Nutritional status of rural children in the Lesotho Highlands.

A baseline cross-sectional study was done to evaluate the nutritional status of the population of the Mohale Dam catchment area before construction of the dam commenced. In this article we report on the anthropometric, clinical and dietary assessment of the children less than 15 years of age in the study population. A two stage stratified sampling technique was used to randomly select 29 of the 83 villages in the study area. Children under 15 years of age from 395 households, representing approximately 50% of households in the selected villages, were included in the study. Anthropometric measurements of body height and weight in relation to age and sex indicated undernutrition varying, with few exceptions, from high to very high levels in children under 15 years. Stunting, indicating chronic undernutrition, was of particular concern in children, even from the first year of life. Very few clinical signs of nutritional deficiencies were found except for a goitre prevalence of 17.5% in 10 to 14 year old children. This was supported by the very low urinary iodine excretion (median 1.3 micrograms/dL) which indicated a severe iodine deficiency. Dietary evaluation showed high initiation rates of breastfeeding as well as a long duration of breastfeeding. Complementary foods were introduced at an early age, resulting in low exclusive breastfeeding rates. Regular meals were reported but qualitative analysis of the diet showed that a too small variety of foods were eaten, with an irregular intake of protein-rich foods and milk. Quantitative data on 3- < 5-year-old children showed that micro-nutrient intakes were low and that the energy intake of these children was inadequate. The results showed that these nutritionally vulnerable children should be monitored for the impact of the dam construction on their nutritional status.

PIP: The nutritional status of children under 15 years of age, from South Africa's Mohale Dam catchment area, was investigated in a cross-sectional baseline study conducted before dam construction began. 323 children, from 29 of the 83 villages in the study area, underwent anthropometric, clinical, and dietary assessment. The mean Z-score of height-for-age varied between -1.39 and -1.93 in the different sex and age groups. The percentage of children with a height-for-age less than -2 standard deviations (SDs) below the median of the reference population (indicating stunting) was 38.5-44.9% among boys and 30.7-37.0% among girls. Weight-for-height scores below -2 SDs (indicating wasting) occurred in 0.7-3.4% of children under 10 years old. 15-17% of children under 10 years old were underweight, but this rate increased to 34.8% in boys aged 12-15 years, and declined to 7.7% in older girls. The prevalence of stunting increased from 21.5% in the first year of life to 38.5% in the second year, while that of underweight increased from 7.7% to 19.2%. Goiter was present in 17.5% of 10-14 year olds, consistent with a median urinary iodine excretion of only 1.3 mcg/dl (severe iodine deficiency). Although breast feeding was widespread and of long duration, complementary foods were introduced early (mean, 4.0 months for liquids other than milk; 4.5 months for solids). Dietary analysis revealed irregular intake of protein-rich foods and milk, as well as a lack of variety; fewer than 10 foods represented almost the entire selection. The energy intakes of children 3-5 years old were inadequate. The high prevalence of stunting in this population indicates a need for interventions such as increased food availability and quality, salt iodization, adequate supplies of potable water, and treatment and prevention of infectious diseases. The impact of dam construction and resettlement on these nutritionally vulnerable children should be monitored.

Failure to thrive and its relationship to serum vitamin A levels and diet.

Serum vitamin A and retinol-binding protein (RBP) levels were determined in a group of 34 children between 1 and 4 years of age with failure to thrive and in 34 age- and sex-matched controls. Both groups of children were also assessed in respect of anthropometry and diet. Vitamin A levels in patients (0-32.2 micrograms/100 ml; median 16.9 micrograms/100 ml) did not differ significantly from controls (6.4-47.2 micrograms/100 ml; median 16.1 micrograms/100ml). Fourteen patients (42%) and 4 controls (12%) had vitamin A levels below 10 micrograms/100 ml. RBP levels in patients (0.45-3.50 mg/100 ml; median 2.17 mg/100 ml) also did not differ significantly from those in controls (1.21-3.66 mg/100 ml; median 2.06 mg/100 ml). No clinical features of vitamin A deficiency were detected. Weight and height for age, weight for height, mid-upper arm circumference and head circumference differed significantly between patients and controls (P < 0.0001 in each instance). Although within the recommendations for intake, patients had a significantly lower intake of the essential fatty acid C 18:2 (N = 6) (linoleic acid) and vitamin A. In view of the current proposed relationship between vitamin A status and infectious diseases, the prevalence of biochemical vitamin A deficiency in children in the Cape Town community studied may contribute to the morbidity and mortality associated with infectious diseases in the area to a greater degree than has been suspected.

