Whadi-ah Parker

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.

Dietary, social, and environmental determinants of obesity in Kenyan women

Aim: To assess the determinants of overweight and obesity in Kenyan women considered to be undergoing the nutrition transition. Methods: A nationally representative sample of women (n = 1008) was randomly drawn. Weight, height, waist, and hip circumference were measured. A 24-hour dietary recall was conducted with each participant and a socio-demographic questionnaire completed. Data was analysed by age, education, location, and socioeconomic status. Risk for obesity was calculated while adjusting for age and location. Results: Overweight and obesity (BMI ≥ 25 kg/m2) were highly prevalent in Kenya (43.3%). Urbanisation appears to be an important determinant of obesity since obesity was most prevalent in urban women in the high income group. Women in the high income group (7278 kJ) and in urban areas (7049 kJ) had the highest mean energy intakes. There were also significant urban/rural and income differences in the contribution of macronutrients to energy intake. Total fat intake was 34.5% of energy (E) in urban areas and 29.7% E in rural areas; while carbohydrates contributed 69.9% E in rural areas and 57.4% E in urban areas (p < 0.0001). Overweight was significantly more likely in the highest income group; among households where room density was low; electricity or gas was used for cooking; and households had own tap and/or own flush toilet. Conclusions: This study suggests that urbanisation and its associated economic advancement as well as changes in dietary habits are among the most important determinants of overweight and obesity in Kenyan women.

They think they know but do they? Misalignment of perceptions of lifestyle modification knowledge among health professionals

OBJECTIVE The present study aimed to evaluate the knowledge and practices of public-sector primary-care health professionals and final-year students regarding the role of nutrition, physical activity and smoking cessation (lifestyle modification) in the management of chronic diseases of lifestyle within the public health-care sector. DESIGN A comparative cross-sectional descriptive quantitative study was conducted in thirty primary health-care facilities and four tertiary institutions offering medical and/or nursing programmes in Cape Town in the Western Cape Metropole. Stratified random sampling, based on geographical location, was used to select the health facilities while convenience sampling was used to select students at the tertiary institutions. A validated self-administered knowledge test was used to obtain data from the health professionals. RESULTS Differential lifestyle modification knowledge exists among both health professionals and students, with less than 10 % achieving the desired scores of 80 % or higher. The majority of health professionals seem to be promoting the theoretical concepts of lifestyle modification but experience difficulty in providing practical advice to patients. Of the health professionals evaluated, doctors appeared to have the best knowledge of lifestyle modification. Lack of time, lack of patient adherence and language barriers were given as the main barriers to providing lifestyle counselling. CONCLUSIONS The undergraduate curricula of medical and nursing students should include sufficient training on lifestyle modification, particularly practical advice on diet, physical activity and smoking cessation. Health professionals working at primary health-care facilities should be updated by providing lifestyle modification education as part of continuing medical education.

Urbanisation and the nutrition transition: A comparison of diet and weight status of South African and Kenyan women

Aims: To determine and compare the extent of the nutrition transition between Kenyan and South African women. Methods: A nationally representative sample of women aged ≥15 years (n=1008) was assessed in Kenya. Weight, height, and waist and hip circumferences were measured. A 24-hour dietary recall was conducted with each participant. This data was compared with data of the Demographic and Health Survey (DHS) of women in South Africa (n=4481). Dietary intake of South African women was based on secondary data analysis of dietary studies using the 24-hour recall method (n=1726). Results: In South Africa, 27.4% women had a BMI ≥30 kg/m2 compared with 14.2% of Kenyan women. In both countries there were large urban–rural differences in BMI, with the highest prevalence in women in urban areas. BMI increased with age, as did abdominal obesity which was equally prolific in both countries with more than 45% of women in the older groups having a waist/hip ratio ≥0.85. The nutrient mean adequacy ratio (MAR) of the South African rural diet was lower than those of the Kenyans diet (55.9; 57.3%, respectively). Dietary diversity score (DDS) and food variety score (FVS) were significantly lower in South African rural women (3.3; 4.9) compared with Kenyans (4.5; 6.8). Conclusions: Urban–rural differences in diet and weight status indicates that the nutrition transition was similar in both countries despite large sociodemographic differences; however, rural Kenyan women had a better MAR, DDS, and FVS than South African women, most probably due to 60% having access to land.

Health promotion services for patients having non-comminicable diseases: feedback from patients and health care providers in Cape Town, South Africa.

