Doctoral Degrees (Human Nutrition)

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The anthropometric, vitamin A and iron status of pre-school children in the Western and Northern Cape Provinces
(Stellenbosch : Stellenbosch University, 1998-11) Blaauw, Renee; Labadarios, D.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Human Nutrition.
ENGLISH ABSTRACT: Vitamin A deficiency (VAD) and anaemia are major nutritional disorders worldwide, including Africa . It has been estimated that ½ million children go blind annually due to vitamin A deficiency, whereas anaemia affects approximately a quarter of the world's population. Furthermore, protein energy malnutrition (PEM) is known to be responsible for 55 % of childhood deaths worldwide. n view of these relationships, the aims of this study were to establish the anthropometric, vitamin A and iron status of pre-school children in the Western Cape (as part of a national survey), as well as to identify major factors contributing to poor status.
Design of an architectural framework for a health assessment information system for urban agriculture interventions in low-resource settings using a soft systems approach to information system design
(Stellenbosch : Stellenbosch University, 2019-04) Idzerda, Leanne; McLachlan, Milla; Michalowski, Wojtek; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Human Nutrition.
ENGLISH SUMMARY: Introduction: Urban agriculture interventions in low-resource settings have not demonstrated the expected improvements to nutrition outcomes. Urban agriculture interventions also pose a number of potential risks to population health. The purpose of this research is to design the architectural framework for a technology-supported information system that can support program managers in developing strategies that aim to improve nutrition outcomes and mitigate the risks to population health. This tool is called the Health Assessment Information System for Urban Agriculture Interventions in Low-Resource Settings (HAIS). Methods: The architectural framework was developed by identifying and capturing the technical and soft elements of the health impact assessment (HIA) approach. Soft systems methodology (SSM) was used in three phases of research to design the architectural framework of the HAIS. Each phase corresponds to a research question and determines (1) what activities need to be supported, (2) what information is required to support these activities, and (3) how to structure that information. Results: Five activities where program managers require support were identified, and the information required to support these activities was defined. The architectural framework of the HAIS, which consists of several components that function together, was developed around these activities. This architectural framework builds the theoretical foundation for the development of a future technology-supported information system that can be used to support program managers to develop their own strategies within a complex organizational context. Conclusion: The HAIS represents the first step towards developing a decision tool that can support program managers in complex low-resource organizational settings to develop strategies to improve nutrition outcomes and mitigate population health risks. This research represents the first attempt to use SSM to identify and capture the technical and soft elements of the HIA approach into an architectural framework for an information system that, when developed, may be used by non-experts to design urban agriculture interventions.
Development and evaluation of a food frequency questionnaire to assess daily total flavonoid intake using a rooibos intervention study model
(Stellenbosch : Stellenbosch University, 2013-03) Venter, Irma; Marnewick, Jeanine L.; Herselman, Marietjie G.; Nel, Daan G.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Interdisciplinary Health Sciences. Human Nutrition.
ENGLISH ABSTRACT: A comprehensive food frequency questionnaire (FFQ) was developed to assess the daily total flavonoid intake over the past fortnight within a 14-week intervention that consisted of four periods to determine the effect of rooibos consumption on oxidative stress in adults (n=40) at intermediate to high coronary heart disease (CHD) risk. Within the intervention the comprehensive FFQ validity (against six estimated dietary records and biomarkers), reproducibility (on administrations in the washout and control periods six weeks apart as these periods had similar flavonoid intake restrictions) and responsiveness (across the four intervention periods of changed dietary conditions) was evaluated. The baseline period dietary record and FFQ dietary sources found to contribute most to the participants’ daily total flavonoid intake, considering the percentage contribution, and the between-person variation in intake, considering the stepwise multiple regression analysis, formed the food list of the resultant abbreviated FFQ. The validity, reproducibility and responsiveness of the latter were also evaluated within the intervention and its validity (against dietary records) and reproducibility (on re-administration two weeks apart) in an additional group (n=90) being at low and intermediate CHD risk to evaluate its external strength. The validity and reproducibility evaluations of the comprehensive and abbreviated FFQs in the intervention and abbreviated FFQ within the additional group comprised paired difference tests (to establish the ability to estimate group intakes), correlation coefficients (to establish the ability to rank individual participants), category agreement and gross misclassification next to the weighted kappa statistic (to establish the ability to classify the participants into tertiles and quintiles of intake) and Bland-Altman plots (as representation of the limits of agreement between the two dietary assessment methods). Correlation coefficients were also used for biomarker validity evaluations in the baseline period. The repeated measures analysis of variance (ANOVA) (Bonferroni correction) was used for the responsiveness evaluations of the comprehensive and abbreviated FFQs across the intervention periods alongside that of the biomarkers as evidence for the changed dietary conditions. The study demonstrated that the comprehensive FFQ could be modified to a format with a brief food list as few items contributed appreciably to the total flavonoid intake and of which most also contributed to the between-person intake variability. The comprehensive and moreover the abbreviated FFQ in the validity evaluations provided sufficiently accurate daily total flavonoid intake estimates. They could determine the intake at group level in correspondence with that of the dietary records. The participant intakes could additionally be categorized and in particular ranked greatly alike to the dietary record intakes. The Bland-Altman plots revealed proportional bias regarding overestimation at the higher intake level. The reproducibility also appeared to be greatly satisfactory although seasonal fruit exclusions from the abbreviated FFQ food list may hamper its repeated administration. Both FFQs also confirmed the changed total flavonoid intakes across the intervention periods in relation to changes in the expected direction concerning the plasma total polyphenol, conjugated diene and thiobarbituric acid reactive substance concentrations.
Development of a roadmap for mainstreaming nutrition-sensitive interventions in Anambra and Kebbi States, Nigeria
(Stellenbosch : Stellenbosch University, 2019-04) Ezekannagha, Oluchi; Mbhenyane, Xikombiso G.; Drimie, Scott; Von Fintel, Dieter; Maziya-Dixon, Busie; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Human Nutrition.
ENGLISH SUMMARY : Malnutrition, though on a slight decline, has continued to be a problem in developing countries. The role of nutrition-sensitivity sectors as a linkage between immediate causes and basic causes of malnutrition has been increasingly recognised in recent years as positively associated with malnutrition reduction. Considering the accumulating evidence pointing to a strong relationship between malnutrition reduction and nutrition-sensitive sectors, including agriculture, education, water, sanitation and hygiene (WASH), and social protection, mainstreaming nutrition into these sectors has been widely discussed, designed and implemented in programmes and policies. Large-scale government programmes in nutrition-sensitive sectors are important elements of delivering nutrition-sensitive malnutrition-preventive benefits to the population. Mainstreaming nutrition into these cross-cutting sectors becomes imperative in the fight for malnutrition reduction. The Mainstreaming Nutrition Initiative Assessment (MNIA) is a framework developed for the assessment of mainstreaming nutrition (Menon et al, 2011), which measures the domains of epidemiology, operational and political commitment. However, there has been little attempt to explore its application in mainstreaming nutrition. The aim of the study was to develop a roadmap for mainstreaming nutrition-sensitivity in Anambra and Kebbi States, Nigeria. The study used a four-phased convergent parallel mixed methods design. In Phase 1, small area estimation methodology was employed to estimate local government prevalence of stunting in Nigeria. Phase 2 was carried out in two stages, first, a nutrition-sensitivity and potential checklist were used to determine the current nutrition-sensitivity and possible potential of programme execution in the various sectors in both states. Subsequently, a theory-based process evaluation that employed key informant interviews, document reviews, and site observations were used to determine the operational factors influencing the implementation of the programmes. In Phase 3, a political commitment rapid assessment test was administered in a workshop to explore the political realities regarding nutrition and nutrition-sensitivity in the states. In Phase 4, the data and information from the previous phases were employed to develop a roadmap for mainstreaming nutrition-sensitivity in both states, which was also validated by the stakeholders. Data were analysed using qualitative thematic analysis and MAXQDA software. LGA stunting prevalence estimations varied across the states. Kebbi State had high state average accompanied by very high LGA stunting estimates. Stunting prevalence in Kebbi State ranged from 54 percent to 67 percent. While in Anambra State, the stunting prevalence ranged from 17 percent to 25 percent, both states were in WHO category of medium to high stunting prevalence. The programmes assessed were averagely nutrition-sensitive but most of them had excellent potential to be highly nutrition-sensitive. The agricultural programmes have the best implementation while programmes in the WASH sector were the weakest in terms of implementation. The process evaluation showed that the programmes’ theory was validly nutrition-sensitive. The programmes had varied implementation dimensions, while the Agricultural Transformation Agenda Programme had a very high dose, the programmes reach was minimal. Programmes such as the Environmental Sanitation and Early Childhood Development Education has wide reach but lower dose and implementation. With regards to political commitment, while Kebbi had high expressed commitment, this was supported with the poor institutional commitment, unlike Anambra where strong institutional commitment existed but lacked financial support. From these findings, a roadmap for mainstreaming nutrition-sensitivity was developed and most stakeholders agreed that the roadmap was implementable and feasible. Future investigation is needed to replicate the study in other states. In addition, following-up Anambra and Kebbi states with the implementation of the roadmap may shed more light on the dynamics and role of the various domains in nutrition-sensitive mainstreaming.
