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226 Pages·2015·4.11 MB·English

DIETARY ADEQUACY, VARIETY AND DIVERSITY
AND ASSOCIATED FACTORS (ANTHROPOMETRY AND SOCIO-
ECONOMIC STATUS) IN PREGNANT WOMEN ATTENDING
THE BISHOP LAVIS MOU IN CAPE TOWN
By
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Celeste Marinda de Bruyn, BSc Dietetics
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SUBMITTED TO THE UNIVERSITY OF CAPE TOWN
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In fulfilment of the reqfuirements for the degree
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MtSc(Med)in Dietetics
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Faculty of Health Sciences
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Date of submission: August 2015
Supervisor:
Dr Janetta Harbron, Division of Human Nutrition, Department Human Biology, UCT
Co-supervisors:
Prof Marjanne Senekal, Division of Human Nutrition, Department of Human Biology, UCT
Prof Hein J Odendaal, Department of Obstetrics and Gynaecology, Stellenbosh University
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The copyright of this thesis vests in the author. No
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quotation from it or information derived from it is to be

published without full acknowledgeement of the source.
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The thesis is to be used for private study or non-
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commercial research purposes only.

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Published by the Universit y of Cape Town (UCT) in terms
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of the non-exclusive license granted to UCT by the author.
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DECLARATION
I, Celeste Marinda de Bruyn , hereby declare that the work on which this dissertation/thesis
is based is my original work (except where acknowledgements indicate otherwise) and that
neither the whole work nor any part of it has been, is being, or is to be submitted for another
degree in this or any other university.
I empower the university to reproduce for the purpose of research either the whole or any
portion of the contents in any manner whatsoever.
Signature: …………………………………
Date: 16 August 2015 .
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ABSTRACT

Aim: The aim of this study was to determine the adequacy of the dietary intake of pregnant women
attending Bishop Lavis MOU, in the Tygerberg area of Cape Town.

Methods: One hundred and fifty-two women between 12 and 20 weeks’ gestational age
participating in the Main PASS study were recruited. They completed three interviewer-
administered 24-hour dietary recall assessments on three different days, each approximately two
weeks apart. Dietary reference values for adequate nutritional intake during pregnancy and the
South African food based dietary guidelines and NARs and MAR were used to assess the
nutritional adequacy. Anthropometric and socio-demographic information was also collected.

Results: The results indicate that just over a quarter of the sample were classified as teenage
pregnancies. The majority had between grade eight and ten, and had a monthly household income
between R500 and R5 000. With a mean energy intake of 10 168.4kJ, majority (79.5%) of the study
sample did not meet the energy DRI. Close to half (42.8%) of the study sample did not meet the
DRI for protein intake. All participants met the carbohydrate EAR, and many exceeded the
recommended fat intake. The intake of sugar and saturated fats exceeded recommendations with
sugar contributing to almost half of the total energy from carbohydrates. The intakes of vitamin A,
D and E, pantothenate, biotin, folate, calcium, iron, magnesium, potassium, and manganese fell
below the recommendations. Sugar was the most commonly consumed food item, followed by
potato, chicken, milk, and white bread. Apples were the most commonly consumed fruit. When
compared to the FBDG, the study sample consumed double the recommended portions of starch,
half the recommended daily fruit and vegetables, and half the recommended legumes.

Conclusion: The high intake of refined carbohydrates, especially sugar, and the high intake of
foods high in saturated fats needs to be addressed. Micronutrient intake is generally poor, especially
with nutrients that are vital to proper growth and development of the foetus. Education on
appropriate dietary changes, as well as suggestions to make implementation of such changes
affordable would be invaluable, and may contribute towards decreasing the incidence of adverse
pregnancy outcomes.

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ACKNOWLEDGEMENTS

To all the amazing people who have supported me through this journey; all my family,
friends and supervisors, the UCT administration team, my employers, and strangers that I
met along the way – a sincere and heartfelt thank you for you support, encouragement,
patience, assistance and friendly smiles.
Each one of you played a special part in helping me reach this end.

“I pass with relief from the tossing sea of Cause and Theory
to the firm ground of Result and Fact.”

