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Background. Ongoing quantification of trends in high blood pressure and the consequent disease impact are crucial for monitoring and decision-making. This is particularly relevant in South Africa (SA) where hypertension is well-established. Objective. To quantify the burden of disease related to high systolic blood pressure (SBP) in SA for 2000, 2006 and 2012, and describe age, sex and population group differences. Methods. Using a comparative risk assessment methodology, the disease burden attributable to raised SBP was estimated according to age, se, and population group for adults aged ≥25 years in SA in the years 2000, 2006 and 2012. We conducted a meta-regression on data from nine national surveys (N=124 350) to estimate the mean and standard deviation of SBP for the selected years (1998 - 2017). Population attributable fractions were calculated from the estimated SBP distribution and relative risk, corrected for regression dilution bias for selected health outcomes associated with a raised SBP, above a theoretical minimum of 110 - 115 mmHg. The attributable burden was calculated based on the estimated total number of deaths and disability-adjusted life years (DALYs). Results. Mean SBP (mmHg) between 2000 and 2012 showed a slight increase for adults aged ≥25 years (127.3 - 128.3 for men; 124.5 - 125.2 for women), with a more noticeable increase in the prevalence of hypertension (31% - 39% in men; 34% - 40% in women). In both men and women, age-standardised rates (ASRs) for deaths and DALYs associated with raised SBP increased between 2000 and 2006 and then decreased in 2012. In 2000 and 2012, for men, the death ASR (339/100 000 v. 334/100 000) and DALYs (5 542/100 000 v. 5 423/100 000) were similar, whereas for women the death ASR decreased (318/100 000 v. 277/100 000) as did age-standardised DALYs (5 405/100 000 v. 4 778/100 000). In 2012, high SBP caused an estimated 62 314 deaths (95% uncertainty interval 62 519 - 63 608), accounting for 12.4% of all deaths. Stroke (haemorrhagic and ischaemic), hypertensive heart disease and ischaemic heart disease accounted for >80% of the disease burden attributable to raised SBP over the period. Conclusion. From 2000 to 2012, a stable mean SBP was found despite an increase in hypertension prevalence, ascribed to an improvement in the treatment of hypertension and subsequent lowering of blood pressure. Nevertheless, the high mortality burden attributable to high SBP underscores the need for improved care for hypertension and cardiovascular diseases, particularly stroke, to prevent morbidity and mortality.

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Background. Worldwide, iron deficiency, and consequent iron-deficiency anaemia, remains the most common nutritional disorder. Iron-deficiency anaemia mostly affects young children and women of reproductive age, especially in Asia and Africa. Iron deficiency may contribute to disability directly or indirectly as a risk factor for other causes of death, and may rarely contribute to death.Objectives. To estimate the changing burden of disease attributable to iron deficiency in males and females (all ages) for the years 2000, 2006 and 2012 in South Africa (SA).Methods. The comparative risk assessment methodology developed by the World Health Organization (WHO) and the Global Burden of Diseases, Injuries, and Risk Factors Studies was used to estimate the burden attributable to iron deficiency in SA for the years 2000, 2006 and 2012. We attributed 100% of the estimated iron-deficiency anaemia burden across all age groups by sex to iron deficiency. For maternal conditions, the attributable burden to iron deficiency was calculated using the counterfactual method and applied to all women of reproductive age. The population attributable fraction calculated for these selected health outcomes was then applied to local burden estimates from the Second SA National Burden of Disease Study (SANBD2). Age-standardised rates were calculated using WHO world standard population weights and SA mid-year population estimates.Results. There was a slight decrease in the prevalence of iron-deficiency anaemia in women of reproductive age from ~11.9% in 2000 to 10.0% in 2012, although the prevalence of anaemia fluctuated over time (25.5% - 33.2%), with a peak in 2006. There has been a gradual decline in the number of deaths from maternal conditions attributable to iron deficiency in SA between 2000 (351 deaths (95% uncertainty interval (UI) 248 - 436)) and 2012 (307 deaths (95% UI 118 - 470)), with a peak in 2006 (452 deaths (95% UI 301 - 589)). Furthermore, our analysis showed a 26% decrease between 2000 and 2012 in the age-standardised burden rates from maternal conditions (truncated to 15 - 49 years) attributable to iron deficiency. Between 2000 and 2012, the age-standardised disability-adjusted life year (DALY) rate from iron-deficiency anaemia attributable to iron deficiency markedly decreased by 33% in males, and increased by 3% in females of all ages. Approximately 1.1 - 1.4% of all DALYs in SA from 2000 to 2012 were attributable to iron deficiency.Conclusion. Iron-deficiency anaemia prevalence can be markedly reduced if iron deficiency is eliminated. Hence it is essential to encourage, reappraise and strengthen the measures that have been put in place to address iron deficiency, especially in women of reproductive age and children.

