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UNIVERSITY OF GHANA 
COLLEGE OF HEALTH SCIENCES 
DEPARTMENT OF NUTRITON AND DIETETICS 
 
 
 
ASSESSING NUTRITION KNOWLEDGE AND NUTRITIONAL 
STATUS OF SICKLE CELL DISEASE PATIENTS 
 
 
 
 
BY 
 
FAUSTINA OFOSUA MINTAH 
(10382594) 
 
 
 
 
 
 THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF 
GHANA, LEGON IN PARTIAL FULFILLMENT OF THE 
REQUIREMENT FOR THE AWARD OF MASTER  
OF SCIENCE IN DIETETICS 
 
 
 
 
JULY 2019 
 
 
 
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DECLARATION 
I, Faustina Ofosua Mintah, declare that this work is the report of the research I undertook at 
the Department of Nutrition and Dietetics, School of Biomedical and Allied Health Sciences, 
University of Ghana, under the supervision of Dr. Joana Ainuson-Quampah, Prof. Solomon 
Ofori-Acquah and Dr. Catherine Segbefia and neither the whole nor any part of it has been 
submitted for another degree at this or any other university. All references cited have been 
fully acknowledged. 
 
Signature                                                                                                                       
               FAUSTINA OFOSUA MINTAH                                                DATE 
                          (STUDENT) 
 
 
Signature                                               …………………. 
               DR. JOANA AINUSON-QUAMPAH                                         DATE 
                          (SUPERVISOR) 
 
 
 
Signature                                                                                                        
                PROF. SOLOMON FIIFI OFORI-ACQUAH                          DATE 
                          (SUPERVISOR) 
 
 
Signature                                                                                                     …………….. 
                DR. CATHERINE SEGBEFIA                                                  DATE 
                         (SUPERVISOR)  
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ABSTRACT 
Background: Sickle cell disease (SCD) is a common haemoglobinopathy that is acquired by 
inheriting the defective gene from both parents. In recent years, it has become an important 
public health issue among people of African descent especially those in Sub-Saharan Africa.  
In Ghana, SCD occurs in almost 1 in 50 (2%) of all births annually. The disease is 
characterised by chronic haemolytic anaemia, vaso-occlusion and inflammation. These events 
increase the resting energy expenditure of individuals and contribute to the hypermetabolic 
state of a sickle cell patient, and consequently impact on the nutritional status. The poor 
nutritional status reported in individuals with SCD can also be attributed to reduced dietary 
intake due to low appetite leading to varied nutrient deficiencies including vitamin A, C, E 
and D deficiencies. In spite of these nutritional challenges faced by this group of people, 
frequent nutritional counselling is not part of the standard of care. However, recent studies 
have identified nutrition knowledge as one of the mechanisms which influence nutritional 
behaviour of individuals thereby improving their nutritional status. 
Aim: To assess nutritional knowledge and nutritional status of people with sickle cell disease. 
Methods: A cross-sectional study design was used. An estimated number of 173 adolescents 
and adults attending the Ghana Institute of Clinical Genetics, Korle Bu who were recruited 
for the SickleGenAfrica project were enrolled for this study. Nutrition knowledge of patients 
was assessed using a pre-tested questionnaire. Anthropometric, biochemical data and a one-
week food frequency questionnaire were used to assess nutritional status. About 0.15ml of 
serum for the SickleGenAfrica project was sampled to assess serum vitamin E and IL-6 levels 
using Enzyme Linked Immunoassay technique. Stata/IC 14.0 was used for data analysis. Chi-
squared was used to test for associations between nutrition knowledge and nutritional status. 
Linear regression was used to determine association between inflammation and nutritional 
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status. Multiple regression was used to test for the strength of the significant associations. A 
p-value < 0.05 was considered statistically significant. 
Results: Malnutrition was recorded among 25% of the participants with prevalence of 
underweight, overweight and obesity as 15.2%, 7.6% and 1.8% respectively. Majority 
(84.8%) of the participants had high nutrition knowledge. There was no association between 
nutritional knowledge and nutritional status. The frequency of fruits and vegetables 
consumption was low. The mean serum vitamin E level of participants was 6.7±9.9µg/ml and 
there was no significant difference between mean levels of Hb SS and Hb SC individuals. 
Even in steady state, IL-6 levels were elevated with a mean of 18.6±33.7 pg/ml and this 
correlated negatively with body weight (r = -0.1698, p = 0.03). Body weight and height could 
predict 3% of the variability in IL-6 levels (F (2, 165) = 2.97; p – 0.05). There was a 
significant difference between the IL-6 levels of Hb SS and Hb SC individuals with means of 
21.4±3.42 pg/ml and 11.2±2.70 pg/ml (p - 0.02) respectively. 
Conclusion: Nutrition knowledge did not influence nutritional status. Results from this study 
show that participants are at risk of vitamin E deficiency. Hb SS individuals experienced 
higher levels of inflammation compared to Hb SC individuals. 
  
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DEDICATION 
This work is dedicated to my parents, Mr. Samuel Ayim Mintah and Ms. Charlotte Adjei, for 
their immense support throughout my academic journey and my siblings for always 
motivating to be better and being my source of stress relief. 
I also dedicate this work to all individuals with sickle cell disease. 
  
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ACKNOWLEDGEMENT 
All the glory to the Almighty God for His grace and protection throughout my study period. 
I am extremely grateful to my supervisors Dr. Joana Ainuson-Quampah, Prof. Solomon 
Ofori-Acquah and Dr. Catherine Segbefia for their mentorship, comments and criticisms 
throughout the compilation of this work.  
A special appreciation to Prof. Ofori-Acquah for allowing me to conduct this study under the 
Sickle Cell Disease Genomic Network of Africa (SickleGenAfrica) project and providing 
funding as well. 
My sincere appreciation goes to Dr. Matilda Asante, lecturers of the Department of Nutrition 
and Dietetics, members of the Ofori-Acquah research group especially Dr. Kudzi, Derek and 
Sheila for their recommendations and contributions towards the work. 
I am grateful to the staff of the Ghana Institute of Clinical Genetics and Mr. Albert Peprah for 
being hospitable and accommodating during the data collection period. I also appreciate 
Enoch, Rhoda and Eugenia, data collection was easier and exciting because of you. 
Many thanks to Prof. Asare-Anane, Dr. Ofori, Comfort and Maame Efua of the Department 
of Chemical Pathology for their assistance during the analysis of the serum samples. 
To my uncle, Mr. Richard Amoako, I say thank you very much for assisting me with the data 
analysis. 
I also want to appreciate my course mates for their assistance during various aspects of this 
study. 
 
 
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TABLE OF CONTENTS 
 
DECLARATION ........................................................................................................................ i 
ABSTRACT ............................................................................................................................... ii 
DEDICATION .......................................................................................................................... iv 
ACKNOWLEDGEMENT ......................................................................................................... v 
TABLE OF CONTENTS .......................................................................................................... vi 
LIST OF FIGURES .................................................................................................................. ix 
LIST OF TABLES ..................................................................................................................... x 
LIST OF ABBREVIATIONS ................................................................................................... xi 
CHAPTER ONE ........................................................................................................................ 1 
1.0 INTRODUCTION ............................................................................................................... 1 
1.1 Background ...................................................................................................................... 1 
1.2 Problem Statement ........................................................................................................... 3 
1.3 Significance of Study ....................................................................................................... 4 
1.4 Hypothesis........................................................................................................................ 4 
1.5 Aim .................................................................................................................................. 4 
1.6 Specific Objectives .......................................................................................................... 4 
CHAPTER TWO ....................................................................................................................... 5 
2.0 LITERATURE REVIEW .................................................................................................... 5 
2.1 History of Sickle Cell Disease ......................................................................................... 5 
2.1.1 Types of Sickle Cell Disease .................................................................................... 6 
2.2 Prevalence of Sickle Cell Disease.................................................................................... 7 
2.3 Complications of Sickle Cell Disease .............................................................................. 8 
2.3.1 Haemolysis and Haematological Complications ...................................................... 8 
2.3.2 Vaso-occlusion .......................................................................................................... 9 
2.3.3 End-organ Dysfunction ............................................................................................. 9 
2.3.4 Infections................................................................................................................. 10 
2.4 Nutritional Status of People with SCD .......................................................................... 10 
2.4.1 Anthropometry of Adolescents and Adults with SCD ............................................ 10 
2.4.2 Dietary Intake and Patterns of SCD Adolescents and Adults ................................. 13 
2.4.3 Biochemical Assessment of Nutritional Status in SCD .......................................... 14 
2.5 Factors That Contribute to Poor Nutritional Status in SCD .......................................... 16 
2.5.1 Chronic Haemolytic Anaemia and Nutritional Status ............................................ 17 
2.5.2 Inflammation and Nutritional Status ....................................................................... 18 
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2.6 The Role of Nutrition in SCD ........................................................................................ 19 
CHAPTER THREE ................................................................................................................. 22 
3.0 METHODOLOGY ............................................................................................................ 22 
3.1 Study Design .................................................................................................................. 22 
3.2 Study Site ....................................................................................................................... 22 
3.3 Study Population ............................................................................................................ 22 
3.3.1 Inclusion Criteria .................................................................................................... 22 
3.3.2 Exclusion Criteria ................................................................................................... 22 
3.4 Sampling Technique ...................................................................................................... 23 
3.5  Sample Size Determination ........................................................................................... 23 
3.6  Data Collection .............................................................................................................. 24 
3.6.1 Socio-demographic Data ......................................................................................... 24 
3.6.2 Nutritional Knowledge Data ................................................................................... 24 
3.6.3 Nutritional Status Data ............................................................................................ 24 
3.7  Data Handling ............................................................................................................... 27 
3.8 Ethical Consideration ..................................................................................................... 28 
3.9 Data Analysis ................................................................................................................. 28 
CHAPTER FOUR .................................................................................................................... 30 
4.0 RESULTS ...................................................................................................................... 30 
4.1 Socio-Demographic Characteristics of Participants ...................................................... 30 
4.2 Feeding Behaviour and Source of Nutrition Information .............................................. 32 
4.2.1 Feeding Behaviour .................................................................................................. 32 
4.2.2 Sources of Nutrition Information ............................................................................ 32 
4.3 Nutritional Knowledge of Participants .......................................................................... 33 
4.3.1 Nutrition knowledge scores and ranking ................................................................ 35 
4.4 Nutritional Status of Participants ................................................................................... 36 
4.4.1 Body Fat Distribution among Males and Females .................................................. 36 
4.4.2 Muscle Mass Distribution among Males and Females ........................................... 37 
4.4.3 BMI Categories of Participants ............................................................................... 38 
4.4.4 Serum Interleukin-6 and Vitamin E levels of Participants ..................................... 40 
4.5 Food Consumption Pattern of Participants .................................................................... 42 
4.5.1 Pattern of fruit consumption ................................................................................... 42 
4.5.2 Pattern of vegetables, stews and soups consumption .............................................. 45 
4.5.3 Pattern of consumption of protein-rich foods ......................................................... 47 
4.5.4 Pattern of consumption of foods high in fats .......................................................... 49 
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4.5.5 Pattern of consumption of carbohydrate-rich foods................................................ 50 
4.6 Association between Nutrition Knowledge and Nutritional Status ............................... 52 
4.7 Association between Inflammatory Biomarker and Nutritional Status ......................... 53 
CHAPTER FIVE ..................................................................................................................... 54 
5.0 DISCUSSION ................................................................................................................ 54 
5.1 Socio-demographic Characteristics of Participants ....................................................... 54 
5.2 Source of Nutrition Information .................................................................................... 55 
5.3 Food Consumption Patterns of Individuals with Sickle Cell Disease ........................... 56 
5.4 Nutritional Status of Participants ................................................................................... 58 
5.5 Serum Vitamin E and Interleukin-6 levels of Participants ............................................ 60 
5.6 Association between nutrition knowledge and nutritional status .................................. 62 
5.7 Limitations ..................................................................................................................... 62 
CHAPTER SIX ........................................................................................................................ 64 
6.0 CONCLUSION AND RECOMMENDATIONS .......................................................... 64 
6.1 Conclusion ..................................................................................................................... 64 
6.2 Recommendations .......................................................................................................... 64 
REFERENCES ........................................................................................................................ 66 
APPENDICES ......................................................................................................................... 79 
APPENDIX I ........................................................................................................................... 79 
INFORMED CONSENT ..................................................................................................... 79 
APPENDIX II .......................................................................................................................... 82 
CHILD ASSENT FORM ..................................................................................................... 82 
APPENDIX III ......................................................................................................................... 84 
QUESTIONNAIRE ................................................................................................................. 84 
APPENDIX IV......................................................................................................................... 90 
INTERPRETATION OF BODY FAT AND MUSCLE MASS PERCENTAGES ............ 90 
APPENDIX V .......................................................................................................................... 91 
ETHICAL CLEARANCE ................................................................................................... 91 
 
