Masters Degrees (Nutrition and Dietetics)

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Open Access
Adherence of patients with type 2 diabetes mellitus with the SEMDSA lifestyle guidelines
(University of the Free State, 2017-01) Birkinshaw, Amy; Walsh, C. M.
English: Over the last decade, the global burden of disease and mortality has shifted from infectious diseases to chronic diseases. Type 2 diabetes mellitus (T2DM) is considered to be the fastest growing chronic disease in the world. T2DM is a progressive disease that is associated with a high degree of morbidity and premature mortality in many countries, including South Africa. The global rise in overweight and obesity is considered to be the main reason that the prevalence of T2DM is increasing at such an alarming rate. T2DM is largely preventable. Multi-sectoral, population-based strategies and approaches are, however, needed to address the modifiable risk factors involved in the development of T2DM. Evidence-based nutrition principals and recommendations are continuously summarised by the Society for Endocrinology, Metabolism and Diabetes in South Africa (SEMDSA) into guidelines for the management of T2DM. In the present study, a cross-sectional study design was applied in a convenient sample (n=50) to determine the adherence of patients with T2DM with the SEMDSA lifestyle guidelines. Participants were over 18 years old and being treated for T2DM at a private physician’s practice in Bloemfontein. The study was approved by the Health Sciences Research Ethics Committee of the University of the Free State and all participants signed written informed consent. Three questionnaires were completed by the researcher in a structured interview with each participant. A Food Frequency Questionnaire (FFQ) was used to obtain information about dietary intake to determine both macronutrient and micronutrient intake. Physical activity intensity and duration was calculated using the Global Physical Activity Questionnaire (GPAQ), developed by the WHO. Information related to travel to and from work/ other places, activity at work and recreational activities as well as sedentary behaviour was obtained. Information related to socio-demographics (age, gender, language, marital status and level of education) and smoking and alcohol intake were collected using a questionnaire developed by the researcher (based on the SEMDSA guidelines). Anthropometric measurements were taken by the researcher according to standardised techniques, to determine BMI, waist circumference and waist-height ratio. The median age of participants was 57.9 years and the median time since T2DM diagnosis was seven years. The majority of participants were married (74%). About half spoke Afrikaans at home (52%) and worked full-time (54%). Gender was fairly equally distributed. The majority of participants were overweight (22%) or obese (66%). Most (90%) had a waist circumference above the high-risk cut point, while 92% had a high risk waist-height ratio above 0.5. The SEMDSA guidelines recommend that carbohydrates should make up 45-60% of total energy intake, total fat should be restricted to < 35% of total energy and of this, < 7% should come from saturated fat. It is recommended that sodium should be restricted to < 2 300 mg daily and that two portions of oily fish should be consumed each week to meet the recommended omega 3 fatty acid intake. Information related to dietary intake indicated that the SEMDSA lifestyle guidelines were poorly adhered to. Most participants followed a diet that was low in carbohydrates, high in fat (especially saturated fat) and low in omega 3 fatty acids. Sodium intake was high. Sedentary behaviour and lack of physical activity were common in the majority of participants, with 84% not meeting the guideline for aerobic exercise and 92% not meeting the guideline for resistance training. Ten percent of the participants were current smokers and of the men that regularly consumed alcohol, two thirds (66.67%) fell into the ‘high’ consumption (> 2 units daily) category. In conclusion, the adherence of participants to the SEMDSA guidelines was poor, thus increasing their risk of long term complications and poor glycaemic control. Complying with the SEMDSA guidelines can assist in maintaining a healthy weight, consuming a healthy diet and performing regular exercise. Further research related to the barriers that prevent patients from following the guidelines is warranted, in order to motivate practical, cost-effective and relevant interventions. researcher according to standardised techniques, to determine BMI, waist circumference and waist-height ratio. The median age of participants was 57.9 years and the median time since T2DM diagnosis was seven years. The majority of participants were married (74%). About half spoke Afrikaans at home (52%) and worked full-time (54%). Gender was fairly equally distributed. The majority of participants were overweight (22%) or obese (66%). Most (90%) had a waist circumference above the high-risk cut point, while 92% had a high risk waist-height ratio above 0.5. The SEMDSA guidelines recommend that carbohydrates should make up 45-60% of total energy intake, total fat should be restricted to < 35% of total energy and of this, < 7% should come from saturated fat. It is recommended that sodium should be restricted to < 2 300 mg daily and that two portions of oily fish should be consumed each week to meet the recommended omega 3 fatty acid intake. Information related to dietary intake indicated that the SEMDSA lifestyle guidelines were poorly adhered to. Most participants followed a diet that was low in carbohydrates, high in fat (especially saturated fat) and low in omega 3 fatty acids. Sodium intake was high. Sedentary behaviour and lack of physical activity were common in the majority of participants, with 84% not meeting the guideline for aerobic exercise and 92% not meeting the guideline for resistance training. Ten percent of the participants were current smokers and of the men that regularly consumed alcohol, two thirds (66.67%) fell into the ‘high’ consumption (> 2 units daily) category. In conclusion, the adherence of participants to the SEMDSA guidelines was poor, thus increasing their risk of long term complications and poor glycaemic control. Complying with the SEMDSA guidelines can assist in maintaining a healthy weight, consuming a healthy diet and performing regular exercise. Further research related to the barriers that prevent patients from following the guidelines is warranted, in order to motivate practical, cost-effective and relevant interventions.
