Feasibility Testing of the Health4LIFE Weight Loss Intervention for Primary School Educators Living with Overweight/Obesity Employed at Public Schools in Low-Income Settings in Cape Town and South Africa: A Mixed Methods Study.

Given the high prevalence of overweight and obesity amongst educators, this study investigated the feasibility of the 16-week Health4LIFE weight loss intervention for primary school educators living with overweight/obesity in low-income settings in Cape Town, South Africa. The research comprised two sub-studies, a pilot randomised controlled trial testing the intervention (10 intervention, n = 79 and 10 control schools, n = 58), and an investigation of the perceptions of participating educators and principals. Feasibility outcomes included reach, applicability, acceptability, implementation integrity, and a hypothesis-generating signal of effect on lifestyle factors and weight. The intervention consisted of a wellness day, weight loss manual, and text messages. Results indicated acceptable reach, with positive feedback on intervention components from principals and educators. Implementation was largely successful, though three schools dropped out due to scheduling issues. Barriers included interruption of teaching time and busy school schedules. The intervention group (n = 42) showed favourable shifts in belief patterns, stages of change, and lifestyle behaviours, with a trend towards weight loss. Control group (n = 43) changes were limited to dietary intake. The triangulation of results supported the intervention's feasibility in terms of primary and secondary outcomes. Recommendations for enhancement include adding in-person follow-up sessions and an app-based element to potentially increase impact on lifestyle indicators and weight loss.

Dietary Patterns, Socio-Demographic Predictors Thereof, and Associations of Dietary Patterns with Stunting and Overweight/Obesity in 1-<10-Year-Old Children in Two Economically Active Provinces in South Africa.

A review of the literature showed that there were only a few studies that reported on the dietary patterns of children in South Africa. The aim of the present study was to characterise the dietary patterns of children aged 1-<10 years who were studied during the Provincial Dietary Intake Survey (PDIS) in 2018 and to investigate the socio-demographic predictors thereof, as well as the associations with stunting and overweight/obesity. Dietary pattern analysis was conducted within three age groups, namely 1-<3-year-olds, 3-<6-year-olds, and 6-<10-year-olds using iterated principal factor analysis with varimax rotation and 24 h recall data from the PDIS. The dietary patterns that emerged seem to be far from ideal. Energy-dense, nutrient-poor patterns were included in the top three strongest patterns in all three age groupings that were investigated. Few of the dietary patterns included vegetables other than starchy vegetables, fruit, dairy, quality proteins, and unrefined carbohydrates. There were no associations between any of the dietary patterns and stunting or overweight/obesity in the children. Key predictors of greater adherence to the mostly unhealthy patterns included indicators of a higher socio-economic status in all three age groups, as well as having an obese mother in the 6-<10-year-old group. Key predictors of greater adherence to the mostly healthy patterns were a higher wealth index and having an obese mother in the two younger groups, with no predictors in the 6-<10-year-old group. We conclude that the dietary patterns of children in the Western Cape contain strong elements of the energy-dense, nutrient-poor dietary patterns. Interventions to improve the dietary intake of children should be directed at both poorer and higher income communities.

Overweight among children decreased, but obesity prevalence remained high among women in South Africa, 1999-2005.

OBJECTIVE: The aim of the present study was to assess anthropometric status in South African children and women in 2005 in order to document temporal trends in selected anthropometric parameters. DESIGN: Heights and weights were measured in a cross-sectional study of children aged 1-9 years and women aged 16-35 years. The WHO reference values and BMI cut-off points were used to determine weight status. SETTING: South Africa, representative sample based on census data. SUBJECTS: Children (n 2157) and women (n 2403). RESULTS: Stunting was the most common nutritional disorder affecting 21·7% of children in 1999 and 20·7% in 2005. The difference was not statistically significant. Underweight prevalence remained unchanged, affecting 8·1% of children, whereas wasting affected 5·8% of children nationally, a significant increase from 4·3% of children in 1999. Rural children were most severely affected. According to the international BMI cut-off points for overweight and obesity, 10% of children nationally were classified as overweight and 4% as obese. The national prevalence of overweight and obesity combined for women was 51·5%. The prevalence of overweight in children based on weight-for-height Z-score did not change significantly (8·0% to 6·8%, P = 0·138), but the combined overweight/obesity prevalence based on BMI cut-off points (17·1% to 14·0%, P = 0·02) decreased significantly from 1999 to 2005. CONCLUSIONS: The double burden of undernutrition in children and overweight among women is evident in South Africa and getting worse due to increased childhood wasting combined with a high prevalence of obesity among urban women, indicating a need for urgent intervention.