 
 
 
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LIST OF FIGURES 
 
Figure 1: Factors that Contribute to Poor Nutritional Status in SCD (Author’s own construct)
.................................................................................................................................................. 17 
Figure 2: Sources of nutrition information .............................................................................. 33 
Figure 3: Heat map of nutrition knowledge scores of participants .......................................... 36 
Figure 4: Nutritional status of participants .............................................................................. 40 
Figure 5: Serum interleukin-6 levels of participants................................................................ 41 
Figure 6: Serum vitamin E levels of participants..................................................................... 42 
Figure 7: Daily fruit consumption over a one-week period ..................................................... 43 
Figure 8: Daily fruit consumption in October over a one-week period ................................... 43 
Figure 9: Daily fruit consumption in November over a one-week period ............................... 44 
Figure 10: Daily fruit consumption in December over a one-week period ............................. 44 
Figure 11: Daily fruit consumption in January over a one-week period ................................. 45 
Figure 12: Daily fruit consumption in February over a one-week period ............................... 45 
Figure 13: Daily vegetables consumption over a one-week period ......................................... 46 
Figure 14: Daily stew consumption over a one-week period .................................................. 47 
Figure 15: Daily soups consumption over a one-week period ................................................. 47 
Figure 16: Daily meat, poultry, fish and egg consumption over a one-week period ............... 48 
Figure 17: Daily milk and milk products consumption over a one-week period..................... 48 
Figure 18: Daily deep-fried foods and spreads consumption over a one-week period ............ 49 
Figure 19: Daily pastries consumption over a one-week period .............................................. 50 
Figure 20: Daily beverages and porridges consumption over a one-week period ................... 51 
Figure 21: Daily starchy foods consumption over a one-week period .................................... 51 
Figure 22: Daily soft drinks and alcoholic beverages consumption over a one-week period . 52 
 
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LIST OF TABLES 
Table 1: Socio-demographic characteristics of respondents (N = 171) ................................... 31 
Table 2: Feeding behaviour ..................................................................................................... 32 
Table 3: Participants’ knowledge on food sources of some nutrients (N = 171) ..................... 34 
Table 4: Participants’ knowledge on some nutrient deficiencies (N = 171) ............................ 34 
Table 5: Participants’ knowledge on expert opinion and making healthy meal choices 
(N=171) .................................................................................................................................... 35 
Table 6: Body fat levels of males ............................................................................................ 37 
Table 7: Body fat levels of females ......................................................................................... 37 
Table 8: Muscle mass levels of males...................................................................................... 38 
Table 9: Muscle mass levels of females .................................................................................. 38 
Table 10: Nutritional status of participants below 20years using BMI-for-age (BAZ) scores 
(N=35) ...................................................................................................................................... 39 
Table 11: Nutritional status of participants 20years and above based on BMI categories (N 
=136) ........................................................................................................................................ 39 
Table 12: Nutritional status per haemoglobin genotype .......................................................... 40 
Table 13: Comparison of mean IL-6 levels between Hb genotypes ........................................ 41 
Table 14: Association between nutritional status and nutritional knowledge ......................... 52 
Table 15: Strength of association between IL-6 levels and weight ......................................... 53 
  
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LIST OF ABBREVIATIONS  
ACS –Acute Chest Syndrome 
BAZ - BMI-for-age  
BF - Body Fat 
BMI - Body Mass Index 
ELISA - Enzyme-Linked Immunosorbent Assay  
FFM - Fat-Free Mass 
FFQ - Food Frequency Questionnaire 
Hb – Haemoglobin 
HRP – Horseradish Peroxidase 
IL-1 -Interleukin-1 
IL-6 -Interleukin-6 
IL-10 -Interleukin-10 
MM - Muscle Mass 
RBC - Red Blood Cell 
REE - Resting Energy Expenditure 
SCA - Sickle Cell Anaemia 
SCD - Sickle Cell Disease 
TNF – Tumour Necrosis Factor 
TMB - 3, 3′, 5, 5′-Tetramethylbenzidine 
WHO - World Health Organisation 
 
 
 
 
 
 
 
 
 
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CHAPTER ONE 
1.0 INTRODUCTION 
1.1 Background 
Sickle cell disease (SCD) is a common genetic condition characterised by inheriting the 
defective haemoglobin gene from both parents (Makani et al., 2013). It is very common 
among people of Indian, Saudi Arabian, Mediterranean and sub-Saharan African descent 
(World Health Organisation (WHO), 2006). About 700 structural haemoglobin (Hb) variants 
have been identified. However only two, that is, Hb S and Hb C are very common in Africa 
with Hb C being exclusive to West Africa (Makani et al., 2013). Sickle cell disease is 
estimated to occur in about 300,000 births worldwide yearly (WHO, 2006). In Africa, about 
10% to 40% of the population are carriers of the sickle cell gene leading to an estimated 2% 
prevalence of SCD in sub-Saharan Africa (WHO, 2006). 
 
Patients with sickle cell disease usually suffer from anaemia, jaundice, infections and chronic 
organ damage. Vaso-occlusion is also very common and is identified as one of the 
contributors to the characteristic painful crises (Makani et al., 2013). Painful crises have been 
recognised as the cause of about 80-90% of hospitalisations (Lemanek et al., 2002). Frequent 
hospitalisations put financial stress on patients and make it difficult to work and raise money 
to support economic needs. Nutritional adaptations have been identified as one of the coping 
strategies that is adopted to help reduce the frequency of pain episodes and hospitalisations 
(Tanabe et al., 2010). 
 
People with SCD are found to have a poor nutritional status with underweight being more 
prevalent among adolescents and adults compared to their healthy peers (Sobo et al., 2007). 
Some proposed mechanisms for the growth deficit include decreased intake, intestinal 
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malabsorption and increased catabolism. However, the most frequently reported mechanism 
is that sickle cell anaemia increases metabolic requirement due to recurrent haemolytic 
anaemia (Hyacinth, Gee, & Hibbert, 2010). This sub-optimal nutritional status has been 
linked to disease severity, number of hospitalisations, risk of infections just to name a few 
(Mandese et al., 2016). Common nutrient deficiencies in patients with SCD include vitamins 
A, C, E and D, zinc and magnesium (Hyacinth et al., 2010). As such, routine 
supplementations with folic acid and multivitamins are given to make up for some of these 
deficiencies. These findings have informed several studies on the role of nutrition in the 
management of SCD (Hundekar et al., 2011; Mandese et al., 2016; Mitchell, Kawchak, Stark, 
Zemel, Ohene-Frempong, et al., 2004; Nwaoguikpe & Braide, 2012; Tanabe et al., 2010). 
Therefore, there have been proposals to increase the recommended nutrient intake for sickle 
cell patients to make up for increased demand and ensure good nutritional status. Laboratory 
experiments have shown that supplementation of nutrients like protein, vitamins A, C and E, 
zinc and magnesium leads to an improvement in the clinical manifestations of the disease 
(Nwaoguikpe & Braide 2012; Ohnishi et al., 2000). This is suggestive of the need for 
nutritional care in the management of sickle cell disease. 
 