Cardiovascular diseases are leading causes of death, globally, and health systems that deliver quality clinical care are needed to manage an increasing number of people with risk factors for these diseases. Indicators of preparedness of countries to manage cardiovascular disease risk factors (CVDRFs) are regularly collected by ministries of health and global health agencies. We aimed to assess whether these indicators are associated with patient receipt of quality clinical care. We did a secondary analysis of cross-sectional, nationally representative, individual-patient data from 187,552 people with hypertension (mean age 48.1 years, 53.5% female) living in 43 low- and middle-income countries (LMICs) and 40,795 people with diabetes (mean age 52.2 years, 57.7% female) living in 28 LMICs on progress through cascades of care (condition diagnosed, treated, or controlled) for diabetes or hypertension, to indicate outcomes of provision of quality clinical care. Data were extracted from national-level World Health Organization (WHO) Stepwise Approach to Surveillance (STEPS), or other similar household surveys, conducted between July 2005 and November 2016. We used mixed-effects logistic regression to estimate associations between each quality clinical care outcome and indicators of country development (gross domestic product [GDP] per capita or Human Development Index [HDI]); national capacity for the prevention and control of noncommunicable diseases ('NCD readiness indicators' from surveys done by WHO); health system finance (domestic government expenditure on health [as percentage of GDP], private, and out-of-pocket expenditure on health [both as percentage of current]); and health service readiness (number of physicians, nurses, or hospital beds per 1,000 people) and performance (neonatal mortality rate). All models were adjusted for individual-level predictors including age, sex, and education. In an exploratory analysis, we tested whether national-level data on facility preparedness for diabetes were positively associated with outcomes. Associations were inconsistent between indicators and quality clinical care outcomes. For hypertension, GDP and HDI were both positively associated with each outcome. Of the 33 relationships tested between NCD readiness indicators and outcomes, only two showed a significant positive association: presence of guidelines with being diagnosed (odds ratio [OR], 1.86 [95% CI 1.08-3.21], p = 0.03) and availability of funding with being controlled (OR, 2.26 [95% CI 1.09-4.69], p = 0.03). Hospital beds (OR, 1.14 [95% CI 1.02-1.27], p = 0.02), nurses/midwives (OR, 1.24 [95% CI 1.06-1.44], p = 0.006), and physicians (OR, 1.21 [95% CI 1.11-1.32], p < 0.001) per 1,000 people were positively associated with being diagnosed and, similarly, with being treated; and the number of physicians was additionally associated with being controlled (OR, 1.12 [95% CI 1.01-1.23], p = 0.03). For diabetes, no positive associations were seen between NCD readiness indicators and outcomes. There was no association between country development, health service finance, or health service performance and readiness indicators and any outcome, apart from GDP (OR, 1.70 [95% CI 1.12-2.59], p = 0.01), HDI (OR, 1.21 [95% CI 1.01-1.44], p = 0.04), and number of physicians per 1,000 people (OR, 1.28 [95% CI 1.09-1.51], p = 0.003), which were associated with being diagnosed. Six countries had data on cascades of care and nationwide-level data on facility preparedness. Of the 27 associations tested between facility preparedness indicators and outcomes, the only association that was significant was having metformin available, which was positively associated with treatment (OR, 1.35 [95% CI 1.01-1.81], p = 0.04). The main limitation was use of blood pressure measurement on a single occasion to diagnose hypertension and a single blood glucose measurement to diagnose diabetes. In this study, we observed that indicators of country preparedness to deal with CVDRFs are poor proxies for quality clinical care received by patients for hypertension and diabetes. The major implication is that assessments of countries' preparedness to manage CVDRFs should not rely on proxies; rather, it should involve direct assessment of quality clinical care.

