Doctoral Degrees (Nutrition and Dietetics)

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    A risk assessment profile and Diet Quality Index for inadequate choline intake in pregnant women in Bloemfontein, South Africa
    (University of the Free State, 2020-11) Robb, Liska; Walsh, Corinna; Joubert, Gina
    Pregnancy is a period of rapid tissue development. These metabolic processes require additional nutrients to ultimately support the normal growth and development of the foetus. A specific nutrient that is the focus of recent investigations, especially related to the functions thereof for optimal foetal development, is choline. Choline is required in higher amounts during pregnancy. Adequate choline intake contributes to a higher diet quality in general and in turn, a high-quality diet can contribute to optimal short- and long-term pregnancy outcomes. The main aim of the study was to determine choline intake and related factors and to compile a risk assessment profile and diet quality index (DQI) for inadequate choline intake in pregnant women in Bloemfontein, South Africa. In order to reach the aim of the study, the following information was collected from 682 pregnant women (median age of 31.8 years; median gestational age of 32.0 weeks) attending the high-risk antenatal clinic at Pelonomi Regional Hospital: socio-demographic and household information; reported health and lifestyle; dietary intake; pregnancy history; anthropometry and household food security. Choline intake was quantified by matching choline intake from foods included in the quantified food frequency questionnaire (QFFQ) to foods in the USDA Database for the Choline Content of Common Foods (Release 2), after which individual choline intake of each participant was calculated. Median daily choline intake was 275.0 mg (interquartile range 184.7 mg – 386.7 mg). Most participants (84.7%) consumed less than the adequate intake level of 450 mg/day for choline. Lower egg and dairy intakes were significantly associated with inadequate choline intake (p<0.0001 and p=0.0002 respectively). Out of the 247 participants who did not consume any eggs, only five (2.0%) consumed an adequate amount of choline. No participant who did not consume any dairy products managed to consume an adequate amount of choline. Regarding socio-demographic variables and household food security, more than half of participants were unmarried (56.5%) and unemployed (52.5%). Sociodemographic indicators that were univariately significantly associated with an inadequate choline intake included a higher household density ratio (p=0.0485), no access to own flush toilet at home (p=0.0059), not owning a refrigerator (p=0.0483) or microwave (p=0.0225), as well as a lower level of education (p=0.0449). One-third of participants were severely food insecure (29.9%), and although not statistically significant, choline intake decreased with higher levels of food insecurity. Logistic regression analysis showed that the odds ratio for having inadequate choline intake was 0.55 for participants who owned a microwave compared to participants who did not. Participants with primary school education versus tertiary education had a higher odds of an inadequate choline intake (odds ratio 4.09); those having a school grade 8-10 versus tertiary education had higher odds of inadequate choline intake (odds ratio 2.12); and those having a grade 11-12 versus tertiary education had higher odds of inadequate choline intake (odds ratio 1.37). Regarding reported health and lifestyle, the majority of participants were either overweight or obese (69.3%). Almost one in ten participants (9.0%) consumed alcohol and 6.2% smoked while pregnant. Hypertension (23.0%) and sexually transmitted diseases (18.5%) were among the most common current diagnoses. Univariate analysis showed that participants without hypertension and those using anti-retroviral medications (thus HIV-infected), were more likely to consume inadequate amounts of choline (p=0.0424 and p=0.0112 respectively). When an established diet quality index, the Diet Quality Index Adapted for Pregnant Women (IQDAG), was applied to the sample, the median final IQDAG score was found to be 69 out of a maximum of 100 points (interquartile range of 63 – 74 points) (N = 680). Almost all participants (94.9%) in the first tertile of IQDAG score consumed below adequate levels (AI) of choline, compared to 78.3% of participants in the second tertile and 80.2% of participants in the third tertile. Differences in the choline intake between the tertiles of final IQDAG scores were significant (P<0.0001). In order to compile the risk assessment profile for inadequate choline intake, logistic regression with backward selection (p < 0.05) was used to select significant independent factors associated with choline intake from those identified in theme-specific logistic regressions. In this sample the odds ratio of inadequate choline intake was 43.61 for participants with no egg intake compared to participants who consumed ≥ 5 eggs per week. The odds ratio for having inadequate choline intake was 2.73 for participants with a daily dairy intake of < 250 g compared to participants who consumed ≥ 250 g. The odds of consuming an inadequate choline intake were lower for participants that were not using ART compared to those using antiretroviral therapy (ART) (thus HIV-infected) with an odds ratio of 0.51. The odds ratio of consuming inadequate choline was 3.38 for participants with the lowest tertile diet quality scores compared to participants with the highest tertile diet quality scores. In order to develop a DQI for use in pregnancy among South African women, a systematic review of the literature was performed to identify currently available DQIs used in pregnancy. The methodology of development and use of components were summarised to provide an overview of identified DQIs. The review identified nine DQIs, of which none were developed using dietary guidelines or data from African countries. Additionally, none of the DQIs specifically included choline or foods that are very high in choline (e.g., eggs and liver) as components. Using the South African Food Based Dietary Guidelines, the Guidelines for Maternity Care in South Africa and other international dietary guidelines and recommendations, the South African Diet Quality Index for Pregnant Women in South Africa (SA-DQI-P) was developed. Egg and dairy intake were incorporated as separate components; thus this tool can be used as an estimate of diet quality, while simultaneously providing an indication of choline intake in pregnant South African women.