I'm Back! :)

I  made it back from the Southern Free State! (And loved it!)

During my time there, I made the realization that their dietetics program seems to be a mixture between our nutrition and health promotion programs. During our time in the Southern Free State, we traveled around to different schools and clinics and gave presentations on different health topics (healthy eating, brushing your teeth and washing your hands properly, breastfeeding, malnutrition, and diabetes). For the purposes of condensing everything that I saw and did this week, I'm including the notes that we were given and those that I took during each lecture.

Monday, June 4th
Noordmansville Primary School

Do a talk on healthy eating, brushing teeth, and washing hands--should be very basic...the children are on in grades 1 and 2. Make sure that they understand...use posters and pictures. Give anything (like coloring picture or fruit...or anything small to be used in school). Approximately 108 children total.

This was by far my favorite talk...even though I didn't understand what was going on because it was all in Afrikaans. In order to demonstrate the passing of germs, we put glitter on our hands and then gave each of the children a high five. They were confused at first, but were very excited to get to interact with the big people. 


We stressed that it was important to wash their hands and brush their teeth to ensure that they removed all of the germs so that they wouldn't get sick. Just like in America, we suggested that they sing "Happy Birthday" to themselves twice to know how long each activity should take. 


In regards to healthy eating, the presenters started by explaining to the children what energy and base building foods were and then built a framework around that. They stressed the importance of getting enough protein, calcium, and fiber to keep them full and help them to build strong muscles and bones. At the end of the presentation, the children were each given an orange and a picture of dancing fruits that they could color in. 


Tuesday, June 5th
Edenburg Combined School

The group of 100+ students that we presented to. 

Problem: Teenagers tend to skip meals to lose weight and can't concentrate in school.
Talk should include: talk about the importance of healthy eating for teenagers and explain the physiology of why it's better to eat small frequent meals to lose weight instead of skipping meals. Also discuss the importance of eating a variety. The teenagers should understand the physiology and understand what a balanced meal is. Be practical...can maybe give examples of healthy eating meals and healthy alternatives for take-aways.

The most interesting thing about this talk was that in the auditorium, the boys sat on one side and the girls sat on the other. We gave this presentation in English, and so I actually helped to present the healthy meals and snacks. And given my strange and exotic (haha, yeah right) accent, I had their full and undivided attention.


The presentation was given in three parts:
1. Five things to remember (demonstrated on a hand)

• Variety--it is important to eat a variety of foods and not just pap, russians, and other typical South African foods. 
• Fruits and veggies--the South African dietary guidelines suggest "5 a day" (2 fruits, and 3 veggies)
• Sugar--it is very important to keep an eye on the amount of sugar we intake each day...for instance, if your going to reach for a cold drink (aka soda), then it is important to choose something like Coke Light as opposed to its more sugary counterpart. 
• Fat--a lot of foods have hidden fats and it is important that we are aware of which foods contain harmful amounts of fat. For example Russians (aka Polish Sausage) has a lot of hidden fat, but is one of the most commonly eaten meats in South Africa. We encouraged the children to watch their intake of fatty foods. 
• Exercise--it's imperative that we exercise during the day. Luckily, the children's school offers either athletics of physical education type classes, so they are at least doing some type of physical activity during the week. 

2. The Physiology of Starvation

• When you continuously skip meals, your body goes in to starvation mode and doesn't know how to digest your food properly. Therefore, when you do finally eat, your body hoards the nutrients because it doesn't know when your next meal is coming. Hence it's opposing effect on weight loss. Instead of losing weight, instead you tend to gain weight because of the body's hoarding tendencies.

3. Healthy Snacks and Meals (My section)

• Based on guidelines given to me from the UFS students that I was accompanying, I suggested the following healthy snacks to the children as alternatives to their preferred Lay's and Simba chips: 

 Brown bread sandwich with peanut butter

1. Popcorn (it provides fiber and will keep them feeling fuller for longer)
2. Water and diet cold drinks (i.e. coke light) (Given that over 70% of your body is made of water, it is important that we replenish it during the day)
3. Fruits and veggies (provide more vitamins and minerals than chips and other snacks)
4. Peanuts and raisins (mmm....fiber and protein!)
5. Low fat milk (full of protein and calcium and can help to prevent osteoporosis later in life)

• Healthy Meals: 

1. Scrambled/boiled eggs (as opposed to fried) with brown (wheat) bread
2. Reheated pap with vegetables and meat (the re-heated pap lowers the GI and will curb their hunger for longer
3. Stews with beans and lentils and soya mince
4. Vegetable Soup
5. Tinned fish with vegetables and re-heated pap
6. Brown bread sandwich with peanut butter

Those were our two biggest presentations and two of the most important because we were speaking to the children...the future of South Africa. I can only hope that they take what we said to heart.