Open Access
Adherence to zinc supplementation guidelines in the management of acute diarrhoea in hospitalized children
(University of the Free State, 2016-01-30) Audie, Lyndal Claire; Lategan, Ronette; Nel, Riette
English: The aim of this research study was to determine adherence to zinc supplementation as part of the treatment guidelines for diarrhoea in infants and children at a tertiary hospital in the Eastern Cape, South Africa. Zinc supplements are recommended by the World Health Organization (WHO) and United Nations Children's Fund (UNICEF) to be given to all children experiencing diarrhoea, as zinc is a proven treatment, known to reduce the severity and duration of diarrhoea. Permission to conduct the study was obtained from the management of the tertiary hospital, as well as the Ethics Committee of the Faculty of Health Sciences, University of the Free State. In this study the researcher gathered information from the case folders of infants and children admitted to the general medical paediatric ward (GMPW) for diarrhoea between 1 January 2013 and 31 December 2013. From statistics obtained from the Department of Information Technology at the hospital, it was determined that 385 infants and children under five years of age were admitted to the ward, and of these, 290 cases were included in the study. The study was a retrospective, prescription audit and all information was obtained from case folders, specifically the prescription charts and medical notes. General patient information, prescription information and medical information was collected from the case folders. Data were captured by the researcher in duplicate and compared and verified electronically. Statistical analysis was performed by the Department of Biostatistics, University of the Free State. Descriptive statistics were mainly used and medians and percentiles where calculated for continuous data, and frequencies and percentages for categorical data. This study reported poor adherence levels to treatment guidelines for zinc supplementation in children with diarrhoea at a tertiary hospital in the Eastern Cape, South Africa. The researcher recommends the need to perform training among health care professionals to increase awareness and improve implementation of zinc supplementation guidelines. Continued monitoring and surveillance were also recommended to ensure sustainability of implementation. It is also recommended that the hospital develop an institutional policy that incorporates zinc supplementation guidelines as part of the management of diarrhoea in hospitalized children.
