<p>&nbsp / </p> <p align="left">This study explores the challenges faced by nurse counselors in the implementation of HIV and Infant Feeding Policy in Amathole District of the Eastern Cape. <b><font face="Times New Roman">Objectives: </font></b><font face="Times New Roman">To describe the demographic characteristics of the study population / Toexplore the challenges faced by nurse counselors in the implementation of current HIV and infant feeding policy and guidelines / &nbsp / To establish the nurse counselors&rsquo / perspectives on the infant feeding policy and guidelines for HIV positive mothers / To examine the support system available to the nurse counselors who give infant feeding advice to HIV positive mothers.</font></p>

This thesis assesses the uptake of the national Prevention of Mother to Child Transmission of HIV (PMTCT) programme in South Africa, and the challenges of achieving safe infant feeding practices in the context of HIV. The research studies contained in this thesis utilised a variety of quantitative and qualitative research methods in order to provide a full understanding of the challenges of moving from efficacy to effectiveness in PMTCT programmes. The first paper utilised a cross-sectional approach to a programme evaluation, papers two and three utilised qualitative methodologies, and paper four was based on a longitudinal cohort study design. The findings highlight the low uptake of PMTCT interventions and inappropriate infant feeding choices. The experiences of women with HIV provide an important insight into the difficulties of operationalising the WHO/UNICEF HIV and infant feeding recommendations in real life settings, where rates of HIV disclosure are low and mixed feeding is the norm. Several personal and environmental characteristics were identified that contributed to success in maintaining exclusive infant feeding practices. The research provides some guidance on the definition of appropriateness in infant feeding choices, and highlights the poor outcomes associated with formula feeding under unsafe conditions. Modifying infant feeding practices is essential in order to reduce postnatal HIV transmission and improve child survival. Interventions to improve infant feeding need to include improving the quality of counselling and support provided by health workers, with more structured assessments used to guide infant feeding choices. Efforts are also needed at the community level to increase rates of disclosure and to promote exclusive infant feeding as a norm.

<p>Promotion of exclusive breastfeeding (EBF), (giving breast milk only without any solids or liquids), has proved to be very challenging in the South African context, although this infant feeding practice has been found to protect babies against diarrhoea and respiratory tract infections and to carry a lower risk of HIV infection than mixed feeding (breastfeeding combined with formula or solids). Study design: The PROMISE-EBF study is a multi-country cluster randomised trial to examine peer support to promote exclusive breastfeeding in Africa. For the South African site in the PROMISE-EBF study, three sites, Paarl, Rietvlei and Umlazi, were selected because of their different geographic settings and each site operated as a separate stratum for cluster selection and randomisation purposes. The clusters were then randomised into intervention and control arms making a total of 17 clusters in each arm. HIV positive and negative women in the intervention arm received support on their choice of infant feeding from the peer supporters who visited them at their homes while the women in the control group only received the standard infant feeding counselling and support provided by health care&nbsp / workers at health facilities. Data collection: Mothers were interviewed at recruitment during the antepartum period to establish eligibility, obtain informed consent and data on socio-economic status. Home visits were scheduled for data collection by trained data collectors at 3, 6, 12 and 24 weeks after birth. Analysis of results: This mini-thesis was a secondary analysis of the PROMISE-EBF data focusing on the South African data only. The data was adjusted for clustering and analysed using SAS. Comparison of variables between the intervention and control groups within sites was done. Results: A significant difference, regarding counselling and infant feeding practices, was observed among all women who received peer support compared to those who received the standard antenatal counselling, with more women in the intervention