BackgroundDue to a paucity of data regarding the availability and efficacy of equipment, health promotion methods and materials currently used by health professionals for the management of patients with non-communicable diseases (NCDs) at primary health care (PHC) facilities in Cape Town, an audit was undertaken.MethodsA multi-centre cross-sectional study was undertaken to interview patients (n = 580) with NCDs at 30 PHC facilities. A questionnaire was used to obtain information on preferences for health promotion methods for lifestyle modification. Individual semi-structured interviews were conducted with selected health professionals (n = 14) and captured using a digital recorder. Data were transferred to the Atlas ti software programme and analysed using a thematic content analysis approach.ResultsBlood pressure measurement (97.6%) was the most common diagnostic test used, followed by weight measurement (88.3%), urine (85.7%) and blood glucose testing (80.9%). Individual lifestyle modification counselling was the preferred health education method of choice for the majority of patients. Of the 64% of patients that selected chronic clubs/support groups as a method of choice, only a third rated this as their first choice. Pamphlets, posters and workshops/group counselling sessions were the least preferred methods with only 9%, 13% and 11% of patients choosing these as their first choice, respectively. In an individual counselling setting 44.7% of patients reported that they would prefer to be counselled by a doctor, followed by a nurse (16.9%), health educator (8.8%) and nutrition advisor (4.8%). Health professionals identified numerous barriers to education and counselling. These can be summarised as a lack of resources, including time, space and equipment; staff-related barriers such as staff shortage and staff turnover; and patient-related barriers such as patient load and patient non-compliance.ConclusionThe majority of patients attending PHC facilities want to receive lifestyle modification education. There is not however, one specific method that can be regarded as the gold standard. Patients’ preferences regarding health education methods differ, and they are more likely to be susceptible to methods that do not involve much reading. Health education materials such as posters, pamphlets and booklets should be used to supplement information received during counselling or support group sessions.

A review of school nutrition interventions globally as an evidence base for the development of the HealthKick programme in the Western Cape, South Africa.

Abstract Aim: The aim of this study was to review all school interventions having a nutrition component, published in peer-reviewed literature between 1995 and 2006, and to document activities that were successful as well as those that were possible barriers in order to develop a best practice school intervention for the Western Cape Province, South Africa. Methodology: A systematic review of school studies revealed 85 interventions that complied with the predetermined search criteria. The following outcome measures were considered in the evaluation of the interventions: (i) changes in nutritional knowledge, attitudes and self-efficacy and stage of change; (ii) changes in dietary behaviours; (iii) changes in clinical/physical markers such as body weight or body mass index, blood pressure or serum cholesterol concentrations; and (iv) process and/or policy outcomes. Results: Key success factors of school-based interventions appeared to be the following: A nutrition-based curriculum offered at school by trained teachers generally improved behavioural outcomes. A physical activity programme and parental component were associated with most of the best practice clinical and behavioural outcomes. Furthermore, all best practice studies were grounded on a firm theory of behaviour, such as social cognitive, social marketing or stages of change. Most of the interventions that included a food service component had best practice behavioural outcomes. Conclusions: Numerous school-based nutrition interventions have shown significant improvements in children’s nutritional behaviours. Consequently, it is necessary to plan programmes based on existing evidence of best practice. The lessons learnt from this review have been applied in the development of the HealthKick programme initiated in schools in the Western Cape in 2007.

Nutrition interventions in the workplace: Evidence of best practice

Abstract Aim: The aim of this desktop study was to review all workplace interventions having a nutrition component, published in peer-reviewed literature between 1995 and 2006 by WHO, and to document activities that were successful, as well as possible barriers to their success. Methodology: A systematic review of workplace studies revealed 41 interventions, of which 30 complied with the predetermined search criteria. The following outcome measures were considered in the evaluation of the interventions: (i) changes in nutritional knowledge, attitudes, self-efficacy, intentions and stage of change; (ii) changes in dietary behaviours; (iii) changes in clinical/physical markers, such as: body weight or body-mass index (BMI), blood pressure (BP) or serum cholesterol concentrations; and (iv) process and/or policy outcomes. Results: A large number of diverse workplace interventions were successful in changing outcomes positively in the interventions evaluated. The following were key success factors: i) there was a nutrition and physical activity component; ii) dietitians were involved in nutrition education; iii) changes occurred in the cafeteria/canteen, which increased the availability of healthy food options and advertised them accordingly; iv) tailored feedback on diet (and clinical values) was given to subjects; v) employees were involved in planning and managing programmes; vi) the reduced prices (of healthy food items) in vending machines encouraged employees to buy healthier options; and vii) the stages of change theory was most commonly associated with best practice outcomes. Conclusions: Numerous workplace interventions have shown significant improvements in employees’ health and behaviours. However, it is necessary to plan intervention programmes based on the existing evidence of best practice.

