Doctoral Degrees (Dietetics And Human Nutrition)

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Developing and assessing the appropriateness of the preliminary food-based dietary guidelines for South Africans.
(2002) Love, Penelope Valmai.; Maunder, Eleni Maria Winifred.; Green, Jannette Maryann.; Ross, Fiona.
Aim. The aim of this study was to document and provide a critical analysis of the South African Food-Based Dietary Guidelines (FBDGs) development process, and to assess the appropriateness of the proposed South African FBDGs. To achieve this aim, specific study objectives included the following : (1) To document and critically analyse the South African FBDGs process in relation to the 10-step development process recommended by the FAO/WHO. (2) To assess the appropriateness of the proposed South African FBDGs in terms of consumer comprehension (perceptions, general understanding and specific interpretations), and application of the guidelines (ability to apply the guidelines when planning a typical day' s meals for their families). (3) To assess the compatibility of the proposed South Africa FBDGs in terms of food categorisation as perceived by consumers, and as depicted in the food guides that are commonly used. Methodology. An extensive literature review on the development of international dietary guidelines, the emergence of FBDGs and the FAO/WHO FBDGs process, together with documentation of the South African FBDGs process, was used to critically analyse the process used for developing the proposed South African FBDGs. Focus group discussions (n=15) and structured individual interviews (n=230) were held in ten magisterial districts within KwaZulu Natal (KZN), randomly selected according to settlement strata (rural, urban informal, urban formal) and ethnicity (Black, Indian, White) to reflect the KZN population. Participants were women with no formal nutrition training, who made the food purchasing and preparation decisions in the household. A total of 103 women participated in the focus group discussions and 230 women in the structured individual interviews. Results. The process followed by the SA FBDG Work Group has ensured that the proposed South African FBDGs are country-specific in that each FBDG is evidence-based and relates to specific nutrition-related public health concerns of South Africans. Except for the "Eat healthier snacks" FBDG, participants understood and interpreted the FBDGs as intended by health professionals, and could construct a day's meals to reflect the FBDGs. Only two other FBDGs were identified as confusing in terms of terminology used, namely, "legumes" and "foods from animals". By rewording these guidelines the FBDGs would be highly compatible in terms of personal food categorisation. Use of food guides was low, mainly due to a lack of knowledge about how to use them. In terms of food categorisation as depicted by the reportedly most commonly used food guides (3- and 5- Food Group Guides), these food guides are incompatible with the proposed FBDGs. Conclusions. Within the South African context, the FAO/WHO FBDGs development process was feasible and practical to implement. However, to ensure sustainability of the South African FBDGs process, it is strongly recommended that the Department of Health appoint a representative scientific committee specifically for the purpose of reviewing and reformulating the South African FBDGs. Results indicate that a single set of FBDGs can be appropriate for all South Africans provided that certain guidelines are reworded as suggested; and that all the guidelines are accompanied by explanatory information citing commonly consumed foods/drinks as well as practical examples of how to apply the guidelines in light of perceived barriers. In terms of the appropriateness of food guides commonly used in South Africa, there is a need to either move away from the concept of food groups and/or to develop a new South African food guide that is compatible with the proposed FBDGs.
Professional development of dietitians completing compulsory community service in South Africa with special focus on KwaZulu-Natal.
(2006) Paterson, Marie.; Green, Jannette Maryann.; Maunder, Eleni Maria Winifred.
Introduction: The aim of this research was to establish the attitudes, knowledge, job satisfaction and professional development of community service dietitians because negative attitudes, poor knowledge, low levels of job satisfaction and poor professional development would be detrimental to the process of community service and ultimately to the provision of health services. Methodology: Three distinct annual intakes of qualified dietitians completing compulsory community service were the subjects of an analytical cross sectional survey conducted biannually for the period 2003-2005. Data collection methods included telephone interviews, mail, emailed questionnaires and focus group discussions. Individual factors: sex, population group, language, university attended; institutional factors: organisation of community service, mentorship rating, hospital manager support type of facility, rural allowance, hospital location, access to resources, working and living conditions and personal safety and other factors: attitude, community nutrition knowledge, job satisfaction and professional development were included in the data set. Management of data: Data were divided into 2003 cohort (n=20) and 2004-2005 cohorts (n=26). Analysis of the demographic details for 2003 and 2004-2005 cohorts were, respectively: mean ages 23.6 (±0.99) and 24.05(±4.96) years, 60 percent and 73 percent white, 90 percent and 96 percent female, 35 percent and 73 percent University of KwaZulu-Natal graduates and 65 percent of both cohorts were placed in rural facilities. Results: Community nutrition knowledge of the 2003 cohort was unacceptable but improved in the 2004-2005 cohort. Subjects had a generally positive attitude towards community service. Community nutrition levels of knowledge of the 2003 ranged between 60 percent at entry and 67 percent at exit and for the 2004-2005 between 72.8 percent and 78.42 percent. The job satisfaction level of the 2003 cohort at exit was 13.65 (±3.573). In the 2004-2005 cohort job satisfaction was 15.75(±3.360) at entry and 15.75 (±3.360) at exit. 85 percent of the 2003 cohort rated their professional development positively whereas 65 percent of the 2004-2005 cohort rated theirs' positively. This decline and associated problems were to some extent shown in the interview responses. The 2004-2005 cohort did however show a tendency for improvement in the professional practitioner ranking (p=0.088). The majority (95%) of the 2004-2005 cohort rated the dietetic services positively. Focus group discussions highlighted problems that the community service dietitian (CSD) encountered such as lack of supervision and support, lack of basic facilities, poor hospital administration, problems with transport, work overload and problem with their professional role in the community and health facility. A model showing the results of the research indicated that the objectives of the Department of Health for improved service in rural areas were obtained but the retention of health professionals and capacity was lost due to annual rotation of subjects. Community service as a strategy to overcome service delivery has merit provided identified problems are addressed.
The tuck shop purchasing practices of grade 4 learners at selected primary schools in Pietermar[it]zburg, South Africa.
(2011) Wiles, Nicola Laurelle.; Green, Jannette Maryann.; Veldman, Frederick Johannes.
