Twelve Weeks of Additional Fish Intake Improves the Cognition of Cognitively Intact, Resource-Limited Elderly People: A Randomized Control Trial.

INTRODUCTION: Dietary omega 3 polyunsaturated fatty acids (PUFA) may reduce the risk of dementia. Many studies have investigated PUFA supplementation in high-income countries, yet food-based randomized control trials using omega 3 PUFA rich fish in lower to middle income countries, are lacking. OBJECTIVE: To determine the effect on cognition of adding either fish or non-fish foods for twelve weeks to an enhanced diet of cognitively intact, independently living, resource-limited elderly people. DESIGN: Randomized control trial (National Health Trial register: DOH-27-061-6026). SETTING: Retirement center in urban South Africa. PARTICIPANTS: Fifty-seven (74% female, mean age: 72±7 years) elderly participants with cognitive function exceeding 22 on the Mini Mental State Examination were randomized into an intervention (n=31) and control (n=26) group. INTERVENTION: The usual diets of both groups were enhanced with context-appropriate foods to mimic elements of the Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) diet. The intervention group additionally received canned pilchards and fish spread every week amounting to an additional (theoretical) intake of 2.2g omega 3 PUFA daily. The control group received canned meatballs and texturized soya every week. MEASUREMENTS: Cognition was measured twice before and once after the intervention phase using the Cognitive Abilities Screening Instrument (CASI). Adherence was assessed by a study-specific food frequency questionnaire and red blood cell (RBC) PUFA biomarkers. Data were analyzed using a non-parametric analysis of covariance (ANCOVA) with, and without, bootstrap imputation. RESULTS: Participants in the intervention group had a significantly higher post intervention (P=0.036) CASI score than the control group, when the model was fitted with imputation and controlled for baseline scores. Participants in the intervention group also had a significantly higher intake of calculated dietary omega 3 PUFA and higher levels of RBC eicosapentaenoic acid and docosapentaenoic acid content than the control group (P < 0.05). CONCLUSION: Twelve weeks of fish intake in the context of a modified MIND diet may improve the cognition of cognitively intact, resource-limited elderly people.

Dietary quality and patterns and non-communicable disease risk of an Indian community in KwaZulu-Natal, South Africa.

BACKGROUND: Limited data exist on the South African Indian diet despite their high prevalence of non-communicable diseases. This study attempted to determine the dietary quality and patterns of an Indian population in KwaZulu-Natal with reference to the high prevalence of non-communicable disease METHODS: Two-hundred-and-fifty apparently healthy Indians, aged 35-55 years participated in a cross-sectional study where diet was assessed using a validated quantitative food frequency questionnaire. Mean intakes were compared to the World Health Organization goals. Dietary quality was determined by index construction and dietary patterns by factor analysis. RESULTS: The mean daily percentage of energy (%E) from n-3 fatty acids (0.24 %E), dietary fibre (18.4 g/day) and fruit and vegetable intakes (229.4 g/day) were below the World Health Organization goals. Total fat (36.1 %E), polyunsaturated fatty acids (11.8 %E), n-6 fatty acids (11 %E) and free sugars (12.5 %E) exceeded the goals. The means for the deficient index reflected a moderate diet quality whereas, the excess index reflected good diet quality. The Pearson partial correlation coefficients between the deficient index and risk markers were weak whilst, the excess index was inversely correlated with waist circumference for the whole sample. Two factors were identified, based on the percentage of fat that contributed to each food group: factor 1 (meat and fish versus legume and cereal pattern), which accounted for added fat through food preparation; and Factor 2 (nuts and seeds versus sugars and visible fat pattern), which accounted for obvious fat. The medians for waist circumference, blood glucose, cholesterol and triglyceride levels showed significant decreasing trends for factor 1 (p < 0.05). The medians for blood glucose and cholesterol showed significant decreasing trends for factor 2 (p < 0.01). CONCLUSION: A shortfall of fruit and vegetable, fibre and n-3 fatty acid intake in the diet is highlighted. When assessing the diet quality and patterns, guidance on the prudent use of added fats may lead to a healthier lifestyle reducing the prevalence of non-communicable diseases.

Dietary intakes assessed by 24-h recalls in peri-urban African adolescents: validity of energy intake compared with estimated energy expenditure.

