Masters Degrees (Nutrition and Dietetics)

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Open Access
Feeding practices of mothers with children attending early childhood development centres in the Xhariep District
(University of the Free State, 2021-11) Carson-Porter, Angelique Celeste; Van den Berg, V. L.; Meko, N. L.
Background and motivation: The nutritional status and health of under five year olds are considered indicators of social progress, development and access to resources within communities. In developing countries, undernutrition is a major contributing factor to children failing to achieve their developmental potential. The prevention of malnutrition requires, among others, safe, nutritious, and diverse foods in early childhood. Young children become vulnerable to malnutrition when complementary foods are introduced, and breastfeeding is discontinued. The 2016 South African Demographic and Health Survey reported that 27% of children younger than five years were stunted. Complementary feeding practices are, therefore, a priority matter that needs to be addressed in South Africa. The Assuring Health For All in the Free State (AHA-FS) study in 2007 already identified malnutrition in the Xhariep District. Also, while rendering health services during community-based education and interprofessional training to the communities in the Xhariep District, the Department of Nutrition and Dietetics of the University of the Free State identified that mothers face many barriers to feeding their young children an appropriate diet. Therefore, this study aimed to explore the perspectives of mothers of children who attend ECD centres in the Xhariep District to gain a nuanced understanding of the driving factors of malnutrition in the area. Methods: This was a qualitative, exploratory study in which the researcher had a constructive paradigm. Twelve participants who met the inclusion criteria were conveniently sampled. Semi-structured interviews were used to determine the mothers' choices and motivation for foods they fed their children until data saturation was reached. The interviews were audio-recorded after informed consent was obtained. Content analysis was used to analyse the data and identify themes, while descriptive statistics described the participants. Results: The participants had a median age of 31 years (IQR: 26.8-41.8; range: 20-71 years), with 1-3 children in their care. Five of the participants finished grade 11 or 12, while six only had some primary school education, and one never went to school. Nine of the participants relied on social grants as a source of income, 11 were unemployed, and only two had a spouse or partner who was employed. The following themes were identified from the interviews: infant and young child feeding practices, social support for child feeding practices, financial restraints to feeding practices, concern for the nutrition wellbeing of the children and household amenities. The participants mostly fed their children cooked maize meal porridge (pap), milk, cordial mixed with water, and vegetables and meat were mostly fed only once a week. When the participants had no meat, they fed the children pap with oil. Fruits were fed to the children only at the beginning of the month and were considered as treats. All the participants reported that they skipped meals so that their young children could have food to eat. Other coping strategies included borrowing money, mostly from loan sharks, and using store credit to purchase electricity and food when they had none. However, these practices, in turn, were detrimental to the overall available household funds because of the interest incurred. The availability of water, and the amount of money spent on electricity, also influenced food choices. The participants reported that they did not have vegetable gardens because they lacked seeds, space, and water. Participants reported that they had received nutrition advice from neighbours, nearby grandmothers, and the staff at their local clinics. They reported that they tend to implement the advice from grandmothers and neighbours because they had raised children before. However, they did not always implement the advice from the clinic staff due to lack of access to the foods they recommended. Conclusion and recommendations: The participants experienced similar challenges that contributed to household food insecurity. The main challenge identified was the lack of employment opportunities in their communities. In conclusion, the effects of unemployment and the level of education of mothers should be acknowledged when policymakers recommend feeding practices for young children. The staff at the local clinics were unaware of the mothers' lived experiences, so the nutritional advice was not adapted to the circumstances of the mothers. Although the mothers received support from the government through social care grants, they still experienced frequent periods of insufficient funds to purchase food and electricity for their households. Thus, it would be worthwhile to teach recipients of social grants to budget their money and thus discourage the use of loan sharks and store credit as coping strategies. Furthermore, empowering women to generate an income through communal agricultural practices, cooking, and sewing skills could help improve their food access.
Open Access
Food: environment, security and experiences of students at the University of the Free State
(University of the Free State, 2021-11) Mabena, Rebecca Nokuthula; Robb, Liska; Van Den Berg, Louise
Background and motivation: The high influx of students from lower socio-economic backgrounds attending universities and their struggle with acquiring nutritious food have been cited as barriers to students' higher learning. Numerous studies show that students are food insecure compared to the overall population. Many student initiatives to curb hunger among students in South African Higher Education Institutions are under pressure owing to the increasing need for food assistance. This study aimed to explore how students experience the concept of 'feeding themselves’ within their current food environments on and off-campus and whether these experiences are associated with food insecurity. These insights may help address students' well-being, which is vital for academic success. Method: A quantitative cross-sectional study was conducted. A self-administered electronic survey was made available via Evasys in early May 2020 to all 42 282 registered students at the University of the Free State (UFS). The framework developed by Turner et al. (2018) was used to create questions related to the personal domain of the food environment that students were exposed to while studying at the UFS, which entails four separate constructs, namely accessibility, affordability, convenience and desirability of food. The United States Department of Agriculture (USDA) 10-item tool included in the questionnaire to assess students' prevalence and severity of food insecurity at the UFS during the reference period as described above. Descriptive statistics were expressed as frequencies and percentages for categorical data, and medians and interquartile ranges for numerical data. Associations were investigated by crosstabulation and chi-square, Fisher's exact and Wilcoxon rank tests as applicable. Results: A total of 1 387 participants provided consent and participated in the study. Most students (80.9%) were single, and approximately half were first-generation students (54.1%). According to institutional statistics, 68.2% of participants received National Student Financial Aid Scheme (NSFAS) to fund their studies. The majority of participants (79.2%) indicated receiving a stipend for food and living expenses. Overall, 8% and 17.1% of participants were classified as having high and marginal food security levels, respectively; and together, these participants were classified as food secure (25.1%). Conversely, 23.4% and 51.5% of participants were classified as having low and very low food security, respectively, and these two categories combined constituted the food insecure students (74.8%). Black, African males and first-generation students, had the highest percentages of food insecurity. Food insecurity was significantly (p<.05) associated with gender (p<.0001), race (p<.0001), relationship status (p=.001), level of study (p=.0002), campus (p<0.0001), faculty (p<.0001), and family history of graduates (p<.0001). Students who received NSFAS were significantly more likely to be food insecure than those who did not. Price, convenience and familiarity of food were identified as the most important factors in guiding food purchases, significantly more so for the most insecure students (p<.0001). Almost three-quarters of participants (70.1%) reported buying ready-to-eat food from street vendors and these students were significantly more likely to do so compared to food insecure students (p<.0001). Less than half of the participants (40.7%) ate breakfast before class. Students classified as very food insecure were least likely to eat breakfast (p<0001). The most food insecure students relied fully on public transport for shopping and indicated that food was expensive, and that shopping was very time consuming when they would rather study. Most indicated that they go shopping for groceries and ingredients only once (59.3%) or twice (18.0%) per month. A quarter (24.5%) carried their shopping home over fairly long distances on foot, while another 31.2% paid for private cabs or shuttle services. The most food-insecure participants were more likely to buy their food from street vendors and Shoprite (p<.0001). Students were reluctant to pool resources for buying and preparing meals in groups, mostly because of not being able to contribute equally. Most participants, particularly the very food insecure students, kept their groceries and produce in their bedroom cupboards and most only had access to very limited fridge and freezer space, if at all. Access to cooking facilities and utensils, as well as lack of confidence in their own cooking skills, and lack of skills to budget and plan ahead for food shopping, emerged as themes that contributed to food insecurity. Conclusion: The study showed that students face numerous obstacles to obtaining food during the academic term. Cross-tabulation of students' food security with food environment factors revealed that students with very low food security were statistically significantly (p<.05) disadvantaged on multiple counts when compared to their food secure peers. It may be driving vulnerable students further down the food insecurity continuum towards hunger by not paying attention to their campus food surroundings, which may significantly impact their physical and mental health and academic progress.
