Gerda J. Gericke

Food security in South Africa: a review of national surveys

OBJECTIVE To assess the status of food security--i.e., access to food, food availability and food utilization--in South Africa. METHODS A systematic search of national surveys that used the Community Childhood Hunger Identification Project (CCHIP) index to measure food security in South Africa over a period of 10 years (1999-2008) was conducted. Anthropometric data for children aged 1-9 years were used to assess food utilization, and household food inventory data were used to assess food availability. FINDINGS Only three national surveys had used the CCHIP index, namely, the 1999 and 2005 National Food Consumption Surveys (NFCS) and the 2008 South African Social Attitudes Survey. These surveys showed a relatively large decrease in food insecurity between 1999 and 2008. However, the consistent emerging trend indicated that in poorer households women were either feeding their children a poor diet or skipping meals so their children could eat. In terms of food access and availability, the 1999 NFCS showed that households that enjoyed food security consumed an average of 16 different food items over 24 hours, whereas poorer households spent less money on food and consumed fewer than 8 different food items. Moreover, children had low mean scores for dietary diversity (3.58; standard deviation, SD: ± 1.37) and dietary variety (5.52; SD: ± 2.54) scores. In terms of food utilization, the NFCS showed that stunting in children decreased from 21.6% in 1999 to 18% in 2005. CONCLUSION The South African government must implement measures to improve the undesirably high level of food insecurity in poorer households.

Nutritional status, quality of life and CD4 cell count of adults living with HIV/AIDS in the Ga-Rankuwa area (South Africa)

Abstract Objective: To determine if there was a relationship between CD4 cell count, nutritional status and self-reported quality of life (QoL) in HIV-infected adults. Design: Descriptive study in the quantitative research domain. Setting: The out-patient antiretroviral (ARV) clinic at Dr George Mukhari Hospital (Ga-Rankuwa) (institutional). Subjects: The study group (n = 90) consisted of male (n = 34) and female patients (18–50 years) diagnosed with HIV/AIDS. Convenience sampling was used. Outcome measures: Anthropometry (weight, height, BMI, MUAC, TSF), dietary intake (habitual food intake recall) and QoL (WHOQoL-HIV questionnaire) were assessed. Data collection was done from January–April 2007. Results: Significant, but poor, positive correlation was found for the following anthropometrical parameters and the CD4 cell count: weight (r = 0.37; ρ = 0.00), BMI (r = 0.39; ρ = 0.00), and MUAC (r = 0.36; ρ = 0.00). The study group had a poor dietary quality. Significant correlation with the CD4 cell count was found for the following domains of the QoL: physical activity (r = 0.27; ρ = 0.01), psychological (r = 0.27; ρ = 0.01), level of independence (r = 0.36; ρ = 0.00), and environmental (r = 0.27; ρ = 0.01). The overall QoL assessment was average, according to the WHOQoL-HIV questionnaire score. Conclusion: Significant positive relationships existed between specific anthropometry and the CD4 cell count, and also between certain QoL domains and the CD4 cell count. Strategies for increasing dietary diversity and QoL ought to be identified and implemented in communities. Recommendation: A longitudinal study would give better understanding of the relationship between nutritional status, the CD4 cell count and QoL.

Effect of a nutrition education programme on clinical status and dietary behaviours of adults with type 2 diabetes in a resource-limited setting in South Africa: a randomised controlled trial

OBJECTIVE To evaluate the effect of a participant-customised nutrition education programme on glycated Hb (HbA(1c)), blood lipids, blood pressure, BMI and dietary behaviours in patients with type 2 diabetes mellitus. DESIGN A randomised controlled trial. The control group (n 41) received education materials. The intervention group (n 41) received the same education materials and participated in eight weekly (2-2·5 h) group nutrition education sessions and follow-up sessions. Outcomes were assessed at 6 and 12 months. An intention-to-treat analysis was conducted. ANCOVA compared the groups (adjustments for baseline values, age, sex and clinic). SETTING Two community health centres, Moretele sub-district (North West Province), South Africa. SUBJECTS Adults (aged 40-70 years) with type 2 diabetes, HbA(1c) ≥8 %. RESULTS Differences in HbA(1c) (primary outcome) were -0·64 % (P=0·15) at 6 months and -0·63 % (P=0·16) at 12 months in favour of the intervention group. Starchy-food intake was significantly lower in the intervention group, 9·3 v. 10·8 servings/d (P=0·005) at 6 months and 9·9 v. 11·9 servings/d (P=0·017) at 12 months. Median energy intake was significantly lower in the intervention group at 12 months (5988 v. 6946 kJ/d, P=0·017). No significant group differences in BMI, lipid profile, blood pressure and intakes of macronutrients, vegetables and fruits were observed. CONCLUSIONS Nutrition education was not efficacious on HbA(1c); however, it improved specific dietary behaviours. Group education and hands-on activities appeared to contribute to the improvement. Optimal goal setting and self-efficacy training/assessment could benefit future nutrition education programmes for people with type 2 diabetes mellitus in resource-limited settings.

