demographic status were determined by means of a questionnaire completed in an interview. BMI of caregivers and weight-for-age, height-for-age and weight-for-height of children younger than six years were obtained using standard techniques. Dietary intake was determined by a questionnaire during an interview. The results in the study identified a number of socio-demographic factors associated with malnutrition. A concerning percentage of households had no income and in most households only one person contributed to income. Although a large proportion of breadwinners in the study areas were employed, a large proportion of household members where either unemployed or were dependent on another source of income, i.e. pension. In a large proportion of households, none of the women used any family planning. The percentage of respondents who ever attended clinics, were high. Level of education of household members older than 18 years showed that only a few of household members received education on tertiary level, while more than ten percent had no schooling. Regarding medical conditions a significant amount of household members indicated hypertension. As expected, diarrhea, loss of appetite and weight loss was generally more prevalent in underweight caregivers, but differences were not statistically significant. The prevalence of overweight and obesity in the studied group of household members was an outstanding anthropometric feature, with almost half of caregivers falling in the overweight or obese categories. Results of this study indicated that the number of well-nourished children in this study was small. The percentage of underweight children (17%) was higher when compared with the NFCS (1999), while a large percentage (30.3%) of children were stunted. As expected, a much smaller percentage of children (9.2%) in the study had a reduced weight-for-height than a weight-for-age or height-for-age. A relatively large proportion of the respondents did not consume foods from all three groups during each meal. Almost all adults did not consume a balanced breakfast, the majority did not include all three food groups for lunch and more than half did not have a balanced supper. In the case of children, a high percentage did not eat a balanced diet. In the case of babies (between birth and six months), results showed that approximately 80.0% of babies received a well balanced diet throughout the day. This is due to the high percentage of mothers who exclusively breastfed their babies. With the view to implementing a relevant nutrition education intervention program in Mangaung in the future, this base-line study (2004) was considered essential. Findings on the existing nutritional status and specific causes of nutritional problems of the community of Mangaung, can make a meaningful contribution to the design of effective nutrition intervention programmes.
Open Access
The health and nutritional status of HIV positive women (25-44 years) in Mangaung
(University of the Free State, 2005) Hattingh, Zorada; Walsh, C. M.; Dannhauser, A.; Veldman, F. J.
English: Human Immunodeficiency Virus infection causes Acquired Immune Deficiency Syndrome, which has caused millions of deaths, with more expected, particularly in developing countries like South Africa, where poverty is a critical factor. The intake, digestion, absorption and metabolism of food and nutrients emerge as a vicious cycle. The undernourished HIV-infected individual develops micronutrient deficiencies, immunosuppression and oxidative stress, thereby accelerating disease progression. Symptoms include weight loss and wasting, with increased risk of secondary infections. A representative sample of 500 African women (25-34 and 35-44 years) from Mangaung in South Africa’s Free State Province participated in the study. Socio-demographic composition and physical activity levels were determined by questionnaire. Weight, height, circumference (waist and hip) and bioimpedance measurements were used to calculate body mass index and fat distribution and percentage. Dietary intake was determined using a food frequency questionnaire, and nutrient intake was analysed. Biochemical nutritional status was determined through blood samples. Socio-demographic characteristics indicated high unemployment rates. Significantly more HIV positive than HIV negative young women had lived in urban areas for over ten years, and smoked and/or used nasal snuff. Few young women had no education, while more older women had only a primary school or Grade 8-10 education. Significantly more younger and older HIV positive women headed their own households. No significant differences were found in housing conditions, room density and household facilities of younger and older HIV positive and HIV negative women Anthropometric results showed that approximately 50% of all women were overweight/obese. Most women had a gynoid fat distribution and were fat/obese according to fat percentage. However, young HIV positive women had significantly lower body mass index and fat percentage than young HIV negative women. The entire sample had low physical activity levels. Median dietary intakes of energy, macronutrients and cholesterol were high, with young HIV positive women having a significantly higher median energy intake than young HIV negative women. Low median intakes of calcium, total iron, selenium, fat-soluble vitamins, folate and vitamin C, but high median intakes of the B vitamins, were reported overall. Younger women with HIV had significantly higher intakes of calcium, phosphorus, potassium, and vitamins B12, D and E than young HIV negative women. Older HIV positive women had significantly lower intakes of haem iron, nonhaem iron and selenium than older HIV negative women. Although median values for most biochemical parameters were normal, younger HIV positive women had significantly lower median haemoglobin and haematocrit levels, while older HIV positive women had significantly higher serum ferritin and lower transferrin values than their HIV negative counterparts. Significantly more HIV positive younger and older women had low haematocrit values, while significantly more HIV negative older women had low serum iron and high transferrin concentrations. Compared to HIV negative women, younger and older HIV positive women had significantly lower median blood values for total lymphocytes and serum albumin, but significantly higher median blood levels of total serum protein. Plasma fibrinogen and serum insulin concentrations were significantly reduced in young HIV positive women. Older HIV positive women had significantly lower total serum cholesterol values than older HIV negative women. Serum glucose and serum triglycerides did not differ significantly between HIV positive and HIV negative women within both age groups. In younger and older women, increased serum total protein and decreased serum albumin were associated with HIV infection. In younger women, smoking and being unmarried increase the odds of HIV infection, while in older women a higher education level and a decreased non-haem iron intake are associated with HIV infection. An adequate diet, nutritional counselling and active physical activity can improve immune function, quality of life and biochemical nutritional status. Dietary intake alone, however, may be insufficient to correct nutritional deficiencies in this poor community, and the role of food-based approaches and micronutrient supplementation merits further attention. Key words: South Africa; African women; HIV; socio-demographic status; anthropometry; dietary intake; physical activity; iron status; metabolic profile
Open Access
Supplement consumption and energy intake of HIV+ children receiving an enzyme-modified, enriched maize supplement
(University of the Free State, 2005-05) Cox, Cindy Deborah; Dannhauser, A.