Nutritional status of 3-6 year-old African children in the Cape Peninsula.

A survey was conducted in the Cape Town metropolitan area in 1990 to determine the dietary intake and anthropometric status of 3-6 year-old African children (N = 163). Dietary data obtained from 24-hour recalls revealed that mean energy intake (5200 kJ) was low and that mean intakes of most nutrients fell considerably below the recommended dietary allowances (RDAs). The average diet included an adequate number of portions from the meat and cereal groups, but was inadequate with respect to the milk and fruit/vegetable groups when compared with the recommendations of the Department of Health Services and Welfare. The macronutrient energy distribution was within prudent dietary guidelines, with 28.1% of energy (E) being obtained from total fat, 63.7% from carbohydrate and 13.2% from protein. Anthropometric profiles expressed in terms of the National Centre for Health Statistics' (NCHS) standards, revealed evidence of growth retardation and wasting in this population, coexisting with emergent obesity. The development of a nutrition and health policy to address the problems of both deficit and excess represents a pressing challenge.

PIP: During the first quarter of 1990, Xhosa-speaking nurses interviewed mothers and took anthropometric measurements of 163 children 3-6 years old living in squatter and formal housing areas of Cape Town, South Africa, to determine the nutritional status of the children. 39% of the children received less than 67% of the recommended daily allowance (RDA) of calories (i.e., deficiency) and 3% received more than 120% of the RDA. Most children were deficient in calcium (80%), iron (77%), vitamin A (64%), riboflavin (52%), niacin (53%), vitamin B6 (58%), and vitamin C (76%). Most children received more than 120% of the RDA for folic acid (68%) and for vitamin B12 (63%). Milk consumption was low (median intake, 0.5 portion vs. 2-3 portions as recommended by the department of national health and population development guidelines). The diet was also deficient in vegetables and fruit intake (1.32 vs. =or 4 portions) and fat intake (2.5 vs. =or 4 portions). Children did receive adequate portions of meat and foods from the cereal group, however. Macronutrient energy distribution fell within prudent dietary guidelines: 28.1% of energy from total fat, 63.7% from carbohydrates, and 13.2% from protein. 44.8% of children had only 2 meals with more than 600 kJ. 15 children (9.2%) had only 1 meal. 27.6% were stunted. 7.7% were underweight. 7.9% were wasted. 20.1% were obese. The undernourished children and the obese children consumed a diet low in micronutrients. These anthropometric findings indicate a population in transition--acutely and chronically undernourished children coexisting with obesity. The overall findings suggest a need to develop a nutrition and health policy to address nutrient deficit and excess.

The food and meal pattern in the urban African population of the Cape Peninsula, South Africa: the BRISK Study.

A cross sectional dietary study, utilising the 24 hour recall method, was conducted among 983 African adults aged 15 to 64 years resident in the Cape Peninsula during 1990. An evaluation of the dietary intake pattern revealed a diet confined to a relatively narrow range of foods, but little evidence of nutrient-empty food intake. In terms of recommendations, insufficient dairy products and vegetables and fruits were consumed, while requirements for intakes of cereals and components of the meat and fat groups were met. Supper emerged as the main meal of the day, contributing most of the energy and was consumed by 89 pc of respondents. Between meal eating made a valuable contribution to total nutrient intake. The low intakes of dairy products and vegetables and fruits and the apparent move away from the traditional diet present particularly great challenges.

Nutrient intake in the urban African population of the Cape Peninsula, South Africa. The Brisk study.