Open Access
Perceptions and experiences of women in Benoni regarding weight loss strategies
(University of the Free State, 2021-11) Cox, Johannita; Du Toit, Elmine; Van Den Berg, Louise; Nel, R.
Obesity is a worldwide disease reaching epidemic proportions and is characterised by abnormal or extreme fat accumulation, affecting all socio-economic groups in both advanced and developing countries irrespective of sex, culture, or age. More women compared to men are overweight in South Africa. With the high percentage of overweight and obesity in South Africa and given the social pressures on women in the media and among their peers to be thin (particularly in certain demographic areas), it might be expected that women would seek help from available weight-loss diets, programmes, strategies, and applications. In response, the weight-loss market has exploded. To date, very little is known regarding South African women’s opinions of and involvement with weight loss programmes and diets. Hence, a cross-sectional survey was conducted to evaluate: The perceptions and experiences of women 18 years and older on weight-loss strategies and how they were perceived by women residing in Benoni, a city close to Johannesburg, South Africa. An electronic self-reported survey, created with Evasys Software®, was shared via the local community newspaper and online social media platforms. Descriptive statistics were calculated, and associations were investigated by crosstabulation and using chi-square, Fisher's exact, and Wilcoxon rank tests as applicable. For the purpose of this study, programmes and different diets known to South African women were categorised and incorporated into the following seven categories: (i) commercial weight-loss diet plans; (ii) commercial weight-loss aids; (iii) commercial coaching methods; (iv) self-imposed dietary restrictions and adapted eating patterns; (v) diets prescribed by a health professional; (vi) diets prescribed by non-health professionals, and (vii) other, including mobile weight loss apps. A total of 272 participants completed the survey. Almost half of the participants fell in the age group between 40 to 60 years (48.2%), 71.7% held a tertiary qualification, 50.3% earned between R19 601.00-R38 200.00 per month, 75.8% were married or in a permanent relationship, and 88.2% were White. Most participants (71.7%) did not smoke, but smokers reported smoking and eating less when stressed. Most participants (76.9%) were overweight or obese, with low activity levels (52.6%), drank less than eight glasses of water per day (86.9%), and rated their health as good (71.2%). Participants reported having followed up to 10 diets in the last three years. A total of 619 diets, strategies, or applications were used across the different categories. The main motivation for following one of these was reported as weight loss. Across the different categories, self-imposed dietary restrictions/adapted eating patterns were used by the highest percentage (54.0%) of participants. Participants provided the following information for each reported strategy that they had followed: the reason(s) for discontinuing the diet plan, whether it was easy or hard to follow, and why it was too difficult, as well as challenges, level of frustration and hunger experienced while using the strategy. Among all the strategies followed, the highest percentage for objective obtained was reported for intermittent fasting. The highest percentage for no challenges experienced was reported for using a mobile weight-loss application, and the highest percentage of no frustration or hunger experienced, while using a strategy for an approach prescribed by a personal trainer. Only 31 out of the 619 strategies followed (chosen by 11.4% of participants) were prescribed by a healthcare professional, with half of these prescribed by dietitians. Dietitians need to position themselves as the preferred choice when spending money on weight loss. Future research needs to focus on exploring the reasons for the poor uptake of weight loss strategies by health professionals and dietitians compared to the other strategies. The insights provided by the current study regarding the weight loss strategies South African women choose and their experiences with these strategies may assist dietitians and other healthcare professionals to design and choose approaches that may lead to improved adherence to following a diet and long-term weight loss.
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
South African dietitians’ practices and perceptions regarding food exchange lists, as part of the food exchange system, in the nutrition care process
(University of the Free State, 2020-11) Brand, Desire Michelle; Robb, L.; Du Toit, E.
The nutrition care process (NCP) is a standardised method to apply nutritional therapy, followed by dietitians to promote evidence-based practice. While various tools can be used by dietitians as part of the NCP, the decision to use a certain tool is based on relevance, convenience, and trustworthiness. As food exchange lists (FELs) can be used in multiple phases of the NCP, and in light of the significance of targeted nutrition therapy and the appropriate use of tools on the nutritional outcome, it is essential to describe dietitians’ practices and perceptions regarding the use of FELs as part of the NCP. Particularly, as limited literature is available on the use of FELs by dietitians in practice, especially in South Africa, where population specific FELs are lacking. This cross-sectional survey aimed to determine South African dietitians’ practices and perceptions regarding the use of FELs as part of the NCP. All dietitians and community service dietitians residing in South Africa who were registered at the Health Professions Council of South Africa (HPCSA), were eligible to participate in this study. Dietitians’ socio-demographic information and practices and perceptions regarding the use of FELs within the NCP were determined using an online survey, created with Evasys Software®. The link to the survey was shared through e-mail newsletters to Association for Dietitians in South Africa (ADSA) members and on Dietetics-Nutrition is a Profession (DIP) and Dietetic Services Facebook pages. The survey was open for completion for a duration of two months, from February to April 2020. Dietitians in the current study were mainly female (96.2%; n = 126), with the greater proportion of dietitians being between 25-30 years of age (42.8%; n = 56), speaking Afrikaans (53.4%; n = 70) or English (50.4%; n = 66) as a home language, practising for one to four years post community service (34.4%; n = 43), based in Gauteng (29.8%; n = 39), and employed in private settings (53.4%; n = 70). Dietitians in South Africa are using FELs for different purposes in the nutritional management of various population groups, throughout all phases of the NCP, although 67.7% of dietitians applied FELs in dietary counselling and 92.1% in meal planning as part of the NCP. More dietitians employed in private settings used FELs (86.3%) compared to government (55.3%) or tertiary education/ research/ pharmaceutical sectors (64.7%). This significant association may partly be ascribed to a greater proportion of dietitians who self-designed FELs in private settings (42.5%), which appeared to have been associated with dietitians’ perceived knowledge of FELs. Also, a significantly larger proportion of dietitians employed in government settings compared to private practices considered patients’ language (25.0%; 5.8%) and literacy level (92.9%; 67.3%) in the decision to provide patients with FELs. Overall, 78.7% of dietitians obtained FELs from universities and most FELs currently in use have been updated in the past five years. Even so, the greater proportion of dietitians (46.6%) reported the lack of South African specific foods as the main reason why FELs are due for an update. Dietitians acknowledged the importance of population-specific FELs with the majority (85.3%) advocating for FELs that are specific to various ethnic groups, mainly cultural (61.9%) and language groups, as well as different literacy levels (65.4%), mostly grade 8-9 level. While a smaller percentage (39.7%) indicated that FELs should be adapted for different religions, the majority (68.3%) reported that vegetarianism / veganism should be considered. Adapting FELs according to socio-economic status was not perceived as essential to most dietitians. Majority of dietitians recommended FELs should be adapted for different stages of the life cycle, especially given the lack of resources on portion sizes in paediatric patients. Given the convenience of use, dietitians reported using alternative tools to the FELs, but also supported the idea of an electronic FEL. Main concerns affecting the use of health applications, comprised dietitians’ doubts about accessibility, ease of use, trustworthiness and costs involved. The use of a comprehensive FEL that is relevant and evidence-based, which dietitians find convenient to use, may improve nutritional outcomes in dietetic practices and promote the dietetics profession.