English: Protein-energy malnutrition (PEM) is an important clinical manifestation of human immunodeficiency virus (HIV) infection in children and have immunosuppressive effects. Reduced energy and oral intake are the most prominent contributing factors leading to malnutrition. Several studies have proven that addition of amylase to bulky cereals decreases the viscosity of cereals and increases children’s dietary intake. However, the impact of amylase modified supplements (AMS) on actual AMS consumption and energy intake from AMS by HIV-infected children is unknown. The main objective of this study was to determine the actual supplement consumption and energy intake from a supplement by HIV-infected children. The study design was a double-blinded, randomized, clinical controlled prospective trial, and included 16 HIV-infected children resident in Lebone House. Children were stratified according to baseline age, CD4+ counts and weight-for-age, and randomly placed into an experimental (E-) group and a control (C-) group. The E-group received an enzyme-modified, enriched maize supplement (E-supplement) and the C-group received an enriched maize supplement (C-supplement). The supplements were served as a breakfast replacement on 4 days per week, for a total period of 16 weeks. The actual supplement consumption was determined by subtracting the amount of leftover supplement from the amount of supplement served. The energy intake from the supplements was calculated by the Department of Biostatistics, University of Free State. The actual supplement consumption was expressed as the mean amount of supplement consumed, the mean percentage of the served supplement consumed, and the percentage of days the participants consumed the entire supplement. The data on the actual supplement consumption demonstrated that the participants consumed large amounts (E-group 489g; C-group 490g) of supplements, which accounted to 98.1 percent and 98.6 percent of the E- and C-supplements served. The median of the percentage of times the E-group consumed the entire served supplement was 94.4 percent and 92.9 percent for the C-group. No statistical significant difference was established between mean amount of supplement consumed (p=0.83), mean percentage of supplement consumed (p=0.67) and the percentage of times the entire served supplement was consumed (p=0.83). The actual supplement consumption was influenced by the viscosities of the supplements and cultural acceptability. The mean energy intake from the supplement for both groups were high (E-group 2540.4 kJ; C-group 2553.2 kJ). The mean percentage of energy consumed from the supplement served was identical to the percentage of the served supplement consumed. No significant difference was observed for the energy intake between the two groups in terms of mean energy intake (p=0.67) and the mean percentage of energy consumed from the portion served (p=0.67). The energy intake of these HIV-infected children was increased with approximately 2000 kJ per day with the addition of a single portion of either supplement, even when the supplements were served as a replacement for their usual breakfast. In conclusion, this study demonstrated that reducing the viscosity of the experimental supplement with amylase did not significantly increase the consumption or the energy intake. Both supplements were palatable and acceptable for these HIV-infected children and also increased the total daily energy intake of the children. Both supplements can therefore be used in the rehabilitation of HIV-infected children in South Africa. Future research should evaluate whether the addition of amylase to an enriched soy-maize supplement would have a positive effect on the weight, immune status and health status of HIV-infected children in comparison to the control supplement without the added amylase. Future research should address the limitations mentioned in this study. Future application of the research if proven to have a significant benefit may include the use of the supplement as part of existing or new feeding schemes to improve the nutritional status of HIV-infected children.
Open Access
Impact of a diet intervention program on the serum albumin concentrations, antropometrical status and quality of life of breast cancer patients receiving chemotherapy
(University of the Free State, 2005-11) Smalberger, René; Dannhauser, A.
English: Breast cancer patients receiving chemotherapy at ECOC, often present with lowered serum albumin concentrations, so much so that the lowered serum albumin concentrations first has to be treated before the next cycle of chemotherapy can be administered. The delay in chemotherapy treatment had financial, medical and emotional effects on the patients. The objective of this study was to determine the effect of an optimal energy increased protein (OEIP) dietary treatment on serum albumin concentrations, anthropometrical status and quality of life of breast cancer patients receiving chemotherapy. In a clinical trial, 27 female breast cancer patients were randomised to an experimental group (E) (n=13), receiving an individualized OEIP diet consisting of food and a nutritional supplement, or a control group (C) (n=14), receiving no dietary intervention. Baseline and three-weekly visits involved determining serum albumin concentrations; anthropometrical assessment, including body weight; BMI, MUAC, TSF, MAFA, MAMA, BF% and LM%; and the completion of a quality of life questionnaire. Both groups kept a food diary for the duration of the study. Median ages of the E-and C-groups were 52.62 and 51.19 years respectively, ranging from 29 to 59 years. Statistical analysis included, median and percentiles for continuous data, and frequencies and percentages for categorical data, with 95% CI for median differences. Due to the small sample size, nonparametric statistics were used to compare results. By taking a daily nutritional supplement, the E-group was able to consume a significantly better amount of all macro- and micronutrients. The C-group showed a median drop of 3 g/dL in serum albumin concentrations with a median end value of 36.5 g/dL, while the E-group showed a statistically significant [2; 6] median increase of 1.5 g/dL, with a median end value of 39 g/dL, suggesting that the dietary intervention had been successful in improving serum albumin concentrations over the treatment period. No statistically significant changes were noted in either the E- or C- group’s performance status scoring. The Rotterdam Quality of Life Survey found the Egroup had a significant improved quality of life scoring during Visits 5:B, compared to the C-group for the same period. Other studies have also shown an improvement in quality of life measurement after the implementation of a dietary intervention programme in cancer patients. An optimal energy diet, sufficient to maintain the patient’s ideal body weight and not actual body weight, with a protein intake of 1.04 g/kg/day was sufficient to significantly improve serum albumin concentrations, to such an extent, that chemotherapy cycles did not have to be postponed. Regardless of nutritional intake, no statistically significant changes were found in weight, BMI, MUAC, TSF, MAFA or MAMA. The E-group showed a significant increase in BF% and a decrease in LM% for the duration of the study, compared to the C-group. The increase in BF% could possibly be explained by the high-energy, increased fat intake of the E-group. Changes in protein metabolism and the increased protein needs of the body could possibly explain the changes in LM%. From this study it may be concluded that an OEIP diet is not effective in preventing LM wasting. An OEIP (1-1.5 g/kg/day) dietary intervention, is therefore recommended for breast cancer patients receiving chemotherapy. Nutritional intervention should commence at an earlier point to determine the effect of such intervention on patients’ quality of life. It is recommended that the study be repeated with a larger sample size, to confirm tendencies found in the present study and to determine the long-term effect of an OEIP diet intervention on serum albumin concentrations, the anthropometrical status, and the quality of life of breast cancer patients receiving chemotherapy.
