Thesis (MNutr)--Stellenbosch University, 2013. / ENGLISH ABSTRACT: The possible advantages of vitamin D supplementation on various cardiometabolic conditions have been examined over the past few years. Vitamin D supplementation has possibly shown effects on each of the individual components of the metabolic syndrome i.e.: obesity, hypertension, dyslipidaemia and glucose intolerance. The aim of this systematic review was to ascertain whether or not vitamin D supplementation has any effect on any of the components of the metabolic syndrome. We searched the (Cochrane Central Register of Controlled Trails (Central), Medline, Science direct, ISI Web of knowledge and Scopus during 2010 (repeated search in 2012). We found four randomized controlled trials that met our inclusion and exclusion criteria. Three hundred and seventy three patients were included in these four randomized controlled trails comparing vitamin D supplementation with placebo. Duration of treatment was a minimum of 4 weeks, through to a maximum of on-year. The different trials looked at various components of the metabolic syndrome as outcomes. The results were not consistent amongst the trials and the results could not be combined in a meta-analysis due to heterogeneity in study design and outcomes measured. The current systematic review highlights the shortcomings in the published data and we recommend further trials be undertaken before vitamin D supplementation can be recommended as beneficial for patients with the metabolic syndrome. / AFRIKAANSE OPSOMMING: Die moontlike voordele van vitamien D-aanvullings op verskillende kardiometaboliese toestande is oor die afgelope paar jaar ondersoek. Daar is aangetoon dat vitamien Daanvullings uitwerkings het op elk van die individuele komponente van die metaboliese sindroom naamlik vetsug, hipertensie, dislipidemie en glukose-intoleransie. Die doel van hierdie sistematiese oorsig was om vas te stel of vitamien D-aanvullings enige uitwerking het op enige van die komponente van die metaboliese sindroom of nie. Ons het gedurende 2010 soektogte uitgevoer op die Cochrane Sentrale register van gekontroleerde proewe (Central), Medline, Science Direct, ISI Web of Knowledge en Scopus (soektog is in 2012 herhaal). Ons het vier verewekansigde gekontroleerde proewe wat aan ons insluiting- en uitsluitingskriteria voldoen het, opgespoor. Driehonderd drie en sewentig pasiënte is by die vier proewe ingesluit. Al vier proewe het vitamien D-aanvullings met plasebo vergelyk. Die duur van behandeling het van 4 weke tot een jaar gestrek. Die verskillende proewe het gekyk na verskillende komponente van die metaboliese sindroom as uitkomste. Die resultate van die onderskeie proewe was nie konsekwent nie. Die huidige sistematiese oorsig belig die tekortkominge in die gepubliseerde data en ons beveel aan dat verdere proewe onderneem word om vas te stel of dit nuttig is om vitamien D aanvullings vir pasiënte met die metaboliese sindroom aan te beveel, en of dit dalk skadelik kan wees.

Thesis (MNutr)--Stellenbosch University, 2013. / ENGLISH ABSTRACT: Objective: To examine the factors that may influence the vitamin A and anthropometric status of 24-59-month-old children from an impoverished community with a very high prevalence of stunting, but virtually no vitamin A deficiency. Design: Cross sectional, descriptive study with analytical components. Setting: Calvinia West, Northern Cape Province, South Africa Subjects: Biological mothers (n=150) and their children aged 24-59 months (n=150) living in Calvinia West from 6 months of age or younger. Methods: A general interviewer-administered questionnaire comprising of socio-demographic information, a 24-hour recall and an adjusted food frequency questionnaire, focussing on liver intake, were used in the data collection process. Anthropometric measurements (weight and height) were also performed. Results: Results showed that liver consumption alone contributed to more than 100% of the Estimated Average Requirement (EAR) for vitamin A of the pre-school children in this community. Liver was eaten by 84.7% (n=127) of the children and 68% (n=102) of them ate liver at least once per month. The average portion size of the children who consumed liver was 66g at a time. The national food fortification programme contributed to a further 80 μg Retinol Equivalents (RE) and the national supplementation programme 122μg RE of vitamin A per day. There was a significant (p=0.028) inverse association between the amount of liver intake and household income. Liver intake was also significantly (p=0.016) higher in the children whose mothers were unskilled as opposed to those with skilled mothers. According to the World Health Organization (WHO) growth standards 36.9% (n=55) of the children were stunted (low height for age), 25.5% (n=38) were underweight for age and 12.1% (n=18) were wasted (low weight for height). The mean birth weight of the children (n=141) was 2826g (SD=592). Of these children, 27.7% (n=39) had a low birth weight (<2500g). There was a significant positive correlation (r=0.250; p=0.003) between the birth weight of the child and the child's current height for age. The height of the mother, as well as several indicators of socio-economic status, also correlated significantly with the height for age of the child. Conclusion: In this impoverished community the anthropometric status of the children was poor, but vitamin A deficiency was largely addressed through the regular intake of liver. Poor anthropometric status is therefore not always an indicator of micronutrient deficiencies and blanket supplementation approaches are not necessarily the solution in a country with diverse cultures and eating habits. Apart from the immediate risks and consequences of underweight, stunting and wasting in a community, stunting may also lead to overweight and obesity in the long term. This may result in diseases of lifestyle in later life, adding a further burden to an already weakened community. Appropriate evidence-based interventions aimed at the first thousand days of life should be a priority in this community. / AFRIKAANSE OPSOMMING: Doel: Om die faktore wat kan bydrae tot die vitamien A en die antropometriese status van kinders 24-59-maande in 'n arm gemeenskap met 'n baie hoë voorkoms van dwerggroei, maar byna geen vitamien A gebrek, te ondersoek. Ontwerp: Beskrywende, deursnit studie met analitiese komponente Omgewing: Calvinia Wes, Nood Kaap provinsie, Suid-Afrika Deelnemers: Biologiese moeders (n=150) en hul kinders in die ouderdomsgroep, 24-59-maande (n=150) woonagtig in Calvinia Wes sedert 6 maande van ouderdom of jonger. Metodes: 'n Vraelys bestaande