Development of contextualised food-based strategy to improve the dietary diversity and nutritional status of children aged 12 to 36 months in rural farming households in central Uganda
(Stellenbosch : Stellenbosch University, 2020-12) Nabuuma, Deborah; Mbhenyane, Xikombiso; Ekesa, Beatrice; Faber, Mieke; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Human Nutrition.
ENGLISH SUMMARY: Food insecurity, low dietary diversity, and malnutrition remain prevalent in sub-Saharan Africa. Food-based strategies have a high potential of improving diet quality in agriculture-dependent communities and their development and effectiveness can be enhanced by systematic approaches. This study aimed to develop a food-based strategy to improve the dietary diversity of children aged 12 to 36 months from rural smallholder farming households in Central Uganda. An embedded-sequential, mixed-methods research design was used: i) quantitative situation analysis using household and market surveys, ii) qualitative assessment of community perspectives using focus group discussions, iii) design of the food-based strategy using intervention mapping, and iv) qualitative validation using key informant interviews and focus group discussions. The results showed household food production and food consumption were mainly based on cereals and grains, roots, tubers, cooking bananas and legumes. There was low dietary diversity; 78% of six- to 23-month-old children did not meet the minimum dietary diversity and 71% of children ≥ 24 months were consuming less than three food groups. The most accessed markets had limited diversity of food groups (six out of 11 (55%)) compared to other markets in the community. Food production and consumption focused on priority crops that alleviated hunger and contributed to income – mainly maize, cooking bananas, sweet potatoes, cassava and beans. Food production was influenced by access to land, production costs, income potential, climate and farmer knowledge. The cost of food and market availability influenced the type and quantity of food bought and consumed. Poor perception towards meetings/training and inadequate nutrition information and skills were noted. These findings, relevant theory and literature were applied using intervention mapping to systematically identify determinants, outcomes, objectives, and pathways to improve dietary diversity. The resulting contextualised food-based strategy (CFBS) aims to improve dietary diversity of children in smallholder farming households through improved household production, income utilisation, and food consumption practices by: i) increasing diversity of foods produced, particularly fruits and vegetables, ii) increasing access to diverse foods through appropriate income and market, including an increase in diversity of foods in consumer markets and financial literacy, and iii) improving the quality of diets consumed, especially diversity, frequency, nutrient quality and safety through nutrition education. Actors included policy makers, development organisations, extension workers, community-level groups, community champions and smallholder farmers. Validation results rated the factors and actors in the CFBS as important for improving productivity, food availability, dietary diversity, livelihoods of smallholder farmers, thereby verifying the strategy and design process used. To improve dietary diversity among rural smallholder farmers, their food security and production challenges need to be addressed. This increases the relevance and motivation to participate and implement recommended practices. Markets have the potential to significantly contribute to dietary diversity. However, this requires adequate supply and demand of diverse foods in rural consumer food markets, as well as income and financial literacy to facilitate financial decisions that promote dietary diversity. The CFBS empowers smallholder farmers to decide on a course of action that achieves dietary diversity, having been equipped with information and skills on agriculture, nutrition and finances.
The effect of caffeine supplementation on Olympic-distance triathletes and triathlon performance in the Western Cape, South Africa
(Stellenbosch : Stellenbosch University, 2013-03) Potgieter, Sunita; Smith, Carine; Wright, H. H.; Warnich, L.; Nel, D. G.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Interdisciplinary Health Sciences. Human Nutrition.
ENGLISH ABSTRACT: Background: Abundant evidence supporting the ergogenic effect of caffeine during endurance exercise exists. Single sporting events, laboratory based studies and inappropriate research design questions the applicability of these studies to triathlon performance. Objectives: The main aims of this study were to i) investigate the ergogenic effect of caffeine supplementation during a triathlon; ii) evaluate parameters that could in part explain why caffeine supplementation is ergogenic, iii) investigate possible factors influencing the ergogenicity of caffeine supplementation and iv) investigate possible confounding factors influencing triathlon performance. Methods: A double-blind, randomized, crossover, controlled, clinical field trial was conducted. Performance data (time to complete (TTC), rating of perceived exertion (RPE) and mood state), parameters explaining the mechanism of action (endocrine-stress response, oxidative stress and plasma lactate), factors influencing ergogenicity (lifestyle, gender and genetics) and triathlon performance (general health, energy- and nutrient intake, body composition, training regime, side-effects of caffeine withdrawal- and supplementation and hydration status) was collected during two Olympic-distance triathlons (T1 and T2). Results: Twenty six Caucasian triathletes (Nm=14, Nf=12) participated (age: 37.8±10.6 years, habitual caffeine intake: 412.7±504.8 mg/day, percentage body fat: 14.5±7.2 %, training/week: 12.8±4.5 hours). There was a 3.7% reduction in swim time (33.5±7.0 vs. 34.8±8.1 minutes) (p=0.05*) and a 1.3% reduction in the overall time to complete the triathlon (149.6±19.8 vs. 151.5±18.6 minutes) (p=0.02*) in the caffeine group. Caffeine did not statistically influence mood state (p=0.72) or RPE (p=0.87), however, a trend was observed for decreased RPE values in the caffeine group. Caffeine supplementation made no difference to markers of endocrine-stress, except for cortisol, which increased beyond the effect observed from exercise (p=0.00*). Oxidative stress was more pronounced in the caffeine group, as seen with elevated leukocyte (p=0.05*), lymphocyte (p=0.05*) and monocyte (p = 0.05*) counts. Caffeine facilitated greater blood lactate accumulation (p=0.04*). Lifestyle, menstrual cycle, menopause, oral contraceptive use and CYP1A2 gene polymorphisms did not statistically influence the effect of caffeine supplementation on triathlon performance. The mean energy- and nutrient intake two days before T1 and T2 was low for energy (36.5±17.6 and 38.9±18.2 kcal/kg BW), estimated energy availability (estEA) (27.9±28.0 and 28.8±25.6 kcal/kg fat free mass) and carbohydrate (CHO) intake (4.1±1.6 and 4.6±2.5 g/kg body weight (BW)) compared to recommendations. The pre-event meal was low in CHO (0.7±0.4 and 0.7±0.5 g/kg BW) and only 62% (N=16) ingested a carbohydrate-electrolyte solution during T1 (CHO: 1.6±2.3 g/kg BW) and T2 (CHO: 0.7±0.4 g/kg BW). Eighty-five percent (N=22) used supplements. Seventy-two percent of pre-menopausal (Nf pre-men=5) and 40% of post-menopausal (Nf post-men=2) females were osteopenic. Of the males, 18% (Nm<50 = 2) had low anterior-posterior spine BMD and 33% (Nm>50 = 1) were osteopenic. Caffeine withdrawal presented as headaches (46%, N=12) and flu-like symptoms (38%, N=10). Side effects of caffeine experienced included shakiness (42%, N=11), heart palpitations (38%, N=10) and gastrointestinal disturbances (38%, N=10). Plasma volume and hydration was not influenced (p=0.70). Conclusion: Caffeine enhanced triathlon performance, but the effect was not as pronounced as seen in previous laboratory trials and did not affect RPE or mood state. Caffeine supplementation augments the endocrine-stress response by further increasing cortisol levels beyond that resulting from endurance exercise and it induces leukocytosis, neutrophillia and lymphocytosis, suggesting the primary ergogenic effect of caffeine may result due to stimulation of both the central and autonomic nervous systems. Lifestyle, gender and genetics did not significantly influence caffeine’s effect on triathlon performance in this cohort. The subjects had low energy, estEA and carbohydrate intake and a high prevalence of osteopenia.
