Diet, cardiovascular disease, and mortality in 80 countries.

AIMS: To develop a healthy diet score that is associated with health outcomes and is globally applicable using data from the Prospective Urban Rural Epidemiology (PURE) study and replicate it in five independent studies on a total of 245 000 people from 80 countries. METHODS AND RESULTS: A healthy diet score was developed in 147 642 people from the general population, from 21 countries in the PURE study, and the consistency of the associations of the score with events was examined in five large independent studies from 70 countries. The healthy diet score was developed based on six foods each of which has been associated with a significantly lower risk of mortality [i.e. fruit, vegetables, nuts, legumes, fish, and dairy (mainly whole-fat); range of scores, 0-6]. The main outcome measures were all-cause mortality and major cardiovascular events [cardiovascular disease (CVD)]. During a median follow-up of 9.3 years in PURE, compared with a diet score of ≤1 points, a diet score of ≥5 points was associated with a lower risk of mortality [hazard ratio (HR) 0.70; 95% confidence interval (CI) 0.63-0.77)], CVD (HR 0.82; 0.75-0.91), myocardial infarction (HR 0.86; 0.75-0.99), and stroke (HR 0.81; 0.71-0.93). In three independent studies in vascular patients, similar results were found, with a higher diet score being associated with lower mortality (HR 0.73; 0.66-0.81), CVD (HR 0.79; 0.72-0.87), myocardial infarction (HR 0.85; 0.71-0.99), and a non-statistically significant lower risk of stroke (HR 0.87; 0.73-1.03). Additionally, in two case-control studies, a higher diet score was associated with lower first myocardial infarction [odds ratio (OR) 0.72; 0.65-0.80] and stroke (OR 0.57; 0.50-0.65). A higher diet score was associated with a significantly lower risk of death or CVD in regions with lower than with higher gross national incomes (P for heterogeneity <0.0001). The PURE score showed slightly stronger associations with death or CVD than several other common diet scores (P < 0.001 for each comparison). CONCLUSION: A diet comprised of higher amounts of fruit, vegetables, nuts, legumes, fish, and whole-fat dairy is associated with lower CVD and mortality in all world regions, especially in countries with lower income where consumption of these foods is low.

Evaluation of ImpENSA technology-enabled behaviour change module delivered to healthcare professionals in South Africa to improve micronutrient nutrition during the first 1000 days.

Healthcare professionals (HCPs) have vital roles in providing evidence-based care to promote healthy micronutrient nutrition in early life. Providing such care requires scalable training to strengthen knowledge and confident application of effective behaviour change skills. Among 33 public and private HCPs (primarily dietitians) in South Africa, we evaluated the behaviour change aspects of a technology-enabled National Qualification Sub-Framework level 6 programme, Improving Early Nutrition and Health in South Africa ('ImpENSA'). This programme comprises two self-directed micronutrient and behaviour change knowledge-based eLearning and one facilitated online practical skills modules to improve maternal and infant micronutrient nutrition. Using assessments, questionnaires and interviews, we collected data at baseline, after module completion and at 3-month follow-up after programme completion. Questionnaire and interview data showed major improvements in understanding of and attitudes towards person-centred behaviour change support immediately following the eLearning module on behaviour change. The assessment pass rate increased from 38% at baseline to 88% postmodule, demonstrating significant knowledge gain in behaviour change support. Intention to change practice towards a person-centred approach was high and many had already started implementing changes. Three months postprogramme, support was centred around patients' needs. Open relationships with patients, improved patient outcomes and increased job satisfaction were among reported outcomes. Many reported becoming better change facilitators and reflective practitioners. Additional improvements in understanding and attitudes to behaviour change support were evident, reinforced by making changes and experiencing positive outcomes. The findings suggest that technology-enabled learning can equip HCPs with knowledge and skills to effectively support behaviour change for healthy micronutrient nutrition during pregnancy and infancy.

Association of dairy intake with cardiovascular disease and mortality in 21 countries from five continents (PURE): a prospective cohort study.