uit sosio-demografiese inligting, 'n 24-uur herroep en 'n aangepaste voedsel frekwensie vraelys gefokus op die inname van lewer, was gebruik om data in te samel en voltooi deur die onderhoudvoerder. Antropometriese metings (gewig en lengte) was ook geneem. Resultate: Resultate het getoon dat lewer inname bygedra het tot meer as 100% van die geskatte gemiddelde behoefte van vitamien A vir die voorskoolse kind in hierdie gemeenskap. Lewer was deur 84.7% (n=127) van die kinders ingeneem en 68% (n=102) het dit ten minste een keer per maand geëet. Die gemiddelde porsie grootte van die kinders wat lewer ingeneem het, was 66g op 'n keer. Die nasionale voedsel fortifisering program het 'n verdere 80 μg Retinol Ekwivalente (RE) en die nasionale supplementasie program 122μg RE vitamin A per dag bygedra. Daar was 'n betekenisvolle (p=0.028) omgekeerde korrelasie tussen die die hoeveelheid lewer wat deur die kinders ingeneem is en die huishoudelike inkomste. Lewer inname was ook betekenisvol (p=0.016) meer in kinders wie se moeders ongeskool was teenoor die met geskoolde moeders. Volgens die Wêreld Gesondheid Organisasie se groeistandaarde het 36.9% (n=55) van die kinders dwerggroei getoon (te kort vir hul ouderdom), 25.5% (n=38) was ondergewig vir hul ouderdom en 12.1% (n=18) uitgeteer (ondergewig vir hul lengte). Die gemiddelde geboortegewig van die kinders (n=141) was 2826g (SA=592). Van hierdie kinders het 27.7% (n=39) 'n lae geboortegewig (<2500g) gehad. Daar was 'n betekenisvolle positiewe korrelasie (r=0.250; p=0.003) tussen die geboortegewig van die kind en die huidige lengte vir ouderdom. Die lengte van die moeder, sowel as ander sosio-ekonomiese status aanwysers het ook betekenisvol gekorreleer met die lengte vir ouderdom van die kind. Samevatting: In hierdie arm gemeenskap was die antropometriese status van die kinders swak, maar vitamien A gebrek was grootliks aangespreek deur die gereelde inname van lewer. 'n Swak antropometriese status is dus nie altyd 'n aanduiding van mikronutriënt tekorte nie en 'n oorkoepelende aanslag van supplementasie is nie noodwendig 'n oplossing in 'n land met diverse kultuur en eetgewoontes nie. Behalwe vir die onmiddelike gevare van ondergewig, dwerggroei en uittering in 'n gemeenskap, het kinders met dwerggroei 'n groter risiko om oorgewig en vetsugtig te word in die langtermyn. Dit kan lewensstyl siektes veroorsaak in latere lewe en 'n verdere las op 'n reeds verswakte gemeenskap plaas. Toepaslike intervensies, gemik op die eerste duisend dae van lewe, behoort 'n prioriteit te wees in hierdie gemeenskap.

Thesis (MNutr)--Stellenbosch University, 2014. / ENGLISH ABSTRACT: Background: A number of observational studies where information was obtained retrospectively have been used in the past to inform guidelines regarding allergy prevention. Studies looking at the causative/protective properties of infant dietary factors on diseases that occur later in life also rely on maternal recall many years later. It is unclear however what the effect of the recall bias was on the accuracy/quality of the information obtained. Objectives: The aim of the study was to determine the impact of recall bias 10 years retrospectively on the accuracy of dietary information in relation to breast feeding, weaning age and introduction of allergenic foods. A literature review was performed into studies assessing the accuracy of data obtained retrospectively and into studies using retrospective data to draw conclusions on the protective/causative factors of infant feeding in relation to food allergy. Methodology: An infant feeding questionnaire was developed from some of the same questions that were asked by mothers recruited into the FAIR study, a prospective birth cohort on the Isle of Wight. Families had been recruited and followed up since 2001/2002 and data has been gathered when the mothers were 36 weeks pregnant, and then when their child was 3, 6, 9 months and 1 and 2 years old. Mothers were asked in 2012, when their children were 10 years of age, to complete this questionnaire. Agreement of answers was computed using Kappa coefficients, Spearman’s correlation and percentage agreement. Results: One hundred and twenty five mothers completed the questionnaire. There was substantial agreement for recall of whether mothers breast fed, the duration of EBF and breast feeding 10 years earlier (k = 0.79, r = 0.70 and r = 0.84 respectively). Seven per cent (n = 9) of mothers however who did breast feed reported not to have. Eighty four per cent (n = 103) of mothers recorded correctly whether their child had a bottle of formula milk in hospital. Ninety four per cent (n = 116) of mothers recalled accurately that their child had received formula milk at some stage of their infancy. The exact age at which formula milk was first given to their child was answered accurately (r = 0.63). The brand of formula milk provided was poorly recalled. Answers to when mothers first introduced solid foods into their child’s diet were not accurate (r = 0.16). The age of introduction of peanuts was the only food allergen that mothers recalled accurately for when they first introduced this into their child’s diet (86% correct answers). Recall of whether peanuts were consumed during pregnancy was accurate after two years (k = 0.64) but not after 8 years (k = 0.39). Conclusion: The study highlights the importance of possible recall bias of infant feeding practices by mothers over a period of 10 years. Recall related to breast feeding and formula feeding were accurately recorded for, but not for age of introduction of solid foods and introduction of allergenic foods. Studies relying on maternal recall of weaning questions need to be cautious. / AFRIKAANSE OPSOMMING: Agtergrond: ’n Aantal waarnemingstudies waarin inligting op retrospektiewe wyse of terugwerkend bekom is, is in die verlede gebruik om riglyne oor die voorkoming van allergie neer te lê. Studies oor die veroorsakende/beskermende kenmerke wat kindervoedingsfaktore op latere siektes het, steun verder op die herinneringe wat die moeder baie jare later kan oproep. Dit is egter onduidelik watter uitwerking hierdie oproepvooroordeel op die akkuraatheid/gehalte van die versamelde inligting het. Oogmerke: Die oogmerk met die studie was om die impak te bepaal wat oproepvooroordeel met terugwerkende effek van 10 jaar op die akkuraatheid van voedingsinligting oor borsvoeding, speenouderdom en die insluiting van allergeniese voedselsoorte uitoefen. ’n Literatuuroorsig was onderneem van studies wat die akkuraatheid evalueer van data wat retrospektief bekom is, asook studies wat retrospektiewe data gebruik om gevolgtrekkings oor die