― Winston S. Churchill, The Story of the Malakand Field Force
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CONTENTS

DECLARATION 1
ABSTRACT 2
ACKNOWLEDGEMENTS 3
CONTENTS 4
LIST OF TABLES AND FIGURES 7
LIST OF ABBREVIATIONS 10
CHAPTER ONE – INTRODUCTION 14
1.1 Motivation for study 15
1.2 Aims and objectives 17
1.3 Outline of thesis 18
1.4 Candidate’s contribution 19
CHAPTER TWO – LITERATURE REVIEW 20
2.1 Introduction 21
2.2 Physiological changes in pregnancy 21
2.2.1 Non-metabolic changes in pregnancy 21
2.2.2 Physiology of foetal development 22
2.2.3 Recommended weight gain for pregnant women 24
2.3 Nutrition and pregnancy 26
2.3.1 Daily nutrient requirements before and during pregnancy 26
2.3.2 Energy, macronutrients and fluids 26
2.3.3 Vitamins 31
2.3.4 Minerals 36
2.3.5 Food portion intake recommendations to meet energy and nutrient 40
requirements during pregnancy
2.3.6 Quality based food recommendations 41
2.3.7 Need for nutrient supplementation during pregnancy 43
2.3.8 Adequacy of dietary intake in pregnant and non-pregnant women 46
2.4 Nutrition-related complications in pregnancy 57
2.4.1 Unhealthy weight and weight gain 57
2.4.2 Dieting 58
2.4.3 Nausea and vomiting 59
2.4.4 Heartburn 59
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2.4.5 Pica 60
2.4.6 Constipation 61
2.4.7 Gestational diabetes mellitus 61
2.4.8 Pregnancy induced hypertension 62
2.4.9 Maternal age 62
2.4.10 Vegetarianism 63
2.4.11 Caffeine consumption 64
2.5 Nutrition related pregnancy outcomes 65
2.5.1 Infant birth weight 65
2.5.2 Perinatal mortality 66
2.5.3 Foetal programming 67
2.5.4 Effects of alcohol consumption during pregnancy 68
2.6 Nutritional status assessment in pregnant women 69
2.6.1 Overview of dietary intake assessment methods 70
2.6.2 Interpretation of dietary intake data 73
2.6.3 Anthropometric assessments 79
2.6.4 Biochemical assessments 81
2.7 Concluding remarks 82
CHAPTER THREE: METHODS AND PROCEDURES 83
3.1 Study design 84
3.2 Sampling and recruitment 84
3.2.1 Study population and sampling 84
3.2.2 Inclusion and exclusion criteria 84
3.2.3 Recruitment process 84
3.2.4 Final sample 85
3.3 Measures and questionnaires 86
3.3.1 Anthropometric measures 86
3.3.2 Socio-demographic questionnaire 89
3.3.3 24-Hour recall 89
3.4 Interpretation of dietary intake data 93
3.4.1 Under- and over-reporters (validity measure) 93
3.4.2 Adequacy of dietary intake 94
3.4.3 Dietary diversity and variety 99
3.5 Statistical procedures and analysis 100
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3.6 Ethical considerations 102
CHAPTER FOUR – SOCIO-DEMOGRAPHIC AND ANTHROPOMETRIC 103
PROFILE
4.1 Introduction 104
4.2 Results 105
4.3 Discussion 111
CHAPTER FIVE – DIETARY ADEQUACY 117
5.1 Introduction 118
5.2 Results 119
5.3 Discussion 131
CHAPTER SIX – DIETARY VARIETY 142
6.1 Introduction 143
6.2 Results 143
6.3 Discussion 154
CHAPTER SEVEN – OVERVIEW, CONCLUSIONS AND 162
RECOMMENDATIONS
7.1 Overview 163
7.2 Integrated results and conclusions 164
7.3 Recommendations 170
REFERENCES 173
ADDENDUM A – PASS STUDY RECRUITMENT INTERVIEW 209
ADDENDUM B – INFORMED CONSENT DOCUMENT 222
ADDENDUM C – FOOD ITEMS CONSUMED BY STUDY SAMPLE 224