group (20.5%) practising EBF than those in the control group (12.8%) by Week 3. When the women‟s HIV status was considered, more than 65% of HIV positive and 40% of HIV negative women practised MF and EFF (giving formula milk only with no breast milk) throughout the study, respectively, regardless of the group they were in. For women who hadintended to practise EBF at recruitment, 33% in the control group and 20% in the intervention group actually practised EBF by Week 3. Regarding disclosure and feeding choice, 77.4% of women who had disclosed their HIV status actually practised MF versus 8.6% who practised EBF by Week 3.Conclusion: Community peer counselling should be strengthened as the results from this study showed that a high percentage of women who practised EBF were those who had received counselling, irrespective of their HIV status. The high percentage of HIV positive women who practised high risk feeding, despite receiving infant counselling, is of concern. Disclosure of the women‟s HIV status did not translate to them practising low risk infant feeding methods, which may suggest that there are other issues that determine the women‟s choice of infant feeding.</p>

This thesis is concerned with how prehistoric infants were fed in different physical and cultural environments, and in particular what impact the economic, social, and epidemiological changes associated with the development of agriculture had on infant feeding practices. In order to examine these effects, stable isotope ratio analysis has been used to assess the duration of breastfeeding and weaning in a variety of prehistoric contexts. The first study is of Pitted Ware Culture hunter-gatherers at the site of Ajvide on Gotland, Sweden. Breastfeeding usually continued for at least two years, but there was some variation in supplementary foods, which is attributed to seasonal variations in resource availability. The second study analysed a number of Neolithic and early Bronze Age sites from south-east Poland. Breastfeeding duration varied both within and between sites and ranged from six months to five years. The third study found that the infant feeding practices of two Iron Age populations on Öland, Sweden, were very varied, and infants may have been fed differently depending on their social status. The fourth study is of the childhood diet in the Únětice Culture of south-west Poland. Individual diets changed little during the lifetime, suggesting that eventual adult identity was determined early in life. A small number of infants in the study were found to have breastfed for differing lengths of time. The final paper considers the health consequences of introducing animal milks into the infant diet in a prehistoric context, and finds that their availability is unlikely to have made it possible to safely wean infants earlier. Comparison of the results from the four stable isotope studies to those of other published studies reveals that the modal age at the end of weaning was slightly lower in agricultural communities than hunter-gatherer communities, but the range of ages was similar. Weaning prior to the age of eighteen months was rare before the post-medieval period. It is argued that the gradual reduction in breastfeeding duration since the Neolithic, and the replacement of breastmilk with animal milk products, means that on the whole the development of agriculture probably served to increase infant morbidity and mortality. / <p>At the time of doctoral defense the following papers were unpublished and had a status as follows: Paper 1: Manuscript; Paper 4: Accepted; Paper 5: Forthcoming 2014</p> / Lactase Persistence and the early Cultural History of Europe (LeCHE)

Background Sweden has experienced a unique epidemic of celiac disease (CD) in children younger than 2 years of age. The epidemic was partly explained by changes over time in infant feeding and indicated a multifactorial aetiology. In CD, a strict lifelong gluten-free diet (GFD) is crucial for health but noncompliance is often reported among adolescents. Knowledge is limited regarding their own perspectives and experiences of managing the disease and adhering to GFD. Objectives To analyse the incidence of CD in epidemic and post epidemic birth cohorts, and explore and understand how adolescents with CD perceive and manage their everyday lives in relation to the GFD. Methods A population-based incidence register of CD in children covering the entire nation from 1998 to 2003, and part of the country back to 1973. ESPGHAN diagnostic criteria for CD and NUTS classification