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Background The potential role of adjunctive anti-inflammatory therapy to enhance tuberculosis (TB) treatment has recently received increasing interest. There is, therefore, a need to broadly examine current host-directed therapies (HDTs) that could accelerate treatment response and improve TB outcomes. Methods This systematic review and meta-analysis included randomised controlled trials of vitamin D and other HDT agents in patients receiving antibiotic treatment for pulmonary TB. Sputum smear conversion rate at 4–8 weeks was the primary outcome. Secondary outcomes included blood indices associated with infectivity and inflammation, chest radiology and incidence of adverse events. Results Fifty-five studies were screened for eligibility after the initial search, which yielded more than 1000 records. Of the 2540 participants in the 15 trials included in the meta-analysis, 1898 (74.7%) were male, and the age at entry ranged from 18 to 70 years. There was a 38% significantly (RR 1.38, 95% CI = 1.03–1.84) increased sputum smear negativity in patients administered with vitamin D in addition to standard TB treatment than those receiving only the TB treatment. Patients treated with other HDT anti-inflammatory agents in addition to TB treatment also had a 29% significantly increased sputum smear conversion rate (RR 1.29, 95% CI = 1.09–1.563). Lymphocyte to monocyte ratio was significantly higher in the vitamin D treatment groups compared to the controls (3.52 vs 2.70, 95% CI for difference 0.16–1.11, p = 0.009) and (adjusted mean difference 0.4, 95% CI 0.2 -- 0.6; p = 0.001); whilst tumour necrosis factor-alpha (TNF-α) showed a trend towards a reduction in prednisolone (p p = 0.27) treatment groups. Vitamin D and N-acetylcysteine also accelerated radiographic resolution in treatment compared to placebo at 8 weeks. No differences were observed in the occurrence of adverse events among all HDT treatments. Conclusions Vitamin D and other anti-inflammatory HDT medications used as adjunct TB treatment may be well tolerated and effective. They significantly improved sputum smear conversion rate and chest radiological appearance, and also exhibited an inflammation resolution effect.

Introduction in hospitals across Africa, the case fatality rates of severe acute malnutrition (SAM) have remained consistently high (over 20%), despite the existence of the WHO treatment guideline. This has been attributed to inconsistencies in the implementation of the WHO treatment guidelines in sub-Saharan African countries. In spite of this awareness, the SAM treatment guidelines adopted by various sub-Saharan African countries and hospitals are unknown. Knowledge of the exact treatment practices employed in the management of SAM in different hospitals in sub-Saharan Africa is not known. This study aims to investigate the admission criteria, in-patient treatment guidelines and practices and outcomes of complicated SAM in sub-Saharan African children aged 0-59 months. Methods this is an observational study which involves the extraction of admission, treatment and discharge data from the medical records of infants and children aged 0-59 months diagnosed and treated for complicated SAM in sub-Saharan Africa. This information is being used to develop a comprehensive database on the treatment of complicated SAM across sub-Saharan Africa. Information on the national and hospital guidelines for the treatment of complicated SAM is also collected. Results results of this study will serve as a useful resource on the true reflection of the treatment of complicated SAM across sub-Saharan Africa and will provide valuable information for optimising SAM treatment. Conclusion in order to advocate best practice and reduce SAM-related mortality in sub-Saharan Africa, the identification of the different diagnostic and treatment methods and respective outcomes across different hospitals and countries is imperative.

MSc (Dietetics), North-West University, Potchefstroom Campus Background: Dietary intervention has been a significant part of chronic kidney disease (CKD) treatment with the emphasis on reducing protein, sodium, phosphorus, and potassium intake, limiting fruit and vegetable consumption. These dietary recommendations are very restrictive and difficult to comply with. Recent evidence shows that fruit and vegetable intake might be a cost-effective and acceptable management option for patients with CKD and that overall healthy dietary patterns rich in fruit and vegetables may improve clinical outcomes of these patients. The aim of the current study was therefore to perform a systematic review that investigated the effect of various fruit and vegetables on specified clinical outcomes of patients with CKD. Methods: Two systematic reviews were performed. The first aimed to investigate the effect of fruit and vegetable intake on clinical outcomes of patients with CKD, especially on estimated Glomerular Filtration Rate (eGFR). Randomised controlled trials (RCTs) of the effect of fruit and vegetable intake on blood pressure, metabolic acidosis and eGFR in adult patients with CKD (eGFR