Open Access
Determination of the glycaemic index of three types of Albany Superior bread
(University of the Free State, 2006-11) Van Zyl, Martha Jacomina; Slabber-Stretch, M.; Walsh, C. M.
English: The glycaemic index (GI) concept was introduced as a means of classifying different sources of carbohydrates (CHO) and CHO-rich foods in the diet, according to their effect on postprandial glycaemia since different carbohydrate containing foods have different effects on blood glucose responses. The GI is defined as the incremental area under the blood glucose response curve of a 50 g glycaemic (available) carbohydrate portion of a test food expressed as a percentage of the response to the same amount of glycaemic CHO from a standard food taken by the same subject. Though not the only factor that will determine whether the food should be included in the diet or not, the GI can be used alongside current dietary guidelines like the Food Based Dietary Guidelines and exchange lists to guide consumers in choosing a particular food with a predicted known effect on blood glucose levels and homeostasis. Variation in the GI values for apparently similar foods may reflect both methodologic factors as well as true differences in the physical and chemical characteristics of the specific food. Differences in GI values of similar foods could also be due to inherent botanical differences from country to country. Two similar foods may also have different ingredients, different processing methods or different degree of gelatinisation resulting in significant variation in the rate of CHO digestion and consequently the GI value. Methodological variables which include food-portion size, the method of blood sampling, sample size and subject characteristics, standard food, available CHO, volume and type of drinks consumed with test meals can markedly affect the interpretation of the glycaemic responses and the GI value obtained. Tiger Brands commissioned an independent assessment of the GIs of three Albany Superior™ breads namely Best of Both™, Brown™ and Whole Wheat™ bread carried out under strictly standardised conditions using methods complying with the most recent internationally accepted methodology. Methods Twenty healthy, fasting male volunteers, aged 18-27 years, each randomly consumed six different test meals consisting of 50 g available carbohydrates from three different test foods (three types of Albany Superior breads) and one type of standard food (glucose) (repeated three times in each subject) according to a Latin square design. Finger-prick capillary blood was collected fasting and within 10-15 min after the first bite was taken for every 15 min time interval for the first hour and thereafter for every 30 min time interval for the second hour, using One Touch Ultra™ test strips and One Touch Ultra™ glucometers (Lifescan™). The AUC and GI for the three different breads, were calculated using the mean of the three glucose responses (standard meals) as standard. Statistically significant differences were also determined. Results The mean GIs were 78.44, 72.01 and 79.62 for Whole Wheat™, Brown™ and Best of Both™ bread respectively. No statistically significant differences were found between the GIs of the three different Albany Superior™ breads. Conclusions From the study it can be concluded that the three different Albany Superior™ breads fell between the intermediate and high categories. Recommendations It is recommended that the methodological guidelines determined by the GI Task Force should be followed. It is also important to inform patients and consumers that in using the GI to choose CHO foods it is a fact that physiological responses to a food may vary between individuals and that it is normal for a specific food to have a high GI in some individuals and a medium or even a low GI in others. For labeling purposes it is recommended that the GI is presented as a mean with 95% confidence intervals.
Open Access
An evaluation of the Protein Energy Malnutrition (PEM) program in children < 5 years at primary healthcare facilities in the Free State
(University of the Free State, 2008-01) Botha, Magda (M. M.); Walsh, C. M.
English: Globally, Protein-Energy Malnutrition (PEM) is a public health problem that af-fects especially children younger than 5 years. Malnutrition, together with acute respiratory infections, HIV and AIDS and diarrhoeal disease, is one of the lead-ing causes of death amongst infants and young children. In South Africa, the Integrated Nutrition Programme (INP) is implemented na-tionally to assist with the reduction of the prevalence of malnutrition and hunger through various child survival strategies, including health facility-based services and community-based interventions. The Protein-Energy Malnutrition Pro-gramme (PEM Program) forms an essential component of the INP. Currently the PEM Program is implemented at public health facilities to treat and manage clients suffering from malnutrition or those that are at risk of be-coming malnourished. Vulnerable children, orphans, pregnant and lactating women and the elderly benefit from the PEM Program in receiving not only nu-trition education, but also food supplements. Food supplements that are distrib-uted include infant formula, enriched maize meal and a high energy drink. The purpose of this cross-sectional descriptive study was to evaluate the imple-mentation of the PEM Program in primary healthcare (PHC) facilities (n = 51) in the Free State. Randomized proportional sampling was applied to include 30% of the total numbers of primary healthcare facilities in the Free State. A repre-sentative sample of 399 children younger than 5 years was selected from these clinics, of which only 46 children participated in the PEM Program. Question-naires were also administered to dieticians (n = 15), professional nurses (n = 43) and mothers / caretakers (n = 46). The professional nurses, mothers / caretakers and children who were included in the research were those who were available at the healthcare facility on the specific day on which the facility was visited by the researcher and the fieldworkers. The dieticians who were included in the sample included all the district dieticians and community service dieticians. Retrospective data was collected by reviewing clinic records and interviews were undertaken with professional nurses and mothers / caretakers. Questionnaires completed by dietitians were self-administered. Body mass index (BMI) of mothers/ caretakers and weight-for-age of children who were attending the clinic on the day of data collection were also determined. The results of the study generally indicated that the PEM Program was not im-plemented effectively in the Free State, where the PEM Program was mainly the responsibility of professional nurses. Poor recordkeeping of client and program information was identified, resulting in poor management of the client’s pro-gress. Food supplements were not continuously available at PHC facilities for distribution to PEM Program clients, due to logistical challenges in the procure-ment, ordering and delivery of food supplements. PEM Program clients had re-ceived food supplements for approximately 7 months. Food supplements were, however, often shared with family members and were often the only food eaten by the PEM Program clients at home. About 20% of the children included in the study were underweight-for-age (W/A below the 3rd percentile of the NCHS median). The majority