In a dietary study on a representative sample of 983 adult African men and women aged 15-64 years, resident in the Cape Peninsula, South Africa, trained professional nurses administered a 24 hour recall interview. This formed part of a cross-sectional study on the prevalence of coronary risk factors (BRISK) in this population. The macronutrient profile reflected a diet meeting the Prudent Dietary Guidelines, but low in fibre. Mean intakes of vitamins and minerals indicated a nutritionally depleted diet. Comparisons with rural African populations have revealed that the dietary intake of this urbanising study population represents a transitional phase towards a progressively atherogenic Western diet.

Community-based intervention: the Coronary Risk Factor Study (CORIS).

The Coronary Risk Factor Study (CORIS) examined the feasibility and effectiveness of a multifactorial community intervention programme to reduce coronary heart disease (CHD) risk factor levels. Three Afrikaner communities were surveyed before and after a 4-year intervention in two of the communities, the third serving as a control (C). Intervention was primarily by small mass media (low-intensity intervention, LII) or by small mass media plus interpersonal intervention to high-risk individuals (high-intensity intervention, HII). After allowing for change in C, significant net reductions in blood pressure, smoking, and risk score were obtained in LII and HII alike. Though the total cholesterol (TC) fell by 10-12%, there was no net reduction in favour of the intervention communities. However, LII and HII resulted in significant increases in high-density lipoprotein cholesterol (HDL-C) levels and HDL-C/TC ratios in comparison to C. Overall, the LII community fared almost as well as the HII community, and high-risk individuals did not show a greater change in risk factors than others. We conclude that community-based intervention works, and that in these particular communities a media-based health education programme was more cost-effective than one which adds a greater degree of interpersonal intervention.

Risk factors for coronary heart disease in the black population of the Cape Peninsula. The BRISK study.

A cross-sectional study of risk factors for ischaemic heart disease (IHD) in a random sample of 986 black people aged 15-64 years living in the Cape Peninsula revealed a population at lower risk for IHD than other South Africans. Blood pressures of 140/95 mmHg or above were found in 14.4% of males and 13.7% of females. Fifty-two per cent of males and 8.4% of females smoked, while 16.5% of males and 25.8% of females had a total cholesterol (TC) level imparting risk for developing IHD. In this population the TC level is not a good surrogate measure for low-density lipoprotein cholesterol because of the high level of high-density lipoprotein cholesterol (HDLC) found in this population. A protective HDLC/TC ratio of 20% was found in 96% of males and 96.1% of females. When considering the three major reversible IHD risk factors at a high level of risk, 30.8% of males and 12.5% of females had at least one such a risk factor. The population was frequently exposed to the media, with 80% listening to the radio every day and 55% watching television at least once a week. This suggests that a healthy lifestyle could be promoted successfully by means of these media. In addition, schools should promote a healthy lifestyle and the prevention of chronic degenerative diseases should be incorporated into the evolving primary health care services in South Africa.

Change in knowledge in a coronary heart disease risk factor intervention study in three communities.

We investigated health and diet knowledge as it relates to coronary heart disease (CHD) in three rural areas which participated in a community-oriented CHD risk factor intervention study. Knowledge of risk factors (risk knowledge) was fairly satisfactory at baseline, but diet knowledge was poor. Males, the young, and individuals with a lower level of education had less knowledge. Intervention consisted of a 3-year small mass media programme in one community (low-intensity intervention, LII), additional interpersonal intervention to high-risk individuals in the second (high-intensity intervention, HII), and no intervention in the control community (C). In the cohorts, with the baseline survey and the follow-up study 4 years apart, knowledge improved by 8.1% points in males (7.5% in females) in the HII community and by 7.1% (6.5%) in the LII community, compared to 5.5% (4.8%) in the C community (P less than 0.01). Diet knowledge improved more than risk knowledge, and individuals with lower initial scores benefitted most. Female scored highest. Educational level made a modest positive contribution to knowledge gain, after adjusting for differences in baseline knowledge. High-risk individuals did not have better knowledge at baseline, nor did they gain more from the intervention. We conclude that community intervention over a 4 year period, based on community diagnosis and tailored to the community's needs, can improve health knowledge.

Relationship between high density lipoprotein subfractions and coronary risk factors in a rural white population.