Background: Complicated severe acute malnutrition (SAM) poses an enormous threat to the survival of children. However, the relationship between admission characteristics and recovery, weight gain and the risk of mortality in children with complicated SAM is limited in Ghana, especially those

PhD (Dietetics), North-West University, Potchefstroom Campus Background: Non-resolving inflammation is characteristic of tuberculosis (TB). This leads to lung tissue damage and anaemia of infection, which is associated with poor clinical outcomes. Iron supplementation may have limited efficacy and may favour bacterial growth. Therefore, anti-inflammatory and pro-resolving host-directed therapy (HDT) have been suggested. Omega-3 long-chain polyunsaturated fatty acids (n-3 LCPUFAs) including eicosapentaenoic and docosahexaenoic acid (EPA/DHA) may provide such a nutritional approach for HDT. Aim: The aim of this thesis was to determine the effects of EPA/DHA and iron supplementation, alone and in combination, on inflammatory and clinical outcomes in Mycobacterium tuberculosis (Mtb)-infected mice and whether these effects were dependent on n-3 polyunsaturated (n-3 PUFA) status prior to infection. Methods: Male C3HeB/FeJ mice were conditioned on n-3 PUFA sufficient or deficient diets for six weeks prior to infection. One week post Mtb infection, n-3 PUFA sufficient mice were randomised to 1) continue on the n-3 PUFA sufficient diet, or were switched to an 2) EPA/DHA-supplemented, 3) iron-supplemented, or 4) EPA/DHA and iron-supplemented diet. Mice conditioned on an n-3 PUFA deficient diet were randomised to 1) continue on the n-3 PUFA-deficient diet, or switched to the 2) n-3 PUFA sufficient, or 3) EPA/DHA-supplemented diets. The mice received these diets for three weeks until euthanasia. Results: The phospholipid fatty acid composition of cell membranes of mice reflected the dietary fatty acid content. Pro-resolving lung lipid mediator profiles were found in the EPA/DHA-supplemented groups in both n-3 PUFA sufficient and low-status arms, and also when combined with iron. Additionally, EPA/DHA supplementation resulted in lower bacterial loads and lung pathology in the sufficient, but not in the low-status group. Iron and EPA/DHA supplementation both individually lowered systemic and lung cytokines, together with improved anaemia of infection markers. However, whilst EPA/DHA supplementation lowered lung T cells, iron resulted in higher lung immune cell counts. Iron also had no effect on lung pathology or bacterial load but lowered body weight gain. There were iron x EPA/DHA interactions to attenuate the lowering effects of iron or EPA/DHA on anaemia of infection, and of iron for higher immune cell counts. Furthermore, compared with the n-3 PUFA sufficient diet, EPA/DHA supplementation provided superior benefits in body weight gain, bacterial load, and lung inflammation in low-status mice. Conclusions: The findings of this thesis showed that EPA/DHA supplementation, after the initial inflammatory response, has antibacterial and inflammation-resolving benefits and improves markers of anaemia of infection in TB, depending on n-3 PUFA status. On the other hand, iron promotes anti-inflammatory effects and improves markers of anaemia, but enhances immune cell recruitment and lowers body weight gain. Providing combination iron and EPA/DHA treatment attenuates their individual beneficial effects. Lastly, in low-status mice, EPA/DHA provides superior effects compared with an n-3 PUFA sufficient diet. Considering this, iron may not be detrimental concerning worsening the bacterial burden in TB, but moreover, n-3 LCPUFA therapy may be a promising approach as HDT in TB. Doctoral