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/m(2) 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.

Prevalence and Determinants of the Double Burden of Malnutrition with a Focus on Concurrent Stunting and Overweight/Obesity in Children and Adolescents.

PURPOSE OF THE REVIEW: To determine the prevalence and determinants of concurrent stunting and overweight/obesity (CSO) in the same child or adolescent. RECENT FINDINGS: After searching PubMed and the Web of Science, 26 articles comprised the prevalence and/or determinants of concurrent stunting and overweight/obesity. Most of the articles were published from 2018 onwards. There is great variation in the prevalence of concurrent stunting and overweight/obesity across the globe. For children under five years the prevalence of CSO is higher among children under two years compared with those 2-<5 years. The main determinants of this condition appear to be associated with gender, age, and urban versus rural ones. Income varied greatly between studies. However, a few additional variables were mentioned including having a mother with a short stature, time of weaning, having an improved toilet facility, being dewormed in the past few months, and the level of education of the mother.

The Nutrition Transition and the Double Burden of Malnutrition in Sub-Saharan African Countries: How Do These Countries Compare with the Recommended LANCET COMMISSION Global Diet?

BACKGROUND: Over the last two decades, many sub-Saharan African (SSA) countries have undergone dietary and nutrition transitions fuelled by rapid urbanisation, economic development, and globalisation. The aim of the current study was to examine outcomes of the nutrition transition and the epidemiologic transition in SSA countries in terms of food intake, health, and socioeconomic and development factors. METHODS: Food balance sheet data-specifically, per capita energy intake per day and per capita gram intake per day-from the CountrySTAT framework of the Food and Agricultural Organization (FAO) were analysed for major food commodities. Additionally, selected health and development indicators supplied by UNICEF, the WHO and the World Bank were analysed. RESULTS: Four dietary patterns emerged. The diet of the southern African/island cluster (South Africa, Mauritius, Eswatini, Namibia, Cabo Verde, and the outlier Seychelles) resembles a Westernised diet, with median values high on sugar/sweeteners, alcohol, meat, animal fats, eggs, and dairy. On the other hand, the diet of countries in the other three clusters appears to be more traditional, with countries in the desert/semi-arid cluster consuming more cereals and pulses/tree nuts, countries in the tropical coastal cluster consuming more fish and vegetable oils, and countries in the equatorial cluster consuming more starchy roots and fruit and vegetables. The resulting median values of health indicators also indicate a higher prevalence of non-communicable diseases in the southern African/island cluster, whereas stunting and anaemia are higher in the other three clusters. CONCLUSIONS: SSA countries are in different stages of the nutrition transition. By superimposing clusters generated using macronutrient intake values on a map of the climatic regions in Africa, one can clearly see the importance of climate on the availability of food and food intake patterns. Climate change presents a great challenge to healthy eating, as the link between climate regions and diets is illustrated.

Illustration of the Importance of Adjustment for within- and between-Person Variability in Dietary Intake Surveys for Assessment of Population Risk of Micronutrient Deficiency/Excess Using an Example Data Set.

Nutrition intervention decisions should be evidence based. Single 24-h recalls are often used for measuring dietary intake in large dietary studies. However, this method does not consider the day-to-day variation in populations' diets. We illustrate the importance of adjustment of single 24-h recall data to remove within-person variation using the National Cancer Institute method to calculate usual intake when estimating risk of deficiency/excess. We used an example data set comprising a single 24-h recall in a total sample of 1326 1-<10-year-old children, and two additional recalls in a sub-sample of 11%, for these purposes. Results show that risk of deficiency was materially overestimated by the single unadjusted 24-h recall for vitamins B12, A, D, C and E, while risk of excess was overestimated for vitamin A and zinc, when compared to risks derived from usual intake. Food sources rich in particular micronutrients seemed to result in overestimation of deficiency risk when intra-individual variance is not removed. Our example illustrates that the application of the NCI method in dietary surveys would contribute to the formulation of more appropriate conclusions on risk of deficiency/excess in populations to advise public health nutrition initiatives when compared to those derived from a single unadjusted 24-h recall.