BACKGROUND: Dietary guidelines recommend minimising consumption of whole-fat dairy products, as they are a source of saturated fats and presumed to adversely affect blood lipids and increase cardiovascular disease and mortality. Evidence for this contention is sparse and few data for the effects of dairy consumption on health are available from low-income and middle-income countries. Therefore, we aimed to assess the associations between total dairy and specific types of dairy products with mortality and major cardiovascular disease. METHODS: The Prospective Urban Rural Epidemiology (PURE) study is a large multinational cohort study of individuals aged 35-70 years enrolled from 21 countries in five continents. Dietary intakes of dairy products for 136 384 individuals were recorded using country-specific validated food frequency questionnaires. Dairy products comprised milk, yoghurt, and cheese. We further grouped these foods into whole-fat and low-fat dairy. The primary outcome was the composite of mortality or major cardiovascular events (defined as death from cardiovascular causes, non-fatal myocardial infarction, stroke, or heart failure). Hazard ratios (HRs) were calculated using multivariable Cox frailty models with random intercepts to account for clustering of participants by centre. FINDINGS: Between Jan 1, 2003, and July 14, 2018, we recorded 10 567 composite events (deaths [n=6796] or major cardiovascular events [n=5855]) during the 9·1 years of follow-up. Higher intake of total dairy (>2 servings per day compared with no intake) was associated with a lower risk of the composite outcome (HR 0·84, 95% CI 0·75-0·94; ptrend=0·0004), total mortality (0·83, 0·72-0·96; ptrend=0·0052), non-cardiovascular mortality (0·86, 0·72-1·02; ptrend=0·046), cardiovascular mortality (0·77, 0·58-1·01; ptrend=0·029), major cardiovascular disease (0·78, 0·67-0·90; ptrend=0·0001), and stroke (0·66, 0·53-0·82; ptrend=0·0003). No significant association with myocardial infarction was observed (HR 0·89, 95% CI 0·71-1·11; ptrend=0·163). Higher intake (>1 serving vs no intake) of milk (HR 0·90, 95% CI 0·82-0·99; ptrend=0·0529) and yogurt (0·86, 0·75-0·99; ptrend=0·0051) was associated with lower risk of the composite outcome, whereas cheese intake was not significantly associated with the composite outcome (0·88, 0·76-1·02; ptrend=0·1399). Butter intake was low and was not significantly associated with clinical outcomes (HR 1·09, 95% CI 0·90-1·33; ptrend=0·4113). INTERPRETATION: Dairy consumption was associated with lower risk of mortality and major cardiovascular disease events in a diverse multinational cohort. FUNDING: Full funding sources are listed at the end of the paper (see Acknowledgments).

Food or nutrient pattern assessment using the principal component analysis applied to food questionnaires. Pitfalls, tips and tricks.

We considered the Blom's transformation, a statistical method aimed to normalise and standardise food intakes before principal component analysis. A simulation study was performed to evaluate the eigenvalue distribution of a correlation matrix under common conditions in food questionnaire analysis. The scree plot visual inspection and the Guttman-Kaiser (GK) criterion were compared to Horn's parallel analysis to evaluate their efficacy in food pattern identification. The scree plot results as a monotone continuous series when no food patterns are present. In this situation, about 50% of the eigenvalues assume a value higher than one, showing a first fallacy of the GK. When three food patterns are simulated a clear discontinuity appears after the third eigenvalue, showing that the scree-plot visual inspection is a suitable method to identify food patterns. Finally, according to the present work it appears that the GK generates a number of false-positive food patterns.

Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study.

BACKGROUND: The relationship between macronutrients and cardiovascular disease and mortality is controversial. Most available data are from European and North American populations where nutrition excess is more likely, so their applicability to other populations is unclear. METHODS: The Prospective Urban Rural Epidemiology (PURE) study is a large, epidemiological cohort study of individuals aged 35-70 years (enrolled between Jan 1, 2003, and March 31, 2013) in 18 countries with a median follow-up of 7·4 years (IQR 5·3-9·3). Dietary intake of 135 335 individuals was recorded using validated food frequency questionnaires. The primary outcomes were total mortality and major cardiovascular events (fatal cardiovascular disease, non-fatal myocardial infarction, stroke, and heart failure). Secondary outcomes were all myocardial infarctions, stroke, cardiovascular disease mortality, and non-cardiovascular disease mortality. Participants were categorised into quintiles of nutrient intake (carbohydrate, fats, and protein) based on percentage of energy provided by nutrients. We assessed the associations between consumption of carbohydrate, total fat, and each type of fat with cardiovascular disease and total mortality. We calculated hazard ratios (HRs) using a multivariable Cox frailty model with random intercepts to account for centre clustering. FINDINGS: During follow-up, we documented 5796 deaths and 4784 major cardiovascular disease events. Higher carbohydrate intake was associated with an increased risk of total mortality (highest [quintile 5] vs lowest quintile [quintile 1] category, HR 1·28 [95% CI 1·12-1·46], ptrend=0·0001) but not with the risk of cardiovascular disease or cardiovascular disease mortality. Intake of total fat and each type of fat was associated with lower risk of total mortality (quintile 5 vs quintile 1, total fat: HR 0·77 [95% CI 0·67-0·87], ptrend<0·0001; saturated fat, HR 0·86 [0·76-0·99], ptrend=0·0088; monounsaturated fat: HR 0·81 [0·71-0·92], ptrend<0·0001; and polyunsaturated fat: HR 0·80 [0·71-0·89], ptrend<0·0001). Higher saturated fat intake was associated with lower risk of stroke (quintile 5 vs quintile 1, HR 0·79 [95% CI 0·64-0·98], ptrend=0·0498). Total fat and saturated and unsaturated fats were not significantly associated with risk of myocardial infarction or cardiovascular disease mortality. INTERPRETATION: High carbohydrate intake was associated with higher risk of total mortality, whereas total fat and individual types of fat were related to lower total mortality. Total fat and types of fat were not associated with cardiovascular disease, myocardial infarction, or cardiovascular disease mortality, whereas saturated fat had an inverse association with stroke. Global dietary guidelines should be reconsidered in light of these findings. FUNDING: Full funding sources listed at the end of the paper (see Acknowledgments).