Since the role of nutrition and the need for frequent nutrition counselling in the management 
of SCD has been emphasised by researchers and even some patients, it is necessary to assess 
nutrition knowledge and how this impact on their nutritional status. This is because nutrition 
knowledge is one of the factors that affect  nutrition behaviour of individuals and 
subsequently overall health (Hakli et al., 2016). 
 
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1.2 Problem Statement 
Sickle cell disease is not only a public health issue especially in Africa but also in Ghana. 
More than 75% of the people with SCD are in Africa (WHO, 2006). In Ghana, about 1.9% (1 
in 50) of all new born babies annually have SCD  (Ohene-Frempong et al., 2008). Ranked as 
the fifth commonest non-communicable disease in Ghana, the Ghana Health Service report 
for 2014 also showed an increase in the number of outpatient SCD cases from 2011- 2014 
(from 29764 in 2011 to 43801 in 2014) (Ghana Health Service, 2015). 
 
Sickle cell disease with its resultant increased energy and nutrient requirements coupled with 
inadequate food intake as a result of eating disorders such as poor appetite and pica, has 
adverse effects on body composition and disease severity (Hyacinth et al., 2010; Kawchak, 
Schall, Zemel, Ohene-Frempong, & Stallings, 2007; Sobo et al., 2007) 
  
Therefore, improving nutritional status seems to be one of the techniques that can be used to 
improve disease outcome and overall quality of life. To achieve this, the nutritional 
knowledge of the patient is key since it has been mentioned as one of the mechanisms for 
improving nutritional status (Hakli et al., 2016). Subsequently, acquiring knowledge is 
influenced by education. However frequent nutrition counselling is still not part of the 
standard of care for the management of the disease. 
 
There is also paucity of data on the nutritional knowledge and its association with the 
nutritional status of SCD patients. Thus, it is necessary to assess the nutrition knowledge of 
people with SCD and its association to their nutritional status so that the appropriate 
measures will be put in place to improve the quality of life of people with SCD. 
 
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1.3 Significance of Study 
This study will provide baseline information on the nutrition knowledge and nutritional status 
of adolescent and adult sickle cell disease patients. 
Information on the association between nutrition knowledge and nutritional status of patients 
with SCD will help the health team such as nurses, dietitians and doctors to come up with a 
comprehensive plan on how to improve care for the patient. It may also reinforce the need for 
nutrition education programmes for patients with SCD. Therefore, the appropriate 
stakeholders like Ministry of Health and Ghana Health Service can use findings from this 
study as a baseline to develop nutrition education programmes and policies that will help 
improve nutritional status and overall health of the SCD patient. 
1.4 Hypothesis 
H0: There is no association between nutrition knowledge and nutritional status of people with 
SCD. 
1.5 Aim 
To assess nutritional knowledge and nutritional status of adolescents and adults with sickle 
cell disease. 
1.6 Specific Objectives 
1. To assess the nutritional knowledge of adolescents and adults with SCD. 
2. To assess the nutritional status of adolescents and adults with SCD. 
3. To assess the food consumption patterns of adolescents and adults with SCD. 
4. To determine the association between nutritional knowledge and nutritional status of 
adolescents and adults with SCD. 
5. To determine the association between inflammatory biomarker and nutritional status 
of people with SCD. 
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CHAPTER TWO 
2.0 LITERATURE REVIEW 
2.1 History of Sickle Cell Disease 
Sickle cell disease (SCD) refers to a group of haemoglobinopathies where at least one sickle 
β-globin gene is inherited together with another type of abnormal haemoglobin (Hyacinth et 
al., 2010). Haemoglobin (Hb) is a protein found in red blood cells (RBCs) and an oxygen 
transporter. In SCD, valine in the sixth codon is substituted with glutamic acid in the β-globin 
gene (Stuart & Nagel, 2004). Due to this abnormality, HbS can polymerise when 
deoxygenated. The polymer formed is an insoluble rope-like fibre that lines up with others to 
form a bundle, deforming the RBC into the characteristic sickle shape (Stuart & Nagel, 
2004). Hence, the name sickle cell disease.  
 
An intern of Dr. Irons named Dr. Herrick was the first to observe these elongated sickle-
shaped RBCs during a routine blood test of a patient admitted for respiratory distress and leg 
ulcer (Herrick, 1910). An article about the disease was later published by Dr. Herrick with the 
caption “peculiar elongated and sickle-shaped red blood corpuscles in a case of severe 
anaemia” (Herrick, 1910). Although Dr. Herrick was the first to document a case report about 
the disease, it was until Dr. Mason observed the fourth reported case of the disease that he 
coined the name sickle cell anaemia (The Sickle Cell Association of Ontario, n.d.). He 
noticed the similarities between all the cases and observed that all the cases were black 
people. This gave rise to the idea that the disease originated from Africans (The Sickle Cell 
Association of Ontario, n.d.).  
 
Since Dr. Mason made this remarkable observation, two schools of thoughts have emerged 
based on the origin of the disease. Whilst one school of thought theorise that the disease 
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originated from the same mutation occurring at five independent locations (multicentre 
theory), the other postulates that the disease originated from a single mutation occurring at a 
particular place (single centre theory). Pagnier et al. (1984) provided evidence for the 
multicentre theory in their study which examined different sickle β-globin haplotypes from 
four different regions in Africa. They concluded that the mutation occurred in 3 different 
locations in Africa namely, Benin, Bantu/ Central African Republic and Senegal. Other 
haplotypes that have been identified are Cameroon and Middle East and India (Arab-India) 
(Piel et al., 2017; Piel & Weatherall, 2015). Even though the hypothesis of five independent 
origins has been accepted almost globally over the years, recent reports have proven that the 
disease originated from just one mutation many years ago. A recent publication by Shriner 
and Rotimi concluded that the disease occurred due to a single mutation occurring at one 
geographic location. From their analysis, it was revealed that the mutation is of an African 
region and occurred once approximately 7,300 years ago either in West-Central Africa or the 
Sahara (Shriner & Rotimi, 2018). 
 
2.1.1 Types of Sickle Cell Disease  
Since the discovery of the disease, about 700 structural haemoglobin variants have been 
identified over the past decades (Makani et al., 2013). Some of the common subtypes which 
have been identified include haemoglobin (S, C, F and E) and thalassemia. Haemoglobin S 
(Hb S) is found to be common in areas of low altitude and high incidence of the Plasmodium 
falciparum malarial parasite (Piel et al., 2010). The other subtype haemoglobin C (Hb) is 
almost exclusive to West Africa with Burkina Faso and northern Ghana recording the highest 
frequencies (Grosse et al., 2011). This is reiterated by Makani et al. (2013) that Hb SS and 
Hb SC disease are the frequently observed SCD cases in Africa. Hyacinth et al. (2010) 
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 Sβthal) minor and major as other variants of SCD 
which are not common in Africa.  
 
People with sickle cell anaemia are those who inherit two copies of the Hb S, that is, 
homozygous (Hb SS) (Hyacinth et al., 2010). Sickle Cell Anaemia (Hb SS) patients have the 
disease phenotype unlike the carriers (Hb AS) since haemoglobin A (Hb A) is the normal 
haemoglobin (Kanter & Kruse-Jarres, 2013). Alternative forms of the disease occur when Hb 
S is inherited together with other abnormal haemoglobin like Hb C and F. This gives rise to 
other forms of the disease like Hb SC, Hb SF, Hb Sβ+ and other haemoglobin genotypes 
(Kanter & Kruse-Jarres, 2013). Hb SS and Hb Sβ0 are known as the most severe forms of 
SCD (Chakravorty & Williams, 2015; Kanter & Kruse-Jarres, 2013). Aside Africa, SCD is 
very common among people of Indian, Mediterranean and Saudi Arabian descent (WHO, 
2006). Migration has contributed to spreading of the disease to other parts of the world like 
America and Europe (Chakravorty & Williams, 2015; Moraes et al., 2017). 
 
2.2 Prevalence of Sickle Cell Disease 
The World Health Organisation (WHO) estimates that about 300,000 babies are born with 
major haemoglobin disorders annually (WHO, 2006). Majority of these newborns are in 
Nigeria, the Democratic Republic of Congo, and India (Piel et al., 2017). About 5% of the 
world’s population are carriers of the genes responsible for haemoglobin disorders. In Africa, 
more than 200,000 newborns have sickle cell anaemia annually and an estimated 2% of all 
children born in Africa annually have SCD (WHO, 2006). 
 
The WHO report also estimates that about 10% to 40% of people across equatorial Africa 
have sickle-cell trait and these decrease to < 2% in Northern and Southern Africa. It is 
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therefore not surprising that about two-thirds of the global population with SCD are in Sub-
Saharan Africa (WHO, 2006). In West African countries like Nigeria and Ghana, the 
frequency of the trait ranges from 15% to 30%. However, in Uganda, there are significant 
variations among tribes with the Baamba tribe having a frequency as high at 45%. The 
variability in this distribution is linked to the survival advantage against malaria that the 
sickle-cell trait confers on individuals. Therefore, areas with a high malaria transmission have 
high frequencies of this mutated gene (WHO, 2006). A study conducted in Ghana has 
estimated about 1.9% of newborns having some form of SCD (Ohene-Frempong et al., 2008). 
 
2.3 Complications of Sickle Cell Disease 
People with SCD usually suffer from a lot of complications due to the disease. Makani et al., 
(2013) categorised the complications into four, namely, haemolysis and haematological 
complications, vaso-occlusion, organ dysfunction and infection.  
 
