NUTRITIONAL STATUS AND RISK FACTORS ASSOCIATED WITH WOMEN PRACTICING GEOPHAGIA IN QWAQWA, SOUTH AFRICA ANNETTE VAN ONSELEN 2013 Nutritional status and risk factors associated with women practising geophagia in QwaQwa, South Africa by Annette van Onselen BSc (Dietetics) (UFS) MSc (Dietetics) (UFS) Thesis submitted in fulfilment of the requirements for the degree Philosophia Doctor in Dietetics Ph.D. (Dietetics) (360 credits) in the Faculty of Health Science Department of Nutrition and Dietetics University of the Free State December 2013 Promotor: Prof. CM Walsh (Ph.D.) Co-Promotor: Dr. CE Brand (D-Tech) Co-Promotor: Prof. FJ Veldman (Ph.D.) i ii Dedicated to my husband Charl, my daughter Charné, my mother Stella, my sister Corrette, my father in law Sam, my mother in law Rita and my father Kalie, for their encouragement and support. iii ACKNOWLEDGEMENTS I would like to thank the following people: Prof. CM Walsh my promoter, for her support, guidance, encouragement and editing of my work. Prof. FJ Veldman for statistical analysis, support, guidance, encouragement and valuable advice during my studies. Dr. M Brand for her support, guidance and editing of my work. Profs. GIE Ekosse and L de Jager for financial support and the opportunity to be involved in the larger study. My husband Charl, for support and words of encouragement. My daughter Charné, for support and her unconditional love. My mother Stella with her support and assistance with my family. My sister Corrette for her support and assistance with Charné. My colleagues at the University of KwaZulu-Natal for their support. Marie van Wyk for the analysis of the blood. Field workers FR Mokoena, MV Raphuthing and LF Mogongoa for continuous assistance and support. iv My friends Elmien Putter, Riana de Klerk and Linda Walters for accommodation, support and encouragement. Participants who agreed to participate in the study and patience to answer all the questions. The editor: Annette Viljoen, for her assistance. My Heavenly Father for giving me the strength and ability to complete this study. v TABLE OF CONTENTS CONTENTS PAGE DECLARATION OF OWN WORK ii DEDICATION iii ACKNOWLEDGEMENTS iv LIST OF TABLES xiii LIST OF FIGURES xv LIST OF ANNEXURES xvi LIST OF ABBREVIATIONS xvii CHAPTER 1: INTRODUCTION 1.1 Problem statement 1 1.1.1 Geophagia 1 1.1.2 Iron deficiency 3 1.2 Aim of the study 5 1.2.1 Objectives 5 1.3 Structure of the thesis 5 CHAPTER 2: LITERATURE REVIEW 2.1 Introduction 6 2.2 Pica 7 2.2.1 Classification of pica 8 2.2.2 Aetiology of pica 9 2.2.2.1 Hunger 9 2.2.2.2 Micronutrient deficiency 10 2.2.2.3 Protection from toxins and pathogens 11 2.2.3 Prevalence of pica 12 2.2.3.1 Worldwide 12 vi PAGE 2.2.3.2 Africa 13 2.2.3.3 South Africa 13 2.2.4 Conditions associated with pica 13 2.2.4.1 Iron deficiency anemia 13 2.2.4.2 Psychiatric conditions 14 2.2.4.3 Pregnancy 15 2.2.4.4 Social and cultural orientation 15 2.3 Geophagia 16 2.3.1 History of geophagia 16 2.3.2 Aetiology of geophagia 16 2.3.2.1 Physiological factors 17 2.3.2.2 Psychological factors 17 2.3.2.3 Environmental factors 17 2.3.3 Prevalence of geophagia 18 2.3.3.1 Worldwide 18 2.3.3.2 Africa 19 2.3.3.3 South Africa 19 2.3.4 Composition of geophagic soil 20 2.3.4.1 Texture of soil 20 2.3.4.2 Mineralogy of soil 21 2.4 Geophagia and Human Health 22 2.4.1 Advantages to human health 22 2.4.1.1 Mineral supplementation 22 2.4.1.2 Creates a barrier 23 2.4.1.3 Relieving gastro-intestinal distress 23 2.4.2 Disadvantages to human health 24 2.4.2.1 Binding with minerals and toxic reactions 24 2.4.2.2 Gastro-intestinal problems 25 2.4.2.3 Organisms in soil 25 2.4.2.4 Dental damage 26 2.5 Conclusion 26 vii PAGE CHAPTER 3: METHODS AND TECHNIQUES 3.1 Introduction 28 3.2 Study design 29 3.2.1 Sample selection 29 3.2.1.1 Population 29 3.2.1.2 Sample 29 3.3 Measurements 31 3.3.1 Variables and operational definitions 31 3.3.2 Geophagic status (Annexure B) 31 3.3.3 Socio-demographic status (Annexure C) 32 3.3.4 Anthropometric nutritional status (Annexure D) 32 3.3.5 Dietary intake (Annexure E) 32 3.3.6 Physical activity (Annexure F) 33 3.4 Blood parameters (pathology) 34 3.5 Techniques 35 3.5.1 Questionnaires 35 3.5.2 Anthropometry 35 3.5.3 Laboratory Analyses 36 3.5.4 Validity and reliability 37 3.5.5 Socio-demographic Questionnaire 38 3.5.6 Food Frequency Questionnaire (FFQ) 38 3.5.7 Anthropometry 38 3.5.8 Physical activity 39 3.5.9 Blood sampling 39 3.5.10 Methodological limitations 39 3.6 The role of the researcher 40 3.7 Training of fieldworkers 40 3.8 Pilot Study 41 3.9 Study procedure 41 viii PAGE 3.10 Statistical Analysis 43 3.11 Intervention 44 