The relationship of serum high density lipoprotein cholesterol (HDL-C) levels and of the HDL2-C and HDL3-C subfractions to several factors associated with coronary risk was examined in a cross-sectional study, which included 655 men and 731 women ages 20 to 64 years. Participants with coronary heart disease (CHD) had lower levels of HDL-C, HDL2-C, and HDL3-C; however, only HDL-C in women was significant. Maleness, body mass index, triglyceride levels, tobacco use, and carbohydrate intake (in men) were significantly inversely related to total HDL-C, while alcohol intake was significantly positively related to HDL-C. The associations were stronger for HDL2-C than for HDL3-C, except that alcohol intake in men was more strongly related to HDL3-C. The findings of this study suggest that several factors that influence CHD risk do so in part through modifying HDL2-C levels.

The snacking habits of white preschool children.

Three-day estimated dietary records were kept for 194 white 3- and 4-year-old children to determine and evaluate the extent, nature and quality of their snacking. All but 1 child ate between meals, with morning and afternoon snacking being favoured in terms of frequency and quantity. Soft drinks were consumed most frequently, followed by fresh fruits and fruit juices, sweets and chocolates, milk and sugar. Between-meal eating contributed more than one-third of the average day's energy and approximately one-quarter of most vitamins and minerals to the children's diets. Foods eaten between meals were, however, significantly less nutrient-dense than mealtime foods. Non-basic foods supplied more energy to the diet than any of the five basic food groups, but minimal quantities of micronutrients. Sugar consumption, mostly in the form of sugary foods and drinks, was high, but was not consumed exclusively between meals. Such children should be encouraged to make more use of basic commodities, particularly when snacking.

Anthropometric profile of the coloured population of the Cape Peninsula.

Study of a sample of 976 randomly selected coloured persons 15-64 years of age living in the Cape Peninsula included measurement of height, weight and mid-arm circumference and calculation of the body mass index (BMI). The mean height of the men was 167.6 cm and that of the women 156 cm. Mean weight, BMI and mid-arm circumference for men were 65.9 kg, 23.4 and 27.5 cm respectively and those for women 65.8 kg, 27.1 and 28.9 cm respectively. The prevalence of underweight for men (BMI less than 20) was 23.6% and for women (BMI less than 19) 9.8%; 17.7% of men were overweight (BMI greater than or equal to 25) and 3.7% obese (BMI greater than or equal to 30), while 35.2% of women were overweight (BMI greater than or equal to 24) and 18.8% obese. Overweight and obesity were more common among the older coloured women than among a group of South African white women of the same age. Obese women in the age group 35-44 years were 4.8 times more likely to be hypertensive than women of normal weight in the same age group (odds ratio; 95% confidence interval 2.2-4). Older women did not show this association. There were too few obese men to analyse in this manner. Many of the obese participants did not see themselves as obese. Only 19.7% of men and 45.2% of women had attempted to lose weight during the year preceding the study, in many cases using methods known to be ineffective. The coloureds of the Cape Peninsula were found to be a population with shorter stature than South African white and American populations. Some young participants of both sexes and some older men were underweight, while among older women there was a high prevalence of overweight and obesity. The findings may suggest previous undernutrition in both sexes, with a marked tendency to current overnutrition in adult females.

Health actions and disease patterns related to coronary heart disease in the coloured population of the Cape Peninsula.

The health-related behaviour of the Cape Peninsula coloured population, which has been shown to have an adverse coronary heart disease (CHD) risk factor profile, is reported. Private medical services were used most often by participants: 54.1% and 51.6% of males and females respectively had made use of these services during the preceding year. Only 17.9% and 21.8% of males and females respectively had attended day hospitals during the year. Blood pressures were measured in 43.8% and 57.1% of male and female participants respectively during the year preceding the study. The results indicated the need for the measurement of blood pressure to determine the true prevalence of hypertension, since patient reporting of the condition was inaccurate. Attempts to give up smoking had been made by 44.4% of male and 47.1% of female smokers. About 75% of the participants were found to have hypercholesterolaemia, yet their knowledge of the prudent diet was poor and few reported appropriate dietary modifications to protect against CHD. Frequent reporting of hypercholesterolaemia, hypertension and constipation by the study population highlights the need for dietary education. Mortality rates (MRs) for CHD and cerebrovascular disease (CVD) for the coloured and the white populations were compared. In all age groups white males had higher MRs for CHD than coloured males, while coloured females older than 34 years had higher rates than their white counterparts. The coloured population had MRs for CVD that were higher than those of whites.