Aim: To determine whether the tuck shop purchasing habits of Grade 4 learners were contributing towards the development of childhood overweight and obesity. Objectives: To assess the nutritional quality of the food and beverages available for learners to purchase; items regularly purchased from the tuck shop as well as factors influencing the learner’s decision to purchase these items; the anthropometric and socio-demographic characteristics of grade 4 learners as well as their nutrition knowledge related to the tuck shop items purchased. Method: A survey administered to 11 tuck shop managers, a questionnaire administered to 311 Grade 4 learners and two single-sex focus groups of 5 learners each were conducted. Results: Fifty six percent of the sample were female (n=173) and 44% were male (n=138). Twenty seven percent of the study sample was overweight (n = 83) and 27% were obese (n = 85). Eighty six percent of learners (n = 266) claimed to buy from their school tuck shop. Twenty two percent of learners purchased from their tuck shop at least three times per week (n =58). Learners who purchased from the tuck shop had a significantly higher BMI than those who did not (p = 0.020). Learners who purchased from the tuck shop spent on average R8,38 per day with a minimum of R1 and a maximum of R40 (standard deviation R5.39). The most popular reasons for visiting the tuck shop included “this is my favourite thing to eat or drink” (66.5%, n = 177) and “I only have enough money to buy this item” (47.0%, n = 125). Savoury pies were the most popular "lunch" item for all learners for both food breaks (45%, n = 5 schools and 27.3%, n = 3 schools) selling the most number of units (43) per day at eight of the eleven schools (72.7%). Iced popsicles were sold at almost every school, ranked as the cheapest beverage and also sold the most number of units (40.7). Healthy beverages sold included canned fruit juice and water, while healthy snacks consisted of dried fruit, fruit salad, bananas, yoghurt and health muffins. The average healthy snack contained almost half the kilojoules of its unhealthy counterpart (465kJ vs 806kJ). Nutritional analyses of the healthy lunch options revealed total fat contents that exceeded the DRI and South African recommended limit. Perceived barriers to stocking healthy items included cost and refrigeration restrictions. The average score for the food groups was only 33% indicating that learners were not familiar with the Food Based Dietary Guidelines (FBDG). Further analyses showed that the total knowledge scores of those learners that reported to buy from the tuck shop frequently, was significantly lower when compared to the total knowledge scores of those learners who bought from the tuck shop less frequently (13.0 ± 3.9 and 11.6 ± 3.1, respectively; p < 0.05). Logistic regression analysis confirmed that the total knowledge of a learner could be used to predict whether he or she is more likely to make purchases from the tuck shop (significance = 0.017). Focus group results revealed that learners are aware of “healthy” and “unhealthy” tuck shop items. Most learners stated that they would continue to purchase items from their tuck shop if all “unhealthy” items were removed. Conclusion: Primary school tuck shops of well resourced schools in Pietermaritzburg are contributing to childhood overweight and obesity through a combination of factors. These include the poor nutritional quality of the items stocked at the tuck shop as well as the poor tuck shop purchasing practices. Much consultation is required amongst dieticians, school principals and privatised tuck shop managers to overcome barriers to stocking healthy items. School management and government have an important role to play in imposing restrictions on the sale of unhealthy items; along with improving the quality of the nutrition education curriculum to ensure that learners are able to translate their knowledge into healthier purchasing practices.
Nutritional quality and consumer acceptability of provitamin A-biofortified maize.
(2011) Pillay, Kirthee.; Siwela, Muthulisi.; Derera, John.; Veldman, Frederick Johannes.
Vitamin A deficiency (VAD) is a major public health problem in developing countries, including South Africa. The potential of provitamin A-biofortified maize for use as a complementary strategy to alleviate vitamin A deficiency in developing countries, where maize is the dominant staple food, is currently a subject of research. Although the nutritional composition of white maize is thought to be similar to that of biofortified maize, apart from the differences in provitamin A carotenoid content, the comparative nutritional composition of the two maize types seems not to have been subjected to a comprehensive scientific study. When setting the target level of provitamin A in the provitamin A-biofortified maize, it is important to consider the potential effect of processing on the final provitamin A carotenoid content of the biofortified food products, as the provitamin A carotenoids levels may decrease on processing. Furthermore, the yellow/orange provitamin A-biofortified maize may not be widely accepted by African consumers who are vulnerable to VAD, and are traditional consumers of white maize. This study firstly aimed to evaluate the nutritional composition, including provitamin A composition, and grain quality of provitamin A-biofortified maize varieties, compared to white maize. The second aim was to assess the effect of processing (milling and cooking) on the retention of provitamin A carotenoids and other nutrients in popular South African maize food products prepared with provitamin A-biofortified maize. Thirdly, the study aimed to assess the acceptability of maize food products prepared with provitamin A-biofortified maize by consumers of different age and gender in rural KwaZulu-Natal, South Africa. The grains of the provitamin A-biofortified maize varieties and grain of a white maize variety (control) were analysed for their nutritional composition using standard or referenced methods. The carotenoid content of the grains was analysed by High-Performance Liquid Chromatography (HPLC) and mass spectroscopy. The provitamin A carotenoids β-cryptoxanthin, and trans and cis isomers of β-carotene, and other unidentified cis isomers of β-carotene were detected in varying levels in the provitamin A-biofortified maize varieties. The total provitamin A content in the biofortified maize varieties ranged from 7.3-8.3 μg/g dry weight (DW), with total β-carotene ranging from 3.5-3.6 μg/g DW, and β-cryptoxanthin from 3.7-4.8 μg/g DW, whilst no carotenoids were detected in the white maize variety. Results of the evaluation of the content of other nutrients showed that, when compared with the white maize variety, the provitamin A-biofortified maize varieties had higher levels of starch, fat and protein but were lower in iron. The zinc and phosphorus levels in the white maize and the biofortified maize were comparable. The biofortified maize varieties were better sources of most of the essential amino acids relative to the white maize, but, similar to the white maize, they were deficient in histidine and lysine, indicating that further improvement is required. Selected quality attributes (grain density, susceptibility of kernels to cracking, milling quality and resistance of the kernels to fungal infection) of grains of 32 provitamin A-biofortified maize varieties and a white variety (control) were assessed. Overall, the quality of the grains of the provitamin A-biofortified maize varieties were found to be superior to that of the white maize grain, although the biofortified maize grains showed less resistance to fungi, including mycotoxin-producing types. This indicates that the trait of grain resistance to infection by fungi should also be incorporated in the provitamin A-biofortified maize varieties during breeding. To assess the retention of provitamin A carotenoids and other nutrients in maize food products, three selected provitamin A-biofortified maize varieties and the control (white maize variety) were milled into mealie meal and samp. The milled products were cooked into three products: phutu and thin porridge (from the mealie meal) and cooked samp. Nutrient retention during processing was determined. Milling resulted in either an increase or slight decrease in the provitamin A carotenoid levels, but there was no major decrease in the total provitamin A level. Most of the other nutrients were well retained during milling, but there were substantial losses of fibre, fat and minerals. Provitamin A carotenoid levels decreased on cooking. In phutu 96.6 ± 20.3% β-cryptoxanthin and 95.5 ± 13.6% of the β-carotene was retained after cooking. In thin porridge 65.8 ± 4.6% β-cryptoxanthin and 74.7 ± 3.0% β-carotene; and in samp 91.9 ± 12.0% β-cryptoxanthin and 100.1 ± 8.8% of the β-carotene was retained after cooking, respectively. Provitamin A retention seemed to be influenced by both maize variety and food form, indicating that suitable varieties and food forms should be found. There was generally a high retention of the other nutrients in all the three cooked products, except for the substantial losses of fat in thin porridge and iron and phosphorus in cooked samp. These findings indicate that an optimal delivery of provitamin A to the consumer can be achieved by processing provitamin A-biofortified maize into foods that have a good retention of provitamin A carotenoids, such as phutu and samp. These food products would be recommended in areas where VAD is prevalent. In order to assess consumer acceptability of provitamin A-biofortified maize, a total of 212 subjects aged 3-55 years from Mkhambathini Municipality, in KwaZulu-Natal province, South Africa, participated in the sensory evaluation of phutu, thin porridge and cooked samp prepared with provitamin A-biofortified maize varieties and a white variety (control). Preference for yellow maize food products was negatively associated with an increase in the age of the subjects. Overall, preschool children preferred yellow maize to white maize food products: phutu (81% vs. 19%), thin porridge (75% vs. 25%) and samp (73% vs. 27%). In contrast, primary school children preferred white maize to yellow maize food products: phutu (55% vs. 45%), thin porridge (63% vs. 38%) and samp (52% vs. 48%). Similarly, secondary school children and adults also displayed a similar preference for white maize food products. There was no association between gender and preference for maize variety. Focus group discussions revealed that participants had a negative attitude towards biofortified maize due to its colour, taste, smell and texture. However, the participants expressed a willingness to consume biofortified maize if it was cheaper than white maize and was readily available in local grocery stores. These findings indicate that there is a potential to promote the consumption of provitamin A-biofortified maize and its food products in this part of South Africa, thereby contributing to a reduction in the incidence of VAD. This study has shown that provitamin A-biofortified maize has a good potential to be used as an additional strategy to alleviate VAD in poor communities of South Africa, including similar environments in sub-Saharan Africa. However, the study has revealed that there are still challenges to be overcome in order to achieve the target provitamin A content of 15 μg/g in provitamin A-biofortified maize, set by HarvestPlus, an international challenge program. This may also explain why provitamin A-biofortified maize varieties with this level of provitamin A have been scarcely reported in the literature. Thus, more research is required to achieve the target provitamin A level in maize by conventional breeding. The results of this study indicate that besides provitamin A, the biofortified maize is also a good source of other nutrients including starch, fat, protein and zinc. However, improving the consumer acceptability of the provitamin A-biofortified maize remains a challenge, due to the negative attitudes towards the yellow/orange maize by African consumers. On the other hand, the results of this study indicate that there is an opportunity to promote the consumption of provitamin A-biofortified maize food products by preschool children, a finding which has not been previously reported in the literature. Nutrition education on the benefits of provitamin A-biofortified maize, as well as improved marketing are recommended, in this part of South Africa and also in similar environments in other sub-Saharan countries.