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
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
Assessing risk of malnutrition in adult patients on hemodialysis in Port Elizabeth
(University of the Free State, 2016-04) Botha, Angelique; Meko, Lucia
English: There are currently 737 patients on renal replacement therapy (RRT) in the Eastern Cape (EC) of South Africa (SA) alone. Diseases of lifestyle are major risk factors for the development and/or progression of chronic kidney disease (CKD). CKD is a growing problem in SA, as diseases of lifestyle are becoming more prevalent. The kidneys play a vital role in the body. The kidneys’ functions include: waste removal through the urine; reabsorption of water, glucose and amino-acids; production of hormones such as calcitriol and erythropoietin; production of the enzyme renin; regulation of homeostasis by regulating electrolytes, the acid-base balance and blood pressure. CKD is present when there are abnormalities in the kidneys prevent these functions. The reduced ability of the kidneys to carry out these functions, leads to the need for renal replacement therapy (RRT), such as hemodialysis (HD). The main objective of this study was to determine the risk for malnutrition amongst adults with CKD receiving HD in Port Elizabeth (PE). A total of 68 patients took part in the study. Only 68, 7% (n = 44) patients were from the National Renal Care Dialysis unit, 20.6% (n = 14) patients from the Mercantile Life Dialysis unit and 14.7% (n = 10) from Fresenius Medical Care dialysis unit. These three centres were included for logistical reasons as well as familiarity with the staff and patients. A structured researcher-administered questionnaire was presented to the HD patients. The information collected included socio-demographics, a short-form mini nutrition assessment (SF-MNA) and anthropometrical data. There were 57.4% (n=39) male patients and 42.7% (n= 29) female patients. The majority of patients were married (58.8%); 47.1% had finished high school and an equal percentage of patients had a tertiary education. The largest percentage of patients (63.2%) was older than 50 years with a median age of 54.5 years. Half of the patients were black (n=34), 22.1% (n=15) were coloured, 4.4% (n=3) were Asian/ Indian and 22.1% (n=15) were white. Most patients spoke isiXhosa (41.3%) while only 23.5% spoke English. Just under a third (29.4%) of the patients was unemployed, while just over a quarter (26.5%) was employed on a full time basis. Pensioners made up 32.4% of the sample and only 2 patients were students. Most patients (94.1%) attend the unit 3 times per week and 5.9% (n= 4) attend the unit only twice per week. The majority of patients have been on HD for more than a year, half (48.9%) had been on HD for 1 to 5 years, and 26.5% had been on HD for more than 5 years. Patients who came from areas outside PE, were from Somerset East, Alexandria, Cradock, Port Alfred or Grahamstown. Most of the patients live within PE. Five patients (7.4%) live within 5 km of their dialysis unit, 39.7% within 5 – 10 km from the unit, and six 8.8% (n= 6) more than 50 km from the unit. Patients were classified as at risk for malnutrition if their SF-MNA scores were ≤ 11, and a score of ≥ 12 was considered acceptable. Of the 68 patients, 52.9% (n = 36) were identified as at risk for malnutrition. Significant associations between the risk of malnutrition, and HD duration, loss of appetite (p-value < 0.0001), weight loss (p-value < 0.0001) and psychological stress and/or acute disease (p-value < 0.0001) were found. In conclusion, a large number (52.9%) of patients that were receiving HD in PE at the time of the study, were at risk for malnutrition. Ongoing monitoring of such at-risk patients is therefore important. Detection of loss of appetite, weight loss and psychological stress and/or acute disease should be reason to suspect a risk for malnutrition. Early dietary and psychosocial intervention may improve the nutritional status and thus improve the patient’s quality of life. Psychological, nutritional and medical support during the first few months after HD is started, is important, as a higher risk for malnutrition is seen amongst patients on HD for 0 – 6 months. It is recommended that appropriate supplementation becomes standard practice and form part of the National Therapeutic Programme (NTP) during the first 6 months of HD.
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
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
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
Diabetes-related knowledge, attitude and practices (KAP) of adult patients with type 2 diabetes in the Free State, South Africa
(University of the Free State, 2016-01) Le Roux, Maretha; Walsh, C. M.; Reid, M.
