Maternal nutrition during pregnancy and its association with birth outcomes and neonatal body composition in the context of HIV in urban Black South Africans

A thesis submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in the fulfillment of the requirements for the degree of Doctor of Philosophy Johannesburg, South Africa 2018.Background: Maternal pre-pregnancy overweight and obesity and excessive gestational weight gain (GWG) are established predictors of fetal growth, which substantially increase the risk of adverse birth outcomes, such as high birth weight and large-for-gestational age deliveries. While sub-optimal growth in utero has serious implications for infant health in the short term, nutritional insults during this critical period of plasticity may additionally impair growth and development of body tissues and thereby, increase long-term risk of obesity and non-communicable diseases in later life. This double burden of malnutrition (maternal overweight coupled with micronutrient deficiencies) is of particular relevance to low-or middle-income countries, such as South Africa, where rapid urbanisation and a transition towards diets high in saturated fat, sugar, salt and processed foods and decreased levels of physical activity has resulted in substantial increases in obesity. Although the implications of anthropometrically defined maternal nutritional status (MNS) on birth size have been well established, the role of dietary patterns within these relationships has not been thoroughly examined. In addition, the use of birth weight as a proxy for fetal growth does not distinguish between the components of body composition (i.e. fat mass and fat-free mass), which may be more indicative of metabolic risk. Lastly, the influence of other maternal factors such as human immunodeficiency virus (HIV) on the associations between maternal nutrition and infant outcomes and metabolic risk is yet to be explored. Aim: The overall aim of this thesis was to examine maternal nutrition (nutritional status; dietary patterns) of urban, black South African women and explore the relationship between maternal dietary patterns during pregnancy and birth outcomes (including neonatal body composition). Furthermore, the extent to which other maternal factors – i.e. HIV/antiretroviral treatment (ART) status, body mass index (BMI) at recruitment, GWG, demographics, socioeconomic status etc. - act as confounders or effect modifiers to these associations was explored. The following four specific study components addressed this aim: 1) To review and report on MNS in African women and its associations with fetal, birth, neonatal and infant outcomes in the first 1000 days; 2) to compare body composition measurements using two methods, namely (i) dual-energy x-ray absorptiometry (DXA) and (ii) air displacement plethysmography (ADP; Peapod), in black South African neonates; 3) to characterise, depict and report on maternal dietary patterns during pregnancy using multivariate dimension-reduction techniques in urban black South African women and to examine the association between dietary patterns and GWG in the context of other maternal lifestyle and socioeconomic factors; and 4) to examine the associations between maternal dietary patterns and birth size and neonatal body composition and explore how specific maternal factors – i.e. HIV/ART status, maternal BMI and GWG – may influence these associations. Methods: Comprehensive literature searches were independently performed by two researchers in May 2015 in order to identify all relevant studies conducted in Africa. The review used a systematic approach to search the following databases: Medline, EMBASE, Web of Science, Google Scholar, ScienceDirect, SciSearch and Cochrane Library. Full-text articles were obtained and reviewed and data were extracted from relevant publications into tables appropriately. Within a wider longitudinal cohort study taking place in Soweto, Johannesburg (the Soweto First 1000-Day Study; S1000), habitual dietary intake of 538 pregnant women was assessed using a quantitative food-frequency questionnaire and dietary patterns were depicted via principal component analysis. Associations between dietary patterns and BMI-specific GWG were analysed using linear and multinomial logistic regression. ―Traditional‖ diet pattern adherence (pattern score) was used to classify