beskermende/veroorsakende kenmerke van kindervoeding met betrekking tot voedselallergie te maak. Metodologie: ’n Kindervoedingsvraelys is saamgestel vanaf sommige van die vrae wat aan gewerfde moeders voorheen in die FAIR-studie, ’n voornemende geboortekohort op die eiland Wight, gestel is. Gesinne is in 2001/2002 gewerf en opgevolg, en data is versamel toe die moeders 36 weke swanger was; en weer toe hulle kinders die ouderdom van 3, 6, 9 maande en 1 en 2 jaar bereik het. In 2012, toe hulle kinders 10 jaar oud was, is die moeders weer versoek om hierdie vraelys in te vul. Ooreenstemming tussen antwoorde is bepaal deur Kappa koeffisiënte, Spearman korrelasies en persentasie ooreenstemming. Resultate: Eenhonderd vyf-en-twintig moeders het die vraelys ingevul. Daar was beduidende ooreenkoms in die moeders se oproep oor die vraag of hulle borsvoeding gegee het, hoe lank eksklusiewe borsvoeding (EBV) geduur het, asook borsvoeding 10 jaar vantevore (k = 0.79, r = 0.70 en r = 0.84 onderskeidelik). Sewe persent (n = 9) van die moeders wat wel borsvoeding gegee het, het egter geantwoord dat hulle dit nie gegee het nie. Vier-en-tagtig persent (n = 103) van die moeders het akkuraat geantwoord op die vraag of hulle kinders bottelvoeding met ’n melkformule in die hospitaal ontvang het. Vier-en-negentig persent (n =116) van die moeders kon akkuraat oproep dat hulle kinders in ’n sekere stadium van hulle kindertyd melkformule ontvang het. Die vraag oor presies hoe oud die kinders was toe hulle die eerste maal melkformule ontvang het, is akkuraat beantwoord (r = 0.63). Die handelsnaam van die melkformule kon nie goed herroep word nie. Antwoorde oor wanneer moeders die eerste maal vaste voedsel by hulle kinders se dieet ingesluit het, was nie baie akkuraat nie (r = 0.16). Die ouderdom waarop grondboontjies ingesluit is, was die enigste antwoord wat moeders akkuraat kon oproep (86% korrekte antwoorde) op die vraag wanneer hulle die eerste maal ’n voedselallergeen by hulle kinders se dieet ingesluit het. Die antwoord op die vraag of hulle tydens hul swangerskap grondboontjies geëet het, was akkuraat na twee jaar (k = 0.64), maar nie na agt jaar (k = 0.39) nie. Gevolgtrekking: Die studie onderstreep die belang van moontlike oproepvooroordeel rakende kindervoedingspraktyke by moeders oor ’n tydperk van 10 jaar. Die oproep oor borsvoeding en formulevoeding is korrek aangedui, maar nie vir die ouderdom waarop vaste voedselsoorte en allergeniese voedselsoorte ingesluit is nie. Studies wat op moederoproep oor speningsvrae staatmaak, moet omsigtig gedoen word.

Thesis (MNutr)--Stellenbosch University, 2014. / ENGLISH ABSTRACT: Objective: The objective of the study was to assess and compare the level of knowledge of South African health professionals) treating patients with Type 1 and Type 2 Diabetes Mellitus (T1 and T2 DM) with regard to nutrition and Diabetes Self-management (DSM). To achieve this objective, two questionnaires (one for T1 DM and one for T2 DM) was developed and validated. In addition the study identifies the areas in need for further education as well as to assess if socio-demographic factors influence the level of knowledge. Methods: The questionnaires were developed by: i) planning and developing constructs on nutrition and DSM by experts (n = 2) in the field of nutrition and diabetes care, ii) compilation and evaluation of a pool of 60 questions for face and content validity by an expert panel comprising six Registered Nurses / Diabetes Educators (RN / DE) and registered dieticians (RD) and iii) testing the questionnaires for criterion validity and reliability by a pilot group (n = 34 RN / DE and RD). Chronbach’s alpha values were calculated to determine validity and questions were disregarded or changed depending on this outcome. These questionnaires were then sent via electronic and hard mail to a randomised sample of RD (n = 1200) and RN / DE (n = 498). Data of 70 questionnaires on T1 DM and 105 on T2 DM was coded and analysed. The cut off value of 70% was considered as adequate knowledge. Results: With regard to questionnaire development, constructs were eliminated by the expert panel and this resulted in the acceptance of 60 constructs for the final questionnaires. Five constructs were replaced to improve content validity and an additional three constructs were adjusted to improve face validity. Recommended amendments were made to improve the criterion validity of the questionnaires. Internal consistency was shown with an overall Cronbach’s alpha value of 0.73 for the T1 DM questionnaire and 0.71 for the T2 DM questionnaire. In terms of the assessment of knowledge for T1 DM, the RD (75.4%) but not the RN/DE (67.2%) had adequate knowledge of nutrition. This was not statistically significant different from the RN / DE (p = 0.07). Both groups scored equally with regard to their knowledge of DSM with scores indicating inadequate knowledge (64.7% and 64.9% respectively) (p = 0.27). For T2 DM, the RD (74.6%) but not the RN / DE (61.6%) showed their knowledge of nutrition to be adequate, and statistically significantly better than the RN / DE (p = 0.0005). Both groups showed inadequate knowledge of DSM (56.0% and 61.9% respectively) (p = 0.31). The main areas of knowledge for diabetes mellitus (DM) identified in need for further education were the glycaemic index (GI) values of food, carbohydrate counting, the use of sugars / sweeteners, timing of meals and snacks with regard to activity, medication used, treatment of hypo- and hyperglycaemia and the use of alcohol. Age affected knowledge (for both nutrition and DSM) with regard to T1 DM, as the age group 30 - 49 years scored significantly better than the rest (nutrition p = 0.005, DSM p = 0.006 respectively). Health professionals in the private sector achieved higher scores compared to those working in the public sector (nutrition p = 0.011, DSM p = 0.016 respectively). Conclusion: Two valid and reliable quantitative questionnaires comprising 4 sections and 30 questions were developed to assess the level of knowledge of health professionals (RN / DE and RD) on nutrition and DSM treating patients with T1 and T2 DM in South Africa. RN / DE required further education towards key nutrition concepts and RN / DE and RD required further education on key concepts regarding DSM for both T1 and T2 DM. / AFRIKAANSE OPSOMMING: Doel: Die doel van die studie was om die hoeveelheid van kennis van verpleeg en dieetkunde personeel wat persone met Tipe 1 en Tipe 2 Diabetes Mellitus (T1DM en T2DM) in Suid – Afrika behandel, te bepaal en te vergelyk. Die studie het gefokus op kennis t.o.v. voeding en diabetiese self-sorg. Om die doel te bereik was twee vrae lyste, een vir T1 DM en een vir T 2 DM ontwikkel. Die verskillende aspekte van kennis wat verdere opleiding benodig is geidentifiseer asook of enige demografiese faktore wat kennis kon beinvloed. Metode: Die volgende stappe was geneem om voldoende geldigheid en betroubaarhied te bereik: 1. Twee kenners het verskeie belangrike aspekte van voeding en diabetiese self-sorg geidentifiseer en ontwikkel. 