Doctoral Degrees (Dietetics And Human Nutrition)

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Dietary intake and nutritional status of primary school children participating in the Botswana school feeding programme, South-east District, Botswana.
(2019) Eluya, Malebogo.; Kassier, Susanna Maria.; Veldman, Frederick Johannes.
Introduction: Optimal nutrition is essential for the growth and development of primary school children. School-based nutrition interventions, especially in resource limited settings, are important for addressing health problems and the improvement of health, as well as nutritional and educational outcomes. The majority of African countries such as Botswana, are currently experiencing nutrition transition. This concept contributes to the double burden of malnutrition (undernutrition and overnutrition) among children. A change in dietary habits, the adopotion of a sedentary lifestyle, and limited dietary diversity are the some of the outcomes linked to the nutrition transition. . Aim: To determine the effect of the Botswana School Feeding Programme (SFP) (all government schools) on the nutritional status of primary school children in the South-east District when compared to non-beneficiaries of the SFP (private schools). Study design: A school-based, comparative cross-sectional study was conducted among primary school children during the school term and immediately after the school holiday (period of no SFP). Setting: This study was conducted in 13 public and private schools located in urban and peri-urban areas in the South-east District, Botswana. Subjects: 392 sampled primary school learners from public and private schools aged 8 – 13 years of age were sampled. Outcome measures: SFP impact was assessed using household food insecurity status (HFIAS), dietary diversity score (DDS) and anthropometric indices such as weight-for-age (WAZ z-scores), height-for-age (HAZ z-scores) and Body Mass Index-for-age (BAZ z-scores). For the calculation of WAZ, the Centre for Disease Control (CDC) tables were used to interpret weight-for-age of learners older than ten years, as WAZ is only available for children up ten years of age on the World Health Organization (WHO) growth standards. Results: Significant differences (p<0.000) were documented for SFP beneficiaries (intervention) versus non-beneficiaries of the SFP (control) for mode of transport to school, HFIAS and DDS. Significant differences (p<0.000) were also found when comparing urban to peri-urban learners for mode of transport to school, HFIAS and DDS. However, a significant difference between beneficiaries of the SFP (intervention) versus non-beneficiaries of the SFP (control) was not documented for Physical Activity Level (PAL), whereas the PAL of peri-urban learners was significantly higher than that of urban learners (p<0.001). Learners participating in the SFP were receiving inadequate energy, macro- and micronutrient from the food rations provided, as they only received 60% of the Dietary Reference Intake (DRI) for energy, 90% of the Recommended Dietary Allowance (RDA) for protein, 46% of the Estimated Average Requiremment (EAR) for vitamin A and 28% of the Adequate Intake (AI) for calcium when comparing the ration scale to 33% of the DRIs. Discussion: The low DDS of learners participating in the SFP indicated that school meals did not make a significant contribution to the DDS of its beneficiaries. When comparing SFP beneficiaries to SFP non-beneficiaries, despite the fact that the majority of learners in both groups had a normal BAZ, the disparity became more evident for those being at risk for becoming overweight. Nearly a third (29.0%) of non-beneficiaries were at risk for become overweight, whereas the same held true for 18.8% of beneficiaries. A similar trend was echoed when comparing the WAZ between the two groups, as the difference was significant. When comparing the WAZ between urban and peri-urban learners, a significant difference was documented, with learners from urban areas having a lower prevalence of normal weight and a higher risk of becoming overweight than their peri-urban counterparts. In addition, recipients of the SFP had a higher prevalence of underweight when compared to non-beneficiaries. A nutrient analysis of the SFP ration scale indicated that it supplied inadequate levels of energy, protein, vitamin A and calcium. Conclusion and Recommendations: The study findings emphasise the need for targeted school feeding and community-based nutrition interventions and public health awareness campaigns to create an awareness of the importance of eating a diverse diet and being aware of the importance of being physically active for the promotion of health and wellbeing, as well as for the prevention of overweight and obesity among primary school learners. Although learners attending public schools in urban and peri-urban areas as well as private schools may face diverse nutritional challenges as a result of differences in socio-economic status and available resources, it is evident that the dietary diversity and prevalence of overweight and obesity among primary school learners attending both public and private schools in the South-east District, Botswana, requires special attention. Participation in the SFP and resultant food security, may have a positive impact on learner anthropometric status as indicated by the low prevalence of undernutrition and stunting documented in this study sample. In addition, as the BAZ categories did not differ significantly.