English: Worldwide Type 2 Diabetes Mellitus (T2DM) is a growing public health problem and is closely linked to overweight and obesity. Many patients with T2DM in South Africa are overweight or obese which has been associated with rapid urbanisation in South Africans over the past 20 years. Urbanisation has resulted in a nutrition transition, characterised by a transition from healthier traditional diets to a more Western unhealthy diet and a sedentary lifestyle. Although it is a common assumption that improvements in knowledge, attitude and practices would be the answer to the diabetic epidemic, researchers agree that good knowledge of diabetes does not always translate to behaviour change. The purpose of this study was thus to determine current diabetes-related knowledge, attitude and practices (KAP) of adults with T2DM in the Free State. This research study was designed as a quantitative descriptive observational study. The population included adult patients older than 18 years with T2DM visiting 12 community health centres and 10 primary health care clinics in the five districts in the Free State. Within the selected facilities, convenience sampling took place until a total of 255 adult participants had been included. An adapted South African-Diabetes KAP questionnaire was used to gather information about demographics and associated factors, quality of life, diabetes-related KAP and perceived care. Participants were also weighed and measured. The questionnaire was piloted in a sample of 5 adult patients with T2DM in Mangaung Metro district. Ethics approval was obtained from the Health Research Ethics Committee, University of Free State. Two hundred and fifty five questionnaires were completed in 22 public health facilities. The majority of participants were black African (92%, n= 235), which is a reflection of the national distribution in South Africa where the majority of citizens are black (80%). Only 8.6% of participants had completed high school and 10% were illiterate. The median age of participants was 57 years,[range:19 to 84] and the median age of diagnosis of T2DM was 48 years [range: 15 to 80]. An overwhelming 87% of participants were either overweight or obese. The majority of the participants (67% of males and 98% of females) had a waist circumference above the recommended cut-off points which is associated with an increased risk of developing T2DM in both sexes. It was therefore not surprising that the majority (61%; n=155) were diagnosed with T2DM following metabolic syndrome related symptoms and another 11% (n=29) with other health related symptoms. This could also explain the predominance of females (75%; n=193) was attributed to glucose intolerance that is associated with higher visceral fat, which is more common in South African women than in men. Participants in the present study had poor knowledge of T2DM. Only half of the participants knew the normal range of blood glucose, although almost 90% knew the common signs of high blood glucose and two thirds were knowledgeable about complications associated with diabetes. Participants were ignorant about food groups, which is a concern considering that healthy eating is a pivotal aspect of treatment. The attitude of the participants toward their disease, in the present study was mostly negative. The majority (81%, n=206) of participants felt that they would be a quite different person if they did not have diabetes. A further 71% (n=181) felt that diabetes was the worst thing that had ever happened to them, and 79% (n=201) felt embarrassed about having diabetes. Poor diabetes-management practices were reported by the majority of participants, characterised by low levels of physical exercise and poor eating habits. Although the majority (96%; n=245) of participants were knowledgeable about the benefits of physical exercise, only 31% (n=78) reported exercising every day during the preceding week. The poor practices were also reflected in the high rates of overweight and obesity that are closely associated with a lack of physical activity and a sedentary lifestyle in general. A statistically significant correlation was found between knowledge and attitudes, indicating that better knowledge about diabetes could be associated with a more positive attitude towards diabetes. Unfortunately this did not translate to improved behaviour. Participants with a higher level of education obtained higher scores in questions related to knowledge and attitude about diabetes, but not, interestingly, in their practice scores. Poor knowledge, a negative attitude and poor practices related to diabetes, were observed in a high percentage of the participants included in this study. Barriers to sustaining improved lifestyles and successful self-management activities should be further researched since these could make a valuable contribution to improving the health and quality of life of people with T2DM.
Open Access
Diabetes-related knowledge, attitudes and practices [KAP] of adult patients with type 2 diabetes in Maseru, Lesotho
(University of the Free State, 2017-06) Chiwungwe, Faith; Reid, M.
Type 2 diabetes mellitus (T2DM) is a major public health concern in Lesotho and is the fourth ranking cause of death in that country. A steady increase in the proportion of patients admitted into hospitals with diabetes-related complications has been observed and may be attributed to poor diabetes-related knowledge, attitudes and practices of adults with T2DM. The study followed a quantitative, descriptive design. Convenient selection of clinics followed by convenient selection of participants (n=291) was used. The researcher interviewed participants using a pre-designed questionnaire based on Azjen’s theory of planned behaviour. Descriptive statistics, namely frequencies and percentages for categorical data, and medians and percentiles for continuous data were calculated. The study received ethical clearance from the University of the Free State and the Lesotho Health Research an Ethics Committee. The majority (63%) of participants were elderly (median 61 years), obese (65.6%) black females with less than four years of secondary school education completed (79%). The study found median percentage of behavioural, normative and control beliefs (reflecting the knowledge component) to be (range: 73.9%-77.8.5%), implying that most participants (85.2%) had a positive attitude towards diabetes (reflecting the attitudes component), which would positively influence the intention to act out certain positive diabetes health-related behaviour. The subjective norms and perceived behavioural control (reflecting the practices component) median was 50%. The participants (95.2%) had very strong intentions to act out certain diabetes-related behaviour. Behavioural, normative and control beliefs (knowledge) were found to be high, while normative beliefs and perceived behavioural control was low. These findings lead to specific recommendations related to the way healthcare providers comprehensively manage T2DM in Maseru. To begin with, diabetes related pamphlets should be distributed to patients to further strengthen their knowledge about the disease. Secondly, clinic based buddie or caregiver support groups are recommended to change the negative perceptions about T2DM of the community within which the patients stay, as it negatively affects patients’ self-management. Lastly, support groups focussed on skills counselling for T2DM patients are recommended to strengthen good practices that reinforce self-management.