maternal diet for the final study objective (objective 4) and multiple linear regression models were used to examine associations between maternal ―traditional‖ diet pattern score, HIV/treatment status [three groups: HIV negative, HIV positive (antenatal ART initiation), HIV positive (pre-pregnancy ART initiation)], BMI and GWG (kg/week) and: newborn (1) weight-to-length ratio (WLR, kg/m) in 393 mother-neonate pairs; (2) Peapod estimated fat mass index (FMI, kg/m3) in a 171-pair subsample. Results: Twenty-six studies met the inclusion criteria for the literature review (objective 1). Overall, MNS in Africa showed features typical of the epidemiological transition; including higher overweight and obesity and lower underweight prevalences, alongside high anaemia prevalences’ and poor-quality diets. Maternal BMI and GWG were positively associated with birth weight; however, maternal overweight and obesity were associated with both increased macrosomia (birth weight >4kgs) and intrauterine growth restriction risk. In addition, maternal anaemia was associated with lower birth weight and both macro- and micronutrient supplementation during pregnancy was associated with improvements in GWG, birth weight and mortality risk. During the comparison of body composition assessment techniques (objective 2), significant correlations were observed between ADP and DXA measurements of fat mass (r = 0.766; p<0.001), fat-free mass (r = 0.942; p<0.001) and %fat (r = 0.630; p<0.001). However, fat mass (408 ± 172 g vs. 337 ± 165 g; p<0.001) and body fat percentage (12.9 ± 4.4% vs. 9.9 ± 4%; p<0.001) were significantly higher and fat-free mass (2681 ± 348 g vs. 2969 ± 375 g; p<0.001) significantly lower when estimated by ADP than by DXA. There was greater consistency in the estimation of fat-free mass between the methods when compared to estimates of fat mass and body fat percentage. Longitudinal assessment (objectives 3 and 4) identified three dietary patterns in urban black South African women during pregnancy: namely ―western‖, ―traditional‖ and ―mixed‖. ―Western‖ and ―mixed‖ diet patterns were associated with 35 g/week (p=0.021) and 24 g/week (p=0.041) higher GWG in normal weight and obese women respectively. High intakes of the ―traditional‖ diet pattern were associated with a reduced odds of excessive weight gain in the total sample (OR: 0.81; p=0.006) and in normal weight women (OR: 0.68; p=0.003). In the final, fully adjusted study models, maternal obesity and GWG were associated with 0.25 kg/m (P=0.008) and 0.48 kg/m (P=0.002) higher newborn WLR, while ―traditional‖ diet pattern score was associated with lower newborn WLR (-0.04 per +1 SD; P=0.033). Additionally, ―traditional‖ pattern score was associated with 0.13 kg/m3 (P=0.027) and 0.32 kg/m3 (P=0.005) lower FMI in the total sample and in newborns of normal weight women, respectively. HIV positive (pre-pregnancy ART) vs. HIV negative (ref) status was associated with 1.11 kg/m3 (P=0.002) higher newborn FMI in a fully adjusted model. Conclusion: This thesis confirms the rapid transition in MNS across urban African populations and demonstrates the implications that the rise in maternal overweight and obesity alongside poor dietary patterns and micronutrient deficiencies may have on birth outcomes, as well as potentially on longer term health trajectories. However, it also highlights a lack of data on infant outcomes beyond birth, and therefore, a need for longitudinal data that examines longer-term implications in the African setting. In South Africa in particular, the thesis indicates that promotion of a traditional-style diet pattern - high in whole grains, legumes, vegetables and traditional meats and low in processed foods - alongside a healthy preconception weight in urban, black women would significantly improve both maternal and infant adiposity profiles. This may have substantial benefits in reducing long-term risk of non-communicable diseases in both current and future generations. However, the need for a holistic approach which incorporates other health and lifestyle determinants of growth and adiposity in the infant is critical in optimising metabolic health trajectories. In HIV-positive women for example, development of targeted monitoring and management strategies is necessary in order to limit the treatment-specific effects on adiposity in the newborn.LG201

