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MSc (Dietetics), North-West University, Potchefstroom Campus Background: Perinatal depression is a serious problem worldwide and the prevalence is higher in low- and middle-income countries (LMIC) than in high-income countries (HIC). The South African prevalence of perinatal depression is estimated to be four times the global average. One of the potential risk factors for depression is an unhealthy diet, which women from LMIC have a higher risk of developing than women from HIC. An “unhealthier” diet has been associated with higher depressive symptoms during the perinatal period. Perinatal fatigue is common and has also been shown to have a bi-directional relationship with depression. Objectives: The aim of this study was to investigate the association between dietary patterns during early pregnancy and perinatal depression and fatigue among women. Methods: Forming part of the Nutrition during Pregnancy and Early Development (NuPED) study, dietary data were obtained at enrolment (< 18 weeks gestation) using a quantified food frequency questionnaire from which nutrient patterns were determined by means of exploratory factor analysis. The Edinburgh Postnatal Depression Scale (EPDS) was used to assess depressive symptoms and the Multidimensional Assessment of Fatigue (MAF) scale to measure fatigue at three time points during pregnancy and two postnatally. Results: The prevalence of perinatal depression ranged from 17.3% to 26.4% and perinatal fatigue ranged from 8.4% to 18.8% across the various time points. Three nutrient patterns were identified: 1) “Plant protein, iron, thiamine and folate”, which decreased the risk of fatigue at 6 months postnatally. This decrease in risk was attributed to the B-vitamins, iron and zinc present in the nutrient pattern; 2) “Animal protein, vitamin A, vitamin B12 and copper”, which increased the risk of depression at 12 months postnatally. The increased risk of depression may be due to the high meat content of the nutrient pattern; 3) “Fatty acids and sodium” which increased the risk for depression at 6 months postnatally. A possible reason for this increased risk of depression may be the high amount of saturated fatty acids in the nutrient pattern. Perinatal fatigue was also found to be positively associated with perinatal depression. Conclusion: This research illustrates the potential role of maternal diet during pregnancy in the development of maternal fatigue and depression. Masters

MSc (Dietetics), North-West University, Potchefstroom Campus Introduction: Childhood wasting is a major public health problem owing to its associated risk for death from infectious diseases such as diarrhoea, pneumonia, and measles. Severe acute malnutrition (SAM), a severe form of wasting, affects 14.3 million children globally and is responsible for nearly half a million deaths of children under 5 years of age annually. Children with SAM who present with medical complications should be treated in hospitals or medical facilities as their mortality increases by 11-fold compared to non-wasted children. To reduce high case fatalities due to complicated SAM, the World Health Organization (WHO) developed therapeutic feeding guidelines for the treatment of complicated SAM. These guidelines, commonly known as “the ten steps,” are implemented in a two-phase approach, namely the stabilisation and rehabilitation phases. A gradual transition phase is proposed between these two steps to avoid feeding complications. However, there are no clear guidelines on ensuring that nutrition requirements are met during the transition phase due to a lack of data at the time the guidelines were updated. Gradual feeding is necessary, as a rapid introduction of a large amount of feed may cause, amongst others, poor feed tolerance. The WHO, hence, suggests the use of formula-100 (F-100) and/or ready-to-use therapeutic food (RUTF) during the transition phase with the number and skills of staff available supervising and monitoring feeds to ensure that nutritional requirements are met. The implementation of the transition phase in Ghanaian referral hospitals remains, as yet, unknown. Therefore, this study's evidence contributes to a better understanding of the transitional phase feeding practices applied in children with complicated SAM in Ghana. Additionally, this study will provide insight into how these practices link to clinical outcomes. Methods: This study forms part of the SAMAC study, of which the protocol was previously published. The SAMAC study is an observational, multi-country, multi-hospital study coordinated by the Centre of Excellence for Nutrition at the North-West University in South Africa. Data for this sub-study was collected from medical records of children aged 6 to 59 months in three randomly selected referral hospitals in Ghana