A comparative analysis of the nutrition status, nutrition knowledge and food frequency of adolescents attending an urban versus a peri-urban school in Hilton, KwaZulu-Natal.
(2014) Audain, Keiron Arthur.; Veldman, Frederick Johannes.
Adolescence is an important stage in human development. Optimum nutrition is crucial during this period, as additional nutrient requirements are needed to promote growth and maturation. With the nutrition transition in low-to-middle-income countries (LMICs), adolescents are increasingly exposed to energy-dense, nutrient poor foods; however it is not entirely clear the impact of socioeconomic status, in particular household food insecurity, on the consumption frequency of these foods. The impact nutrition knowledge may have on the dietary choices adolescents make is also unclear. Poor food choices among adolescents can contribute towards overweight/obesity and stunting, leading to the susceptibility to both communicable and non-communicable diseases (NCDs) in adulthood. The objective of this study was to determine the prevalence of overweight/obesity and stunting among South African adolescents from different socioeconomic backgrounds, in relation to their nutrition knowledge, household food insecurity status, and frequency of food consumption. The study consisted of a cross-sectional descriptive survey conducted among learners from a high-income, private urban school and a low-income, government peri-urban school in Hilton, KwaZulu-Natal. A total of 98 grade nine to eleven learners from the urban school and 111 grade nine to eleven learners from the peri-urban school volunteered to participate (N= 209). Nutritional status was determined by anthropometric measurements that included weight, height and MUAC. Subsequently BMI was calculated. Nutrition knowledge and food frequency were determined via non-quantified nutrition knowledge and food frequency questionnaires. A socio-demographic questionnaire (SDQ) was used to collect information on parental level of education and employment status. Household food security was determined using the Household Food Insecurity Access Scale (HFIAS). A higher prevalence of overweight and obesity was observed among urban learners compared to their peri-urban counterparts, however only for the boys as peri-urban girls had a notable prevalence of overweight and obesity compared to urban girls. Stunting was present among peri-urban learners but virtually absent in their urban counterparts, which was indicative of a double-burden of overweight/obesity and stunting within the peri-urban group. Peri-urban learners had parents with lower education and employment levels compared to urban learners. Adolescents with mothers that were educated up to tertiary level were associated with a higher nutrition knowledge scores (NKS). Urban learners had a higher mean NKS than peri-urban learners; however it did not necessarily reflect healthier food choices, as urban learners had a high consumption frequency of fatty red and processed meat, white bread and fizzy drinks. Peri-urban learners reported a higher preference for deep-fried, high-fat snacks such as vetkoeks and samosas; which may be related to the high levels of household food insecurity that was noted. Among grade ten peri-urban learners, 50% reported having no food to eat of any kind in the household, with 5% reporting that it occurred often. Poor dietary habits among adolescents in general were observed in this study; although food sources varied between urban and peri-urban learners possibly due to differences in cost and availability of food items. A lower SES was an underlying factor for the consumption of energy-dense foods among peri-urban learners; while a higher SES was associated with the consumption of more expensive fatty foods among urban learners. Thus, the risk of malnutrition (overweight/obesity and stunting) and subsequent disease susceptibility is present in both groups as a result.
Nutritional, sensory and functional properties of a Bhambara groundnut complimentary food.
(2016) Oyeyinka, Adewumi Toyin.; Pillay, Kirthee.; Siwela, Muthulisi.
Abstract available in PDF file.
The prevalence and nutritional status of woman between the ages of 18 to 45 years, practicing geophagia in the Umzinyathi and uMgungundlovu Districts, KwaZulu-Natal.
(2017) S'khosana, Lindokuhle Happiness.; Van Onselen, Annette.
Abstract available in PDF file.
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.
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 potential of provitamin A-biofortified maize and sweet potato, and bambara groundnut for improving the nutritional status of rural communities in KwaZulu-Natal, South Africa.
(2020) Govender, Laurencia.; Pillay, Kirthee.; Siwela, Muthulisi.