BACKGROUND/OBJECTIVE: The objective of this study is to determine the relative validity of reported energy intake (EI) derived from multiple 24-h recalls against estimated energy expenditure (EE(est)). Basal metabolic rate (BMR) equations and physical activity factors were incorporated to calculate EE(est). SUBJECTS/METHODS: This analysis was nested in the multidisciplinary PhysicaL Activity in the Young study with a prospective study design. Peri-urban black South African adolescents were investigated in a subsample of 131 learners (87 girls and 44 boys) from the parent study sample of 369 (211 girls and 158 boys) who had all measurements taken. Pearson correlation coefficients and Bland-Altman plots were calculated to identify the most accurate published equations to estimate BMR (P<0.05 statistically significant). EE(est) was estimated using BMR equations and estimated physical activity factors derived from Previous Day Physical Activity Recall questionnaires. After calculation of EE(est), the relative validity of reported energy intake (EI(rep)) derived from multiple 24-h recalls was tested for three data subsets using Pearson correlation coefficients. Goldberg's formula identified cut points (CPs) for under and over reporting of EI. RESULTS: Pearson correlation coefficients between calculated BMRs ranged from 0.97 to 0.99. Bland-Altman analyses showed acceptable agreement (two equations for each gender). One equation for each gender was used to calculate EE(est). Pearson correlation coefficients between EI(rep) and EE(est) for three data sets were weak, indicating poor agreement. CPs for physical activity groups showed under reporting in 87% boys and 95% girls. CONCLUSION: The 24-h recalls measured at five measurements over 2 years offered poor validity between EI(rep) and EE(est).

Association between consumption of black tea and iron status in adult Africans in the North West Province: the THUSA study.

The association between black tea consumption and iron status was investigated in a sample of African adults participating in the cross-sectional THUSA (Transition and Health during Urbanization of South Africans) study in the North West Province, South Africa. Data were analysed from 1605 apparently healthy adults aged 15-65 years by demographic and FFQ, anthropometric measurements and biochemical analyses. The main outcome measures were Hb and serum ferritin concentrations. No associations were seen between black tea consumption and concentrations of serum ferritin (men P = 0.059; women P = 0.49) or Hb (men P = 0.33; women P = 0.49). Logistic regression showed that tea consumption did not significantly increase risk for iron deficiency (men: OR 1.36; 95 % CI 0.99, 1.87; women: OR 0.98; 95 % CI 0.84, 1.13) nor for iron deficiency anaemia (men: OR 1.28; 95 % CI 0.84, 1.96; women: OR 0.93; 95 % CI 0.78, 1.11). Prevalence of iron deficiency and iron deficiency anaemia was especially high in women: 21.6 and 14.6 %, respectively. However, the likelihood of iron deficiency and iron deficiency anaemia was not significantly explained by tea consumption in sub-populations which were assumed to be at risk for iron deficiency. Regression of serum ferritin levels on tea consumption in women

Cardiovascular disease risk factors and socio-economic position of Africans in transition: the THUSA study.

In many developing countries with advanced stages of the nutrition transition, the burden of coronary artery disease (CAD) has shifted from the rich to the poor. In South Africa, it is mainly the African population that is experiencing rapid urbanisation and the nutrition transition. It is not clear where the burden of CAD lies in this population group. We tried to answer this question by comparing CAD risk factors within African groups of different socio-economic positions (characterised by total household income and education level) that participated in the THUSA study from 1996 to 1998. The THUSA study was a cross-sectional population- based epidemiological study that examined the influence of urbanisation and related changes in lifestyle and eating patterns on health and disease risk. A total of 1 854 apparently healthy African volunteers were recruited from 37 randomly chosen sites in rural and urban areas of the North-West Province. The results indicated that although the group with the highest socio-economic position had significantly lower serum glucose levels, systolic blood pressures, higher micronutrient intakes and fewer smokers, their sustained increases in total and saturated fat intakes and higher serum total and LDL cholesterol levels, as well as increased body mass indices in men suggested that at that point in time and possibly in the foreseeable future, the burden of CAD will be carried by those Africans with higher socio-economic positions.

Inadequate dietary intake is not the cause of stunting amongst young children living in an informal settlement in Gauteng and rural Limpopo Province in South Africa: the NutriGro study.

