Doctoral Degrees (Nutrition and Dietetics)
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Item Metadata only A risk assessment profile and Diet Quality Index for inadequate choline intake in pregnant women in Bloemfontein, South Africa(University of the Free State, 2020-11) Robb, Liska; Walsh, Corinna; Joubert, GinaPregnancy is a period of rapid tissue development. These metabolic processes require additional nutrients to ultimately support the normal growth and development of the foetus. A specific nutrient that is the focus of recent investigations, especially related to the functions thereof for optimal foetal development, is choline. Choline is required in higher amounts during pregnancy. Adequate choline intake contributes to a higher diet quality in general and in turn, a high-quality diet can contribute to optimal short- and long-term pregnancy outcomes. The main aim of the study was to determine choline intake and related factors and to compile a risk assessment profile and diet quality index (DQI) for inadequate choline intake in pregnant women in Bloemfontein, South Africa. In order to reach the aim of the study, the following information was collected from 682 pregnant women (median age of 31.8 years; median gestational age of 32.0 weeks) attending the high-risk antenatal clinic at Pelonomi Regional Hospital: socio-demographic and household information; reported health and lifestyle; dietary intake; pregnancy history; anthropometry and household food security. Choline intake was quantified by matching choline intake from foods included in the quantified food frequency questionnaire (QFFQ) to foods in the USDA Database for the Choline Content of Common Foods (Release 2), after which individual choline intake of each participant was calculated. Median daily choline intake was 275.0 mg (interquartile range 184.7 mg – 386.7 mg). Most participants (84.7%) consumed less than the adequate intake level of 450 mg/day for choline. Lower egg and dairy intakes were significantly associated with inadequate choline intake (p<0.0001 and p=0.0002 respectively). Out of the 247 participants who did not consume any eggs, only five (2.0%) consumed an adequate amount of choline. No participant who did not consume any dairy products managed to consume an adequate amount of choline. Regarding socio-demographic variables and household food security, more than half of participants were unmarried (56.5%) and unemployed (52.5%). Sociodemographic indicators that were univariately significantly associated with an inadequate choline intake included a higher household density ratio (p=0.0485), no access to own flush toilet at home (p=0.0059), not owning a refrigerator (p=0.0483) or microwave (p=0.0225), as well as a lower level of education (p=0.0449). One-third of participants were severely food insecure (29.9%), and although not statistically significant, choline intake decreased with higher levels of food insecurity. Logistic regression analysis showed that the odds ratio for having inadequate choline intake was 0.55 for participants who owned a microwave compared to participants who did not. Participants with primary school education versus tertiary education had a higher odds of an inadequate choline intake (odds ratio 4.09); those having a school grade 8-10 versus tertiary education had higher odds of inadequate choline intake (odds ratio 2.12); and those having a grade 11-12 versus tertiary education had higher odds of inadequate choline intake (odds ratio 1.37). Regarding reported health and lifestyle, the majority of participants were either overweight or obese (69.3%). Almost one in ten participants (9.0%) consumed alcohol and 6.2% smoked while pregnant. Hypertension (23.0%) and sexually transmitted diseases (18.5%) were among the most common current diagnoses. Univariate analysis showed that participants without hypertension and those using anti-retroviral medications (thus HIV-infected), were more likely to consume inadequate amounts of choline (p=0.0424 and p=0.0112 respectively). When an established diet quality index, the Diet Quality Index Adapted for Pregnant Women (IQDAG), was applied to the sample, the median final IQDAG score was found to be 69 out of a maximum of 100 points (interquartile range of 63 – 74 points) (N = 680). Almost all participants (94.9%) in the first tertile of IQDAG score consumed below adequate levels (AI) of choline, compared to 78.3% of participants in the second tertile and 80.2% of participants in the third tertile. Differences in the choline intake between the tertiles of final IQDAG scores were significant (P<0.0001). In order to compile the risk assessment profile for inadequate choline intake, logistic regression with backward selection (p < 0.05) was used to select significant independent factors associated with choline intake from those identified in theme-specific logistic regressions. In this sample the odds ratio of inadequate choline intake was 43.61 for participants with no egg intake compared to participants who consumed ≥ 5 eggs per week. The odds ratio for having inadequate choline intake was 2.73 for participants with a daily dairy intake of < 250 g compared to participants who consumed ≥ 250 g. The odds of consuming an inadequate choline intake were lower for participants that were not using ART compared to those using antiretroviral therapy (ART) (thus HIV-infected) with an odds ratio of 0.51. The odds ratio of consuming inadequate choline was 3.38 for participants with the lowest tertile diet quality scores compared to participants with the highest tertile diet quality scores. In order to develop a DQI for use in pregnancy among South African women, a systematic review of the literature was performed to identify currently available DQIs used in pregnancy. The methodology of development and use of components were summarised to provide an overview of identified DQIs. The review identified nine DQIs, of which none were developed using dietary guidelines or data from African countries. Additionally, none of the DQIs specifically included choline or foods that are very high in choline (e.g., eggs and liver) as components. Using the South African Food Based Dietary Guidelines, the Guidelines for Maternity Care in South Africa and other international dietary guidelines and recommendations, the South African Diet Quality Index for Pregnant Women in South Africa (SA-DQI-P) was developed. Egg and dairy intake were incorporated as separate components; thus this tool can be used as an estimate of diet quality, while simultaneously providing an indication of choline intake in pregnant South African women.Item Metadata only Development of a nutrition screening tool for the prediction of birth outcomes of women attending the antenatal clinic at Pelonomi hospital(University of the Free State, 2021) Jordaan, Elizabeth Margaretha; Walsh, C. M.; Joubert, G.In countries with limited resources, poor birth outcomes significantly contribute to morbidity and mortality and hold short- and long-term consequences for both the mother and her offspring. Optimal nutrition during pregnancy may lead to improved birth outcomes. Nutrition screening during pregnancy may identify women who are at risk of poor birth outcomes, including premature birth and growth retardation (stunting or wasting). This quantitative, cohort analytical study aimed to develop a nutrition screening tool to identify women at risk of poor birth outcomes among pregnant women attending the high-risk antenatal clinic at Pelonomi Hospital, Bloemfontein. During the first phase, questionnaires were completed for 682 pregnant women in their second or third trimester using structured interviews after which each participant was weighed and measured according to standard techniques. During the interview, information related to socio-demographic and household