Effect of malted sorghum-based porridge on nutritional status of moderately malnourished breastfed infants and young children aged 6 to 18 months in Arua, Uganda.
(2019) Kajjura, Richard Stanley Bazibu.; Kassier, Susanna Maria.; Veldman, Frederick Johannes.
Moderate acute malnutrition (MAM) among infants and young children (IYC) has a negative impact on their immature digestive system and requires an energy rich, nutrient dense supplementary food to reverse the condition and promote catch up growth and development. In this study, a malted sorghum-based porridge (MSBP) was formulated using locally available ingredients. It was subsequently used as a supplementary food in the management of IYC with MAM to determine whether it could serve as an alternative supplementary porridge when compared to fortified corn soy blend (CSB+), the standard care for managing IYC with MAM in Uganda. The effect of MSBP supplementation, in conjunction with nutrition education, on the nutritional status of IYC with MAM was determined. In addition, maternal knowledge regarding appropriate complementary feeding and hygiene practices were determined before the supplementation intervention commenced (baseline), as well as after the completion of the three month intervention period. In addition, the study also determined maternal perceptions regarding the MSBP versus CSB+, as well as perceived barriers encountered in the course of the intervention. Hence the study developed an acceptable energy rich and nutrient dense MSBP for managing MAM. The MSBP was formulated (using estimated values generated by NutVal software) from malted sorghum flour and extruded soy-maize flour. Four formulations estimated to meet the specifications of a supplementary food for treatment of IYC with MAM (in accordance with World Health Organisation criteria), were subsequently assessed for consumer acceptability. Analysis of variance was used to compare the acceptability scores and viscosity level of four different MSBP formulations to test for significant differences between mean scores. The four formulations had significantly different (p<0.05) acceptability scores for flavour, taste, mouth feel, sweetness and overall acceptability. The best formulation had significantly (p<0.05) higher mean acceptability scores. In addition, the best MSBP formulation had a significantly (p<0.05) higher energy and nutrient content than CSB+. At a flour rate of 25%, this formulation also had the best energy density, protein density and viscosity of 1.6kcal/g, 4g/100kcal and 2809cP respectively. The results showed that a quarter sorghum malt mixed with three quarters of extruded soy-maize, produced an energy rich, nutrient dense MSBP with acceptable sensory attributes at optimal viscosity. The best formulated MSBP met the energy, protein and viscosity level requirements for the management of IYC with MAM. To evaluate the efficacy of MSBP in alleviating malnutrition among IYC with MAM, the intervention component of the study established maternal socio-demographic characteristics and associated complementary feeding practices at baseline. A cross sectional community assessment was conducted among 204 randomly sampled breastfeeding mothers of IYC aged 6 to 18 months with MAM in four out of eighteen sub counties in Arua district, Uganda. Multivariate logistic regression analysis showed that maternal level of education as well as that of the head of the household, were significantly associated with IYC minimum meal frequency (p=0.003) and (p=0.023) respectively. In addition, maternal care, determined in terms of the preparation of food such as porridge especially for the IYC, was also significantly associated with minimum meal frequency (p<0.001) and with the IYC food intake meeting that of a minimum acceptable (p=0.004). These findings suggested that optimal complementary feeding practices in terms of minimum dietary diversity, minimum meal frequency and minimum acceptable diet were not met by the majority of IYC with MAM. The baseline study was followed by evaluating the effect of MSBP and CSB+ in combination with nutrition education, on the anthropometric status and blood haemoglobin levels of IYC aged 6 to 18 months diagnosed with MAM. A double blind cluster randomised control trial was conducted with 204 mother-IYC pairs, with a cluster consisting of nine to ten pairs per parish where mothers consented to participate (Appendix B, p197). A daily ration of 150g of either MSBP or CSB+ was fed to IYC for ninety days. Weekly anthropometric measurements (weight, length and mid-upper arm circumference) of IYC were conducted, whereas