from January 2013 to June 2018. Data was captured into Microsoft Access and analysed using version 26 of IBM SPSS. Results: Medical records of 380 children with complicated SAM were included in the analysis. The majority (54%) of children included were boys. Two hundred and twenty (58%) study participants were admitted at TTH, 94 (25%) at PML, and 66 (17%) at KATH. The median age of children at admission was 15 months (IQR: 10.0; 24.0 months), and the majority (41%) of those with SAM were within the 12 to 23 months age group. Nearly half (49%) of the children with complicated SAM presented with diarrhoea, 48% with vomiting, and 43% with dehydration on admission. During the transition phase, the majority (40%) of children with complicated SAM, and treated at Ghanaian referral hospitals, were prescribed F-100, 32% were prescribed RUTF, 24% RUTF + F-75, and 2% were prescribed “other foods”. The median energy prescribed per kilogram body weight during the transition phase was 153.2 kcal/kg/day (IQR: 102.3; 208.3 kcal/kg/day), which was higher than the recommended 100 to 135 kcal/kg/day for the transition phase. Over-prescription of energy was present in 58% of children treated for complicated SAM while 26.8% had under-prescription of energy. Children aged 6 to 11 months across all the hospitals were prescribed the highest energy quantities, with a median of 172.4 kcal/kg/day (IQR 110.20; 219.96 kcal/kg/day). During the transition phase, 74 (21%) children had diarrhoea, and 26 (8%) children vomited. The majority (72%) of children with complicated SAM failed the transition phase on the first attempt. There were though no significant associations found between the transition feeding regimens and diarrhoea status, vomiting, and length of the transition. However, oedematous malnutrition, vomiting and diarrhoea during admission, and an HIV positive status were found to be predictors of vomiting and diarrhoea during the transition period, as well as increased length of the transition phase. Conclusion: Most children treated for complicated SAM in Ghana were given WHO-recommended feeds during the transition phase. However, these transition feeding regimens were not significantly associated with diarrhoea status, vomiting, and length of the transition phase. In addition, the current transition feeding regimens recommended by WHO appeared to have a low transition success rate due to over-prescriptions which resulted in overfeeding and poor digestibility, as observed from previous studies. As we can predict that children with complicated SAM presenting with oedematous malnutrition, diarrhoea, vomiting and HIV at admission are likely to have a longer and more complicated transition, these populations could benefit from specialised feeds, for example, lactose free or a more cautious transition phase. Therefore, this calls for a study in this specific population to develop guidelines specific to them. We also recommend a large multi-hospital and rigorous controlled prospective study to explore the actual consumption and improvements in monitoring and documentation for children treated for complicated SAM. Masters

Introduction in hospitals across Africa, the case fatality rates of severe acute malnutrition (SAM) have remained consistently high (over 20%), despite the existence of the WHO treatment guideline. This has been attributed to inconsistencies in the implementation of the WHO treatment guidelines in sub-Saharan African countries. In spite of this awareness, the SAM treatment guidelines adopted by various sub-Saharan African countries and hospitals are unknown. Knowledge of the exact treatment practices employed in the management of SAM in different hospitals in sub-Saharan Africa is not known. This study aims to investigate the admission criteria, in-patient treatment guidelines and practices and outcomes of complicated SAM in sub-Saharan African children aged 0-59 months. Methods this is an observational study which involves the extraction of admission, treatment and discharge data from the medical records of infants and children aged 0-59 months diagnosed and treated for complicated SAM in sub-Saharan Africa. This information is being used to develop a comprehensive database on the treatment of complicated SAM across sub-Saharan Africa. Information on the national and hospital guidelines for the treatment of complicated SAM is also collected. Results results of this study will serve as a useful resource on the true reflection of the treatment of complicated SAM across sub-Saharan Africa and will provide valuable information for optimising SAM treatment. Conclusion in order to advocate best practice and reduce SAM-related mortality in sub-Saharan Africa, the identification of the different diagnostic and treatment methods and respective outcomes across different hospitals and countries is imperative.