of regions were used. Incidence rates for each year of diagnosis, age group, gender and region, and cumulative incidence by age for each birth cohort were calculated. Ten focus groups were conducted with 47 CD adolescents aged 15-18 years. Transcribed interviews were analysed to illustrate and explain adolescents’ own perspectives concerning life with a GFD, and to search for recurrent stigma-related themes across the groups. Results A considerable gap in the cumulative incidence of CD at comparable ages was demonstrated between birth cohorts of the epidemic and post-epidemic periods. The gap persisted during pre-school years, although it decreased somewhat with age. During the final years of follow-up there was again a gradual increase in incidence rate among children younger than 2 years of age. The childhood populations in ‘West Sweden’ and ‘Småland and the islands’ had a significantly higher incidence rate compared to ‘North Middle Sweden’ and ‘Stockholm’. CD adolescents described an awareness of being different from others produced by meal appearance and the poor availability of gluten-free (GF) food. Eating in public had the effect of making an invisible condition visible and thereby creating a context for felt or enacted stigma. Maintaining invisibility avoided the negative consequences of stigma. The probability of compliance with the GFD was compromised by insufficient knowledge of significant others, problems with the availability and sensory acceptance of GF food, insufficient social support and their perceived dietary deviance. Three different approaches to the GFD emerged: compliers, occasional non-compliers, and non-compliers. Conclusions The difference in CD risk between birth cohorts at comparable ages may suggest an opportunity for primary prevention. Based on post-epidemic incidence trends, the Swedish epidemic might not have been as unique as previously thought, even though its magnitude was striking. The regional variation in CD risk supports multifactorial aetiology. Continued efforts are warranted to define factors besides gluten exposure that modulate CD risk. CD adolescents experience various dilemmas related to the GFD. It can produce stigma experiences in adolescence, and dietary compliance (or lack of) can be understood in terms of dealing with GFD concealment and disclosure. The increase in CD prevalence over time and unmet needs in young celiacs require resources to attain adequate levels of dietetic provision, regulated subsidies for covering additional costs for GF food, evidence-based practice, and increased general CD awareness for optimum clinical outcomes.

<p>&nbsp / </p> <p align="left">This study explores the challenges faced by nurse counselors in the implementation of HIV and Infant Feeding Policy in Amathole District of the Eastern Cape. <b><font face="Times New Roman">Objectives: </font></b><font face="Times New Roman">To describe the demographic characteristics of the study population / Toexplore the challenges faced by nurse counselors in the implementation of current HIV and infant feeding policy and guidelines / &nbsp / To establish the nurse counselors&rsquo / perspectives on the infant feeding policy and guidelines for HIV positive mothers / To examine the support system available to the nurse counselors who give infant feeding advice to HIV positive mothers.</font></p>

<p>Promotion of exclusive breastfeeding (EBF), (giving breast milk only without any solids or liquids), has proved to be very challenging in the South African context, although this infant feeding practice has been found to protect babies against diarrhoea and respiratory tract infections and to carry a lower risk of HIV infection than mixed feeding (breastfeeding combined with formula or solids). Study design: The PROMISE-EBF study is a multi-country cluster randomised trial to examine peer support to promote exclusive breastfeeding in Africa. For the South African site in the PROMISE-EBF study, three sites, Paarl, Rietvlei and Umlazi, were selected because of their different geographic settings and each site operated as a separate stratum for cluster selection and randomisation purposes. The clusters were then randomised into intervention and control arms making a total of 17 clusters in each arm. HIV positive and negative women in the intervention arm received support on their choice of infant feeding from the peer supporters who visited them at their homes while the women in the control group only received the standard infant feeding counselling and support provided by health