2.3.1 Haemolysis and Haematological Complications 
The haematological complications are marked by the chronic haemolytic anaemia that 
persists throughout life. Chronic haemolytic anaemia in SCD is due to the shortened lifespan 
of sickled RBCs. Unlike normal RBCs with a lifespan of 120 days, sickled RBCs have a 
lifespan between 10-20 days (Kanter & Kruse-Jarres, 2013). The rapid destruction of RBCs 
causes hyperbilirubinemia and subsequently leads to jaundice and gall bladder diseases. 
Aside chronic haemolytic anaemia, SCD patients sometimes have intermittent sessions of 
reduced haemoglobin known as anaemic crisis (Makani et al., 2013). This combined with 
chronic haemolytic anaemia is known as hyperhaemolysis crises and it is defined by a sudden 
fall in steady state haemoglobin coupled with increased reticulocytosis and exaggerated 
hyperbilirubinemia (Makani et al., 2013). Acute splenic sequestration is very common in 
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children and Makani et al. (2013) adds that it can also be a cause of anaemia because when 
red blood cells are trapped in the spleen there is a reduced number of circulating RBCs. 
 
2.3.2 Vaso-occlusion 
Vaso-occlusion which is thought to be the primary cause of the painful crises period in SCD 
occurs secondary to blockage of the blood vessels by the sickled RBCs (Chakravorty & 
Williams, 2015; Mulumba & Wilson, 2015; Serjeant, 2013). As mentioned earlier, 
polymerisation of Hb S when deoxygenated leads to the formation of strands of Hb that cause 
the sickled shape of the RBCs (Stuart & Nagel, 2004). The polymerisation also makes the 
cell rigid and increases its adhesion to the endothelium of the microvasculature. This can lead 
to blockage of the blood vessels which can progress to tissue ischaemia and necrosis (Piel et 
al., 2017). Vaso-occlusive crisis is named as the most common cause of frequent 
hospitalisations and pain episodes in SCD (Mulumba & Wilson, 2015; Serjeant, 2013; Stuart 
& Nagel, 2004). However, some patients manage this episode at home using hydration, anti-
inflammatory drugs, opioid and non-opioid drugs (Stuart & Nagel, 2004). 
 
2.3.3 End-organ Dysfunction 
As the survival rate of SCD patients’ increases, there is a rise in the destruction of major 
organs (Makani et al., 2013). End-organ dysfunction can be as a result of vaso-occlusion and 
the damage can affect any organ system. Given that, when blood vessels supplying an organ 
are occluded, there is decreased blood flow to the organ leading to ischaemia and finally 
tissue necrosis. Some organs that are mostly affected are the lungs and brain leading to acute 
chest syndrome (ACS) and stroke respectively (Kanter & Kruse-Jarres, 2013). Stroke and 
ACS are reported to be very common in SCD and are risk factors for mortality (Makani et al., 
2013).  
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2.3.4 Infections  
People with SCD are highly susceptible to infections from encapsulated bacteria such as 
Streptococcus pneumonia, Neisseria meningitis and Haemophilus influenza (Bender, 2003 & 
Makani et al., 2013). Reports prove that prophylactic penicillin and vaccination programmes  
significantly reduce mortality (Bender, 2003). According to Makani et al. (2013), the 
increased risk to infection is attributed to the low immunity and complications and/or 
treatment of the disease itself. For example, patients with splenic dysfunction have an 
increased risk to septicaemia and meningitis because the spleen is a very vital organ in the 
immune system. Iron overload due to frequent blood transfusions can also increase risk of 
infections due to Yersinia Enterocolitica. End-organ damage to liver, lung, skin and kidney 
leave these sites susceptible to infections (Makani et al., 2013). The reduced immunity is in 
part related to the poor nutritional status of people with SCD (Makani et al., 2013). 
 
2.4 Nutritional Status of People with SCD 
Numerous studies have documented poor nutritional status which is characterised by 
underweight, stunting and wasting in SCD patients. Anthropometric, dietary and biochemical 
data have been used in the assessment of nutritional status of people with SCD.  
 
2.4.1 Anthropometry of Adolescents and Adults with SCD 
Anthropometry entails taking body measurements of an individual and comparing them to 
reference standards (Litchford, 2017). This gives an indication of growth and development 
over a period time. Litchford (2017) mentions that anthropometric indices are good predictors 
of over-nutrition and undernutrition. Common anthropometric indices that have been used to 
assess nutritional status in adults include Body Mass Index (BMI) and waist-to-hip ratio as 
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predictors of overweight and risk of developing cardiovascular diseases respectively 
(Litchford, 2017).  
 
People with SCD usually have a thinner outlook compared to their peers and available 
anthropometric data shows growth deficits in this group of people regardless of their 
geographic location. In a review by Al-Saqladi et al. (2008) on the growth and nutritional 
status of people with homozygous SCD, it was documented that most of the subjects in the 46 
studies reviewed had growth deficits. Sobo et al., (2007) found that underweight was 
prevalent among SCD patients in Ogun State, Nigeria with the mean BMI being 17.66±2.41 
kg/m2. A comparison of BMI between people with SCD and non-SCD persons also showed 
that unlike the non-SCD group, overweight and obesity was not prevalent in the SCD group. 
Thus the BMI of the SCD group were mostly underweight or normal (Aminu et al., 2017).   
In contrast, another study conducted among SCD patients of African descent living in 
London reported patients having a normal BMI with a mean BMI of 24.56±4.69 kg/m2  
(Osuobeni et al., 2009). Although Helvaci and Kaya (2011) also reported significant variance 
between the mean BMI of non-SCD patients and SCD patients, with the SCD group 
recording a lower BMI than control, the mean BMI was 20.7 ± 2.9 which is within the normal 
range. 
 
Cases of overweight and obesity have also been reported among people with SCD especially 
in developed countries. Nearly half of the subjects in a study carried out in United States of 
America were reported to be overweight with 20% being obese (Pells et al., 2005). This is 
reinforced by a current study conducted by Kaufman et al. (2018) which reported that 44% of 
their study participants were overweight, that is, BMI ≥25  kg/m2  . 
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There is paucity of data regarding the nutritional status of adolescents and adults with SCD 
living in Ghana. Most data in Ghana seems to focus on the nutritional status of children with 
SCD and these studies have shown that wasting, stunting and underweight are very prevalent 
among SCD children in the country ( Bonsu, 2017; Boadu, 2016 & Osei-Yeboah, Rodrigues, 
& Enweronu-Laryea, 2011). Drawing from these findings, it is likely that the story may be 
similar amongst adolescents and adults. For the adolescents, poor nutritional status may even 
be more prominent since puberty puts additional metabolic stress on the body. 
 
2.4.1.1 Body Composition of SCD adolescents and adults using Bioelectric Impedance 
Analysis 
The Bioelectric Impedance Analysis (BIA) scale can also be used to determine the body 
composition of an individual in terms of percentage body fat and body mass and has been 
widely used to assess nutritional status in different populations (VanderJagt, Okolo, Rabasa, 
& Glew, 2000). The principle of operation is that tissues contain electrolyte-containing fluids 
and conduct an electric current. Resistance (R, opposition to flow through intra- and 
extracellular ionic solutions) and reactance (Xc, extra opposition from the capacitant effect of 
cell membranes and tissue interfaces) affects current flow. Impedance (Z), is expressed as a 
composite of R and Xc. The association between Xc and R in circuits is given by phase angle 
(PA), arctangent of Xc/R. A lower PA is related with cell loss whilst a high PA indicates 
increased body cell mass (VanderJagt et al., 2000). 
Using this technique, VanderJagt et al. (2000) conducted a study in Nigeria which compared 
the body composition of children and adolescents with SCD to healthy controls. Their study 
saw a significant difference in percentage body fat (%BF) and percentage fat free mass 
(%FFM) between subjects aged 10years and above in the two groups. The cases had a 
significantly lower and higher %FFM and %BF respectively compared to controls. 
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A similar study was conducted in the United States and contrary to the Nigerian study, there 
were significantly lower and higher %BF and %FFM respectively between SCD males and 
controls (VanderJagt, Harmatz, Scott-Emuakpor, Vichinsky, & Glew, 2002). Unlike the 
Nigerian study which recorded significant differences in the body composition of SCD 
females and controls, this study recorded no significant difference between cases and controls 
(VanderJagt et al., 2002). 
 
2.4.2 Dietary Intake and Patterns of SCD Adolescents and Adults 
Assessment of dietary intake and patterns can be done using numerous tools like the 24-hour 
recalls, food frequency questionnaire and weighed food record (Raymond & Couch, 2017). 
Poor nutritional status in SCD is often attributed to inadequate dietary intake. This has led 
researchers to investigate the dietary intakes of this group of people. Early studies have 
shown that male SCD patients consumed significantly less total calories, carbohydrates, fat 
and protein daily compared to controls however there was no significant difference the 
dietary intake of SCD females and their controls (Modebe & Ifenu, 1993). Kawchak et al., 
(2007) followed Hb SS children and adolescents for four years and assessed their dietary 
intake over these years by collecting 24-hour dietary recalls daily. Analysis of the dietary 
data showed suboptimal energy and nutrient intake with vitamin D, folate, vitamin E and 
calcium being the most deficient nutrients in the diets of participants. More importantly, the 
study showed a reduced dietary intake among adolescents with protein, vitamin C, riboflavin, 
vitamin B-12 and magnesium consumption being significantly low. In contrast, a study 
among Jamaican cohorts documented an increased consumption of fats and carbohydrates, 
however, protein intake was within normal ranges  (Anglin et al., 2011). Carbohydrates and 
fats intake exceeded the Dietary Reference Intake by 51% and 48% respectively. Anglin et al. 
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(2011) further documented that except for vitamin D and E, intake of the other vitamins was 
higher than the Recommended Daily Allowance. Calcium intake was also higher than the 
Adequate Intakes. 
 
Tanabe et al. (2010), documented that subjects consumed a healthy diet made of fruits, whole 
grain and vegetables with a limited intake of fast foods and refined foods. Changes in feeding 
behaviour have also been reported during painful episodes as a study showed that 87% of its 
subjected consumed less food when in pain (Pells et al., 2005). In this study, subjects 
reported a decrease in fat and protein intake but not sugar and salt. 
 