of the children (82.41%) that were weighed had gained approximately 1 kilogram since previ-ously being weighed. Twenty two percent of children that did not gain weight were at risk of severe malnutrition and had weights below the 3rd centile. Ac-cording to the BMI half of the mothers / caretakers were overweight or obese (BMI ≥ 25 kg/m2), while only 15% of the mothers / caretakers that accompanied the children to the health facilities were underweight (BMI < 18.5 kg/m2). Almost all the children younger than 5 years had an original copy of the RTHC, but RTHC’s were often not completed in full by healthcare workers and children were often not effectively screened. Mothers / caretakers were requested by healthcare professionals to bring children back to the clinic if the child lost weight. In cases where both the mother and child were underweight, or when a lactating mother and her infant were underweight, both the mother and her child received food supplements. Eighty percent of children had been breastfed for a period of approximately 5 months, but healthcare professionals often advised mothers to end or interrupt breastfeeding for reasons unknown to the mothers. Most of the children partici-pating in the PEM Program had an inadequate food intake for the day. In most cases, the food intake for breakfast and lunch were adequate; however the food intake for supper was mostly inadequate. Health professionals indicated that more training about the PEM Program would improve the implementation of the PEM Program. Staff felt that in-service train-ing should focus on the entry and exit criteria of the program, how to issue and control the food supplementation stock, criteria for identifying underweight children, when to supplement children of HIV positive mothers, HIV and infant feeding, nutrition education to mothers, how to prepare and feed the food sup-plements and recording of the PEM Program.
Open Access
Nutritional status of HIV/AIDS infected adults on HAART
(University of the Free State, 2009-05) Julsing, Claire Eanette
English: The aim of this study was to describe the nutritional status of HIV/AIDS infected patients on two HAART regimens. A convenience sample of 111 HIV infected patients on HAART from the Helen Joseph CCMT site in Johannesburg were included (55% on regimen 1 and 45% on regimen 2). HAART regimens differed, with regimen 2 including protease inhibitor (PI) based therapy and regimen 1 a non-PI based therapy. Dietary intake, biochemical markers, lifestyle and anthropometric variables, as well as associations between the above were determined. Dietary intake was determined by means of a 24-hour recall of usual intake and a short food frequency questionnaire. Weight, height, body composition (using bioelectrical impedance), waist and hip circumference measurements were obtained to calculate body mass index (BMI) and fat distribution. Lifestyle factors included smoking habits, alcohol consumption and physical activity levels. These variables were determined by means of a questionnaire completed by the researcher in a structured interview with each participant. Adequacy of diet was evaluated by comparing each patient's dietary intake to the recommended servings of the Food Guide Pyramid. Approximately 70% of patients on HAART consumed less than the required amount of fruit servings per day. Low vegetable consumption was reported, and 98% (regimen 1) and 94% (regimen 2) of patients did not consume the recommended number of servings of vegetables per day. Refined carbohydrates were consumed by 96% of patients on regimen 1 and 84% of patients on regimen 2. Salt intake in this population group was high, with 93.44% of patients on regimen 1 and 94% of patients on regimen 2 consuming added salt every day. Polyunsaturated fats like sunflower oils and margarines were used daily by 92% of patients on regimen 1 and 80% of patients on regimen 2. Full cream dairy products were used more frequently than low fat dairy products, due to the cheaper price. Peanut butter, a monounsaturated fat, was consumed relatively frequently (66% on regimen 1 and 62% on regimen 2). Medians for carbohydrates, proteins, fat and total energy intake were 310g, 77g, 54g and 7968kJ per day for the 1st line regimen group. In the 2nd line regimen group the medians were as follows: carbohydrates 220.5g, protein 68g, fat 45g and total energy 9233kJ per day. Total energy intake and carbohydrate intake as a percentage of total energy were significantly higher in patients on regimen 1. Dietary intakes of participant in this study showed that the quality of the diet was poor and not conducive to optimal nutritional status. Anthropometric information included BMI, body composition analysis, waist circumference and waist hip ratio. Median BMI of patients in the 1nd regimen (25.34kg/m2) group were significantly higher that that of patients in the 1st regimen group (22.80kg/m2) when comparing medians for BMI. BMI was above 25kg/m2 in 32.79% and 56% of patients on regimen 1 and 2 respectively. Approximately half of all patients in this study had waist circumference measurements above the recommended 80cm for females and 94cm for males. Undesirable waist to hip ratio measurements (for females >0.8 and for males >0.9) occurred in 95% of patients on regimen 1 and 66% of patients on regimen 2. Central obesity, increased BMI and high risk waist circumference and waist to hip ratios were evident in the majority of patients. High body fat percentages (more than 25%) were present in more than half of all the patients in this study. No significant differences were apparent when comparing anthropometric medians between the two groups. A large percentage of patients in this study were at risk of developing chronic diseases according to the results of the anthropometric assessments. The incidence of dyslipidemia in this population was high, with almost half of patients (47.92%) on regimen 2 and 34.43% of patients on regimen 1 having elevated tryglyceride levels. HDL levels were low in 43.75% of patients on regimen 1 and 22.95% of patients on regimen 2. High cholesterol levels were prevalent in 39% of patients on regimen 1 and 27.66% of patients on regimen 2. Patients on regimen 1 had significantly higher median cholesterol levels than patients on regimen 2. LDL cholesterol levels were elevated in a 60.66% of patients on regimen 1 and 52.08% on regimen 2. Despite all patients being on HAART, low CD4 counts (<500) and high viral loads (≤25) were prevalent in the majority of participants. In regimen 1, 80.8% of patients had a CD4 count below 500 and viral load above 25, while patients on regimen 2, 78.0% showed similar results. The majority of patients reported never smoking, with only 18.03% of participants on regimen 1 and 14.00% on regimen 2 reporting current smoking. Reported alcohol consumption was relatively low with 21.31% of patients on regimen 1 and 24.00% of regimen 2 currently using alcohol. Eighty two percent of patients on regimen 1 and 93.88% of patients on regimen 2 were sedentary. The nutritional status of the HIV infected patients on HAART in this study was found to be poor. Anthropometric measurements, lifestyle factors and biochemical markers indicated that these patients had an increased risk for developing chronic disease. HIV/AIDS and HAART are linked with metabolic abnormalities and associated chronic diseases. Poor nutrition exacerbates the risk and urgent interventions are required in this population.