3.12 Ethical Considerations 45 CHAPTER 4: INTERVENTION 4.1 Introduction 47 4.2 Background information 48 4.2.1 Communication 48 4.2.2 Behaviour change 50 4.2.2.1 Behaviour learning 50 4.2.2.2 Humanistic approach 51 4.2.2.3 Integrated Theory of Health Behaviour Change (ITHBC) 52 4.2.2.4 Motivational Interviewing with Acceptance and Commitment 52 Therapy 4.2.2.5 The Health believe model 53 4.3 The intervention phase 53 4.3.1 Conceptualization-Phase 1 54 4.3.2 Formulation- Phase 2 55 4.3.2.1 Setting of objectives 55 4.3.2.2 Choosing media and multimedia communication 57 4.3.2.3 Designing messages 58 4.3.3 Implementation-Phase 3 59 4.3.4 Monitoring and evaluation – Phase 4 62 ix PAGE CHAPTER 5: RESULTS 5.1 Introduction 63 5.2 Socio-demographic status 63 5.3 Dietary intake 68 5.3.1 Total energy and macronutrient intake 68 5.3.2 Micronutrient intake 70 5.3.2.1 Minerals 70 5.3.2.2 Vitamin intake of geophagia and control groups 70 5.4 Anthropometric nutritional status 72 5.5 Activity levels 73 5.6 Blood results 74 5.7 Correlation between dietary intake and blood results of 77 geophagia and control groups pre- and post-intervention 5.8 Iron status and geophagia 78 5.9 The geophagia knowledge and habits pre- and post- 79 intervention, as well as the food based dietary guidelines compliance post- intervention will be presented in tables 5.9.1 Geophagia knowledge and habits before intervention 79 5.9.1.1 Knowledge and habits related to geophagia group before 79 intervention 5.9.2 Geophagia knowledge and habits after the intervention 85 5.9.3 Food-based Dietary Compliance after the intervention 88 5.9.4 Differences between Geophagia and Control group pre- and 89 post- intervention x PAGE CHAPTER 6: DISCUSSION 6.1 Introduction 92 6.2 Limitation of the study 92 6.3 Socio-demographic status 94 6.4 Dietary intake 97 6.4.1 Total energy and macronutrients 97 6.4.2 Micronutrient intake 98 6.4.2.1 Minerals 98 6.4.2.2 Vitamin intake of geophagia and control groups 99 6.5 Anthropometric nutritional status 101 6.6 Activity levels 102 6.7 Blood results(Pathology) 102 6.8 Correlation between dietary intake and blood(pathology) results 103 6.9 Iron status and geophagia 104 6.10 Knowledge and habits related to geophagia in participants 108 practicing geophagia and the knowledge of geophagia in the control group before intervention 6.11 The knowledge and habits related to geophagia after the 109 intervention xi PAGE CHAPTER 7: CONCLUSIONS AND RECOMMENDATIONS 7.1 Conclusions 112 7.1.1 Socio-demographic status 112 7.1.2 Dietary intake 112 7.1.3 Anthropometric nutritional status and the activity levels 113 7.1.4 The relationship between geophagia and iron status 114 7.1.5 Knowledge and habits related to geophagia and the 114 impact of the intervention 7.2 Recommendations 115 7.2.1 Implications for practice 115 7.2.2 Future research 116 7.3 Benefits of the research and implementation of the 117 findings REFERENCES 118 SUMMARY 209 xii LIST OF TABLES PAGE Table 3.1 Distribution of respondents among participants in South Africa (Free 30 State, North West and Gauteng regions) for phase 1 and QwaQwa for phase 2 Table 4.1 The advantages and disadvantages of different communication 49 methods and materials Table 4.2 Baseline results used for the development of the brochure 60 Table 5.1 Socio-demographic information of Geophagia and Control groups 65 Table 5.2 Final model of socio-demographic factors that were significantly 67 associated with the practice of geophagia Table 5.3 Mean, energy macronutrient and cholesterol intake of Geophagia 69 and Control group Table 5.4 Mean mineral and trace elements intake of Geophagia and Control 71 groups Table 5.5 Mean vitamin intake of Geophagia and Control groups 72 Table 5.6 Mean anthropometric values of Geophagia and Control groups 73 Table 5.7 Categorical Body Mass Index (BMI) Values 73 Table 5.8 Final model of anthropometric factors associated with geophagia 73 Table 5.9 Continuous activity level 74 Table 5.10 Categorical activity level 74 Table 5.11 Mean blood levels 75 Table 5.12 The correlation between the dietary intake and blood results of the 77 Geophagia and Control group before intervention Table 5.13 Final model of blood (pathology) associated with geophagia 79 Table 5.14 Geophagia knowledge and habits of the Geophagia group pre- 81 intervention Table 5.15 The geophagia knowledge and habit compliance post-intervention 86 xiii Table 5.16 The Food Based Dietary Guidelines compliance post-intervention 89 Table 5.17 Significant Differences between the Geophagia and Control group 90 after the intervention xiv LIST OF FIGURES PAGE Figure 2.