haemoglobin levels were determined only at baseline and at the end of the study. A comparison between mean anthropometric outcomes namely weight gain, length gain, length-for-age z-scores, weight-for-age z-scores, length-for-weight z-scores, and mean blood haemoglobin levels in the treatment (MSBP) and control (CSB+) groups were determined using the independent t-test. Proportions of the anthropometric and haemoglobin levels in the treatment and control groups were determined using the z-test. At three months, the mean weight-for-age z-score of IYC in the treatment group was significantly higher than in the control group (p=0.01). The change in mean blood haemoglobin levels was significantly smaller in the treatment group when compared to that of the control group (p=0.01). No significant difference was observed in the proportion of IYC who recovered from MAM between the treatment group and control group (p=0.055). Thus, MSBP supplementation of IYC with MAM resulted in comparable recovery rates to CSB+ in terms of weight-for-length and improved blood haemoglobin levels. Therefore, MSBP could be considered as an alternative to CSB+ in the management of breastfed IYC with MAM. The effect of nutrition education on the feeding and hygiene practices of mothers with IYC with MAM being supplemented with either MSBP or CSB+, was also determined. A cross-sequential study using a pre-test-post-test design was used among the 204 mothers in the 24 clusters. Mothers’ knowledge, complementary feeding and hygiene practices were analysed as mean scores before and after the intervention. The paired t-test was used to determine the differences between baseline and end line mean scores for knowledge and practices. Mothers’ mean knowledge scores regarding complementary feeding in terms of dietary diversity and meal frequency were significantly higher at end line compared to baseline (p<0.001). Maternal practices regarding food safety and water quality was significantly higher at end line compared to baseline (p<0.001). Thus, nutrition education of mothers in combination with supplementing their IYC with either MSBP or CSB+, improved meal frequency, dietary diversity, water quality, and food safety. Lastly, maternal perceptions and barriers experienced while using either MSBP or CSB+ to manage their IYC with MAM was determined via qualitative research techniques. A qualitative study using, focus group discussions (FGD) and in depth interviews (IDI) was conducted among mothers a week after completion of the three months supplementation period. One hundred eight mothers were purposively sampled to participate in 12 focus group discussions. This was followed by selecting 48 mothers to participate in IDI. Five FGD were conducted with mothers whose IYC were fed CSB+, while the remaining seven FGD included mothers whose IYC were fed with MSBP. The qualitative data on maternal perceptions and barriers were analysed using an inductive approach. The results showed that both MSBP and CSB+ were perceived as being responsible for IYC weight gain, reduction in illness, improved appetite, glowing healthy skin, and improved active play. Hence, mothers had positive attitudes towards using MSBP and CSB+. Collectively, the perceived barriers mothers encountered during the supplementary feeding intervention included household chores, limited time to feed IYC regularly, limited household income and household food insecurity in addition to minimal social support from household members. Mothers believed in the use of MSBP and CSB+ in the management of their IYC with MAM and were satisfied with the health benefits such as weight gain and improved appetite observed among their IYC. However, factors contributing to maternal stress should be addressed by improving household food security status and the distribution of an even workload among household members so that IYC with MAM can reap maximum benefits from supplementary food interventions. Overall, this study provided an opportunity to gather additional evidence regarding the use of a locally formulated energy rich, nutrient dense supplementary porridge MSBP with suitable consumer acceptability, energy content and nutrient density in the management of IYC with MAM. Nevertheless, nutrition service providers of supplementary foods in the management of IYC with MAM should endeavour to educate mothers on potential barriers they may encounter in the course of intervention strategies for the management of MAM. This should include potential socio-care barriers, in addition to emphasising the health and nutrition benefits of the supplementary foods for their IYC.