2. ‘n Paneel van 34 geregistreerde dieetkundiges en verpleeg personeel wat in Diabetes Mellitus spesialiseer , het die inhoud van ‘n totaal van 60 vrae ge- evalueer vir geldigheid en toepaslikheid. 3. Die paneel het die vraelyste verder ge- evalueer vir ‘n aanvaarbare standard van betroubaarheid. Chronbach-alfa waardes was gebruik vir die aanvaarbaarheid van alle vrae. 4. Die finale weergawe van 30 aanvaarbare vrae in elke vraelys was gestuur via elektroniese en normale pos na 1200 RD en 489 verpleegpersoneel wat spesialiseer in T1 en T2 DM. 5. Inligting van onderskeidelik 70 T1DM en 105 T2 DM vraelyste was gekodeer en ge-analiseer. Resultate: Tydens die ontwikkeling van die vraelyste, was sekere aspekte van kennis deur die twee kenners ge-elimineer. Die evaluering van die groep van dieetkundiges en verpleeg personeel het verder bygedra tot die vervanging en aanpassing van sekere aspekte van kennis. Dit het bygedra tot die vlak van voldoende geldigheid en toepaslikheid. Vir voldoende betroubaarheid was die Chronbach- alfa waardes van 0.73 vir T1DM and 0.71 vir T2 DM onderskeidelik aanvaar. Die studie het getoon dat die dieetkundiges voldoende kennis besit t.o.v. voeding vir T1 DM (75.4%). Dit was egter nie statisties betekenisvol meer in vergelyking met die kennis soos behaal deur die verpleegpersoneel (62.2%) (p = 0.07). Beide groepe se kennis t.o.v diabetiese self sorg was bepaal as onvoldoende met onderskeidelik 64.7% en 64.9%. In terme van T2 DM, het die dieetkundiges statisties betekenisvol beter kennis getoon vir voeding (74.6%) in vergelyking met die vlak van kennis soos behaal deur die verpleeg personeel (61.6%) (p = 0.0005). Soos in die geval van T1 DM het beide groepe onvoldoede kennis getoon vir diabetiese self sorg met onderskeidelike waardes van 56.0% en 61.9%. (p = 0.31). Die areas van kennis wat geidentifiseer was vir verdere opleidig, was die glisemiese indeks van voedsel, bepaling van die hoeveelheid koolhidrate in voedsel, die gebruik van suiker en versoeters, die neem van maaltye en versnapperinge, oefening, medikasie, voorkoming van lae en hoe blood glukose vlakke asook die gebruik vam alkoholiese drankies. Die ouderdoms groep tussen 30-49 jaar het statisties ‘n hoer vlak van kennis getoon vir beide voeding (p = 0.005) en diabetiese self sorg (p = 0.006) vir T 1 DM in vergelyking met die ander ouderdoms groepe. Personeel wat in die private sektor werk het ‘n beter vlak van kennis getoon in vergelyking met personeel wat in die openbare sektor werk (p = 0.011 en p = 0.016 vir voeding en diabetiese self sorg onderskeidelik. Samevatting: Twee geldige en betroubare vrae lyste met 30 vrae in totaal was ontwikkel om die vlak van kennis van dieetkundiges en verpleeg personeel te bepaal in terme van voeding en diabetiese self sorg vir beide T1 en T2 DM. Die verpleegpersoneel benodig verder opleiding t.o.v sekere aspekte van voeding en diabetiese self -sorg en die dieetkundiges t.o.v. diabetiese self -sorg vir beide T1 en T2 DM.

Thesis (MSc)--University of Stellenbosch, 2005. / ENGLISH ABSTRACT: The Birth to Twenty (BTT) study involves the monitoring of the health status and related factors of urban-born children from birth until age twenty. When the cohort reached age 13 years in 2003, nutrition knowledge assessment was identified as an important new priority and a nutrition knowledge questionnaire was required for these purposes. Subsequently a valid and reliable nutrition knowledge questionnaire was developed for the BTT study. This process started with the development of a conceptual framework of nutrition-related issues facing urban South African adolescents and identification of related nutrition concepts. A pool of potential questionnaire items reflecting the concepts was subsequently developed. These items were evaluated by an expert panel to ensure content and face validity before being structured into a questionnaire. The resulting 88-item questionnaire was completed by adult and adolescent samples, each age group comprising subgroups of those likely to have good nutrition knowledge and those likely to have poor nutrition knowledge. The data obtained from the completion of the questionnaire by these groups was used to refine the questionnaire through the determination of difficulty and discriminatory indices of the items, and the deletion of items that did not meet the stated criteria. The construct validity of the remaining 63 items was assessed using the same data set. To assess the internal consistency reliability (ICR) of the 63-item questionnaire it was completed by an adolescent sample population considered to be representative of the BTT cohort, after which the questionnaire underwent further steps of refinement. The result was a 60-item questionnaire of which the ICR and construct validity was reassessed and found to be satisfactory. However, to ensure the accurate interpretation of scores obtained by testees, the development of a performance-rating scale was necessary. A norm-referenced performance-rating scale (norms) was developed by administering the nutrition knowledge questionnaire to a sample population similar to the BTT cohort (norm group) and transforming their performance scores to z-scores. The z-scores ranges were then categorised into stanines, thereby resulting in a norm-referenced performance-rating scale that can be used to rate the performance of the BTT cohort. The validity of the norms was assessed by administering the nutrition knowledge questionnaire to three validation groups that comprised groups who were expected to obtain different performance-ratings on the questionnaire based on their varying levels of nutrition knowledge. The validation groups performed as expected, with significant differences in performance-rating profiles found among the three groups, indicating the validity of the norms. The study was successful in developing a reliable and valid nutrition knowledge questionnaire for use on the urban adolescents who participate in the BTT study. A norm-referenced performance-rating scale for use with the questionnaire was also successfully developed. The questionnaire and norms will be useful in assessing nutrition knowledge as well as in comparing the changes in knowledge of the BTT cohort as they move