Background - The first 1000 days of life (from conception to two years of age) is a critical period of nutritional vulnerability, affecting lifelong health. Iron deficiency (ID) and iron deficiency anaemia (IDA) are considered major public health problems that adversely affect development and growth, impair immunity, and increase morbidity and mortality in infants. ID and IDA in sub-Saharan Africa can be attributed to poor dietary, socioeconomic and disease conditions. One of the major obstacles in determining the prevalence of ID, using serum ferritin (SF) as marker of iron status, is that it not only reflects the amount of iron that is stored in the body, but also functions as an acute phase reactant that is raised in the presence of infection or inflammation. Aim - We conducted a re-analysis of the International Research on Infant Supplementation (IRIS) study’s baseline data to determine a more accurate estimation of the ID prevalence in apparently healthy four to thirteen-month-old infants from rural KwaZulu-Natal while accounting for the effect of chronic and acute inflammation on SF. Study design and methods - A cross-sectional analysis was performed on the baseline data (192 infants) of the IRIS study that was conducted in 2000. Infants’ haemoglobin (Hb), SF, C-reactive protein (CRP) and alpha-1 glycoprotein (AGP) concentrations were interpreted to determine the prevalence of ID. Literature of the past four years served as a guide to compare the ID prevalence obtained from four methods that account for the influence of inflammation on SF concentrations, to a reference method that does not take inflammation into consideration, and to what was reported in the original IRIS study. Weight and recumbent length measurements were converted to z-scores to interpret subjects’ anthropometric nutritional status. Results - A high prevalence of inflammation (52.6%) was present, with 11.5% of the subjects being in the incubation, 17.2% in the early convalescent, and 24% in the late convalescent phase of inflammation. SF was significantly associated with both CRP (ß = 0.200; P = 0.005) and AGP (ß = 0.223; P = 0.002) when adjusting for gender and age. The IRIS study reported an ID prevalence of 18.3%, whereas the results of this study ranged from 17.2 to 52.1%. We derived an IDA prevalence that ranged from 12 to 24.5% according to the different methods. The prevalence of stunting [length-for-age Z-score <-2SD] was 12.5%; while 25.1% of infants were overweight/obese [weight-for-length z-score >2SD]. Conclusion - A double burden of malnutrition was evident from the high prevalence of both overweight and ID, together with inflammation. The disconcertingly large variance in ID prevalence observed between the different methods that were employed highlights that iron supplementation interventions to treat anaemia must be based upon accurate estimates of IDA prevalence, otherwise they pose an increased risk of adverse effects to susceptible, iron-replete, but anaemic infants. Given the detrimental consequences of ID, it is imperative that governments, health care providers and parents must act to prevent or treat ID and IDA among vulnerable infants. / MSc (Dietetics), North-West University, Potchefstroom Campus, 2014

Background - The first 1000 days of life (from conception to two years of age) is a critical period of nutritional vulnerability, affecting lifelong health. Iron deficiency (ID) and iron deficiency anaemia (IDA) are considered major public health problems that adversely affect development and growth, impair immunity, and increase morbidity and mortality in infants. ID and IDA in sub-Saharan Africa can be attributed to poor dietary, socioeconomic and disease conditions. One of the major obstacles in determining the prevalence of ID, using serum ferritin (SF) as marker of iron status, is that it not only reflects the amount of iron that is stored in the body, but also functions as an acute phase reactant that is raised in the presence of infection or inflammation. Aim - We conducted a re-analysis of the International Research on Infant Supplementation (IRIS) study’s baseline data to determine a more accurate estimation of the ID prevalence in apparently healthy four to thirteen-month-old infants from rural KwaZulu-Natal while accounting for the effect of chronic and acute inflammation on SF. Study design and methods - A cross-sectional analysis was performed on the baseline data (192 infants) of the IRIS study that was conducted in 2000. Infants’ haemoglobin (Hb), SF, C-reactive protein (CRP) and alpha-1 glycoprotein (AGP) concentrations were interpreted to determine the prevalence of ID. Literature of the past four years served as a guide to compare the ID prevalence obtained from four methods that account for the influence of inflammation on SF concentrations, to a reference method that does not take inflammation into consideration, and to what was reported in the original IRIS study. Weight and recumbent length measurements were converted to z-scores to interpret subjects’ anthropometric nutritional status. Results - A high prevalence of inflammation (52.6%) was present, with 11.5% of the subjects being in the incubation, 17.2% in the early convalescent, and 24% in the late convalescent phase of inflammation. SF was significantly associated with both CRP (ß = 0.200; P = 0.005) and AGP (ß = 0.223; P = 0.002) when adjusting for gender and age. The IRIS study