Open Access
Knowledge, attitudes and practices of healthcare workers related to breastfeeding in the Motheo District, Free State
(University of the Free State, 2020-11) Hennop, Imke; Walsh, C. M.
Breastfeeding is widely recognised as the ideal method of infant feeding. Despite this, the percentage of South African mothers that breastfeed (especially exclusively for the first six months of life) remains alarmingly low. Healthcare workers (HCWs) play a key role in promoting, protecting and supporting breastfeeding. A lack of knowledge, negative attitudes and unfavourable practices of HCWs have a major impact on the protection, promotion and support of breastfeeding. Evidence-based recommendations for infants are continuously summarised by a number of organisations including the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF). The current study aimed to assess the breastfeeding knowledge, attitudes and practices (KAP) of HCWs whose responsibilities include supporting breastfeeding in the Motheo district, Free State. These findings were compared to the 2016 WHO and UNICEF guidelines on Infant and Young Child Feeding (IYCF) and 2018 Mother-Baby Friendly Initiative (MBFI) guidelines. A cross-sectional study design was applied in a total population of 117 HCWs, including paediatricians, obstetricians, general practitioners (GPs) and midwives working in the private and public healthcare sectors. Participants were registered with the Health Professions Council of South Africa (HPCSA) and South African Nursing Council (SANC). A self-developed questionnaire was used to obtain information related to sociodemographics (age, years practicing in current position, current place of employment and gender) and KAP related to breastfeeding. The questionnaire was selfadministered and available in paper and online format. The median age of participants was 34.0 years and the median years practicing in current profession was 7.0 years. The majority of GPs (85.9%) and midwives (82.1%) worked in public hospitals, while the majority of paediatricians (60%) and half of the obstetricians (50%) were in private practice. More than half of the participants were female (65.8%). In terms of knowledge related to breastfeeding, a significantly higher percentage of GPs (60.6%) than paediatricians (30%), obstetricians (25%), and midwives (50%) were able to list three benefits of breastfeeding for the baby (p=0.0180). Although the percentage of HCWs that could list three benefits of breastfeeding for the mother was low (26.7%), a higher percentage of GPs (33.8%) than paediatricians (20%), obstetricians (25%), and midwives (10.7%) were able to list three benefits of breastfeeding for the mother (p=0.0016). Almost ninety percent of HCWs (89.7%) knew that formula milk does not have the same nutrient composition as breast milk. Although the majority of the total group of HCWs (70%) knew that a breastfeed should not be time limited, a significantly higher percentage of obstetricians (100%) and midwives (82.1%) were aware of this compared to 40% of paediatricians and 66.2% of GPs (p=0.0015). Most HCWs (92.3%) knew that placing a baby in skinto-skin contact can contribute to the stabilisation of newborn blood glucose levels. Less than fifteen percent of the total group of HCWs (14.5%) were able to name at least one step of the MBFI 10 Steps to Successful Breastfeeding. In terms of knowledge pertaining to breastfeeding in the context of human immunodeficiency (HIV), only 6% of the total group of HCWs knew that breastfeeding is recommended for an HIV infected mother if the mother is from a lower socioeconomic background and does not meet the AFASS (Acceptable, Feasible, Affordable, Sustainable and Safe) criteria. Less than fifty percent (46.1%) of the total group of HCWs were aware of the newest 2017 WHO guideline pertaining to HIV and continued breastfeeding up to two years and beyond while being fully supported for antiretroviral therapy (ART) adherence. The majority of GPs (76.1%) and midwives (78.6%) recommend exclusive breastfeeding up to the age 6 months, compared to only 10% of paediatricians and 25% of obstetricians, who recommend exclusive breastfeeding for 4 - 6 months. Fewer than 30% of the total group of HCWs (28.3%) recommended continued breastfeeding together with complementary feeding up to 24 months and beyond.Half of the obstetricians and more than half of paediatricians (60%) en courage mothers to initiate breastfeeding within one hour after birth, compared to the majority of GPs (64.8%) and midwives (71.4%) who encourage mothers to initiate breastfeeding within half an hour after birth, a difference that was statistically significant (p=0.0137). If a mother and baby are separated after birth due to an inadvertent situation and the mother is still able to express enough breast milk, 60% of paediatricians and 50% of obstetricians would recommend using formula milk with a cup, compared to 80.3% GPs and 89.3% midwives who recommend breastmilk with a cup as feeding method (p<0001). Less than half the paediatricians (40%) and obstetricians (37.5%) recommended rooming in for 24 hours a day, compared to the majority of GPs (80.3%) and midwives (78.6%) (p=0.0152). If a baby did not regain birth weight before 2 weeks of age and the medical examination results are normal, 60% of paediatricians would recommend supplementing with formula, the majority obstetricians (100%), GPs (60.6%) and midwives (78.6%) would recommend the mother to breastfeed more often and only a quarter of HCW (15.4%) would refer the mother to a lactation specialist (p=0.0096).In terms of attitude toward breastfeeding, a significantly higher percentage of midwives than other HCWs felt highly confident to successfully show a new mother how to correctly position and attach the baby to the breast for breastfeeding a nd to give her breastfeeding advice (p=0.0004 and p=0.0050 respectively). Fewer than half of paediatricians (41%), GPs (40.8%) and 50% of midwives felt highly confident to give mothers advice on how to treat breastfeeding complications e.g. mastitis, bleeding nipples, breast abscess, engorgement, nipple bleb and blocked duct. Fifty percent of paediatricians and 37.5% of obstetricians believed that there is no harm in using pacifiers and/or bottles, compared to the majority of 71.8% GPs and 85.7% midwives who would not recommend the use of bottles and pacifiers, a difference that was statistically significant (p=0.0007). In terms of practices related to breastfeeding, more than half of the total group of HCWs (56%) had not previously completed the 20 hour WHO Lactation Management Training. Seventy percent of the paediatricians, 100% obstetricians and 56.3% GPs felt that the breastfeeding training that they received during their studies was not adequate and did not equip them to support and educate breastfeeding mothers, compared to more than half of midwives (57.1%) that felt that their breastfeeding training was adequate (p=0.0481).In conclusion, in-depth knowledge pertaining to certain important aspects of breastfeeding were lacking in all HCWs. In addition, a large percentage of HCWs were not confident to support mothers to breastfeed and their practices did not comply with the 2016 WHO Infant and Young Child Feeding guidelines and with the 2018 MBFI 10 Steps to Successful Breastfeeding. In order to successfully promote, protect and support breastfeeding, the 20 hour WHO Lactation Management Training should be implemented universally and regularly to ensure that HCWs stay updated with the most recent IYCF guidelines and MBFI 10 Steps to Successful Breastfeeding.