The effect of β-glucan prebiotic fibre (oats) on the gut microbiome of chronic kidney disease patients (Stage IV and V) and impact on kidney function
(Stellenbosch : Stellenbosch University, 2022-04) Ebrahim, Zarina; Blaauw, Renée; Moosa, M. Rafique; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Human Nutrition.
ENGLISH SUMMARY: Background: Chronic kidney disease (CKD) is increasing in global prevalence and has many nutritional complications. Increasing evidence suggests that gut dysbiosis is involved in CKD progression through various mechanisms including intestinally derived uraemic toxins, dietary, and immune-mediated factors. Therefore, modulating the gut microbiome may improve outcomes in CKD. The aim of this research project was to investigate the effect of a ß-glucan prebiotic supplement on kidney outcomes, uraemic toxins and the gut microbiome in predialysis CKD participants. Methods: This study was a randomised controlled intervention study over 18 weeks, performed at Tygerberg Hospital predialysis clinic in Cape Town, South Africa. There was a pre-randomisation period of four weeks where participants were counselled on a CKD diet before being randomised. At randomisation, the intervention group received the ß-glucan supplement and continued the diet, while the control group continued with the diet only. There were follow-ups at weeks 4, 8 and 14 after randomisation. The objectives were to assess nutritional status, kidney function, plasma levels of uraemic toxins and gut microbiota using 16S rRNA sequencing at pre-randomisation. Additionally, differences in these outcomes were measured at randomisation baseline (week 0), week 8 and week 14 between the intervention and the control groups. Anthropometrical measurements were done which included weight, height, waist circumference, mid-upper arm circumference and triceps. Clinical investigations included investigating for oedema as well as gastrointestinal symptom measurement. Stool consistency was described using the Bristol Stool Score (BSS). Dietary intake was measured using a quantified food frequency questionnaire (QFFQ) and a dietary adherence score sheet. Although most of the investigations was done locally, the uraemic toxins analysis was performed at the nephrology laboratories at the University of Ghent in Belgium, while the gut microbiome analysis was performed at VIB laboratories (Leuven, Belgium). Statistical analysis was performed using IBM®SPSS®version 26/27 and R Statistical Software. Results: Seventy participants were enrolled in the study at the pre-randomisation visit. The mean age of the participants was 41.7 ± 11.8 years, with a slight predominance of females (53%). Most participants were unemployed, earning less than US$126 per month. Hypertension was the main cause of kidney failure and most participants were in stage 5 CKD. A very high prevalence of overweight (30%) and obesity (36%) was found at pre-randomisation, with a low prevalence of undernutrition (3%). Abdominal obesity was found in 60% of participants. Dietary assessment showed an unhealthy dietary pattern. After four weeks, 59 participants were randomised. The diet intervention resulted in significant nutritional changes in participants after four weeks, while uraemic toxins remained unchanged. There was a significant reduction in body mass index (P < 0.006) and waist circumference (P < 0.001). Almost all dietary intake variables were significantly reduced and there was a high dietary adherence. Serum total cholesterol (P < 0.045) and triglyceride levels (P < 0.017) were also reduced. After randomisation to either the ß-glucan prebiotic or the diet, kidney function did not significantly change. However, there was a significant reduction in uraemic toxins in free IxS at week 8 (P = 0.003) and week 14 (P < 0.001), total and free pCG (P < 0.001, P < 0.001, respectively) and free pCS (P = 0.006) at week 14. There were no significant changes in dietary intake, clinical symptoms or anthropometry during the trial. The gut microbiome revealed that two enterotypes were prevalent, namely the Bacteroides2 and Prevotella enterotypes. The inter-individual Bray–Curtis distance (ß-diversity) was significantly higher in the control group than the intervention group at baseline (P < 0.0001), week 8 (P < 0.0001) and week 14 (P = 0.02). There were no differences in relative abundance of genera between groups. The redundancy analysis showed a few factors significantly affected the gut microbiome: these included triglyceride levels (P < 0.001), cause of kidney failure (P < 0.001), gender (P < 0.001), body mass index (P = 0.002), high- density lipoprotein (P < 0.001) and the prebiotic intervention (P = 0.002). Conclusion:While four weeks of the diet resulted in some nutritional changes in participants before randomisation, it did not affect other outcomes of the study. Once randomised, the prebiotic did not significantly affect kidney function, while it significantly reduced uraemic toxins and the gut microbiome, according to the RDA analysis. The ß-glucan prebiotic therefore had some beneficial effects on outcomes in CKD participants.
Effects of initial nutritional status on the responses to a school feeding programme among school children aged 6 to 13 years in the Millennium Villages Project, Siaya, Kenya
(Stellenbosch : Stellenbosch University, 2013-12) Masibo, Peninah Kinya; Labadarios, Demetre; Herselman, Marietjie; Ettyang, Grace; Deckelbaum, Richard J.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Interdisciplinary Health Sciences. Human Nutrition.
ENGLISH ABSTRACT: Aim: To assess the effects of initial nutritional status on the responses to a school feeding programme (SFP) among school children in the Millennium Villages Project (MVP), Siaya District, Kenya. Objectives: To establish baseline data on the dietary intake, prevalence of undernutrition, body composition, prevalence of anaemia, body iron stores and vitamin A status in order to assess the impact of the SFP over a 30-month period on the same outcomes. Further, the study assessed the effect of initial nutritional status on the responses to the SFP on growth, the prevalence of anaemia, body iron stores and vitamin A status. Methods: In the MVP, a school meal additional to the children’s usual daily food intake was provided consisting of locally available foods (containing whole fish omena and beef). The meals contributed approximately 25% of the Estimated Energy Requirement (EER), 70% of the Estimated Average Requirement (EAR) for protein, and 18% of EAR for fat. A school meal, additional to the children’s usual daily food intake, was introduced to the control group 6 months into the study as a project scale up initiative. The meal provided 15% EER, 49 % EAR for protein and 10% EAR for fat. A total of 235 children participated in the study and were followed up for 30 months, with 118 in the MVP and 117 in the control group. Statistical analysis included descriptive, Pearson’s chi-square test, repeated measures ANOVA and multivariate logistic regression models. Results: The mean subject age was 7.9 years (2.0 SD) at baseline, and half (51.4%) were boys. More than half of the children (66%) had energy intakes less than the EER. At baseline, the prevalence of stunting, wasting and underweight was 16.9%, 6.0% and 3.6% respectively. Prevalence of linear growth deficit based on height-for-age z-score ≤-1 standard deviation was 48%. Anaemia was higher in the MVP group (82.2%; P < 0.0001) compared to controls (58.1%) while depleted body iron stores was observed in 10.7% of the children. Half of the children in the control group and 30% in the MVP group had an inadequate vitamin A status while 11% of the children had infection/inflammation. At six months after initiation of the intervention, anaemia prevalence was reduced to 41.2% among the controls and 9.3% in the intervention group (P < 0.001). Among the MVP group, children with initial inadequate nutritional status based on weight-for-age z-score WAZ ≤ -1 SD had a higher (P < 0.01) height velocity (2.3 cm/six months) by the 24th month study interval compared to those who had an initial adequate nutritional status based on weight-for-age z-score WAZ > -1 SD. Conclusion: SPF menus were associated with potential for improved growth, gain in lean body mass and reduced anaemia prevalence when inadequate nutritional status was present at baseline.
Evaluation of two counseling strategies improving exclusive breastfeeding among HIV-negative mothers in Kibera Slum, Nairobi, Kenya : a randomized controlled trial
(Stellenbosch : Stellenbosch University, 2008-12) Ochola, Sophie Atieno; Labadarios, Demetre; Nduati, Ruth; Nel, D. G.; Stellenbosch University. Faculty of Health Sciences. Dept. of Interdisciplinary Health Sciences. Human Nutrition.
