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Background The potential dire consequences of iron deficiency (ID) and iron deficiency anaemia (IDA) on childhood development are of major public health concern. Many factors contribute to anaemia, ID being only one progressive factor. The prevalence of ID and IDA must be accurately determined before iron intervention strategies can be safely prescribed. There is continued uncertainty regarding the optimal approach to identifying and measuring ID, as indicators have different roles, explore different aspects of iron metabolism and cannot be directly compared. Furthermore, inflammation and infection have a confounding effect on the commonly applied indicator and acute phase reactant, serum ferritin (SF). In the public health setting, a suitable method to assess iron status in developing countries has to be inexpensive, standardised, established, easy to measure and its applications specific to identifying ID. Aim We conducted secondary analysis of screening data from three independent iron intervention studies to critically evaluate the indicators used to determine iron status in 6-11-year-old primary school children from three South African provinces. Study design and methods A cross-sectional descriptive analysis was performed on the screening data collected in 2009 and 2010 during iron intervention studies in KwaZulu-Natal (n=736), Northern Cape (n= 1045), and North West (n=546). The three distinct study sites were analysed independently and collectively. Children’s haemoglobin (Hb), SF, transferrin receptor (TfR), zinc protoporphyrin (ZPP), and C-reactive protein (CRP) concentrations were measured and body iron calculated. ID prevalence was compared using different methods (namely the single indicators SF, TfR and ZPP, body iron and the multiple criteria model), and the influence of inflammation on SF was considered. Literature suggests that the multiple criteria model provides a more complete assessment of iron status. The performance of single and body iron indicators were compared to the multiple criteria model (by assessing sensitivity, specificity and predictive values). Results Significant positive correlations between CRP (indicator of inflammation) and SF existed in all study sites and the combined sample (p < 0.01). The mean SF concentration was substantially higher in subjects with inflammation than those without. A different SF cut-off to identify ID was applied to subjects with inflammation. The percentage of ID subjects varied using different indicators (4.2 – 26.5% in KwaZulu-Natal; 4.1 – 13.4% in Northern Cape; 7.0 – 24.4% in North West; and 5.4 – 15.2% in the combined sample). The sensitivity, specificity and predictive values of alternate ID indicators varied within and between study sites, compared to the multiple criteria model. Conclusion Simply using Hb as an ID indicator is inaccurate. The vast differences between percentages identified as ID by different indicators is reason for concern. No consistent agreement appeared between single ID indicators, body iron and the multiple criteria model for ID identification after correcting for inflammation in primary school children. The global view of the multiple criteria model as the gold standard for estimating ID is debatable and potentially impractical at a public health level. Current evidence cautions against overestimating the prevalence of ID, as there is more associated harm than deficiency underestimation. This critical analysis has confirmed a need for research to identify a suitable, accurate and precise alternative to Hb as a tool in the South African public health setting. Furthermore, the impact of inflammation on iron status indicators, in particular SF, should be assessed in context to clearly set parameters for its use in nationally-representative nutrition surveys, the cornerstone of iron intervention strategies. / MSc (Nutrition), North-West University, Potchefstroom Campus, 2015