from lower to higher school grades. / AFRIKAANSE OPSOMMING: Die “Birth to Twenty” (BTT)-studie behels die monitering van die gesondheidstatus en verwante faktore van kinders wat in stedelike gebiede gebore is van geboorte tot twintigjarige ouderdom. Toe die kohort in 2003 dertienjarige ouderdom bereik het, is die evaluering van die voedingkennis van die kinders as ‘n belangrike nuwe prioriteit geïdentifiseer. ‘n Toepaslike voedingkennisvraelys is vir hierdie doeleindes benodig en gevolglik is ‘n geldige en betroubare vraelys vir gebruik in die BTT-studie ontwikkel. Hierdie proses is begin deur die ontwikkeling van ‘n konseptueleraamwerk oor voedingverwante vraagstukke wat stedelike Suid-Afrikaanse adolessente in die gesig staar, asook die identifisering van verwante voedingkonsepte. ‘n Poel van potensiële vraelysitems wat die konsepte reflekteer is daarna ontwikkel. Die items is eers deur ‘n paneel van kenners evalueer om inhoud- en gesigsgeldigheid te verseker alvorens dit in ‘n vraelys omskep is. Die produk was ‘n vraelys wat 88 items ingesluit het wat vervolgens deur volwasse en adolessente groepe voltooi is. Die groepe het subgroepe ingesluit van diegene met verwagte goeie voedingkennis en diegene met verwagte swak voedingkennis. Die data wat tydens hierdie stap gegenereer is, is gebruik om die vraelys verder te verfyn deur die bepaling van die moeilikheids- en diskriminatoriese-indekse van die items. Die items wat nie aan vooraf gestelde kriteria voldoen het nie, is weggelaat. Die konstrukgeldigheid van die oorblywende 63 items is bepaal deur dieselfde datastel te gebruik. Om die interne-konsekwensie-betroubaarheid (IKB) van die vraelys te bepaal, is dit deur ‘n steekproef van adolessente, wat verteenwoordigend van die BTT-kohort is, voltooi. Hierna is die vraelys verder verfyn. Die uitkoms was ‘n 60-item vraelys waarvan die IBR en konstrukgeldigheid weereens bepaal is. Dit is gevind dat dié twee indikatore van geldigheid en betroubaarheid bevredigend is. Om akkurate interpretasie van die punt wat deur ‘n respondent vir die toets behaal te verseker, is die ideal om ‘n skaal te ontwikkel wat gebruik kan word om dié punt te takseer. ‘n Norm-gebaseerde prestasietakseringskaal is ontwikkel deur die voedingkennisvraelys deur ‘n steekproef wat verteenwoordigend is van die BTT-kohort (normgroep), te laat voltooi. Die prestasiepunte is getransformer na z-tellings wat vervolgens getransformeer is na stanneges, wat ‘n norm-gebaseerde prestasietakseringskaal opgelewer het wat gebruik kan word om die prestasie van die BTT-kohort te takseer. Valideringsgroepe met verskillende vlakke van voedingkennis, wat dus na verwagting verskillend getakseer behoort te word indien die norme toegepas word, het die voedingkennisvraelys voltooi om die geldigheid van die norme te bepaal. Dié valideringsgroepe het soos voorspel presteer, met betekenisvolle verskille in die prestasieprofiele van die verskillende groepe. Hierdie resultate dui daarop dat die norme geldig is. Die ontwikkeling van ‘n geldige en betroubare voedingkennistoets vir gebruik in die BTT-studie is suksesvol in hierdie studie deurgevoer. ‘n Norm-gebaseerde prestasietakseringskaal vir gebruik saam met die vraelys is ook suksesvol ontwikkel. Die vraelys en norme sal van waarde wees vir die evaluering van die voedingkennis van die BTT-kohort. Dit sal ook met sukses gebruik kan word om die verandering in die voedingkennis van die kinders soos wat hulle ouer word, te bepaal.

Thesis (MNutr (Human Nutrition))--University of Stellenbosch, 2009. / INTRODUCTION: The aim of this study was to determine the characteristics of and factors impacting on the intake of fast-foods by young adults from different socio-economic areas in Gauteng, South Africa. The population for the study (n = 341) included males (n = 180) and females (n = 161) with a mean age of 24.48 years (SD = 3.492). METHODS: A descriptive cross-sectional, observational study was performed using an interviewer-administered, validated questionnaire to elicit characteristics of the studied population (gender, education level, income status and income level), reasons for – and frequency of – fast-food intake, specific food choices at certain categories of fast-food outlets, as well as consumers’ attitude towards health and healthier meal options. Purposive sampling of shopping malls was done to collect data on three weekend days at grocery stores in the shopping complexes. Statistical analysis included: Pearson Chisquare tests, likelihood ratios, linear by linear associations and Cramer’s V and Kendall tau b tests. RESULTS: The studied population consisted primarily of working young adults with at least secondary education. Almost half (n = 103) of the employed participants from all socio-economic groups earned less than R5 000 per month, but spent more than R200 each month on fast-food. The majority of participants consumed take-away meals from two to three times a month to two to three times per week (85.3% (n = 291)). Socio-economic grouping (SEG) and gender were significantly related to fast-food intake (p < 0.01) with a larger proportion of participants (n = 76) in the lower socio-economic grouping (LSEG) showing more frequent use and males consuming fast-food more frequently than females. The most popular fast-foods consumed by participants in descending order were burgers 69.5%, pizza 56.6% and fried chicken 38.4%. A significant difference in the consumption of fried chicken was observed between the different SEGs, with significantly more participants from the LSEG consuming fried chicken 47.0% (p < 0.05). Choice of fast-food outlet concurred with the most popular fast-food choices. Sweetened soft drinks comprised the most popular beverage for more than half of the studied population (n = 191). The main reasons for choosing fast-food were time limitations (58.9%), convenience (58.2%) and taste (52.5%). The majority of participants were concerned about health (93.3%), with almost half of the total sample being always concerned. The majority of participants indicated concern about overweight and obesity (44.3%). Seventy-eight percent of participants indicated that they would choose a healthier option, if available. Television provided the most effective media influence on food choices. CONCLUSION: The findings of the study show a clear discrepancy between fast-food intake and health consciousness, indicating a gap between knowledge and practice. In the light of the spread of the obesity epidemic in South Africa, further research on fast-food consumption in other areas in South Africa and in other age groups (especially children and adolescents) is strongly recommended.