Although there may be contrasting findings on the dietary intake of SCD adolescents and 
adults, most studies report suboptimal energy and nutrient intake compared to healthy 
controls. This is usually attributed to reduced appetites especially during painful episodes and 
frequent hospitalisations (Hyacinth et al., 2010; Mitchell, Kawchak, Stark, Zemel, & Ohene-
Frempong, Kweku Stallings, 2004).  
 
2.4.3 Biochemical Assessment of Nutritional Status in SCD 
Dietary intake may not paint the true nutritional status picture due to reporting biases. 
Additionally, intestinal malabsorption can impede absorption leading to no correlation 
between dietary intake and serum/plasma levels of nutrients. Biomarkers are therefore used 
as better predictors of nutrient deficiencies or excesses. Although they present objective ways 
of assessing nutritional status, identifying the ideal biomarker is quite challenging because 
numerous factors may affect them. For instance, serum albumin which historically used to be 
a common biomarker for assessing nutritional status has been proven to be an unreliable 
marker for assessing protein-energy malnutrition (Bharadwaj et al., 2016). Other biomarkers 
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like prealbumin, retinol-binding protein and transferrin have also been shown to be weak 
predictors of malnutrition especially when the person has a chronic disease condition 
(Bharadwaj et al., 2016).  
 
To make things easier, some studies use analysis of individual nutrients as indicators of 
specific nutrient deficiencies. In SCD, common nutrient deficiencies that have been identified 
are zinc, iron, magnesium, vitamin C, D and E (Mohanty et al. 2017; Hyacinth et al. 2010; 
Al-Saqladi et al. 2008; Mohanty et al. 2008).  
 
Hyacinth et al. (2010) cites zinc as the most studied micronutrient in SCD. One of the earliest 
observations of zinc deficiency among adult SCD patients was made by Prasad and 
colleagues. in 1975 (Prasad et al., 1975). In this study, it was seen that plasma, erythrocyte, 
urinary and hair zinc levels were low in study subjects giving an indication of zinc 
deficiency. On the contrary, Abshire, English, Githens and Hambidge (1988) found  that zinc 
deficiency was not prevalent amongst young adults assessed in their study. 
 
Apart from zinc, the antioxidant vitamins have also been widely studied because of the role 
they play in vaso-occlusion and haemolysis. These studies have found deficiencies in people 
with SCD. Oyeyemi, Sonuga and Oyebanji (2017) found reduced serum vitamin C and E 
levels amongst Hb SS patients as compared to that of carriers (AS) and non-carriers (AA). An 
assessment of the vitamin E status of steady state Hb SS patients also showed a decrease in 
serum levels compared to healthy controls (AA) (Tukur et al., 2015). The reduction in these 
vitamins supports the hypothesis that SCD puts oxidative stress on the cells and causes a 
decrease in level of antioxidant vitamins (Oyeyemi et al., 2017). Furthermore, the 
deficiencies seem to occur at a very early age and runs through adulthood. 
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Quite recently, there has been a growing interest in the role of inflammation on nutritional 
status. Therefore, there are studies where inflammatory markers have been used as predictors 
of nutritional status in certain chronic inflammatory diseases. For example, elevated C-
reactive protein (CRP) levels is considered as a good predictor of cancer cachexia and is 
sometimes used by some researchers in the definition cancer cachexia (McMillan, 2009). 
Another study that explored association between CRP markers and nutritional status of 
people with Chronic Obstructive Pulmonary Disease (COPD) found that CRP levels 
increased when subjects anthropometric measurements like skinfold thickness, mid upper 
arm circumference and BMI decreased (Arora et al., 2010). 
 
A linkage has also been made between nutrient deficiencies and disease severity. This has led 
to the investigations on the effect of nutrition in the management of SCD. 
 
2.5 Factors That Contribute to Poor Nutritional Status in SCD  
Poor nutritional status refers to over or undernutrition. In SCD this usually presents as 
undernutrition and is characterised by growth deficits like wasting, stunting and underweight. 
Various factors have been linked to the poor nutritional status of people with SCD. Some of 
these include inadequate dietary intake, increased catabolism and intestinal malabsorption. 
Recently, the most common mechanism cited by researchers as the cause of the poor 
nutritional status in SCD is the hypermetabolic nature of the disease (Hyacinth et al., 2010). 
This has been shown to cause an increase in the energy and nutrient demands.  
 
According to Hibbert et al. (2006), the rapid rate of erythropoiesis and increased cardiac 
output have been suggested as the driving force for the hypermetabolism. Inflammation is 
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also cited as a factor for the hypermetabolic nature of the disease (Bandeira et al., 2014 & 
Keikhaei et al., 2013).  
 
Figure 1: Factors that Contribute to Poor Nutritional Status in SCD (Author’s own 
construct) 
 
2.5.1 Chronic Haemolytic Anaemia and Nutritional Status 
 
Unlike normal RBCs with a lifespan of about 100-120 days, sickled RBCs have a life span of  
8-25 days (Hyacinth, Adekeye, & Yilgwan, 2013). The rapid destruction of these cells create 
a need for increased erythropoiesis; this leads to increased protein turnover and subsequently  
increased energy demand (Hibbert et al., 2006). 
 
Hibbert et al. (2006) also observed that there is an increase in myocardial energy demand in 
Hb SS patients due to an increased heart rate. This is explained as a compensatory 
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mechanism to maintain constant tissue oxygenation since anaemia leads to low RBC count.  
The rise in myocardial energy requirement increases the resting energy expenditure (REE), 
which is the energy the body expends at rest, of SCD patients. This indicates that most of the 
energy is directed from building muscle for growth and other functions to meeting the 
increased myocardial energy demand and erythropoiesis (Hibbert et al., 2006). 
 
2.5.2 Inflammation and Nutritional Status 
Inflammation is a very common phenomenon in SCD as the disease is even described as a 
chronic inflammatory disease (Bandeira et al., 2014). This chronic inflammatory state is 
attributed to the nature of the RBCs in SCD and infections ( Makani et al., 2013; Lee, 2006 & 
Stuart & Nagel, 2004). Sickled cells have an increased adhesiveness to the endothelium even 
during their steady state. The pathophysiology of vaso-occlusion, a popular complication in 
SCD is linked to this adhesive property of sickled cells which is a stimulator of inflammation 
(Lee, 2006). Increased adhesion of these cells to the endothelium leads to chronic activation 
and damage of the endothelium as well as increased production of inflammatory mediators 
like (IL-1, IL-6, IL-8, TNF-α) by endothelial cells (Keikhaei et al., 2013).  Conversely, the 
presence of these cytokines also exacerbate inflammation as they activate the vascular 
endothelium, elevate sickle cells adhesion to the endothelium and ultimately lead to painful 
vaso-occlusive crisis (Keikhaei et al., 2013 & Pathare et al., 2004). According to Hibbert et 
al.( 2005), CRP, a positive acute phase reactant, levels were raised in steady state Hb SS 
patients and this correlated strongly to resting energy expenditure (REE). This gives an 
indication that chronic inflammation leads to hypermetabolism which can consequently affect 
nutritional status. This is because a high REE confirms that the body is using a lot of energy 
and an inadequate supply of energy will lead to depletion of body stores.   
 
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In their study on pro-inflammatory cytokines and hypermetabolism in children with SCD, 
Hibbert et al. (2005)  also found that steady state Hb SS patients had elevated levels of IL-6. 
Interleukin-6 is an inflammatory cytokine that has been reported as a strong  predictor of 
malnutrition especially disease-induced malnutrition (Hyacinth et al., 2010). This cytokine is 
reported to cause anorexia, weight loss, changes in the lipid and protein metabolism, 
increased concentrations of catabolic hormones, reduction of anabolic hormones and 
metabolic impairment (Belizário, Oliveira, Borges, Kashiabara, & Vannier, 2016). Since the 
disease presentation is similar for all age groups, similar trends may also be observed among 
adolescents and adults. Tsujinaka et al. (1998) found that elevated levels of IL-6 in transgenic 
mice correlated positively with muscle wasting since IL-6 is considered as a proteolysis-
inducing factor because of its modulation of muscle proteolytic systems.  
  
Aside the nature of sickled RBCs contributing to inflammation, frequent infections is also a 
contributor to the chronic inflammatory nature of the disease. As stated earlier, SCD patients 
are particularly highly susceptible to infections from microorganisms such as Streptococcus 
pneumonia, Neisseria meningitis (Bender, 2003). Since inflammation is a natural response to 
any foreign agent in the human body, a state of recurrent infections will lead to frequent 
inflammation in attempts to remove the injurious agent.  
 
2.6 The Role of Nutrition in SCD 
Hyacinth et al. (2013) document that several studies report nutritional deficiencies, that is, 
macro and micronutrients deficiencies in SCD patients. Attempts have also been made by 
some researchers to examine the efficacy of nutritional interventions on improving clinical 
outcomes of the disease. Adequate nutrition has been indicated as a means of decreasing 
severity the disease and Mandese et al. (2016) documented that children with poor nutritional 
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status had an increase in the risk of disease severity. Some indicators of disease severity are 
the number of pain episodes, hospitalizations, total haemoglobin, foetal haemoglobin and 
lactose dehydrogenase (Mandese et al., 2016).  
 
Antioxidant supplementation prevents the oxidative damage to erythrocytes and this leads to 
reduced frequency of haemolysis (Hundekar et al., 2011). Prophylactic folic acid is also given 
to patients to prevent the development of folate deficiency due to increased folate turnover 
(Hyacinth et al., 2010). 
 