Fruit, vegetable, and legume intake, and cardiovascular disease and deaths in 18 countries (PURE): a prospective cohort study.

BACKGROUND: The association between intake of fruits, vegetables, and legumes with cardiovascular disease and deaths has been investigated extensively in Europe, the USA, Japan, and China, but little or no data are available from the Middle East, South America, Africa, or south Asia. METHODS: We did a prospective cohort study (Prospective Urban Rural Epidemiology [PURE] in 135 335 individuals aged 35 to 70 years without cardiovascular disease from 613 communities in 18 low-income, middle-income, and high-income countries in seven geographical regions: North America and Europe, South America, the Middle East, south Asia, China, southeast Asia, and Africa. We documented their diet using country-specific food frequency questionnaires at baseline. Standardised questionnaires were used to collect information about demographic factors, socioeconomic status (education, income, and employment), lifestyle (smoking, physical activity, and alcohol intake), health history and medication use, and family history of cardiovascular disease. The follow-up period varied based on the date when recruitment began at each site or country. The main clinical outcomes were major cardiovascular disease (defined as death from cardiovascular causes and non-fatal myocardial infarction, stroke, and heart failure), fatal and non-fatal myocardial infarction, fatal and non-fatal strokes, cardiovascular mortality, non-cardiovascular mortality, and total mortality. Cox frailty models with random effects were used to assess associations between fruit, vegetable, and legume consumption with risk of cardiovascular disease events and mortality. FINDINGS: Participants were enrolled into the study between Jan 1, 2003, and March 31, 2013. For the current analysis, we included all unrefuted outcome events in the PURE study database through March 31, 2017. Overall, combined mean fruit, vegetable and legume intake was 3·91 (SD 2·77) servings per day. During a median 7·4 years (5·5-9·3) of follow-up, 4784 major cardiovascular disease events, 1649 cardiovascular deaths, and 5796 total deaths were documented. Higher total fruit, vegetable, and legume intake was inversely associated with major cardiovascular disease, myocardial infarction, cardiovascular mortality, non-cardiovascular mortality, and total mortality in the models adjusted for age, sex, and centre (random effect). The estimates were substantially attenuated in the multivariable adjusted models for major cardiovascular disease (hazard ratio [HR] 0·90, 95% CI 0·74-1·10, ptrend=0·1301), myocardial infarction (0·99, 0·74-1·31; ptrend=0·2033), stroke (0·92, 0·67-1·25; ptrend=0·7092), cardiovascular mortality (0·73, 0·53-1·02; ptrend=0·0568), non-cardiovascular mortality (0·84, 0·68-1·04; ptrend =0·0038), and total mortality (0·81, 0·68-0·96; ptrend<0·0001). The HR for total mortality was lowest for three to four servings per day (0·78, 95% CI 0·69-0·88) compared with the reference group, with no further apparent decrease in HR with higher consumption. When examined separately, fruit intake was associated with lower risk of cardiovascular, non-cardiovascular, and total mortality, while legume intake was inversely associated with non-cardiovascular death and total mortality (in fully adjusted models). For vegetables, raw vegetable intake was strongly associated with a lower risk of total mortality, whereas cooked vegetable intake showed a modest benefit against mortality. INTERPRETATION: Higher fruit, vegetable, and legume consumption was associated with a lower risk of non-cardiovascular, and total mortality. Benefits appear to be maximum for both non-cardiovascular mortality and total mortality at three to four servings per day (equivalent to 375-500 g/day). FUNDING: Full funding sources listed at the end of the paper (see Acknowledgments).