The relationship between dietary factors and serum cholesterol values in the coloured population of the Cape Peninsula.

A cross-sectional study of 976 coloured subjects aged 15-64 years identified a population consuming a typical Western diet. Nutrient intake, determined by the 24-hour dietary recall method, reflected a diet high in fat (37% of total energy intake) and animal protein and a polyunsaturated/saturated fatty acid ratio of 0.85. Only 32.2% of men and 27.5% of women consumed a prudent diet (Keys score less than or equal to 28). The influence of this Western diet on serum total cholesterol (TC) levels was seen to be marked when participants with a high risk of developing coronary heart disease (CHD) were compared with those with a TC level putting them at low risk; the former consumed significantly more saturated fat and had a higher mean Keys score. Multiple linear regression analysis on TC levels of men identified six variables that explained 26.9% of the variation of TC. These were body mass index, age, the inverse of the polyunsaturated fat intake, saturated fat intake, polyunsaturated/saturated fat ratio and cholesterol intake. For women only three variables (age, the inverse of the polyunsaturated/saturated fat ratio, and body mass index) explained 30.2% of the variation of TC. Promotion of the prudent diet to lower TC levels of the coloured population of the Cape Peninsula is an increasingly urgent priority.

An evaluation of two guidance programmes to promote breast-feeding.

During the past ten years a comprehensive research project has been undertaken to develop a guidance programme in three adjacent communities in the South-Western Cape with the aim of lowering the high incidence of coronary heart disease. The purpose of this substudy was to determine whether the guidance provided in the different communities had any influence on the knowledge of and attitudes towards the nutrition of pregnant women, babies and infants as well as breast-feeding practices of the women who gave birth during the period 1980 to 1986. In the first community guidance was provided by means of small mass media and interpersonal communication whereas only the small mass media were employed in the second. The third served as the control community. The findings suggest that the combined interpersonal and mass media programme was more successful than the mass media programme alone.

Factors associated with high density lipoprotein cholesterol in a population with high high density lipoprotein cholesterol levels.

A cross-sectional study of a random sample of 976 coloureds (mixed race) of the Cape Peninsula, ages 15 to 64 years old, revealed a population with unexpectedly high levels of high density lipoprotein (HDL) cholesterol. The mean level for men was 55.4 +/- 16.1 mg/dl (SD) and for women, 60.8 +/- 16.0 mg/dl. The ratio of HDL cholesterol to total cholesterol expressed as a percentage was 26.3% +/- 9.5% for men and 28.1% +/- 9.3% for women. The HDL cholesterol levels were apparently lower than those of black and Negro populations, yet higher than those of Caucasian populations. Men with levels of HDL cholesterol above the median reported a personal history and a family history of coronary heart disease less frequently than did men with lower levels, while women with high levels of HDL cholesterol were less likely to have a history of hypertension or diabetes. Stepwise multiple regression analysis of variables significantly associated with HDL cholesterol levels showed that they explained 29.7% and 24.7%, respectively, of the variation in HDL cholesterol in men and women. Those variables independently associated with HDL cholesterol in both men and women were: serum triglyceride (-), cigarette consumption (-), alcohol, body mass index (-), age, and serum low density lipoprotein cholesterol levels (-). The reasons for the relatively high HDL cholesterol levels in this population are unknown. However, it would seem possible that these levels offer some protection against the high risk factors of smoking, hypertension, and hypercholesterolemia.

The contribution of different food groups to the energy, fat and fibre intake of the Coronary Risk Factor Study (CORIS) population.