This study aims to determine the prevalence of risk of malnutrition on admission and discharge in African hospitals, and to identify the association with selected indicators. In this multi-center prospective cohort study, adult patients from hospitals in South Africa, Kenya, and Ghana were screened on admission and discharge and contacted 3 months post-discharge. Relevant morbidity and mortality outcomes were assessed. At risk of malnutrition was indicated if NRS-2002 score &ge, 3. Adult patients (n = 2126, 43.11 years, IQR: 31.95&ndash, 55.60, 52.2% female) were screened on admission and 61% were identified as at risk of malnutrition. The proportion of at-risk patients for the three hospitals in Kenya and Ghana (66.2%) were significantly higher than that of the three South African hospitals (53.7%) (Chi2 = 31.0, p &lt, 0.001). Discharge risk of malnutrition was 71.2% (n = 394). Mean length of stay (LOS) was 6.46 &plusmn, 5.63 days. During hospitalization, 20.6% lost &ge, 5% body weight, 18.8% were referred for nutrition support, and discharge BMI (23.87 &plusmn, 7.38 kg/m2) was significantly lower than admission BMI (24.3 &plusmn, 7.3 kg/m2) (p &lt, 0.001). Admission nutrition risk was associated with lower admission and discharge BMI (p &lt, 0.001), longer LOS (p &lt, 0.001), increased 3-month re-admission rates (Chi2 = 1.35, p = 0.245) and increased mortality (Chi2 = 21.68, 0.001). Nearly two-thirds of patients were at risk of malnutrition on admission. This was associated with longer LOS and greater hospital mortality. The nutritional status of patients deteriorated during hospitalization. Routine screening practices with appropriate nutrition support action should be implemented as a matter of urgency.

The promotion and support of human milk banks (HMBs) can enhance exclusive breastfeeding rates. The success and sustainability of HMBs depend on the support from relevant healthcare workers and related communities. This study aimed to determine attitudes of key stakeholders, including mothers, healthcare workers and grandmothers, regarding the donation and receipt of human breastmilk. This study was conducted at a public hospital and clinics in the North West Province, South Africa. Eight focus group discussions explored the attitudes regarding donating and receiving human breastmilk: three groups with mothers of infants (n = 13), three with grandmothers (&gt, 60 years old) (n = 17) and two with healthcare professionals working with infants (n = 11). Four main themes emerged: perception regarding breast and formula feeding, exposure to the concept of &ldquo, wet nursing&rdquo, breastmilk donation, and utilization and opinions of community members and traditional healers. Specific barriers identified included the processes for donating and receiving milk, safety, human immuno-deficiency virus (HIV) screening and cultural beliefs. Mothers&rsquo, fears included having insufficient milk for their own infants, changes in the quality of donated milk during pasteurization and transportation and HIV transmission. Despite barriers towards donations to and the use of HMBs, sufficient information could enhance donations by mothers and breastmilk utilization.

ObjectiveTo determine undernutrition prevalence in 0–59-month-old children and its determinants during the period 2000–2015 in sub-Saharan Africa.DesignEcological study of time series prevalence of undernutrition in sub-Saharan Africa assessed from 2000 to 2015.SettingUnderweight and stunting prevalence from the World Bank database (2000–2015) were analysed. Mixed models were used to estimate prevalence of underweight and stunting. Country-specific undernutrition prevalence variation was estimated and region comparisons were performed. A meta-regression model considering health and socio-economic characteristics at country level was used to explore and estimate the contribution of different undernutrition determinants.ParticipantsCountries of sub-Saharan Africa.ResultsDuring 2000–2015, underweight prevalence in sub-Saharan Africa was heterogeneous, ranging between 7 and 40 %. On the other hand, stunting prevalence ranged between 20 and 60 %. In general, higher rates of underweight and stunting were estimated in Niger (40 %) and Burundi (58 %), respectively; while lowest rates of underweight and stunting were estimated in Swaziland (7 %) and Gabon (21 %). About 1 % undernutrition prevalence reduction per year was estimated across sub-Saharan Africa, which was not statistically significant for all countries. Health and socio-economic determinants were identified as main determinants of underweight and stunting prevalence variability in sub-Saharan Africa.ConclusionsUndernutrition represents a major public health threat in sub-Saharan Africa and its prevalence reduction during the period 2000–2015 was inconsistent. Improving water accessibility and number of medical doctors along with reducing HIV prevalence and poverty could significantly reduce undernutrition prevalence in sub-Saharan Africa