Background The potential dire consequences of iron deficiency (ID) and iron deficiency anaemia (IDA) on childhood development are of major public health concern. Many factors contribute to anaemia, ID being only one progressive factor. The prevalence of ID and IDA must be accurately determined before iron intervention strategies can be safely prescribed. There is continued uncertainty regarding the optimal approach to identifying and measuring ID, as indicators have different roles, explore different aspects of iron metabolism and cannot be directly compared. Furthermore, inflammation and infection have a confounding effect on the commonly applied indicator and acute phase reactant, serum ferritin (SF). In the public health setting, a suitable method to assess iron status in developing countries has to be inexpensive, standardised, established, easy to measure and its applications specific to identifying ID. Aim We conducted secondary analysis of screening data from three independent iron intervention studies to critically evaluate the indicators used to determine iron status in 6-11-year-old primary school children from three South African provinces. Study design and methods A cross-sectional descriptive analysis was performed on the screening data collected in 2009 and 2010 during iron intervention studies in KwaZulu-Natal (n=736), Northern Cape (n= 1045), and North West (n=546). The three distinct study sites were analysed independently and collectively. Children’s haemoglobin (Hb), SF, transferrin receptor (TfR), zinc protoporphyrin (ZPP), and C-reactive protein (CRP) concentrations were measured and body iron calculated. ID prevalence was compared using different methods (namely the single indicators SF, TfR and ZPP, body iron and the multiple criteria model), and the influence of inflammation on SF was considered. Literature suggests that the multiple criteria model provides a more complete assessment of iron status. The performance of single and body iron indicators were compared to the multiple criteria model (by assessing sensitivity, specificity and predictive values). Results Significant positive correlations between CRP (indicator of inflammation) and SF existed in all study sites and the combined sample (p < 0.01). The mean SF concentration was substantially higher in subjects with inflammation than those without. A different SF cut-off to identify ID was applied to subjects with inflammation. The percentage of ID subjects varied using different indicators (4.2 – 26.5% in KwaZulu-Natal; 4.1 – 13.4% in Northern Cape; 7.0 – 24.4% in North West; and 5.4 – 15.2% in the combined sample). The sensitivity, specificity and predictive values of alternate ID indicators varied within and between study sites, compared to the multiple criteria model. Conclusion Simply using Hb as an ID indicator is inaccurate. The vast differences between percentages identified as ID by different indicators is reason for concern. No consistent agreement appeared between single ID indicators, body iron and the multiple criteria model for ID identification after correcting for inflammation in primary school children. The global view of the multiple criteria model as the gold standard for estimating ID is debatable and potentially impractical at a public health level. Current evidence cautions against overestimating the prevalence of ID, as there is more associated harm than deficiency underestimation. This critical analysis has confirmed a need for research to identify a suitable, accurate and precise alternative to Hb as a tool in the South African public health setting. Furthermore, the impact of inflammation on iron status indicators, in particular SF, should be assessed in context to clearly set parameters for its use in nationally-representative nutrition surveys, the cornerstone of iron intervention strategies. / MSc (Nutrition), North-West University, Potchefstroom Campus, 2015

This study was conducted to determine the impact of nutrition edu cation on participants of the Supplemental Food Program for Women, Infants and Children (WIC) and the Expanded Food and Nutrition Education Program (EFNEP). The specific objectives were to: 1) determine the impact of participation in EFNEP on iron status as assessed by hematocrit (hct) and ferritin levels; 2) determine the effect of nutrition knowledge on hct and ferritin values; and 3) determine the effect dietary behavior has on hct and ferritin levels for both WIC and EFNEP participants. Each study participant completed a 24-hour dietary recall record plus food frequency record, medical history, validated nutrition knowledge test, and finger stick blood sample prior to program enrollment or nutrition education, and again six months later. There were 42 WIC, 26 EFNEP, 23 WIC-control, and 23 EFNEP-control participants. Paired t-tests were used to find differences between preprogram and postprogram evaluation scores for the variables of nutrition knowledge score, hematocrit level, ferritin level, and levels of several nutrients. Nutrition knowledge test scores increased significantly from preprogram to postprogram for both WIC and EFNEP participants (14.2 ± 3.27 to 15.5 ± 2.89 for WIC, 14.2 ± 3.77 to 15.6 ± 2.79 for EFNEP). EFNEP participants also increased significantly in hct levels (38.5% ± 3.78 to 40.7% ± 2.13). Hematocrit levels did not change significantly for the WIC or control groups and nutrition knowledge did not increase for the control group between preprogram and postprogram evaluations. Mean intakes of vitamin A, vitamin c, calcium, and protein were above the RDA at preprogram and postprogram evaluations, yet the percentage of individual participants who consumed less than 67% of the RDA in this study was higher than in the continuing survey of Food Intake of Individuals - 1985. Improvement in nutrient intake at postprogram evaluations was encouraging. Regression analysis indicated that nutrition education classes in college, income level, and level of formal education each had a positive effect on nutrient intake and nutrition knowledge.