Objective: To detennine the vitamin D status of older 'coloured' South Africans who had not sustained a fracture. Design: Cross-sectional analytic study. Methods: A random sample of 200 non-institutionalised subjects in Cape Town aged ≥65 years was drawn using a two-stage cluster design. Trained fieldworkers interviewed subjects to obtain demographic, dietary and lifestyle data, to draw fasting blood samples for the analysis of serum 25-hydroxyvilamin D (25(OH)D) and other biochemical parameters. and to take anthropometric measurements. Results: Seventeen per cent of the subjects (95% Cl: 11.4 - 22.6%) had serum 25(OH)D levels in the deficient range for the elderly < 10 nglml); 7.5% (95% Cl: 3.611.4%) had concentrations in the moderately severe range of deficiency < 8 nglml). Sixty-three per cenl of the subjects had raised serum alkaline phosphatase concentrations. Regression modelling showed neither a sex difference in 25(OH)D levels nor a sex-age interaction; however, a negative association with age was found (r = -0.18; P < 0.05). Mean oral vitamin D intake was low (3.6 (SO = 2.7) µg and 2.8 (SO = 1.7) µg for men and women, respectively), but no association between dietary vitamin D intake and serum 25(OH)D was found. Conclusions: The prevalence of suboptimal vitamin D status was high. However, the interpretation of the data, with regard to bone health, is limited by the crosssectional design of the study. Further investigation is required to detennine the potential benefits of intervention in this age group.S Afr Med J 1996; 86: 1406-1410

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Objectives. To compare the effects of 1% and 2% propofol on the maximum and average lipid levels, the relative frequency of hyperlipidaemia, the propofol dose required to achieve an equivalent degree of sedation, the pharmacodynamic effects at the required infusion rates, and the effect on respiratory function.Design. Open, randomised, parallel group, multicentre comparison study.Setting. Intensive care units (ICUs) at the Faculty of Medicine, University of Stellenbosch and at Vergelegen Medicity, Somerset West.Subjects. Patients who were artificially ventilated for at least 72 hours in the ICUs and who required sedation or analgesia..Outcome measures. Continuous intravenous infusion of 1% or 2% propofol to provide an administration rate in the range of 1 - 4 mg/kg/h. The initial infusion rate was about 2 mg/kg/h, adjusted to achieve the appropriate level of sedation. Results and conclusions. Seventy-five patients were enrolled in the study, of which 72 were evaluable for safety analysis and 58 were evaluable for efficacy analysis. The total daily dose of propofol (ml/ day) in the 2% propofol group was about 60% of that in the 1% propofol group, indicating that the lipid load in the 2% propofol group had only slightly more than half the lipid load in the 1% propofol group. Thirteen of 27 patients (48%) in the 2% propofol group had abnormally