The effect of therapeutic feed in the management of severe acute malnutrition in children, South Africa.
Botha, Maria Magdalena.; Veldman, Frederick Johannes.; Kassier, Susanna Maria.
Globally, 14.3 million infants and young children (IYC) suffer from severe acute malnutrition (SAM), with 75% living in low and low-middle income countries like South Africa (SA). Inpatient management of SAM forms an essential component of SAM treatment among IYC. In SA, the SAM treatment protocol is based on the World Health Organization (WHO) Ten Steps to the Successful Management of SAM. As a result of SA efforts, the SAM mortality rate decreased from 12,7% in 2012 to 8% in 2017, being below the global and national target of 9%. The study aim was to determine if compliance with the national SAM treatment protocol improves SAM treatment outcomes. A multi-centre prospective, descriptive and comparative observational study was employed. IYC hospitalized for SAM treatment (N=245) were conveniently sampled. The study sample comprised of 150 males (61.2%) and 95 females (38.8%) with a mean age of 14.6 ± 8.2 months. Mean admission and discharge weight, heightfor- age and MUAC was 6.63 ± 1.89kg and 7.03 ± 2.02kg; 66.16 ±16.06 cm and 71.29 ± 11.47 cm, and 11.38 ±2.35cm and 11.51±2.35cm. There was a significant difference between mean admission and discharge weight (p= 0.0278) and height-for-age (p= 0.0005), with no significant difference between admission and discharge MUAC (p= 0.6533). Prevalence of mild, moderate and severe oedema was 21.7%, 11.1% and 8.2% respectively. The study sample had a mortality rate of 6.1%. SAM treatment was complicated by LARIs, sepsis, HIV, TB, anaemia, herbal intoxication, vomiting, hypoglyceamia and cerebral palsy. Using the designed scoring tool, overall compliance with the SAM treatment protocol was 63.1%, with 98.6% compliance with admission and 4.4% compliance with discharge standards. Nearly three out of ten (27.2% of households) were food insecure, of which 14.6% were moderately and 10.7% severely food insecure. Food insecurity was associated with delayed recovery from oedema (X2= -0.235; 0.035) and diarrhoea (X2= -0.199; 0.037), inadequate daily weight gain of less than 10g/kg/day (X2= -0.190; 0.003) and IYC mortality (X2= -0.131; 0.522). These associations define HHFIS as a predictable risk factor for poor SAM treatment outcomes, recovery and possible mortality. Compliance with the SAM treatment protocol was average (61.3%), with premature discharge, increasing the risk for relapse, readmission and mortality. A cyclic link between HHFIS and the outcome of inpatient management of SAM should be considered when revising and updating national SAM treatment protocols.
Nutritional status and quality of life in HIV positive pre- and post- kidney transplant recipients, from HIV positive donors.
(2019) Martin, Claire Juliet.; Kassier, Susanna Maria.