care&nbsp / workers at health facilities. Data collection: Mothers were interviewed at recruitment during the antepartum period to establish eligibility, obtain informed consent and data on socio-economic status. Home visits were scheduled for data collection by trained data collectors at 3, 6, 12 and 24 weeks after birth. Analysis of results: This mini-thesis was a secondary analysis of the PROMISE-EBF data focusing on the South African data only. The data was adjusted for clustering and analysed using SAS. Comparison of variables between the intervention and control groups within sites was done. Results: A significant difference, regarding counselling and infant feeding practices, was observed among all women who received peer support compared to those who received the standard antenatal counselling, with more women in the intervention group (20.5%) practising EBF than those in the control group (12.8%) by Week 3. When the women‟s HIV status was considered, more than 65% of HIV positive and 40% of HIV negative women practised MF and EFF (giving formula milk only with no breast milk) throughout the study, respectively, regardless of the group they were in. For women who hadintended to practise EBF at recruitment, 33% in the control group and 20% in the intervention group actually practised EBF by Week 3. Regarding disclosure and feeding choice, 77.4% of women who had disclosed their HIV status actually practised MF versus 8.6% who practised EBF by Week 3.Conclusion: Community peer counselling should be strengthened as the results from this study showed that a high percentage of women who practised EBF were those who had received counselling, irrespective of their HIV status. The high percentage of HIV positive women who practised high risk feeding, despite receiving infant counselling, is of concern. Disclosure of the women‟s HIV status did not translate to them practising low risk infant feeding methods, which may suggest that there are other issues that determine the women‟s choice of infant feeding.</p>

To determine the relationship between infant-feeding practices and diarrhoeal infections, a descriptive survey was conducted to infants between six to 12 months of age. A guided interview was conducted to 105 mothers of infants who attended the health facilities of Mbabane, Swaziland. The results show that breast-feeding is routinely practiced by the majority of mothers and exclusive breast-feeding is very low, but supplementary feed in the form of formula or solids are introduced by the majority of respondents within the first three months of life. Infants who were given colostrum and breast milk had fewer diarrhoeal attacks. Other factors, for example education and cultural factors influenced the feeding practices and number of diarrhoeal attacks. It is recommended that breast-feeding should be promoted as an important intervention in the control of diarrhoea / Health Studies / M.A. (Nursing Science)

Abstract Increasing evidence suggests that early-life exposures influence the health and wellbeing in later life. Preterm birth (before 37 weeks of gestation) is associated with an increased risk of cardiometabolic disorders in later life. This risk may be partly mediated by nutrition along the course of life. As a part of the Helsinki Study of Very Low Birth Weight Adults, the aim of the present work was to investigate the association between energy and macronutrient intake during the first weeks after preterm birth at very low birth weight (VLBW, birthweight &#60; 1500g) and body composition and energy metabolism in adulthood (n=127). A further aim was to examine traits related to eating disorders and food and nutrient intake in young adults born early (&#60;34 weeks of gestational age, n=191) and late (34-&#60;37 weeks of gestational age, n=364) preterm and term-born controls (n=657) from the ESTER study and Arvo Ylppö Longitudinal study. Relatively low neonatal energy and nutrient intakes during the first weeks of life of infants born at VLBW predicted body composition and energy metabolism in adulthood. When adjusted for sex, age, gestational age and birth-weight SD score every 1g/kg/day greater early protein intake was associated with 10.4% (95% CI 2.4, 19.1) higher lean body mass (LBM) and 8.5% (0.2, 17.0) higher resting energy expenditure (REE). The ratio of REE/LBM however was 5.5% (0.8, 10.0) lower. In addition, higher protein and energy intakes predicted lower energy intake per unit of LBM in young adults. These associations were only partly mediated by early growth. Young women born early