The double burden of malnutrition, under- and over-nutrition, is a serious health problem and a leading contributor to the global disease burden. Undernutrition presents as wasting, stunting, underweight and micronutrient deficiencies, such as vitamin A, iron and zinc, while over-nutrition presents as overweight, obesity and several non-communicable diseases. Children under the age of five years and pregnant women are the most affected by malnutrition, especially in rural areas. In developing countries, such as South Africa (SA), the major contributing factors to all forms of malnutrition are poverty, food and nutrition insecurity as well as the shift from traditional diets to more westernised diets. There have been several strategies employed in SA to alleviate malnutrition, especially vitamin A deficiency (VAD), yet it still remains a problem. Provitamin A (PVA)-biofortified crops could be used as a complementary strategy to address VAD; however, there are challenges of poor consumer acceptability. The poor acceptability of PVA-biofortified foods could be improved by combining them with other commonly consumed plant food items and animal food sources such as chicken to produce provitamin A-rich traditional dishes. However, animal food products can be unaffordable to many economically disadvantaged households, thus legumes could be used as an alternative and cheaper protein source. Bambara groundnut is an underutilised indigenous legume that is found in sub-Saharan Africa (SSA). It is a good source of protein and when consumed together with cooked starch-based products, it forms a complementary protein. Therefore, combining PVA-biofortified maize with bambara groundnut could contribute to improving the nutritional status of vulnerable population groups in SSA, including SA. Cream-fleshed sweet potato (CFSP) (Ipomoea batata L.) is a commonly consumed crop in SA and would be ideal for PVA-biofortification to produce orange-fleshed sweet potato (OFSP). Unlike PVA-biofortified maize that showed poor consumer acceptability, OFSP has been found acceptable to consumers. The OFSP has a high PVA carotenoid concentration, therefore it could be used as a food-based approach to address VAD among the economically disadvantaged population groups who are usually at risk of VAD, particularly rural communities. Research conducted on the nutritional composition and consumer acceptability of composite dishes made with PVA-biofortified maize and OFSP is limited, especially in SA. Furthermore, there is paucity of literature on the nutritional composition and consumer acceptance of bambara groundnut combined with cooked PVA-biofortified maize. Thus, this study investigated the potential of PVA-biofortified maize and sweet potato, and bambara groundnut for improving the nutritional status of rural communities in KwaZulu-Natal (KZN), SA. In order to formulate an effective food-based approach to address malnutrition, the nutritional status and dietary patterns of the target population group/s (communities) needed to be determined. Thus, the first study objective was to assess the nutritional status, using selected anthropometric indices and dietary intake methods, of four rural communities in KZN, who had been selected for investigating the proposed food-based nutrition approach. Purposive sampling generated a sample of 50 households each in four rural areas of KZN: Swayimane, Tugela Ferry and Umbumbulu and 21 households at Fountain Hill Estate. Anthropometric [height, weight, mid-upper arm circumference (MUAC), and waist circumference] and dietary intake data (repeated 24-hour recall and food frequency) were collected. The Food Finder 3 software of the Medical Research Council (MRC), SA, was used to analyse dietary intake data, and the Statistical Package for Social Sciences (SPSS, version 25) was used to analyse the other data sets. The Estimated Average Requirement (EAR) cut-point method was used to assess the prevalence of inadequate nutrient intake. The results of the study indicated that 17.9 % (n=7), 30.8% (n=12) and 15.5% (n=6) of the children under five years were underweight, stunted and overweight, respectively. According to the MUAC measurements, 20.5% (n=8) and 5.1% (n=2) of the children under five years had severe acute malnutrition (SAM) and moderate acute malnutrition (MAM), respectively. The Fisher’s Exact test showed that a significant proportion (37.5%; n=3) of those with a MUAC below 11.5 cm had a weight-for-height (WFH) Z-score below -3 standard deviation (SD) of the WHO child growth standards median, indicating severe malnutrition (p=0.046). The majority of the adult participants were either overweight (23.6%; n=76) or obese (29.5%; n=95), with a higher prevalence of overweight and obesity among females than males. According to the Binomial test, a significant number (67.0%; n=213) of adult participants had waist circumference measurements below 88 cm and 102 cm for females and males, respectively (p<0.05). The Chi-square test indicated that there was a significant relationship between gender and waist circumference (p<0.05). A significant proportion of adult males (92.9%; n=105) had a normal waist circumference and were not at risk of obesity-related diseases, whilst a significant proportion (p<0.05) of adult females (47.3%; n=97) were at risk of obesity-related diseases, such as diabetes, high cholesterol and hypertension. Adult participants that were underweight or had a normal body mass index (BMI) were not at risk of co-morbidities and obesity, whilst participants who were classified as obese class I, II and III had a high risk of co-morbidities (p<0.05). Although not statistically significantly different, there was a higher prevalence of over-nutrition than undernutrition at all four research sites for females aged 16-35 years old. There was a significant relationship between BMI and the risk of having a clinically undesirable waist circumference (p<0.05). There was frequent consumption of food items high in carbohydrates (mainly the cereal grain foods), and low intake of micronutrients and fibre by most age groups. The food frequency results indicated that onion, phutu, brown bread, tomato, rice, apple, eggs and chicken were the most commonly consumed food items. Results of analysis by the EAR-cut point method indicated that, among most of the age groups, there was a high prevalence of inadequate intake of several nutrients, including dietary fibre, vitamins, including vitamin A and minerals, including zinc and iron. The second study objective was to determine the effect of replacing white maize and CFSP with PVA-biofortified maize and OFSP, respectively, on the nutritional composition of traditional and indigenous dishes of KZN, SA. The phutu combinations were selected based on a survey conducted in four selected rural study sites in KZN to determine popular dishes in which maize was combined with other food items. Popular indigenous knowledge systems (IKS)-based recipes were collected to determine methods of preparing and processing white maize and CFSP into food products. Phutu (traditional crumbly porridge) was selected as the cooked maize meal dish, curried cabbage as a vegetarian dish and curried chicken as a meat dish. Curried bambara groundnut was selected as an alternative animal protein source. Grains of one PVA-biofortified maize variety and one white variety (control) was cooked into phutu. Both varieties of phutu were served with either curried cabbage, chicken or bambara groundnut. Two types of boiled sweet potato were used in the study; OFSP and CFSP (control). Composite dishes were prepared by combining either PVA-biofortified phutu or white phutu with other food items, separately, i.e. curried cabbage, curried chicken and curried bambara groundnut and the nutritional composition of the dishes were analysed. Generally, the proximate composition of the PVA-biofortified phutu composite dishes were not significantly different from those of white phutu composite dishes (controls) (p>0.05). However, the PVA concentration of PVA-biofortified phutu composite dishes was higher than that of the white phutu composite dishes (controls). The OFSP had a significantly lower protein concentration, but was significantly higher in other nutrients, including PVA relative to the CFSP (p<0.05). The third investigation determined the effect of replacing white maize and CFSP with PVA-biofortified maize and OFSP, respectively, on the sensory properties and consumer acceptance of traditional and indigenous dishes of KZN, SA. The sensory acceptability of the composite dishes and sweet potatoes was evaluated by 60 participants each from the two rural areas (Swayimane and Umbumbulu), using a five-point facial hedonic scale and a paired preference test. Focus group discussions (FGDs) were conducted with 56 participants recruited from the consumer panel to assess consumer perceptions about the composite dishes made with PVA-biofortified phutu and OFSP. The majority of the participants rated the composite dishes containing PVA-biofortified phutu as “good” and the acceptability of the composite dishes varied significantly (p<0.05). Compared to other age groups, the 50-59 year age group showed a higher preference for the white phutu and curried chicken composite dish, whereas the 30-39 year age group showed a higher preference for the PVA-biofortified phutu and curried chicken composite dish. The acceptability of OFSP and CFSP was similar. The FGDs indicated that participants had positive perceptions of the PVA-biofortified phutu when served with curried chicken or cabbage. However, they had mixed perceptions when served with curried bambara groundnut. The older FGD participants perceived that some of the composite dishes, such as phutu and curried bambara groundnut, would not be acceptable to younger consumers as they were not accustomed to bambara groundnut, especially its sensory attributes such as taste, texture and aroma. There were positive responses to the proposal to replace the CFSP with OFSP. Most of the FGD participants perceived the OFSP to be butternut due to its orange colour, sweet taste and visual appeal. The FGD participants expressed a willingness to grow and purchase the PVA-biofortified maize and PVA-biofortified OFSP, if planting materials were made available or if the two types of biofortified crops were available in the local markets for utilisation as staple foods. The study findings show that under- and over-nutrition, and poor dietary diversity are prevalent in rural KZN. There was a low intake of several nutrients, including dietary fibre and several micronutrients. The study findings indicate that there is a need to increase the availability, accessibility, and utilisation of diverse foods through appropriate agricultural and nutritional interventions. Biofortification could be used as a complementary strategy to assist with the alleviation of VAD in SSA. Although, in several studies, PVA-biofortified foods have been found less acceptable compared to counterpart white maize foods, the PVA-biofortified foods investigated in this study were perceived positively by most of the participants. Overall, the study findings suggest that PVA-biofortified maize and OFSP can replace white maize and CFSP, respectively, in selected traditional dishes of the rural communities studied, to alleviate VAD. Further research should be conducted using a larger sample size, larger area and with different PVA-biofortified maize food types and varieties of OFSP, to obtain results for large rural populations in all provinces of SA.
Caregiver and child acceptability of a provitamin A carotenoid, iron and zinc rich complementary food prepared from common bean and pumpkin in Uganda.
(2020) Buzigi, Edward.; Siwela, Muthulisi.; Pillay, Kirthee.