Has Food Security and Nutritional Status Improved in Children 1-<10 Years in Two Provinces of South Africa between 1999 (National Food Consumption Survey) and 2018 (Provincial Dietary Intake Study (PDIS)).

The 1999 National Food Consumption Survey in South Africa showed that food insecurity (hunger) was prevalent in households with children aged one to <10 years. A repeat of the survey in two provinces: Gauteng (GTG) and the Western Cape (WC) was undertaken in 2018. Results showed that in all domains (living areas) in GTG, food shortage prevalence decreased between 1999 and 2018, from 55.0% to 29.6% in urban informal areas, from 34.1% to 19.4% in urban formal areas and from 42.1% to 15.6% in rural areas. While the prevalence of food shortage in urban formal areas in the WC remained similar in 2018, prevalence decreased from 81.8% to 35.7% in urban informal areas and from 38.3% to 20.6% in rural areas. Energy and macronutrient intakes improved significantly in GTG between 1999 and 2018 but not in the WC; intakes were significantly higher in the WC at both time points. The only significant change in stunting, wasting, overweight and obesity prevalence was that 7-<10-year-olds in GTG were significantly more likely to be wasted (BAZ < 2SD) in 2018 than in 1999 (20.2% versus 6.9% respectively). In the WC, 1-3-year-olds were significantly more likely to be obese in 2018 than in 1999 (8.1% versus 1.7% respectively) and 7-<10-year-olds were less likely to be stunted (14.5% versus 4.9% respectively). There were significant negative correlations between the hunger score and dietary variables in both provinces in 1999. In GTG in 2018, only the correlation with fat intake remained while there were still several significant correlations in WC in 2018. Changes in top 12 energy contributors reflect a shift to high or moderate energy foods low in nutrients from 1999 to 2018. Nutrient dense (high micronutrients, low energy/g) foods (e.g., fruit) fell off the list in 2018. Logistic regression analyses reflect the importance for food security of having a parent as head of the household and/or caregiver, and parents having grade 12 or higher education and being employed. We conclude that food security nutritional status indicators improved amongst 1-<10-year-old children especially in GTG between 1999 and 2018. However, the shift to poorer food choices and increase in wasting in older children and overweight in younger children are of concern.

Factors which influence the consumption of street foods and fast foods in South Africa--a national survey.

BACKGROUND: Very little is known about street food and fast food consumption patterns in South Africa despite this being a large sector of the national economy in terms of employment provided and sales of food. The objective of this study was to determine the use of street foods and fast foods purchased by South Africans living in different provinces and geographic areas. METHODS: A cross-sectional survey was conducted. Structured interview-administered questionnaires in 11 official languages were conducted at the participants' homes. A nationally representative sample (n = 3287) was drawn from all ethnic groups, and provinces including participants 16 years and older. Logistic regression was done to evaluate factors impacting on fast food consumption. RESULTS: Frequent (2 ≥ times/week) street food consumption ranged from 1.8% in Northern Cape to 20.6% in Limpopo; frequent (2 ≥ times/week) fast food consumption ranged between 1.5% in North West Province to 14.7% in Gauteng. The highest intake of street food was in the medium socio-economic category (14.7%) while the highest intake of fast foods was in the high socio-economic category (13.2%). Overall, fruit was the most commonly purchased street food by all ethnic groups over the previous week although this practice was highest in black participants (35.8%). Purchases of soft drinks ranged from 4.8% in whites to 16.4% in blacks and savoury snacks from 2.3% to 14.5% in whites and blacks, respectively. Consumption of fast foods and street foods were influenced by a number of socio-demographic factors including ownership of major home appliances. Frequent fast food consumers had a significantly higher dietary diversity score (4.69; p < 0.0001) while frequent street food consumers had a significantly lower score (3.81; p < 0.0001). CONCLUSIONS: A large percentage of the population purchase street foods and fast foods. This is of some concern when one notes the high prevalence of soft drink consumption in terms of its association with obesity and non-communicable diseases. These findings need to be taken into consideration when evaluating dietary patterns and nutritional adequacy of population diets.