Open Access
Eating practices, nutritional knowledge and body weight in nursing science students at the University of Fort Hare
(University of the Free State, 2009-09) Okeyo, Alice Phelgona; Dannhauser, A.
English: The prevalence of overweight and obesity in college and health science students is increasing. This study determined whether eating practices and nutrition knowledge are associated with body weight in nursing science students. The study also evaluated the association between socio-demographic factors and body weight status. A cross-sectional survey of 161 full time undergraduate nursing science students (31.7 % male and 68.3 % female), aged 18 and above, were chosen randomly from the University of Fort Hare. Validated questionnaires were used to determine the socio-demographic factors, eating practices and nutrition knowledge. Eating practices were determined by means of a 24-hour recall and a short food frequency questionnaire. Standard techniques involving a calibrated platform electronic scale and stadiometer, as well as a standard tape measure were used to measure weight, height, waist and hip circumference so as to calculate body weight status (Body mass index (BMI), Waist circumference (WC), and Waist hip ratio (WHR)). Descriptive statistics were used to describe the data, including, frequencies and percentage for categorical variables and means and standard deviations or medians and percentiles for continuous data. The underweight, normal weight and overweight/obese groups were compared by means of 95 % confidence intervals for median differences. This study showed that less than half of the students (46.0 %) were of normal weight (58.8 % male students compared to 40.0 % female students). The prevalence of overweight and obesity was more common among female students compared to males (36.4 % and 21.8 % versus 21.6 % and 9.8 %, respectively). In contrast, 9.8 % male students were underweight compared to 1.8 % females. Sixty two students had WC values above the cut off points (≥ 88 cm: F; ≥ 102 cm: M) while sixty students had WHR values above the cut off points (≥ 0.8: F; ≥ 0.9: M). Important observations of the usual daily food intake showed that less than the daily recommended number of food portions from the food groups were consumed for milk and milk products (92.6% of students); vegetables (97.5 %) and fruits (42.2 %). More than the recommended number of portions per day was consumed for meat and meat alternatives (81 %), sweets and sugar (77.8 %), fats and oils (50 %). The recommended number of servings per day was only met for bread and cereals (82.7 %). Median daily energy intake for female students (5543.3 kJ) was significantly lower than that of males (6333.3 kJ). For all students the median energy and fat intakes were relatively low, while carbohydrate and protein intakes were higher than the RDA. Usual meal patterns showed that 59 % of students ate three meals daily and the most frequently skipped meal was breakfast. Foods most often consumed on a daily basis were salt/stock/royco (85.8 %), margarine/oils/fats (67.9 %), sugar (58.6 %), bread (55.6 %) and cereal (34.7%). Foods most often not consumed included low fat/skim milk (76.5 %), alcohol (73.5 %), cremora (48.2 %), soy mince/legumes, baked beans, dried beans/peas and lentils (45.7 %), and peanut butter (42.6 %). A significant higher percentage of underweight (14.3 %) than overweight/obese (1.3 %) individuals consumed bread and cereals below the recommended daily requirements. More overweight/obese (72.5 %) than underweight (28.6 %) students ate chips/crisps on a daily basis. Fat consumption in underweight students was significantly less than that of overweight/obese students. Significantly more overweight/obese (90 %) than underweight (57.1 %) students ate sweets and chocolate on a daily basis, and significantly more underweight (57.1 %) than normal weight (16.2 %) students consumed low fat/ skim milk on a daily basis. Of 162 students, 69.3 % were uninformed of the food groups to eat the most and 24.9 % of which food groups to eat least, according to dietary guidelines. The recommended daily portions from the food groups were not known by the students: 85.7 % of students did not know the daily recommended servings for bread, cereal and pasta, 54.7 % did not know the recommended servings for vegetables and 54.7 % did not know the recommended serving for meat, poultry, fish dry beans, eggs and nuts. Over 60.2 % did not know the daily recommended servings for milk and milk products. Over 55.3 % of students knew the recommended servings for fruits, 92.6 % knew foods with high fiber content, 50.3 % knew that peanut butter has a high fat content, while 96.3 % knew the best sources of beta carotene. The median percentage for correct answers obtained in the nutrition knowledge test was 56.3 %. Of 162 students, 34.2 % scored less than 50 % while 65.8 % scored more than 50 % in a nutrition knowledge questionnaire. There was no statistical significant difference between BMI categories in terms of the score in the nutrition knowledge test. However, significantly more underweight (63.5 %) than overweight/obese (1.4 %) students knew the recommended servings for milk, cheese and yoghurt. Significantly more normal weight students (20.3 %) than overweight/obese (8.8 %) students knew the daily recommended servings for bread, cereal, rice and pasta. Significantly more overweight (95.0 %) than underweight (71.1 %) students knew carrot as a good source of ß-carotene. In conclusion, healthy eating practices need to be emphasized in this group while ensuring an adequate awareness campaign. The findings suggest the need for strategies designed to improve competence in the area of nutrition, especially with respect to information relating to guidelines for healthy eating practices and healthy weight management. Nutritional education for female students, especially related to body weight management is recommended. Interventions for the prevention and control of obesity must go much further than simply prompting nutrition knowledge.