Nutritional status of school-age children and adolescents in eastern and southern Africa: A scoping review

Aims: This review aims to summarize available literature on the nutritional status of school-age children (SAC) and adolescents aged 5-19 years in Eastern and Southern Africa (ESA) and interventions aiming to tackle malnutrition in this age group. Methods: We searched Pubmed, Cochrane Database of Systematic Reviews, Web of Science, Africa Wide Information, ArticleFirst, Biomed Central, BioOne, BIOSIS, CINAHL, EBSCOHost, JSTOR, ProQuest, Google Scholar, SAGE Reference Online, Scopus, ScienceDirect, SpringerLink, Taylor &amp; Francis, and Wiley Online for articles published between 2005 and 2020 according to eligibility criteria. Results: A total of 129 articles were included, with the majority of studies presenting data from Ethiopia (N = 46) and South Africa (N=38). The prevalence of overweight and obesity ranged between 9.1 – 32.3 % and 0.8 – 21.7 % respectively across countries in ESA. Prevalence of thinness, stunting and underweight ranged as follows: 3.0 – 36.8 %; 6.6 – 57.0 %; 5.8 – 27.1 %. Prevalence of anemia was between 13.0 – 76.9 % across the region. There was a dearth of data on other micronutrient deficiencies. There was limited evidence from intervention studies (N = 6), with half of the interventions targeting anemia or iron deficiency using iron supplementation or fortification methods and reporting no significant effect on anemia prevalence. Interventions targeting stunting and thinness (N = 3) reported beneficial effects of providing vitamin A fortified maize, iron supplementation and nutrition education. Conclusions: A triple burden of malnutrition underlines the need to prioritize implementation of double-duty interventions for SAC and adolescents in ESA. Key data gaps included either limited or a lack of data for the majority of countries, especially on micronutrient deficiencies and a scarcity of intervention studies. Greater investment in nutrition research amongst this population is needed to strengthen the evidence base and inform policies and programs to improve nutritional status amongst SAC and adolescents in ESA

Food insecurity, diet quality and body composition:data from the Healthy Life Trajectories Initiative (HeLTI) pilot survey in urban Soweto, South Africa

Objective: To determine whether food security, diet diversity and diet quality are associated with anthropometric measurements and body composition among women of reproductive age. The association between food security and anaemia prevalence was also tested. Design: Secondary analysis of cross-sectional data from the Healthy Life Trajectories Initiative (HeLTI) study. Food security and dietary data were collected by an interviewer-administered questionnaire. Hb levels were measured using a HemoCue, and anaemia was classified as an altitude-adjusted haemoglobin level &lt; 12·5 g/dl. Body size and composition were assessed using anthropometry and dual-energy x-ray absorptiometry. Setting: The urban township of Soweto, Johannesburg, South Africa. Participants: Non-pregnant women aged 18-25 years (n 1534). Results: Almost half of the women were overweight or obese (44 %), and 9 % were underweight. Almost a third of women were anaemic (30 %). The prevalence rates of anaemia and food insecurity were similar across BMI categories. Food insecure women had the least diverse diets, and food security was negatively associated with diet quality (food security category v. diet quality score: B = -0·35, 95 % CI -0·70, -0·01, P = 0·049). Significant univariate associations were observed between food security and total lean mass. However, there were no associations between food security and body size or composition variables in multivariate models. Conclusions: Our data indicate that food security is an important determinant of diet quality in this urban-poor, highly transitioned setting. Interventions to improve maternal and child nutrition should recognise both food security and the food environment as critical elements within their developmental phases.</p

Examining the relationships between body image, eating attitudes, BMI, and physical activity in rural and urban South African young adult females using structural equation modeling.

The persistence of food insecurity, malnutrition, increasing adiposity, and decreasing physical activity, heightens the need to understand relationships between body image satisfaction, eating attitudes, BMI and physical activity levels in South Africa. Females aged 18-23 years were recruited from rural (n = 509) and urban (n = 510) settings. Body image satisfaction was measured using Stunkard's silhouettes, and the 26-item Eating Attitudes questionnaire (EAT-26) was used to evaluate participants' risk of disordered eating. Minutes per week of moderate to vigorous physical activity (MVPA) was assessed using the Global Physical Activity Questionnaire (GPAQ). Significant linear correlates were included in a series of regressions run separately for urban and rural participants. Structural equation modeling (SEM) was used to test the relationships between variables. Urban females were more likely to be overweight and obese than rural females (p = 0.02), and had a greater desire to be thinner (p = 0.02). In both groups, being overweight or obese was positively associated with a desire to be thinner (p<0.01), and negatively associated with a desire to be fatter (p<0.01). Having a disordered eating attitude was associated with body image dissatisfaction in the urban group (β = 1.27, p<0.01, CI: 0.38; 2.16), but only with a desire to be fatter in the rural group (β = 0.63, p = 0.04, CI: 0.03; 1.23). In the SEM model, body image dissatisfaction was associated with disordered eating (β = 0.63), as well as higher MVPA participation (p<0.01). These factors were directly associated with a decreased risk of disordered eating attitude, and with a decreased desire to be thinner. Findings indicate a shift in both settings towards more Westernised ideals. Physical activity may provide a means to promote a healthy body image, while reducing the risk of disordered eating. Given the high prevalence of overweight and obesity in both rural and urban women, this study provides insights for future interventions aimed at decreasing adiposity in a healthy way

Maternal and early life nutrition and physical activity: setting the research and intervention agenda for addressing the double burden of malnutrition in South African children.