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/m(2)) 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.

Mean ± Standard Deviation Intake Values for 1-<10-Year-Old South African Children for Application in the Assessment of the Inflammatory Potential of Their Diets Using the DII® Method: Developmental Research.

This study aimed to develop a set of mean ± standard deviation (SD) intake values for South African (SA) children for 36 of the 45 food parameters included in the original Dietary Inflammatory Index (DII®) tool. The SA food composition database contains 30 of the 45 food parameters included in the original DII®, and a supplementary database was developed for six of the food parameters not included in the SA database. The SA child mean ± SD intake of macronutrients, micronutrients and select flavonoids was calculated by age in years, using eight data sets from dietary surveys conducted in SA in the last three decades. A total sample of 5412 children was included in the calculation of the mean ± SD. The current study sample was determined to be representative of 1-<10-year-old children in SA, and the plausibility of the mean intake values was confirmed by being in line with age-appropriate recommendations. Furthermore, an increase in energy, macronutrient, and most micronutrient intakes with increase in age was evident. The generated mean ± SD values for SA children can be used for calculation of the inflammatory potential of the dietary intake of SA children in the age range of 1-<10-year-old children.

Provincial Dietary Intake Study (PDIS): Energy and Macronutrient Intakes of Children in a Representative/Random Sample of 1-<10-Year-Old Children in Two Economically Active and Urbanized Provinces in South Africa.

The double burden of malnutrition is still prevalent in South Africa, hence the importance of a dietary survey to identify risks of under- and over-nutrition. A multistage stratified cluster random sampling design was applied in two economically active provinces, Gauteng (GTG) (N = 733) and Western Cape (WC) (N = 593). Field workers completed questionnaires, and a 24 h recall with children taking part aged 1-<10-years (N = 1326). Important findings were that 71% and 74%, respectively, of 3-<6-year-olds and 6-<10-year-olds had an energy intake below the estimated energy requirement (EER), while 66% 1-<3-year-olds had intakes above the EER. The percentage of children with a total fat intake below recommended levels decreased as age increased ((51%, 40% and 5%) respectively, for the three age groups). Similarly, the percentage of those who had a total fat intake above the recommendation increased with increasing age (4%, 11% and 26%, respectively, for the three age groups). Saturated fat intake above 10%E was highest in the youngest and oldest children (33% and 32%, respectively). The percentage of children with a free sugars intake above 10%E was 47%, 48% and 52% respectively, and 98%-99% had a fibre intake that was less than recommended. Overall, the diet was not healthy, with the main food items being very refined, and the diet being high in salty snacks and sugary items, and low in fruit, vegetables and legumes.

Dietary Practices and Adolescent Obesity in Secondary School Learners at Disadvantaged Schools in South Africa: Urban-Rural and Gender Differences.

South Africa has a high prevalence of obesity in black female adolescents and a paucity of knowledge regarding contributing dietary practices. The aim of this study was to assess the dietary practices and weight status of male and female adolescents at secondary schools in the Eastern Cape province in urban and rural areas. Sixteen schools and grade 8-12 learners (N = 1360) were randomly selected from three health districts comprising poor disadvantaged communities. A short unquantified food frequency questionnaire was used to collect data on learners' usual eating practices with regards to weekly meal pattern, breakfast consumption, foods taken to school, takeaways, and snacks eaten while watching television (TV). Body mass index measurements were determined for each learner. Prevalence of combined overweight and obesity differed significantly between genders, 9.9% in males versus 36.1% in females (p < 0.001). Significant gender differences were noted regarding eating practices. Females had a higher frequency of eating sugary snacks (p < 0.001) and a lower frequency of eating breakfast (p < 0.01) than males. Females ate significantly more fried fish (p < 0.05), pizza (p < 0.05) fat cakes (fried dough balls) (p < 0.05), hotdogs (p < 0.01), candy (p < 0.001), cake (p < 0.01), and crisps (p < 0.001). Compared to urban areas, the frequency of eating breakfast (p < 0.01) and sugary snacks (p < 0.05) was significantly higher in rural areas. Significantly more learners in urban areas consumed boerewors (beef sausage) rolls (p = 0.027), hamburgers (p = 0.004), and soft drinks (p = 0.019), while more learners in the rural areas consumed cordial (p = 0.001). In conclusion, a high prevalence of combined overweight and obesity was found in black female adolescents and a high prevalence of poor dietary practices was observed, with significant gender and urban-rural differences.