OBJECTIVE: To measure dietary intakes of young children aged 12-24 months and to determine the impact of poor diets on stunting. DESIGN: A quantitative food-frequency questionnaire was adapted, tested and standardised. Trained enumerators conducted in-depth interviews with the mothers/caregivers of the children. Forty stunted children in urban informal settlements and 30 stunted children in rural areas were selected and pair-matched with controls. The data were captured on the Food Finder Program of the Medical Research Council. RESULTS: In both urban and rural areas, the diet of stunted and non-stunted groups did differ significantly and all diets were of poor nutritional quality. CONCLUSION: Diets in both areas resembled the recommended prudent diet, i.e. low in fat and high in carbohydrates. Poor quality diets were not the primary cause of stunting.

The determinants of overweight and obesity among 10- to 15-year-old schoolchildren in the North West Province, South Africa - the THUSA BANA (Transition and Health during Urbanisation of South Africans; BANA, children) study.

AIM: To investigate the determinants of overweight and obesity among 10- to 15-year-old schoolchildren in a population in the transitional phase in the North West Province of South Africa. METHODS: A cross-sectional survey was used to investigate weight status (anthropometric indicators) and determinants of overweight/obesity including dietary intake, physical activity and socio-economic status. A single, random sample (n=1257), stratified for gender, type of school and ethnic group, was used. Data were collected on demographics, family circumstances, habitual physical activity, dietary intake and anthropometry to evaluate weight status and body fat content. One-way analysis of variance, the generalised linear models procedure of SAS and the Tukey post hoc honest significant difference test were used to analyse the data. RESULTS: Few children were overweight or obese (7.8%) according to International Obesity Task Force (IOTF) standards (body mass index (BMI)-for-age). These standards were compared with other accepted standard values. Both Cole's IOTF/BMI-for-age standard and the sum of skinfold thicknesses standard classified normal-weight status similarly at a level of 92% (P<0.01) and were found to be useful in determining overweight/obesity. The prevalence rate was higher in females and white children, and was more apparent in urban areas, smaller households and children of parents with low- or high-income occupations. Boys and pre-menarcheal girls had mean body fat percentage in the normal/optimal range, whereas that of post-menarcheal girls was moderately high. Few variables showed a significant association with high body fat percentage: in boys, only the number of members in the household and physical activity levels over the weekend; in girls, only age. The overweight/obese boys mostly lived in smaller households, and the overweight/obese post-menarcheal girls were most inactive on both weekdays and weekends, and more overweight with increasing age. CONCLUSION: Smaller households, inactivity and increasing age for girls were found to be determinants that influence the development of overweight/obesity, while female gender and age post-menarche were identified as determinants of higher body fat content. For overweight/obesity prevention, the focus should be on pre-menarcheal girls, aged 10-13 years, using these determinants to identify overweight/obesity risk. Preventive programmes should aim to increase the physical activity of children to improve their current and future weight status.

Dietary intakes and caries experience in children in Limpopo Province, South Africa.

INTRODUCTION: The identification of a rural village with a very low incidence of dental caries among the children provided the opportunity to study the diets of children apparently not exposed to risk factors for dental caries and compare them with children who were at risk. OBJECTIVE: To compare the diet, nutritional status and dental caries experience of 10- and 15-year-olds in an urban town (Malamulele) and a rural village (Mahonisi) in the Limpopo Province, South Africa. METHODS: Dental examinations and anthropometric measurements were done according to standard procedures. Dietary intakes were assessed by four 24-hour recalls. RESULTS: Mean dft/DMFT (decayed and filled deciduous teeth/Decayed, missing and filled permanent teeth) scores were 1.21 and 0.65 for 10- and 15-year-olds in urban Malamulele compared to 0.33 and 0.02 in rural Mahonisi. The percentage caries free in Malamulele was 36% compared to 88% in Mahonisi. The children in Mahonisi were shorter and lighter than those in Malamulele. Estimated fluoride intakes were significantly lower in Malamulele than in Mahonisi (p = 0.01). Mean total added sugar (all sugar not naturally occurring in foods) intake in Malamulele was significantly higher than in Mahonisi (p < 0.05). CONCLUSION: The most significant dietary differences between the two areas were total added sugar and fluoride intakes. The lower added sugar and higher fluoride intake among the rural Mahonisi children contributed to the lower dental caries experience.

Increase in childhood asthma admissions in an urbanising population.