preterm reported on average healthier body image and fewer traits related to eating disorders when compared with term-born peers. However, their adherence to recommended eating guidelines was on average lower. According to the results of present work, energy balance is partly programmed by relatively small variations in the amount of protein in the diet in infancy. Among young adults born preterm, focusing on primary prevention, such as dietary counseling, is suggested. / Tiivistelmä Elämän varhaisvaiheet muokkaavat terveyttä ja hyvinvointia pitkällä aikavälillä. Ennenaikaisesti (ennen 37. raskausviikkoa) syntyneillä aikuisilla on todettu olevan suurempi riski sairastua sydän- ja verisuonitauteihin verrattuna täysiaikaisina syntyneisiin ikätovereihin. Ravitsemuksella, läpi elämänkaaren, on keskeinen rooli tuon riskin muokkaajana. Tämän väitöskirjatutkimuksen tavoitteena oli selvittää osana Pikku-k-tutkimusta (n=127), miten pienipainoisina (syntymäpaino &#60;1500g) syntyneiden keskosten elämän ensimmäisten viikkojen energian ja ravintoaineiden saanti ennustaa kehonkoostumusta ja energiankulutusta sekä energian saantia aikuisiässä. Lisäksi tavoitteena oli tutkia ESTER- tai AYLS-kohorttitutkimuksiin osallistuneiden, hyvin (&#60;34 raskausviikolla syntyneiden, n=191) ja lievästi (34-37, n=364) keskosena syntyneiden ja täysiaikaisena syntyneiden (n=657) nuorten aikuisten syömishäiriöpiirteitä, kehonkuvaa sekä ruoan käyttöä ja ravintoaineiden saantia. Suhteellisen matala elämän ensimmäisten viikkojen aikainen energian ja ravintoaineiden saanti ennusti kehonkoostumusta ja energia-aineenvaihduntaa aikuisiässä. 1g/kg/päivä korkeampi proteiininsaanti oli yhteydessä 10,4 % (95% luottamusväli 2,4; 19,1) suurempaan rasvattomaan painoon sekä 8,5 % (0,2; 17,0) korkeampaan lepoenergiankulutukseen aikuisiässä. Lepoenergiankulutus rasvatonta painoyksikköä kohden oli kuitenkin 5,5 % (0,8; 10,0) matalampi enemmän proteiinia saaneilla keskosilla. Lisäksi korkeampi energian ja proteiininsaanti elämän ensimmäisten viikkojen aikana ennusti matalampaa energiansaantia painoyksikköä kohden aikuisiässä. Varhaisella kasvulla oli vain pieni rooli tämän yhteyden välittäjänä. Nuorilla, hyvin ennenaikaisena (ennen 34. raskausviikkoa) syntyneillä, naisilla oli vähemmän syömishäiriöihin liittyviä piirteitä ja terveellisempi kehonkuva verrattaessa heitä täysiaikaisena syntyneisiin ikätovereihin. Arvioitaessa heidän ruokavaliotaan, todettiin kuitenkin heidän syövän hieman epäterveellisemmin ikätovereihin verrattuna. Tämän väitöskirjatutkimuksen tulosten valossa varhainen puuttuminen keskosena syntyneiden lisääntyneeseen sydän- ja verisuonitautien riskiin on mahdollista kiinnittämällä huomiota varhaiseen ravitsemukseen ja varhaisen aikuisiän elintapaohjaukseen, etenkin ravitsemukseen liittyen.

A obesidade infantil é considerada uma epidemia em nível mundial e tem recebido uma atenção importante por parte dos profissionais de saúde. Esta doença possui causas multifatoriais com destaque aos hábitos de vida e alimentares, sendo estes relacionados ao crescimento no número de indivíduos obesos. No período entre 1989 e 2009 registrou-se um aumento de 300% no número de crianças acima do peso no Brasil, entre a faixa etária de cinco a nove anos de idade, com uma grande prevalência de dislipidemia. O presente estudo buscou avaliar a possível influência de atitudes, crenças, práticas, habito alimentar e Estado Nutricional (EN) de um responsável pela alimentação da criança perante o hábito alimentar e EN de crianças de seis a dez anos que residiam na área de abrangência das Unidades de Saúde da Família (USF) da cidade de Ribeirão Preto SP. Um total de 164 crianças e seus respectivos responsáveis (n=164) participaram deste estudo. Foram aplicados os seguintes instrumentos: Questionário de Caracterização da Amostra, Critério de Classificação Econômica Brasil, Questionário de Alimentação da Criança (QAC), Questionário de Avaliação de Hábitos Saudáveis de Alimentação, Escala de Crenças sobre Dieta, Recordatório de 24 horas (para cálculo do Índice de Qualidade da Dieta Revisado IQD-R). Foi realizada, ainda, aferição de peso e estatura do responsável e da criança. Os resultados obtidos mostraram que 75% (n=123) dos principais cuidadores das crianças eram as mães, mas que outros responsáveis vêm assumindo esse papel no cuidado da criança (avó, pai, tia, irmã). O EN das crianças e seus responsáveis apresentaram alta prevalência de excesso de peso (18,3% e 32,9%, respectivamente) e obesidade (15,9% e 37,9%, respectivamente). A maior parte das crianças que