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
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
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
Effectiveness of the prevention of mother-to-child transmission (PMTCT) policy in the Northern Cape, South Africa
(University of the Free State, 2015-07) Myburgh, Bianca; Lategan, Ronette
English: Introduction Human Immunodeficiency Virus (HIV) infection in children is mainly caused by Mother-to-Child Transmission (MTCT). The Prevention of Mother-to-Child Transmission (PMTCT) policy has been implemented in South Africa to reduce the rate of MTCT. Even though this policy has been in place for more than ten years and despite the reduction in MTCT, the challenge remains to eliminate MTCT completely. This study investigates the factors that may influence the effectiveness of the PMTCT policy. Methods Four clinics in the Frances Baard District, South Africa, where PMTCT services are rendered were included. A hundred mothers-child-pairs, where the mother is HIV infected and breastfed her child, but has stopped breastfeeding and the six week post cessation of breastfeeding HIV test was done on child, were included in the study. A questionnaire was completed by the researcher during an interview with the mother and anthropometric measurements of both mother and child were taken. The clinic files of mothers were also used to collect data. Ethical approval to conduct this study was obtained from the Ethics Committee, Faculty of Health Sciences, University of the Free State and the Northern Cape Department of Health Research Ethics Committee. Mothers provided informed consent before interviews were conducted. The Department of Biostatistics, University of the Free State performed the statistical analysis of data. Results All mothers included in this study attended antenatal clinics. Mothers who were not known to be HIV infected were tested antenatal and CD4 cell counts and HIV stages were indicated in all files. Twenty two mothers visited the antenatal clinic less than four times as recommended and 23 mothers visited for the first time during their third trimester. Only one mother reported that she received no counselling on feeding practises, and even though mothers were mostly knowledgeable about feeding practices, only 58 mothers introduced solids at the correct age and 31 mothers mixed fed their children.The number of counselling sessions did not affect breastfeeding duration (95% CI: [-2; 3]) or the age of introduction of solids (95% CI:[-2; 1]) Knowledge about MTCT was poor as most mothers (82%) only knew that MTCT could occur during breastfeeding. Younger mothers were more knowledgeable (95% CI: [0.17; 5.56]). The number of counselling sessions did not affect the knowledge of the mother (p=0.12). Five children and eight mothers never started with any antiretroviral therapy (ART). Thirteen children and 27 mothers defaulted their ART treatment. No children tested HIV infected at six weeks but three children tested HIV infected at the 18 month test. Mothers with HIV infected children had a more advanced stage of HIV infection (95% CI: [23.5%; 87.1%]), lower CD4 cell count (p=0.03) and defaulted their ART during breastfeeding (95% CI: [21.5%; 85.4%]) compared to mothers with HIV uninfected children. All three children that tested HIV infected were of mothers with Stage 2 HIV infection, with a CD4 cell count of less than 350 cells/mmᶾ and defaulted their ART during breastfeeding. Conclusions and recommendations Using the 2010 and 2013 PMTCT policies as benchmark, the PMTCT programme is implemented relatively well in this district although improvements still need to be made. The knowledge of the mothers about feeding practices and MTCT should be addressed by means of counselling by properly informed health care professionals. Missed opportunities for training resulted, as mothers did not attend antenatal clinic as soon and as often as recommended. Mothers should be motivated to improve ART adherence as this can affect CD4 cell count and HIV progression, all factors that contributed to MTCT. Counselling should be focussed on ART adherence and MTCT. Shortages of ART at clinics should be addressed to eliminate this reason for ART defaulting. All women of childbearing age should also be made aware of the importance of early antenatal attendance. The rate of HIV transmission in this district is below the national reported rate but it remains a challenge to eliminate MTCT completely.