The Food and Nutrition Environment at Secondary Schools in the Eastern Cape, South Africa as Reported by Learners.

Overweight and obesity are growing concerns in adolescents, particularly in females in South Africa. The aim of this study was to evaluate the food and nutrition environment in terms of government policy programs, nutrition education provided, and foods sold at secondary schools in the Eastern Cape province. Sixteen schools and grade 8-12 learners (N = 1360) were randomly selected from three health districts comprising poor disadvantaged communities. Based on age and sex specific body mass index (BMI) cut-off values, 13.3% of males and 5.5% of females were underweight, while 9.9% of males and 36.1% of females were overweight or obese. The main food items purchased at school were unhealthy energy-dense items such as fried flour dough balls, chocolates, candies, and crisps/chips. Nutrition knowledge scores based on the South African food-based dietary guidelines (FBDGs) were poor for 52% to 23.4% learners in Grades 8 to 12, respectively. Female learners generally had significantly higher nutrition knowledge scores compared to their male counterparts (p = 0.016). Questions poorly answered by more than 60% of learners, included the number of fruit and vegetable portions required daily, food to eat when overweight, foods containing fiber, and importance of legumes. It was noted that the majority of teachers who taught nutrition had no formal nutrition training and their responses to knowledge questions were poor indicating that they were not familiar with the FBDGs, which are part of the curriculum. Nutrition assessment as part of the Integrated School Health Program was done on few learners. Overall however, despite some challenges the government national school meal program provided meals daily to 96% of learners. In general, the school food and nutrition environment was not conducive for promoting healthy eating.

Provincial Dietary Intake Study (PDIS): Prevalence and Sociodemographic Determinants of the Double Burden of Malnutrition in A Representative Sample of 1 to Under 10-Year-Old Children from Two Urbanized and Economically Active Provinces in South Africa.

The objective of this study was to determine the prevalence and socio-demographic predictors of malnutrition in two urbanized economically active provinces (Gauteng N = 733, Western Cape N = 593) in South Africa. A multistage stratified cluster random sampling design was applied. Fieldworkers visited homes, measured children aged 1-<10-years old (N = 1326) and administered a questionnaire (mother/primary caregiver). In under-five year old children (N = 674) 21.6% were stunted [height-for-age z-score < -2 SD], 5.6 % underweight [weight-for-age z-score < -2 SD], 10.3% overweight (body mass index-for-age z-score) (BAZ)> +2 SD ≤ +3 SD] and 7.0% obese (BAZ > +3 SD). In 5-<10-year olds (N = 626) 6.7% were stunted, 6.8% underweight, 13.4% overweight and 6.8% obese. Stunting and overweight in the same child was present in 5.7% under-five year olds and 1.7% in 5-<10-year olds. Multiple logistic regression analyses identified having a mother with a post-grade 12 qualification (OR = 0.34) and having an obese mother (OR 0.46) as protectors and being in the under-five age group (OR = 3.73) as a risk factor for stunting. Being in the under-five age group was also a risk factor for a BAZ > 1 (OR 2.39), while being in the third wealth quintile was protective (OR = 0.62). Results indicate that stunting and overweight/obesity are still present at concerning levels, especially in the under-five age group.

Determinants of target organ damage in black hypertensive patients attending primary health care services in Cape Town: the Hi-Hi study.

