Seizing the big missed opportunity: linking HIV and maternity care services in sub-Saharan Africa

This paper draws on two reviews commissioned by the UK Department for International Development in 2006-2007 that explore progress in linking HIV prevention and maternity services in sub-Saharan Africa. Although pilot and demonstration projects have been successful, progress in scaling up PMTCT has been slow, reaching just 11% of pregnant HIV positive women in much of Africa, less than half the percentage of coverage achieved by antiretroviral treatment programmes for adults in need. Despite ongoing efforts to promote comprehensive approaches, significant policy, financing and institutional barriers, and weak co-ordination and leadership, continue to hamper progress. Maternal health services face human and financial resource shortages which affect their capacity to integrate HIV prevention. Both HIV and maternal health programmes often receive targeted financial and technical assistance that does not take the other into account. However, proposals in 2007 from a number of countries to the Global Fund to Fight AIDS, TB and Malaria incorporate sexual and reproductive health programming that will have an impact on HIV, including certain maternity services. Moreover, Botswana, Kenya and Rwanda have shown that progress can be made where national commitment and increased resources are enabling maternal and newborn care to address HIV.     

Mean ± Standard Deviation Intake Values for 1–<10-Year-Old South African Children for Application in the Assessment of the Inflammatory Potential of Their Diets Using the DII® Method: Developmental Research

This study aimed to develop a set of mean ± standard deviation (SD) intake values for South African (SA) children for 36 of the 45 food parameters included in the original Dietary Inflammatory Index (DII^®) tool. The SA food composition database contains 30 of the 45 food parameters included in the original DII^®, and a supplementary database was developed for six of the food parameters not included in the SA database. The SA child mean ± SD intake of macronutrients, micronutrients and select flavonoids was calculated by age in years, using eight data sets from dietary surveys conducted in SA in the last three decades. A total sample of 5412 children was included in the calculation of the mean ± SD. The current study sample was determined to be representative of 1–<10-year-old children in SA, and the plausibility of the mean intake values was confirmed by being in line with age-appropriate recommendations. Furthermore, an increase in energy, macronutrient, and most micronutrient intakes with increase in age was evident. The generated mean ± SD values for SA children can be used for calculation of the inflammatory potential of the dietary intake of SA children in the age range of 1–<10-year-old children.     

Illustration of the Importance of Adjustment for within- and between-Person Variability in Dietary Intake Surveys for Assessment of Population Risk of Micronutrient Deficiency/Excess Using an Example Data Set

Nutrition intervention decisions should be evidence based. Single 24-h recalls are often used for measuring dietary intake in large dietary studies. However, this method does not consider the day-to-day variation in populations’ diets. We illustrate the importance of adjustment of single 24-h recall data to remove within-person variation using the National Cancer Institute method to calculate usual intake when estimating risk of deficiency/excess. We used an example data set comprising a single 24-h recall in a total sample of 1326 1–<10-year-old children, and two additional recalls in a sub-sample of 11%, for these purposes. Results show that risk of deficiency was materially overestimated by the single unadjusted 24-h recall for vitamins B12, A, D, C and E, while risk of excess was overestimated for vitamin A and zinc, when compared to risks derived from usual intake. Food sources rich in particular micronutrients seemed to result in overestimation of deficiency risk when intra-individual variance is not removed. Our example illustrates that the application of the NCI method in dietary surveys would contribute to the formulation of more appropriate conclusions on risk of deficiency/excess in populations to advise public health nutrition initiatives when compared to those derived from a single unadjusted 24-h recall.     

Liver is widely eaten by preschool children in the Northern Cape province of South Africa: Implications for routine vitamin A supplementation

Previous research has demonstrated a virtual absence of vitamin A deficiency and adequacy of vitamin A intake through consumption of liver in preschool children of a community in the Northern Cape province of South Africa where sheep farming is common, and liver, an exceptionally rich source of vitamin A, is frequently eaten. Only 60–75 g of liver per month is needed to meet the vitamin A requirement of preschool children. Because this may have implications for routine vitamin A supplementation, and because liver consumption for the rest of the province is unknown, the study aim was to establish the prevalence and frequency of liver intake in a provincial‐wide survey. An unquantified liver‐specific food frequency questionnaire, covering a period of 1 month, complemented by a 1‐year recall, was administered to mothers of 2‐ to 5‐year‐old children (n = 2,864) attending primary health care facilities in all five districts and 26 subdistricts. A total of 86% of children were reported to eat liver, which was eaten in all districts by at least 80% of children. The overall median frequency of liver intake was 1.0 [25th, 75th percentiles: 0.5, 3.0] times per month and ranged from 1.0 [0.3, 2.0] to 2.0 [1.0, 4.0] for the various districts. Based on a previously reported portion size of 66 g, these results suggest vitamin A dietary adequacy in all districts and possibly also vitamin A intake exceeding the Tolerable Upper Intake Level in some children. Routine vitamin A supplementation in this province may not be necessary and should be reconsidered.     