Early life is important for later health outcomes, yet there are few studies which adequately address all of the potential early life insults that may affect later life health and growth trajectories. This is particularly evident in low- to middle-income countries such as South Africa, where women of childbearing age are particularly vulnerable to high levels of physical inactivity, malnutrition, and obesity. Pregnancy may therefore be an opportune time to change behaviours and improve maternal and offspring health outcomes, and decrease the inter-generational transfer of risk. We show clear evidence that physical activity and nutrition are important target areas for intervention during pregnancy and in the early years of life, yet that current literature in Africa, and specifically South Africa, is limited. We have outlined the available literature concerning the impact of maternal and early life nutrition and physical activity on the health status of South African children, and have provided some recommendations for future research and policy

Integrating Women and Girls' Nutrition Services into Health Systems in Low- and Middle-Income Countries: A Systematic Review.

Women's nutrition has been highlighted as a global priority to ensure the health and well-being of both them and future generations. This systematic review summarises the available literature on the integration of nutrition services for girls and women of reproductive age (GWRA) into existing public health systems across low- and middle-income countries, as well as any barriers to integration. We searched PubMed and Cochrane Database of Systematic Reviews for articles published since 2011 according to eligibility criteria. A total of 69 articles were included. Evidence suggested that several services for GWRA are well integrated into public health systems, including antenatal care services, nutrition education and counselling, and micronutrient supplementation programmes. However, there was limited evidence on the integration of family planning, adolescent health, and reproductive health services. Barriers to integration fell into five main themes: lack of training and capacity building, poor multisectoral linkages and coordination, weak advocacy, lack of M&E systems, and inequity. We identified a lack of evidence and services for non-pregnant GWRA and for women postpartum. Addressing barriers to integration and gaps in nutrition services for GWRA would increase service coverage and contribute to improving health outcomes for GWRA and future generations

Nutritional status of school-age children and adolescents in low- and middle-income countries across seven global regions: a synthesis of scoping reviews.

OBJECTIVE: To summarise available evidence on the nutritional status of school-age children and adolescents (5-19 years) from seven global regions, and on interventions implemented to improve malnutrition in this population. DESIGN: Findings were compiled from seven scoping literature reviews, including data from low- and middle-income countries (LMICs) within the following UNICEF-defined global regions: East Asia and Pacific (EAP); Europe and Central Asia (ECA); South Asia (SA); West and Central Africa (WCA); Eastern and Southern Africa (ESA); Middle East and North Africa (MENA); and Latin America and the Caribbean (LAC). RESULTS: A double burden of malnutrition was evident across the world regions reviewed: stunting, thinness, anaemia and other micronutrient deficiencies persisted, alongside rising overweight and obesity prevalence. Transitions towards diets increasingly high in energy-dense, processed and micronutrient-poor foods were observed. Evidence from intervention studies was limited, but suggested that providing multiple micronutrient-fortified foods or beverages at school may effectively target micronutrient deficiencies and facilitate weight gain in undernourished populations. Interventions to prevent or manage overweight and obesity were even more limited. There was minimal evidence of using novel technological approaches to engage school-age children and adolescents, or of involving them in designing interventions. CONCLUSION: The limited data available on nutrition of school-age children and adolescents is neither standardised nor comparable. Consensus on methods for assessing nutritional status and its determinants for this age group is urgently needed to set targets and monitor progress. Additionally, strategies are required to ensure that nutritious, safe and sustainable diets are available, affordable and appealing

Nutritional status of school-age children (5-19 years) in South Asia: A scoping review.