Wednesday, June 6th
Springfontein Clinic
Ante-natal breasfeeding talk (in Afrikaans/English)

During this talk, we discussed breast feeding recommendation, advantages of breastfeeding, proper attachment, and  proper positioning with four expectant mothers. They seemed very receptive to the information we were giving them and eager to put them in to practice when their babies arrived. 


Wednesday, June 6th
Springfontein Clinic
Information session to Sprinfontein Clinic personnel on identification and management of malnutrition.

I was quite honestly shocked that we were asked to give a presentation on malnutrition in a clinic where it appeared to be so prevalent, but happy that we could try to help in some way. To make this section a little easier, I will just give you an outline of what we talked about. 


Weight/Weighing
Make sure that the scale weighs accurately (It is important to zero the scale every day!)
The scale must be placed on a hard surface (They often place it on the beds)
If the child is <2, use a pediatric scale or tared weight (i.e. zeroed with a person on the scale)
If a child is >2, weigh the child alone if the child will stand still
It is important that the child is completely naked and that all procedures are explained to the mothers


Length/Height (there's a difference!)
Length--child is measured laying down (If a child is <2 years old)
Height--child is measured standing up (If a child is >2 years old)
Measuring tapes and mats are not recommended for taking measurements


Mid Upper Arm Circumference (MUAC)
Should be measured every 3 months and the date of the visit and the measurement should always be recorded
MUAC <11.cm is considered severe acute malnutrition and the child should be referred to a better medical facility IMMEDIATELY. 
MUAC >11.5 cm to <12.5 cm without edema indicates moderate acute malnutrition and the children should be supplemented and managed according to IMCI guidelines. 


Malnutrition
2 causes: decreased food consumption and/or illness 
Consequences: liver and kidney damage/failure, hypothermia, heart damage, gut damage, electrolyte and fluid imbalance in the body
4 main causes of death in children with severe malnutrition: heart failure, hypoglycemia, hypothermia, and infections


Growth Charts
There are 3 different types of growth charts used: weight-for-age, length/height-for-age, and weight-for-length/height. 


Clinical Signs
Marasmus (severe wasting)

• Thin appearance, "old man" face
• Apathy: the child is very quite and does not cry
• The ribs and bones are easily seen
• The skin under the upper arms appears loose
• On the back, the ribs and shoulder bones are easily seen
• In extreme cases of wasting, the skin on the buttocks has a "baggy pants" look
• No bilateral pitting edema 

These children have lost fat and muscle and will weight less than other children of similar height 


Kwashiorkor (bilateral pitting edema)

• "Moon face"
• Dermatosis: flaky skin or patches of abnormally light or dark skin (in severe cases) 
• Apathy, little energy
• Loss of appetite
• Hair changes
• Irritable, cries easily

Marasmic Kwashiorkor

• Bilateral pitting edema and severe wasting

It was sad to witness some of the malnourished children come in to the clinic, but hopefully this presentation will help the Sisters (aka Nurses) to refer them to the bigger hospitals. 

Thursday, June 7th

Edenburg

Our last presentation! This presentation was given to about 20 women who lived in a township and covered sugar disease (aka diabetes). It was given in Afrikaans, so I didn't understand exactly what was going on, but the senior dietitian used food models and pictures to demonstrate and reiterate her point, so I was able to follow along slowly. 

All in all, I'd say that I learned A LOT this week and I'm very thankful that this was part of our program. Hopefully next week in the Universitas Hospital will be as much of a learning experience!  

Blood pressures, blood glucose, and urine analysis

Yesterday while we were sitting in our "lecture," I noticed that here they go in to a lot more depth and hands on experience than we do in the States. Provided I am not a Nutrition major, but I have heard from Kalie and Brittany that over here, the students go through much more clinical and hands on practice before they graduate than similar programs in the US.

For example, during our Friday lecture, we practiced taking blood pressures, urine analysis, and blood glucose levels. As a Health Promotion major, I have learned to take blood pressure before and so that part was a review for me and Ryland, but Kalie and Brittany had not yet learned how to do it (and I don't think that they would have in our Nutrition program).