Vitamin A deficiency (VAD), iron deficiency (ID), and zinc deficiency (ZnD) are the three leading micronutrient deficiencies causing morbidity and mortality among children under five years in developing countries, including Uganda. A high prevalence of VAD, ID and ZnD among children in developing countries begins during the period of complementary feeding, which is between the ages of six to 24 months. This is the period when children are fed complementary foods (CFs) prepared from vitamin A, iron, and zinc deficient staple tubers and cereals. To combat VAD, ID, and ZnD, the World Health Organization (WHO) recommends that CFs be diversified with vitamin A, iron and zinc rich food sources, such as animal source foods (ASFs), food supplements and commercially fortified foods. However, ASFs, commercially fortified foods and food supplements are either unaffordable or inaccessible to rural Ugandan caregivers. Therefore, the aim of this study was to prepare a complementary food (CF) rich in provitamin A carotenoids (PVACs), iron and zinc using locally available common bean and pumpkin and to test the acceptability of the CF among caregivers and their children in rural Uganda. The study objectives were to: (i) select one common bean landrace superior in iron and zinc, and one pumpkin landrace superior in PVACs from a variety of local landraces available in the local market; (ii) evaluate the effect of home cooking methods on provitamin A carotenoid (PVAC) retention in the selected pumpkin (superior in PVACs), and iron and zinc retention in the selected common bean (superior in iron and zinc); (iii) assess child acceptability of an innovative CF- a common bean pumpkin blend (BPB) prepared with common bean (superior in iron and zinc) and pumpkin (superior in PVACs); (iv) assess caregiver perceptions and acceptability of the innovative CF (BPB). The study was conducted in rural Kyankwanzi district, Uganda, East Africa. Cross-sectional and randomised control trial designs were used in this study for the consumer acceptability investigations; and a controlled laboratory experiment for the nutrient retention investigation. Three pumpkin landraces on the local market of the study area were screened for PVACs, whilst five common bean landraces also on the local market were screened for iron and zinc content. Iron and zinc content were determined by flame atomic absorption spectrometry (FAAS), whilst PVAC content was determined by high performance liquid chromatography (HPLC). True retention of iron, zinc and PVAC was determined after expert caregivers cooked pumpkin by either boiling or steaming, whilst the common bean was cooked by either boiling with or without prior soaking. Caregivers prepared the test CF and the control according to the consistency (thickness or thinness) fit for child consumption based on the child’s age and stage of development. The test CF (BPB) was prepared by mixing and blending two parts of cooked pumpkin and one part of cooked common bean, whilst the control CF, pumpkin puree (PP) was prepared by mashing one part of cooked pumpkin. Seventy children, aged 6 to 24 months participated in the child acceptability randomised crossover study. In the current study, the CFs test food (BPB) and control (PP) were considered acceptable if the child consumed at least 50 g and more of the 100 g of the CF offered. Mean duration for intake of the CFs and vitamin A, iron and zinc intake were calculated. A paired t-test was used to determine whether there were significant differences in the amount, duration, and micronutrient intake between the BPB and PP. Further, 70 caregivers (whose children participated in the child acceptability study) participated in the caregiver acceptability study. A cross-sectional sensory evaluation study design was used to assess caregiver perceptions and acceptability of the study CFs. Sensory attributes (taste, colour, aroma, texture and general acceptability) of the BPB and PP were rated using a five-point facial hedonic scale (1=very bad, 2=bad, 3=neutral, 4=good, 5=very good). Focus group discussions (FGDs) were also conducted to assess caregiver perceptions about using the BPB as a CF. A chi-square (X2) test was used to detect the proportionate difference for each sensory attribute between BPB and PP, whilst focus group discussions (FGDs) data was analysed by thematic analysis. A p value of 0.05 was considered statistically significant. For objective one (first investigation), β-carotene content in Sweet cream (1 704 μg/100 g) was significantly higher compared to Dulu (1 333 μg/100 g) and Sun fish (1041 μg/100 g) (p<0.0001). The α- carotene content of Sweet cream was significantly lower (46 μg/100 g, p<0.0001) compared to Dulu (77.3 μg/100 g) and Sun fish (79.3 μg/100 g). However, the total retinol activity equivalent (RAE) was highest in Sweet cream (143.9 μg/100 g), compared to Dulu (115.4 μg/100 g) and Sun fish (90.1 μg/100 g). Iron content was highest in Obwelu (7.75 mg/100g), compared to Masavu (6.95 mg/100 g), Nambale (6.55 mg/100g), Kanyebwa (7.15 mg/100 g) and Obwayelo (6.5 mg/100 g). Obwelu had significantly higher iron concentrations than Obwayelo (p<0.05). Zinc content was highest in Obwelu (3.05 mg/100 g), but was not significantly different (p >0.05) compared to the other common bean landraces of Masavu (2.95 mg/100 g), Nambale (2.35 mg/100 g), Kanyebwa (2.9 mg/100 g) and Obwayelo (3.0 mg/100 g). The findings of the first investigation suggested that Sweet cream was superior in PVAC content compared to the other pumpkin landraces, whilst Obwelu was superior in iron and zinc content compared to the other common bean landraces. Therefore, Sweet cream and Obwelu were selected for use in the preparation of a CF rich in PVACs, iron and zinc. For objective two (second investigation), β-carotene, α-carotene, and total provitamin A content in raw pumpkin was 1704 μg/100 g, 46 μg/100 g and 1437 μg/100 g, respectively. Either boiling or steaming pumpkin resulted in over 100% retention of PVACs and total provitamin A. Iron and zinc retention in soaked boiled common bean was 92.2% and 91.3%, respectively. Boiling common bean without soaking resulted in 88.4% and 75.6% retention of iron and zinc, respectively. The findings of the second investigation suggested that there was a high retention of PVACs in pumpkin, Sweet cream after boiling or steaming, and a high retention of iron and zinc in common bean, Obwelu after boiling with prior soaking. For objective three (third investigation), the mean amount of BPB (53.9 g) and the control (PP) (54.4 g) consumed by children was high, but not significantly different from each other (p>0.05). The mean duration for child consumption of BPB was 20.6 minutes and 20.3 minutes for the control and the durations for child consumption were not significantly different from each other (p<0.05). The mean child intake of vitamin A was significantly higher (p<0.05) from the control (PP) (152.5 μgRAE) compared to the test food (BPB) (100.9 μgRAE). The mean iron intake was significantly higher (p<0.05) from BPB (1.1 mg) compared to the control (0.3 mg). Furthermore, zinc intake was significantly higher (p<0.00001) from the (0.58 mg), compared to control (0.13 mg). For objective four (fourth investigation), between 64% and 96% of the caregivers rated both BPB and PP as acceptable (good to very good) for all the sensory attributes. There was no significant difference (p>0.05) in caregiver acceptability for all sensory attributes between BPB and PP (p>0.05). Caregivers had positive perceptions about the taste, texture, aroma, and colour of the BPB. Caregivers were keen to know the specific varieties of common bean and pumpkin used to formulate the PVAC, iron and zinc rich BPB. Findings from this study suggest that a complementary food, BPB, rich in PVACs, iron and zinc prepared from locally available common bean, Obwelu and pumpkin, Sweet cream was acceptable to caregivers and their children who were in the age range of complementary feeding in Uganda. To contribute towards combating child VAD, ID and ZnD, policy makers in Uganda, such as the district nutrition coordination teams should support and promote the cultivation and utilisation of common bean, Obwelu and pumpkin, Sweet cream as major ingredients of CFs. The use of BPB as a CF should not replace other existing nutrition interventions such as micronutrient supplementation, commercial fortification, biofortification programmes and the use of ASFs that aim to combat micronutrient deficiencies during the period of complementary feeding. However, the use of BPB as a CF should be a complementary strategy to these existing nutrition interventions. Future studies should investigate the effect of BPB intake on the vitamin A, iron and zinc status of children.