MSc (Dietetics), North-West University, Potchefstroom Campus Background: Complicated severe acute malnutrition (SAM) in children under 59 months demonstrates an increase on a country’s economic burden and higher child mortality rates. Despite focussed efforts, 17 million children remain affected by SAM, with a quarter of them residing in Africa. High in-patient mortalities up to 46% have been reported within sub-Sahara Africa. Very few studies have verified the efficacy of the current World Health Organization (WHO) in-patient hospital admission and transfer criteria against clinical outcomes such as recovery, hospital stay (LOS) and mortality. In Botswana, the updated WHO SAM management guidelines have been taken into consideration when drafting the more recent ‘integrated management of acute malnutrition and underweight in children and adolescents (IMAMU)’ guidelines. However, since these guidelines are still in draft format, the current WHO admission and transfer criteria serve only as a reference. Furthermore, the association between the admission and transfer criteria with clinical outcomes are yet to be established. The aim of this study was to determine the association between SAM in-patient admission and transfer criteria and clinical outcomes of children aged 0 - 59 months in Botswana. Objectives: To achieve the study aim, the following objectives were set: to describe basic demographic profiles of those represented on the data extraction forms, to describe admission and transfer criteria, to describe basic clinical outcomes (recovery, LOS and mortality) and to identify associations between admission and transfer criteria and clinical outcomes. Methods: Data was extracted from medical records of children aged 0 – 59 months admitted for the in-patient treatment of SAM in a referral hospital from January 2013 - May 2018. Data extracted included demographic and anthropometric profiles and clinical presentations on both admission and transfer. Data were analysed using SAS version 9.4. and logistic regressions were conducted to test for associations between admission and transfer criteria and clinical outcomes (LOS, weight gain and mortality). Results: All available, relevant files in the hospital were idendified. A total of 101 medical records were included in the study. Admission and transfer practices observed were not in line with the current WHO recommendations. Weight-for-height z-scores (WHZ) were measured in 54% of children at admission and in none on transfer. The mid-upper-arm-circumference (MUAC) was poorly measured. Only 17% and 1% of children had a MUAC measurement at admission and transfer respectively. Results revealed a LOS of 17 days, average daily weight gain of 5.4 g/kg/day, and a mortality rate of 28%. Oedema at admission was associated with an increased risk of mortality (P = 0.045). Neither a WHZ < -3 SD or a MUAC ≤ 115 mm at admission or transfer had any associations on the LOS (P = 0.998 and P = 0.906), weight gain (P = 0.914 and P = 0.218) and mortality (P = 0.377 and P = 0.265) respectively. Conclusion: Adherence to the recommended WHO admission and transfer criteria was poorly conducted. Daily weight gain and mortality were below and above the acceptable global SPHERE levels respectively. Oedema on admission was associated with an increased risk of mortality. The lack of association between other admission and transfer criteria and clinical outcomes of interest could have been due to the poor compliance of anthropometric measures. Masters

MSc (Nutrition), North-West University, Potchefstroom Campus The high prevalence of undernutrition in infants and children under five years remains a global problem. Undernutrition and micronutrient deficiencies are responsible for over 3.1 million deaths annually. Several reports have shown the great progress in the reduction of under-five mortality(u5M) due to improved in-patient management of children with severe acute malnutrition (SAM) globally. Sub-Saharan Africa (SSA) was, though, reported as one of the regions with an insufficient decrease in u5M. Inadequate health workforce has been identified as a core factor contributing to u5M and thus more research are needed. This sub-study aimed to determine the association between the health workers involved in hospital management of SAM and treatment outcomes. Methods: In this retrospective study, data were collected from the medical records of children aged 0-59 months, admitted with SAM at Konfo Anokye Teaching Hospital (KATH), Tamale Teaching Hospital (TTH) and Princess Marie Louise (PML) between January 2013 and July 2018.Based on the medical records, the clinical conditions and nutritional status were assessed at admission. The identified clinical signs and medical conditions were reported according to the assessment of health workers, of whom included dieticians, general practitioners (GP), house officers, nutrition officers and paediatricians. At discharge, the treatment outcomes