Open Access
Refeeding syndrome characterised by hypophosphataemia in children 0 – 59 months diagnosed with severe acute malnutrition in a South African setting
(University of the Free State, 2020-11) Fourie, Natalie; Van den Berg, V. L.
Background and motivation: The World Health Organisation (WHO) uses the term severe acute malnutrition (SAM) to describe children under five years who are severely malnourished and present with severe wasting, classified by weight-forlength/height <-3 standard deviation (SD) according to the WHO growth standards or mid-upper arm circumference (MUAC) <11.5 cm, or bilateral pitting oedema. Children with complicated SAM require hospitalisation and urgent care including nutritional intervention. Too rapid introduction of nutrition can result in refeeding syndrome (RFS), a life-threatening complication with onset usually within five days of starting nutritional therapy. Yet, RFS remains underdiagnosed because a universally agreed definition does not exist, and many physicians are unaware of the syndrome. Moreover, current WHO guidelines for the dietary treatment of SAM, and published guidelines for the prevention of RFS in the clinical setting, are incongruent. Very few studies to date have investigated the incidence of RFS in SAM, particularly in relation to a high prevalence of human immune deficiency virus (HIV). This study, therefore, aimed to identify the incidence of RFS, as well as factors that may be associated with the onset of RFS, among children with SAM in a South African public health setting. Methods: A retrospective analytical cohort study of children aged 0 – 59 months admitted with SAM to Rahima Moosa Mother and Child Hospital, Johannesburg, from 1 October 2014 to 31 December 2018, was conducted. Among the hospital files that could be retrieved from the archives, the diagnosis of SAM according to the WHO definition was confirmed for 126 files. In these participants, the occurrence of RFS, as characterised by a drop in blood phosphate levels by >0.16 mmol/L to a level <0.65 mmol/L, was noted. Biochemical and clinical features on admission, as well as dietary intake, were compared between participants who developed RFS and those who did not, using Fisher’s exact, Chi-square or Kruskal-Wallis tests as appropriate. P-values <0.05 were considered statistically significant. Results: The incidence of RFS in the sample (63% male; median age: 34 months) was 8.7% (n=11) of whom 18.2% died. The development of RFS was statistically significantly associated with hypophosphataemia, hypokalaemia, hyponatraemia, dehydration, international normalised ratio (INR) >1.7, and urinary tract infection (UTI) on-admission, and longer length of hospitalisation, but not with being HIV positive. HIV-exposure was, however, borderline statistically significant and diarrhoea had a trend towards significance on admission in participants who later developed RFS. Findings on protein and energy intakes were inconclusive as the grade of oedema, which influences the dietary requirements, was not recorded consistently in the hospital files. Most participants developed RFS after day five of hospitalisation, which is inconsistent with the usual timing of the development of RFS. Most participants were receiving F-75 substitutes (standard, soy or extensively hydrolysed infant formula with or without additional modular supplementation) during the initial phase of dietary treatment, thus high protein intake in oedematous participants may have contributed to the development of RFS in this study. Conclusions and recommendations: This study confirms the occurrence of RFS in patients with SAM and identifies several biochemical and clinical features present on admission that may aid in the identification of high-risk patients. This information may assist in the revision and standardisation of feeding protocols. Further investigation into risk factors which might predispose a child with SAM to develop RFS may help in reducing the incidence of RFS and the concurrent risk of death that it poses and, therefore, assist with the WHO’s goal to reduce the mortality of children under the age of five. Physicians, nurses and dietitians should be educated on RFS in order to diagnose and treat patients with SAM more effectively. The study highlights the importance of identifying and recording the grades of oedema in children with complicated SAM, which is vital for prescribing the correct dietary requirements. It also highlights the need for dietitians and other healthcare professionals to follow the WHO guidelines for the treatment of SAM, and use F-75 substitutes with great caution as their protein content is higher and their micronutrient composition is lower compared to F-75.
Open Access
Knowledge, attitudes and practices of primary caregivers of foundation phase learners in Bloemfontein regarding breakfast and lunchboxes
(University of the Free State, 2019) Hansen, Thelma; Lategan-Potgieter, R.; Du Toit, E.
Healthy breakfasts and school lunchboxes contribute to optimal nutrition during the school day and also influences the development of healthy eating habits in children over the long term. Caregivers are the most important role players in the food intake of their child, as they decide what the children in their care eat through food procurement and the meals they prepare. Children are also dependent on their caregiver to learn about healthy food practices from them. It is therefore important to determine whether caregivers are informed about healthy eating and practices and whether they have a positive or negative attitude towards providing healthy food to the children in their care. The aim of this study was to examine caregivers’ knowledge, attitudes and practices regarding healthy breakfasts and school lunchboxes and to determine whether the attitudes of the caregivers reflected in their practices regarding the provision of breakfast and lunchbox foods. The knowledge, attitudes and practices of the caregivers were also compared to socio-demographic variables to determine aspects that may affect the practices of caregivers. A cross-sectional, descriptive study was conducted, using in a sample of 1286 caregivers of foundation phase learners (aged 6 – 12 years) attending independent and public Quintile 5 primary schools in Bloemfontein, South Africa. Data on knowledge, attitudes and practices regarding breakfast and lunchbox provision were collected through printed questionnaires and caregivers had to be willing to complete the questionnaire in English. The median breakfast knowledge score of caregivers was 55.6% and median lunchbox knowledge score 73.1%. Breakfast and lunchbox food knowledge were higher for caregivers older than 35 years (median=55.6, P=0.0479 and median=76.9, P<0.0001 respectively) and those who possessed a tertiary qualification (median=55.6, P=0.0009 and median=76.9, P<0.0001 respectively), than for caregivers younger than 35 years and those without a tertiary qualification. The attitudes of caregivers were generally positive towards providing healthy breakfast and lunchbox foods to the children in their care (median=71.4% and 82.5% respectively), except for caregivers with an income of less than R20 000/month that had a lower attitude score towards providing lunchboxes (P=0.0086). Caregivers with a higher income provided a daily breakfast more often (P=0.0014) than caregivers with a lower income. Higher income caregivers however ate breakfast together with children less often (P=0.0296). Caregivers with a higher qualification also provided children more often with a daily breakfast (P=0.0011) than those with lower qualifications; and provided children with fruit (P<0.0001) and vegetables (P=0.0027) in the lunchbox more often than those with a secondary qualification. In contrast, caregivers with a lower income provided tuck shop money (P<0.0001) and fast foods (P=0.0006) more often than those with a higher income and were less positive towards healthy eating habits (P=0.0089). Caregivers with a higher income and those living with a life partner perceived healthy food to be more expensive than less healthy food (P=0.0003 and P=0.0045 respectively) and that lunchbox preparation results in an extra workload (P=0.0027 and P=0.003 respectively). Caregivers’ primary objective when providing a lunchbox was health considerations (54.2%, n=658) followed by to be filling (22.8%, n=277). The average practices score for the provision of healthy breakfast foods was 26.7% and for lunchbox foods 35.6%. Even though the practice scores were low, healthier breakfast (P=0.0013) and lunchbox foods (P=0.0001) were provided to children with caregivers that had a tertiary qualification. Overall, caregivers had a positive attitude towards providing children in their care with healthy breakfast and lunchbox foods. Unfortunately, differences still exist between the nutritional knowledge of caregivers older than 35 years and those with a tertiary qualification and younger caregivers and those with a lower qualification and the food they provide to their children. Caregivers with a higher level of nutritional knowledge tended to provide the children in their care with healthier breakfast and lunchbox foods. Therefore, the focus should be on the improvement of the nutritional knowledge of primary caregivers.