These interventional studies have recorded improvements in disease outcomes such as 
improved growth, decreased pain episodes and frequency of hospitalisation (Hundekar et al., 
2011; Williams et al., 2004; Ohnishi et al., 2000). This gives a hint that some of the 
complications of the disease have nutritional underpinnings just like they have genetic 
underpinnings. Nutrition interventions also seem to be the most affordable and readily 
accessible treatment option especially considering that majority (about 75%) of the people 
with SCD are in Africa, a resource poor area (Hyacinth et al., 2013; WHO, 2006). 
 
Evidence of the importance of nutrition in the management of the disease is not only from 
experimental studies. However, some of these nutritional modifications are being practiced 
by patients sometimes without the guidance of a healthcare provider. SCD patients have also 
mentioned that they use nutrition as a coping strategy in managing the disease (Tanabe et al. 
2010). This is to say that they employ nutritional strategies and techniques like following a 
healthy diet consisting of fruits, vegetables, and whole grain fibre; and reducing intake of fast 
foods and refined foods to help improve their health and disease outcome (Tanabe et al., 
2010).  
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Although nutrition has been identified as an important means of managing the disease, 
patients have challenges in making the right meal choices especially in an era where there is a 
lot of meal options due to food processing. This coupled with reduced dietary intake due to 
chronic inflammation and frequent hospitalisations poses a serious threat to the nutritional 
status of people with SCD. This calls for serious interventions to help manage the situation 
and improve overall quality of life of these people. Given the important influence of nutrition 
knowledge on dietary intake and nutritional status, it will be thought-provoking to assess 
nutrition knowledge and its possible association with nutritional status of people with SCD.  
 
  
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CHAPTER THREE 
3.0 METHODOLOGY 
3.1 Study Design 
A cross-sectional study design was used. 
3.2 Study Site 
The study site was the Ghana Institute of Clinical Genetics (GICG) at Korle Bu. The GICG is 
located between the fevers unit of the Korle Bu Teaching Hospital and the Korle Bu 
Polyclinic. Established in 1947, the institute provides comprehensive outpatient care for 
people aged 13 years and above with sickle cell disease. As the first adult sickle cell clinic in 
Ghana, it has the largest number of registered sickle cell adolescents and adults. Patients from 
all over Ghana can attend the clinic however most patients are usually from the southern part 
of Ghana. The clinic operates every weekday except for holidays and has an average 
attendance of 50 patients per day. 
3.3 Study Population 
3.3.1 Inclusion Criteria 
 All patients aged (16 years and above) diagnosed with SCD attending the clinic in 
steady state and recruited for the SickleGenAfrica project. The vision of the 
SickleGenAfrica project is to align the survival of individuals with the disease in 
Africa with national norms. Understanding and improving the nutritional knowledge 
and status of the people with SCD will help improve on the survival of these group of 
people. 
3.3.2 Exclusion Criteria  
 Patients with other chronic diseases that can affect growth like HIV, cancer, chronic 
kidney disease, congenital heart disease and cerebral palsy. 
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 Patients who were unwell or have recently been unwell (not less than a week). This is 
because levels of IL-6 would increase under this condition. 
 Patients who were recently transfused (˂3 months). This is because transfusion can 
lead to iron overload and subsequently depletion of vitamin E (Marwah et al., 2002). 
Thus, if these patients are used, their serum vitamin E may not be a true 
representation of their vitamin E status. 
 Patients who are pregnant or breastfeeding because during these phases of life there 
is weight gain and this will not give a true representation of the patient’s weight. 
3.4 Sampling Technique 
Convenience sampling technique was used. At the clinic, patients were approached 
individually and briefed about the study. Interested patients who met the inclusion criteria 
were enrolled for the study. 
3.5 Sample Size Determination 
In studies designed to measure a characteristic in terms of a proportion, the equation for 
𝑍2× 𝑃(1−𝑃)
calculating sample size is  𝑁 =  2   (Wayne, 1999) 𝑑
Where N – sample size 
          Zcrit – 1.96 for a confidence interval of 95% 
          d – Allowable error = 0.075    
        P – Estimate of proportion of population with adequate nutritional knowledge and good 
nutritional status = 50 %  
P was set at 50% because there is paucity of data on the nutrition knowledge of SCD patients 
in Ghana. Thus, P at 50% estimates that about half of the population SCD patients have 
adequate nutritional knowledge. 
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(1.96)20.5 (0.5) 3.84 (0.25)
Therefore,  𝑁 =    =    = 171.4 ≈ 171 people 
0.0752 0.0056
3.6 Data Collection 
An interviewer administered questionnaire was used to gather data on the socio-demographic 
details and nutritional knowledge of participants. Nutritional status of sickle cell patients was 
assessed using anthropometric and biochemical data. Food consumption pattern was assessed 
using a one-week food frequency questionnaire. The anthropometric and dietary data were 
collected by the researcher. The estimated time for data collection was 25-30 minutes per 
participant. 
3.6.1 Socio-demographic Data 
A structured questionnaire was used to obtain socio-demographic information such as age, 
gender, educational level and sickle cell disease type.  
3.6.2 Nutritional Knowledge Data 
Nutritional knowledge was assessed using a modified pre-tested questionnaire 
adapted from Tandoh (2015). The questionnaire contains only close-ended questions. 
The questionnaire is categorised in three sections: the first section assessed the 
knowledge of participants on food sources of some nutrients, the second section - 
knowledge on some nutrient deficiencies (focusing on the common nutrient 
deficiencies in SCD patients) and the last section - knowledge on expert opinion and 
healthy choices. A score of 1 was assigned to a correct answer and 0 to a wrong 
answer. A total score of more than half of the questions was categorised as high 
nutritional knowledge and below half as poor nutritional knowledge (Tandoh, 2015). 
3.6.3 Nutritional Status Data 
3.6.3.1 Anthropometric Data 
All anthropometric measurements were taken using standard procedures. 
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Height 
The Seca 786 mechanical column scale stadiometer (Hamburg, Germany) was used to 
measure the height of participants. Participants stood erect on a base plate without shoes with 
their heads in Frankfurt’s plane position and back straight, feet together and heels touching 
the back of the plate. The head plate was lowered to touch the top of the head and height 
recorded. The heights were recorded to the nearest 0.1cm. 
Weight 
The Omron BF511 body composition scale was used to determine the weight as well as other 
body composition parameters like body fat, muscle mass and visceral fat. To do this, 
participants’ personal data was entered into the unit. Immediately the display screen shows 
0.0 kg, they were asked to stand on the scale barefooted with their knees and back straight 
and feet positioned on the electrodes whilst holding the display unit in their hands firmly. 
With the display unit in their hand, they were required to press their palms firmly on the grid 
electrode, raise their arms and extend their elbows straight to form a 90º angle to their bodies. 
Participants were asked to step off the scale after their weights have been displayed. Weight 
readings were recorded to the nearest 0.1kg. 
 
3.6.3.2 Dietary data 
A modified pretested Food Frequency Questionnaire (FFQ) by Asante, Pufulete, Thomas, 
Wiredu, & Intiful, (2015) was used to collect information on the dietary pattern of adults with 
sickle cell disease over a one-week period. The questionnaire contained a list of common 
Ghanaian foods, participants were required to recall the number of times they had eaten a 
particular food within the week prior to data collection. 
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3.6.3.3 Biochemical data 
About 0.15 ml of serum obtained from the SickleGenAfrica project stored at -80ºC was used 
to assess biomarkers like serum vitamin E and interleukin-6 levels. Among the antioxidant 
vitamins, vitamin E deficiency has been identified in a lot of SCD patients. Also because it 
has antioxidant properties, deficiencies will contribute to haemolysis and subsequently poor 
growth due to the hypermetabolic burden of haemolysis (Hyacinth et al., 2010). A link has 
also been established between CRP and IL-6 and muscle wasting, higher levels correlates 
with increased muscle wasting (Belizário et al. 2016 ; Archer et al. 2008).  
 Procedure for analysing vitamin E levels 
Enzyme-Linked Immunosorbent Assay (ELISA) kit from Kamiya Biomedical Company 
(vitamin E (VE) ELISA Cat. No. KT-32385) was used for this analysis. This kit employed 
the competitive inhibition enzyme immunoassay technique to determine the serum vitamin E 
levels of participants. Standards, controls and samples were pipetted into specific wells on a 
microplate pre-coated with monoclonal antibody specific to vitamin E. A biotin labelled 
vitamin E (Detection reagent A) was added to each well and a competitive inhibition reaction 
was launched between the pre-coated antibody specific to vitamin E and the Detection 
reagent A plus standard or control or sample. After 1hour of incubation at 37ºC, the 
microplate was aspirated and washed with an automatic washer. Excess water was blotted out 
against an absorbent paper to prevent dilution of solutions that will be added later. Next, 
avidin conjugated to Horseradish Perioxidase (HRP) was added to each well and also 
incubated for 30 minutes at 37ºC. The aspiration and wash procedure was repeated after 
incubation. 3, 3′, 5, 5′-Tetramethylbenzidine (TMB) substrate solution was added to each 
well and the plate was incubated for 13 minutes at 37ºC. A blue colour was observed in most 
of the wells. The intensity of the colour was inversely proportional to the concentration of 
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vitamin E in the sample. After incubation, a stop solution was added to each well and the blue 
colour changed to yellow, this was mixed thoroughly by gently tapping the sides of the plate.  
The absorbance of each well was read using a spectrophotometer at a wavelength of 450nm. 
A standard curve was plotted and used to determine the concentration of vitamin E in the 
samples. 
 