Thesis (MVoeding)--University of Stellenbosch, 2004. / ENGLISH ABSTRACT: Objectives and scope of investigation Following the 1996 recommendations of a FAO/WHO expert panel for the development of food-based dietary guidelines (FBDGs) unique and specific to the needs of the populations of different countries, a South African FBDG Working Group was formed and ultimately also a Paediatric FBDG (PFBDG) Working Group with the task of the latter being the development of FBDGs for children younger than 7 years. A set of preliminary PFBDGs, chosen to address the most pressing paediatric public health issues, namely protein-energy malnutrition, micronutrient deficiencies and infectious diseases, were formulated for each age group sub-category (0-6 months, 6-12 months and 1-7 years). The following set of preliminary PFBDGs for the age group 6-12 months were approved by the Working Group to be subjected to consumer testing: • Enjoy time with your baby • From six months start giving your baby small amounts of solid foods • Gradually increase your baby’s meals to five times a day • Keep breast feeding your baby • Offer your baby clean, safe water regularly • Teach your baby to drink from a cup • Take your baby to the clinic every month Assessment of the consumer’s comprehension, interpretation of the proposed guidelines, and ability to apply them, was considered essential before the PFBDGs could be finalised, disseminated to the consumer, and implemented as an educational tool for health professionals and community workers. This study was also the first in which PFBDGs were tested, and was intended to be a pilot study for further testing of PFBDGs for this age category in other parts of the country, adapted for different circumstances. The investigation was conducted among women who were mothers or caregivers to infants 6-12 months of age in the Afrikaans-, English- and Xhosa-speaking communities of the greater Oudtshoorn area, including Bongulethu, Bridgeton and Toekomsrus and its adjacent rural areas of Dysselsdorp, Calitzdorp, Uniondale, Ladismith and Zoar. Methodology The study was designed to be an observational, descriptive and cross-sectional study. Qualitative data was collected from a sample of 64 volunteers who took part in ten focus group discussions each attended by between 3 and 11 participants. Group discussions were recorded on videotape and quantitative and qualitative questionnaires measured pre-discussion knowledge and comprehension of guidelines, perceived hindrances to compliance with guidelines and perceived importance of guidelines as well as socio-demographic data. Results and conclusions With this study, useful and enlightening information was obtained which met the research objectives. Participants discussed the guidelines in depth and information obtained from the questionnaires were found to support what was said during the discussions. Body language or non-verbal communication as observed, and recorded on videotape, also complemented the information gained from the discussions. Summarily it can be said that the guidelines were well-received and perceived as important by the majority of respondents, although some of the guidelines were initially not well-understood without explanation. Furthermore, the fact that the applicability of the guideline on prolonged breast feeding seems to be the most problematic, is a cause for concern. In view of the results obtained in this study, it can be concluded that PFBDGs will have to be supported by extensive and appropriate educational material to be effective when introduced to the public. The findings of this study will be submitted to the PFBDG Working group for consideration before finalisation of the guidelines for the age group 6-12 months. / AFRIKAANSE OPSOMMING: Doelwitte en omvang van die studie Na aanleiding van die 1996 aanbevelings van ‘n VLO/WGO paneel van kenners vir die ontwikkeling van voedselgebaseerde dieetriglyne (VGDR) wat uniek en spesifiek gerig is tot die behoeftes van die bevolkings van verskillende lande, is ‘n Suid-Afrikaanse VGDR Werkgroep gevorm en uiteindelik ook ‘n Pediatriese VGDR (PVGDR) Werkgroep met die opdrag van laasgenoemde om VGDRe te ontwikkel vir kinders jonger as 7 jaar. ‘n Stel voorlopige Pediatriese VGDRe, gekies om die mees dringende pediatriese publieke gesondheidsvraagstukke, naamlik proteïn-energie wanvoeding, mikronutriënttekorte en infektiewe siektetoestande aan te spreek, is geformuleer vir elke ouderdomsgroep subkategorie (0-6 maande, 6-12 maande en 1-7 jaar). Die volgende stel voorlopige PVGDRe vir die ouderdomsgroep 6-12 maande is deur die Werkgroep goedgekeur om aan verbruikerstoetsing te onderwerp: • Geniet tyd saam met jou baba • Begin vanaf ses maande om jou baba klein hoeveelhede vaste kos te gee • Vermeerder jou baba se maaltye geleidelik na vyf keer per dag • Hou aan om jou baba te borsvoed • Bied gereeld vir jou baba skoon, veilige drinkwater aan • Leer jou baba om uit ‘n koppie te drink • Neem jou baba elke maand kliniek toe Evaluering van die verbruiker se begrip, interpretasie van die riglyne en die vermoë om die riglyne te implementeer, is as noodsaaklik beskou voordat die PVGDRe gefinaliseer kon word, vrygestel kon word aan die publiek, en aan professionele- en gemeenskapsgesondheidswerkers beskikbaar gestel kon word as ‘n onderrighulpmiddel. Hierdie studie was die eerste waarin PVGDRe getoets is en dit is bedoel as ‘n voorloperstudie vir verdere toetsing van PVGDRe vir hierdie ouderdomskategorie in ander dele van die land en aangepas vir ander omstandighede. Die ondersoek is gedoen onder vroue wat moeders of versorgers van babas van 6-12 maande was in die Afrikaans- Engels- en Xhosasprekende gemeenskappe van die groter Oudtshoorn area wat Bongulethu, Bridgton en Toekomsrus insluit asook die nabygeleë plattelandse gemeenskappe van Dysselsdorp, Calitzdorp, Uniondale, Ladismith en Zoar. Metodiek Die studie is ontwerp om ‘n waarnemende en beskrywende analise van ‘n deursnee van die studiepopulasie moontlik te maak. Kwalitatiewe data is verkry van ‘n proefmonster van 64 vrywilligers wat deelgeneem het aan tien fokusgroep besprekings wat elk deur 3 tot 11 persone bygewoon is. Groepbesprekings is op videoband opgeneem en kwantitatiewe en kwalitatiewe vraelyste het voorbesprekings kennis en begrip van die voorgestelde riglyne, vermeende verhindering tot uitvoering van die riglyne en vermeende belangrikheid van riglyne sowel as sosio-demografiese inligting gemeet. Resultate en gevolgtrekkings Met hierdie studie is bruikbare en verhelderende inligting verkry wat beantwoord het aan die doelwitte van die studie. Deelnemers het die riglyne in diepte bespreek en dit is bevind dat inligting wat van die vraelyste verkry is, ook dit bevestig het wat gedurende die sessies bespreek is. Lyftaal en nie-verbale kommunikasie soos waargeneem en soos op videoband vasgelê, het ook die inligting ondersteun wat van die besprekingsessies verkry is. Opsommend kan gesê word dat die riglyne goed ontvang is en as belangrik beskou is deur die meerderheid van respondente. Sommige van die riglyne was nie vir deelnemers goed verstaanbaar sonder meegaande verduideliking nie. Verder is die feit dat die toepasbaarheid van die riglyn met betrekking tot ‘n verlengde tydperk van borsvoeding voorgekom het as die mees problematiese, ‘n rede tot kommer In die lig van die resultate van hierdie studie, kan daar tot die slotsom gekom word dat PVGDRE ondersteun sal moet word deur omvattende en gepaste onderrigmateriaal om effektief te kan wees wanneer dit aan die publiek bekend bekend gestel word. Die bevindings van hierdie studie sal aan die Pediatriese VGDR Werkgroep voorgelê word vir oorweging voordat riglyne vir die ouderdomsgroep 6-12 maande gefinaliseer word.