MSc (Dietetics), North-West University, Potchefstroom Campus INTRODUCTION: Worldwide, severe acute malnutrition (SAM) is an important risk factor for morbidity and mortality, contributing to more than half of deaths in children under-five years. Inasmuch as the World Health Organization (WHO) has provided diagnostic criteria to be used for admitting into inpatient care for the management of SAM in children aged 6 - 59 months, these are not based on strong evidence. Furthermore, there are limited studies on the relationships of WHO admission and transfer criteria in relation to clinical outcomes, such as mortality rate, length of stay (LOS) in the hospital and daily weight gain in children aged 6 - 59 months with SAM when categorised into different age groups. This study was therefore undertaken to determine the associations of admission diagnostic and transfer criteria with clinical outcomes of infants aged 6 - 23 months diagnosed with SAM, admitted, treated and subsequently discharged. METHODS: A collection of already existing data was carried out at three referral hospitals in Ghana namely the Komfo Anokye Teaching Hospital, the Princess Marie Louis Children's Hospital and the Tamale Teaching Hospital. The medical records of 399 infants aged 6 - 23 months who were diagnosed with SAM, admitted, treated and subsequently discharged at the three study sites between January 2013 and June 2018 were included in the final analysis. Data on demographic, anthropometric, clinical signs and complications, recovery, LOS in the hospital and death were collected. Anthropometric and clinical characteristics on admission were assessed in relation to mortality, daily weight gain, admission z-scores and improvement in mid-upper arm circumference (MUAC). Data was analysed using SAS version 9.4 and linear regression analysis was used to determine the association between admission characteristics and the clinical outcomes. RESULTS: At admission, 89.1% (n = 229) had a weight-for-age z-score (WAZ) < -3 standard deviation (SD), 81.4% (n = 131) had a MUAC < 115 mm, 83.2% (n = 79) had a weight-for-length z-score (WLZ) < -3 SD, 34.8% (n = 69) had oedema and 6.5% (n = 26) had MUAC < 115 mm complicated by oedema. Among infants with clinical signs, complications or co-morbidities, 51% (n = 208) presented with diarrhoea; 51% (n = 203) presented with vomiting while 8% (n = 33) tested positive for HIV. Overall, 15.8% (n = 63) of the infants died with 65.1% (n = 41) of the deaths occurring within 92 hours of admission. The median LOS in the hospital and weight gain was 11 days (Interquartile range (IQR): 7, 17) and 6.8 g/kg/day (IQR: 0.8, 11.8), respectively. With the exception of admission WLZ, a non-statistically significant difference was observed between admission anthropometric criteria in infants who died compared to those who survived. Infants with a WAZ < -3 SD had 5.05 (95% Cl: 1.80, 14.17; p = 0.002) higher odds of weight gain of > 10 g/kg/day than those with a WAZ ≥ -3 SD. Infants with an admission MUAC < 115 mm had 4.64 (95% Cl: 1.64, 13.12; p = 0.02) higher odds of being hospitalised for more than 7 days when compared to those with a MUAC ≥ 115 mm. Infants with convulsions and shock at admission had 6.76 (95% CI: 2.57, 17.83; p = 0.0001) and 5.18 (95% CI: 1.49, 18.08; p = 0.01) higher odds of mortality than those without convulsion and shock, respectively. The odds of mortality for infants with HIV infection was 4.04 (95% CI: 1.86, 8.81; p = 0.0004) while that for those with dermatitis was 3.46 (95% CI: 1.77, 6.75; p = 0.0003). CONCLUSIONS AND RECOMMENDATIONS: There was a statistically significant difference between admission WLZ for infants who died and those who survived but it was not statistically significantly associated with death in infants aged 6 - 23 months. Although non-statistically significant, it was observed that, infants with MUAC < 115 mm at admission were two times more likely to die compared to those with a MUAC < 115 mm at admission. With the exception of recovery rate (defined as resolution of oedema) and LOS in the hospital, mortality and daily weight gain were observed to be outside the minimum range recommended by Sphere for the inpatient management of SAM. Therefore, it is recommended that the Ministry of Health in collaboration with Ghana Health Service (GHS) should try and improve the diagnostic skills of health workers/clinicians in the area of SAM by incorporating weight, height and MUAC measurements into paediatric clinics as well as the provision of appropriate child growth standard charts. There is also the need to update clinicians in the recognition and management of SAM, especially children with SAM who present with complications and co-morbidities such as convulsions, shock and HIV infection for better treatment outcomes. Masters

