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Background: Cardiovascular disease (CVD) is becoming one of the leading causes of death in middle and low income countries, with ischaemic heart disease specifically being predicted to be the 4th and 5th causes respectively. The numerous risk factors for the development of CVD have been extensively researched; however, the same wealth of data is not available for the black South African population as there is for Caucasians. Although the same risk factors that are present in Caucasians have been seen to be present in the black South Africans, there are questions regarding the contributory roles of the individual risk factors, particularly within the context of urbanisation. The role of diet in CVD has been widely studied and it is known that with urbanisation there are dietary changes which are thought to add the development of CVD. With urbanisation, however, there are numerous other lifestyle changes taking place within a population, making it difficult to isolate and make conclusions of the individual role of diet. Added to this is the complex issue of assessing dietary intake. Assessing only nutrient or food intake does not give a holistic picture of dietary habits. The main aim of this study was to determine the association between dietary intake and CVD risk in black South Africans in the context of urbanisation. Methods: The first study that forms part of this thesis was a case-control study aimed at exploring the risk factor profile and clinical presentation of black South African patients with coronary artery disease (CAD). In this study clinical, biochemical and nutrient intakes were compared with a black South African control group that were matched for age and body composition. The second study to form part of this thesis aimed to relate the dietary intakes of the Prospective Urban and Rural Epidemiological (PURE) study population to CVD risk associated with urbanisation, by using both nutrient intake and predefined diet quality scores (DQS). The Healthy Diet Indicator (HDI) and the Deficiency and Excess Score were carefully selected from the large number of available scores and adapted as best as possible for the black South African population. The third study aimed to investigate the role of dietary intake by using nutrients as well as food group consumption patterns as a risk factor in urbanised black South African CAD patients. The dietary habits of the coronary artery disease (CAD) patients were compared to that of an apparently healthy reference group of volunteers selected from the PURE study population. This urbanised reference group was from a similar socio- demographic background and was selected according to their risk for CVD. The Reynolds Risk score which includes C-reactive protein as factor was used to stratify the PURE population into CVD risk categories, in order to select the reference group, which had a low risk (

Thesis (M.Sc. (Nutrition))--North-West University, Potchefstroom Campus, 2005. Motivation - Cardiovascular disease (CVD) is one of the most important causes of mortality and morbidity in South Africa. The major risk factors are prevalent in both the developed and developing areas of the world, among all social classes, and are of similar public health significance in all countries regardless of their level of development. This indicates that much scope remains for further reducing coronary heart disease (CHD) death rates in developed countries and for preventing the emerging CHD epidemic in poorer nations. This study aims at identifying the beliefs of the South African adult population regarding food and cardiovascular health and to therefore identify target groups for education programs. Objectives - To investigate the beliefs of South African adults towards the importance of the link between food and cardiovascular health, especially between the different races, living standards, age and gender groups. Also to determine whether this population looks for the Heart Foundation symbol on food products, as well as where the link between food and heart disease ranks in terms of importance compared to other highly prevalent diseases. Method - The design of the study was a randomized cross-sectional study. Trained field workers administrated questionnaires by conducting face-to-face interviews with consumers in the language of their choice. Two thousand South African individuals (1 6 years and older) were randomly selected from metropolitan areas in South Africa. The data was weighted to be representative of the total South African metropolitan consumer population, based on gender, age and race distribution (n=10 695 000). The total population was representative of both genders (5 423 000 men and 5 272 000 women) and major race groups (2 615 000 whites, 6 252 000 blacks, 1 255 000 coloureds and 573 000 Indians), from different age and living standards groups. The market research group, MARKINOR, was contracted to collect the data. Quantitive data was statistically analysed in order to generate the relevant descriptive statistics, cross tabulations and statistical tests. Results - The majority of the population found the link between food and cardiovascular risk related health issues to be important, especially the higher LSM groups within the different race groups. The link between food and weight loss was considered the least important compared to other cardiovascular risk factors (cholesterol, blood pressure, diabetes, healthy blood vessels). Only 35% of the study population agreed with the statement that they look for the Heart Foundation symbol, while 46% disagreed with the statement. There was a greater tendency for the higher LSM groups to look for the Heart Foundation symbol than the lower LSM groups. Heart disease was considered just as important and in some cases more important when compared with HIVIAIDS and cancer. Conclusions - This study shows that the metropolitan South African adult population is aware of the importance of food on CVD. Nutritional education needs to be aimed at both genders and all ages of the lower socio-economic groups of South Africa. The reasons why such a large percentage of the South African metropolitan adults do not look for the Heart Foundation symbol, or are undecided about it, needs to be investigated and addressed. Prevention programs promoting a healthy lifestyle, which would address the risk factors associated with CVD, should be received with a positive attitude. Masters

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

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.