including length of stay (LOS), weight-gain and resolution of infections were evaluated in relation to the type of health workers who cared for the patient. Continuous variables were described with median and interquartile range and categorical data with frequencies and percentages. SAS software version 9.4 was used for statistical analysis. Results Five hundred and ninety-six medical records of infants and children between the ages of 0 to 59 months admitted to three hospitals for the treatment of SAM were included; 304 were boys and 292 were girls. SAM was higher amongst the children aged 12 to 24 months (n=226, 38%) followed by 6 to 12 months (n=169, 28%), and lower in older children aged 36 to 48 months and 48 to 59 months (n=24, 4% and n=14, 2% respectively). The children presented with malaria, HIV, tuberculosis (TB), gastroenteritis, diarrhoea, respiratory infection, meningitis, urinary tract infection and/ or oedema at admission; 51% of the children had diarrhoea. Comorbidities were higher amongst the children aged 12 to 24 months. Starter feeds were mainly prescribed by the nutrition officers (37%) and the house officers (36%) across the hospitals. Transition feeds were mostly prescribed by nutrition officers at TTH, by dieticians at PML and by house officers and nutrition officers at KATH. At all the hospitals, micronutrients and medication were mostly prescribed by house officers. Health worker who prescribed the transition feed, electrolytes and micronutrients were not reported in 166, 347 and 279 children respectively. Discharge rate was 80% and mortality was 17%; and was higher in children aged 12 to 24 months (31% and 7% respectively). Seventy percent had a good appetite and 44% had their infections resolved. Median weight-gain was 6.25 g/kg/day and median LOS was 10 days.The data from three Ghanaian referral hospitals alone was not sufficient to address the association between the health workers and clinical outcomes because of a large number of missing data and a large possibility of reverse association. Conclusion and recommendation There was considerable heterogeneity in service delivery between the three hospitals. However, most of the children admitted with SAM across the hospital were attended to by nutrition officers and house officers. Therapeutic feeding including starter feeds and transition feeds were mainly prescribed by dieticians, nutrition officers and house officers at PML, TTH and KATH respectively, and medication was mainly prescribed by house officers across all the hospital. There was a high possibility of reverse association because more skilled health workers such as paediatricians were likely attended to more severe children.The high mortality rate in this study highlights a need for further health facilities' research on factors that contributed to the results of this study including the challenges hindering the health workers to provide services according to their scope of practice, and the reasons behind the premature discharge of children treated for SAM at hospitals. It also emphasises an urgent requirement for the Ghanaian health facilities to prioritise on implementing the new WHO guidelines for the treatment of SAM in order to improve the treatment outcomes. This study, furthermore, recommends the future studies to use a large sample size when investigating the association between types of health workers involved in SAM treatment at hospitals and clinical outcomes of SAM. Masters

MSc (Dietetics), North-West University, Potchefstroom Campus Introduction: Severe acute malnutrition (SAM) affects more than 50 million children worldwide of which more than a quarter resides in Africa. A patient presenting with indices of SAM who experiences medical complications requires admission to in-patient treatment as their mortality risk is increased by almost 12 times in comparison to non-wasted children. Thus, the World Health Organisation (WHO) developed a guideline for the treatment of in-patients, which includes the criteria for admission and transfer of SAM patients. SAM is diagnosed in children aged 6 - 59 months as a weight-for-length/height (WLZ/WHZ) below the -3 standard deviation (SD) of the WHO child growth standards or a mid-upper arm circumference (MUAC) of less than 115mm and/or the presence of bilateral pitting oedema. The transfer from in-patient to community-based management is not recommended to be based on anthropometric assessments, but rather on clinical improvement. The WHO guideline is however based on low or very low-quality evidence, as research remains limited. The WHO identified the admission- and transfer criteria as an area that requires significant evaluation to improve clinical outcomes, especially in different age groups. Further, the implementation of the criterion used to diagnose and transfer Ghanaian patients remains, as yet, unknown. It is envisaged that this study will contribute to a better understanding of the clinical practices