Child mortality is a major public health problem in sub-Saharan Africa and is influenced by nutritional status. A conceptual framework was proposed to explain factors related to undernutrition. Previously proposed conceptual frameworks for undernutrition do not consider child mortality and describe factors related to undernutrition from a qualitative viewpoint only. A structural equation modelling approach was applied to the data from World Bank and FAO databases collected from over 37 sub-Saharan countries from 2000 to the most recent update. Ten food groups, exclusive breastfeeding, poverty and illiteracy rates, and environmental hygiene were investigated in relation to underweight, stunting, low birthweight, and child mortality. Standardized beta coefficient was reported, and graphical models were used to depict the relations among factors related to under-five mortality in sub-Saharan Africa. Child mortality in sub-Saharan Africa ranged between 76 and 127 × 1,000. In the same period, low birthweight rate was about 14%. Poverty and illiteracy are confirmed to affect health resources, which in turn influenced nutritional status and child mortality. Among nutritional factors, exclusive breastfeeding had a greater influence than food availability. Low birthweight, more than underweight and stunting, influenced child mortality. Structural equation modelling is a suitable way to disentangle the complex quantitative framework among factors determining child mortality in sub-Saharan Africa. Acting on poverty at the base appear to be the more effective strategy along with improvement of breastfeeding practice and improvement of hygiene conditions.

MSc (Dietetics), North-West University, Potchefstroom Campus Introduction: Complicated severe acute malnutrition (SAM) poses an enormous threat to the survival of children 0 - 59 months old. Even though the World Health Organisation (WHO) has provided diagnostic guidelines for in-patient management of SAM, these are not based on strong evidence. Furthermore, knowledge of the protocols used in various hospitals and the actual clinical practices regarding SAM diagnosis, admission and discharge remains limited. In addition, information on the relationship between the admission characteristics of children with complicated SAM and length of hospital stay (LOS), mortality and weight gain is scant. This study, therefore, aimed to assess the protocols of the hospitals compared with actual clinical practices and the WHO guidelines, with regard to the diagnosis, in-patient admission and discharge of children with SAM in relation to patient treatment outcomes. Methods: Data on the protocols of two Ghanaian hospitals for SAM diagnosis, admission and discharge were collected and compared with the WHO guidelines. The study also involved a retrospective collection of data from the medical records of children aged 0 - 59 months, diagnosed and admitted with SAM, treated and subsequently discharged between January 2013 and June 2017 at the Princess Marie Louis Children’s hospital and the Komfo Anokye teaching hospital in Ghana. Anthropometric and clinical characteristics on admission were assessed in relation to LOS, mortality, daily weight gain, weight-for-age z-scores (WHZ) and improvement in mid-upper arm circumference (MUAC). Data was analysed using SAS version 9.4. Spearman’s correlation and linear regression were used to determine the association between admission characteristics and the treatment outcomes. Results: There were some similarities but a few disparities between the hospitals’ protocols and the WHO guidelines. In the hospitals’ protocols, MUAC was the only anthropometric tool recommended for SAM diagnosis as compared with the use of MUAC or WHZ as anthropometric tools recommended by the WHO. Additionally, children 6 - 59 months weighing < 4 kg are considered severely malnourished and require in-patient treatment according the protocols of the hospitals. There were also some differences between the protocols of the hospitals and the practices as observed in the medical records. Although, MUAC is the only anthropometric tool recommended by the hospitals for SAM diagnosis, only 34.3% of the children had MUAC assessed at admission. Among the discharged children, only 58.5% had their infections resolved and 74.1% had good appetite while only 44.2% had both good appetite and all infections treated at the time of discharge. In total, 289 medical records were included in the study. Discharge, death and abscond rates were 77.7%, 17.7% and 3.8% respectively. Average LOS was 11.4 days with 5.8 g/kg/day weight gain. Oedema and WHZ < -5 SD were associated with longer LOS (14.1 days; 95% CI: 11.5; 17.2; P = 0.02 and 14.0; 95% CI: 11.1; 17.7; P = 0.02 respectively). Average time to death was 4.8 days, with infants < 6 months dying earlier (1.5 days; 95% CI: 0.7; 3.2; P = 0.001) than the 6 - 59 month group (5.9 days). No significant changes in MUAC (P = 0.31) and WHZ (P = 0.69) were observed from admission to discharge. MUAC < 11.5 cm and WHZ < -3 SD were associated with a 3.9 and 1.7 times increased risk of death, although this increase was not statistically significant (P = 0.38 and P = 0.53 respectively). Shock, oedema and HIV-positive status were associated with an increased risk of death that was 7.1 (95% CI: 2.7; 20.5; P < 0.001), 2.5 (95% CI: 1.2; 5.5; P = 0.02) and 3.1 (95% CI: 1.3; 7.2; P = 0.03) higher. Conclusion and recommendations: There were differences between the hospitals’ protocols and the WHO guideline. The clinical practices observed regarding SAM diagnosis, admission and discharge in the hospitals are not adequately commensurate with the hospitals’ protocols. MUAC was not assessed in a large proportion of the children, although it was the only anthropometric diagnostic indicator for SAM, recommended in the protocols of the hospitals. The average weight gain was 5.8 g/kg/day over a LOS of 11.4 days. Furthermore, the high mortality rate was beyond the acceptable SPHERE minimum. These results emphasise the need for detailed health systems research and an in-depth investigation into additional factors contributing to the results found in this study in order to curb the high SAM mortality rate. They also highlight the urgent need for the Ghana Health Service, the Ministry of Health, the administration of the hospitals and the healthcare professionals to implement strategies to optimise the healthcare system in order to reduce SAM deaths in the hospitals by early identification, diagnosis and optimum treatment. Masters