Objective. To assess the effect of renal transplantation on the nutritional status of patients.Design. Prospective descriptive study.Setting. Renal Transplant Clinic at Tygerberg Hospital, Western Cape.Subjects. Fifty-eight renal transplant patients from Tygerberg Hospital were enrolled in the study. The sample was divided into two groups of 29 patients each: group 1, less than 28 months post-transplant; and group 2, more than 28 months post-transplant.Outcome measures. Nutritional status assessment comprised biochemical evaluation, a dietary history, anthropometric measurements and a clinical examination.Results. Serum vitamin B6 levels were below normal in 56% of patients from group 1 and 59% from group 2. Vitamin B6 intake, however, was insufficient in only 14% of patients from group 1and10% from group 2. Serum vitamin C levels were below normal in 7% of patients from group 1 and 24% from group 2, while vitamin C intake was insufficient in 21%and14% of patients from groups 1 and 2 respectively. Serum magnesium levels were below normal in 55% of patients from group 1, and in 28% from group 2. Serum albumin and cholesterol levels increased significantly during the post-transplant period in the total sample (P = 0.0001). There was also a significant increase in body mass index (P = 0.0001) during the post-transplant period.Conclusions. Several nutritional abnormalities were observed, which primarily reflect the side-effects of immunosuppressive therapy. The causes, consequences and treatment of the vitamin B6 and vitamin C deficiencies in renal transplant recipients need further investigation.

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Objectives: The aim of the present study was to determine the current nutrition staffing profile of the Integrated Nutrition Programme (INP) inDepartment of Health in the Western Cape, and establish whether it is adequate to meet the objectives of the INP.Method: Self-administered questionnaires compiled in English were used as the main data collection instrument for nutrition staff in districtsand at hospitals (n = 647). Eight individual questionnaires, one per staff category, were developed and utilised in the study.Results: Foodservice workers were the largest group of nutrition personnel (n = 509; 79%), followed by dietitians (n = 64; 10%), managers(n = 31; 5%), auxiliary workers (n = 28; 4%), and administrative workers (n = 15; 2%). Sixty-two per cent of the nutrition workforce waslocated in urban areas and 38% in rural districts. Hospital and district dietitians experienced common problems, as well as specific differences.Regarding problems, both categories referred to limited resources, inadequate number of available posts, and lack of acknowledgementand support from administrative and supply chain management. District dietitians were also hampered by lack of space for consultations,poor referrals from doctors, insufficient posts for nutrition advisers, and difficulty in communicating with Xhosa-speaking patients. Hospitaldietitians were hampered by insufficient interaction with district dietitians and lack of dietitians for specialised units. They also mentioned thatpoor salaries were affecting morale.Conclusion: Recommendations such as additional posts for dietitians, improved conditions of service and salaries, increased advocacy fornutrition, and a number of human resources recommendations were made, and should be considered if the INP objectives are to be met.

A great need exists for ongoing breastfeeding training. Students of today relate well to computers in the learning environment. In this study, computer-based learning (CBL) was explored in the context of breastfeeding training for undergraduate Dietetic students. Aim: To adapt and validate an Indian computer-based undergraduate breastfeeding training module for use by South African undergraduate Dietetic students.Methods and materials: The Indian module was adapted to suit the South African scenario and converted into low-bandwidth, interactive computer-based material. It was assessed for face and content validity by 19 peer reviewers and 17 third-year Stellenbosch University (SU) Dietetic student reviewers by means of self-administered questionnaires. Impact of the adapted module on knowledge was evaluated on second-year SU (n = 14) and University of the Western Cape (UWC) (n = 15) Dietetic students by means of pre- and post-knowledge tests.Results: All reviewers rated their information technology (IT) skills as suffi cient and enjoyed the presentation mode of the adapted module. Student reviewers indicated that CBL was a “nice way of learning”, but requested that it should not be used as the sole source of instruction. Fifty three per cent (n = 19) of the reviewers rated CBL to be equally effective compared to conventional lectures, 36% (n = 13) rated it as being more effective and 11% (n = 4) as less effective. Pre- and post-knowledge test scores showed a signifi cant increase (SU p < 0.0001 and UWC p < 0.00115).Conclusion: It is recommended that validated computer-based breastfeeding training modules be integrated as part of multi-media methods to increase coverage and enhance breastfeeding learning for undergraduate Dietetic students. Other students of health care professions and health care workers may also benefi t from such modules.