Open Access
Factors contributing to malnutrition in children 0-60 months admitted to hospitals in the Northern Cape
(University of the Free State, 2010-05) De Lange, Johanna Christina; Walsh, C. M.
English: INTRODUCTION A wide range of factors, including underlying, immediate and basic factors, play a role in the development of malnutrition. Globally, the prevalence of malnutrition is highest in Sub-Saharan African, with the HIV pandemic further compromising the situation. Both underweight and stunting are threatening the health of children younger than five years old, with the Northern Cape having the highest percentage of stunted children in South Africa. Malnutrition is still the leading cause of mortality and morbidity in children younger than five years old. The main aim of this study was to determine which of the underlying, immediate and basic factors contributing to malnutrition are prevalent in the Northern Cape. METHODS Fifty-four malnourished children 0 to 60 months admitted to Kimberley Hospital Complex and Upington Hospital were included in the study. Inclusion criteria included all malnourished children 0 to 60 months admitted to paediatric or infant care units between August 2007 and July 2008with a weight-for-age below 80% of expected weight, with an RtHC and whose mother/ caregiver was present to sign the informed consent form. The anthropometric measurements of both the child and mother/caregiver were taken. Blood values of the child that were available in the files were consulted. Socio-demographic, household, maternal information, medical history of the child, infant feeding information and adherence to the FBDG were noted on a questionnaire during a structured interview conducted with the mother/caregiver. RESULTS Factors contributing to malnutrition were categorized into the immediate, underlying and basic factors as set out in the UNICEF conceptual framework of the causes of malnutrition. Some of the socio-demographic findings associated with malnutrition included rural households, male children, education level and marital status of the mother. Educated and married mothers were less likely to have a malnourished child. Anthropometric findings showed that low birth weight and the size of the child’s mother were associated with malnutrition, with undernourished and obese mothers having a higher chance of having a malnourished child. Household food insecurity and inadequate nutrition information received on care practices were often contributing factors. Most of the malnourished children included in the study were marasmic. The medical history of the child indicated that even though all the children had an RtHC, the cards were often completed incorrectly. Clinic attendance was poor and the screening for HIV and TB was insufficient as the children’s statuses were mostly unknown. Significantly more children were up to date with their immunizations, but significantly fewer children were up to date on their vitamin A supplementation. The NSP was not accessed effectively and even children that did access the NSP were found to be malnourished after eight months on the programme. Some of the other household and maternal findings related to malnutrition included a big household with more than five family members, a high birth order of more than four children and if the child had any siblings that had died of malnutrition related illnesses. The education levels of the mothers were generally low and health and feeding information given at clinics did not have a significant impact. Information on infant feeding showed that exclusive breastfeeding is still a challenge and mothers are not effectively using milk alternatives when breastfeeding is ceased. Cup feeding was not practiced, and the use of bottles can increase the risk of diarrhoea. Children are either introduced to solid foods too early (before six months) or too late (after six months). When the application of the FBDG was evaluated, the study found that children had high intakes of fats, salt, sugar and sugary foods and tea and low intakes of animal proteins, fruit and vegetables and milk (after breastfeeding was ceased). CONCLUSIONS Inadequate access of available interventions programmes such as the NSP, immunizations, vitamin A supplementation, screening and treatment of diseases such as HIV and TB was noted. Parents were generally uneducated, especially regarding infant and young child feeding and the importance of correct food for the prevention of malnutrition. Household factors were a major challenge, especially in rural areas. Low levels of schooling and poverty are basic factors contributing to malnutrition that are prevalent in the Northern Cape. RECOMMENDATIONS Maternal and community education are some of the most important interventions to combat malnutrition in the Northern Cape. Intervention programmes at facilities should be strengthened to empower health care professionals and the community they serve to prevent and manage severe malnutrition. Detecting malnourished children earlier in the communities by using the MUAC to screen children is recommended. The management of severe malnutrition according to the 10 Steps of the WHO should be implemented at all levels of care.
Open Access
A description of behaviour that may indicate crossover from weight‐restored anorexia nervosa to bulimia nervosa
(University of the Free State, 2011) Barr, Donna; Walsh, C. M.
Introduction: The course and outcome of eating disorders can be characterised by the degree of diagnostic crossover. Crossover is relatively common, with the crossover from Anorexia Nervosa (AN) to Bulimia Nervosa (BN) being the most prevalent. Crossover commonly occurs within the first 5 years of illness and is often observed when patients are progressing to partial or full recovery. No information regarding crossover in South African persons with eating disorders has been published, hence the purpose of this study. Main objective: The main objective of the study was to describe the behaviour that may indicate crossover from weight‐restored AN to BN in South African young adults. In order to achieve the main objective, anthropometric measurements and descriptive information regarding disordered eating patterns were obtained. Information regarding behaviour that may be associated with crossover from AN to BN or within AN sub‐types was collected. In addition BN patients were assessed to determine whether they have a previous history of AN, which may further indicate crossover. Subjects and methods: Participants were recruited from the student population of the University of the Free State and Bloemcare Psychiatric Clinic. Anthropometric measurements were taken by the researcher and one of two questionnaires (compiled by the researcher), depending on diagnosis, was completed during a semi‐structured, one‐to‐one interview between the researcher and each participant. Questionnaires were coded by the researcher and analysed by the Department of Biostatistics (UFS). Results:: Nine participants were recruited and included in the study. Five out of the nine participants were diagnosed with Anorexia Nervosa Restrictive type (ANR). These five participants had all crossed over to bulimic tendencies during and after the process of weight restoration. One of the five participants has crossed over to a current diagnosis of Anorexia Nervosa Binging and Purging type (ANBP). The five participants indicated that they engaged in inappropriate compensatory behaviour after a binge episode in order to prevent further weight gain or to lose weight. The most common inappropriate compensatory behaviour reported was self‐induced vomiting. Two of the five participants indicated that they could currently be diagnosed with EDNOS because they had not completely recovered, whereas the other two participants indicated that they have fully recovered. The remaining four of the nine participants were diagnosed with BN. Two were currently diagnosed and the other two had previously been diagnosed with BN. Of the previously diagnosed BN participants, one participant had a history of ANR. The particular participant never fully recovered from the initial diagnosis and therefore crossed over from ANR to BN. The two previously diagnosed BN participants also indicated that they could be diagnosed with EDNOS at the time of the interview because they had not completely recovered. Overall the nine participants reported that they were still preoccupied with their weight at the time that the study was conducted. Seven of the nine participants indicated that they were more comfortable at a lower weight, whereas two participants indicated that they could not identify a weight at which they felt most comfortable. Conclusions: The course and outcome of eating disorders is partially determined by the occurrence of crossover. Comparable to reviewed literature, despite the small sample crossover was observed from AN to bulimic tendencies. In addition, crossover occured more commonly during the progression to partial or full recovery. With this in mind, further research should focus on whether crossover occurs as a result of the weight gain associated with recovery and whether the fear or anxiety thereof acts as a trigger. This knowledge may enable the multidiscliplinary health care team to prevent crossover from occurring in patients during the recovery period.