Objectives: The aim of this study was to investigate the risk factor profile of coronary artery disease (CAD) in black South Africans. The study was motivated by the increased prevalence of CAD in South Africa, probably as a result of urbanisation. Despite this increase, however, very little is known regarding the cause, risk factor profile and clinical presentations of CAD in the black South African population. Design: A case control study was performed investigating 40 (33 men, 7 women) angiographically defined CAD patients and 20 (13 men and 7 women) age and body composition matched controls. Results: There was no difference in physical activity, sociodemographic factors or dietary intakes between the CAD and control group, except for the CAD patients consuming less vit C (40.9 vs 61.3 mg). The CAD group had significantly higher LDL-C, fasting glucose and CRP. There was also a significantly higher prevalence of smokers (35 vs 10%), hypertension (95 vs 75%) small dense LDL (73 vs 15%) and insulin resistance (M-value of 4.15 vs 12.5 mg/kg/min) in the CAD compared to the control group. In a logistic regression model, small dense LDL and insulin resistance were the main predictors of CAD. Conclusions: Black South African CAD patients had increased levels of the same risk factors that are typically seen in Caucasians with insulin resistance and small dense LDL being particularly significant in their contribution.

ObjectivesTo investigate the beliefs of South African metropolitan adults regarding the importance of influencing cardiovascular health by eating certain food types, and to compare these beliefs between different race, living standards, age and gender groups.DesignRandomised cross-sectional study. Trained fieldworkers administered questionnaires by conducting face-to-face interviews with consumers.SubjectsTwo thousand South Africans (16 years and older) were randomly selected from metropolitan areas in South Africa. The data were weighted to be representative of the total South African metropolitan population (N = 10 695 000) based on gender, age and race distribution.ResultsThe majority (94 %) of the population indicated that it is important to influence cardiovascular risk-related health issues by eating certain food types, especially the higher LSM (Living Standard Measure) groups within the different race groups. Weight loss was considered the least important (61 % indicated that it is important) compared with cholesterol lowering (80 %), blood pressure (89 %), diabetes (86 %) and healthy blood vessels (89 %). In the higher LSM groups (7–10) higher proportions of respondents agreed than in the lower LSM groups (2 and 3). No differences were seen in responses between different gender, race and age groups.Conclusions and recommendationsThis study shows that the metropolitan South African adult population considers the influence on cardiovascular health by eating certain food types to be important. However, modifying weight loss by eating certain food types was considered less important.

The following case study was discussed during the fourth-year dietetics evaluation process at North-West University, Potchefstroom Campus. It is a reflection of the opinion of the dietitians, students and lecturers involved, describes the actions taken during the nutritional management of the case, and is based on current literature and guidelines relevant to the topic.