information, reported health and lifestyle, pregnancy history, household food security (using the Household Food Insecurity Access Scale) and individual dietary intake (using a quantitative food frequency questionnaire and a 24-hour recall) was obtained. Participants were asked to return to Pelonomi Hospital after the delivery to provide the information recorded in the Road to Health Booklet at their babies' birth. A total of 331 mothers returned and, together with their 347 babies, were included in the second phase of the study. Associations between socio-demographic, reported health and lifestyle, and nutrition information and the following individual birth outcomes were investigated, namely method of delivery, gestational age at delivery, birth length-for-age and birth weight-forlength, as well as overall poor birth outcome (defined as prematurity, or birth length-for-age below the -2 SD, or birth weight-for-length below the -2 SD). Separate theme-specific (sociodemographic, reported health and lifestyle and nutrition) logistic regressions with backward selection (p<0.05) were used to select significant independent factors associated with overall birth outcome. Variables with a p-value of < 0.15 on univariate analysis were considered for inclusion in the model. Variables found to be significant in the theme-specific logistic regressions were considered for inclusion in the final logistic regression, which identified variables to be included in the screening tool. The median age of participants was 31.9 years (interquartile range 26.8–36.5 years). Most women had access to basic amenities such as a flush toilet and/or their own tap, inside or outside the house. A concerning percentage of women continued to smoke (30.0%), use snuff or chew tobacco (40.3%), or use alcohol (12.1%) during pregnancy. A large percentage of participants were exposed to various forms of stress during their pregnancy, including not being able to find a job for more than six months (themselves or a close family member) (70.9%) and having so much debt that they did not know how they were going to repay it (36.0%). A high prevalence of overweight and obesity as well as food insecurity was observed. About half of participants returned for phase two of the study. Significant differences were observed in terms of socio-demographic indicators and nutrient intake between women who provided their babies' birth information (responders) compared to those who did not (non responders). Generally, responders were better off, indicating that responders may not have been representative of the population and may be indicative of non-response bias. Most babies were born full-term and by means of caesarean section, with almost one in ten being part of a twin pregnancy. Low birth weight (<2.5 kg) was evident in 14.4%. According to the World Health Organization’s (WHO) Z-scores, 12.6% of neonates were underweight, 18.9% were stunted and 14.5% were wasted at birth. Just over a third of neonates were exposed to Human Immunodeficiency Virus (HIV). Overall, 37.1% of neonates experienced overall poor birth outcome. Several social determinants of health were significantly associated with at least one of the defined birth outcomes. Significant associations between various reported health and lifestyle factors and the individual birth outcomes were also observed, most notably, premature delivery. Significant associations between individual poor birth outcomes and nutrient intakes seem to indicate that improved birth outcomes are associated with improved nutrient intake. The proposed tool included all variables identified in the final logistic regression model of predictors of overall birth outcome namely ownership of a stove, participant’s highest level of education, participant’s employment status, being in real danger of being killed by criminals in the past six months (themselves or a close family member), being diagnosed with or treated for high blood pressure during the current pregnancy, number of babies expected and gestational body mass index (replaced by current body mass index for ease of application in the screening tool). Experiencing weight loss of more than 3 kg during the current pregnancy was added to the tool. A score of two or more was considered as indicative of an overall poor birth outcome since this cut-off gave the best combination of sensitivity and specificity namely. 68.8% and 70.5% respectively, while the positive predictive value was 58.1%, and the negative predictive value was 79.1%. Pregnant women should be educated on the importance of regularly attending antenatal follow-up visits, focusing on the risks associated with poor lifestyle choices during pregnancy and the benefits of following a healthy diet and lifestyle. Pregnant women who regularly attend antenatal visits may be more likely to be screened and referred for specialised nutrition care at an early stage when such interventions can still make a difference to birth outcomes.Item Open Access Nutritional factors associated with HIV-infected adults in the Free State(University of the Free State, 2013) Pienaar, Michelle; Walsh, C. M.; Joubert, G.English: HIV-infection has a significant impact on health and quality of life. Nutritional factors can be described as those directly related to food and nutrition (such as diet) and those indirectly related to food and nutrition (such as poverty). Dietary diversity is associated with improved socio-economic status and household food security, both of which impact on nutritional status and health. Poor nutritional status is characterised amongst other indicators, by fatigue, physical inactivity, weight loss and wasting, which are associated with poor prognosis in HIV-infection. All of these factors impact on people living with HIV/AIDS, but remain largely undetermined in the Free State. The objective of the present study was to determine significant independent nutritional factors associated with HIV status in rural and urban communities in the cross-sectional Assuring Health for All (AHA) study, which aimed to determine how living in rural and urban communities can influence lifestyle and health. The AHA study was undertaken in rural Trompsburg, Philippolis and Springfontein during 2007 and in urban Mangaung during 2009. Adults between 25-64 years were eligible to participate. The study was approved by the Ethics Committee of the Faculty of Health Sciences at the University of the Free State (ETOVS 21/07) as well as the Free State Department of Health and local municipalities. The venues where data was collected included stations for the collection of blood and urine samples; a food station; medical examination; as well as anthropometric measurements. Thereafter, questionnaires related to the following were completed: socio-demography (one per household); household food security (one per household); diet (one for each participant); physical activity (one for each participant); and reported health (one for every participant). Logistic regression with forward selection (p < 0.05) was used to select significant independent factors (socio-demography, household food security, dietary diversity, physical activity, anthropometry, reported health) associated with HIV status. Variables with a p-value of < 0.15 were considered for inclusion in the model. Of the 570 rural participants, 567 had HIV results. Of these 97 (17.1%) were HIV-infected. Of the 426 urban participants, 424 had HIV results. Of these 172 (40.6%) were HIV-infected. As expected, in rural areas, HIV-infected participants were significantly younger (median age 40.5 years) than HIV-uninfected participants (median age 51 years) (p = 0.001). The same was found in urban areas, with HIV-infected participants having a median age of 38 years compared to 49 years in HIV-uninfected participants (p = 0.0001). In this sample, the