BACKGROUND: In South Africa (SA) cardiovascular disease (CVD) is the second leading cause of death, with hypertension (HTN) being the predominant contributor to morbidity and mortality associated with this disease. We examined the prevalence and determinants of target organ damage (TOD) among urban black hypertensive South Africans attending primary health-care (PHC) services in Cape Town. METHODS: Patients on HTN treatment, 35-65 years of age, participated in this cross-sectional study. Data relating to sociodemographic factors, medical history, lifestyle patterns, and HTN care regimens were obtained. Blood and urine samples were analyzed and electrocardiographs (ECGs) were recorded. Sokolow-Lyon and Minnesota Code (MC) criteria were used for identifying left ventricular hypertrophy (LVH). Reduced creatinine clearance (Cockroft-Gault), microalbuminuria, proteinuria, and elevated serum creatinine levels were used for identifying "renal impairment by any criteria" (RIC). Ischemic ECG patterns were classified in terms of MC criteria. Multivariate logistic regression analyses were carried out to identify variables independently associated with TOD. RESULTS: The study sample comprised 403 participants. RIC was identified in 26%, LVH in 35%, and ischemic ECG patterns in 49% of the participants. Uncontrolled HTN and an absence of diabetes were associated with LVH as per Sokolow-Lyon criteria. Older age, the presence of diabetes, and the use of beta-blockers were associated with RIC. Ischemic ECG patterns were associated with uncontrolled HTN, older age, male gender, the consumption of less alcohol, and higher levels of low-density lipoprotein cholesterol (LDL-C). CONCLUSIONS: TOD is common in this group of black hypertensive patients attending PHC sites. Uncontrolled HTN and older age were most often associated with TOD. Reducing the burden of TOD will require improving the quality of HTN care in PHC settings.

The MNA, but not the DETERMINE, screening tool is a valid indicator of nutritional status in elderly Africans.

OBJECTIVES: We compared the validity of existing nutrition screening tools for use in older South Africans. METHODS: This was a cross-sectional study in 283 free-living and institutionalized black South Africans > or = 60 y of age. Trained fieldworkers administered a 24-h recall, the DETERMINE and Mini-Nutritional Assessment (MNA) screening tools, and performed anthropometric measurements and physical function tests. Biochemical indicators assessed included serum albumin, hemoglobin, ferritin, vitamin B12, red blood cell folate, cholesterol, and vitamin C. The six-item Cognitive Impairment Test was used to assess cognitive function. RESULTS: The MNA score was positively and significantly associated with anthropometric measurements, cognitive function, instrumental activities of daily living and, in women only, percentage of body fat, handgrip strength, and activities of daily living. Compared with the MNA, the DETERMINE instrument had a low positive predictive value (55.6%) and specificity (11.2%), resulting in a high rate of false positives classified as being malnourished. CONCLUSION: The MNA, but not the DETERMINE, screening tool is appropriate for use in identifying older black South Africans who are malnourished or at risk of malnutrition.

Food items consumed by students attending schools in different socioeconomic areas in Cape Town, South Africa.

OBJECTIVE: We investigated the food consumption patterns of adolescent students at schools. Our findings are intended to reveal the overall nutritional quality of foods eaten by students at school, including foods brought to school and foods purchased at school. METHODS: A questionnaire was completed by 476 students, mostly from grades 7 and 10, from 14 schools in Cape Town, South Africa. The schools were representative of the various ethnic groups and socioeconomic strata of the population. The questionnaire requested information on eating habits at school, foods brought to school and food purchases, and breakfast consumption before school. We also tested whether students knew which foods are healthy and which are less healthy choices. RESULTS: The students were mostly 12 to 16 y of age (mean age 14.5 y). The large majority had breakfast before school (77.8%) and ate at school (79.7%). Food was brought to school by 41% to 56%, whereas 69.3% purchased food at school, mainly at the school store (tuck shop). Predefined "unhealthy" foods brought to school outnumbered "healthy" ones by 2 to 1. Among students who purchased food at school, 70.0% purchased no healthy items, whereas 73.2% purchased two or more unhealthy items. With six foods 84% of students correctly stated whether they were healthy or unhealthy; however, with cola drinks, samoosas (deep-fried pastry with spicy filling), and pies, only 47% to 61% knew that these were less healthy choices. Students' scores on this question were unrelated to whether they purchased healthy or unhealthy foods. Students who attended schools of high socioeconomic status were twice as likely to bring food to school (64.7% versus 31.0%, P<0.001), scored higher marks on the quiz of healthy versus unhealthy foods (P<0.01), but were no more likely to purchase healthy food. CONCLUSIONS: The large majority of food eaten by adolescent students in Cape Town is classified as being unhealthy choices. This applies to foods brought to school and food purchases. Consideration needs to be given to policy measures to improve this situation and to improve education of students and their parents.