Objectives: To determine the impact of facility-based semi-intensive and home-based intensive counseling strategies to improve exclusive breastfeeding rates and to identify factors associated with exclusive breastfeeding. Methods: This was a randomized trial in which villages in the Kibera slum, Nairobi Kenya were assigned to two intervention groups and a control group. Study participants from among 34-36 week pregnant, HIV-negative women, attending antenatal clinic at Lang’ata health centre, were assigned to study groups and followed up in their homes until 6 months postpartum. Experimental group 1, the Home-Based Intensive Counseling Group (HBICG)] received 7 counseling sessions; 1 prenatally and 6 postnatally. Experimental group 2, the Facility-Based Semi-Intensive Counseling Group (FBSICG) received 1 counseling session prenatally. The control group (Control Group) received irregularly provided health education by health personnel. Information on infant feeding practices, using a validated 24-hour recall questionnaire was collected monthly at participant homes; observations were conducted on a random 10% sub-sample to verify the reported information. Qualitative data from focus group discussions provided information on the rationale for feeding choices. Information on infant morbidity and weight measurements were taken on a monthly basis. Results: At six months, exclusive breastfeeding rate was 23.6% in HBICG; 9.2% in FBSICG; and 5.6% in CG. Mothers from HBICG had a 4.2 increased likelihood to exclusively breastfeed compared to those in the CG (RR=4.20; 95% CI; 1.66-10.64; p=0.002). Cumulative exclusive breastfeeding rate for 6 months was 3.2% in the CG; and 6.9% and 15.6% in the FBSICG and HBICG respectively (p<0.00001). Mothers from HBICG had a 3.4 increased likelihood to practice exclusive breastfeeding for 6 months compared to those in CG (RR=3.4; 95% CI: 1-34-8.80; p=0.010). Exclusive breastfeeding rates in FBSICG were insignificantly higher than those in the CG. The median duration of exclusive breastfeeding was one month in both the CG and FBSICG and three months in the HBICG. The predictors of exclusive breastfeeding were non-giving of post-lacteal feeds; planned long breastfeeding duration; living in smaller households; non-ownership of telephones and televisions; absence of breast health problems; and correct knowledge of breastfeeding duration. The major hindrances to exclusive breastfeeding were: inadequate knowledge of exclusive breastfeeding; cultural perceptions about infant feeding; and absence of mother from home for long periods. The prevalence of acute respiratory infections and diarrhoea were significantly lower among exclusively breastfed infants than those non-exclusively breastfed. The prevalence of underweight was significantly lower among the exclusively breastfed infants than those non-exclusively breastfed at one month (p=0.006) and three months (p=0.005). Conclusions: It is feasible to promote and sustain exclusive breastfeeding for six months in low socioeconomic conditions, using the home-based intensive counseling strategy. Breastfeeding promotion programmes should adopt strategies to allow for wider dissemination of information, targeting both mothers and the community at large, as this study showed family members were major decision-makers in the choice of infant feeding practices. Hospital-based breastfeeding education should offer detailed information on a consistent basis. Breastfeeding promotion messages should be re-packaged to address cultural perceptions in infant feeding practices.
Exploring stakeholder commitment and capacity to address infant and young child nutrition in the capital of the Breede Valley, Western Cape Province, South Africa
(Stellenbosch : Stellenbosch University, 2015-12) Du Plessis, Lisanne Monica; McLachlan, Milla; Drimie, Scott; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Human Nutrition.
ENGLISH SUMMARY: There is experience with - and documented evidence on multi-stakeholder processes (MSPs) on a global - and national level and on how to build and assess commitment and capacity to address infant and young child nutrition (IYCN) at these levels. Little experience and documented evidence, however, exist for such processes at local level. In countries with a decentralised government system, part of the lack of experience and evidence on MSPs lies in the challenge of building commitment and capacity at various political and bureaucratic levels. There is, thus, a need to build an evidence-base of how to engage stakeholders at implementation level and to assess and advance their commitment and capacity to implement responses to address IYCN. There is also a call to better define enabling environments for successful action in this field. In this research, a qualitative study design and selected participatory research methods were used to explore a diversity of perceptions, willingness, abilities, relationships and powers of key stakeholders to address IYCN at sub-district level in the Breede Valley, Western Cape Province, South Africa. The study built on baseline research in the Community-based Nutrition Security Project (CNSP), which provided insight into maternal and child nutrition challenges in the Breede Valley. Stakeholders were identified and categorised during a focus group discussion (FGD) with individuals who knew the sub-district well. Subsequently, the researcher conducted semi-structured interviews with twenty seven key stakeholders to explore their perspectives, commitment and capacity concerning IYCN. Hereafter, they were invited to participate in a workshop to map stakeholder relationships and power related to IYCN governance. Lastly, FGDs were held to reflect on the research process and to explore elements of an enabling environment conducive to action on IYCN at implementation level. Main themes from the overall research findings include: the value of local knowledge and information; the appeal of the 1000 days message and its link to development; the urgent need for IYCN advocacy; the value of stakeholder engagement and seeing the broad IYCN stakeholder landscape; the need for multi-sectoral work, while recognising the difficulty in functioning across sectors; realising the capacity inherent in “people” as a resource, the need for a “whole of society approach” in advancing the IYCN agenda and the importance of strategic capacity in local forums, combined with national legislation, to advance action for IYCN. The study provides insight into the elusive concepts of commitment and capacity in relation to IYCN governance at local level. The personal and professional perspectives of key stakeholders involved at this level offered distinct information about the unique challenges they experienced as well as practical responses required to ensure action. The barriers to multi-sectoral work at the sub-district level hinged on narrow sector-specific focus areas, mandates and budgets leading to poor integration around the social determinants of health, lack of resources and lack of targeted advocacy. The core conclusion of the study is that a detailed exploration of initial stages of an MSP is a valuable practice - and research model to create awareness of IYCN as a development issue of crosscutting importance at implementation level. This process, though time and resource intensive, has supported the development of commitment and revealed collective capacity that could be unlocked to address IYCN at the sub-district level in the Breede Valley. Such an approach, appropriately adapted to local conditions, could be helpful in scaling-up efforts to improve IYCN at sub-district level elsewhere in the country. The next phase of the CNSP should involve joint planning and concrete action to improve IYCN in the Breede Valley. The proposed expansion of the definition of the enabling environment and adaptation of the nutrition governance framework could be introduced into international debates and agendas for continued deliberation, research and action to improve IYCN as a global, national and local priority.
Heavy alcohol use in adolescents : potential influences on nutritional status
(Stellenbosch : Stellenbosch University, 2012-03) Naude, Celeste Estelle; Senekal, Marjanne; Carey, Paul; Stellenbosch University. Faculty of Health Sciences. Dept. of Interdisciplinary Health Sciences. Human Nutrition.
ENGLISH ABSTRACT: Introduction: Adolescents are recognised as a nutritionally at-risk group, as they have high nutritional demand for growth and development, poor eating behaviour as well as a propensity for unhealthy behaviours. Heavy alcohol use, particularly in the form of binge drinking, is typical for an alarming proportion of school-going adolescents and is a plausible contributor to the nutritional challenges in adolescents, but this has not yet been fully investigated. Aim: This study investigated the potential influences of alcohol use on the nutritional status of adolescents with alcohol use disorders (AUDs), specifically with regards to their eating behaviour and dietary intake, growth and weight status, iron status, as well as vitamin D and calcium status. Methods: Substance use, physical activity, eating behaviour, dietary intake, growth and weight status, iron status and vitamin D and calcium status were assessed and compared in heavy drinking adolescents (meeting DSM-IV criteria for AUDs) (n=81) and in light/non-drinking adolescents without AUDs (non-AUDs)(n=81), matched for age, gender, language, socio-economic status and education. Observed dietary intake distributions were adjusted statistically to obtain usual nutrient intake distributions. Regression-adjusted differences between the groups were assessed using multi-level mixed effects linear regression, adjusting for potential confounders. Results: Lifetime alcohol dose in standard drinks of alcohol was orders of magnitude higher in the AUDs group compared to the non-AUDs group. AUDs adolescents had a binge alcohol use pattern and a “weekends-only” style of alcohol consumption. Poor eating patterns (breakfast skipping and frequent snacking), poor food choices (energy-dense and nutrient-poor foods) and low fruit and vegetable intake (non-AUDs 90 [42.4-153.3]; AUDs 88.3 [30.0-153.0] grams per day) in both groups were reflected in the poor nutritional quality of the diet. More than half of adolescents in both groups were at risk of inadequate intakes of folate (non-AUDs 97.5%; AUDs 98.8%), vitamin C (non-AUDs 65%; AUDs 67.5%), vitamin A (non-AUDs 80%; AUDs 82.5%), vitamin E (non-AUDs 78.8%; AUDs 51.3%), magnesium (non-AUDs 98.8%; AUDs 97.5%), and phosphorus (non-AUDs 76.3%; AUDs 73.8%) and all participants were at risk of inadequate calcium and vitamin D intakes. AUDs adolescents had a greater intake of unhealthy foods (energy-dense nutrient-poor) and a significantly greater energy intake than non-AUDs adolescents (p<0.001) that exceeded energy requirements. AUDs adolescents consumed foods high in unhealthy fats significantly more frequently (p=0.037) than the non-AUDs adolescents and had ensuing greater total fat (p<0.001), saturated fat (p<0.001) and cholesterol (p=0.009) intakes. Frequency of intake of sodium-rich foods was significantly higher in AUDs adolescents (p=0.001) and prevalence of risk of excessive sodium intake was significantly greater in the AUDs adolescents (45%) compared to non-AUDs adolescents (18.8%) (p<0.001). Anthropometric indices of growth and weight status were comparable between the groups and in line with that of the South African adolescent population. Female AUDs adolescents had increased odds (OR 2.42) of being overweight/obese compared to non-AUDs females. Physical activity in both groups was well below the WHO global recommendation. Iron store depletion (serum ferritin < 20 μg/L) was evident in a quarter of adolescents in both groups (non-AUDs 23.5%; AUDs 24.7%), with biochemical iron status measures (serum iron and total iron binding capacity) indicating a greater risk of iron store depletion in the AUDs group. Biochemical vitamin D insufficiency/deficiency (serum 25-hydroxyvitamin D < 30 ng/mL) was prevalent in both groups (non-AUDs 70.4%; AUDs 88.8%), although this was significantly greater in the AUDs group (p=0.013), with significantly lower serum 25-hydroxyvitamin D levels in the AUDs group compared to the non-AUDs group (p=0.038). Conclusions: Heavy alcohol use in the form of binge drinking in adolescents may have the following nutrition-related influences: increased intake of energy; unhealthy fats and sodium, increased risk of overweight/obesity in females; increased risk of iron store depletion; and increased risk of vitamin D insufficiency/deficiency. Persistence of heavy alcohol use, poor food choices and dietary intake may increase the risk for adverse nutrition-related health outcomes in the AUDs adolescents.
