South African Medical Journal (SAMJ)
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Medical nutrition therapy in obesity management
No full textRECOMMENDATIONS
We suggest that nutrition recommendations for adults of all body sizes should be personalised to meet individual values, preferences and treatment goals to support a dietary approach that is safe, effective, nutritionally adequate, culturally acceptable and affordable for long-term adherence (Level 4, Grade D).
PLWO should receive individualised MNT provided by a registered dietitian (when available) to improve weight outcomes (body weight, BMI), waist circumference (WC) and glycaemic control, and to establish lipid and blood pressure (BP) targets (Level 1a, Grade A).
PLWO and impaired glucose tolerance (prediabetes) or type 2 diabetes (T2DM) may receive MNT provided by a registered dietitian (when available) to reduce body weight and WC and improve glycaemic control and BP (Level 2a, Grade B).
PLWO can consider any of the many medical nutrition therapies to improve health-related outcomes, choosing the dietary patterns and food-based approaches that support their best long-term adherence:
CR dietary patterns emphasising variable macronutrient distribution ranges (lower, moderate or higher carbohydrate with variable proportions of protein and fat) to achieve similar body weight reduction over 6 - 12 months within a CR plan (Level 2a, Grade B).
Mediterranean dietary pattern to improve glycaemic control, high-density lipoprotein cholesterol (HDL-C) and triglycerides (Level 2b, Grade C), reduce cardiovascular events (Level 2b, Grade C), reduce risk of T2DM (Level 2b, Grade C) and increase reversion of metabolic syndrome (Level 2b, Grade C),[11] with little effect on body weight and WC (Level 2b, Grade C)
Vegetarian dietary pattern to improve glycaemic control and established blood lipid targets, including low-density lipoprotein cholesterol (LDL-C), and reduce body weight (Level 2a, Grade B), risk of T2DM (Level 3, Grade C), and coronary heart disease incidence and mortality (Level 3, Grade C).
Portfolio dietary pattern to improve established blood lipid targets, including LDL-C, apolipoprotein B (apo B) and non-HDL-C (Level 1a, Grade B),[16] and reduce C-reactive protein (CRP), BP and estimated 10-year coronary heart disease risk (Level 2a, Grade B)
Low glycaemic index dietary pattern to reduce body weight (Level 2a, Grade B), improve glycaemic control (Level 2a, Grade B) and established blood lipid targets, including LDL-C (Level 2a, Grade B), and reduce BP (Level 2a, Grade B)[20] and the risk of T2DM (Level 3, Grade C) and coronary heart disease (Level 3, Grade C).
Dietary Approaches to Stop Hypertension (DASH) dietary pattern to reduce body weight and WC (Level 1a, Grade B), improve BP (Level 2a, Grade B), established lipid targets, including LDL-C (Level 2a, Grade B), CRP (Level 2b, Grade B)and glycaemic control (Level 2a, Grade B), and reduce the risk of T2DM, cardiovascular disease, coronary heart disease and stroke (Level 3, Grade C).
Nordic dietary pattern to reduce body weight (Level 2a, Grade B)[26] and body weight regain (Level 2b, Grade B), improve BP (Level 2b, Grade B)[27] and established blood lipid targets, including LDL-C, apo B (Level 2a, Grade B)[28] and non-HDL-C (Level 2a, Grade B), and reduce the risk of cardiovascular and all-cause mortality (Level 3, Grade C)
Partial meal replacements (replacing one to two meals per day as part of a CR intervention) to reduce body weight, WC and BP and improve glycaemic control (Level 1a, Grade B).
Intermittent and continuous CR achieved similar short-term body weight reduction (Level 2a, Grade B)
Pulses (i.e. beans, peas, chickpeas, lentils) to improve body weight (Level 2, Grade B), glycaemic control (Level 2, Grade B), established lipid targets, including LDL-C (Level 2, Grade B), and systolic BP (Level 2, Grade C), and reduce the risk of coronary heart disease (Level 3, Grade C).
Vegetables and fruit to improve diastolic BP (Level 2, Grade B) and glycaemic control (Level 2, Grade B),[39] and reduce the risk of T2DM (Level 3, Grade C) and cardiovascular mortality (Level 3, Grade C).
Nuts to improve glycaemic control (Level 2, Grade B) and established lipid targets, including LDL-C (Level 3, Grade C) and reduce the risk of cardiovascular disease (Level 3, Grade C).
Whole grains (especially from oats and barley) to improve established lipid targets, including total cholesterol and LDL-C (Level 2, Grade B).
Dairy foods to reduce body weight, WC and body fat and increase lean mass in CR diets, but not in unrestricted diets (Level 3, Grade C), and reduce the risk of T2DM and cardiovascular disease (Level 3, Grade C).