The development of a single health-endorsement logo for South Africa.

OBJECTIVE: To develop health-endorsement logos (HEL) for food products indicating healthy choices based on the South African nutrient profile model and to pilot test these logos with consumers. DESIGN: Multistage mixed-methods design. SETTING: Cape Town, South Africa. SUBJECTS: Nine focus group discussions (FGD) were conducted with adult consumers to explore what types of HEL are preferred and why. Based on the findings, ten HEL were designed by a graphic design team. A modified Delphi technique, conducted with experts in the fields of nutrition and food science, was employed to eliminate lowest-scoring HEL and to improve the design of the remaining logos. Participants from the initial FGD participated in pilot testing the improved logos. RESULTS: Participants from FGD (n 67) were positive about a single HEL, stating it would make food labelling less confusing as they did not understand the various HEL used. Participants indicated the logo should include wording related to 'healthy choice' or 'better choice' and pictures/symbols related to health and/or food. During two rounds of scoring and comments by experts (n 19), five logos were eliminated and the design of the remaining five improved. Three of five remaining logos received overall rankings of 3·08/5, 3·28/5 and 3·39/5, respectively, during FGD (n 36) in the pilot-testing phase. CONCLUSION: HEL were designed and consumer tested. Three designs were submitted to the national Department of Health to consider for implementation, after further testing, as a tool to assist in addressing the high incidence of non-communicable diseases in South Africa.

Changes in food intake from 2005 to 2010 by a cohort of black rural and urban African men and women in the North West Province of South Africa: the PURE-NWP-SA study.

OBJECTIVE: We have shown that nutrient intakes of rural and urban black Africans in the North West Province (NWP) of South Africa (SA) followed the typical nutrition transition pattern upon urbanization and modernization. The current study aimed to examine and report on the changes in food intakes from 2005 to 2010 in rural and urban black South Africans participating in the PURE-NWP-SA study.Design/Setting/SubjectsThe PURE-NWP-SA study recruited 2010 volunteers aged 35-70 years in 2005, from which detailed food intakes, measured with a validated quantified FFQ, for 1858 participants were available. In 2010, food intakes of a cohort of 1154 of these participants were measured. RESULTS: Median energy intake increased in men and women in both rural and urban areas from 2005 to 2010. Changes in food intake were interpreted keeping these changes in energy intake and the contribution of foods and food groups to total energy intake in mind. No 'new' foods were eaten in 2010, but more participants consumed certain foods and products in 2010 than in 2005. Beneficial changes were increased intakes of vegetables, fruit and milk in most groups. The contribution of cooked staple porridges and bread made from fortified maize and bread flour decreased and therefore also did their contribution to micronutrient intakes. CONCLUSIONS: By promoting and supporting observed beneficial changes such as increased intakes of milk, vegetables and fruit by appropriate policies and educational interventions, it should be possible to steer the nutrition transition in this population into a positive direction.

Accelerated nutrition transition in the North West Province of South Africa: results from the Prospective Urban and Rural Epidemiology (PURE-NWP-SA) cohort study, 2005 to 2010.

OBJECTIVE: South Africa (SA) is in the midst of a health transition characterized by a quadruple burden of diseases and a nutrition transition. The existing nutrition transition in SA, accompanied by the coexistence of under- and overnutrition in the population, motivated the present study. Its objectives were to measure and report the changes in nutrient intakes of rural and urban black Africans over time to assess the impact of urbanization and modernization of lifestyles on dietary intakes and non-communicable disease (NCD) risk. DESIGN: The PURE-NWP-SA study recruited 2000 black South African volunteers aged 35-70 years in 2005, of which detailed nutrient intakes from 1858 participants were available. In 2010 nutrient intakes of a cohort of 1154 participants were measured. RESULTS: Median energy intake increased over time. In 2010, rural participants consumed the amount of energy (men 9·7 MJ/d; women 9·1 MJ/d) that urban participants consumed in 2005 (men 9·9 MJ/d; women 9·0 MJ/d). The nutrition transition was characterized by increases in the percentage of energy from animal protein, total fat (rural men and women), saturated (not urban women) and monounsaturated fat, as well as added sugar. Despite the higher energy intake, not all the participants met total micronutrient needs in 2010. CONCLUSIONS: The PURE nutrient intake data confirmed that the nutrition transition in the North West Province of SA is extremely rapid in rural areas. The shift towards higher energy intakes, an animal food-based diet, higher intakes of fat and lower intake of fibre, at the cost of lower plant protein and starchy food intakes, could increase the risk of NCD.