Procedure for analysing interleukin-6 (IL-6)  
The Abcam IL-6 Human High Sensitivity ELISA kit which employed the sandwich ELISA 
technique was used for this assay.  Standards, controls and samples were pipetted into 
specific wells on a microplate pre-coated with monoclonal antibody specific for interleukin-6. 
A Biotinylated anti-IL-6 was then added to each well, the plate was covered and incubated at 
21ºC for 3 hours. After incubation, each well was aspirated and washed using an automatic 
washer. Excess water was blotted against an absorbent paper to prevent dilution of solutions 
that will be added. Next, Streptavidin-HRP solution was added to each well and incubated for 
30 minutes at 21ºC. After incubation, the aspiration and wash procedure was repeated again. 
Chromogen TMB substrate solution was added to each well and incubated for 13 minutes at 
21ºC in the dark by wrapping the plate in aluminium foil. There was a blue colour 
development of different intensities. After addition of the stop solution, the blue colour 
turned yellow. 
The absorbance was read immediately using a spectrophotometer at a wavelength of 450nm. 
A standard curve was drawn and the concentrations of IL-6 calculated. 
3.7 Data Handling 
The raw data from this study was under restricted access by password protection. Answered 
questionnaires were stored in a locked cabinet which was accessible to only researchers and 
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also uploaded unto RedCap for safety. It was withheld from public access during the period 
of the research. Respondents were assigned random codes for the purpose of confidentiality. 
3.8 Ethical Consideration 
This project is under the SickleGenAfrica project and thus operated under its ethical 
clearance from the Ethical and Protocol Review Committee of the College of Health 
Sciences, University of Ghana. Additionally, informed consent was sought from all 
participants aged 18 years and above as well parents of participants below 18 years before 
they were recruited for the study. An assent was also sort from participants below 18 years. 
This project benefitted from NIH/NHLBI grant for the SickleGenAfrica project, project 
number 1U54HL141011-01. 
3.9 Data Analysis 
Data was entered in Microsoft Excel and analysed using the Stata/IC 14.0.  
Nutritional status was assessed using Body Mass Index (BMI) and participants were 
categorized into underweight, normal, overweight or obese based on WHO recommendations 
(World Health Organisation, 2009). For participants below 20 years BMI-for-age Z-scores 
were calculated using the WHO AnthroPlus software v1.0.4. 
The biochemical tests, that is, serum IL-6 and vitamin E values were compared to reference 
values. 
Descriptive analysis like means, percentages, standard deviations and frequencies were used 
to summarise continuous and categorical variables. Some continuous variables include age 
and height. Categorical variables include nutrition knowledge, nutritional status, sex and 
sickle cell type. Dietary data from the FFQ was presented as frequencies.  
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Chi-squared test was used to test the associations between the nutritional knowledge and 
nutritional status.  A linear regression was used to test for the association between IL-6 and 
body weight. Multiple regression was used to test for the strength of this association. A p-
value (p < 0.05) was considered as statistically significant. 
  
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CHAPTER FOUR 
4.0 RESULTS  
4.1 Socio-Demographic Characteristics of Participants 
One hundred and seventy-three people were recruited for the study over a four month period. 
However, after confirmation of their Hb genotypes 2 people were excluded from the study. 
Table 1 shows the socio-demographic information of the study participants. The mean age 
was 26.7± 9.07 years with the male to female ratio being 1:1.5. Majority of the participants 
had sickle cell anaemia (Hb SS). 
Almost all of the participants reside in the Greater Accra region (94.1%) and majority were 
Christians (88.3%). Majority were single (85.4%) and almost all (99.4%) of the participants 
had received some form of formal education. A little over half (58.5%) of the participants 
were either students or unemployed, they represented the group with no source of monthly 
income. However, for the working group, most of them (12.3%) earned between GH¢300- 
GH¢ 499 monthly. 
 
 
 
 
 
 
 
 
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Table 1: Socio-demographic characteristics of respondents (N = 171) 
 
Variable n (%) 
Age groups   
 
<20 35 (20.5) 
20-29 84 (49.1) 
 
30-39 37 (21.6) 
≥40 15 (8.8)    
 
Gender  
Male 105 (61.4) 
 Female   66 (38.6)       
Haemoglobin genotype  
 SS           122 (71.4) 
SC         49 (28.6)      
 
Place of Residence           
Greater Accra 161 (94.1) 
 
Central      8 (4.7) 
Eastern                  2 (1.2)       
 Religion   
Christian           151 (88.3) 
 Muslim            20 (11.7)      
Marital Status  
 
Single  145 (84.8) 
 Married             25 (14.6) 
Divorced/Widowed                            1 (0.6) 
 Educational Level   
 No formal education              1 (0.6)        
Primary           11 (6.4)        
 JSS           23 (13.4)        
SSS/SHS/Vocational           75 (43.9)       
 Tertiary  61 (35.7)       
 Occupation   
Formal    31 (18.1) 
 Informal   41 (24.0) 
Unemployed  39 (22.8) 
 Students   60 (35.1) 
 Monthly Income  
No income             99 (57.9) 
 Below 300            18 (10.5) 
GH¢ 700 - GH¢ 899                6 (3.5) 
 
GH¢300- GH¢ 499            22 (12.9)   
 GH¢500 - GH¢ 699              14 (8.2) 
≥GH¢ 900             12 (7.0) 
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4.2 Feeding Behaviour and Source of Nutrition Information  
4.2.1 Feeding Behaviour 
The participants were asked whether they had a good appetite for food or not for which they 
responded “yes” or “no”. Majority (79.0%) responded that they had a good appetite for food. 
Except for one respondent who mostly ate once daily, all respondents ate more than once 
daily with about 49.1% of the participants eating twice daily.    
Table 2: Feeding behaviour 
Variable n (%) 
Appetite   
Yes  135 (79.0) 
No  36 (21.0) 
Meals per day  
Once   1 (0.6) 
Twice 60 (35.1) 
Thrice 84 (49.1) 
>3x 26 (15.2) 
 
4.2.2 Sources of Nutrition Information 
Almost all participants (94%) had received some form of information about nutrition. 
Participants who had received some form of nutrition information were asked to identify 
sources of their information. Figure 3 shows the sources of nutrition information according to 
participants. The most frequent source of nutrition information was family and friends as 
illustrated in figure 4. This was followed by doctors and nurses. Dietitians and nutritionists 
are the least contacted for nutrition information. Some participants also got information from 
other sources like the internet, gym instructors and teachers. 
 
 
 
 
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101
88
73
60
48
15
Sources of Nutrition Information
 
*Others represents internet, gym instructors, teachers and magazines 
Figure 2: Sources of nutrition information 
 
4.3 Nutritional Knowledge of Participants 
A 14-item questionnaire was used to assess the nutritional knowledge of participants. These 
questions are divided into three sub-topics as shown below. The first section (Table 3) 
assessed participants’ knowledge on food sources of some nutrients. Most of the participants 
(80%) were able to identify food sources of the macronutrients, that is, carbohydrates, protein 
and fat. Less than half of the participants were able to identify the food source of iron and 
dietary fibre. Table 4 shows participants’ knowledge on some nutrient deficiencies and for all 
questions, less than half of the participants were able to answer correctly. Majority of the 
participants knew what nutrition experts’ recommend and what constituted a balanced diet as 
shown in table 5. 
 
 
 
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Frequencies
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Table 3: Participants’ knowledge on food sources of some nutrients (N = 171) 
Variable  Proportion of participants 
who answered correctly   
n (%)  
1. Cassava, yam and gari are rich sources of; 148 (86.6)   
2. Chicken, eggs and fish are rich sources of; 148 (86.6) 
3. Which of the following is a rich source of fat? 164 (95.9) 
4. Milk and milk products are rich in;   98 (57.3) 
5. Which of the following is a rich source of iron?   74 (43.3) 
6. Which of the following is a rich source of dietary   62 (36.3)       
fiber/roughage; 
7. Which of the following will give you blood? 167 (97.7)      
 
Table 4: Participants’ knowledge on some nutrient deficiencies (N = 171) 
Variable  Proportion of participants who 
answered correctly  
 n (%) 
8. Inadequate intake of ……….will make you look very 78 (45.7)        
thin; 
9. Rickets/ bow legs are caused by lack of; 35 (20.5)      
10. Anaemia is caused by lack of; 85 (49.7)     
11. Bleeding of gums is caused by inadequate intake of; 77 (45.0)  
 
 
 
 
 
 
 
 
 
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Table 5: Participants’ knowledge on expert opinion and making healthy meal choices 
(N=171)   
Variable  Proportion of participants who 
answered correctly  
n (%) 
12. Do you think fruits and vegetables should be eaten 168 (98.3)        
frequently? 
13. Which of the following snacks is healthy? 161 (94.2)      
14. Which of the following foods is balanced? 149 (87.1)     
 
4.3.1 Nutrition knowledge scores and ranking 
The nutrition knowledge questionnaire was scored; a correct answer was scored as 1 and a 
wrong answer, 0. Figure 3 shows a heat map of the nutrition knowledge scores of all 
participants. Based on the score, participants’ nutrition knowledge was ranked as either low 
or high. A score from 1-7 was ranked as low and 8-14 was ranked as high. The mean score 
was 9.5±2.26, the minimum and maximum scores were 2 and 14 respectively. Majority 
(85%) of the respondents had high nutrition knowledge. 
 