OBJECTIVE: In South Africa, rapid urbanisation has increased the risk of childhood asthma. This report reviews the pattern of asthma admissions to the Paediatric Department of Ga-Rankuwa Hospital, South Africa, from 1986 to 1996. DESIGN: Inpatient admission data were reviewed for 1986-1996. A detailed analysis of the records of asthma patients admitted between 1992 and 1996 was done. Outpatient data were reviewed from 1992. SETTING: Ga-Rankuwa Hospital, situated on the border of the Gauteng and North West provinces of South Africa and serving a large black population in various stages of urbanisation. MAIN OUTCOME MEASURES: Trends in admission numbers and demographic characteristics. RESULTS: Asthma admissions were 2.5 times higher in 1996 than 1986. The greatest increase in admissions was in the 1-47-month age group. The male to female ratio was 1.5:1. More patients came from urban than from rural areas. Admissions peaked during the summer. Re-admissions occurred most frequently within 3 months of the first admission. CONCLUSION: Paediatric asthma admissions have shown an increase in the past decade. This may be associated with changes in the environment of the community. There is a need for preventive programmes for asthma at community and national level.

A combination of statistical methods for the analysis of the relative validation data of the quantitative food frequency questionnaire used in the THUSA study. Transition, Health and Urbanisation in South Africa.

OBJECTIVE: To apply structural equation modelling (SEM) and estimation of variance components to the relative validation data obtained from the quantitative food frequency questionnaire (QFFQ) used in the Transition, Health and Urbanisation in South Africa (THUSA) study. DESIGN: A cross-sectional study. SETTING: A community-based field study in an African population conducted during 1996. SUBJECTS: Residents of the North West Province, South Africa, aged between 15 and 65 years. METHODS: Relative validity of the QFFQ was tested against 7-day weighed food records, 24-hour urinary nitrogen (UN) excretion and estimated basal metabolic rate (BMR). SEM and estimation of variance components were applied to the log-transformed energy, protein, fat, calcium, iron, vitamin A and vitamin C intakes. UN excretion was used as a biomarker in the application of the SEM to protein and estimated BMR to energy intakes. RESULTS: Constant bias (alphaQ) derived by the SEM varied from 0.85 (vitamin C) to 5.8 (energy). There was significant proportional bias for all nutrients except vitamin C. Validation coefficients (ro(Q,T) varied from 0.3 (fat, calcium, iron) to 0.7 (vitamin C). The inclusion of estimated BMR in the SEM for energy increased ro(Q, T) from 0.38 to 0.42. The estimation of variance components gave slightly lower correlations for the relationship between intakes from the QFFQ and the unknown true intake. CONCLUSIONS: Robust statistical methods were successfully applied in a relative validation study for a QFFQ in an African population. Estimated BMR as a biomarker for energy intake produced more meaningful results than UN excretion as a biomarker for protein intake.

A culture-sensitive quantitative food frequency questionnaire used in an African population: 1. Development and reproducibility.

OBJECTIVE: To develop and assess the reproducibility of a quantitative food frequency questionnaire (QFFQ) sensitive to the culture of the African population of the North West Province, South Africa. DESIGN: A cross-sectional study. SETTING: A community-based field study in a population stratified according to level of urbanization from deep rural to urban upper class. SUBJECTS: A total of 144 (99 women and 45 men) residents of the North West Province, aged between 15 and 65 years. participated in the study. METHODS: A culture-sensitive. 145-item interviewer-administered QFFQ was designed to cover the whole diet. Portion sizes were estimated from a food portion photograph book (FPPB) showing foods in three portion sizes. The QFFQ was administered twice, 6-12 weeks apart. RESULTS: Spearman rank correlation coefficients between the two administrations varied from 0.14 for calcium to 0.75 for alcohol. The mean percentage difference between intakes was 8.5 (standard deviation= 9.9). Energy. protein, carbohydrate and calcium gave differences within 10%. Few significant differences among correlation coefficients or percentage difference for gender, age group or strata of urbanization were present. Bland-Altman plots showed significant proportional bias for protein, fibre and vitamin C. More than 70% of the participants were classified into adjacent quintiles for all nutrients. For food groups, correlation coefficients ranged from 0.25 for milk to 0.45 for vegetable and maize meal groups and 809/a of participants were classified into adjacent quintiles. CONCLUSIONS: The QFFQ appeared to be a reproducible dietary intake assessment instrument.

A culture-sensitive quantitative food frequency questionnaire used in an African population: 2. Relative validation by 7-day weighted records and biomarkers.