Monitoring the South African population's salt intake: spot urine v. 24 h urine.

OBJECTIVE: The present study set out to determine whether morning spot urine samples can be used to monitor Na (and K) intake levels in South Africa, instead of the 'gold standard' 24 h urine sample. DESIGN: Participants collected one 24 h and one spot urine sample for Na and K analysis, after which estimations using three different formulas (Kawasaki, Tanaka and INTERSALT) were calculated. SETTING: Between 2013 and 2015, urine samples were collected from different population groups in South Africa. SUBJECTS: A total of 681 spot and 24 h urine samples were collected from white (n 259), black (n 315) and Indian (n 107) subgroups, mostly women. RESULTS: The Kawasaki and the Tanaka formulas showed significantly higher (P≤0·001) estimated Na values than the measured 24 h excretion in the whole population (5677·79 and 4235·05 v. 3279·19 mg/d). The INTERSALT formula did not differ from the measured 24 h excretion for the whole population. The Kawasaki formula seemed to overestimate Na excretion in all subgroups tested and also showed the highest degree of bias (-2242 mg/d, 95 % CI-10 659, 6175) compared with the INTERSALT formula, which had the lowest bias (161 mg/d, 95 % CI-4038, 4360). CONCLUSIONS: Estimations of Na excretion by the three formulas should be used with caution when reporting on Na intake levels. More research is needed to validate and develop a specific formula for the South African context with its different population groups. The WHO's recommendation of using 24 h urine collection until more studies are carried out is still supported.

Restricting the marketing of foods and non-alcoholic beverages to children in South Africa: are all nutrient profiling models the same?

The WHO has called for governments to improve children's food environment by implementing restrictions on the marketing of 'unhealthy' foods to children. Nutrient profiling (NP) models are used to define 'unhealthy' foods and support child-directed food marketing regulations. The aim of the present study was to assess the suitability of the South African NP model (SANPM), developed and validated for health claim regulations, for child-directed food marketing regulations. The SANPM was compared with four NP models specifically developed for such regulations. A representative list of 197 foods was compiled by including all foods advertised on South African free-to-air television channels in 2014 and foods commonly consumed by South African children. The nutritional information of the foods was sourced from food packaging, company websites and a food composition table. Each individual food was classified by each of the five NP models. The percentage of foods that would be allowed according to the different NP models ranged from 6 to 45 %; the models also varied considerably with regard to the type of foods allowed for marketing to children. The majority of the pairwise comparisons between the NP models yielded κ statistics >0·4, indicating a moderate agreement between the models. An almost perfect pairwise agreement (κ=0·948) existed between the SANPM and the UK Food Standards Agency model (United Kingdom Office of Communication nutrient profiling model), a model extensively tested and validated for such regulations. The SANPM is considered appropriate for child-directed food marketing regulations in South Africa.

The use of predefined diet quality scores in the context of CVD risk during urbanization in the South African Prospective Urban and Rural Epidemiological (PURE) study.

OBJECTIVE: Urbanization is generally associated with increased CVD risk and accompanying dietary changes. Little is known regarding the association between increased CVD risk and dietary changes using approaches such as diet quality. The relevance of predefined diet quality scores (DQS) in non-Western developing countries has not yet been established. DESIGN: The association between dietary intakes and CVD risk factors was investigated using two DQS, adapted to the black South African diet. Dietary intake data were collected using a quantitative FFQ. CVD risk was determined by analysing known CVD risk factors. SETTING: Urban and rural areas in North West Province, South Africa. SUBJECTS: Apparently healthy volunteers from the South African Prospective Urban and Rural Epidemiological (PURE) study population (n 1710). RESULTS: CVD risk factors were significantly increased in the urban participants, especially women. Urban men and women had significantly higher intakes of both macro- and micronutrients with macronutrient intakes well within the recommended CVD guidelines. While micronutrient intakes were generally higher in the urban groups than in the rural groups, intakes of selected micronutrients were low in both groups. Both DQS indicated improved diet quality in the urban groups and good agreement was shown between the scores, although they seemed to measure different aspects of diet quality. CONCLUSIONS: The apparent paradox between improved diet quality and increased CVD risk in the urban groups can be explained when interpreting the cut-offs used in the scores against the absolute intakes of individual nutrients. Predefined DQS as well as current guidelines for CVD prevention should be interpreted with caution in non-Western developing countries.