Open Access
Measured height and height estimated from body segments in hospitalised adults in Bloemfontein, South Africa
(University of the Free State, 2019-06) Williamson, Hanna Eugenie; Van den Berg, V. L.; Walsh, C. M.
Background and motivation: Accurate height measurement is essential in the assessment of the hospitalised patient, amongst others, to screen for malnutrition or risk of malnutrition, which negatively affects morbidity and mortality. Height is also used to calculate nutrition requirements, adjust drug dosages and predict lung volumes, muscle strength and glomerular filtration rate. The gold standard is measuring standing height with a stadiometer using a standardised technique. In the hospital setting, however, patients often cannot stand up straight and unassisted for accurate height measurements according to the standardised technique. Globally, several equations predicting height have been standardised on various populations; none have been developed specifically for the general or hospitalised South African population. Methods: This study investigated the agreement and association between directly measured (reference) height, and self-reported height, height recorded on admission in the medical files, recumbent length, and height estimated by indirect methods based on body segment measurements (, demi-span, ulna length, knee height, tibia length, fibula length, and foot length) in three public hospitals in Bloemfontein, South Africa. Bland–Altman analysis was used to assess the 95% limits of agreement between the height predicted from published estimate equations and reference height. Spearman correlations and multiple regression analysis were used to identify the body segment that best predicted height in this population. Results: Less than 5% of 141 participants (61.7% male; median age 38.8 years [interquartile range: 10.1 years] could self-report their height, and, although stadiometers were available in all the wards, only 16% had height recorded in their medical files. Healthcare practitioners, thus, did not seem to consider the measuring and recording of height as a priority. Eleven published equations developed for adults <65 years (and standardised for gender), based on various upper and lower body segments, were tested. Only a set of equations standardised for males and females, and black and white ethnicities, by Chumlea et al. (1994) on 5415 healthy adults <60 years in the United States, yielded predicted heights that did not significantly differ from the reference height measured in this study (95% CI; -0.9; 0.2) (95% limits of agreement indicating that, in 95% of cases, height was underestimated by 5.8 cm to overestimated by 7.2cm). Knee height also correlated the strongest with height in both genders (males: R2:0.77; females R2:0.86; p<0.0001) and was identified by multiple regression analysis as the best predictor of reference height. Foot length and ulna length showed the weakest correlation with reference height and performed weakest in the regression analysis. Recumbent height, measured strictly according to the standardised technique, differed significantly from reference height, but yielded 95% limits of agreement indicating that, in 95% of cases, the recumbent length only underestimated height by 4.0 cm to overestimated height by 1.3 cm. Conclusions: Clinical studies commonly suggest that body segment-based equations for predicting height, need to be standardised for each population, and suggested ethnic differences as the reason. The findings of this study, however, support evidence from forensic science, anthropology and growth studies that environmental stresses, including disease load and dietary niche, influence the development and growth of the various long bones in ways that affect the body proportions. This developmental plasticity differs across different body segments, causing lower limb length to show a greater proportionality to height. Relative leg growth is accelerated during the early years of life; thus, stunting seems to have a more pronounced effect on the length of the lower leg long bones. Thus, the high prevalence of stunting among South Africans may explain why knee height, outperformed upper body measurements in this population of patients admitted to public hospitals in a South African city. Recommendations: Health care practitioners should be educated on the importance of accurately measuring height, especially as an integral part of screening for malnutrition or those at risk of malnutrition. More extensive studies across different South African populations are needed to confirm the findings, better the current understanding of the effects of environmental stressors on body proportion, and to develop accurate height- prediction equations that may be used in South African populations. Stunting in South Africa should also be addressed.
Open Access
Feeding practices of mothers with infants and children attending preschools in a high socioeconomic area in Johannesburg
(University of the Free State, 2019-04) Rust, Annica Madeleen; Meko, Lucia
Breastfeeding is the preferred feeding method, as it is not only nutritionally complete for the first four to six months but will also provide immunological, psychological, physiological, and developmental benefits for the infant. In recognition of the benefits of breastfeeding, the World Health Assembly has set a target of 50% for all infants to be breastfed exclusively from birth up to six months. Despite the well-known benefits of exclusive breastfeeding (EBF), the exclusive breastfeeding rate at six months was 32% in South Africa (ZA) in 2016. The EBF rates mentioned above, published by the South African Department of Health, are said to be representative of the country, but do not distinguish between feeding practices of mothers of different socioeconomic levels. The aim of this study was to determine breastfeeding practices and associations between breastfeeding practices and demographics of mothers in a high socioeconomic area in Johannesburg. To achieve the aim, the following factors were assessed: mother and infant/child’s socio-demographic information, mothers’ feeding practices, and factors affecting feeding practices. The majority of mothers were younger than 35 years of age (58.9%), were married or cohabiting (83.5%), and had an education level higher than Grade 12 (88.8%). Although most of the mothers initiated breastfeeding at birth (n=102, 94%); however, the duration of EBF was short. Thirty-four mothers (31.3%) breastfed their infants at four months, and 64 mothers (58.7%) breastfed their infants at six months. Only two mothers (1.8%) exclusively breastfed their infants at six months. A statistically significant difference was not found between breastfeeding duration at six months and the mothers’ age (p=1.0000), highest level of education (p=1.0000), gross household income (p=0.3368), marital status (p=0.2825), and type of delivery (p=1.0000). In an effort to guide researchers in describing factors affecting breastfeeding practices, Hector and co-workers developed a conceptual framework of factors affecting breastfeeding practices. They categorised these factors as individual-level, group-level and society-level factors. The most common factor (on group level) why mothers with a high socioeconomic status in this study decided not to breastfeed was that formula milk was more convenient when working and less time consuming (63%). The misperception of insufficient milk supply was a common individual-level factor (37%) why mothers in this study decided not to breastfeed. The most common society-level factor why mothers did not breastfeed was that it was culturally unacceptable to breastfeed in public or in front of others (29%). The majority of mothers (60.4%) based their choice of formula on the advice of paediatricians. The most common property that influenced the choice of infant formula used by mothers was the brand name of the infant formula (42.5%). It is evident that advertising of infant formula did not significantly affect mothers’ decisions of formula to use. Rather, 17.6% of mothers indicated that their own research on infant formula influenced their decision of which formula to use. This study supports the literature published that the feeding practices of mothers with different demographics differ from one another. To compare feeding practices among different demographic statuses best, it is recommended that a validated screening tool be developed. Future research should investigate the options to make breastfeeding more convenient and implement interventions for modifiable factors such as breastfeeding intention, social support (including work environment), and expression of breast milk confidently. More research should be conducted on the infant formula information given on websites to determine if manufacturers comply with Article 4.1 of the World Health Organization (WHO) International Code of Marketing of Breast Milk Substitutes.