Thesis (MNutr (Human Nutrition))--University of Stellenbosch, 2006. / INTRODUCTION: The primary objective was to determine whether acidified formulae (pH 3.5 and 4.5) decreased gastric and tracheal colonisation, as well as microbial contamination of the enteral feeding delivery system, compared with a non-acidified control formula (pH 6.8) in critically ill patients. Secondary objectives included tolerance of the trial formulae and mortality in relation to the administration of acidified formulas. DESIGN: The trial was a controlled, double-blinded, randomised clinical trial of three parallel groups at a single centre. METHOD: Sixty-seven mechanically ventilated, medical and surgical critically ill patients were randomised according to their APACHE II scores and included in the trial. Patients received either an acidified (pH 3.5 or 4.5) or control polymeric enteral formula via an 8-Fr nasogastric tube at a continuous rate. Daily samples were taken for microbiologic analyses of the enteral formulae at various stages of reconstitution and at 6-hour and 24-hour intervals during administration thereof (feeding bottle and delivery set). Daily patient samples included nasogastric and tracheal aspirates, haematological evaluation and gastro-intestinal tolerance. The trial period terminated when patients were extubated, transferred from the ICU, enteral nutrition became contraindicated, a patient died, or for a maximum of 21 days. RESULTS: Gastric pH showed no significant difference (p = 0.86) between the 3 feeding groups [pH 3.5 (n = 23), pH 4.5 (n = 23) and pH 6.8 (n = 21)] at baseline prior to the administration of enteral formulae. After initiation of feeds, the gastric pH decreased significantly (p< 0.0001) in the acidified formulae as compared to the control formula during the trial period. Patients who received acidified enteral formulae (pH 3.5 and 4.5) had significantly less (p < 0.0001) contamination from the feeding bottles and delivery systems in respect of Enterobacteriacea, and Enterococcus., The more acidified group (pH 3.5) showed significantly less gastric contamination (p = 0.029) with Enterobacteriacea, , but not for fungi. The 3.5 acidified group also had the lowest gastric growth in terms of colony counts (≤104) of these organisms, but not for fungi, when compared to the control group (≤105). Vomiting episodes were 22% and abdominal distension 12%, with a higher incidence in the control group. Adverse events occurred equally between the groups with a higher, but not significantly different incidence of 37% in the control group and 32% for the acidified groups. There was no evidence of gastro-intestinal bleeding in any patient. Overall, the mortality rate in this trial was 6%, with 6.5% for the acidified groups (n=46) and 4.8% for the control group (n=21), a statistically insignificant difference. CONCLUSION: Acidified enteral formulae significantly decrease gastric colonisation by preserving gastric acidity that decreases the growth of Enterobacteriaceaes organisms. Acidified formulae significantly decrease bacterial contamination of the enteral feeding system (bottle and delivery set) of Enterobacteriaceae and Enterococcus organisms. Acidified formulae are tolerated well in critically ill patients.

Thesis (MNutr (Interdisciplinary Health Sciences. Human Nutrition))--University of Stellenbosch, 2009. / ENGLISH ABSTRACT: The aim of the study was to investigate current perceived role of nutritional supplements in adolescent (16-18 years) male rugby players and establish usage practices within Kwazulu Natal (KZN) schools. Methods The nutritional supplementation practices of 68 rugby players from 7 KZN secondary schools were surveyed using an anonymous paper-based questionnaire. The boys were asked to identify from a list (with Other as a selection) which supplement they used, the frequency of use, sources of supplement information and advice they base their choices on, where products were bought from, reasons for use, average monthly spend on buying these supplements, whether dietary changes were made in conjunction with taking a supplement and what was their understanding of the role of supplementation in achieving their performance goals. Results Sixty eight out of 236 invited participants completed the questionnaire. This translated into a response rate of 29%. Fifty four percent of participants admitted to using nutritional supplements, protein and creatine being the most popular products listed (43% and 22% of supplement users, respectively). Thirty five percent of supplement users supplemented daily and 24% supplemented 3-4 times per week. Friends were the most popular source of advice and information regarding nutritional supplements 32% (n=12), with supplement company representatives the next most commonly used source 22% (n=8). Seventy percent (n=26) of supplements are bought from a pharmacy, with an average monthly cost of R250, but ranging from R30 to as much as R1500 per month. Seventy percent (n=26) indicated that they also made dietary changes in addition to taking the nutritional supplement. These dietary changes included making healthier food choices 81% (n=21), increasing intake of protein foods 65% (n=17), planned snacks around exercise 35% (n=9), increasing carbohydrate-rich foods 62% (n=16), increasing fruit and vegetable intake 50% (n=13), and including snacks between meals 35% (n=9). The study participants rated practice sessions and weight training as most important in terms of helping them achieve their goals; diet, rest and supplements were similarly ranked as being between fairly to very important. Twenty two percent admitted that they would consider taking an illegal supplement if it would assist them in achieving their goals. Conclusions This study indicates that at least half of rugby-playing school boys (age 16-18 yrs) are making use of some form of supplementation, with protein and creatine supplementation being the most popular. The data indicate that rugby-playing school boys see their peers as a good source of information, and are willing to spend a large amount of money obtaining it (about R250 per month on average). This is concerning as peer pressure combined with lack of knowledge on nutritional supplement usage (and nutrition) can lead to widespread misuse of supplements, and potential detrimental side-effects in this young study population. However it highlights the value that school-level educational programmes (age and sport specific) can have in improving supplement usage practices and creating sound nutritional practices amongst this