The influence of nutrition labelling and logos on food purchasing behaviour in Cape Town, Western Cape, South Africa
(Stellenbosch : Stellenbosch University, 2017-12) Koen, Nelene; Blaauw, Renee; Wentzel-Viljoen, Edelweiss; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Human Nutrition.
ENGLISH SUMMARY : Introduction: Nutrition information on food labels is a population-based approach to nutrition education that enables consumers to make healthier food choices. In South Africa (SA) there has been a paucity of data on food and nutrition labelling and the consumer since the publication of the new food-labelling legislation. Rationale: A better understanding of how consumers engage with nutrition information on food labels is required to make recommendations to improve education campaigns to assist consumers in making healthier food choices. Additionally, food-labelling factors that influence consumer food-purchasing behaviour, and expectations/barriers to reading nutrition information on labels, could assist in making recommendations for a single front-of-pack labelling scheme to be used in SA as well as for its development. Methods: A multi-stage mixed-methods design was employed. In phase one, a cross-sectional, descriptive, interviewer-administered electronic survey was conducted on adult consumers (N=960) at 16 randomly selected grocery stores in four health districts of Cape Town (CT). In phase two, nine focus-group discussions (FGDs) were held with purposively selected consumers (N=67) to further explore phase one’s findings and what type of health- endorsement logos (HELs) are preferred and why. In phase three, ten HELs were developed by a graphic design company based on the data collected in previous phases. A modified Delphi technique, conducted with experts in the fields of nutrition/food science (N=19), was employed to eliminate lowest scoring HELs and to improve the design of the HELs. Participants from the initial survey and/or FGDs took part in pilot testing of the HELs during four FGDs. Results: Main self-reported factors influencing food-purchasing behaviour included price, sell-by date and products on special/promotion, with price being the most important. Taste, brand loyalty, marketing and convenience were also major influencers. Less than half of participants indicated that nutrition information always influenced their product choice. The main reasons for not reading nutrition information included buying the same type of product all the time and being uninterested in the information. In exploring this further with FGDs, a lack of time, poor understanding of nutrition information (specifically the nutrition information table) and lack of trust in labelling information also emerged as important factors. The mean food and nutrition label knowledge score was 44%. The majority of participants preferred a single HEL to be used on food products as they don’t understand the various HELs used. Such a logo should include pictures/symbols directly related to health and/or food and should state “healthy choice”. During the pilot testing, three HELs (developed and improved during two rounds of scoring) received overall rankings of 3.08/5, 3.28/5 and 3.39/5 respectively. Conclusion: CT consumers have poor food and nutrition label knowledge and nutrition information on food labels is not a major influencer of food-purchasing behaviour. Consumers struggle to understand the nutrition information provided and have expressed a need for a single HEL to be used. Consumer education on utilising the nutrition information on labels and the development of a single HEL for SA, could assist consumers to make healthier food choices and in turn address the high incidence of non-communicable diseases in SA.
Information technology (IT) with a human face : a collaborative research project to improve higher nutrition training in Southern Africa
(Stellenbosch : Stellenbosch University, 2008-12) Marais, Debbie; Labadarios, Demetre; Ogle, Britta; Stellenbosch University. Faculty of Health Sciences. Dept. of Interdisciplinary Health Sciences. Human Nutrition.
Various enabling factors are required to incorporate technology in teaching and learning, moving towards a more learner-centred approach. Although efforts are being made to address the situation, the effective incorporation of ICT is not yet the norm in African higher education institutions (HEI). Data is available regarding the situation in African HEI, but very little is known about the situation of nutrition training. This research programme was divided into three phases. Phase I, assessment of the current use, awareness, attitudes and practices of ICT in nutrition training followed a descriptive, cross-sectional approach. A convenience sample of six HEI in South Africa, Malawi, Zambia, Swaziland and Zimbabwe was included. Data were collected from students (N = 591) and lecturing staff (N = 29) in nutrition-related courses using a questionnaire on ICT awareness, attitude and practices. Phase II, development and validation of a purpose-designed e-learning nutrition module followed a descriptive, cross-sectional approach. An e-learning module on Nutrition and HIV/AIDS with eleven sub-modules was developed, using an e-learning platform taking the specific constraints of developing countries into account. It was validated by expert reviewers (N = 27) for content validity and students (N = 175) for face validity. Phase III, to determine the impact of the module on cognitive knowledge followed an experimental before-after approach and used a set of twenty True/False questions for eight of the sub-modules (N = 173). Although there is widespread accessibility to computers, less so to the internet, in nutrition-related courses at Southern African HEI, respondents still felt that more computers should be made available. Computers are not fast enough and lack of finances is the main barrier to home and internet access. Students rate their ICT skills as average to good. Institutional ICT policies and support seem to be lacking, but their attitude to ICT is positive and supportive. Respondents felt that ICT could add a new dimension to nutrition training and are in favour of application of ICT in different modes. Most indicate that the current use of ICT in nutrition training is inadequate. The Nutrition in HIV/AIDS module was validated and found to be useful as an educational tool, being user-friendly, interactive and self-paced. The majority of students reported that their ICT skills were sufficient to complete the e-learning activity. Although generally rated as at least as effective, or more effective than conventional lectures, clearly this mode of elearning should not replace traditional teaching. The content was found to be comprehensive and evidence-based. The depth of the content was sufficient, the level correct for undergraduates and the material relevant to the Southern African context. The interactivity was deemed important, helpful and effective. Most students indicated that they would recommend the Nutrition in HIV/AIDS module to other students, that they enjoyed the presentation and learnt something new. There was an improvement in knowledge scores and/or the number of questions being answered correctly in all but one sub-module. The results confirm previous studies indicating that well-designed elearning modules have the potential to increase the performance of students.
An Institutional Understanding of the Transfer of Knowledge to Policy Processes: The Case of The Southern African Development Community’s Regional And National Vulnerability Assessment Committees.
(Stellenbosch : Stellenbosch University, 2015-03) Landman, Annie Petronella; McLachlan, Milla; Drimie, Scott; Loots, Ilse; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Human Nutrition.