reported an ID prevalence of 18.3%, whereas the results of this study ranged from 17.2 to 52.1%. We derived an IDA prevalence that ranged from 12 to 24.5% according to the different methods. The prevalence of stunting [length-for-age Z-score <-2SD] was 12.5%; while 25.1% of infants were overweight/obese [weight-for-length z-score >2SD]. Conclusion - A double burden of malnutrition was evident from the high prevalence of both overweight and ID, together with inflammation. The disconcertingly large variance in ID prevalence observed between the different methods that were employed highlights that iron supplementation interventions to treat anaemia must be based upon accurate estimates of IDA prevalence, otherwise they pose an increased risk of adverse effects to susceptible, iron-replete, but anaemic infants. Given the detrimental consequences of ID, it is imperative that governments, health care providers and parents must act to prevent or treat ID and IDA among vulnerable infants. / MSc (Dietetics), North-West University, Potchefstroom Campus, 2014

Background: Fibulin-1, an extracellular matrix component and mediator in cardiac fibrosis, is expressed in cardiac valves, heart muscles and blood vessels and may contribute to different cardiovascular pathological conditions such as hypertension, aortic valve stenosis, atrial fibrillation and coronary artery disease. The most conspicuous functions of fibulin-1 include cell adhesion and cell migration within the extracellular matrix (ECM). This was found to reflect vascular dysfunction contributing to the development of fibrosis in the myocardium by means of changes in the ECM, possibly as a result of inflammation. Inflammatory mediators such as C-reactive protein (CRP) and albumin have been investigated over the years for the role they play in the inflammatory processes. However, one inflammatory mediator, soluble urokinase-type plasminogen activator receptor (suPAR), only emerged as a potential biomarker in the development of sclerotic disease. SuPAR is a soluble bioactive form of the urokinase-type plasminogen activator receptor (uPAR) secreted by inflammatory cells such as macrophages, endothelial cells and monocytes. The most profound functions of suPAR such as cell migration and cell adhesion contribute to the development of diseases such as infection, autoimmune diseases, cancer and atherosclerosis. Motivation and aim: This study was motivated by an awareness of the limited data on the potential link between fibulin-1 and suPAR, along with other markers of inflammation (CRP and albumin). We aimed to compare the levels of a marker of cardiac fibrosis (fibulin-1) and inflammatory mediators (suPAR, CRP and albumin) in African and Caucasian men and women. A second aim was to explore fibulin-1 and its potential association with these inflammatory markers independent of haemodynamic and metabolic risk factors in a bi-ethnic cohort from South Africa. Methodology: Data from the cross-sectional SAfrEIC study (South African study regarding the role of Sex, Age and Ethnicity on Insulin sensitivity and Cardiovascular function) were used, which initially included 756 participants. Our study population comprised 290 Africans (men: n=130; women: n=160) and 343 Caucasians (men: n=160; women: n=183). We excluded HIV-infected participants (n=115) as well as those with missing data (n=8). Traditional cardiovascular measurements together with the relevant biochemical analyses were done. T-tests and Chi-square tests were used to compare means and proportions between groups, respectively. Single and partial correlations were performed to determine the relationship of fibulin-1 with suPAR, CRP and albumin, with adjustments for age. SuPAR, CRP and albumin were divided into tertiles to explore the association with fibulin-1 levels, while adjusting for age, body mass index (BMI) and diastolic blood pressure (DBP) by using analysis of covariance (ANCOVA). Multiple regression analysis was performed to explore independent associations. Results: Participants were divided into African and Caucasian men and women due to significant interactions of the main effects of ethnicity and gender on the association of fibulin-1 with suPAR (ethnicity: F(633)=7.29; p<0.001 and gender: F(633)=7.99; p<0.001). Fibulin-1 levels were higher in African men (p=0.010), whereas CRP was higher in African women (p<0.001) compared to their Caucasian counterparts. In both gender groups suPAR levels were higher and albumin lower in Africans compared to Caucasians (p<0.006). In single regression analyses, a positive correlation existed between fibulin-1 and suPAR in African (r=0.19; p=0.028) and Caucasian men (r=0.37; p<0.001), also in African (r=0.193; p=0.028) and Caucasian women (r=0.14; p=0.036). After adjustments were applied for age, this correlation remained in African (r=0.23; p=0.010) and Caucasian men (r=0.22; p=0.005) only. An inverse correlation was found between fibulin-1 and albumin in African men (r=-0.28; p=0.002), but not in Caucasian men (r=-0.09; p=0.245). No significant correlation was found between fibulin-1 and CRP in any group. Forward stepwise regression analysis was performed in men and the previous associations between fibulin-1 and suPAR were confirmed in African and Caucasian men; along with the inverse relationship of fibulin-1 with albumin (Adj. R2=0.217; β=–0.210; p=0.013) in African men only. Conclusion: Fibulin-1 was positively associated with suPAR in African and Caucasian men, but not in women. We also found fibulin-1 to be negatively associated with albumin in African men only. These results are indicative of the presence of potential subclinical low-grade inflammation as depicted by suPAR within the extracellular matrix. This low-grade inflammation may contribute to the potential onset of cardiac fibrosis or vascular sclerosis among these South African men with lower albumin levels. / MSc (Physiology), North-West University, Potchefstroom Campus, 2014