Thesis (Ph.D. (Nutrition))--North-West University, Potchefstroom Campus, 2009.

The aim of this thesis was to study maternal and infant effects of delayed cord clamping (≥180 seconds, DCC) compared to early (≤10 seconds, ECC) in a randomised controlled trial. Practice and guidelines regarding when to clamp the cord vary globally, and different meta-analyses have shown contradictory conclusions on benefits and disadvantages of DCC and ECC. The study population consisted of 382 term infants born after normal pregnancies and randomised to DCC or ECC after birth. The primary objective was iron stores and iron deficiency at 4 months of age, but the thesis was designed to investigate a wide range of suggested effects associated with cord clamping. Paper I showed that DCC was associated with improved iron stores at 4 months (45% higher ferritin) and that the incidence of iron deficiency was reduced from 5.7% to 0.6%. Neonatal anaemia at 2-3 days was less frequent in the DCC group, 1.2% vs. 6.3%. There were no differences between the groups in respiratory symptoms, polycythaemia, or hyperbilirubinaemia. In paper II we demonstrated that DCC versus ECC was not associated with higher risk for maternal post partum haemorrhage and rendered a comparable ratio of valid umbilical artery blood gas samples. In paper III, the Ages and Stages Questionnaire was used to assess neurodevelopment at 4 months. The total scores did not differ, but the DCC group had a higher score in the problem-solving domain and a lower score in the personal-social domain. Immunoglobulin G level was 0.7 g/L higher in the DCC group at 2–3 days, but did not differ at 4 months. Symptoms of infection up to 4 months were comparable between groups. Finally, in paper IV, iron stores and neurodevelopment were similar between groups at 12 months. Gender specific outcome on neurodevelopment at 12 months was discovered, implying positive effects from DCC on boys and negative on girls. We conclude that delaying umbilical cord clamping for 180 seconds is safe and associated with a significantly reduced risk for iron deficiency at 4 months, which may have neurodevelopmental effects at a later age.

Thesis (Ph.D. (Nutrition))--North-West University, Potchefstroom Campus, 2009.

AIM Poor iron status and under–nutrition among children are of concern not only in South Africa but worldwide. Both independent and combined associations between poor iron status, under–nutrition and cognitive development and function have been investigated. This mini–dissertation investigated possible associations between iron status indicators, anthropometric nutritional status and cognitive performance in the Beverage Fortified with Micronutrients (BeForMi) study population (black South African children aged 6–11 years in the North–West province of South Africa). METHODS The study was cross–sectional and based on the BeForMi study baseline data. Primary school children (n = 414) with the highest serum transferrin receptor (STR) and zinc protoporphyrin (ZnPP) levels were included. Anthropometric z–scores - BMI–for–age (BAZ), height–for–age (HAZ), and weight–for–age (WAZ) - and iron status indicators - haemoglobin (Hb), serum ferritin (SF), STR and ZnPP - were determined. The Kaufman Assessment Battery for Children, Second edition (KABC–II) was used to generate cognitive scores. RESULTS Fourteen percent of children were underweight (WAZ <= 2 SDs), 12.8% stunted (HAZ <= 2 SDs) and 8.4% wasted (BAZ <= 2 SDs). Of the children, 7.1% were anaemic (Hb < 11.5 g/dL), 13% iron depleted (Hb < 11.5 g/dL and SF < 12 ug/L) and 2.7% had iron deficiency anaemia (Hb < 11.5 g/dL and SF < 12 ug/L). Low iron stores (SF < 12 ug/L) were observed in 15.7% of the children. Positive correlations were found between SF and WAZ (r = 0.1, p = 0.047), Hb and HAZ (r = 0.13, p = 0.007) and WAZ (r = 0.13, p = 0.009). Positive correlations with small effect sizes were observed between some cognitive scores and z–scores (p < 0.05, r–value range 0.10 – 0.24). Negative correlations with small effect sizes were observed for the subtests Triangles and Rover (both subtests on simultaneous processing) with Hb (p = 0.008, r = –0.13) and SF (p = 0.04, r = –0.1) respectively. Higher HAZ, WAZ and education level of the head of household were all significantly associated with the likelihood that a child would fall within the upper quartile of Hb values in our study group (p = 0.036, p = 0.032 and p = 0.036 respectively). CONCLUSION The results suggested that under–nutrition was positively associated with poor iron status and lower cognitive scores in this study population. Further research, investigating specific effects of poor iron status at different stages of growth and the relationship with cognitive function later in life may help explain the negative correlations observed between current iron status indicators and cognitive scores. / Thesis (M.Sc (Dietetics))--North-West University, Potchefstroom Campus, 2011.