PLWO and impaired glucose tolerance (prediabetes) should consider intensive behavioural interventions that target a 5 - 7% weight loss to improve glycaemic control, BP and blood lipid targets (Level 1a, Grade A), reduce the incidence of T2DM (Level 1a, Grade A)[48] and microvascular complications (retinopathy, nephropathy and neuropathy) (Level 1a, Grade B), and reduce cardiovascular and all-cause mortality (Level 1a, Grade B).
PLWO and T2DM should consider intensive behavioural therapy that targets a 7 - 15% weight loss to increase the remission of T2DM (Level 1a, Grade A) and reduce the incidence of nephropathy (Level 1a, Grade A) obstructive sleep apnoea (Level 1a, Grade A) and depression (Level 1a, Grade A)
We recommend a non-restrictive dietary approach to improve QoL, psychological outcomes (general wellbeing, body image perceptions), cardiovascular outcomes, body weight, physical activity, cognitive restraint and eating behaviours (Level 3, Grade C)
Primary care and primary healthcare in obesity management
No full textRECOMMENDATIONS
1. We recommend that PHPs identify PLWO, and initiate patient-centred, health-focused conversations with them (Level 3, Grade C).2. We recommend that PHPs ensure that they ask PLWO for their permission prior to discussing weight or taking anthropometric measurements (Level 3, Grade C).
3. Primary care interventions should be used to increase health literacy in individuals’ knowledge about and skills in weight management as an effective intervention to manage weight (Level 1a, Grade A).
4. PHPs should refer PLWO to primary care multi-component programmes with personalised obesity management strategies as an effective way to support obesity management (Level 1b, Grade B).
5. PHPs can use collaborative deliberation with motivational interviewing to tailor action plans to individuals’ life context in a way that is manageable and sustainable to support improved physical and emotional health, and weight management (Level 2b, Grade C).
Features of primary care and primary healthcare community-based interventions for PHPs and developers:
6. Interventions that target a specific ethnic group should consider the diversity of psychological and social practices with regard to excess weight, food and physical activity as well as socioeconomic circumstances, as they may differ across and within different ethnic groups (Level 1b, Grade B).
7. Longitudinal primary care interventions should focus on incremental, personalised, small behaviour changes (the ‘Small Changes’ approach) to be effective in supporting people to manage their weight (Level 1b, Grade B).
8. Primary care multi-component programmes should consider personalised obesity management strategies as an effective way to support PLWO (Level 1b, Grade B).
9. Primary care interventions that are behaviour based (nutrition, exercise, lifestyle), alone or in combination with pharmacotherapy, should be utilised to manage PLWO (Level 1a, Grade A).
10. Group-based nutrition and physical activity sessions informed by the Diabetes Prevention Program and the Look AHEAD (Action for Health in Diabetes) programme should be used as an effective management option for PLWO (Level 1b, Grade A).
11. Interventions that use technology to increase reach to larger numbers of people asynchronously should be a potentially viable lower-cost method in a community-based setting (Level 1b, Grade B).
Educational recommendations to support development of obesity management skills in the primary healthcare clinical workforce:
12. Educators in undergraduate, graduate and continuing education programmes for PHPs should provide courses and clinical experiences to address the gaps in skills, knowledge of the evidence, and attitudes necessary to confidently and effectively support PLWO (Level 1a, Grade A).[20
Prevention and harm reduction of obesity (clinical prevention)
No full textKEY MESSAGES FOR HEALTHCARE PROVIDERS
Obesity is a complex chronic disease in which abnormal or excess body fat (adiposity) impairs health, increases the risk of long-term medical complications, and reduces lifespan.
Obesity arises from a complex interplay of genetic, biological, behavioural, psychosocial and environmental factors, and can develop via slow and steady weight gain over an extended period, or from rapid bursts of weight gain.
Obesity prevention should take place in a range of settings that access whole populations or high-risk groups. The individual-based approach to prevention is primarily used by healthcare providers and targets those with the highest level of risk of obesity. The population-based approach addresses the behavioural, sociocultural and environmental factors that contribute to non-communicable diseases in populations, including obesity.
Primary care clinicians have an important role in early identification of people living with obesity. Regular assessments of body weight are needed to catch early weight gain. (See the chapters ‘Assessment of people living with obesity’ and ‘Primary care and primary healthcare in obesity management’.)
Primary care clinicians should initiate discussion around weight gain early and contemplate interventions that consider its complex causes, providing guidance beyond ‘eat less and move more’.
Many medications are associated with weight gain side-effects that can contribute to long-term weight gain. The risks and benefits of such medications should be weighed up for each specific person before prescribing.
Excess pregnancy weight gain and post-pregnancy weight retention are significantly reduced with behavioural interventions. Primary care clinicians should counsel women attending prenatal care not to exceed pregnancy weight gain guidelines, in the course of dietary, physical activity and psychological interventions during prenatal visits.
Health benefits of smoking cessation outweigh the cardiovascular consequences associated with smoking cessation-related weight gain.
Short-term behavioural interventions (generally 6 months or less) aimed at preventing weight gain during young adulthood, menopause, smoking cessation and breast cancer treatment have not yet been shown to be effective.