apresentaram excesso de peso (100%; n=56) possuía seu responsável também com excesso de peso (82,1%; n=46). Doenças Crônicas Não Transmissíveis (DCNT) se mostraram muito prevalentes entre os familiares próximos das crianças participantes deste estudo, independentemente do EN da criança (Diabetes Mellitus: 46,3%; Hipertensão Arterial: 62,8% e Dislipidemia: 31,1%). A preocupação dos responsáveis com o peso da criança foi maior entre os responsáveis das crianças que estavam acima do peso (3,6±1,29). Por outro lado, uma maior pressão para comer foi identificada entre os responsáveis com crianças abaixo do peso ou com peso normal (3,3±0,97 e 3,9±0,99, respectivamente). A média do IQD-R das crianças (50,0±13,6) foi muito similar à dos responsáveis (56,5±12,1), mais especificamente 51,8% (n=85) das crianças apresentaram dieta inadequada e 47,0% (n=71) apresentaram dieta que necessita de modificação. Por outro lado, entre os responsáveis esses valores foram um pouco melhores: 30,5% (n=50) dos responsáveis apresentaram dieta inadequada e 67,1% (n=110) apresentaram dieta que necessita de modificação. Os dados gerais obtidos através dos instrumentos propostos neste trabalho sugerem que o EN dos responsáveis pode influenciar o EN das crianças, o padrão de consumo dos responsáveis pode influenciar o consumo alimentar das crianças e algumas práticas de controle da alimentação da criança podem interferir também em seu consumo e consequentemente em seu EN. / Childhood obesity is considered a worldwide epidemic and has received important attention from health professionals. This disease has multifactor causes with emphasis on lifestyle and eating habits, and these are related to the growth in the number of obese individuals. In the period between 1989 and 2009, there was a 300% increase in the number of overweight children in Brazil (five- to nine-year-old subjects), with a high prevalence of dyslipidemia. This study aimed at evaluating the possible influence of attitudes, beliefs, practices, dietary habits and nutritional status (NS) of a caregiver individual, responsible for feeding the child in relation to the eating habit and NS of children from six to ten years old, in the area of coverage of Health Units (USF) in the city of Ribeirão Preto - SP. A total of 164 children and their respective caregivers (n = 164) were sampled for this study. The following instruments were applied: Sample Characterization Questionnaire, Brazil\'s Economic Classification Criteria, Child Feeding Questionnaire (CFQ); Healthy Eating Habits Assessment Questionnaire; Dietary Beliefs Scale; 24-hour Reminder (Calculation of the Revised Diet Quality Index). The weight and height of the caregiver and the child were also measured. The results showed that 75% (n=123) of the main caregivers of the children were their mothers, but that other caregivers have assumed this role as well (grandmother, father, aunt, sister). NS of children and caregivers showed prevalence of overweight condition (18.3% and 32.9%, children and caregivers, respectively) and obesity (15.9% and 37.9%, respectively). Most overweight children (100%; n=56) had caregivers also overweight (82,1%; n=46). Non-transmissible chronic diseases (NTCDs) were very prevalent among the close relatives of the children participating in this study (Diabetes Mellitus: 46.3%, Arterial Hypertension: 62.8% and Dyslipidemia: 31.1%). A concern about NS (in particular regarding the child\'s weight) was perceived among caregivers and was higher among those responsible for children who were overweight (3.6 ± 1.29). On the other hand, a higher effort to feed their children was noticed among caregivers responsible for underweight or normal weight children (3.3 ± 0.97 and 3.9 ± 0.99, respectively). The mean IQD-R of children (50.0 ± 13.6) was very similar to that of those responsible (56.5 ± 12.1), more specifically 51.8% (n=85) of the children whose diet was characterized as \"inadequate\" and 47.0% (n=71) were characterized as having a diet that \"requires adjustments\". Among caregivers, these values were slightly better: 30.5% (n=50) for responsible-individuals classified as having an \"inadequate\" diet, and 67.1% (n=110) were considered as \"requiring adjustments\" to their diets. The overall results of this research suggest that NS of caregivers can influence their children\'s NS. Moreover, food consumption patterns of caregivers can influence feeding patterns of their children, and some control practices of the child\'s diet may also interfere in their food consumption, and consequently in their NS.