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
An evaluation of common health and nutritional risk factors for anaemia in rural women between 25 and 49 years
(University of the Free State, 2015) Jordaan, Elizabeth Margaretha; Walsh, C. M.; Van Den Berg, V. L.; Van Rooyen, F. C.
English: Anaemia, a global public health problem that particularly affects women, holds major consequences for human health. For this reason, the factors that play a role in the development of anaemia need to be identified. Determining the causal factors of anaemia can contribute to addressing the problem through appropriate interventions. The aim of this study was to determine the prevalence of anaemia, dietary diversity, anthropometric status, reported health status, socio-demography and associations between these factors among rural women aged 25–49 years. A cross-sectional descriptive study design was applied in a sample of 134 women living in the rural towns of Trompsburg, Springfontein and Philippolis in the Southern Free State, South Africa. Women who were pregnant at the time of data collection and who were HIV positive were excluded from the current study. This study made use of data collected as part of the Assuring Health for All in the Free State study. Blood samples were collected and analysed according to standard techniques. These included full blood counts, transferrin saturation, ferritin, homocysteine and red cell folate levels. A 24-hour recall was completed in a structured interview to determine dietary diversity, categorised as low (≤3 groups), medium (4–5 groups) and high (≥6 groups). A reported health questionnaire was completed for each woman and included information on tobacco and alcohol consumption patterns, medical history and medications as well as menstruation patterns and contraceptive use. A socio-demographic questionnaire was completed for each household which assessed basic demographics of household members; structure of the house; household income; amenities; access to water and sanitation; employment status and cooking facilities. Questions pertaining to language, race, gender, age, employment status and income as well as type of dwelling were also included. Information related to water, sanitation, source of energy and food storage facilities was obtained in terms of household information. Information for all questionnaires were obtained through structured interviews. Weight, height, waist circumference, triceps, biceps, subscapular, and suprailiac skinfold measurements were measured according to standard techniques. Weight and height were used to calculate body mass index (BMI) which was categorised as underweight (<18.50kg/m2), normal weight (18.50–24.99kg/m2), overweight (25.00–29.99kg/m2), obesity class I (30.00–34.99kg/m2), obesity class II (35.00–39.99kg/m2) and obesity class III (≥40.00kg/m2). Waist circumference was categorised as normal (<80cm), at risk (≥80cm) and high risk (≥88cm). Body fat percentage was determined by means of the sum of the four skinfolds and categorised as too low (≤8%), acceptable lower end (9–23%), acceptable upper end (24–31%) and too high (≥32%). The median age of the women in the study was 41 years with most of the women (79.9%) falling in the older age group (35–49 years). Occurrence of anaemia (4.6%), iron deficiency anaemia (0.7%) and iron deficiency (1.5%) among the women was low. However, the prevalence of anaemia of more than 4.9% within a specific population is considered a mild public health problem by the WHO (2008:Online) which is close to the 4.6% of the women in the current study. Elevated homocysteine levels were present in 7.5% of the sample with only 3.8% presenting with low red cell folate levels indicative of folate deficiency. More than half of the women (54.1%) reported that they menstruated regularly and 71.6% had currently or previously used injectable contraceptives. As expected, women who menstruated regularly had significantly lower median haemoglobin levels than those who did not. With regard to the women’s diets, almost half (44.7%) of the women in the sample had a low dietary diversity with flesh meats and fish (good sources of haem iron) consumed by 76.9% of the women. Only a quarter (25.4%) of the women ate dark green leafy vegetables (sources of non-haem iron and folate). All the women consumed starchy foods, some of which are sources of folate and iron due to their mandatory fortification. Significant associations between median MCV and MCH levels and dietary diversity score may indicate that the mandatory food fortification programme is having a positive impact on the micronutrient intake of these women. A predominant pattern of malnutrition, characterised by overweight and obesity (70.8%), high rates of abdominal obesity (79.2%) and unhealthy body fat percentages (86.2%) were prevalent. Significant associations between BMI, waist circumference and body fat percentage categories with MCV, MCH levels and transferrin saturation indicate that risk for iron deficiency is associated with obesity. In terms of the women’s reported health, median haemoglobin levels were significantly higher among those women who smoked compared to those who did not. A small percentage of the women (17.9%) had been hospitalised within the past 24 months with some women reporting breathlessness with usual activity (41.0%), loose stools/ diarrhoea for at least three days (17.3%), vomiting (18.0%), loss of appetite (41.0%), blood in their urine (7.5%) and involuntary weight loss of more than 3kg (42.5%) in the past six months. Unexpectedly, median haemoglobin levels were significantly higher among those women who experienced breathlessness with usual activity, but did not differ significantly between women who suffered from anaemia and those who did not, which could indicate that the breathlessness was due to other reasons not investigated in the current study. Poverty was prevalent in the sample with 37.7% of women being unemployed and only 21.6% having a husband or partner who was a full time wage earner. Even though most women had access to basic infrastructure, low levels of income and dependence on social grants as main source of income (52.7%) show that poverty was prevalent. In the poorest households (with no flush toilet), women were more likely to have a lower median haemoglobin. Results from the current study thus indicate that regular menstruation, poverty, smoking and obesity are factors that influenced the women’s risk for anaemia. Attention should be given to improving the nutritional status and lifestyles of these women in order to improve their overall health and to reduce their risk for chronic diseases and anaemia.