Open Access
The association of body weight, 25-hydroxy vitamin D, sodium intake, physical activity levels and genetic factors with the prevalance of hypertension in a low income, black urban community in Mangaung, Free State, South Africa
(University of the Free State, 2011) Lategan, Ronette; Van den Berg, V. L.; Viljoen, C. D.; Walsh, C. M.
English: Hypertension is responsible for a large and increasing proportion of the global disease burden and is becoming increasingly significant in low-income countries. The aim of this study was to determine the association of body weight, 25-hydroxy vitamin D, sodium and potassium intakes, physical activity levels and genetic factors, with the prevalence of hypertension in a low income, black urban community. Various factors influence blood pressure, with especially body weight showing a strong relationship with hypertension. More than half of this study population suffered from hypertension and the majority was overweight or obese, increasing the risk for disease and premature death. All indices of abdominal obesity and body fatness, including BMI, WHtR, adiposity index and waist circumference were significantly related to blood pressure, supporting weight loss as first line intervention for treatment and prevention of hypertension and its accompanying disease burden in this population. Findings also suggest the use of WHtR to screen for hypertension in this population. Higher blood pressure levels are associated with lower levels of vitamin D and low vitamin D levels have been linked to obesity markers. Although the majority of participants in this study were overweight/obese, almost 96% had adequate vitamin D status, despite expected low vitamin D intakes. HIV status did not influence vitamin D status directly, but through BMI. The latitude and high levels of sun exposure could have been responsible for the favorable vitamin D status in the participants. Results confirm the inverse relationship between vitamin D status and hypertension reported by other researchers, but found that this relationship seemed to be dependent on BMI in this study population. Lower sodium intakes accompanied with increased potassium intakes are recommended for the prevention and treatment of hypertension. The blood pressure elevating effect of sodium have been found to be even more profound in black population groups, urging investigation into this possible race-related cause of hypertension. Sodium intakes, as reflected by urinary sodium excretion, were high in this study. Association between sodium intakes and systolic, diastolic and mean arterial pressure were found, with higher sodium intakes being associated with elevated blood pressure levels, indicating the need for dietary sodium reduction strategies to control hypertension in this population. Despite high sodium intakes and low potassium intakes, no association was found between sodium or potassium intakes and the prevalence of hypertension. Increased activity is often advocated as first line treatment in the prevention of hypertension, even when weight loss is not achieved. The majority of participants in this study reported being sedentary or low active. No significant association could be shown between activity level and the prevalence of hypertension. Although HIV status showed a negative correlation with BMI, no correlation could be found between HIV status and activity level. Chronic diseases such as hypertension are likely the result of more than one gene and multiple variants of each gene that interacts with different environmental factors, with each combination making a small contribution to overall homeostasis, function, and therefore health. The high risk polymorphisms of the AGT (M235T and -217); GRK4 (A142V, A486V) and CYP11B2 genes did not seem to play a major genetic role in the high prevalence of hypertension in this population. Only GRK4 (R65L) showed an association with the prevalence of hypertension and a weak negative correlation with mean arterial pressure. Results show that overweight/obesity and excessive sodium intake are the major contributors towards hypertension in this study population. Intervention programmes should focus on preventative strategies that create awareness to promote weight loss and encourage lower salt consumption.
Open Access
Prevalence of the known risk factors in women diagnosed with breast cancer at Queen II Hospital, Maseru
(University of the Free State, 2011-11) Lehlasoa, 'Mamotlatsi Rose; Dannhauser, A.; Van den Berg, V. L.