Longer-term interventions are likely to be needed to properly examine strategies for preventing weight gain for many of these high-risk groups and in the general population
Neck dissection for advanced laryngeal cancer: Role and relevance in KwaZulu-Natal Province, South Africa
Get PDFBackground. The global standard of care for advanced laryngeal squamous cell carcinoma (SCC) is total laryngectomy and neck dissection. While this approach aligns with international guidelines, there is no consensus on whether elective neck dissection (END) should be incorporated during primary surgery for clinically negative neck nodes (cN0) or as a therapeutic option after nodal relapse. It is therefore imperative to evaluate associated oncological outcomes and local contextual factors regarding END surgical approach in advanced laryngeal SCC.
Objective. To evaluate the lymph node outcomes and the rate of occult metastases (OM) of patients with advanced laryngeal cancer who underwent total laryngectomy with neck dissection.
Methods. A retrospective chart review was conducted at a South African hospital. Clinical records of 113 patients with stage III/IV laryngeal cancer who underwent total laryngectomy were retrieved from the hospital’s health information system for analysis. Demographic data, postoperative care, and clinical and pathological reports were analysed.
Results. The patients were predominantly male (92.6%), of African origin (62%), with a mean age of 61.0 years and HIV seroposivity rate of 13.2%. Combined alcohol and tobacco use prevalence was 58.4%, while that of tobacco use alone was 31%. Overall histopathological tumour analyses showed that 74.3% had clear margins, 16.8% close margins and 8.0% positive margins. A total of 71.7% of the patients were initially classified as cN0, before histopathological results revealed 30.9% to have OM, with 3.75% having extranodal involvement. Substance use in the cN0 group with OM, regardless of HIV serostatus, was strongly associated with OM.
Conclusion. This study supports the importance of END in advanced laryngeal SCC and cN0 patients, aligning with global OM rates. These findings provide critical insights into the local context, supporting the continuation of END as standard of care in our institution
The assessment of preventive measures in infants admitted with acute diarrhoeal disease to Pelonomi Tertiary Hospital in Bloemfontein, South Africa
Get PDFBackground. Diarrhoeal disease is easily preventable and treatable. Despite proven interventions to prevent and treat the condition, it remains one of the leading causes of death in children under the age of 5 years.
Objectives. To assess whether preventive measures of childhood diarrhoea were applied in infants admitted with acute diarrhoea, and to quantify morbidity and mortality in infancy due to acute diarrhoea.
Method. This retrospective descriptive study was conducted at Pelonomi Tertiary Hospital in Bloemfontein, South Africa. Information on infants admitted with acute diarrhoeal disease was collected, namely their age in months, gender, length of stay, need for intensive care, the application of preventive measures of childhood diarrhoeal disease, such as breastfeeding, up-to-date immunisations, appropriate complementary feeds and their nutritional status.
Results. A total of 297 infants met the inclusion criteria over the 2-year period. The prevalence of acute diarrhoea was 24.8%. A total of 67% of the infants were not breastfeeding. Of the 67%, 52.2% had stopped breastfeeding before the age of 6 months, while 14.8 % were never breastfed. The average length of stay was 9.7 days. Severe malnutrition was noted in 29.3% of the infants. Of these, 8.42% had severe malnutrition with oedema, while 20.9% had severe malnutrition without oedema. Appropriate complementary feeds were provided to 79.5% of participants, and 61 (20.5%) were not provided with appropriate complementary feeds. Of these 61 infants, 48 were undernourished. Although most infants were discharged home, 4% (n=12) died. Five of the 12 infants (41.7%) who died did not receive the rotavirus vaccine.
Conclusion. Acute diarrhoeal disease in infancy remains an important contributor to morbidity and mortality within this setting. This study suggests the implementation of preventive measures such as exclusive breastfeeding, appropriate complementary feeds, immunisations and early identification of undernourished infants to reduce infant mortality
Child abuse: A socio-historical perspective: By Sebastian van As. 1st ed. Durban: Reach Publishers, 2023. ISBN 978-1-77636-607-1
Get PDFThe genesis of a Paediatrics and Child Health department over the past 40 years at South Africa’s oldest rural medical school
No full textWhen conflicting interests challenge relevance: History of the development of Public Health at Walter Sisulu University
No full textCommercial products and programmes in obesity management
No full textRECOMMENDATIONS
1. For adults living with overweight or obesity, some commercial programmes exist that should achieve mild-to-moderate weight loss over the short or medium term, and a mild reduction in glycated haemoglobin values over a short term in adults with type 2 diabetes compared with usual care or education.
2. We do not recommend the use of over-the-counter commercial weight loss products for obesity management, owing to lack of evidence (Level 4, Grade D).
3. We do not suggest that commercial weight loss programmes be used for improvement in blood pressure and lipid control in adults living with obesity (Level 4, Grade D)