odds of having HIV consistently decreased as age increased. In rural areas more HIV-infected participants were female (73.0%) compared to male (27.0%). The same was found in urban areas where 78.0% of the HIV-infected respondents were women and only 22.0% men. As far as socio-demographic and household food security indicators are concerned, in the rural sample HIV-infection was negatively associated with having a microwave oven (odds ratio 0.15, 95% CI 0.06; 0.42); having access to vegetables from local farmers or shops (odds ratio 0.43, 95% CI 0.21; 0.89); and being married (odds ratio 0.20, 95% CI 0.09; 0.41). On the other hand, HIV-infection was positively associated in the rural sample with spending less than R50 on food per week versus R101+ (odds ratio 3.29, 95% CI 1.58; 6.87) or spending less than R100 on food per week versus R101+ (odds ratio 1.22, 95% CI 0.68; 2.20). In the urban sample, HIV-infection was also negatively associated with being married (odds ratio 0.54, 95% CI 0.33; 0.89), while HIV-infection was positively associated with experiencing periods of food shortages (odds ratio 2.14, 95% CI 0.91; 0.95). In the rural sample, one out of five participants had low and medium dietary diversity scores. HIV-infection was negatively associated with a person consuming no eggs (odds ratio 0.41, 95% CI 0.20; 0.82) and consuming no sweets (odds ratio 0.19, 95% CI 0.04; 0.85). On the other hand, HIV-infection was positively associated with being sedentary versus very active (odds ratio 3.18, 95% CI 1.31; 7.70); low active versus very active (odds ratio 2.27, 95% CI 1.08; 4.77); and active versus very active (odds ratio 2.44, 95% CI 1.31; 4.55). No significant dietary diversity or physical activity factors were identified in the urban sample. As far as anthropometric indicators in the rural sample are concerned, HIV-infection was positively associated with a low versus high body fat percentage (odds ratio 15.56, 95% CI 0.80; 303.81); an acceptable low versus high body fat percentage (odds ratio 4.21, 95% CI 2.13; 8.31); and acceptable high versus high body fat percentage (odds ratio 1.85, 95% CI 0.81; 4.22). In the urban sample, HIV-infection was negatively associated with male gender (odds ratio 0.29, 95% CI 0.15; 0.53) and positively associated with a low or acceptable low versus high body fat percentage (odds ratio 9.18, 95% CI 4.89; 17.23) and acceptable high versus high body fat percentage (odds ratio 2.73, 95% CI 1.46; 5.12). When indicators of reported health and coping strategies were considered, a negative association was found between being a member of a church and HIV-infection [odds ratio 0.22 (95% CI 0.06; 0.76) in the rural sample and odds ratio 0.46 (95% CI 0.23; 0.91) in the urban sample]. In rural areas, HIV-infection was positively associated with losing weight involuntarily (>3kg in the past 6 months) (odds ratio 1.86, 95% CI 1.08; 3.20); ever being diagnosed with TB (odds ratio 2.50, 95% CI 1.18; 5.23); being on TB treatment (odds ratio 3.29, 95% CI 1.00; 10.80); and having experienced death of a spouse during the past year (odds ratio 4.91, 95% CI 2.06; 11.73). In the urban sample, HIV-infection was positively associated with having diarrhoea for at least 3 days in the past 6 months (odds ratio 2.04, 95% CI 1.23; 3.41) and having ever been diagnosed with TB (odds ratio 2.49, 95% CI 1.37; 4.53). When all factors identified above were considered for the final model, the odds of having HIV decreased as age increased. In rural areas, HIV-infection was negatively associated with microwave oven ownership (odds ratio 0.20, 95% CI 0.07; 0.57) and being married (odds ratio 0.17, 95% CI 0.08; 0.36). HIV-infection was positively associated with spending less than R50 per week on food versus R101+ (odds ratio 3.15, 95% CI 1.43; 6.95); having a body fat percentage of <5% versus 25%+ (odds ratio 4.41, 95% CI 1.69; 11.51); or having been diagnosed with tuberculosis (odds ratio 3.81, 95% CI 1.93; 7.52). In the urban sample, HIV-infection was negatively associated with male gender (odds ratio 0.29, 95% CI 0.15; 0.57). On the other hand, HIV-infection was positively associated with experiencing periods of food shortage (odds ratio 2.34, 95% CI 1.26; 4.37) and having a body fat percentage of <15% versus 25%+ (odds ratio 8.62, 95% CI 4.42; 16.84). Lower socio-economic status [spending very little on food (rural); and food shortage (urban)], was positively associated with HIV-infection. Being physically inactive [indicated by being sedentary versus very active; low active versus very active; and active versus very active], was positively associated with HIV-infection in the rural sample of this study, probably because lower levels of physical activity are an outcome of HIV-infection. In addition, HIV-infection was positively associated with decreasing body fat percentage (rural and urban). These results confirm the higher prevalence of opportunistic infection and associated symptoms (such as diarrhoea and weight loss) that are outcomes of HIV-infection. Indicators related to wasting, previous tuberculosis and a lower socio-economic status [indicated by being female (urban) and unmarried (rural); spending very little on food (rural); and food shortage (urban)], were associated with HIV-infection, either as outcomes of the disease or as exposures. A vicious cycle develops, with poverty increasing the likelihood of contracting HIV/AIDS and HIV/AIDS contributing to poverty. Interventions that focus on poverty alleviation can make a significant contribution to addressing HIV in South Africa. Interventions of this nature have the potential to improve food security and nutritional status which in turn will assist in preventing weight loss, promoting physical activity and improving quality of life. The social and moral support offered by organisations such as churches is invaluable in the fight against HIV.Item Open Access Impact of micro-nutrient supplementation on semen parameters(University of the Free State, 2016) Du Toit, Elmine (WC); Lategan, R.; Grobler, S.English: The health of parents determine the development of their children and a link between paternal diet, metabolic health, body weight and semen parameters have been shown. Various factors may influence semen parameters and in this study the effect of micro-nutrient and omega-3 supplementation on semen parameters was investigated by evaluating semen parameters and fatty acid composition of intact semen at baseline and three months after intervention. The study also investigated the effect of age, environmental-, lifestyle-, anthropometric and dietary factors on semen parameters. A placebo controlled intervention study on 50 apparently healthy volunteers between the ages of 18 and 45 years was conducted and data collection took place at the Faculty of Health Sciences, University of the Free State. Participants completed a self-reporting questionnaire to report on age, environmental-, lifestyle- and dietary factors. Standard techniques were used to obtain anthropometric measures and physical activity was determined using the self-administered short International Physical Activity Questionnaires (IPAQ). Two semen samples were collected and the average used to provide a representative reflection of sperm parameters. Semen analysis included semen volume, sperm concentration, -morphology, quantitative and qualitative motility, pH as well as fatty acid analysis. Descriptive statistics were used to describe the sample and Chi-squared tests or Fisher exact tests were used to determine associations between variables and two tailed Pearson’s or Spearman’s correlations, as well as analysis of variance were used to describe correlations. A relation between aging and sperm parameters are described in literature, however in this younger study sample with a median age of 24 years, no correlation was