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
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
Effects of a low-insulin-response, energy-restricted diet on weight loss and endocrinological parameter in obese, anovulatory women in their reproductive years
(University of the Free State, 2002-12) Lusardi, Liz-Mare; Slabber, M.; Meyer, G. M.
There is consistent evidence that obese women are less fertile than women of normal body weight. Obesity, in particular android obesity, is associated with several sex steroid abnormalities in premenopausal women including: increased free estrogen and androgen fractions, reduced sex hormone-binding globulin and increased bioactive estrogen delivery to target tissue. The state of insulin resistance with secondary hyperinsulinemia is commonly observed in obese, infertile women whereas the gonadotrophic effects of insulin on ovarian steroid hormone synthesis have been indicated in vivo and in vitro. Insulin can directly and indirectly stimulate ovarian androgen production. The exaggerated insulin action on ovarian tissues may present the pathological mechanism for disturbances in the endocrine profile and menstrual cycle and infertility in some obese women. Due to certain limitations we did not diagnose anovulation whereas only a certain percentage of the subjects in each group were hyperinsulinemic. One of the problems experienced was the drop outs in each group. Weight loss is associated with a significant improvement in menstrual abnormalities, ovulation and fertility rates with a reduction in hyperandrogenism and hyperinsulinemia. It is suggested that weight loss should be the first option in the treatment of overweight infertile women. Intervention studies suggest that reducing weight and/or hyperinsulinemia either by diet alone or a combination of diet and drug therapy should be investigated. This study was undertaken to evaluate the effects of a low-insulin-response, energyrestricted diet (LID) on anthropometric and endocrinological parameters in obese women with menstrual abnormalities. For the purpose of this study we compared the effects LID to a normal balanced-energy restricted diet. The principles for the LID were based on the available literature regarding the insulin response to foods and their combinat ions. At baseline 37 candidates were randomly assigned into two groups. Group A followed the LID and consisted of 19 candidates whereas Group B followed the NO and consisted of 18 subjects. The inclusion criteria were: obese (BMI > 30kg/m2), premonopausal, insulin resistance, anovulation and between the ages of 18 and 04 years of age whereas the exclusion criteria included increased fasting and stimulated glucose concentrations, cigarette-smokers, and the presence of any chronic medical condition. Subject fasted for a 10 to 12 hour period after following a 250 g carbohydrate diet for three-days prior to baseline blood sampling. Blood samples were collected at baseline and at the end of the 16-week trial and analyzed for fasting insulin and glucose, testosterone (T), luteinizing hormone (LH), follicle stimulating hormone (FSH), estrogen (E), prolactin, thyroid stimulating hormone (TSH), thyroxine (FT4), leptin and progesterone. Insulin resistance were defined as a glucose-to-insulin ratio < 4.5. Stimulated 30 and 120-minute insulin and glucose were collected after subjects consumed 82.5g of monohydrate glucose powder diluted in 300ml water. Due to certain limitations we did not diagnose anovulation whereas only a certain percentage of the subjects in each group were hyperinsulinemic. One of the problems experienced was the drop outs in each group. Results form this trial indicated a significant reduction in fasting and JO-minute stimulated insulin, LH, and testosterone and leptin concentrations in the NO group whereas only leptin concentrations reduced significantly in the LID group. A significant reduction occurred in mean weight, BMI, body fat percentage, waist and hip circumference in both groups. Numerous studies evaluated the effects of weight loss on fertility but to our knowledge this is the first trial of its kind to evaluate the effects of two different test diets on fertility parameters. Results from this trial confirm the positive effects of weight loss on endocrinological and anthropometric parameters in obese women, however, the LID showed no beneficial effects over the NO. Future research is needed to evaluate the effect of diet manipulation on fertility parameters with specific regard to diet manipulation in combination with drug therapy. This trial, however, serves as a good pilot study for future research of this kind.
Open Access
The effect of a combination of short-chain fatty acids on glycometabolic control in men
(University of the Free State, 2002-12) Van Onselen, Annette; Dannhauser, A.; Veldman, F. J.
English: Dietary fibre has revealed benefits for health maintenance and disease prevention and as a component of medical nutrition therapy. Dietary fibre forms an important part of the Westemised diet, which is characterised by low-fat, low-carbohydrate and low-fibre intake. A high-fibre diet may favourably influence glycometabolic control. It is believed that short-chain fatty acids (SCF As) may partially be responsible for some of the beneficial effects of dietary fibre on metabolism. These SCFAs namely, acetate, propionate and butyrate arc the major products of colonic fibre fermentation. Some of the SCFAs have been shown to improve blood glucose and insulin levels. However, the effect of a combination of SCFAs on glycometabolic control is still unclear. The main aim of the study was to determine the effect of a combination of SCFAs (acetate: propionate: butyrate in the ratio of 70: 15: 15, respectively) and (acetate & propionate: in the ratio of 50:50, respectively) on glycometabolic control in men. The study was a randomised, placebo-controlled, double-blinded clinical trial. Voluntary subjects were recruited for this study using a very strict set of inclusion criteria. All subjects received a placebo for a period of one week following the collection of baseline blood samples and other information. A second baseline blood sample was collected from each individual at the end of this period to ensure accurate reflection of the variables and a stable baseline. Subjects were randomly assigned to three different intervention groups and consumed the different mixtures of either placebo, acetate-propionatebutyrate or acetate-propionate supplement for a period of four weeks following the second baseline blood collection. Supplementation of eight capsules daily was sustained for four weeks. Metabolic indicators (serum glucose, serum insulin, serum albumin, total protein, total cholesterol (TC), high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, non-esterified fatty acids (NEF A), anthropometric status and blood pressure were measured at baseline two (day 8) and after supplementation (day 36). A wash-out period of one week following the supplementation period measured any changes in the metabolic indicators (day 43). The usual dietary intake of the subjects was obtained using a food frequency questionnaire (FFQ) at baseline one (day 0) and after supplementation (day 36). Anthropometric status included body mass index (BMI) and waist-to-hip ratio (WHR), which were measured by means of standardised methods (on days 1, 8 and 36). The BMI and WHR fell within the normal range, and remained within the normal range during the study. This indicated that the subjects were apparently healthy. The study group was also of homogeneous nature, mainly as a result of the strict inclusion criteria applied at the time of recruitment of the subjects. The fasting serum glucose levels were within the higher normal range (5.1 - 5.7mmollL). No statistically significant changes were observed in any of the glycometabolic parameters following supplementation with the different SCFAs regimens (acetate, propionate and butyrate; acetate and propionate). Total cholesterol (TC) levels of the subject group as a whole fell within the normal range of the population (3.0 - 5.2mmollL). However, the observed levels fell in the higher normal range (4.1 - 4.8mmol/L). The HDL-C levels increased slightly in group three (acetate and propionate) and slightly decreased in group two (acetate, propionate and butyrate), however not significantly. The LDL-C significantly decreased in group two (acetate, propionate and butyrate). The observed decreased in systolic blood pressure were statistically significant after the intervention period in group two (acetate, propionate and butyrate). However, observed changes in LDL-C and systolic blood pressure were of no clinical importance. The FFQ indicated a tendency towards the adoption of an atherogenic Westenised diet. This study could not shown that a combination of short chain fatty acids have a beneficial effect on glycometabolic control. The findings of this study are supported by other studies, which indicate that acetate, propionate and butyrate do not improve glucose metabolism in healthy subjects. In contrast, other studies indicated a decrease in fasting serum glucose concentration from propionate (Todesco et aI., 1991) and acetate (Jenkins et aI., 1991) as well as from a combination of acetate, propionate and butyrate (De Wet, 1999). The controversial results regarding the effect of short chain fatty acids on glucose metabolism emphasize the importance of further investigation about the association between physical characteristics and formation of SCFAs, as well as the different combinations of SCFAs over a longer period of time.