Objective: To develop a regression equation to estimate the weight of black male paraplegic South African subjects. Design: Cross-sectional study. Setting: Outpatient paraplegic clinic of Kalafong Hospital, Tshwane, South Africa. Subjects: Subjects (n = 43) were selected from a population of black paraplegic males attending the clinic. Outcome measures: The following measurements were obtained in triplicate from the consenting subjects: weight, waist, calf, chest and neck circumference, mid upper-arm circumference (MUAC), supine length, upper-arm length and wrist circumference. The age of the subject, time elapsed since injury, level of injury and level of spasticity were recorded. Results: Body weight correlated significantly with waist, calf, chest and neck circumference and MUAC with respective Pearson correlation coefficient values (R) of 0.85 or higher and significant levels (p-values) of p < 0.0001. A regression equation to estimate weight was chosen on the basis of strength and practicality and included the following variables: circumferences of the calf, chest, and neck as well as the supine length. The regression equation was significant (p < 0.0001). Conclusion: A regression equation was developed which could be used, when further validated, to estimate the weight of black South African paraplegic males. SAJCN Vol. 21 (3) 2008: pp. 127-131

Objective. This study determined hazard analysis and critical control point (HACCP) awareness among managers of food-producing small and micro enterprises (SMEs) as well as selected aspects of the knowledge, attitude and practices of respective food handlers regarding food safety. Setting. SMEs within a 30 km range of Tygerberg Academic Hospital. Methods. SMEs were divided into two categories: those providing food to clients at risk of illness (N = 64) and to clients free of illness (N = 81). SMEs were randomly selected and managers/employees completed validated questionnaires regarding HACCP (145 managers) and food safety (159 food handlers). Results. Only 6% of managers reported awareness of HACCP being mandatory in South Africa. More than 70% of managers and food handlers had received no formal training regarding food safety. The perception that food safety control should focus on general cleanliness still prevailed among 57.2% of managers. Food handlers achieved an unsatisfactory score (46.0%) on the basic principles of food safety. Ignorance among food handlers regarding important risk factors was as follows: ways of identifying contaminated food likely to cause food poisoning (77.5%), period of keeping prepared food safe (50.9%), correct way of cooling food (63.1%) or reheating food (84.9%), reason for checking date codes (68.1%) and use of a thermometer (90.6%). There was no significant difference in the results obtained between food handlers in SMEs providing food to healthy clients or clients at risk of illness. Conclusion. Creating awareness and understanding of HACCP among managers of SMEs and education regarding the control of risk factors remain crucial.South African Journal Clinical Nutrition Vol. 20 (2) 2007: pp. 50-61

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Objectives. To estimate the burden of disease attributable to vitamin A deficiency in children aged 0 - 4 years and pregnant women aged 15 - 49 years in South Africa in 2000. Design. The framework adopted for the most recent World Health Organization comparative risk assessment (CRA) methodology was followed. Population-attributable fractions were calculated from South African Vitamin A Consultative Group (SAVACG) survey data on the prevalence of vitamin A deficiency in children and the relative risks of associated health problems, applied to revised burden of disease estimates for South Africa in the year 2000. Small community studies were used to derive the prevalence in pregnant women. Monte Carlo simulation-modelling techniques were used for the uncertainty analysis. Setting. South Africa. Subjects. Children under 5 years and pregnant women 15 - 49 years. Outcome measures. Direct sequelae of vitamin A deficiency, including disability-adjusted life years (DALYs), as well as mortality associated with measles, diarrhoeal diseases and other infections, and mortality and DALYs associated with malaria in children and all-cause maternal mortality. Results. One-third of children aged 0 - 4 years and 1 - 6% of pregnant women were vitamin A-deficient. Of deaths among young children aged 0 - 4 years in 2000, about 28% of those resulting from diarrhoeal diseases, 23% of those from measles, and 21% of those from malaria were attributed to vitamin A deficiency, accounting for some 3 000 deaths. Overall, about 110 467 (95% uncertainty interval 86 388 - 136 009) healthy years of life lost, or between 0.5% and 0.8% of all DALYs in South Africa in 2000 were attributable to vitamin A deficiency. Conclusions. The vitamin A supplementation programme for children and the recent food fortification programme introduced in South Africa in 2003 should prevent future morbidity and mortality related to vitamin A deficiency. Monitoring the effectiveness of these interventions is strongly recommended. South African Medical Journal Vol. 97 (8) Part 2 2007: pp. 748-753