Dietitians in South Africa require more competencies in public health nutrition and management to address the nutritional needs of South Africans.

The aim of this study was to determine whether dietitians in South Africa are competent to meet the requirements of working in a health care setting during a compulsory one-year community service (CS) program immediately after receiving their degree. A national survey was conducted using questionnaires to illicit information from dietitians on their training and competencies. In 2009, data were collected from both community service dietitians (CSDs) participating in community service programs in primary, secondary and tertiary health care centers in all provinces of South Africa, as well as from their provincial managers (nutrition coordinators). Sixteen (100% response) nutrition coordinators and 134 (80% response) dietitians participated in the quantitative survey. The majority of the CSDs reported that, overall, their academic training had prepared them for most aspects of nutrition service delivery. However, some recommended that academic programs include more training on community-based nutrition programs and in delivering optimal services to under-resourced communities as they believed that their competencies in these two areas were weakest. Furthermore, many CSDs were required to establish dietetics departments where none had previously existed; consequently, their capacity in management and administration needed improvement. In conclusion, academic training institutions should align their programs to the transformation of the health sector in South Africa by ensuring that dietitians are empowered to provide optimal public health nutrition services in under-resourced communities.

Early evidence for the effectiveness of South Africa's legislation on salt restriction in foods: the African-PREDICT study.

South Africa was among the first countries to adopt mandatory regulation in 2016 to lower the salt content in processed foods, aiming to reduce population salt intake to <5 g/day. To assess the effectiveness of this regulation in 20-30 year-old adults, we determined the change in salt intake over a mean follow-up time of 4.56-years spanning the implementation of the regulation. This observational study included baseline (2013-2016; N = 668; 24.9 ± 3 years; 47.8% black; 40.7% men) and follow-up data (2018-ongoing; N = 311; 25.4 ± 3.05 years; 51.1% black; 43.4% men) for participants of the African-PREDICT study. Salt intake was estimated from 24-h urinary sodium excretion. Median salt intake at baseline (N = 668) was 7.88 g/day (IQR: 5.67). In those followed (N = 311), salt intake reduced from baseline [median (IQR): 7.91 g/day (5.83)] to follow-up [7.26 g/day (5.30)] [unadjusted median: -0.82 g/day]. After adjusting for baseline salt intake to address regression to the mean, the mean salt reduction was -1.2 g/day. The greatest reductions were in men [mean difference: -1.47 g/day], black adults [mean difference: -2.04 g/day], and participants from low [mean difference: -1.89 g/day] or middle [mean difference: -1.84 g/day] socio-economic status groups, adjusting for baseline salt intake. Our preliminary findings suggest that South Africa's salt regulation has been effective in lowering salt intake in young adults by ~1.2 g salt/day. Our study supports the effectiveness of upstream interventions to lower population salt intake, particularly for vulnerable groups who may typically consume more processed foods. It needs to be determined if the legislation has the anticipated population health gains.

Challenges for efficient health service delivery: experiences of dietitians completing their compulsory community service year in South Africa.

OBJECTIVE: To evaluate the successes and shortcomings of the community service programme implemented by the Department of Health (DOH) in South Africa by evaluating community service dietitians' experiences and challenges during the 2009 community service year. DESIGN: The study employed both quantitative and qualitative research designs. A national survey was conducted using a questionnaire to illicit information on community service dietitians' working environments and the challenges they experienced. Furthermore individual interviews were conducted with a purposively selected subsample of community service dietitians to further explore issues that arose in the survey. SETTING: Data were collected from community service dietitians in the public health sector in South Africa. SUBJECTS: Dietitians completing their community service year in 2009. RESULTS: Of the 168 community service dietitians placed in 2009, 134 (80 %) participated in the survey, while five community service dietitians in each province (n 45) were interviewed. Overall the community service dietitians were positive about the community service year and reported that it improved their confidence, skills and competencies. However, they experienced challenges related to the orientation programme, supervision/mentoring, resources available, patient referrals and communication. CONCLUSIONS: Despite the overall success of the community service year there are still challenges which the DOH needs to address in order to provide the best nutrition service possible for its patients.

Factors influencing complementary feeding practices in rural and semi-urban Rwanda: a qualitative study.