OBJECTIVE: To determine the relative validity of the culture-sensitive quantitative food frequency questionnaire (QFFQ) developed for the Transition, Health and Urbanisation in South Africa (THUSA) study by 7-day weighed food records, urinary nitrogen excretion and basal metabolic rate (BMR). DESIGN: A cross-sectional study. SETTING: A community-based study in a population stratified according to level of urbanization. SUBJECTS: Residents of the North West Province, South Africa. aged between 15 and 65 years. The weighed food record study comprised 74 participants while 104 participants collected 24-hour urine samples. METHODS: All participants were interviewed using the QFFQ. For the weighed food record study, participants kept detailed weighed food diaries for seven consecutive days. For the urinary nitrogen study, participants made one 24-hour urine collection. Completeness of the urine collections was checked against 240 rug pan-aminobenzoic acid. BMR was estimated by the Schofield equations. RESULTS: Spearman rank correlation coefficients between the QFFQ and weighed food record ranged between 0.14 (fibre) and 0.59 (vitamin C). The QFFQ tended to underestimate intakes compared with the weighed records. Quintile distributions were similar for both methods. The correlation between urinary nitrogen excretion and dietary intake was poor. Possible underreporting was identified for 43% of the participants with the QFFQ and 28% with the weighed food record. CONCLUSIONS: The QFFQ appeared to be a relatively valid instrument for the assessment of dietary intakes of the population of the North West Province. The use of biomarkers in this population was difficult and needs further investigation.

The development and testing of a food portion photograph book for use in an African population.

OBJECTIVE: To develop and test a book of photographs of commonly eaten foods to be used as a visual aid in the description of portion sizes in a large cross-sectional study on the health profile of Africans in transition (THUSA - Transition, Health and Urbanization in South Africa). SETTING: Clinics in the North West Province of South Africa. PARTICIPANTS: One hundred and sixty-nine adult African volunteers DESIGN: Data on commonly eaten foods, preparation methods, recipes and portion sizes were collected in a pilot study. Colour photographs, taken of foods prepared by the researchers and measured into three or four portion sizes, were enlarged and put together in a book. The food portion photograph book (FPPB) was tested by presenting subjects with a portion of real food and asking them to estimate the portion size by matching it with one of the portion photographs. MAIN RESULTS: Of 2959 portions tested, 68% were accurately estimated (estimated weight within 10% of actual weight). Clearly defined solid foods were better estimated than foods that had an amorphous appearance. Accuracy of estimation was not affected by gender, age or education. CONCLUSION: The FPPB was accepted as a useful and convenient visual aid to estimate portion sizes in the cross-sectional dietary intake study.

Lactation--how important is it?

In Africa, with poverty rising, and health care diminishing, a nutritional question is-what are the limits of successful physiological adaptation to low dietary intakes? In this review the practice of lactation is discussed, from both past and present viewpoints. Orthodox Recommended Allowances for lactation are scarcely ever met. Yet, through various adaptations, the huge majority of African and similarly placed mothers lactate successfully and produce milk of good quantity and quality. The benefits from supplements are discussed; broadly, results have been disappointing. Some good and adverse non-dietary practices are considered. Benefits for infant and mother from lactation, even for protracted periods, far exceed drawbacks.

Combating protein-energy-malnutrition in a rural/peri-urban southern African black population.

PROTEIN-ENERGY-malnutrition (PEM) is a major cause of morbidity and mortality in young children in Africa. In South Africa, in 1987, to help combating and preventing PEM in the rural black population, the Gold Fields Nutrition Unit was inaugurated at the Medical University of Southern Africa. In 1987-9, 442 patients (rural/peri-urban) plus their mothers or child carers were admitted, and 406 attended as outpatients. Average age was 15.4 +/- 7.6 months, weight 7.0 +/- 1.6kg, stay in hospital, 12 +/- 10.8 days, and daily weight gain during treatment was 31 +/- 48g. Mothers mainly were young and unmarried. Primary causative factors were infections, ignorance, and insufficiency of food. Since results from rehabilitation are usually poor, mothers and carers were taught how best to prepare meals using local foodstuffs. The interventions included teaching and demonstrations of how to grow vegetables, maintain an orchard, a fowl-run, and improve kitchen and laundry facilities. In 1990, in a follow-up of 73 patients, no deaths had occurred within a 12 month period. This far better than usual outcome is being furthered by setting up satellite nutrition clinics.