The efficacy and related factors of the growth monitoring and promotion programme in clinics of Vhembe district, South Africa.
(2021) Mandiwana, Tshifhiwa Cynthia.; Veldman, Frederick Johannes.; Kassier, Susanna Maria
Aim: To determine the growth monitoring and promotion (GMP) related knowledge, perceptions and skills of nursing staff and mothers with IYC under five at selected clinics in the rural areas of Vhembe district, Limpopo Province, South Africa. Methods: The study sample included 82 randomly selected clinics from the four subdistricts in Vhembe district, Limpopo province. In three of the four sub-districts, 24 clinics were sampled from from each, while the fourth sub-district was represented by ten clinics. A cross-sectional exploratory descriptive survey employing quantitative and qualitative data collection techniques was conducted to explore the variables under investigation. The quantitative phase included 312 nursing staff with an equal number of participants from each randomly sampled clinic. Data collection was conducted by trained fieldworkers using a research instrument consisting of open- and closed-ended questions, as well as an observation tool. A recording sheet was used for documenting the prevalence of moderate- and severe acute malnutrition in the district. For the qualitative phase, nine focus group discussions (FGDs), with a total of 83 purposively sampled biological mothers of IYC were conducted in three of the four sub-districts using a semi-structured interview guide. Means and standard deviations were computed for continuous variables. A comparison between means was conducted using the independent samples t-test, while correlations between continuous variables were done with Pearson’s correlations. Frequency distributions were calculated for categorical variables, followed by Chi-square tests to determine the relationship between categorical variables. Time series analysis by means of ANOVA was used to analyse the prevalence of SAM/MAM across the five years for which clinic statistics were obtained. For the qualitative phase of the study, FGDs were recorded on a digital voice recorder with verbatim transcripts being translated into English by back translation. These transcripts were imported into Atlas ti. version 8.4 computer software for thematic content analysis, followed by the creation of themes and sub-themes for creating codes and networks of responses. Results: Participating nursing staff that worked with GMP for 12.0 ± 8.8 years, had a mean knowledge score regarding GMP of 48.9%, with 40% having a score of ≤ 50%. Fieldworker observations of nursing staff while conducting growth monitoring (GM), generated evidence that the majority of participants did not follow the correct procedure when measuring weight, length, height or mid-upper arm circumference (MUAC). The low mean scores obtained for knowledge, as well as the ability to interpret growth indicators, are cause for concern. In addition, 20.1% of the study sample was never offered training and/or never attended refresher training following completion of their formal training. A significant positive correlation was documented for knowledge regarding GMP and the ability of participants to interpret growth indicators if both mean values were expressed as percentages (r=0.251; p<0.000). Based on the FGD discussions conducted with mothers, it was evident that they knew the importance of taking their IYC to the clinic for GMP, despite the fact that some were not familiar with the reasons for its importance. Conclusion: Although nursing staff had positive perceptions regarding GMP, their knowledge regarding the programme, as well as their ability to accurately conduct anthropometric measurements was not optimal. Mothers of IYC that make use of GMP in Vhembe district have the necessary knowledge regarding its importance. However, there are several barriers preventing them from optimally utilising the GMP services offered by clinics. Findings highlight the need for nursing staff, clinics and the Department of Health to address the barriers mothers face, as it has the potential to impact on the aims and successful implementation of GMP in the district. Key concepts: Clinics, GMP, knowledge, mothers with IYC, nursing staff and skills.
Structural, nutritional and protein functional properties of trichilia emetica and trichilia dregeana seeds.
(2022) Tsomele, Gugu Felicity.; Siwela, Muthulisi.; Wokadala, Obiro Cuthbert.
Food and nutrition insecurity are prevalent in developing regions, especially in the predominantly low-economic status of sub-Saharan Africa. Yet, several edible domesticated and wild plants are grossly under-utilised as food sources. The woody plants Trichilia species are indigenous to Africa and are also found in other developing countries. Although the oily seeds of Trichilia species seem to have great potential for contributing towards the alleviation of malnutrition in the developing regions, they are grossly under-utilised and there is a dearth of scientific literature regarding their nutritional potential. To improve the utilisation of Trichilia seeds on a commercial scale, it is vital to study their physical characteristics and the nutritional and food-related (functional) physico-chemical properties of their components. In this study, the structural and chemical composition of Trichilia emetica (T. emetica) and Trichilia dregeana (T. dregeana) seeds, in addition to the nutritional and functional properties of their proteins, were investigated and compared with the soybean. The results of the seeds analysis showed that Trichilia seeds had difficulty sliding on surfaces due to their oblate shape. Trichilia seeds showed lower sphericity (0.66) than soybean (0.99), with higher bulk density (645.9 kg/m3 and 433.6 kg/m3, respectively) and lower true density (875.8 kg/m3 and 950.4 kg/m3, respectively). The porosities for T. emetica and T. dregeana were significantly lower (55.07% and 54.38%), with a higher geometric mean diameter (29.7 mm and 16.9 mm) than soybean. Trichilia species showed similar shapes, but different localisation of the seeds‟ protein bodies when compared with soybean. Trichilia seeds‟ protein bodies were larger in size and more round in shape than those of the soybean. The other investigations in this study determined the nutritional properties of the flour and protein of T. emetica and T. dregeana seeds, and compared the chemical structure and functional properties of protein in the Trichilia seeds with the soybean. The results showed that T. emetica and T. dregeana seeds contained substantial protein (25.6% and 17.3%, respectively) and high concentrations of fat (49% and 51.5%, respectively). Potassium, calcium, iron and zinc were the major minerals in the Trichilia seeds. T. emetica and T. dregeana protein had substantial concentrations of Phenylalanine, Leucine, Isoleucine, Valine and Lysine and Methionine, which were comparable with those of the soybean. The concentrations of essential amino acids in Trichilia seeds, similar to their concentrations in soybean, were above the recommended Food and Agricultural Organisation standards for adults. The proportion of essential amino acids to total amino acids of T. emetica and T. dregeana seeds was similar to that of the soybean. The Trichilia spp protein had more β- conformation than α-helices (21%) comparable with soybean protein. The protein concentrates of T. emetica seed had higher Water holding Capacity, Foaming Capacity and Foaming Stability with lower Oil holding Capacity and Emulsion activity Index when compared with soybean and T. dregeana seeds. The findings of the current study indicate that the physical and nutritional properties of T. emetica and T. dregeana seeds and their protein properties had comparable properties to existing commercial oilseeds. This could improve the utilisation of the seeds as complementary foods and can cause an increase in the number of available food sources for food and nutrition security, thereby improving the livelihoods of individuals. However, there would be a need to modify the existing technologies for drying, milling, packaging and transportation to accommodate the Trichilia seeds. Furthermore, the bioavailability of the minerals and protein of the Trichilia seeds should be assessed.
Assessment of mothers and preschool-age children's food and nutrition security status: a cross-sectional case study of North central zone, Nigeria.
(2023) Omachi, Bosede Alice.; Van Onselen, Annette.; Kolanisi, Unathi.