The relationship between stunting and overweight among children from South Africa: Secondary analysis of the National Food Consumption Survey--Fortification Baseline I.

BACKGROUND Globally, in children the prevalence of overweight and obesity is increasing, and this is associated with an increased risk of non-communicable diseases in adulthood. There is a need to examine the growing trends of overweight and obesity in children and their consequences in low- and middle-income countries. OBJECTIVES To describe the prevalence of, and determine the relationship between, stunting and overweight among children in two provinces of South Africa. METHODS Secondary data analysis was conducted on anthropometric measurements of 36-119-month-old children from Gauteng and Mpumalanga provinces (N=519) participating in the South African National Food Consumption Survey--Fortification Baseline I (2005). The International Obesity Task Force (IOTF) body mass index (BMI) reference percentiles were used to determine overweight and obesity. The World Health Organization standards were used to derive z-scores. RESULTS The prevalence of overweight was 12.0% (IOTF BMI≥25 kg/m2), including 3.7% obesity (IOTF BMI≥30 kg/m2). The predominantly urban Gauteng Province had a significantly higher prevalence of overweight children (14.1%) compared with Mpumalanga (6.3%) (p=0.0277). The prevalence of stunting was 17.0% (16.5% Gauteng, 18.2% Mpumalanga; p>0.05). There was a significant correlation (r=-0.32) between BMI and height-for-age z-scores (p<0.0001). In the obese group, 68.4% were stunted, while in the normal and underweight group only 13.6% were stunted. CONCLUSIONS Stunted children were more likely to be obese. Further research is necessary for clarity on the physiological mechanisms of this relationship. In the interim, prevention of stunting requires priority.

Subjects’ experiences of a nutrition education programme: a qualitative study of adults with type 2 diabetes mellitus living in a rural resource-limited setting in South Africa

Abstract Objective: The objective of the study was to explore the views and experiences of adults with type 2 diabetes mellitus on a nutrition education programme. Design: Interpretative phenomenological design. Setting: The setting was two community health centres in Moretele, North West province, South Africa. Subjects and outcome measures: The study subjects were adults with type 2 diabetes mellitus (n = 41, aged 40–70 years) participating in a nutrition education intervention (one-year randomised controlled trial). The intervention was based on the assessed nutrition education needs of the target group, and included the provision of nutrition education materials. Data were collected at the end of the training intervention (eight weeks) and at the end of the study (12 months). A self-administered, open-ended questionnaire was used at eight weeks (n = 31). Five focus group discussions were conducted at 12 months. A framework thematic analysis technique was employed. Results: The majority of participants indicated that they enjoyed the nutrition education programme at the two time periods. They were satisfied with its content and delivery. The education materials (pamphlet and fridge or wall poster) were seen as useful for the whole family, and as constant reminders of positive behaviour. Benefits indicated by the participants included a gain in health knowledge and skills, positive dietary changes, and improved health and family support. Participants also recommended the programme to other people with diabetes mellitus. Positive educator characteristics, such as competence, patience, being respectful and approachable, were cited as desirable. Conclusion: Participant-customised nutrition education can contribute to programme satisfaction, perceived benefits and adherence to the programme. The provision of education materials should form part of such programmes. Facilitators of nutrition education programmes should take responsibility for employing desirable personal attributes as this can enhance client participation.

Impact of nutrition education on diabetes knowledge and attitudes of adults with type 2 diabetes living in a resource-limited setting in South Africa: a randomised controlled trial

Objective: To evaluate the effect of a nutrition education (NE) programme on diabetes knowledge and attitudes of adults with type 2 diabetes mellitus (T2DM). Methods: Eighty-two adults (40–70 years) with poorly controlled T2DM (HbA1c ≥ 8%) and attending two community health centres in Moretele, North West Province (South Africa) participated in a one-year randomised controlled trial. Participants were randomised to the intervention group (n = 41; 8 weekly group education (2–2.5 hours); follow-up meetings and education materials) or control group (education materials only). Diabetes Knowledge Form B assessed knowledge about diabetes. Diabetes Attitudes Scale-III assessed the attitudes towards diabetes and treatment. Assessments were done at 6 and 12 months. Analysis of co-variance compared the groups (baseline, age, gender and clinic adjustments). An intention-to-treat analysis was employed. Results: The intervention group had higher mean diabetes knowledge scores + 0.95 (p = 0.033) and + 2.05 (p < 0.001) at 6 and 12 months respectively. However, the scores were below 50%. Patient autonomy for diabetes attitudes was the only score significantly higher in the intervention group + 0.27 (p = 0.028) at 12 months. Conclusion: NE significantly improved diabetes knowledge in the intervention group, though not satisfactorily, but had limited effects on the attitudes towards diabetes.