Fine mapping analysis confirms and strengthens linkage of four chromosomal regions in familial hypospadias

Hypospadias is a common male genital malformation and is regarded as a complex disease affected by multiple genetic as well as environmental factors. In a previous genome-wide scan for familial hypospadias, we reported suggestive linkage in nine chromosomal regions. We have extended this analysis by including new families and additional markers using non-parametric linkage. The fine mapping analysis displayed an increased LOD score on chromosome 8q24.1 and 10p15 in altogether 82 families. On chromosome 10p15, with the highest LOD score, we further studied AKR1C2, AKR1C3 and AKR1C4 involved in steroid metabolism, as well as KLF6 expressed in preputial tissue from hypospadias patients. Mutation analysis of the AKR1C3 gene showed a new mutation, c.643G>A (p.(Ala215Thr)), in a boy with penile hypospadias. This mutation is predicted to have an impact on protein function and structure and was not found in controls. Altogether, we homed in on four chromosomal regions likely to harbor genes for hypospadias. Future studies will aim for studying regulatory sequence variants in these regions.     

Racial differences in patients with adenocarcinoma of the endometrium.

OBJECTIVE: To determine the differences between white and black women with regard to the presentation and behavior of adenocarcinoma of the endometrium. METHOD: Records of 273 (68%) white patients and 117 (32%) black patients with endometrial adenocarcinoma were reviewed in Bloemfontein, South Africa. Survival data was calculated according to the direct method where losses in follow-up were regarded as tumor deaths. RESULTS: Most patients (82%) were treated by pre-operative radium followed by total abdominal hysterectomy and bilateral salpingo-oophorectomy, with post-operative external irradiation where indicated. Pre-operatively, fewer black women had reached FIGO stage I, while a larger number had advanced to stages II-IV (P = 0.0024). In addition, the tumor differentiation was more often poor in the black group (P < 0.0001). Ten-year follow-up was achieved in 84% of the white patients and 51% of the black patients and the 10-year survival figures were 67% for white patients and 28% for blacks (P < 0.0001). CONCLUSION: Endometrial adenocarcinoma is a more aggressive disease in black women than it is in whites.     

Risk of pulmonary tuberculosis in children with congenital heart disease

Children with low-flow congenital heart lesions are reported to have an increased incidence of pulmonary tuberculosis. The aim of this study was to investigate if children with congenital heart disease have an increased incidence of pulmonary tuberculosis and to determine if patients with certain heart conditions are more susceptible to pulmonary tuberculosis than others. This retrospective study over a 6-year period showed that pulmonary tuberculosis was 2.5-fold more common in children with congenital heart disease than in normal children from the same community. Children with congenital pulmonary stenosis had a prevalence equal to those with acyanotic (ventricular and atrial septal defects) and cyanotic (transposition of the great arteries) high-flow heart lesions, whereas there were no cases of tuberculosis in children with low-flow cyanotic heart lesions such as tetralogy of Fallot. Cardiac surgery had to be postponed as a result of pulmonary tuberculosis in 7.2% of all patients in whom it was required. Over the 6-year period of the study, cardiac surgery had to be delayed in 60% of cases with pulmonary tuberculosis and congenital heart lesions so antituberculosis therapy could be completed. Physicians treating children with congenital heart lesions should maintain a high index of suspicion for the development of pulmonary tuberculosis, especially in those with acyanotic and cyanotic high-flow lesions and pulmonary stenosis.     

Micronutrient dilution associated with added sugar intake in elderly black South African women

OBJECTIVES: To investigate the association between added sugar and macronutrient and micronutrient intakes, and to assess whether added sugar intake is related to biochemical indices of nutritional status, Mini-Nutritional Assessment (MNA) score, body mass index (BMI) and performance on physical function tests. DESIGN: A cross-sectional, analytical study. SETTING AND SUBJECTS: Convenient sample of 285 institutionalised and community-dwelling black South African men and women aged 60+ y. METHODS: An interviewer-administered 24-h dietary recall and MNA were performed. Serum albumin, vitamin B12, ferritin, cholesterol, haemoglobin, red blood cell (RBC) folate and plasma vitamin C were measured. Handgrip strength, BMI, 'sit-to-stand' and 'get-up-and-go' tests were measured. Outcome variables were analysed according to tertiles of added sugar, in grams and as a percentage of total energy (% E). RESULTS: In each tertile of sugar intake, mean MNA score fell in the 'at-risk' classification. In women, energy, protein, % E protein, fibre, thiamin, riboflavin, niacin, vitamin B6, folate, pantothenic acid, biotin, vitamin C, calcium, iron, magnesium, phosphorus, zinc, copper and selenium intake were significantly lowest in subjects in the highest % E sugar tertile. In men, no differences were found for micronutrient intake according to tertiles of total added sugar or % E added sugar. Physical function declined with increasing sugar intake, and suboptimal RBC folate and plasma ascorbic acid status was associated with increasing sugar intake (in women). No relationship was found between added sugar intake and the very high prevalence (65%) of obesity in women. CONCLUSION: A nutrient-diluting effect of added sugars intake was demonstrated in elderly black South African women. Further studies in this population are required in order to develop food-based dietary guidelines, which include messages on added sugar intake.