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LIST OF TABLES AND FIGURES

TABLE 2.1 Summary of key physiological changes that take place in a pregnant 22
woman
FIGURE 2.1 Critical stages of development in the foetus 23
TABLE 2.2 Average weight and height of a healthy foetus by trimester 24
TABLE 2.3 Recommended weight gain for pregnant women based on pre-conception 25
weight
TABLE 2.4 Components of maternal weight gain 25
TABLE 2.5 Daily macronutrient Dietary reference intakess 26
TABLE 2.6 Calculating EER for pregnant females 27
TABLE 2.7 Pre-calculated EER for pregnant women 30 years or older 27
TABLE 2.8 RDAs, AIs, EARs and ULs of Vitamins for non-pregnant and pregnant 32
women
TABLE 2.9 RDAs, AIs, EARs and ULs of Minerals for non-pregnant and pregnant 37
women
TABLE 2.10 Comparison of food portion intake recommendations for non-pregnant 41
and pregnant women
TABLE 2.11 Studies on the adequacy of dietary intake in pregnant women in South 54
Africa
TABLE 2.12 Studies on adequacy of dietary intake in non-pregnant women of child- 56
bearing age in South Africa
TABLE 2.13 Caffeine content of commonly consumed foods and drinks 65
TABLE 2.14 Advantages and disadvantages of food records, FFQs and 24-recall(s) 71
for dietary intake assessment
TABLE 2.15 Examples of Dietary Diversity Scores (DDSs) applied in studies in 75
developing countries
TABLE 2.16 Proposed MUAC indices to detect low birth weight pregnancies 80
TABLE 2.17 MUAC cut-offs as indicators of malnutrition during pregnancy 80
TABLE 3.1 Distribution of interviews across the seasons 90
TABLE 3.2 Distribution of fruit and vegetable intake across the seasons 91
TABLE 3.3 The Dietary Reference Intakes 95
TABLE 3.4 Categories as per the South African food based dietary guidelines 97
TABLE 3.5 Broad food groups and per capita portions 98
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TABLE 4.1 Socio-demographic profile of the total study sample (n = 152) 106
TABLE 4.2 Anthropometric profile of the total study sample (n = 152), and 108
comparisons between adolescent and adult participants
TABLE 4.3 Arm anthropometry of total study sample (n=152) and comparisons 109
between adolescent and adult participants
TABLE 4.4 Correlation between socio-demographic and anthropometric data 111
TABLE 5.1 Energy and macronutrient intakes of the study sample (n=152)# 120
TABLE 5.2 Accuracy of reporting of energy intake according to the Goldberg cut-off 121
method by BMI categories; row% and column %
TABLE 5.3 Mean and adequacy of vitamin intake by the study sample (n=152) 123
TABLE 5.4 Mean and adequacy of mineral intake by the study sample (n=152) 124
TABLE 5.5 Average per capita daily number of servings per food group consumed 125
by the study sample compared to recommended servings according to the South
African Food Based Dietary Guidelines
TABLE 5.6 Nutrient adequacy ratios (NARs) for the dietary intake of the study 126
sample (n=152)
TABLE 5.7 Correlation matrix for association between energy and macronutrient 128
intake and anthropometric and socio-demographic variables for total study sample
and by age groups
TABLE 5.8 Correlation matrix for association between mineral intake and 129
anthropometric and socio-demographic variables for total study sample and by age
groups
TABLE 5.9 Correlation matrix for association between vitamin intake and 130
anthropometric and socio-demographic variables for total study sample and by age
groups
TABLE 6.1 Top 20 most commonly consumed foods for the total study sample 145
(n=152) and for adolescent and adult participants
TABLE 6.2 Top 20 fruit consumed by the total study sample (n=152) and for 146
adolescent and adult participants
TABLE 6.3 Top 20 vegetables consumed by the total study sample (n=152) and for 147
adolescent and adult participants
TABLE 6.4 Top 10 food items contributing to total energy intake for the total study 148
sample (n=152) and for adolescent and adult participants
TABLE 6.5 Top 10 food items contributing to total protein intake for the total study 149
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