Information on malnutrition for school-age children and adolescents (5-19 years) in South Asia is fragmented and inconsistent, which limits the prioritization of nutrition policies, programmes and research for this age group. This scoping review aimed to synthesize existing evidence on the burden of malnutrition for children and adolescents aged 5-19 years in South Asia, and on interventions to improve their nutritional status. Cochrane Library, EMBASE, Medline and Google Scholar were systematically searched for articles published between January 2016 and November 2022. Eligible studies reported the prevalence of undernutrition, overweight/obesity, micronutrient deficiencies and unhealthy dietary intakes, and interventions that aimed to address these in South Asia. In total, 296 articles met our inclusion criteria. Evidence revealed widespread, yet heterogeneous, prevalence of undernutrition among South Asian children and adolescents: thinness (1.9%-88.8%), wasting (3%-48%), underweight (9.5%-84.4%) and stunting (3.7%-71.7%). A triple burden of malnutrition was evident: the prevalence of overweight and obesity ranged from 0.2% to 73% and 0% to 38% (with rapidly rising trends), respectively, alongside persistent micronutrient deficiencies. Diets often failed to meet nutritional requirements and high levels of fast-food consumption were reported. Education, fortification, supplementation and school feeding programmes demonstrated beneficial effects on nutritional status. Comprehensive and regular monitoring of all forms of malnutrition among children and adolescents, across all countries in South Asia is required. Further, more large-scale intervention research is needed to ensure policy and programmes effectively target and address malnutrition among children and adolescents in South Asia

How age and sex affect treatment outcomes for children with severe malnutrition: A multi-country secondary data analysis

Key messages * There are few differences in recovery outcomes for wasting treatment by age and sex. * Though differences are small, mean daily weight gain (g/kg/day) appears to be significantly lower in boys than girls. Likewise, though differences are small, younger children (6–23 months) often have a significantly longer mean length of stay compared with older children (24–59 months). * The strength of our evidence does not indicate the need to change current inclusion criteria for wasting treatment programmes on the basis of age and sex but does suggest the need for further research to understand the effects of different confounders on treatment outcomes.Data Availability Statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.Supporting Information is available online at: https://onlinelibrary.wiley.com/doi/full/10.1111/mcn.13596#support-information-section .Age and sex influence the risk of childhood wasting. We aimed to determine if wasting treatment outcomes differ by age and sex in children under 5 years, enroled in therapeutic and supplementary feeding programmes. Utilising data from stage 1 of the ComPAS trial, we used logistic regression to assess the association between age, sex and wasting treatment outcomes (recovery, death, default, non-response, and transfer), modelling the likelihood of recovery versus all other outcomes. We used linear regression to calculate differences in mean length of stay (LOS) and mean daily weight gain by age and sex. Data from 6929 children from Kenya, Chad, Yemen and South Sudan was analysed. Girls in therapeutic feeding programmes were less likely to recover than boys (pooled odds ratio [OR]: 0.84, 95% confidence interval [CI]: 0.72–0.97, p = 0.018). This association was statistically significant in Chad (OR: 0.61, 95% CI: 0.39–0.95, p = 0.030) and Yemen (OR: 0.47, 95% CI: 0.27–0.81, p = 0.006), but not in Kenya and South Sudan. Multinomial analysis, however, showed no difference in recovery between sexes. There was no difference between sexes for LOS, but older children (24–59 months) had a shorter mean LOS than younger children (6–23 months). Mean daily weight gain was consistently lower in boys compared with girls. We found few differences in wasting treatment outcomes by sex and age. The results do not indicate a need to change current programme inclusion requirements or treatment protocols on the basis of sex or age, but future research in other settings should continue to investigate the aetiology of differences in recovery and implications for treatment protocols

South Africa's Health Promotion Levy: excise tax findings and equity potential

In 2016, the South African government proposed a 20% sugar-sweetened beverage (SSB) tax. Protracted consultations with beverage manufacturers and the sugar industry followed. This resulted in a lower sugar-based beverage tax, the Health Promotion Levy (HPL), of approximately 10% coming into effect in April 2018. We provide a synthesis of findings until April 2021. Studies show that despite the lower rate, purchases of unhealthy SSBs and sugar intake consumption from SSBs fell. There were greater reductions in SSB purchases among both lower socioeconomic groups and in subpopulations with higher SSB consumption. These subpopulations bear larger burdens from obesity and related diseases, suggesting that this policy improves health equity. The current COVID-19 pandemic has impacted food and nutritional security. Increased pandemic mortality among people with obesity, diabetes, and hypertension highlight the importance of intersectoral public health disease-prevention policies like the HPL, which should be strengthened