found between age and semen parameters, probably because age related changes are only expected later. According to body mass index classification the majority of participants were overweight/ obese and according to neck circumference measurements a large percentage of participants were overweight/obese, but none of the anthropometric measures showed an association with semen concentration, -motility or morphology. In literature, the number of sitting hours per day is linked to semen quality and in this study a weak correlation was found between sperm morphology and the number of hours per day spent sitting. Reported high activity levels did not show an association with sperm parameters. More than half of participants spent more than four hours per day using electronic devices connected to Wi-Fi. A significant association between using electronic devices connected to Wi-Fi for four hours or more per day and a lower sperm motility was found. No statistically significant association between where the cellular phone is carried and normal or abnormal sperm parameters were shown. Although more than half of participants in this study took hot baths, no significant association was found between the use of hot baths and below reference limits for sperm parameters. More than a third of participants wore tight fitting underwear or trousers, which may contribute to an elevation in scrotal temperature and consequently poor semen quality, however no association was found between wearing tight fitting clothing and poor sperm parameters. A healthy prudent diet has been proposed as an economical and safe way to improve sperm function. Although the intake of vegetables and fruit were inadequate and a cause for concern in this study, no association with poor semen quality was found. Alcohol intake of more than five units per week however was significant associated with lower sperm concentration. Supplementing a healthy group of young men with a multi vitamin-mineral and omega-3 supplement over a period of 90 days did not influence the fatty acid composition of their semen or most of the sperm parameters, but showed an improvement in the percentage of sperm with normal forms. For future studies, it is recommended that a larger sample be included if more resources are available and that other geographic areas in South Africa be included, especially as habitual food intake can differ considerably. This study provided valuable information about the possible negative effects of alcohol and use of electronic devices on sperm parameters and the potential of nutrient supplementation to improve sperm morphology. These results can be used when advising males about reproductive health, in order to optimise sperm parameters, which could influence the health of future generations.Item Open Access The impact of an enzyme-modified enriched maize-based supplement on the anthropometric nutritional status of institutionalised HIV+ children(University of the Free State, 2013-07) Van der Walt, Erika; Dannhauser, A.; Veldman, F. J.English: HIV/AIDS negatively influences the health, quality of life and nutritional status of infected individuals. The negative influence on nutritional status is even worse in children than in adults, due to children’s additional needs for growth. The aim of this study was to determine the impact of an enzyme‐modified, enriched maizebased supplement on the anthropometric nutritional status of children infected with HIV, and residing in or attending day care at institutions for HIV‐infected and affected children in Mangaung. A total of 155 food secure HIV‐infected children aged 1 – 10 years were screened to determine HIV status. HIV‐infection was confirmed in 37 clinically stable, antiretroviral naïve children, who were included in the study sample. The study was a randomised, double blind, clinically controlled, prospective trial. Intervention over a period of 16 weeks consisted of an experimental and control supplement given to the children in the experimental‐ (E) and control (C) groups respectively. Both products were enriched maize/soy blends of exactly the same nutritional value, except that α‐amylase was added to the E‐product. The addition of α‐amylase to starchy foods decreases the viscosity of the mixed product, enabling the individual to consume larger quantities for more energy and nutritional benefit, especially in the case of young children with high nutritional needs but lack of capacity to consume large enough quantities to provide in these needs. Twenty‐nine children completed the intervention. The mean age of the 29 (E=14; C=15) at baseline was 64.1 months (SD 23.6 months). Baseline nutritional status of the children was poor. Underweight for age was identified in 42.9% of both the E‐ and C‐groups. The median Z‐score for WAZ was ‐1.9 for both the E‐ and the C‐group. These findings support findings of other researchers that growth in HIV‐infected children is significantly slower than in noninfected children. A high percentage of stunting was found in both groups: 57.1% in the E‐group and 80% in the C‐group were stunted. The median Z‐scores for HAZ were ‐2.3 for the E‐ and ‐2.9 for the C‐group. This was in accordance with findings of other researchers who reported that HIVinfected children are more often stunted than non‐infected children. The prevalence of stunting in this study is high in comparison to existing national data for children of unknown HIV status. The poor anthropometric nutritional status in children in care centres emphasises the detrimental effect of HIV‐infection on the nutritional status and growth in young children, as well as the importance of extending community based nutrition intervention initiatives to care centres and other facilities taking care of HIV‐infected and HIV‐affected children. Although the data of the intervention phase of this study did not show significant improvement in the anthropometrical nutritional status, other studies using a product with added α‐amylase did show improvement in anthropometrical nutritional status. The practical problems experienced in the present study may have had a negative effect on the outcome of the study. In conclusion, the high prevalence of malnutrition found at baseline, indicate that children infected with or affected by HIV are vulnerable and that being a resident or being registered at a care centre does not necessarily protect them from malnutrition. It is important that children in these facilities are included in routine health and nutritional assessments and that the centres are included in initiatives that target malnutrition. HIV‐infected children in care centres should receive more aggressive nutrition support to make provision for their increased requirements and also to protect them from malnutrition and early disease progression. The inclusion of additional sources of energy dense supplements such as RUTF to current supplementation regimens for malnourished children may be needed to achieve catch‐up growth in malnourished children.Item Open Access Impact of an education intervention addressing risk factors for iron deficiency among mothers and their young children in Northern Ghana(University of the Free State, 2015) Abu, Brenda Ariba Zarhari; Van Den Berg, V. L.; Louw, V.J.English: When anemia prevalence in a population is above 40%, as is the case in Northern Ghana among children (81%) and women of reproductive age (59%), it may be assumed that the entire population suffers from some degree of iron deficiency (ID). This study aimed to assess the socio-demographic profile, nutritional status, and knowledge, attitude and practices (KAP), regarding known risk factors for ID/anemia and pica, among mothers and their children six to 59 months old in Northern Ghana; and to design, implement and evaluate a nutrition education programme (NEP) to address the