Child and maternal nutrition are essential to any country's food and nutrition security, encompassing all the components of maternal and child growth, well-being, development, and productivity, as contained in the modified UNICEF 2020 conceptual framework on determinants of maternal and child nutrition. According to the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC), preschool children are regarded as being between 3 and 5 years old. This period entails intensive cognitive development in children, where developmental milestones that help shape their personality, interpersonal relationships, and thinking patterns are fostered; hence, the need to consume healthy meals following the recommended minimum dietary diversity requirements of at least five to eight food groups per day for children is a bedrock for positive health outcomes. The prevalence of nutrition-related maternal and child morbidity has continued to increase in recent times across many low- and middle-income countries (LMICs) owing to several complex multifactorial and interrelated determinants. The complexity and interconnectedness of the determinants of maternal and child nutrition in developing countries, such as Nigeria, are yet to be well conceptualised and have become a public health issue due to the emerging triple burden of malnutrition (TBM) and the prevalence of diet-related non-communicable diseases ravaging the nation. Therefore, this study assessed the food and nutrition security status of mothers and their preschoolers in North Central Nigeria. A cross-sectional descriptive design and a multi-stage sampling technique were used to recruit 450 mother-child pairs (preschool children aged 3-5 years) across the North South senatorial district in Niger State, North Central Nigeria. Sociodemographic information and biodata of mothers and their preschoolers were collected using semi-structured questionnaires. Feeding patterns of mother-child pairs were assessed using a qualitative food frequency questionnaire based on 24-hour and 7-day dietary recall. The dietary diversity of households, mothers, and children was assessed using the Household Dietary Diversity Score (HDDS), Minimum Dietary Diversity Score for Children (MDD_C), and Minimum Dietary Diversity Score for women of reproductive age (MDD_W), respectively, as recommended by the Food and Agriculture Organization (FAO), Family Health International (FHI) and World Health Organization (WHO). The Household Food Insecurity Access Scale (HFIAS) was used to assess the food insecurity status of the participants. Anthropometric indices of the preschoolers were assessed based on weight-for-age, height-for-age, and weight-for-height indicators, while maternal anthropometry was assessed using body mass index (BMI) and waist/hip ratio. Maternal nutrition knowledge was assessed using a Likert-type scale. Retrieved information was analysed using SPSS version 28. Descriptive statistics are presented in tables and charts, while regression models were used for inferential statistics, with statistical significance being considered at a 95% confidence interval with a p-value of < 0.05. The study was conducted in two phases: the first phase considered an in-depth narrative literature review that evaluated the food and nutrition security status of preschool children in North Central, Nigeria, as well as the food insecurity and vulnerability of the food environment among Nigerian mothers. This study explored the literature using a qualitative approach and an overview of online sources, peer-reviewed articles, books, and other publications and relevant reports from official websites to investigate the concept of the food environment, food acquisition and utilisation complexities among Nigerian women, and the prevalence of food and nutrition insecurity and its determinants among preschool children. This review found that the global prevalence of the Triple Burden of Malnutrition (TBM) is alarming, especially among developing nations, affecting more women than men. Food acquisition and utilisation are important determinants of women’s food and nutritional security status. Full but empty plates have continued to be a dilemma among women from countries undergoing urbanisation and nutrition transitioning; hence, poor nutrient intake has been reported to account for the high risk of maternal morbidity and mortality related to nutritional causes in most developing countries, such as Nigeria. This revealed that the interconnectedness of the food environment to food acquisition and utilisation in addressing food insecurity and malnutrition as an innovative concept is yet to be well understood and explored in many studies across Nigeria. It also elucidates the drivers of poor dietary diversity, meal quality, and food consumption patterns among preschool children and possible health outcomes of compromised feeding patterns and the risk of non-communicable diseases and malnutrition among the study participants. In addition, the review also focused on the drivers of the food environment, food acquisition, nutrient utilisation, and the prevalence of TBM among women across the six geopolitical zones in the country. The high prevalence of malnutrition and diet-related noncommunicable diseases in this study accounts for the high maternal and child morbidity and mortality rates, especially in many rural and poor households across the nation, thus becoming a significant public health concern. Some factors found to significantly impact food utilisation among women were food literacy, poverty, insurgence, lack of support systems, seasonality, and family size. To mitigate these challenges, efforts should be geared towards improving both the community and consumer food environments, thus ensuring the consumption of nutrientdense meals for optimal health outcomes and well-being, especially among women and preschool children living in rural areas, urban slums, and low-income households across the six geopolitical zones of the nation and among other developing nations experiencing food and nutrition insecurity around the world. The second phase was the experimental section and was divided into two parts: the first part explored the socioeconomic status, household food security status using the HFIAS and the feeding patterns of the preschool children using the qualitative 24 hour and 7-day dietary recall. Dietary diversity was assessed using the MDD_C, while the anthropometric indicators for under-five children were used to categorise the children into stunting, wasting, underweight, and normal weight. The results showed that the majority (76.4%) of the preschool children were from rural communities; more than half (51.8%) of the children were from mothers who had only Islamic education (no formal education), and only a few (1.2%) of the children were born to single mothers. Almost all (95.6%) of the children were from Islamic religious homes, and the majority (71.6%) of the mothers were unemployed, while 83.8% of the monthly household income was below N18,000 ($40), which is far below the national minimum income range of N36,000. Most (73.6%) of the children were from male-headed households. The predominant ethnic group was Nupe (68.4%), whereas the least dominant was Gwari (<1%). Most (98.8%) of the preschool children were from food-insecure households, and almost half (42.4% and 40.2%) of the preschool children were either moderately food insecure or severely food insecure, respectively. The severity of food insecurity increased with parity, and its prevalence was higher among children from multiparous and grand multiparous households. The most consumed food group among preschoolers was cereal-based food products, while the least consumed food groups were fruits and vegetables. This study also showed that over half (60.0%) of the preschoolers did not meet the minimum dietary diversity score (MDD_C) recommended for their age. The anthropometric indices of the preschool children showed that half (50.0%) of the children were stunted (height-for-age), 21.0% had wasting (weight-forheight), and 29.0% were underweight (22.2% were severely underweight) (weight-for-age). The logistic regression model showed that the socioeconomic status of mothers, such as education, income, religion, occupation, employment status, means of waste disposal, source of potable water (water suitable for human consumption), and water treatment methods, were associated with the household food insecurity status of the children and were associated with inadequacy in children’s MDD (p < 0.05). The second part of the experiment explored the contribution of maternal nutrition literacy to the nutritional status of mothers in Niger State, North Central Nigeria. The results showed that the majority (63.8%) of the mothers were between 26 and 35 years old. More than half (51.6%) of the mothers did not know what a balanced diet was based on the definitions provided in the questionnaire. Social media or online information was the most explored source of nutritional information among mothers (36.4 %). Fifty-four per cent of the mothers indicated that their nutrition literacy had no positive impact on their dietary quality. The food consumption pattern showed that fruits/vegetables, and dairy products were the least consumed food groups among the mothers (7.1% and 9.1%, respectively). More than half (57.6%) of the mothers were within the normal BMI range, and the mean waist/hip ratio was 0.82 ± 0.08. The regression model showed that place of residence, occupation, source of potable water, and method of waste disposal were significantly associated with adequacy of maternal minimum dietary diversity. Although nutrition knowledge has been reported to influence dietary quality among mothers, this study showed that other intrinsic factors besides nutrition knowledge significantly impacted the dietary quality and nutritional status of mothers in the study area. Therefore, to optimise health outcomes among mothers, stakeholders at all levels must implement programs and policies that address issues such as insurgence, inflation, climate change, disparity in wealth distribution, and seasonal vulnerability. In conclusion, the prevalence of food and nutrition insecurity was high among the participants due to poor socioeconomic status and poor food environment, thereby compromising the meal quality and consumption frequency of mothers and their preschoolers. Most mothers adopted the consumption of ultra-processed foods and beverages as coping strategies to salvage the impact of hunger and starvation, thereby predisposing them to the risk of TBM and NCDs among mothers and their preschool children. To mitigate these challenges, efforts should be geared towards addressing the determinants of food and nutrition insecurity with a multidimensional approach at the grassroots level and involving all stakeholders and policymakers, to enable a sustainable food system through nutrition-sensitive agriculture at the household and community level. Draught resistant and improved variety crops should be used to mitigate climate change impact on food access and affordability and thus, enhance adequate consumption of nutrient-dense meals for optimal health outcomes among the participants and across most food insecure developing nations.