ENGLISH SUMMARY : This thesis explores institutional blockages to and catalysts for the uptake of vulnerability research in vulnerability-reducing policies in southern Africa. The Southern African Development Community’s (SADC’s) Vulnerability Assessment Committee (VAC) constitutes the case study. It offers a unique empirical account of issues of research-policy transfer to reduce vulnerability in complex socio-ecological systems (SESs). Complexity theory provides insights into the research field. It conceptually draws together contextual challenges that contribute to vulnerability in the complex southern African context, the VAC, research processes, and policy processes. Southern Africa is a complex SES with a governing subsystem. The VAC forms part of this subsystem. VAC actors collect contextual information from the SES to inform governing actors of regional vulnerability. Governing actors could then apply the information to make policies reducing regional vulnerability in the SES. An institutional approach and the Policy Arrangement Approach (PAA) are useful for researching the research-policy transfer in the VAC policy arrangement. A PAA-analysis is organised from four integrated analytical dimensions: discourses, actors and coalitions, power and resources, and institutional rules. The PAA also uncovers links between the VAC and its context. Regional food emergencies strongly influenced the establishment and evolution of the VAC. The VAC was formed as a consensual platform to address challenges created by parallel-operating multi-sectoral administration structures hindering collaboration to deal with uncertainty, as well as different frameworks producing conflicting food security results. Discourse findings indicate the VAC mainly interprets vulnerability as vulnerability to food insecurity. Discursive shifts to broader vulnerability and resilience are stunted by a governing mode that does not accommodate multi-actor governance. Findings from the combined actors and power dimensions show that the process of formalising NVACs within national governments has increased government power, reducing the power of international agencies, whose participation is vital to addressing immediate regional challenges. Untransparent political processes have excluded international agencies from VAC activities and politicised vulnerably information. Institutional rules have emerged, including formalising NVACs within governments; set research frameworks; a minimum set of vulnerability indicators to report; a consultancy culture; multiagency VAC membership; volunteerism in un-formalised NVACs; and the strategic exploitation of food security information by international agencies focused primarily on food aid interventions. From these PAA dimension insights, identified catalysts for research-policy transfer include sufficient capacity and funding, technical assistance, communication strategies between research and policy processes, and high-level political support. Research process blockages include a focus on informing emergency interventions, a lack of VAC capacity, neglected communication and dissemination strategies, and politicised research. Policy process blockages include weak national policy processes and a lack of easy access to VAC outputs. The thesis also unpacks contextual factors and spin-offs from VAC processes that perpetuate blockages. Although currently experiencing challenges, the VAC is ideally positioned to house research-policy transfer initiatives. If policy continues to be a strategy to address regional vulnerability, policies need to acknowledge complex contexts and consequently continuously adapt to changes in complex SESs. Research remains a useful tool for better contextualising adaptive policies.
Nutrient intake, gastrointestinal microbiota and the effect of Lactobacillus plantarum 299V in irritable bowel syndrome patients
(Stellenbosch : Stellenbosch University, 2014-12) Stevenson, Cheryl; Roux, Saartjie; Blaauw, Renee; Visser, Janicke; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Interdisciplinary Health Sciences:. Division of Human Nutrition.
ENGLISH ABSTRACT: Background: Irritable bowel syndrome (IBS) is a common gastrointestinal (GI) disorder. GI symptoms and impaired quality of life affect between 10-20% of all adults, corresponding to about 25-50% of all patients who visit a gastroenterologist’s clinic. In recent years, several novel mechanisms of IBS that likely relate to previously established theories have been identified. Inflammation, postinfectious low-grade inflammation, immunological and genetic predisposition along with altered microbiota are critical in IBS development, while several dietary factors may also play a role in this syndrome. However, none of these factors accounts for the full repertoire of IBS symptoms, and the pathophysiology of this condition is not fully understood. The overarching aim of this study was to investigate the nutrient intakes, GI microbiota and the effect of Lactobacillus plantarum (L.plantarum) 299v in IBS patients. Sub-aims: 1) Update healthcare professionals on current probiotic information and provide an overview of probiotic treatment approaches, with special emphasis on IBS, 2) conduct a well designed randomised, double blind, placebo-controlled trial (RCT) with L. plantarum 299v as part of an intervention and establish whether a course of probiotics may alleviate undesirable symptoms of IBS and improve quality of life, 3) assess nutrient intake in patients with irritable bowel syndrome (IBS) compared to dietary recommendations, 4) validate and assess the reproducibility of food records and 5) identify possible nutrient risk components for establishing GI microbiota involved in IBS and as part of an intervention, determine whether a course of probiotics may alter stool microbiota. Results: 1) A review article published by the author provides an overview of current probiotic treatment options to health care professionals and indicates certain probiotics are a promising therapeutic treatment option for management of IBS symtpoms, 2) the effects of the single strain probiotic, L. plantarum 299v, supplementation was evaluated in a RCT. Compared to placebo, the probiotic supplementation showed no significant reduction in GI symptom severity scores, particularly abdominal pain relief. Quality of life was also not improved in the treatment versus control group. Both the treatment and placebo groups improved significantly over the trial period, indicating a large placebo effect, 3) nutrient intakes of the IBS patients compared to current dietary reference recommendations indicates that this group of patients are at risk for nutrient inadequacies in key macro and micronutrients, 4) the validity and reliability of the dietary data showed good reliability but poor validity as measured by plasma fatty acids and 5) the GI microbiota composition in the phenotypically different diarrhoea-predominant IBS (D-IBS) vs. constipation-predominant IBS (C-IBS) showed that D-IBS patients had significantly lower counts of Lactobacillus plantarum compared to C-IBS patients. The probiotic had no significant effects on the GI microbiota as measured by quantitative polymerase chain reaction (qPCR). It was found that nutrient intakes had a significant impact on the microbiota. Lower fibre intakes were associated with higher Bacteroides spp., lower Bifidobacteria bifidum and Lactobacillus plantarum counts in both IBS groups. Conclusion: Taken together, L.plantarum 299v did not alleviate the GI symptoms of IBS, nor was it associated with significant changes in the GI microbiota. IBS patients may be at risk of key nutrient inadequacies. The influence of nutrient intakes on the GI microbiota provides an attractive explanation as a potential pathophysiological factor for IBS.
Nutrition education message topics and accessibility for the well-being of infants in an urban slum area
(Stellenbosch : Stellenbosch University, 2004-04) De Villiers, Anniza; Senekal, M.; Albertse, E. C.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Interdisciplinary Health Sciences. Human Nutrition.
ENGLISH ABSTRACT: The aim of the study was to contribute to the nutritional well-being of 0 - 24 month old children who attend primary health care clinics (PHC) in Duncan Village, an urban slum. This was to be achieved by first formulating essential nutrition-related message topics and second by formulating recommendations for optimising the accessibility of services, including nutrition-related messages, aimed at mothers attending PHC clinics in Duncan Village. In order to formulate targeted and relevant nutrition-related messages for mothers attending the PHC clinics (Phase I of the research) the need for more information on the six focus areas for intervention that were identified in the previous Duncan Village Day Hospital (DVDH) study" was determined. This was done through key-informant interviews and studying other relevant published research. Eleven research questions related to the six focus areas were subsequently formulated to guide further research. Non-scheduled structured interviews were conducted with mothers with children in specific age groups until data saturation was achieved. A total of 31 interviews were thus conducted at the homes of participants and observation data was also collected at the same time. Three focus groups with corresponding participant categories were also conducted to check the information obtained through the interviews. Two focus groups were conducted with grandmothers to serve as a further form of checking research but also to obtain a different perspective on the research questions. The data available for the formulation of the message topics was analysed qualitatively by hand. The focus areas and the research questions gave a specific focus to the analysis process and the unprocessed data was available in these broad predetermined categories. All the information from all sources (DVDH study, the non-scheduled structured interviews with mothers, focus groups with mothers and grandmothers and observation data) was studied, interpreted and integrated for each identified category. During this process key-factors, which need to be addressed in nutrition-related messages essential for the well-being of infants attending PHC clinics in Duncan Village, were identified. The final step in the analysis process was the formulation of message topics based on these key-factors. During the analysis process it became clear that some of the identified key factors were not suitable for the formu lation of nutrition-related message topics but rather give insight into the total context of the mothers attending the clinics in Duncan Village. It was evident that the information contained in the key factors could be used by health workers to identify and assist vulnerable mothers. These key-factors led to the formulation of relevant help topics. Eighteen main message topics and 16 help topics were formulated. The message topics included topics on: self-development, household food security, breastfeeding, good feeding practices, mothers' health and nutrition and hygiene practices. in Phase 2 of the study the accessibility of services, including nutrition-related messages, to mothers attending PHC clinics in Duncan Village was determined. This was done by determining how mothers inDuncan Village experience the clinics where they could be exposed to nutrition-related messages and by determining the experiences of health care workers with mothers as clients as well as with service delivery. This information was obtained through focus group discussions with different participant categories. These categories included mothers with children in the same age groupings as in Phase I who had either attended clinic for all the child's immunisations or who had not attended clinic for all the child's immunisations or who had attended clinics outside Duncan Village for immunisation purposes. Pregnant women who had either attended antenatal clinics or had not attended antenatal clinics were also included. The last participant category involved health workers. This category included health workers from the obstetric unit where mothers from Duncan Village give birth, the primary health care clinics and community health care workers. The data obtained was analysed with ATLAS/ti, computer software specifically designed for qualitative data analysis. Twelve code families were created during the analysis process, each family referring to a specific aspect of accessibility of services provided at the PHC clinics. A detailed description of each code family is presented after which six networks were compiled. The data and networks were used to create a framework for data interpretation. According to the framework it is proposed that the final elements in the process of providing accessible nutrition-related messages to clients at clinics are (1) that the clients must attend the clinic and (2) that appropriate nutrition-related messages must be available. Problems with interpersonal and organisational aspects of service delivery were found to be two of the most important aspects that influence accessibility of clinic services and therefore nutrition-related messages at the clinics. The last phase of the study (Phase 3) involved the formulation of recommendations to the relevant authorities about targeted and relevant nutrition-related message topics to be included in the education of mothers and pregnant women as well as recommendations to optimise accessibility of nutrition-related messages at the three PHC clinics in Duncan Village and the obstetric unit where mothers of Duncan Village give birth. A total of fifteen recommendations were formulated based on the frndings and recommendations of Phase I and Phase 2. These recommendations focus especially on the necessity for the municipality to create a health empowering environment at the clinics, on the provision of appropriate nutrition-related messages at the clinics and on the need to reach vulnerable mothers. The importance of involving the community in these processes was also emphasised in the recommendations. It is concluded that the implementation of the recommendations will contribute to the nutritional well-being of all young children in Duncan Village and could play an important role in realising the rights of children living in the area.