gaps identified at baseline. A questionnaire on socio-demographics, household food production, food frequencies, household food security (CHIPP index), and three 24-hour recalls, KAP regarding pica (excessive craving/eating of food and/or non-food substances) and ID were administered via structured interviews; and BMI and Z-Scores were assessed among non-pregnant mothers with children (six to 59months) in Tolon-Kumbungu district (Gbullung (n=81 mothers; 85children) and Tamale metropolitan (Tugu & Tugu-yepala (n=80) mothers; 90 children). Dietary intakes were analysed with the Ghana Nutrient Database® (Version 6.02). Iron intakes were assessed by the probability method at 5% and 10% bioavailability, and vitamins A, B12, folate and vitamin C intakes were evaluated in relation to estimated average requirements (EAR) cut-points. Data was analysed with SAS® version 16.0. At baseline the mean age for mothers was 33.0 ± 8.3 years. Most were from the Dagomba ethnic group; practiced the Muslim religion (98.1%), and were married (97.5%) in polygamist marriages. Over 90.0% had no formal education. More than half the households were food insecure. A usual daily intakes consisted of (of maize meal (tuo zaafi (TZ)) (mostly whole) 96.2%), green leafy vegetables (7%) (mostly amaranth leaves), shea butter and tea. Legumes and nuts were included on a weekly basis and meat, eggs and citrus fruits occasionally. Children had basically the same dietary patterns. Based on 24-hour recall, inadequate intakes of protein (30%), and vitamin B12 (94.4%) were observed. Similarly, inadequate intake of vitamin A (58.5%), vitamin B12 (98.2%), and vitamin C (21.3%) were observed for children. Mean fibre intakes were 47.8 ± 19.0 among mothers and 19.8 ± 13.9 g/day among children. At an assumed bioavailability of 5% , 80.3% of mothers and 67.3% of the children, had probable inadequate intakes of iron. A tenth of mothers were underweight and 11.3% overweight/obese. About half of children (47.3%) were stunted (≤-2SD), 38.0% (≤-2SD) underweight, and 17.2% (≤-2SD) wasted. The knowledge scores of the mothers were below average regarding sources of iron and enhancers of iron absorption. Pica practice was reported among 16.8% of mothers and 9.0% of children; and among 29.3% of pregnancies with the index children; mostly for clay, kola nuts and soil. A child’s current pica practice was significantly associated (p=0.002) with his/her mother’s pica practice when she was expecting him/her. Mother’s views on pica were mostly negative and they thought it was untreatable. Gaps identified from the baseline survey, were summarised into 10 themes, and translated into key messages presented in July, 2013, as a 5-day (90 minutes/day) NEP in the Tolon-Kumbungu district, while Tamale Metropolis was the control. Three months after the intervention (attrition: 20 mothers, 23 children), the data collection were repeated in both the original groups of mothers. For both mother and children inadequate intakes of vitamins A, B12, protein and iron persisted. BMI, HAZ and WHZ decreased from baseline in both groups with a significantly higher (p<0.05) decrease in the intervention group. A significant improvement in total score on knowledge of iron sources and iron absorption enhancers was observed in both the intervention (p<0.0001) and control (P=0.0016) groups. Hand washing was the most practiced key message. Financial constraint and lack of social support was the main challenges to behavioural change. Post-intervention 12.8% of mothers in the intervention group mentioned anemia/ID as a possible cause of pica, and 7.1% stated that when you treat ID/Anemia, pica may also be treated compared to 1.4% in the control group. Conclusion: A context specific NEP on ID and pica improved the knowledge on iron sources, and mother’s ability to associated pica with ID, but did not improve nutrient intake or anthropometry at three months post intervention.Item Open Access Impact of a nutrition education intervention on nutritional status and nutrition-related knowledge, attitudes, beliefs and practices of Basotho women in urban and rural areas in Lesotho(University of the Free State, 2013) Ranneileng, Mamotsamai; Walsh, C. M.; Dannhauser, A.Abstract not availableItem Open Access Impact of a nutrition education programme on the nutritional status of children aged 3 to 5 years and the nutritional practices and knowledge of their caregivers in rural Limpopo province, South Africa(University of the Free State, 2011-11) Mushaphi, Lindelani Fhumudzani; Dannhauser, A.; Walsh, C. M.; Mbhenyane, X. G.Globally, the prevalence of acute malnutrition and micronutrient deficiency is high in young children, especially in developing countries. This study was undertaken to determine the impact of a nutrition education intervention programme (NEIP) on the nutritional knowledge and practices of caregivers, as well as the nutritional status of children between the ages of three to five years in the Mutale Municipality in Vhembe district, Limpopo Province. A pre-test–post-test control group design was chosen using eight villages (four villages in the experimental group (E); four villages in the control group (C). At baseline, the study population was 125 caregivers and 129 children aged three to five years (E = 66; C = 63 children). After intervention, 86 caregivers and 89 children (E = 40; C = 49 children) were found. Only participants who participated at baseline and postintervention were included for comparison. A valid structured interview schedule was used to determine nutritional practices and knowledge. The nutrient intake was determined by two 24-hour recalls. Weight and height (to determine weight/height status) and blood samples (vitamin A and iron status) were taken using standard techniques. The NEIP was developed by the researcher using South African Food-based Dietary Guidelines (SAFBDGs) and South African Paediatric Food-based Dietary Guidelines (SAPFBDGs) as basis. The NEIP was implemented on the experimental group on two occasions, namely every week during the first three months and then during the last three to four months in a period of 12 months. Data were analysed using Statistical Analysis Software (SAS®) version 9.2 and expressed using median, minimum and maximum values to describe continuous data. Frequencies and percentage were used to describe categorical data and 95% confidence intervals were used for median and percentage differences to determine the impact of the intervention programme. The 24-hour recall data were analysed using Food Finder III version 1.1.3. The study revealed that the socio-demographic information and anthropometric nutritional status of the children did not change after intervention in both groups. Furthermore, at baseline, nearly one third of the children in both groups had marginal vitamin A status. However, after intervention, all children in both groups had adequate to normal vitamin A status, which could be due to the vitamin A supplementation and food fortification programme of the SA Government. The iron indicators were within adequate levels at pre- and post-intervention in both groups. The impact of NEIP was observed in some of the nutritional practices, since the majority of caregivers usually included starchy foods, protein-rich foods and vegetables in the child’s plate daily at baseline in both groups. However, the number of children who were given more than three meals per day showed a tendency towards an increase in the experimental group. The intake of milk and yoghurt improved significantly in the experimental group. The majority of children were eating indigenous foods. However, the intake of black jack, spider flower, wild jute plant, baobab fruit, paw-paw, mopani worms and termites improved significantly in the experimental group. The median carbohydrate and protein intake was