English: Breast cancer is the leading cancer in the world among women, both in industrialised and developing countries. While the USA has the highest prevalence and mortality rates of the disease, with middle prevalence rates in Eastern Europe; Africa and Asia have low rates. In South Africa breast cancer is the most common cancer and is being diagnosed with increasing prevalence among the black population. No literature is, however, currently available regarding the prevalence of breast cancer, the prevalence of the risk factors for breast cancer, or the associated mortality rates for breast cancer in Lesotho. The aim of this study was to determine the prevalence of the known risk factors for breast cancer among adult women who were diagnosed with the disease at the Queen Elizabeth II hospital, Maseru. A descriptive survey was conducted on 52 adult breast cancer patients seen at the Queen II hospital in Maseru, who gave informed consent. A trained researcher performed anthropometric measurements and administered a questionnaire on usual dietary intake and non-modifiable and modifiable risk factors for breast cancer, during structured interviews. Reliability was ensured by repeating the same questionnaire with 10% of the sample a month after conducting the main study. Regarding the non-modifiable risk factors for breast cancer, the majority of the Basotho women in this study were diagnosed with breast cancer at 46 years and older (78.7%), experienced menarche at 12 years and older, (93.9%), had reached natural menopause, did not use hormone replacement therapy, and had reached menopause before the age of 55 years (96.8%). Regarding the modifiable risk factors for breast cancer, the Basotho women had a low risk profile with low levels of education (80.8% had only primary or high school educations), low incomes (59.6%), low oral contraceptive use (65.4% had never used), and were mostly non-drinking (48.1%) and low-drinking (36.5%). Most were also, or had been, married at the time of the study (82.7%), had children (80.8%), and had breastfed for ≥12 months (86.8%). However, these Basotho women were very inactive (82.6%), with high body mass indexes (21.1% overweight; 63.5% obese), waist circumferences, and waist to hip ratios putting them at high risk for breast cancer and other chronic diseases of lifestyle. Their self-reported median total energy and macronutrient intakes were 5414.5 kJ, 49g protein (0.63 g/kg/day), 210g carbohydrate, and 21.5g fat. Dietary intakes were evaluated according to the recommendations of the USDA Food Guide Pyramid and the Dietary Guidelines for Americans 2010. Although they had low intakes of meat, particularly red meat, drank tea regularly, and used cooking methods that did not produce cancer promoting agents, all of which protect against breast cancer development; their low intakes of fruits, and low variety of plant foods put them at risk of breast cancer and other diseases due to low supply of protective antioxidants and phytochemicals. Particularly vegetables were mostly only consumed as green leafy types (moroho), while other vegetables were only consumed occasionally and by small percentages. This study is the first to report on the known risk factors of breast cancer among women in Lesotho. In summary, these Basotho patients were found to have a low risk profile for breast cancer with regard to non-modifiable risk factors, reproductive history and socio-demographic factors. The main risk factors for breast cancer were inactivity and obesity, combined with a diet low in variety of protective plant foods. Intervention programmes should thus focus on addressing these modifiable risk factors.
Open Access
Impact of a nutrition education programme on the nutritional status of children aged 3 to 5 years and the nutritional practices and knowledge of their caregivers in rural Limpopo province, South Africa
(University of the Free State, 2011-11) Mushaphi, Lindelani Fhumudzani; Dannhauser, A.; Walsh, C. M.; Mbhenyane, X. G.
Globally, the prevalence of acute malnutrition and micronutrient deficiency is high in young children, especially in developing countries. This study was undertaken to determine the impact of a nutrition education intervention programme (NEIP) on the nutritional knowledge and practices of caregivers, as well as the nutritional status of children between the ages of three to five years in the Mutale Municipality in Vhembe district, Limpopo Province. A pre-test–post-test control group design was chosen using eight villages (four villages in the experimental group (E); four villages in the control group (C). At baseline, the study population was 125 caregivers and 129 children aged three to five years (E = 66; C = 63 children). After intervention, 86 caregivers and 89 children (E = 40; C = 49 children) were found. Only participants who participated at baseline and postintervention were included for comparison. A valid structured interview schedule was used to determine nutritional practices and knowledge. The nutrient intake was determined by two 24-hour recalls. Weight and height (to determine weight/height status) and blood samples (vitamin A and iron status) were taken using standard techniques. The NEIP was developed by the researcher using South African Food-based Dietary Guidelines (SAFBDGs) and South African Paediatric Food-based Dietary Guidelines (SAPFBDGs) as basis. The NEIP was implemented on the experimental group on two occasions, namely every week during the first three months and then during the last three to four months in a period of 12 months. Data were analysed using Statistical Analysis Software (SAS®) version 9.2 and expressed using median, minimum and maximum values to describe continuous data. Frequencies and percentage were used to describe categorical data and 95% confidence intervals were used for median and percentage differences to determine the impact of the intervention programme. The 24-hour recall data were analysed using Food Finder III version 1.1.3. The study revealed that the socio-demographic information and anthropometric nutritional status of the children did not change after intervention in both groups. Furthermore, at baseline, nearly one third of the children in both groups had marginal vitamin A status. However, after intervention, all children in both groups had adequate to normal vitamin A status, which could be due to the vitamin A supplementation and food fortification programme of the SA Government. The iron indicators were within adequate levels at pre- and post-intervention in both groups. The impact of NEIP was observed in some of the nutritional practices, since the majority of caregivers usually included starchy foods, protein-rich foods and vegetables in the child’s plate daily at baseline in both groups. However, the number of children who were given more than three meals per day showed a tendency towards an increase in the experimental group. The intake of milk and yoghurt improved significantly in the experimental group. The majority of children were eating indigenous foods. However, the intake of black jack, spider flower, wild jute plant, baobab fruit, paw-paw, mopani worms and termites improved significantly in the experimental group. The median carbohydrate and protein intake was adequate when compared to EAR/RDA in both groups at pre- and post-intervention. The median energy, carbohydrate and plant protein intake had increased significantly in the control group. The intake of iron and folate had increased significantly in both groups, while zinc intake increased significantly in the control group. After the intervention, the intake of tshimbundwa (traditional bread made with maize) also increased significantly in the control group. Furthermore, the intake of stinging nettle, meldar, wild peach, pineapple, dovhi, tshigume and thophi had improved significantly in both groups. The nutrition knowledge score was good at baseline, as the majority of caregivers in both groups were aware that children should be given a variety of foods, indigenous foods, starchy foods, protein-rich foods, vegetables and fruit. However, in the experimental group the percentage of caregivers who knew that children should be given full-cream milk and fat increased significantly at post-intervention. On other hand, the percentage of caregivers who knew tshimbundwa increased significantly in the control group. The majority of caregivers were including most of the food items on the child’s plate (starchy, protein-rich foods, vegetables and indigenous) at baseline, which left little room for improvement. However, the impact of NEIP was observed in some nutritional practices. On the other hand, minimal impact of the NEIP on nutrition knowledge was observed, since most of the caregivers had good nutritional knowledge at baseline. It is recommended that the NEIP developed in this study be adapted for the Department of Health (Nutrition Section) so that healthcare workers can present it in different communities using different media so as to increase coverage.