Background: Fibulin-1, an extracellular matrix component and mediator in cardiac fibrosis, is expressed in cardiac valves, heart muscles and blood vessels and may contribute to different cardiovascular pathological conditions such as hypertension, aortic valve stenosis, atrial fibrillation and coronary artery disease. The most conspicuous functions of fibulin-1 include cell adhesion and cell migration within the extracellular matrix (ECM). This was found to reflect vascular dysfunction contributing to the development of fibrosis in the myocardium by means of changes in the ECM, possibly as a result of inflammation. Inflammatory mediators such as C-reactive protein (CRP) and albumin have been investigated over the years for the role they play in the inflammatory processes. However, one inflammatory mediator, soluble urokinase-type plasminogen activator receptor (suPAR), only emerged as a potential biomarker in the development of sclerotic disease. SuPAR is a soluble bioactive form of the urokinase-type plasminogen activator receptor (uPAR) secreted by inflammatory cells such as macrophages, endothelial cells and monocytes. The most profound functions of suPAR such as cell migration and cell adhesion contribute to the development of diseases such as infection, autoimmune diseases, cancer and atherosclerosis. Motivation and aim: This study was motivated by an awareness of the limited data on the potential link between fibulin-1 and suPAR, along with other markers of inflammation (CRP and albumin). We aimed to compare the levels of a marker of cardiac fibrosis (fibulin-1) and inflammatory mediators (suPAR, CRP and albumin) in African and Caucasian men and women. A second aim was to explore fibulin-1 and its potential association with these inflammatory markers independent of haemodynamic and metabolic risk factors in a bi-ethnic cohort from South Africa. Methodology: Data from the cross-sectional SAfrEIC study (South African study regarding the role of Sex, Age and Ethnicity on Insulin sensitivity and Cardiovascular function) were used, which initially included 756 participants. Our study population comprised 290 Africans (men: n=130; women: n=160) and 343 Caucasians (men: n=160; women: n=183). We excluded HIV-infected participants (n=115) as well as those with missing data (n=8). Traditional cardiovascular measurements together with the relevant biochemical analyses were done. T-tests and Chi-square tests were used to compare means and proportions between groups, respectively. Single and partial correlations were performed to determine the relationship of fibulin-1 with suPAR, CRP and albumin, with adjustments for age. SuPAR, CRP and albumin were divided into tertiles to explore the association with fibulin-1 levels, while adjusting for age, body mass index (BMI) and diastolic blood pressure (DBP) by using analysis of covariance (ANCOVA). Multiple regression analysis was performed to explore independent associations. Results: Participants were divided into African and Caucasian men and women due to significant interactions of the main effects of ethnicity and gender on the association of fibulin-1 with suPAR (ethnicity: F(633)=7.29; p<0.001 and gender: F(633)=7.99; p<0.001). Fibulin-1 levels were higher in African men (p=0.010), whereas CRP was higher in African women (p<0.001) compared to their Caucasian counterparts. In both gender groups suPAR levels were higher and albumin lower in Africans compared to Caucasians (p<0.006). In single regression analyses, a positive correlation existed between fibulin-1 and suPAR in African (r=0.19; p=0.028) and Caucasian men (r=0.37; p<0.001), also in African (r=0.193; p=0.028) and Caucasian women (r=0.14; p=0.036). After adjustments were applied for age, this correlation remained in African (r=0.23; p=0.010) and Caucasian men (r=0.22; p=0.005) only. An inverse correlation was found between fibulin-1 and albumin in African men (r=-0.28; p=0.002), but not in Caucasian men (r=-0.09; p=0.245). No significant correlation was found between fibulin-1 and CRP in any group. Forward stepwise regression analysis was performed in men and the previous associations between fibulin-1 and suPAR were confirmed in African and Caucasian men; along with the inverse relationship of fibulin-1 with albumin (Adj. R2=0.217; β=–0.210; p=0.013) in African men only. Conclusion: Fibulin-1 was positively associated with suPAR in African and Caucasian men, but not in women. We also found fibulin-1 to be negatively associated with albumin in African men only. These results are indicative of the presence of potential subclinical low-grade inflammation as depicted by suPAR within the extracellular matrix. This low-grade inflammation may contribute to the potential onset of cardiac fibrosis or vascular sclerosis among these South African men with lower albumin levels. / MSc (Physiology), North-West University, Potchefstroom Campus, 2014