adequate when compared to EAR/RDA in both groups at pre- and post-intervention. The median energy, carbohydrate and plant protein intake had increased significantly in the control group. The intake of iron and folate had increased significantly in both groups, while zinc intake increased significantly in the control group. After the intervention, the intake of tshimbundwa (traditional bread made with maize) also increased significantly in the control group. Furthermore, the intake of stinging nettle, meldar, wild peach, pineapple, dovhi, tshigume and thophi had improved significantly in both groups. The nutrition knowledge score was good at baseline, as the majority of caregivers in both groups were aware that children should be given a variety of foods, indigenous foods, starchy foods, protein-rich foods, vegetables and fruit. However, in the experimental group the percentage of caregivers who knew that children should be given full-cream milk and fat increased significantly at post-intervention. On other hand, the percentage of caregivers who knew tshimbundwa increased significantly in the control group. The majority of caregivers were including most of the food items on the child’s plate (starchy, protein-rich foods, vegetables and indigenous) at baseline, which left little room for improvement. However, the impact of NEIP was observed in some nutritional practices. On the other hand, minimal impact of the NEIP on nutrition knowledge was observed, since most of the caregivers had good nutritional knowledge at baseline. It is recommended that the NEIP developed in this study be adapted for the Department of Health (Nutrition Section) so that healthcare workers can present it in different communities using different media so as to increase coverage.Item Open Access Food safety indicators in household food security in the Ruralvhembe district, Limpopo province, South Africa(University of the Free State, 2014-07) Nesamvuni, C. N.; Dannhauser, A.; Viljoen, B. C.; Joubert, G.English: Available literature emphasises the importance of food safety in obtaining coordinated and conceptually informed results of food security, with the view to improve intervention programmes to achieve progress in obtaining food security in households. The study was undertaken intending to investigate possible food safety indicators that might possibly contribute towards improved assessment of household food security (HFS) in the rural Vhembe District, Limpopo Province, South Africa. The objectives were to determine HFS and household food safety, as well as the relationship between HFS and food safety, and to develop food safety indicators of HFS. A cross-sectional study was undertaken. Twenty nine villages were randomly selected from the total number of 299 villages in Thulamela local municipality in the Vhembe District. For proportional sampling of households from the selected villages 4 village clusters were created according to their population sizes. Households were randomly selected from villages. The final randomly selected sample consisted of 335 households with at least 1 child (3-5 years of age) and a caregiver. The caregiver could be the mother of the child or any caregiver over the age of 18 years of age who was mostly responsible for food preparation in the household. A structured interview schedule was used, consisting of questionnaires and data/record sheets that were completed during an interview with the respondent of each household. A sociodemographic questionnaire; food availability and access questionnaire; a food inventory; an 8-item hunger scale; a food frequency questionnaire; a food handling practices questionnaire; and a food handling knowledge test; a 24 hour recall and child health status questionnaire; as well as record sheets were included. Five repeatedly trained (for consistency) field workers (all Nutritionists) collected all types of data. Weight and height status were determined and laboratory techniques were used to determine microbiological content of the water and food samples (114 of 335 of households: 34%) and worm content of stool samples (from all 335 children 3-5 years of age). Data was analysed using statistical analysis software (SAS) version 9.2. Frequencies and percentages were used to describe categorical data. Continuous data (symmetric distributions) were expressed using means and standard deviations while medians, lower and upper quartiles as well as minimum and maximum values were used to describe skewed continuous data. Anthropometric data was summarised using Z-scores. Chi-square tests or Fisher’s exact tests in case of small numbers were used to determine associations 229 between the indicators of household food safety and HFS. A statistical reduction process was used to develop the household food safety indicators that can be used in rural HFS assessments. Household food insecurity was indicated by all indicators used, as well as the sociodemographic indicators. Salary, affordability and the presence of protein rich foods, vegetables, milk and fat were significantly related to the household food security status as indicated by the hunger scale. The levels of food security were evenly distributed among the households: food insecure (32.8%), at risk (37%) and food secure (30.2%) households. However, the anthropometric indicators showed that most children (>88%) had an acceptable weight/height status. The dietary intake of the children suggested sufficient energy intake with probable low intake of micronutrients especially β-carotene. Furthermore, the diet seemed to lack variety, with inadequate intake of fruits, vegetables, milk and dairy products. The health status of the children was apparently good as shown by the less than 20% of children with diarrhoeal episodes and 35.2% with reported worm infestations. Stool examination results also showed few cases of children with worm infestation, Ascaris (1.2%), Trichuris (1.9%) and Giardia lambia (5.6%). In general, caregivers had acceptable scores of self-reported food handling practices and knowledge. Water and food used in the households were both likely to pose a food safety risk in the households respectively. Poor microbial quality was detected in more than 94% of water and 75.9% food samples. Hand-washing water had higher bacterial load than stored water. Both stored and hand-washing water had food safety risk levels of total counts (median = 2.3 x 104 & 2.5 x 105 respectively) and coliforms (median = 5.6 x 104 & 1.6 x 105 respectively). Salmonella and Listeria tested negative on food samples however, coliforms exceeded the safety limits. The presence of E. coli in protein rich foods suggested a faecal pollution. Food handling practices and knowledge were not significantly different in food secure and at risk households but were significantly different in the food insecure households. Self-reported and observed food handling practices did not differ. Availability of protein rich foods including milk in the households was linked to food handling practices, while a significant association was observed between worm infestation in children 3 to 5 years and food handling practices. The microbial quality of stored water was significantly associated with that of hand-washing water. Both stored and hand-washing water were significantly linked with poor microbial 230 quality of left over vhuswa (maize meal porridge) but had no association with fresh vhuswa. Poor microbial quality of fresh and left over vhuswa were significantly related to contaminated protein rich foods. A step by step analysis was done during the development process of food safety indicators, in which indicators that did not show significant associations and did not show sufficient variation were eliminated. In the final step the indicators of household food safety to be included in measuring of HFS in rural