Nutrition education practices of primary school teachers in a resource-constrained community in Gauteng, South Africa

ABSTRACT We investigated the nutrition education (NE) practices of teachers of grade 4‒7 learners in 11 primary schools (85% of total number) of the Bronkhorstspruit district (Gauteng Province) to identify opportunities for improving NE in these schools. A descriptive cross-sectional survey was carried out among a convenient sample of the teachers (N = 73) using a structured nutrition education practice questionnaire. Descriptive data analysis was done. Results showed that the majority of the teachers taught nutrition in about 10% to 20% of their teaching time. Thirty percent had no training to teach nutrition, and most teachers (86%) would like to receive training in nutrition. Teachers mostly taught nutrition as part of the curriculum (67%) and very few (18%) integrated nutrition into other subjects. Needing improvement were adequate classroom time for nutrition education delivery, continuing training in nutrition for teachers, and provision of up-to-date instructional materials for teaching nutrition.

Factors that influenced mothers and/or caregivers in the Tshwane Metropolitan Municipality, South Africa, to purchase infant formula for their infants

Abstract Objective: The objective of the study was to identify and categorise factors that influence the choice behind the purchase of an infant formula brand by mothers and/or caregivers, and the reasons for their choice. Design: This was a descriptive cross-sectional study in the quantitative research domain. Setting: The setting was a pharmacy in Centurion Mall, and large food retail stores in Centurion Mall, Centurion Lifestyle Centre, Lyttleton Centre, Attlyn (Atteridgeville) and the Quagga Centre (Pretoria West) in Tshwane Metropolitan Municipality, South Africa. Subjects and outcome measures: The 200 participants who were selected using purposive sampling completed a point-of-purchase questionnaire. Results: The majority of the participants who purchased infant formula were aged 25-34 years, married, educated, affluent and employed full-time. Influencing factors were advice from others [76% (of which 32% was advice from a paediatrician)], a perceived claim that the infant formula provided a specific health benefit (49.5%), brand loyalty (13.5%), having seen an infant formula being used in hospital (10.5%) and the infant’s taste preference (9%). Half of the participants (51%) purchased infant formula manufactured by one of the largest manufacturers of this product globally. Conclusion: Paediatricians’ recommendations, as well as perceived health claims, were considered to be primary influencing factors with regard to the purchase of infant formula by mothers. Appropriate training should target paediatricians and other healthcare professionals to ensure that they advocate breastfeeding uncompromisingly, and advise mothers and/or caregivers on appropriate indications for infant formula.

School-based nutrition education: features and challenges for success

Purpose – The aim of this review is to critically assess published articles on school-based nutrition education (NE) intervention to identify factors hindering or contributing to the success of interventions. School-based NE possesses the capacity to influence learners’ nutrition behaviours. Design/methodology/approach – An electronic search of articles was conducted in Medline, PubMed, the Cumulative Index to Nursing and Allied Health Literature databases, Google and snowballing. Included in the review were school-based studies with classroom NE with or without nutrition services and studies published between 2000 and 2013. School-based non-intervention studies and interventions that did not include a nutrition teaching component were excluded in the review. Findings – Thirty-nine studies met the inclusion criteria. Features of successful NE interventions included the use of behavioural theories, especially the social cognitive theory and the involvement of trained teachers in the implementation of interventions. Capacity development for teachers, time constraints, school policies and implementation problems of multicomponent interventions were some of the identified challenges encountered in the studies reviewed. Originality/value – Trained teachers are invaluable assets in interventions to improve nutrition behaviours of learners. Challenges associated with teacher-oriented school-based NE intervention can be overcome by properly designed and implemented interventions based on behavioural theory.

South African private practising clinical dietitians’ perceptions of the relevance of service-specific healthcare marketing principles and communication elements

Abstract Background: South African dietitians are confronted with the challenge of effectively marketing themselves as a sound source of information on nutrition to both the public and other health professionals. The marketing initiative should focus on the promotion of both the profession itself and individual practices. The aim was to assess the perception of South African private practising clinical dietitians of the relevance of service-specific healthcare marketing principles and communication elements (within the ambit of Act 53 of 1974). The design was a descriptive cross-sectional survey in the quantitative domain. Convenience sampling was used (n = 79). Method: Data were collected by means of an electronic questionnaire. The response rate was low (16.8%), and the results could not be generalised. Results: The dietitians seemed more focused on the science of nutrition, than on marketing their profession and individual practices. There was an overall awareness of the need for marketing in the dietetic private sector, but the importance and implementation thereof did not receive the amount of attention that it justifies. A number of service-specific healthcare marketing principles received “slightly relevant” or “not relevant” ratings. Conclusion: For the dietetic profession to reach its full potential in South Africa, and for dietetic private practices to be successful on all levels, dietitians need to focus more of their time and energy on business-related aspects such as marketing. By integrating the theory from the literature with the findings from the study, a profession-specific marketing flow diagram and recommendations could be proposed. S Afr J Clin Nutr 2011;24(4):192-198