in terms of whether Ghanaian children are admitted early enough and transferred timeously to Community-based Management of Acute Malnutrition (CMAM). Methods: Secondary data of the Severe Acute Malnutrition in African Children (SAMAC) larger study was used for this mini-dissertation. The SAMAC study is a multi-country, multi-hospital study which is based on a retrospective case-control design, and data are collected from medical records only. Data collection for the purpose of this sub-study took place at three referral hospitals in Ghana and included records of children aged 24 - 59 months, admitted for SAM between January 2013 and June 2018. Data was captured into Microsoft Access and analysed using version 9.4 of Statistical Analysis System (SAS). Results: Medical records of 135 children aged 24 - 59 months were included for analysis. The age group 24 — 35 months presented 70% of the study sample. Tamale Teaching Hospital (TTH) had almost three times the amount of admissions compared to Komfo Anokye Teaching Hospital (KATH) and Princess Marie Louise (PML) Children's Hospital. Weight is the most reported anthropometry measurement on admission. The results will also be discussed as per hospital. Considering the indices of SAM, MUAC were reported in 48% (n=65) of medical records (median = 110mm and interquartile range (IQR): 103.0; 120.0), while WHZ was reported in 12.5% (n=17) of medical records with a median of -4.14 (IQR: -5.37; -2.53). Visible signs of emaciation and oedema occurred in 56% and 46% of patients, respectively. The median length of hospital stay (LOS) was 11 days with an IQR between 8 and 18, while a median weight gain of 0.03kg (IQR: -0.02; 0.08) was observed. Seventy-five percent (n=103) of patients were discharged from in-patient treatment, while 1% (n=2) were referred to CMAM. A 19% (n=25) mortality rate was observed of which TTH had the highest rate (24%; n=21). Discussion: The occurrence of malnutrition differs from region to region in Ghana as TTH remains burden with higher malnutrition rates than KATH and PML. The majority of MUAC and WHZ were unreported at admission, while visible signs of emaciation remain the diagnostic criteria for diagnosis of SAM. The high percentage of oedema occurring, as well as the low MUAC and WHZ values on admission indicates the severity of SAM within our study sample. No other association could be found between anthropometric measurements on admission and clinical outcomes. Since no readmissions occurred, associations between transfer criteria and clinical outcomes could not be evaluated. Conclusion: The practice for admitting a SAM patient is not occurring as per WHO protocol. Further research is thus required to understand poor compliance of these guidelines in Ghanaian hospitals. Furthermore, more focus is required on CMAM to ensure children are admitted early enough to prevent complications, as well as transferred for follow-up treatment. Masters

ObjectiveTo determine undernutrition prevalence in 0–59-month-old children and its determinants during the period 2000–2015 in sub-Saharan Africa.DesignEcological study of time series prevalence of undernutrition in sub-Saharan Africa assessed from 2000 to 2015.SettingUnderweight and stunting prevalence from the World Bank database (2000–2015) were analysed. Mixed models were used to estimate prevalence of underweight and stunting. Country-specific undernutrition prevalence variation was estimated and region comparisons were performed. A meta-regression model considering health and socio-economic characteristics at country level was used to explore and estimate the contribution of different undernutrition determinants.ParticipantsCountries of sub-Saharan Africa.ResultsDuring 2000–2015, underweight prevalence in sub-Saharan Africa was heterogeneous, ranging between 7 and 40 %. On the other hand, stunting prevalence ranged between 20 and 60 %. In general, higher rates of underweight and stunting were estimated in Niger (40 %) and Burundi (58 %), respectively; while lowest rates of underweight and stunting were estimated in Swaziland (7 %) and Gabon (21 %). About 1 % undernutrition prevalence reduction per year was estimated across sub-Saharan Africa, which was not statistically significant for all countries. Health and socio-economic determinants were identified as main determinants of underweight and stunting prevalence variability in sub-Saharan Africa.ConclusionsUndernutrition represents a major public health threat in sub-Saharan Africa and its prevalence reduction during the period 2000–2015 was inconsistent. Improving water accessibility and number of medical doctors along with reducing HIV prevalence and poverty could significantly reduce undernutrition prevalence in sub-Saharan Africa