Objectives. To estimate the extent of iron deficiency anaemia (IDA) among children aged 0 - 4 years and pregnant women aged 15 - 49 years, and the burden of disease attributed to IDA in South Africa in 2000. Design. The comparative risk assessment (CRA) methodology of the World Health Organization (WHO) was followed using local prevalence and burden estimates. IDA prevalence came from re-analysis of the South African Vitamin A Consultative Group study in the case of the children, and from a pooled estimate from several studies in the case of the pregnant women (haemoglobin level < 11 g/dl and ferritin level < 12 μg/l). Monte Carlo simulation-modelling was used for the uncertainty analysis. Setting. South Africa. Subjects. Children under 5 years and pregnant women 15 - 49 years. Outcome measures. Direct sequelae of IDA, maternal and perinatal deaths and disability-adjusted life years (DALYs) from mild mental disability related to IDA. Results. It is estimated that 5.1% of children and 9 - 12% of pregnant women had IDA and that about 7.3% of perinatal deaths and 4.9% of maternal deaths were attributed to IDA in 2000. Overall, about 174 976 (95% uncertainty interval 150 344 - 203 961) healthy years of life lost (YLLs), or between 0.9% and 1.3% of all DALYs in South Africa in 2000, were attributable to IDA. Conclusions. This first study in South Africa to quantify the burden from IDA suggests that it is a less serious public health problem in South Africa than in many other developing countries. Nevertheless, this burden is preventable, and the study highlights the need to disseminate the food-based dietary guidelines formulated by the National Department of Health to people who need them and to monitor the impact of the food fortification programme. South African Medical Journal Vol. 97 (8) Part 2 2007: pp. 741-746

The study aimed to determine whether knee height would be a more appropriate surrogate measurement than armspan in determining height and body mass index (BMI) in a group of South African older people (􀁲 60 years). A random sample of adults (older than 18 years) who attended selected clinics or who lived in selected old-age homes in the Western Cape volunteered to participate in the study. Subjects were divided into a study group of older people (􀁲 60 years of age, N = 1 233) and a comparative group of younger adults (18 - 59 years, N = 1 038). Armspan, knee height, standing height and weight were measured using standardised techniques. The standing height measurements were significantly different between the two groups (p = 0.0001), with a mean for adults of 1.61 m (standard deviation (SD) 0.09) compared with that of older peole (1.57 m (SD 0.09)). Mean standing height decreased with age. Knee-height measurements were not significantly different between the two groups, but when used to calculate height, the adults were significantly taller (p = 0.0001), with a mean height of 1.67 m (SD 0.06) compared with that of the older people (1.59 m (SD 0.08)). Mean armspan also decreased with age, and derived standing height was significantly different (p = 0.0001) between the two groups, with adults being taller (1.67 m (SD 0.11)) than the older people (1.63 m (SD 0.11)). In this study group, the knee-height measurements were more closely related to the standing height than the armspan. The BMI calculated from armspan-derived height tended to classify the older people towards underweight. Knee-height measurement would appear to be a more accurate and appropriate method to determine height in older people in South Africa. South African Journal of Clinical Nutrition Vol. 20 (1) 2007: pp. 39-44

No Abstract. South African Journal of Clinical Nutrition Vol. 19(1) 2006: 6-10