Promoting healthy lifestyle behaviour through the life-orientation curriculum: teachers' perceptions of the HealthKick intervention

This study explores the feasib0ility of implementing the curriculum and action-planning components of the HealthKick (HK) intervention in eight low-resourced schools in the Western Cape, South Africa. Process evaluation comprising workshops and personal interactions with teachers and principals were followed up with semi-structured interviews and focus group discussions, along with a questionnaire and evaluation sheet, during three implementation phases. Since promoting healthy habits during the early formative years is of key importance, the research team actively intervened to ensure successful implementation of the curriculum component. Time constraints, teachers’ heavy workload, and their reluctance to become involved in non-compulsory activities, were the main reasons for non-compliance in using the curriculum document. Furthermore, the priorities of the teachers were not necessarily those of the researchers. However, findings indicate that with an appropriate introduction and continued interaction and support, the integration of specific healthy lifestyle outcomes into a curriculum can be sustainable if teachers are well informed and motivated. Key words: action-planning process; curriculum intervention; healthy lifestyle; nutrition; physical activity; primary school

Quantifying unmet need for hypertension care in South Africa through a care cascade: evidence from the SANHANES, 2011-2012

Introduction Hypertension has become a major cause of morbidity and premature mortality in South Africa, but population-wide estimates of prevalence and access to care are scarce. Using data from the South African National Health and Nutrition Examination Survey (2011–2012), this analysis evaluates the national prevalence of hypertension and uses a care cascade to examine unmet need for care. Methods Hypertension was defined as blood pressure over 140/90 mm Hg or use of antihypertensive medication. We constructed a hypertension care cascade by decomposing the population with hypertension into five mutually exclusive and exhaustive subcategories: (1) unscreened and undiagnosed, (2) screened but undiagnosed, (3) diagnosed but untreated, (4) treated but uncontrolled and (5) treated and controlled. Multivariable logistic regression models were used to explore factors associated with hypertension prevalence and diagnosis. Results In South Africans aged 15 and above, the age standardised prevalence of hypertension was 35.1%. Among those with hypertension, 48.7% were unscreened and undiagnosed, 23.1% were screened but undiagnosed, 5.8% were diagnosed but untreated, 13.5% were treated but uncontrolled and 8.9% were controlled. The hypertension care cascade demonstrates that 49% of those with hypertension were lost at the screening stage, 50% of those who were screened never received a diagnosis, 23% of those who were diagnosed did not receive treatment and 48% of those who were treated did not reach the threshold for control. Men and older individuals had increased risks of being undiagnosed after controlling for other factors. Conclusions There is significant unmet need for hypertension care in South Africa; 91.1% of the hypertensive population was unscreened, undiagnosed, untreated or uncontrolled. Data from this study provide insight into where patients are lost in the hypertension care continuum and serve as a benchmark for evaluating efforts to manage the rising burden of hypertension in South Africa.

Prevalence and unmet need for diabetes care across the care continuum in a national sample of South African adults: evidence from the SANHANES-1, 2011-2012

South Africa faces an epidemic of chronic non-communicable diseases (NCDs), yet national surveillance is limited due to the lack of recent data. We used data from the first comprehensive national survey on NCDs—the South African National Health and Nutrition Examination Survey (SANHANES-1 (2011–2012))—to evaluate the prevalence of and health system response to diabetes through a diabetes care cascade. We defined diabetes as a Hemoglobin A1c equal to or above 6.5% or currently on treatment for diabetes. We constructed a diabetes care cascade by categorizing the population with diabetes into those who were unscreened, screened but undiagnosed, diagnosed but untreated, treated but uncontrolled, and treated and controlled. We then used multivariable logistic regression models to explore factors associated with diagnosed and undiagnosed diabetes. The age-standardized prevalence of diabetes in South Africans aged 15+ was 10.1%. Prevalence rates were higher among the non-white population and among women. Among individuals with diabetes, a total of 45.4% were unscreened, 14.7% were screened but undiagnosed, 2.3% were diagnosed but untreated, 18.1% were treated but uncontrolled, and 19.4% were treated and controlled, suggesting that 80.6% of the diabetic population had unmet need for care. The diabetes care cascade revealed significant losses from lack of screening, between screening and diagnosis, and between treatment and control. These results point to significant unmet need for diabetes care in South Africa. Additionally, this analysis provides a benchmark for evaluating efforts to manage the rising burden of diabetes in South Africa.