MSc (Dietetics), North-West University, Potchefstroom Campus INTRODUCTION: Worldwide, severe acute malnutrition (SAM) is an important risk factor for morbidity and mortality, contributing to more than half of deaths in children under-five years. Inasmuch as the World Health Organization (WHO) has provided diagnostic criteria to be used for admitting into inpatient care for the management of SAM in children aged 6 - 59 months, these are not based on strong evidence. Furthermore, there are limited studies on the relationships of WHO admission and transfer criteria in relation to clinical outcomes, such as mortality rate, length of stay (LOS) in the hospital and daily weight gain in children aged 6 - 59 months with SAM when categorised into different age groups. This study was therefore undertaken to determine the associations of admission diagnostic and transfer criteria with clinical outcomes of infants aged 6 - 23 months diagnosed with SAM, admitted, treated and subsequently discharged. METHODS: A collection of already existing data was carried out at three referral hospitals in Ghana namely the Komfo Anokye Teaching Hospital, the Princess Marie Louis Children's Hospital and the Tamale Teaching Hospital. The medical records of 399 infants aged 6 - 23 months who were diagnosed with SAM, admitted, treated and subsequently discharged at the three study sites between January 2013 and June 2018 were included in the final analysis. Data on demographic, anthropometric, clinical signs and complications, recovery, LOS in the hospital and death were collected. Anthropometric and clinical characteristics on admission were assessed in relation to mortality, daily weight gain, admission z-scores and improvement in mid-upper arm circumference (MUAC). Data was analysed using SAS version 9.4 and linear regression analysis was used to determine the association between admission characteristics and the clinical outcomes. RESULTS: At admission, 89.1% (n = 229) had a weight-for-age z-score (WAZ) < -3 standard deviation (SD), 81.4% (n = 131) had a MUAC < 115 mm, 83.2% (n = 79) had a weight-for-length z-score (WLZ) < -3 SD, 34.8% (n = 69) had oedema and 6.5% (n = 26) had MUAC < 115 mm complicated by oedema. Among infants with clinical signs, complications or co-morbidities, 51% (n = 208) presented with diarrhoea; 51% (n = 203) presented with vomiting while 8% (n = 33) tested positive for HIV. Overall, 15.8% (n = 63) of the infants died with 65.1% (n = 41) of the deaths occurring within 92 hours of admission. The median LOS in the hospital and weight gain was 11 days (Interquartile range (IQR): 7, 17) and 6.8 g/kg/day (IQR: 0.8, 11.8), respectively. With the exception of admission WLZ, a non-statistically significant difference was observed between admission anthropometric criteria in infants who died compared to those who survived. Infants with a WAZ < -3 SD had 5.05 (95% Cl: 1.80, 14.17; p = 0.002) higher odds of weight gain of > 10 g/kg/day than those with a WAZ ≥ -3 SD. Infants with an admission MUAC < 115 mm had 4.64 (95% Cl: 1.64, 13.12; p = 0.02) higher odds of being hospitalised for more than 7 days when compared to those with a MUAC ≥ 115 mm. Infants with convulsions and shock at admission had 6.76 (95% CI: 2.57, 17.83; p = 0.0001) and 5.18 (95% CI: 1.49, 18.08; p = 0.01) higher odds of mortality than those without convulsion and shock, respectively. The odds of mortality for infants with HIV infection was 4.04 (95% CI: 1.86, 8.81; p = 0.0004) while that for those with dermatitis was 3.46 (95% CI: 1.77, 6.75; p = 0.0003). CONCLUSIONS AND RECOMMENDATIONS: There was a statistically significant difference between admission WLZ for infants who died and those who survived but it was not statistically significantly associated with death in infants aged 6 - 23 months. Although non-statistically significant, it was observed that, infants with MUAC < 115 mm at admission were two times more likely to die compared to those with a MUAC < 115 mm at admission. With the exception of recovery rate (defined as resolution of oedema) and LOS in the hospital, mortality and daily weight gain were observed to be outside the minimum range recommended by Sphere for the inpatient management of SAM. Therefore, it is recommended that the Ministry of Health in collaboration with Ghana Health Service (GHS) should try and improve the diagnostic skills of health workers/clinicians in the area of SAM by incorporating weight, height and MUAC measurements into paediatric clinics as well as the provision of appropriate child growth standard charts. There is also the need to update clinicians in the recognition and management of SAM, especially children with SAM who present with complications and co-morbidities such as convulsions, shock and HIV infection for better treatment outcomes. Masters

The following case study was discussed during the fourth-year dietetics evaluation process at North-West University, Potchefstroom Campus. It is a reflection of the opinion of the dietitians, students and lecturers involved, describes the actions taken during the nutritional management of the case, and is based on current literature and guidelines relevant to the topic.