Thesis (Ph.D. (Nutrition))--North-West University, Potchefstroom Campus, 2009.

AIM Poor iron status and under–nutrition among children are of concern not only in South Africa but worldwide. Both independent and combined associations between poor iron status, under–nutrition and cognitive development and function have been investigated. This mini–dissertation investigated possible associations between iron status indicators, anthropometric nutritional status and cognitive performance in the Beverage Fortified with Micronutrients (BeForMi) study population (black South African children aged 6–11 years in the North–West province of South Africa). METHODS The study was cross–sectional and based on the BeForMi study baseline data. Primary school children (n = 414) with the highest serum transferrin receptor (STR) and zinc protoporphyrin (ZnPP) levels were included. Anthropometric z–scores - BMI–for–age (BAZ), height–for–age (HAZ), and weight–for–age (WAZ) - and iron status indicators - haemoglobin (Hb), serum ferritin (SF), STR and ZnPP - were determined. The Kaufman Assessment Battery for Children, Second edition (KABC–II) was used to generate cognitive scores. RESULTS Fourteen percent of children were underweight (WAZ <= 2 SDs), 12.8% stunted (HAZ <= 2 SDs) and 8.4% wasted (BAZ <= 2 SDs). Of the children, 7.1% were anaemic (Hb < 11.5 g/dL), 13% iron depleted (Hb < 11.5 g/dL and SF < 12 ug/L) and 2.7% had iron deficiency anaemia (Hb < 11.5 g/dL and SF < 12 ug/L). Low iron stores (SF < 12 ug/L) were observed in 15.7% of the children. Positive correlations were found between SF and WAZ (r = 0.1, p = 0.047), Hb and HAZ (r = 0.13, p = 0.007) and WAZ (r = 0.13, p = 0.009). Positive correlations with small effect sizes were observed between some cognitive scores and z–scores (p < 0.05, r–value range 0.10 – 0.24). Negative correlations with small effect sizes were observed for the subtests Triangles and Rover (both subtests on simultaneous processing) with Hb (p = 0.008, r = –0.13) and SF (p = 0.04, r = –0.1) respectively. Higher HAZ, WAZ and education level of the head of household were all significantly associated with the likelihood that a child would fall within the upper quartile of Hb values in our study group (p = 0.036, p = 0.032 and p = 0.036 respectively). CONCLUSION The results suggested that under–nutrition was positively associated with poor iron status and lower cognitive scores in this study population. Further research, investigating specific effects of poor iron status at different stages of growth and the relationship with cognitive function later in life may help explain the negative correlations observed between current iron status indicators and cognitive scores. / Thesis (M.Sc (Dietetics))--North-West University, Potchefstroom Campus, 2011.