Background: Kidney transplantation from a HIV-positive donor to a HIV-positive recipient is now a treatment option available for patients with ESRD. Impairments in nutritional status are common, and increase the risk of adverse clinical and health-related quality of life (HRQOL) outcomes. Therefore Optimising nutritional status is therefore an important adjunct of medical care that begins with a nutritional status assessment. Aim: To describe the nutritional status and HRQOL of HIV-positive kidney transplant recipients from a HIV-positive donor and candidates on the waiting list to receive one. Objectives: To determine nutritional status through the assessment of body composition, bone mineral density (BMD), dietary intake, biochemical indicators and gastrointestinal symptoms (GIS). To determine HRQOL based on the patient’s perception of their health. Methods: The frequency and severity of GIS was determined using a previously validated questionnaire; the gastrointestinal symptom rating scale (GSRS). BMD and body composition were measured by dual-energy x-ray absorptiometry (DEXA). Dietary intake was evaluated using a 24-hour recall. Biochemical indicators of albumin, prealbumin fasting glucose, lipids and serum 25-hydroxyvitamin D [25(OH)D] were analysed. Adiposity and musculature were determined through anthropometric indices of weight, body mass index (BMI), waist circumference (WC) and mid-arm muscle circumference (MAMC). HRQOL was assessed using a validated questionnaire; the Short form-36 (SF-36) and semi-structured interviews. With the exception of DEXA, all other assessments were done at baseline and at six months. Results: The study sample consisted of 76 participants (n=22 transplant recipients, n=54 transplant candidates), who were predominantly black (93.4 %) and male (60.5%), with a mean age of 43.6 ± 8.1 years. The frequency of GIS was high for both groups. Indigestion was a frequent and severe GIS. Amongst transplant candidates, females had significantly higher GSRS severity scores for selected subscales and the overall global mean score (p=0.030) compared to males. Age and duration of treatment correlated with selected subscales in transplant candidates. WC correlated positively with constipation amongst transplant recipients. BMD was assessed in 56 participants. Osteoporosis was more prevalent amongst transplant recipients (20.0%), while osteopenia was more prevalent amongst transplant candidates (27.8%). T-scores strongly correlated with lean mass at the BMD of the spine (r = 0.707, p = 0.007), and moderately with each side of the total hip (r = 0.455, p = 0.007 and r = 0.420, p = 0.007). Serum 25(OH)D vitamin D levels was low for the group as a whole, with a mean of 22.04 ±12.74 ng/ml, and was not related to BMD. There was a significant positive association between dietary calcium and all BMD sites for transplant recipients. In a subset of participants (n = 34), there was a significant positive association between anthropometry and DEXA derived indices of adiposity. These were BMI and percent body fat (%BF) (r = 0.773, p < 0.001), WC and truncal fat (TF) (r = 0.799, p = 0.00) and visceral adipose tissue (VAT) (r = 0.885, p < 0.001). The indicator of muscularity (MAMC) correlated with appendicular lean mass index (ALMI) (r = 0.511, p = 0.011), establishing these anthropometric indices as suitable proxy measures of overall and regional adiposity (including visceral adipose tissue) as well as musculature. The majority of transplant candidates were overweight (38.5%), or had normal BMI (36.5%) At six months, 62.7% had a statistically significant weight loss t (50) = 2.072, p = 0.043). Metabolic syndrome (MetS) was present in 47.5% and 51.0% of candidates at baseline and six months respectively. The mean daily energy and protein intake were below recommendations for dialysis. The majority of transplant recipients had a normal BMI (71.4%). At six months, 52.4% showed a weight gain trend and a significant increase in WC (t (14) = -2.861, p 0.013). MetS was present in about 35% of transplant recipients. At baseline, weight correlated with total protein (r = 0.609, p = 0.003), animal (r = 0.513, p = 0.017) and plant protein (r = 0.534, p = 0.013) intake. At six months, WC correlated with animal protein (r = 0.517, p = 0.028) intake. 68 patients completed the SF-36 at baseline and 6 months. Transplant candidates had lower HRQOL than recipients. The main mental stressors were income, employment and waiting for a donor. Physical health complaints were body pain and fatigue. In transplant recipients, the composite physical and mental scores were above the average for the general population. Prealbumin, BMI, albumin and MAMC showed positive correlations with selected SF-36 domains. Conclusion: A series of studies showed altered nutritional status and HRQOL in a substantial proportion of transplant candidates and some transplant recipients. These results can be used to improve nutritional status and hence optimise graft and patient outcomes.

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Browsing Doctoral Degrees (Dietetics And Human Nutrition) by Author "Kassier, Susanna Maria."