It was also very interesting that after they explained how to measure blood glucose levels, we were sent to practice on each other. Meaning, we were given a finger prick needle and told to go to town. At first Kalie and I both tried to prick our own fingers...but we both jumped when we pulled the trigger and so the lab instructor had to prick them for us. As we were practicing all of these skills, I sat there and wondered if this would ever be done in the US. Blood pressure measurements, sure, but blood glucose analysis? I was just so shocked that they let us stick each other with needles...although they were small, it still made me nervous.

Other than that, I didn't experience too much of a culture shock this week because I was shadowing dietitians in the private sector and wasn't really exposed to the public sector at all. Next week I'm going to the Southern Free State where I think I will see a little more of rural South African culture...and hopefully will have more to blog about!

Probiotics and Antioxidants

Today, we talked a lot about probiotics and antioxidants at the hospital. According to the dieticians, physicians in South Africa are wary of the use of probiotics, and so I thought I would go in to a little more research to see how much they are used in the US. 

As of 2008, a review article published by Vanderhoof and Young showed that there is a validated indication for the use of some probiotics in the US. However, they have discovered that there is a need to clarify the regulatory and safety issues. So perhaps South Africa and the United States can figure out the benefits and consequences together. All I know is that I will have to keep an eye out for more knowledge on probiotics upon my return home.

As for antioxidants…I know that they are all the rage in the US. For example…why do you think so many people drink a glass of red wine a day? Oh right…antioxidants.

In addition to these riveting topics, we also talked about how your diet can affect arthritis pain, so I decided to do a little more research on that too. Here’s what I came up with:

Researchers have found that the Mediterranean diet had the greatest effect at reducing arthritis pain. The Mediterranean diet emphases foods like fruits, vegetables, grains, fish and olive oil, while limiting the amount of red meat. In a study done, in 12 weeks, people on the diet reported 15% less pain, but no improvements in physical function or morning stiffness. A vegetarian diet that allowed eggs and dairy products had a similar effect.

On the other hand, some foods like potatoes and tomatoes have long been said to contribute to arthritis pain. Some researchers have speculated that a group of compounds in the vegetables called alkaloids might worsen inflammation in sensitive people. But so far, no solid studies have confirmed this.

Interestingly, the dietician I was working with today suggested that her patient try to increase the amount of omega 3 fatty acids that she was consuming each week. Omega 3’s are found in fish (salmon, tuna, and halibut), some plants, and nut oils. Omega 3’s have been shown to have an anti-inflammatory effect on the body and may help to reduce the swelling of arthritis patients. She also suggested a diet high in green, leafy vegetables.

Needless to say, I think that this might be an interesting field of study upon my return. 

Day 1

Today was our first day in the internship and I'm starting out with my first week in the Medi-Clinic. At the Medi-Clinic, I will be working with a dietitian who has her own private practice and works in the private sector. It is her job to ensure that the patients in pediatric and neonatal intensive care units are receiving the proper nutritional supplements to aid in their growth and healing. In order to do this, she calculates their energy needs based on their weight and health condition and then counsels the doctors about appropriate levels for liquid and protein supplementation. When a patient is being released from the hospital, she will then counsel the family on how to move forward.

After shadowing Vandghie, I shadowed one of her partners, Anna Marie, while she did the same nutrition counseling for adults in an intensive care unit and those who are part of an assisted living community. They both said that the rest of the week would be much of the same old thing.

However, I did have the opportunity to chat with both of them about different cultural practices in South Africa in comparison to those in the States. Vandghi and I talked about the differences between the public and private sectors in SA and how most people would not be able to afford the private sector without medical aid (something that is very similar to our health insurance). In terms of the public sector, the government subsidizes the facilities and as we may all assume, they are not in the best conditions.

While traveling to and from different hospitals, Anna Marie and I talked about the different cultural practices of Black South Africans. She was telling me how it is often a struggle to work in the public sector as a white woman because they don't always respect or believe in what she is telling them. For example, the Black community does not believe in birth control or family planning, so they will give birth to many children without the means of supporting them throughout their lives. In fact, many black men will impregnate a woman before marrying her to ensure that she is able to give birth to his children. Often times, these women will be left behind in the dust to raise the children on their own. It's really quite sad.

Anna Marie also told me about her research in breast feeding and how she's been reading the Healthy People 2020/2010 goals. I got really excited when I knew exactly what she was talking about--as a health promotion student, we discuss the Healthy People goals often. We also talked about the WHO and CDC. It was nice to have a conversation that didn't deal strictly with nutrition.