The aim of the present study was to identify and describe the factors influencing feeding practices of children aged 6-23 months in Rwanda. This is a cross-sectional descriptive qualitative study. A total of ten focus group discussions were conducted separately with mothers, fathers, grandmothers and community health workers (CHWs) from five different districts in Rwanda. The discussions were recorded, transcribed verbatim, and thematically analysed using qualitative data analysis software, Atlas.ti. The study participants were mothers, fathers and grandmothers of children aged 6-23 months and CHWs in charge of child health. Caregivers' knowledge and beliefs about the benefits of breast-feeding and timely introduction of complementary food were found to be the primary individual factors facilitating good infant and young child feeding practices. The common belief of caregivers that infants should be given liquids (thin gruel, fruit juices and meat broth) as first foods instead of semi-solid foods was a barrier to good feeding practices. The community-based nutrition education and counselling programmes were facilitators of good complementary practices at the group level. At the society level, poverty in rural agrarian households was a barrier to optimal feeding practices. The study shows that there is a need to empower caregivers with more specific guidelines, especially on complementary feeding.

Associations of Fish Consumption With Risk of Cardiovascular Disease and Mortality Among Individuals With or Without Vascular Disease From 58 Countries.

Importance: Cohort studies report inconsistent associations between fish consumption, a major source of long-chain ω-3 fatty acids, and risk of cardiovascular disease (CVD) and mortality. Whether the associations vary between those with and those without vascular disease is unknown. Objective: To examine whether the associations of fish consumption with risk of CVD or of mortality differ between individuals with and individuals without vascular disease. Design, Setting, and Participants: This pooled analysis of individual participant data involved 191 558 individuals from 4 cohort studies-147 645 individuals (139 827 without CVD and 7818 with CVD) from 21 countries in the Prospective Urban Rural Epidemiology (PURE) study and 43 413 patients with vascular disease in 3 prospective studies from 40 countries. Adjusted hazard ratios (HRs) were calculated by multilevel Cox regression separately within each study and then pooled using random-effects meta-analysis. This analysis was conducted from January to June 2020. Exposures: Fish consumption was recorded using validated food frequency questionnaires. In 1 of the cohorts with vascular disease, a separate qualitative food frequency questionnaire was used to assess intake of individual types of fish. Main Outcomes and Measures: Mortality and major CVD events (including myocardial infarction, stroke, congestive heart failure, or sudden death). Results: Overall, 191 558 participants with a mean (SD) age of 54.1 (8.0) years (91 666 [47.9%] male) were included in the present analysis. During 9.1 years of follow-up in PURE, compared with little or no fish intake (≤50 g/mo), an intake of 350 g/wk or more was not associated with risk of major CVD (HR, 0.95; 95% CI, 0.86-1.04) or total mortality (HR, 0.96; 0.88-1.05). By contrast, in the 3 cohorts of patients with vascular disease, the HR for risk of major CVD (HR, 0.84; 95% CI, 0.73-0.96) and total mortality (HR, 0.82; 95% CI, 0.74-0.91) was lowest with intakes of at least 175 g/wk (or approximately 2 servings/wk) compared with 50 g/mo or lower, with no further apparent decrease in HR with consumption of 350 g/wk or higher. Fish with higher amounts of ω-3 fatty acids were strongly associated with a lower risk of CVD (HR, 0.94; 95% CI, 0.92-0.97 per 5-g increment of intake), whereas other fish were neutral (collected in 1 cohort of patients with vascular disease). The association between fish intake and each outcome varied by CVD status, with a lower risk found among patients with vascular disease but not in general populations (for major CVD, I2 = 82.6 [P = .02]; for death, I2 = 90.8 [P = .001]). Conclusions and Relevance: Findings of this pooled analysis of 4 cohort studies indicated that a minimal fish intake of 175 g (approximately 2 servings) weekly is associated with lower risk of major CVD and mortality among patients with prior CVD but not in general populations. The consumption of fish (especially oily fish) should be evaluated in randomized trials of clinical outcomes among people with vascular disease.

Assessing the construct validity of nutrient profiling models for restricting the marketing of foods to children in South Africa.

BACKGROUND: In an effort to combat childhood obesity the WHO has called on governments to restrict the marketing of unhealthy foods to children. Regulators have turned to nutrient profiling (NP) to provide the evidence for their decisions. This has resulted in the development of NP models, of which the validity of only a few have been established. The aim of this study was to assess the construct validity of various NP models for the purpose of restricting the marketing of unhealthy foods to children in South Africa by comparing the classification of foods by the models to the ranking of the same foods by registered dietitians. METHODS: Six current NP models were identified, then a representative food database of 120 foods was developed and each individual food was classified by each of the six models. Lastly dietitians were recruited to rank the healthfulness of the same 120 foods. RESULTS: Dietitians allowed 24% of the included foods for marketing to children, whereas the percentage of foods allowed by the included models ranged from 7 to 47%. Majority of pairwise comparisons between the NP models and dietitians yielded Ò¡ statistics >0.6, indicating substantial agreement. An almost perfect pairwise agreement was found between dietitians and the WHO Regional Office for Europe model. CONCLUSION: The included NP models displayed good construct validity by agreeing with dietitians on what are 'less healthy' foods, thus the foods not allowed for marketing. The findings of this study contributes to the process of establishing validity of NP models.