Probiotics, prebiotics and synbiotics use in neonates : a critical appraisal of the evidence and evaluation of its application by the food industry
(Stellenbosch : Stellenbosch University, 2014-04) Mugambi, Mary Letizia Nkatha; Blaauw, Renee; Young, Taryn; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Interdisciplinary Health Sciences. Human Nutrition.
ENGLISH ABSTRACT: Background: Synbiotics, probiotics and prebiotics are being added to infant formula. This study was an in-depth evaluation of research on infants fed infant formula containing synbiotics, probiotics or prebiotics and was carried out in two phases. Phase one included two systematic reviews that assessed if synbiotics, probiotics or prebiotics led to improved growth and clinical outcomes in formula fed full term and preterm infants. Phase two included two studies: A systematic review compared the methodological quality and outcomes of industry and non-industry sponsored randomized controlled trials (RCTs) and a descriptive study evaluated how the food industry applies the knowledge and evidence gained from probiotics, prebiotics or synbiotics research in infants. The research questions were: Does the consumption of probiotics, prebiotics or synbiotics supplemented infant formula lead to improved clinical outcomes in infants? Is there an association between source of funding and methodological quality, clinical outcomes and author’s conclusions in trials using probiotics, prebiotics or synbiotics supplemented formula in infants? Does the food industry use the evidence gained through probiotics, prebiotics and synbiotics research trials on infants for the benefit of the general paediatric population? The hypotheses were: Consumption of probiotics, prebiotics or synbiotics by infants leads to improved clinical outcomes; The source of funding in research trials using probiotics, prebiotics or synbiotics supplemented formula in infants is associated with outcomes in favour of the sponsor’s products and authors’ conclusions; Methodological qualities of non-industry sponsored trials are equivalent to industry sponsored trials; Evidence gathered through probiotics, prebiotics and synbiotics research is implemented by the food industry. Methods: Phase one: Both systematic reviews on preterm and full term infants: Cochrane methodology was followed using RCTs which compared preterm or full term formula containing probiotics, prebiotics or synbiotics to conventional infant formula with / without placebo among healthy preterm or full term infants. The mean difference (MD) and corresponding 95% confidence intervals (CI) were reported for continuous outcomes, risk ratio (RR) and corresponding 95% CI for dichotomous outcomes. Phase two: In the systematic review, Cochrane methodology was used to assess the risk of bias of included RCTs. Association between source of funding and risk of bias, clinical outcomes and conclusions were assessed. In the descriptive study, all listed companies that manufacture infant food products with added synbiotics, probiotics or prebiotics for infants were identified and invited to participate. A letter of invitation was sent and if they expressed willingness to take part in the study, a questionnaire with a written consent form was sent. Descriptive statistics and associations between categorical variables were to be tested using a Chi-square test. Results: Phase one: Review on preterm infants: 8 studies were included. Probiotics increased stool frequency with no effect on other clinical outcomes. Prebiotics increased stool frequency and bifidobacteria counts only. Review on full term infants: 25 studies were included. Synbiotics improved stool frequency but had no effect on other clinical outcomes. Probiotics did not have an effect on any clinical outcome. Prebiotics increased weight gain and stool frequency with no effect on other outcomes. Phase two: Systematic review: 67 studies were included, majority were funded by food industry. There was no significant association between the source of funding and four domains (sequence generation, allocation concealment, blinding, selective reporting), majority of reported clinical outcomes or authors’ conclusions. Source of funding was significantly associated with two domains (incomplete outcome data, free of other bias), antibiotic use and conclusions on weight gain. Descriptive study: 25 companies were identified and invited to participate. No company agreed to participate in the survey for different reasons. Conclusions Phase one: Review on preterm infants: There is not enough evidence to state that supplementation with probiotics or prebiotics results in improved growth and clinical outcomes in exclusively formula fed preterm infants. Review on full term infants: There is not enough evidence to state that supplementation of term infant formula with synbiotics, probiotics or prebiotics does result in improved growth or clinical outcomes in term infants. There is no data available to establish if synbiotics are superior to probiotics or prebiotics. Phase two: Systematic review: In RCTs on infants fed infant formula containing probiotics, prebiotics or synbiotics, the source of funding does not influence majority of outcomes in favour of the sponsors’ products. More non-industry funded research is needed to further assess the impact of funding on reported clinical outcomes and authors’ conclusions. Descriptive study: Due to companies refusing to participate in this study, no conclusion could be drawn on how the food industry applies evidence gained through probiotics, prebiotics or synbiotics research on infants. More transparency is needed from the infant formula manufactures on how they apply the evidence gained from probiotic, prebiotic or synbiotic research on infants.
The role of a multi-strain probiotic in very low birth weight premature infants
(Stellenbosch : Stellenbosch University, 2024-03) Sowden, Marwyn; van Niekerk, Evette; van Weissenbruch, Mirjam; Bulabula, Andy; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Human Nutrition.
ENGLISH SUMMARY: Background: Researchers have established that the preterm neonate is born with an immature gastrointestinal tract. The preterm neonate is thus susceptible to various complications often seen in the neonatal intensive care unit, e.g. feeding intolerances, necrotising enterocolitis, and hospital-acquired bloodstream infections. These complications can be life-threatening, and if survived, can have an unfavorable effect on the neonate’s growth and development. Aim: The aims of this narrative review article were to provide an in-depth understanding of the various factors contributing to the development of the preterm neonatal microbiome. Further, we reviewed gastrointestinal microbiome dysbiosis and its potential role in the development of feeding intolerances, necotising enterocolitis, and hospital-acquired bloodstream infections. Lastly, we described the potential role of probiotics in this vulnerable population. Methods: A PubMed database search was conducted identifying articles that describe the development and function of the neonatal microbiome, the role of gastrointestinal dysbiosis, and the development of neonatal complications as well as the role of probiotics in gastrointestinal dysbiosis. Results: Various maternal, neonatal, and environmental factors play a role in the development of gastrointestinal dysbiosis in the preterm neonate. This can lead to feeding intolerances, necrotising enterocolitis, and hospital-acquired bloodstream infections. Discussion: The pathogenesis of the development of short-term complications in the preterm neonate can be linked to the immaturity of the host immune system as well as alterations seen in the intestinal microbiome. There is a growing body of evidence that probiotics can play a role in preventing dysbiosis and thus complications observed in the preterm neonate. However, the optimal combination of probiotic strains and dosage still needs to be identified.
The role of agricultural biodiversity, dietary diversity, and household food security in households with and without children with stunted growth in rural Kenya
(Stellenbosch : Stellenbosch University, 2014-04) M'Kaibi, Florence K.; Steyn, Nelia; Ochola, Sophie; Du Plessis, Lisanne; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Interdisciplinary Health Sciences. Division of Human Nutrition.