households were identified. The food safety indicators identified by this study and recommended for use in measuring rural HFS, include use of stored water, communal hand-washing practices and observed food handling practices. It is recommended that these indicators be evaluated and included in the measuring of rural HFS.Item Open Access The association of body weight, 25-hydroxy vitamin D, sodium intake, physical activity levels and genetic factors with the prevalance of hypertension in a low income, black urban community in Mangaung, Free State, South Africa(University of the Free State, 2011) Lategan, Ronette; Van den Berg, V. L.; Viljoen, C. D.; Walsh, C. M.English: Hypertension is responsible for a large and increasing proportion of the global disease burden and is becoming increasingly significant in low-income countries. The aim of this study was to determine the association of body weight, 25-hydroxy vitamin D, sodium and potassium intakes, physical activity levels and genetic factors, with the prevalence of hypertension in a low income, black urban community. Various factors influence blood pressure, with especially body weight showing a strong relationship with hypertension. More than half of this study population suffered from hypertension and the majority was overweight or obese, increasing the risk for disease and premature death. All indices of abdominal obesity and body fatness, including BMI, WHtR, adiposity index and waist circumference were significantly related to blood pressure, supporting weight loss as first line intervention for treatment and prevention of hypertension and its accompanying disease burden in this population. Findings also suggest the use of WHtR to screen for hypertension in this population. Higher blood pressure levels are associated with lower levels of vitamin D and low vitamin D levels have been linked to obesity markers. Although the majority of participants in this study were overweight/obese, almost 96% had adequate vitamin D status, despite expected low vitamin D intakes. HIV status did not influence vitamin D status directly, but through BMI. The latitude and high levels of sun exposure could have been responsible for the favorable vitamin D status in the participants. Results confirm the inverse relationship between vitamin D status and hypertension reported by other researchers, but found that this relationship seemed to be dependent on BMI in this study population. Lower sodium intakes accompanied with increased potassium intakes are recommended for the prevention and treatment of hypertension. The blood pressure elevating effect of sodium have been found to be even more profound in black population groups, urging investigation into this possible race-related cause of hypertension. Sodium intakes, as reflected by urinary sodium excretion, were high in this study. Association between sodium intakes and systolic, diastolic and mean arterial pressure were found, with higher sodium intakes being associated with elevated blood pressure levels, indicating the need for dietary sodium reduction strategies to control hypertension in this population. Despite high sodium intakes and low potassium intakes, no association was found between sodium or potassium intakes and the prevalence of hypertension. Increased activity is often advocated as first line treatment in the prevention of hypertension, even when weight loss is not achieved. The majority of participants in this study reported being sedentary or low active. No significant association could be shown between activity level and the prevalence of hypertension. Although HIV status showed a negative correlation with BMI, no correlation could be found between HIV status and activity level. Chronic diseases such as hypertension are likely the result of more than one gene and multiple variants of each gene that interacts with different environmental factors, with each combination making a small contribution to overall homeostasis, function, and therefore health. The high risk polymorphisms of the AGT (M235T and -217); GRK4 (A142V, A486V) and CYP11B2 genes did not seem to play a major genetic role in the high prevalence of hypertension in this population. Only GRK4 (R65L) showed an association with the prevalence of hypertension and a weak negative correlation with mean arterial pressure. Results show that overweight/obesity and excessive sodium intake are the major contributors towards hypertension in this study population. Intervention programmes should focus on preventative strategies that create awareness to promote weight loss and encourage lower salt consumption.Item Open Access The health and nutritional status of HIV positive women (25-44 years) in Mangaung(University of the Free State, 2005) Hattingh, Zorada; Walsh, C. M.; Dannhauser, A.; Veldman, F. J.English: Human Immunodeficiency Virus infection causes Acquired Immune Deficiency Syndrome, which has caused millions of deaths, with more expected, particularly in developing countries like South Africa, where poverty is a critical factor. The intake, digestion, absorption and metabolism of food and nutrients emerge as a vicious cycle. The undernourished HIV-infected individual develops micronutrient deficiencies, immunosuppression and oxidative stress, thereby accelerating disease progression. Symptoms include weight loss and wasting, with increased risk of secondary infections. A representative sample of 500 African women (25-34 and 35-44 years) from Mangaung in South Africa’s Free State Province participated in the study. Socio-demographic composition and physical activity levels were determined by questionnaire. Weight, height, circumference (waist and hip) and bioimpedance measurements were used to calculate body mass index and fat distribution and percentage. Dietary intake was determined using a food frequency questionnaire, and nutrient intake was analysed. Biochemical nutritional status was determined through blood samples. Socio-demographic characteristics indicated high unemployment rates. Significantly more HIV positive than HIV negative young women had lived in urban areas for over ten years, and smoked and/or used nasal snuff. Few young women had no education, while more older women had only a primary school or Grade 8-10 education. Significantly more younger and older HIV positive women headed their own households. No significant differences were found in housing conditions, room density and household facilities of younger and older HIV positive and HIV negative women Anthropometric results showed that approximately 50% of all women were overweight/obese. Most women had a gynoid fat distribution and were fat/obese according to fat percentage. However, young HIV positive women had significantly lower body mass index and fat percentage than young HIV negative women. The entire sample had low physical activity levels. Median dietary intakes of energy, macronutrients and cholesterol were high, with young HIV positive women having a significantly higher median energy intake than young HIV negative women. Low median intakes of calcium, total iron, selenium, fat-soluble vitamins, folate and vitamin C, but high median intakes of the B vitamins, were reported overall. Younger women with HIV had significantly higher intakes of calcium, phosphorus, potassium, and vitamins B12, D and E than young HIV negative women. Older HIV positive women had significantly lower intakes of haem iron, nonhaem iron and selenium than older HIV negative women. Although median values for most biochemical parameters were normal, younger HIV positive women had significantly lower median haemoglobin and haematocrit levels, while older HIV positive women had significantly higher serum ferritin and lower transferrin values than their HIV negative counterparts. Significantly more HIV positive younger and older women had