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
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
Experiences of health care professionals working with childhood malnutrition in the Xhariep District, Free State
(University of the Free State, 2021-06) De Figueiredo, Natasha Alexandra Bico; Meko, N. M. L.; Van Den Berg, V. L.
Introduction: Childhood malnutrition remains a global health crisis where more than 149 million children are stunted. The rate of childhood malnutrition is a persistent issue in South Africa, where many challenges exist regarding management. Priority nutrition interventions aimed at lessening the burden of malnutrition have been identified; however, several challenges hamper progress in achieving the country’s goal to reduce the prevalence of malnutrition. By identifying the experiences of health care professionals, who treat childhood malnutrition daily at an operational level, their experiences can be recorded, and aid policy makers understand the factors that presently affect the management of malnutrition from the health professionals’ perspectives. Aim: This study aims to describe the experiences of health care professionals during the management of childhood malnutrition. Methods: The study followed a typical descriptive design using a qualitative approach. Six healthcare professionals (two doctors, two registered dietitians, and two professional nurses) who work with childhood malnutrition in the Xhariep District were identified and included in the study. Open-ended questions were asked in semi-structured one-on-one narrative interviews conducted with each participant, following an interview protocol. Every interview was audio recorded with informed consent. Data were coded, grouped into categories, and then further organized into themes. Results: The majority of the participants work at district hospital facilities; however, services are still rendered to primary health care facilities using community outreaches. Participants showed a general understanding of the term malnutrition with an inclination towards the immediate causes thereof. Substance abuse, caregivers’ lack of knowledge, and social problems and economic constraints were the common perceptions of why childhood malnutrition is still high in South Africa. Recurring challenges experienced by the health care professionals with the treatment of childhood malnutrition included: lack of medical and human resources, uncooperative patients, mismanagement by staff and emotional burdens. To overcome these challenges, participants mentioned: availing additional assistance for patients, engaging community support, sourcing other supplementation stock, promoting education and health campaigns, and acquiring more human resources as methods and solutions. The general opinion regarding the protocols and programs currently in place to help treat childhood malnutrition is that they are good and valuable. If implemented correctly, it improves the patient’s health significantly. However, most participants felt that the implementation and lack of human and financial resources cause the protocols and programs to fail. Conclusion and Recommendations: Although the participants came from three different components with varying responsibilities within the health system, they all experienced similar challenges. A pattern resulting from the cascade of these challenges was noted, which stemmed from financial constraints. With limited financial resources allocated at primary health institutions, stock and human resources availability is negatively impacted, which leads to poor service delivery. Patients who do not receive adequate quality health care are left unsupported and uninformed, which can factor caregivers of children with malnutrition to neglect their responsibilities, ultimately resulting in a persistent decline of the child’s health and nutritional status. The quality-of-service delivery at public health facilities correlates with the rate of malnutrition in South Africa. To decrease the rate of childhood malnutrition, policies need to be revised to greatly improve the quality of care patients receive at public health facilities.
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.