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.
A randomised double blind placebo controlled trial to determine the effect of soluble dietary fibre (inulin-type fructans) on disease progression and body composition of HIV positive ARV naive adults attending a wellness clinic in KZN South Africa.
Biggs, Chara.; Coutsoudis, Anna.
Abstract available in PDF file.
Knowledge, acceptance and barriers to optimal use of iron supplements amongst pregnant women attending Mutare city clinic in Manicaland, Zimbabwe.
Mahundi, Plaxcedia.; Pillay, Kirthee.; Wiles, Nicola Laurelle.
Iron deficiency anaemia (IDA) is a global public health challenge, most prevalent in developing countries, including Zimbabwe. It mostly affects young children and women of childbearing age, particularly pregnant women. In the developing world, unbalanced diets which lack haemiron from animal sources due to high costs, predisposes many pregnant women to IDA. Most women usually enter pregnancy with already depleted iron stores, consequently resulting in high maternal mortality and morbidity, premature deliveries and low birth weight infants. Pregnant women with IDA have a high risk of complications at delivery and are also prone to infections. Therefore, to increase haemoglobin levels and prevent IDA, the World Health Organization (WHO) recommends a daily supplement of 60 mg of iron for all pregnant women for at least six months during pregnancy, until six weeks post-partum. This is meant to complement iron from the diet, because dietary sources of iron alone are inadequate to meet the iron requirements during pregnancy. However, there are many barriers to the acceptance and use of iron supplements among pregnant women. This is also exacerbated by poor knowledge on the importance of iron supplements during pregnancy. Mutare City, in Zimbabwe was chosen as the study site because there is a lack of published data on the use of iron supplements by pregnant women in this area. The aim of this study was to assess the knowledge and acceptance levels of iron supplements among pregnant women, attending Mutare City Clinic, Manicaland, Zimbabwe. The study also aimed to identify possible barriers to optimal use of iron supplements among the pregnant women. In addition, the study aimed to develop and test a nutrition education tool with the aim of creating awareness regarding the importance and use of iron supplements among pregnant women, thus improving acceptance and use of the supplements. The objectives of the study were as follows: (i) To assess knowledge on the importance of iron supplements during pregnancy amongst pregnant women attending Mutare City Clinic, Manicaland, Zimbabwe. (ii) To assess the acceptance levels of iron supplementation given during pregnancy amongst pregnant women attending Mutare City Clinic, as perceived by nurses and pregnant women attending Mutare City Clinic for ante-natal care (ANC). (iii) To identify the barriers to optimal iron supplementation by pregnant women attending Mutare City Clinic. (iv) To ascertain from pregnant women attending Mutare City Clinic, the form of the nutrition education tool to be developed, the importance of the tool, information and language to be used in the tool. (v) To develop a nutrition education tool for pregnant women attending Mutare City Clinic with the purpose of creating awareness of iron supplements. (vi) To test the developed nutrition education tool to determine its user-friendliness and acceptability among pregnant women attending the Mutare City Clinic. A survey was conducted to assess knowledge and acceptance on the importance and use of iron supplements by pregnant women. A total of 103 pregnant women, aged 16-36 years participated in the study and were selected on the basis of being either in their second or third trimesters of pregnancy, and attending Mutare City Clinic for ante-natal care (ANC). It was found that the pregnant women had inadequate nutrition knowledge to motivate them to consistently take iron supplements. Most pregnant women appreciated the importance of iron supplements, but lacked detailed knowledge to substantiate their need for taking them. The study therefore recommends early ANC booking and commencement of iron supplementation, as well as adequate nutrition education for pregnant women. To identify barriers preventing optimal use of iron supplements by pregnant women, eight focus group discussions (FGD) were conducted, with 64 women, aged 17-39 years. Major barriers preventing the optimal use of iron supplements included erratic supplies at healthcare centres, cultural and religious influences and side-effects associated with supplements and poverty. Ignorance due to inadequate nutrition education and poor communication between nurses and pregnant women, were other notable barriers. The erratic availability of iron supplements at the healthcare centre resulted in many women not taking supplements because they could not afford to buy them from private pharmacies. However, in the few instances when supplies were available at healthcare centres, some women collected iron supplements but did not use them, while some managed to use the supplements consistently. Therefore, continuous reinforcement of positive supplementation practices is recommended to motivate for compliance among pregnant women. Adequate nutrition education and counselling is necessary for promoting awareness regarding the importance of iron supplements, dietary diversity and management of side-effects. Improvements in the procurement and delivery system at a national level will help to ensure timeous provision of iron supplements to healthcare centres. Sixty-seven pregnant women in their second and third trimesters were purposively sampled to participate in eight FGDs on the development of a nutrition education tool. Pregnant women gave their views on the nutrition education tool they most preferred and the most appropriate language and information to include. The pregnant women indicated that a pamphlet was the most preferred form of nutrition education tool, with English as the preferred main language of communication, along with some Shona phrases for clarification. Three extra FGDs were conducted with 28 pregnant women to test the developed nutrition education tool for acceptability and user-friendliness by pregnant women. It was found that good use of images which are culturally sensitive, appropriate use of colours, and labelling foods in both English and Shona enhanced the identification of foods, thus improving acceptability of the developed pamphlet. Earlier results obtained from both nurses and pregnant women revealed that most pregnant women did not receive adequate nutrition education on the importance and use of iron supplements during pregnancy, leading to poor compliance. Late ANC bookings at healthcare centres affected the initiation of iron supplementation. Thus, the development of a nutrition education tool for use by pregnant women could enhance knowledge on the importance of iron supplementation, since most women had inadequate nutrition knowledge. Intensive nutrition education programmes, routine iron supplementation and use of the developed nutrition education pamphlet are recommended to reduce the prevalence of IDA among pregnant women in Zimbabwe. This study has shown that issuing iron supplements without an accompanying nutrition education tool may not effectively alleviate maternal IDA. Poor compliance with iron supplementation regimens remains a challenge because of several barriers, which also include inadequate baseline knowledge among pregnant women. Therefore, the development of a nutrition education tool is a positive move towards improving compliance, especially if the tool is offered to pregnant women timeously. The study has indicated that the tool may likely enhance understanding by consolidating nutrition education conducted at healthcare centres and iron supplements given to pregnant women. However, erratic supplies of supplements remains a challenge, as well as delayed ANC bookings by many pregnant women. Thus, this study has shown that offering a nutrition education pamphlet along with iron supplements, has the potential to create awareness and motivate towards compliance with iron supplements. This has the potential to reduce the prevalence of maternal IDA amongst pregnant women in Zimbabwe and sub-Saharan Africa.

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