Open Access
Evaluation of the iodine deficiency disorders control program in Lesotho
(University of the Free State, 2003-05) Sebotsa, Masekonyela Linono Damane; Dannhauser, A.; Jooste, P. L.
The broad range of disorders in a population caused by an inadequate dietary supply of iodine was denoted as iodine deficiency disorders (JDD), which include endemic goitre, hypothyroidism, cretinism and congenital anomalies. When iodine deficiency is widespread, mental retardation impedes national human resource development. Despite the known effective control measures, 130 WHO member states have a significant JDD problem. Severe to mild JDD have been reported in Lesotho since 1960. The most cost-effective and sustainable intervention to eliminate JDD is the iodisation of all edible salt. However, several countries with long standing salt iodisation programs have reported declining levels of urinary iodine. In Lesotho, the legislation on universal salt iodisation was promulgated in 2000. Therefore the aim of the study was to evaluate the salt iodisation program in Lesotho in terms of process, impact and sustainability indicators. A 30 cluster national survey was conducted where the proportion to population size method was administered. In each cluster, 30 women aged 15 to 30 years, and 30 primary school children aged 8 to 12 years, were randomly selected. The selected women and children were palpated and thyroid size graded according to WHOIUNICEFIICCJDD (2001) criteria and urine samples collected. 30 salt samples were collected from these selected women, 6 samples from 2 randomly selected retailers in each cluster, and 107 samples collected from all the commercial entry points in the country. The salt samples were analysed using the iodometric titration method while urine samples were analysed using the method using ammonium persulfate according to WHOIUNICEFIICCJDD (2001) recommendations. This analysis was performed at the Medical Research Council in Cape Town (South Africa) where the Coefficient of Variation for urinary iodine analysis was 7.7 at a concentration of IOug/l, and was 2.7 at a concentration of 70ppm for titration method of salt analysis. The statistical analysis was done using the SAS program at the University of the Free State (South Africa). A total of927 children and 930 women who were palpated, and 912 children and 924 women who gave urine samples, were included in the analysis of the results. 930 salt samples from household level, 186 from retail level and 107 from entry point level were analysed. 3 salt samples from entry point, 18 and 6 data sheets for urinary iodine of women and children respectively were not included during statistical analysis. The median iodine concentration of salt was 36.2ppm (ranging from 30.5-55.4ppm in the different entry points), 37.3ppm (ranging from 12.4-50.2ppm in the different districts) and 38.5ppm (ranging from 29.2-43.2ppm in the different districts) at entry point, retail level and household level respectively. At household level only 1.6 percent used non iodised salt and 86.9 percent used adequately iodised salt. The analysis of the urine samples showed that the median urinary excretion was 214.7flg/1 (ranging from 62.9flg/1 to 302.6flg/l in the different districts) for the children and 280.1flg/ (ranging from 124.8flg/1 to 381.6flg/l in the different districts) for the women, indicating more than adequate iodine intake according to the WHOIUNICEFIICCIDD (2001) report. The median iodine concentration was higher in boys (219.3flg/l) than in girls (212.6flg/I), higher in the Lowlands (256.0 flg/l in children and 329.9 ug/l in women) than in the Mountains (99.30flg/l for children and 182.6flg/1 in women) and higher in non-pregnant women (283.0 ug/l) than in pregnant women (212.1 ug/l). In the whole country, the prevalence of goitre was 10.7 percent (ranging from 6.6% to 22.6 % in the different district) in children and 19.4 percent (ranging from 6.7% to 36.7% in the different districts) in women, which indicates mild IDD (WHOIUNICEFIICCIDD, 2001). IDD were observed more in females (14.0%) than in males (7.0%) and was less (4.3%) in children aged 8 than in children aged 12 years (12.9%). In women IDD increased with age from the age group of 15 to 19 (17.3%) to the age group of 20 to 25 (22 %) and decreased in the age group of 26 to 30 (18.4%). Similar to urinary iodine results, IDD was observed more in the Mountains (17.7% for women and 18.1% for children) than in the Lowlands (14.3% for women and 6.7% for children). Only the urinary iodine excretion reached the WHOIUNICEFIICCIDD (2001) sustainability goals. At household level, 86.9 percent of the households, which is slightly lower than the recommendation of at least 90 percent, use adequately iodised salt. Out of 10 programmatic indicators of sustainability, only 4 indicators have been attained by the salt iodisation program in Lesotho. According to the WHOIUNICEFIICCIDD (2001) at least 8 of the programmatic indicators should be attained for sustainable elimination ofIDD. The study demonstrates a major achievement in the household use of iodised salt and adequately iodised salt. However, salt is not iodised according to the legislation on universal salt iodisation in Lesotho due to under iodisation and non- uniformity of salt iodisation at the production site. Iodine deficiency has been eliminated as a public health problem in Lesotho and this is due to the introduction of the legislation on universal salt iodisation. This study highlighted the effectiveness of iodised salt in increasing urinary iodine concentration. Iodine deficiency increased with age and was higher in girls than in boys, and higher in the Mountains than in the Lowlands. IDD elimination in Lesotho will be sustainable if more than 90 percent of the households use adequately iodised salt and the programmatic indicators such as commitment to reassessment, political commitment, implementation of social mobilization program and reqular monitoring are achieved by the IDD control task force. The administrative structure and activities of the IDD control task force need to be revised and strengthened for the sustainable elimination ofIDD. The terms of reference of the committee should be revised, budgets for the activities be drawn, new members added and trained and responsibilities given to each member. Awareness campaigns, which will start at policy makers' level, should be initiated. Law enforcement should be an integral part of the salt iodisation program. Effective regular monitoring of salt iodine content at all levels with special attention to iodisation of coarse salt is recommended together with periodic evaluation of the iodisation program.