A dietary survey done in 1979 on a randomly selected 15% subsample (454 males and 659 females, 15-64 years old) of the 1979 Coronary Risk Factor Study (CORIS) population showed that this population consumed a typical Western diet. In order to identify specific weaknesses in the dietary habits of the population, additional analyses were performed on the data. Foods consumed by the respondents were grouped into 8 groups and the percentage contribution of each of these food groups to total energy intake, total macronutrients, dietary cholesterol and dietary fibre intake was determined. A reference, an 8.4 MJ diet, calculated according to the prudent diet guidelines, was also analysed as described above. The results showed that the CORIS respondents' dietary intake compared unfavourably with the values of the reference diet. The meat group was the main source of total fat, saturated fat and dietary cholesterol. The fat group was the second most important source of total fat in the diet, while the milk group was the second most important source of saturated fat. The study population preferred refined cereals and had a low fruit and vegetable intake. These results revealed specific shortcomings in the dietary habits of the CORIS population and emphasised the need for changes necessary to meet the requirements for a prudent diet.

The relationship between alcohol consumption and coronary risk factors in the CORIS Study.

The cross-sectional relationship between reported alcohol consumption and coronary risk factors was investigated in the three-community Coronary Risk Factor Study (CORIS) population, consisting of 7,188 participants. Among drinkers of both sexes, the lowest level of systolic and diastolic blood pressure, serum cholesterol, tobacco use, body mass index, total daily energy expenditure, uric acid and Bortner score were found at the lower end of the alcohol consumption range. Non-drinkers had higher mean values for most of these risk factors than light drinkers. An increase in alcohol consumption was associated with a progressive increase in almost all the risk factors. Although men used more alcohol than women, at comparable alcohol consumption levels women generally had lower levels of risk factors than men.

Intake of macronutrients and their relationship with total cholesterol and high-density lipoprotein cholesterol. The Coronary Risk Factor Study, 1979.

In a dietary study on a subsample (1,113 males and females, 15-64 years of age) of the Coronary Risk Factor Study (CORIS) population, dietitians used the 24-hour recall method by interview to quantify nutrient intake and energy distribution and to investigate the relationship between dietary variables and blood lipid values. Mean total fat intakes varied from 35% to 37% of daily energy intake for different age groups. Dietary polyunsaturated/saturated fatty acid ratios varied from 0.48 to 0.59. Cholesterol intakes ranged from 243 mg/d to 500 mg/d and when expressed per 4.2 MJ (1,000 kcal) were similar for males and females. The results of this intrapopulation cross-sectional study showed no significant relationship between dietary variables and total serum cholesterol and high-density lipoprotein cholesterol. However, the low percentage of respondents who met the prudent dietary guidelines add dietary risk factors to the already high prevalence of other major risk factors in this population.

Hypercholesterolaemia in the coloured population of the Cape Peninsula (CRISIC study).

A cross-sectional study of hypercholesterolaemia in a random sample of 976 subjects showed that hypercholesterolaemia was common in a coloured population. Of the males 17.4% and of the females 16.2% had total serum cholesterol values above 6.5 mmol/l. Using a cut-off point of 5.7 mmol/l the age-standardised prevalence of hypercholesterolaemia was 34.5% for males and 32.9% for females. Age- and sex-specific cut-off points showed that 69.2% of males and 65.9% of females were at risk for coronary heart disease (CHD) by virtue of the total cholesterol level. Of the males 19.1% and of the females 13.4% warranted investigation for possible familial hypercholesterolaemia. A protective high-density lipoprotein cholesterol/total cholesterol ratio was found in 61.2% of males and 51.9% of females. Hypercholesterolaemia was statistically significantly associated with a reported history and a familial history of CHD as well as with hypertension and diabetes in some groups studied. Unlike most cross-sectional studies this study showed that hypercholesterolaemic participants consumed more saturated fat and their diets had a higher Keys score than did normocholesterolaemic participants. Only 16.5% of males and 21.7% of females had modified their diets to prevent heart disease. High levels of total cholesterol were found to be associated with high levels of serum triglycerides and uric acid, high body mass index, high diastolic and systolic blood pressure and higher socio-economic standing. An education programme to initiate the dietary modifications that lead to the lowering of serum cholesterol levels is necessary to reduce CHD in the coloured population.