ENGLISH ABSTRACT: Research aim The study aimed to explore the associations between agricultural biodiversity, household food security and dietary diversity in households with children aged 24 to 59 months in two rural areas of Kenya, of which one had higher rainfall and agricultural biodiversity than the other. Methods Study sample and location The study adopted a cross-sectional analytical approach to investigate the associations in resource in poor households in two rural areas; Akithii and Uringu of Kenya. Of the 525 households randomly selected, 261 were from Uringu division and 264 from Akithii division. Two independent cross-sectional surveys were conducted; Phase one in September to October 2011 (during the dry season) while Phase 2 took place in March 2012 (during the rainy season). A questionnaire was developed to gather information on the socio-demographics of the household, breastfeeding and infant feeding practices, immunization and childhood illnesses. Dietary intake was measured during each season by conducting a repeated 24-hour recall (24-hr recall) with the mother/care giver of the household. A nutrient adequacy ratio (NAR) was calculated for each nutrient as the percent of the nutrient meeting the recommended dietary intake (RDI) value for that nutrient. A mean adequacy ratio (MAR) was calculated for 11 nutrients as the mean of the NARs of these nutrients. Dietary diversity was measured using data from the 24-hour recalls and classifying it into nine food groups. A dietary diversity score (DDS) was calculated based on each different food group which was consumed during the period of recall up to a maximum of nine if the food had been consumed from each of the nine groups. Household food security (HFS) was measured using the Household Food Insecurity Access Scale (HFIAS). The agricultural biodiversity was calculated by counting the number of different crops and animals eaten either from domestic sources or from the wild. Weight and height measurements of children and their mothers/care givers were taken. Weight for age (WAZ), height for age (HAZ) and weight for height z (WHZ) scores were determined for children, while body mass index (BMI) measurements were calculated for the adult women. The relationships between continuous response variables and nominal input variables were analyzed using appropriate analysis of variance (ANOVA) or pooled, paired and independent mean T-tests when only two groups were involved. Results Dietary intake was low with the majority of households not meeting the RDIs for most nutrients. The MAR was 61.3%; 61.8% for Phase 1 and 2 respectively. The DDS was low at 3.3 ±1.2 for both Phases. The majority of households were food insecure with a HFIAS mean of 12.8 ± 6.19 and 10.9 ± 7.49 for Phase 1 and 2 respectively. Agricultural biodiversity was low with a total of 26 items; 23 domesticated and 3 from the natural habitat. Two food items from the natural habitat originated from plants and one from animals. Exclusive breastfeeding up to the recommended six months was practiced at low rates of 23.4% while 39.3% of mothers in both divisions introduced complementary foods before 6 months of age. Stunted growth among the children was high at a mean of 30.5% (n=291). Boys had higher stunted growth rates in both divisions compared to the girls. A significant positive relationship was established between the number of contributors to household income with height for age z-scores (HAZ) scores of the children (Spearman r=-0.15, p=0.02). The number of household assets also significantly influenced HAZ scores (Spearman r=-0.17, p=0.01), the higher the number of household assets, the lower HAZ scores were. During Phase 1 (dry season) (pooled t-test, p<0.001), levels of food insecurity were higher compared to Phase 2 (wet season) (pooled t-test, p<0.001); showing the influence of season on food security. Phases 1 & 2 showed that Akithii had a significantly higher level of food insecurity (Mann-Whitney U; p<0.01), and a lower DDS (chi-square test, p<0.001) compared to Uringu. Children in Akithii consumed a less diversified diet than those in Uringu. Agricultural biodiversity was positively and significantly related to: HFIAS (Spearman r=-0.10, p=0.02); DDS (ANOVA, p<0.001); all NARs (Spearman, p<0.05) and MAR (Spearman, p<0.001).This implies that households with higher agricultural biodiversity were more likely to be food secure, have higher dietary diversity levels and a diet comprising a higher nutritional value. DDS was significantly correlated to MAR and NARs of all the nutrients studied in this study. Findings showed that DDS was also consistently significantly inversely correlated to Household Food Insecurity Access Prevalence (HFIAP) (R =-0.185, t (N-2)-3.889), p=0.0001). This correlation showed that an increase in dietary diversity inversely affected HFIAS. A significant relationship was found between HFIAP and MAR (ANOVA, p=0.00268); indicating that households with a higher MAR were more likely to be food secure. There was a significant correlation between the BMI of the mother/care giver and the WAZ scores of the children (r=0.1410, p<0.001); indicating that higher HAZ scores were found in mothers with higher mean BMI values. There was a significant difference between households with and without children with stunted growth in DDS (ANOVA; p=0.047) and HFIAS (ANOVA; p=0.009) but not with agricultural biodiversity score (ANOVA; p=0.486). The agricultural biodiversity mean score for households with children presenting with stunted growth were, however, lower at 6.8, compared to 7.0 for those with normal growth however the p value was not significant. This indicates that households with children with stunted growth and those without are significantly different in DDS and HFIAS but not regarding agricultural biodiversity. This further implies that the potential of DDS and HFIAS to be used as proxy measures for stunting be further explored. Conclusion Agricultural biodiversity has a positive impact on household food security, dietary diversity, dietary adequacy and child growth. Food security is closely linked to dietary diversity and dietary adequacy; therefore improving one is likely to improve the other two and impact positively on child growth status. Interventions to improve child health and food security in resource poor rural households should aim at increasing dietary diversity through agricultural biodiversity.
Support for exclusive breastfeeding in the workplace : development of a practice model for designated workplaces in the Breede Valley sub-district, Western Cape Province, South Africa
(Stellenbosch : Stellenbosch University, 2020-03) Daniels, Lynette Carmen; Mbhenyane, Xikombiso; du Plessis, Lisanne Monica; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Human Nutrition.
ENGLISH SUMMARY: Globally, mothers have identified employment as one of the leading barriers to exclusive and continued breastfeeding. This study aimed to develop a practice model to support exclusive breastfeeding for working mothers. The study was conducted with participants from designated workplaces in the Breede Valley sub-district, Western Cape, South Africa. An explanatory, sequential, mixed methods research design was employed, comprising a quantitative, descriptive, cross-sectional study (phase one), followed by a qualitative, multiple case study (phase two), and the development and validation of a practice model (phase three). In phase one an online survey was conducted to assess current breastfeeding support practices. In phase two, data was collected at nine purposively selected workplaces, using focus group discussions (FGDs) and in-depth interviews. FGDs were also conducted with employed breastfeeding mothers from designated workplaces who exclusively or predominantly breastfed their children for any period up to six months. In phase three, the practice model was developed, drawing on the analysis of data from phases one and two and making use of programme theory approaches and logic models. The draft model was sent to 11 experts. After input from the two modified Delphi rounds had been received and amendments to the model had been made, it was presented for feedback to the nine participating workplaces during four FGDs and one in-depth interview. A response rate of 36.8% (14/38) was achieved for the online survey. The results revealed that arrangements surrounding breastfeeding in designated workplaces were limited and inadequate, with few support practices. Onsite or nearby crèche facilities (n=2, 14.3%), breastfeeding counsellors (n=1, 7.1%), promotion of the benefits of breastfeeding to employees (n=2, 14.3%) and provision of private space for expressing (n=2, 14.3%) were not common practice. Workplace breastfeeding policies (n=4, 28.6%) were not readily available, and were mostly found in the public sector. Forty-three percent of workplaces (n=6, 42.9%) did not allocate time for expressing breastmilk at work. Phase two revealed that employees viewed their workplaces as unsupportive in terms of providing breastfeeding time and designated spaces for expressing breastmilk. Returning to work was viewed as challenging, mainly because of the unsupportive attitudes of co–workers and supervisors and a lack of space and time to express breastmilk. The challenges reported by managers related to the absence of appropriate space and infrastructure, as well as the resources to finance what was needed. The majority of managers claimed that they valued a supportive workplace environment and a culture of caring focusing on staff wellness. They regarded themselves as flexible (including in respect of allowing employees personal time). This was in conflict with employees’ views. Employees felt that their employers were unsupportive, strict and un-accommodating with regard to the provision of time for expressing, mentioning that they mostly used their lunch and tea breaks. Participants were positive about the final practice model and viewed it as informative and well designed. They were positive that the model would be feasible and commended the tiered approach to implementation. The model was perceived as an ideal tool to use, if accompanied by some training. The study showed that legislated breastfeeding breaks are poorly implemented or mostly absent, mainly due to widespread ignorance of breastfeeding rights in the formal sector. There is an urgent need for advocacy around creating an enabling workplace environment for breastfeeding. The practice model has the potential to be locally applied and will be of particular use to workplaces that want to initiate and/or strengthen breastfeeding support.

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