Open Access
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
Nutritional status of patients with tuberculosis and TB/HIV co-infection at Standerton TB specialised hospital, Mpumalanga
(University of the Free State, 2017-06) Wessels, Janke; Walsh, C. M.
English: Tuberculosis (TB) is a leading cause of morbidity and mortality, especially in middle- and low-income countries. Globally, an estimated 2 billion people are infected with TB, of which 1 billion are malnourished. TB is strongly influenced by nutritional status, with nutrition interventions being likely to impact on prevalence of active disease, response to drug therapy and quality of life. The aim of this study was to determine the nutritional status of patients with TB and TB/HIV co-infection. A convenience sample of a 100 hospitalised patients in Standerton TB Specialised Hospital, Mpumalanga, were included (60 men and 40 women). Socio-economic status, nutritional status (focusing on eating related side effects, food security, anthropometric measurements, overall risk of malnutrition and biochemical parameters), and lifestyle behaviours (smoking habits and alcohol use), as well as associations between the above were determined. Food security was determined by means of the Community Childhood Hunger Identification Project (CCHIP) tool (that includes questions related to food insecurity, food shortages, perceived food insufficienty or altered food intake due to constraints on resources). Weight and height were obtained to calculate body mass index (BMI), while mid-upper arm circumference (MUAC) and triceps skinfold were taken to determine malnutrition and muscle wasting. The overall risk of malnutrition was determined by means of the Malnutrition Universal Screening Tool (MUST) (which calculates the overall risk of malnutrition by making use of a BMI score, a weight loss score and an acute disease score). Biochemical parameters were recorded from patient files. Socio-economic status included gender, age, marital status, education level, employment status, household income and housing density. Lifestyle factors included smoking habits and alcohol use. These variables were determined by means of a questionnaire completed by the researcher in a structured interview with each participant. The majority of participants (91%) did not complete matric and two thirds (66%) were unemployed. More than one out of ten participants (12%) indicated that they had no monthly income and in 64% of households, only one person contributed to the monthly income. Room density of more than 2.5 persons per room (crowded) was present in 29% of households. Only 26% of participants reported having a household vegetable garden. As far as household food security was concerned, only 3% were classified as food secure with 27% of households being at risk of hunger and 70% being food insecure (hungry). The food related side effects reported most commonly included loss of appetite (59%) followed by dry mouth (48%). According to the MUST, the overall risk for malnutrition was as follows: 70% had a high risk, 22% had a medium risk and 8% had a low risk. Actual unplanned weight loss and percentage of unplanned weight loss were significantly higher in patients with TB and HIV co-infection than in patients with TB only (95% CI [1.5%; 38.2%] and [5.3%; 51.0%] respectively). Median BMI was in the underweight category at 18.3 kg/m². Half of participants (51%) had a MUAC in the low category, while half (49.9%) had triceps skinfold measurements below the 15th percentile, indicating malnutrition. The majority of participants had albumin and haemoglobin values below the normal ranges (79% and 92% respectively). Almost six out of ten participants (58%) indicated that they were former (44%) or current (14%) smokers. The average cigarettes, pipes or cigars smoked by the former and current smokers were 4 with a maximum of 20 per day. The average amount of years that the former or current smokers smoked was 9 years with a minimum of 1 year and a maximum of 30 years. Nearly half of participants (49%) reported that they did use alcohol with 25% drinking alcohol more than three times per week. Statistically significantly more females than males were non-smokers and more men drank alcohol three times or more per week than females. Participants that indicated that they were either former or current smokers had significantly lower levels of education than participants who were non-smokers (95% CI [-26.7%; -2.6%] and [-39.9%; -1.0%] respectively). There were no statistically significant differences in terms of BMI in smokers versus non-smokers. In the present study, the nutritional status of patients with TB and TB/HIV co-infection was found to be poor. They were characterised by poor socio-economic status, high levels of food insecurity, malnutrition (underweight, anaemia and hypoalbuminaemia) and poor lifestyle habits (smoking and alcohol use). Recommendations to address the poor nutritional status of patients with TB and TB/HIV co-infection should include relief of poverty in communities, a focus on relevant and culturally acceptable nutrition education and the establishment of sustainable support networks.
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
The goitre prevalance and urinary iodine status of primary school children in Lesotho
(University of the Free State, 2000-11) Sebotsa, Masekonyela Linono Damane; Dannhauser, A.; Jooste, P. L.
English: Iodine deficiency has been called the world's most significant cause of mental retardation. Studies conducted since 1960 have indicated iodine deficiency as public health problem in Lesotho. The ICCIDD has been instrumental in focusing the world's attention on 100 and the goal of virtual elimination of 100 as a public health problem by the year 2000 was accepted by the united systems in 1990. This goal was reaffirmed by the e" World Health Assembly in 1993, which also provided a strategic guidance including emphasis on salt iodisation. The main objective of this study was to estimate the current 100 situation in Lesotho 5 years after the 1993 National Micronutrient Survey which was followed by iodised oil capsule supplementation as a short term intervention and the introduction of the legislation on universal salt iodisation as a long term intervention. This was a cross sectional study where stratified random sampling was used to select 5 schools in each of the 10 districts of Lesotho. All children aged 8 to 12 years from the selected schools participated in the study. The size of the thyroid gland was determined by palpation and graded according to the Joint criteria of the WHO/UNICEF/ICCIDD (1994). Casual urine samples were obtained from 10 children in each school in the morning during school hours and frozen until they were analysed for urinary iodine level using the Sandell-Kolthoff reaction involving alkaline ashing at the National University of Lesotho. Using a structured questionnaire, iodised oil supplementation coverage was determined. Salt samples brought by children were also analysed for the presence of iodine using the rapid (spot) test kits. The SAS package was used for statistical analysis of the results at the University of Orange Free State. 4071 primary school children were palpated and responded to the questionnaire, 4071 salt samples and 500 urine samples were analysed. The median urinary iodine concentration of 26.3IJg/l, which ranged from 22.3IJg/1to 47.91Jg/l and from 25.7IJg/1 to 27.2IJg/1 in the different districts and ecological zones respectively, indicated moderate 100. The prevalence of goitre, which increased with age and was higher in females than males, ranged from 2.2 to 8.8 percent and from 2.3 to 6.3 percent in the different districts and ecological zones respectively indicating mild to normal iodine deficiency. The adjusted prevalence of goitre for the whole country was 4.9 percent, indicating the absence of 100. 94.2 percent of salt samples were iodised. Coverage on iodised oil capsules supplementation, which was 55.1 percent, was not adequate. Lesotho was found in this study as having mild to moderate 100, which is still of public health concern according to WHO/UNICEF/ICCIOO (1994). Iodine deficiency was higher in the Mountains than in the Lowlands. However there is an improvement in controlling 100 in Lesotho as observed from the results of the present study and those of the previous studies. The use of iodised salt and iodised oil capsules has most likely contributed to a decrease in the 100 prevalence. Similar studies using ultrasonography and the titration method need to be conducted in the future. More iodised oil supplementation is recommended in the Mountains and in schools, which never received the capsules and this needs to be coupled with efficient awareness programs. An effective monitoring program needs to be initiated to ensure that the entire population use adequately iodised salt.
Open Access
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.