low haematocrit values, while significantly more HIV negative older women had low serum iron and high transferrin concentrations. Compared to HIV negative women, younger and older HIV positive women had significantly lower median blood values for total lymphocytes and serum albumin, but significantly higher median blood levels of total serum protein. Plasma fibrinogen and serum insulin concentrations were significantly reduced in young HIV positive women. Older HIV positive women had significantly lower total serum cholesterol values than older HIV negative women. Serum glucose and serum triglycerides did not differ significantly between HIV positive and HIV negative women within both age groups. In younger and older women, increased serum total protein and decreased serum albumin were associated with HIV infection. In younger women, smoking and being unmarried increase the odds of HIV infection, while in older women a higher education level and a decreased non-haem iron intake are associated with HIV infection. An adequate diet, nutritional counselling and active physical activity can improve immune function, quality of life and biochemical nutritional status. Dietary intake alone, however, may be insufficient to correct nutritional deficiencies in this poor community, and the role of food-based approaches and micronutrient supplementation merits further attention. Key words: South Africa; African women; HIV; socio-demographic status; anthropometry; dietary intake; physical activity; iron status; metabolic profileItem Open Access Nutritional status and risk factors associated with women practicing geophagia in Qwaqwa, South Africa(University of the Free State, 2013-12) van Onselen, Annette; Walsh, C. M.; Brand, C. E.; Veldman, F. J.English: Geophagia is the most common type of pica, characterized by the urge to consume clay or soil. QwaQwa houses a very dense black African population and covers 254.2 km2. This rural area with the largest concentration of Basotho's in South Africa is characterized by a strong focus on traditional beliefs and practices, making it a favourable area to investigate the phenomenon of geophagia. The main aim of this study was to determine the nutritional status and risk factors associated with women practicing geophagia in QwaQwa, South Africa. Socio-demographic factors, dietary intake, anthropometry, physical activity and blood measures were investigated at baseline. After the intervention, the impact of the nutrition education on knowledge and habits related to geophagia were determined. The study design comprised of an observational epidemiological study which included an exposed (geophagia) and non-exposed (control) group followed by an intervention phase. An assessment of the impact of the intervention was also conducted. A logistical regression analysis was performed in order to identify factors that were likely to be associated with the practice of geophagia. At baseline, the sample consisted of 69 participants, of whom 42 were in the geophagic group (G) and 27 in the control group (C). The majority of participants in both groups (G=77.5%; C=70.4%)were unmarried. Sotho was spoken by more than 90% of participants. A large percentage of participants in both groups had an education level of grade 11 - 12 (G = 42.9% and C = 51.9%) and were unemployed (G = 90.48% and C = 74.1%). Electricity was used by both groups as the main source of energy for cooking (G = 83.3% and C = 85.2%), followed by paraffin (G = 11.9% and C = 7.4%). The primary employment status of the group with geophagia was part-time or piece jobs (54.8%), while in the control group a full-time wage earner was present in 48.15% of households. The logistic regression showed that women who were wage earners and those that owned a refrigerator (and thus had a higher socio-economic status), were less likely to practice geophagia. A food frequency questionnaire was implemented to determine dietary intakes of participants. The mean total energy intake for the group with geophagia and the control group were similar at 10324.31 ± 2755.00 kJ and 10763.94 ± 2556.30 kJ respectively, which was considered high. The macronutrient distribution was within the recommended levels. Mean total protein intake was also similar in both groups (G = 75.59 ± 20.12 g; C = 85.55 ± 29.07 g) at 12.5% (G group) and 13.6% (C group) of total energy intake. The percentage total energy intake from fat was 33.1% for the geophagia group and 31.5% for the control group. Both groups had intakes that were higher than the estimated average requirement (EAR) for dietary iron (G = 11.60 mg; C = 13.49 mg). The intake of nutrients that may be related to iron metabolism, are vitamin A, vitamin C and folate. Standardized techniques were used to determine anthropometric measurements namely body mass index (BMI), waist circumference, and hip circumference. The mean BMI of both groups of participants fell within the overweight category (G = 25.59 kg/m2; C = 25.14 kg/m2). The physical activity levels of participants were determined by recalling the physical activity of the previous day. Mean levels of physical activity fell in the low active category for both groups. Logistic regression indicated that women with a waist:hip ratio above 0.8 (android category) were less likely to practice geophagia. The mean serum iron levels of the geophagia group were significantly lower (p = 0.000) than that of the control group (G = 6.92 μmol/L; C = 13.75 μmol/L). There was also a significant difference in the serum haemoglobin (G = 11.23 g/L; C = 13.26 g/L; p = 0.00) and serum ferritin levels (G = 11.98 μg/L; C = 42.31 μg/L; p = 0.00) between the geophagia and control groups. Serum transferrin and serum transferrin saturation levels also differed significantly between groups (G = 3.21; 7.97 and C = 2.68; 7.78; p = 0.00). The logistic regression also established which of the measured blood variables were significantly affected by the practice of geophagia. A highly significant association between the practice of geophagia and the cluster of metabolic indicators of iron status, including serum iron, haem-iron, non-haem iron, haemoglobin, ferritin, transferrin, and transferrin saturation was identified. The majority (57.1%) of participants consumed soil once a day and 42.9% more than once a day. The craving for soil was reported by most of the participants as the reason that they practiced geophagia (97.6%) and a preference for whitish clay was also found. A number of habits related to geophagia changed after the intervention. In this study the nutrition education programme was effective in improving some aspects of a participant's knowledge and practices related to geophagia, while others remained unchanged. The intervention was successful in reducing the consumption of soil per day and almost forty per cent of participants in the group with geophagia stopped consuming soil after the intervention. Before the intervention, more than fifty per cent of participants did not know that pregnant women and children should not consume soil, while more than sixty per cent knew in the control group and all the partiipants in the geophagia group after the intervention. Geophagia was confirmed to be a risk factor for iron deficiency in black women between 18 and 45 years of age. Factors that were identified as decreasing the likelihood of having geophagia included being a wage earner, owning a refrigerator, having a greater WHR (waist-to-hip ratio) and not having iron deficiency. The significantly strong association between geophagia and iron deficiency emphasizes the importance of identifying the practice of geophagia in women, especially during their child bearing years. The intervention that was developed for this study could be applied in a wider setting to address the problem of geophagia and its harmful effects on health.