population, better equipping them at making informed decisions. In addition, educational programmes should be extended to other influential sources of information such as school coaches, teachers and parents. / AFRIKAANSE OPSOMMING: Die doel van die studie was om die huidige persepsie oor die waarde van voedingsupplemente en die gebruikspraktyke daarvan in 16 -18 jarige adolessente manlike atlete in Kwazulu Natal (KZN) skole te bepaal. Uitkomste van die studie was om die voorkoms en tipe supplemente wat gebruik word, redes aangevoer vir die gebruik daarvan, kennis oor die rol van supplemente asook die bron van inligting te bepaal. Metodes Die voedingsupplementasie praktyke van 68 rugby spelers uit 7 KZN sekondêre skole is ondersoek deur gebruik te maak van n annonieme vraelys (papier basis). Die seuns is gevra om van n lys (die opsie ander was ingesluit) te identifiseer watter supplement hulle gebruik, die frekwensie van gebruik, die bronne van inligting en raadgewing ontvang, waar die produk aangekoop is, redes vir gebruik, gemiddelde maandelikse kostes aangegaan en of dieetveranderinge tesame met die supplementasie aangegaan is. Kennis rondom die rol van supplementasie in prestasie doelwitte is getoets. Resultate: Agt-en-sestig uit n totaal van 236 deelnemers wat uitgenooi is om deel te neem aan die studie, het die vraelys voltooi. Dus het 29% van die studie-deelnemers het dus op die vraelys gereageer. Vier en vyftig persent van die deelnemers het erken dat hulle supplemente gebruik waarvan kreatien en proteïen gelys is as die mees gewildste produkte (onderskeidelik 43% en 22%). Vyf en dertig persent het daagliks supplemente gebruik en 24% het 3-4 keer per week supplemente gebruik. Vriende was die mees gewildste bron van raad en inligting (32%), gevolg deur supplement maatskappy verteenwoordigers (22%). Sewentig persent van supplemente word gekoop by n apteek en n gemiddelde maandelikse bedrag van R250 word gespandeer, maar dit wissel van R30 tot soveel as R1 500 per maand. Sewentig persent het erken dat hulle dieet veranderinge in hul dieet tesame met die supplementasie aanbring. Hierdie veranderinge het die volgende ingesluit: die keuse van gesonder voedselsoorte (81%); n verhoogde inname van proteïenryke voedselsoorte (65%); beplanning van peuselhappies rondom oefening (65%); verhoogde inname van koolhidraatryke voedsel (62%); meer vrugte en groente (50%) en die neem van peuselhappies tussen maaltye (35%). Die deelnemers het oefening met gewigte en oefensessies as die mees belangrike faktore geag om hul doelwitte te bereik. Dieet, rus en supplemente is daarnaas gelyk geag as redelik belangrik en 22% het erken dat hulle n verbode middel sal gebruik indien dit hulle sal help om hulle doelwitte te bereik. Gevolgtrekkings Die studie wys dat ten minste die helfte van skoolseuns wat rugby speel (16-18 jr) een of ander vorm van supplementasie gebruik, waarvan proteïen en kreatien die mees gewildste is. Die data dui daarop dat skoolseuns wat rugby speel hul tydgenote ag as n goeie bron van inligting oor supplement gebruik en dat hulle bereid is om groot bedrae geld te spandeer om die supplemente te bekom (gemiddeld R250,00 per maand). Dit is kommerwekkend aangesien groepsdruk tesame met n gebrek aan kennis oor supplementasie (en voeding) kan lei tot algemene misbruik van supplemente en moontlike newe effekte in hierdie jong studie populasie. Dit beklemtoon egter ook die waarde wat skool gebasseerde opvoedingsprogramme kan hê om die bewustheid en kennis oor supplement gebruik in hierdie populasie te verbeter om hul in staat te stel om ingeligte besluite te neem. Dit moet ouderdom -en sportspesifieke voedingsonderrig insluit. Opvoedingsprogramme moet ook uitgebrei word na ander partye wat invloedryke bronne van inligting is soos skool afrigters, onderwysers en ouers.

Thesis (MNutr (Human Nutrition))--Stellenbosch University, 2008. / INTRODUCTION: The best known reference standards used to evaluate the growth and development of infants and children are the 1977 National Centre for Health Statistics (NCHS) - , the 2000 Centres for Disease Control and Prevention (CDC) - and the World Health Organization (WHO) (2006). The NCHS reference standards were used to analyse anthropometric data from the 1999 National Food Consumption Survey (NFCS). It was anticipated that using the 2000 CDC and the 2006 WHO reference standards may lead to differences in the previously estimated prevalences of stunting, wasting, underweight, risk of overweight, overweight and obesity in the study population. AIM: To compare the anthropometric status of children aged 12 - 60 months when using the 1977 NCHS -, the 2000 CDC -, and the 2006 WHO reference standards. METHODS: A secondary analysis of anthropometric data from the 1999 NFCS was conducted using different reference standards to compare anthropometric status in terms of the prevalences of stunting, wasting, underweight, risk of overweight, overweight and obesity. Relationships between anthropometric status and other variables such as breastfeeding, maternal education level and type of housing were explored. RESULTS: The prevalences of stunting, obesity and overweight were significantly higher and the prevalence of underweight and wasting were lower when using the 2006 WHO compared to the 1977 NCHS and the 2000 CDC reference standards. A significant relationship was found between weight-forheight and breastfeeding when using any one of the reference standards and between BMI-for-age and breastfeeding when using the 2006 WHO reference standard. A significant relationship was shown between maternal education level and height-for-age and weight-for-age when using any one of the three reference standards and a significant association was found between weight-for-height and BMI-for-age and the type of housing when using any of the three reference standards. CONCLUSIONS: The prevalences of stunting and obesity were higher when using the 2006 WHO reference standards compared to the 1977 NCHS and 2000 CDC reference standards. This may be due to the linear growth and rate of weight gain of breastfed infants differing from formula fed infants and the 2006 WHO reference made use of the exclusively and predominantly breastfed infant living under normal healthy conditions as the normative model which is a prescription of how children should not grow and .not an indication of how children are growing. In conclusion, the 2006 WHO reference standard must be the only reference standard used nationally and internationally when assessing the growth and nutritional status of infants and children.