White Rice Intake and Incident Diabetes: A Study of 132,373 Participants in 21 Countries.

OBJECTIVE: Previous prospective studies on the association of white rice intake with incident diabetes have shown contradictory results but were conducted in single countries and predominantly in Asia. We report on the association of white rice with risk of diabetes in the multinational Prospective Urban Rural Epidemiology (PURE) study. RESEARCH DESIGN AND METHODS: Data on 132,373 individuals aged 35-70 years from 21 countries were analyzed. White rice consumption (cooked) was categorized as <150, ≥150 to <300, ≥300 to <450, and ≥450 g/day, based on one cup of cooked rice = 150 g. The primary outcome was incident diabetes. Hazard ratios (HRs) were calculated using a multivariable Cox frailty model. RESULTS: During a mean follow-up period of 9.5 years, 6,129 individuals without baseline diabetes developed incident diabetes. In the overall cohort, higher intake of white rice (≥450 g/day compared with <150 g/day) was associated with increased risk of diabetes (HR 1.20; 95% CI 1.02-1.40; P for trend = 0.003). However, the highest risk was seen in South Asia (HR 1.61; 95% CI 1.13-2.30; P for trend = 0.02), followed by other regions of the world (which included South East Asia, Middle East, South America, North America, Europe, and Africa) (HR 1.41; 95% CI 1.08-1.86; P for trend = 0.01), while in China there was no significant association (HR 1.04; 95% CI 0.77-1.40; P for trend = 0.38). CONCLUSIONS: Higher consumption of white rice is associated with an increased risk of incident diabetes with the strongest association being observed in South Asia, while in other regions, a modest, nonsignificant association was seen.

Association of nut intake with risk factors, cardiovascular disease, and mortality in 16 countries from 5 continents: analysis from the Prospective Urban and Rural Epidemiology (PURE) study.

BACKGROUND: The association of nuts with cardiovascular disease and deaths has been investigated mostly in Europe, the USA, and East Asia, with few data available from other regions of the world or from low- and middle-income countries. OBJECTIVE: To assess the association of nuts with mortality and cardiovascular disease (CVD). METHODS: The Prospective Urban Rural Epidemiology study is a large multinational prospective cohort study of adults aged 35-70 y from 16 low-, middle-, and high-income countries on 5 continents. Nut intake (tree nuts and ground nuts) was measured at the baseline visit, using country-specific validated FFQs. The primary outcome was a composite of mortality or major cardiovascular event [nonfatal myocardial infarction (MI), stroke, or heart failure]. RESULTS: We followed 124,329 participants (age = 50.7 y, SD = 10.2; 41.5% male) for a median of 9.5 y. We recorded 10,928 composite events [deaths (n = 8,662) or major cardiovascular events (n = 5,979)]. Higher nut intake (>120 g per wk compared with <30 g per mo) was associated with a lower risk of the primary composite outcome of mortality or major cardiovascular event [multivariate HR (mvHR): 0.88; 95% CI: 0.80, 0.96; P-trend = 0.0048]. Significant reductions in total (mvHR: 0.77; 95% CI: 0.69, 0.87; P-trend <0.0001), cardiovascular (mvHR: 0.72; 95% CI: 0.56, 0.92; P-trend = 0.048), and noncardiovascular mortality (mvHR: 0.82; 95% CI: 0.70, 0.96; P-trend = 0.0046) with a trend to reduced cancer mortality (mvHR: 0.81; 95% CI: 0.65, 1.00; P-trend = 0.081) were observed. No significant associations of nuts were seen with major CVD (mvHR: 0.91; 95% CI: 0.81, 1.02; P-trend = 0.14), stroke (mvHR: 0.98; 95% CI: 0.84, 1.14; P-trend = 0.76), or MI (mvHR: 0.86; 95% CI: 0.72, 1.04; P-trend = 0.29). CONCLUSIONS: Higher nut intake was associated with lower mortality risk from both cardiovascular and noncardiovascular causes in low-, middle-, and high-income countries.