Development and validation of a questionnaire to test knowledge and practices of dietitians regarding dietary supplements.

OBJECTIVE: We developed a questionnaire to evaluate dietitians' knowledge and practices about the use of dietary supplements in light of new draft regulations in South Africa that will allow dietitians to prescribe supplements for the management of nutrition-related diseases. METHODS: A cross-sectional validation study was carried out in two phases: 1) questionnaire planning and development and 2) determination of reliability (internal consistency). The study sample comprised 48 nurses, 105 dietetic interns, and 367 registered dietitians. An expert academic group comprising nine dietitians with research and teaching experience rated the academic relevance and importance of knowledge questions in an item pool of 355 questions to ensure face and content validity. Criterion validity was measured by testing the knowledge questions (KQs) on 48 nurses and 105 dietetic interns. Thereafter questions were deleted based on their difficulty, discrimination, and Cronbach's alpha values. The final questionnaire, which at this point included a test of 50 KQs, was mailed to registered dietitians (n = 1450) in South Africa to determine internal consistency of the final KQs. RESULTS: Criterion validity of the KQs was indicated by a significant difference (P = 0.000) in the mean test scores between nurses (36.9, 95% confidence interval 24.2 to 39.6) and dietetic interns (40.2, 95% confidence interval 38.8 to 41.7). Item discrimination was attained by the deletion of NQs having a minimum correlation of 0.20 with overall test score. Further, item difficulty was controlled for by removal of questions correctly answered by more than 80% (too easy) or fewer than 20% (too difficult). Internal consistency of the KQs, after completion by 367 dietitians, was 0.87 (Cronbach's alpha). The mean knowledge score of dietitians ranged from 56.5% to 62.5%, with the oldest group (> or =40 y) having the highest score (P = 0.018). Thirty-eight percent of dietitians recommended dietary supplements at least 3 times a week; 51% consumed dietary supplements themselves; and 17% sold them to clients. CONCLUSIONS: A valid and reliable questionnaire that tests knowledge and practices of dietary supplements was developed for dietitians. This tool can be used by academic institutions to evaluate the knowledge and practices of final-year students. It can also be used on a representative sample of dietitians in South Africa and possibly elsewhere within the profession.

Diet and blood pressure in South Africa: Intake of foods containing sodium, potassium, calcium, and magnesium in three ethnic groups.

OBJECTIVES: We investigated whether habitual intakes of sodium (Na), potassium, magnesium, and calcium differ across South African ethnic groups, assessed the proportion of Na intake, which is discretionary, and identified which food sources were the major contributors to Na intake. METHODS: This was a cross-sectional study of 325 black, white, and mixed ancestry hypertensive and normotensive subjects. Three repeated 24-h urine samples were collected for assessment of urinary Na, and three corresponding 24-h dietary recalls were administered by trained fieldworkers. Blood pressure and weight were measured at each visit. Secondary analyses were performed on existing dietary databases obtained from four regional surveys undertaken in South African adults. RESULTS: Mean urinary Na excretion values equated to daily salt (NaCl) intakes of 7.8, 8.5, and 9.5 g in black, mixed ancestry, and white subjects, respectively (P < 0.05). Between 33% and 46% of total Na intake was discretionary, and, of the non-discretionary sources, bread was the single greatest contributor to Na intake in all groups. Ethnic differences in calcium intake were evident, with black subjects having particularly low intakes. Urban versus rural differences existed with respect to sources of dietary Na, with greater than 70% of total non-discretionary Na being provided by bread and cereals in rural black South Africans compared with 49% to 54% in urban dwellers. CONCLUSION: White South Africans have higher habitual intakes of Na, but also higher calcium intakes, than their black and mixed ancestry counterparts. All ethnic groups had Na intakes in excess of 6 g/d of salt, whereas potassium intakes in all groups were below the recommended level of 90 mM/d. Dietary differences may contribute to ethnically related differences in blood pressure.