 
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9 11 6 13 8 10 11 7 12
8 5 12 11 8 10 8 12 13
7 11 8 10 8 13 13 10 5
9 7 5 9 12 7 7 7 8
10 9 9 11 2 12 10 12 12
14 12 8 7 10 9 10 9 8
11 11 6 11 8 14 6 12 12
11 7 10 12 9 11 8 8 10
10 8 8 13 9 11 10 8 8
9 11 8 9 11 10 12 4 12
5 11 7 6 8 11 10 6 10
12 8 6 11 8 9 9 10
10 12 9 11 8 10 12 9
11 9 11 8 8 8 9 13
6 11 11 11 11 7 10 3
3 9 10 13 11 8 12 9
9 7 9 12 12 13 11 10
11 8 10 9 12 8 12 10
10 14 9 11 11 10 13 11
13 10 8 8 9 10 8 9  
Keys: Black – below 4; red – 4 – 7; yellow – 8-10; green – 11 -14 
Figure 3: Heat map of nutrition knowledge scores of participants 
 
4.4 Nutritional Status of Participants 
4.4.1 Body Fat Distribution among Males and Females 
The percentage body fat and muscle mass of participants were estimated and ranked into low, 
normal, high and very high based on the standards of the manufacturers of the body 
composition monitor attached as appendix 4. The percentage body fat (%BF) of 85% of the 
participants was obtained. However, the %BF of 15% of the participants was not obtained 
due to technical errors that occurred during measurements. Out of the 85% that was obtained, 
females represented a greater majority (64%). The percentage body fat distribution among 
males and females is shown in tables 6 and 7 respectively. For both genders, a little over half 
of the participants had a normal percentage body fat. However, more males than females had 
a low body fat percentage. In contrast, more females than males had a high and very high 
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percentage body fat. The mean %BF for females and males are 30.6±7.04 and 11.9±5.82 
respectively.  
Table 6: Body fat levels of males 
Age group Low Normal High Very High TOTAL 
(years) n (%) n (%) n (%) n (%) N (%) 
16 1 (50) 1(50) - - 2 (100) 
18-39 15 (31.3) 28 (58.3) 3 (6.3) 2(4.1) 49(100) 
40-59 - 2 (100) - - 2 (100) 
TOTAL 16(30.8) 32(59.6) 3(5.8) 2(3.8) 52 (100) 
 
Table 7: Body fat levels of females 
Age group Low Normal High Very High TOTAL 
(years) n (%) n (%) n (%) n (%) N (%) 
16 - 3(100) - - 3 (100) 
17 - 5(100) - - 5 (100) 
18-39 3 (4.1) 39 (52.7) 25 (33.8) 7(9.5) 74 (100) 
40-59 1 (9.1) 6 (54.6)        3 (27.3) 1 (9.1) 11 (100) 
 
TOTAL 4 (4.3) 53(57.0) 28(30.1) 8 (8.6) 93 (100) 
 
4.4.2 Muscle Mass Distribution among Males and Females 
Although the percentage muscle mass (%MM) of 145 (84.8%) of the participants was 
obtained, only that of 135 participants could be ranked as low, normal, high or very high. 
This is because per the manufacturer’s standards, the %MM of persons below 18years is not 
ranked and there were 10 participants below 18years.  
Table 8 shows the %MM of males was skewed towards the high and very high end, this 
represented 86% of males. The mean %MM for males is 43.3±6.32. Majority (74.1%) of the 
females had a normal %MM as shown in table 9 with a mean of 28.1±3.17.   
 
 
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Table 8: Muscle mass levels of males 
Age group Low Normal High Very High TOTAL 
(years) n (%) n (%) n (%) n (%) N (%) 
18-39 1 (2.1) 5 (10.4) 12 (25.0) 30(62.5) 48(100) 
40-59 - 1 (50.0) 1 (50.0) - 2 (100) 
TOTAL 1(2.0) 6(12.0) 13(26.0) 30(60.0) 50 (100) 
 
Table 9: Muscle mass levels of females 
Age group Low Normal High Very High TOTAL 
(years) n (%) n (%) n (%) n (%) N (%) 
18-39 2 (2.7) 56 (75.7) 15 (20.3) 1(1.3) 74 (100) 
40-59 1 (9.1) 7 (63.6) 3 (27.3) - 11 (100) 
TOTAL 3(3.5) 63(74.1) 18(21.2) 1(1.2) 85 (100) 
 
4.4.3 BMI Categories of Participants 
To determine overall nutritional status of participants, the WHO standard definition for 
underweight, normal, overweight and obese using Body Mass Index (BMI) was used. 
However, for participants below 20 years, BMI-for-age (BAZ) scores were used to classify 
them into underweight, normal, overweight and obese as recommended by WHO. Table 10 
and 11 show the nutritional status of participants below 20 years based on BAZ scores and 
BMI categories respectively. 
 
 
 
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Table 10: Nutritional status of participants below 20years using BMI-for-age (BAZ) 
scores (N=35) 
Nutritional status n (%) 
Underweight   1 (2.8) 
Normal  33 (94.4) 
Overweight  1 (2.8) 
According to WHO, 2009; BAZ score:  >2SD – Overweight;   1≥ x ≥ -2 SD – Normal;   < -2 SD – Wasted / Underweight 
 
Table 11: Nutritional status of participants 20years and above based on BMI categories 
(N =136) 
Nutritional status n (%) 
Underweight  25 (18.4) 
Normal  96 (70.6) 
Overweight & Obese 12 (8.8) 
Obese    3 (2.2) 
BMI Interpretation: <18.5 kg/m2 – Underweight; 18.5 – 24.9 kg/m2 – Normal;   25.0 – 29.9 kg/m2 – Overweight;   ≥30 kg/m2 – Obese  
 
Combining the BAZ categories of participants below 20 years with the BMI categories of 
participants 20 years and above, the nutritional status of all participants was obtained and 
shown in figure 4. Majority of the participants were well-nourished with 25% being 
malnourished, that is, underweight, overweight or obese. Table 12 shows the nutritional 
status distribution per haemoglobin genotype, there was no significant difference between the 
nutritional status of participants in the two genotypes (p = 0.09).  
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8% 2% 15%
75%
Underweight Normal Overweight Obese
 
Figure 4: Nutritional status of participants 
 
Table 12: Nutritional status per haemoglobin genotype 
Haemoglobin Underweight Normal Overweight & Total  p-value 
genotype n (%) n (%) Obese N (%) 
n (%) 
SC 5 (10.2) 36 (73.5) 8 (16.3) 49 (100)  
0.09 
SS 21 (17.2) 93 (76.2) 8 (6.6) 122 (100) 
Total  26 (15.2) 129 (75.4) 16 (9.4) 171 (100)  
 
 
4.4.4 Serum Interleukin-6 and Vitamin E levels of Participants 
Out of the 171 participants, the serum IL-6 and vitamin E levels of 168 participants were 
analysed and the results presented in figures 5 and 6. Both figures show that the levels of 
these biomarkers in the participants were skewed to the right. The mean IL-6 and vitamin E 
level were 18.6±33.7 pg/ml and 6.7±9.9 µg/ml respectively. An independent t-test shows that 
IL-6 levels were significantly elevated in individuals with sickle cell anaemia compared to 
Hb SC individuals as shown in table 13. 
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Figure 5: Serum interleukin-6 levels of participants 
 
Table 13: Comparison of mean IL-6 levels between Hb genotypes 
Hb genotype Observations Mean±SD p-value 
SS 121 11.19±2.7 0.02* 
SC 47 21.49±3.4 
 
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Interleukin-6 (pg/ml)
100 150 200 250
50
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Figure 6: Serum vitamin E levels of participants 
 
4.5 Food Consumption Pattern of Participants 
Out of the 171 participants interviewed, the dietary pattern data of 168 was obtained. Figure 
7-22 shows the dietary patterns of these participants over a one-week period. The food items 
are categorized into groups as shown in the figures below. 
4.5.1 Pattern of fruit consumption 
 
Figure 7 shows that fruit consumption was generally low amongst participants as more than 
half of them had not consumed the fruits mentioned except for banana which recorded almost 
60% consumption rate. Grapes were the least consumed fruit and less than 10% of the 
participants consumed fruits almost daily. Most participants ate fruits once/twice in a week. 
Since the data was collected over a 5 month period and fruit availability is seasonal, the fruit 
consumption pattern was sub-divided into the various months and presented below. Banana 
recorded the highest frequency of consumption in all the months. Pawpaw, apples and citrus 
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Vitamin E (µg/ml)
10 20 30 40 50
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recorded the second highest consumption rate depending on the month of assessment. Except 
for October, grapes were the least consumed fruit in all the other months. 
Banana
Coconut
Grapes
Apples
Mangoes
Watermelon
Citrus
Pineapple
Pawpaw
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
1-2 times 3-4 times 5-6 times never
 
Figure 7: Daily fruit consumption over a one-week period 
 
Banana
Coconut
Grapes
Apples
Mangoes
Watermelon
Citrus
Pineapple
Pawpaw
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
1-2 times 3-4 times 5-6 times never
 
Figure 8: Daily fruit consumption in October over a one-week period 
 
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Banana
Coconut
Grapes
Apples
Mangoes
Watermelon
Citrus
Pineapple
Pawpaw
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
1-2 times 3-4 times 5-6 times never
 
Figure 9: Daily fruit consumption in November over a one-week period 
 
Banana
Coconut
Grapes
Apples
Mangoes
Watermelon
Citrus
Pineapple
Pawpaw
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
1-2 times 3-4 times 5-6 times never
 
Figure 10: Daily fruit consumption in December over a one-week period 
 
 
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Banana
Coconut
Grapes
Apples
Mangoes
Watermelon
Citrus
Pineapple
Pawpaw
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
1-2 times 3-4 times 5-6 times never
 
Figure 11: Daily fruit consumption in January over a one-week period 
 
Banana
Coconut
Grapes
Apples
Mangoes
Watermelon
Citrus
Pineapple
Pawpaw
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
1-2 times 3-4 times 5-6 times never
 
Figure 12: Daily fruit consumption in February over a one-week period 
 
4.5.2 Pattern of vegetables, stews and soups consumption 
Except for cucumber, more than half of the participants consumed cabbage/lettuce, green 
pepper and carrots weekly as presented in figure 13. However, most of the participants did 
not consume these vegetables on a daily basis rather once/twice weekly. Figure 14 shows that 
except for tomato stew, less than half of the participants had consumed the other stew types 
like okro, beans and kontomire stew. About 40% of the participants consumed tomato stew 
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about once/twice weekly. Consumption of kontomire with agushie recorded the lowest 
frequency. 
More than half of the participants had not consumed all the soups assessed except for light 
soup as shown in figure 15. For all the soups, the highest rate of consumption was once/twice 
weekly although a few people consumed it almost every day. 
 
Cucumber
Greem pepper
Carrots
Cabbage/lettuce
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
1-2 times 3-4 times 5-6 times never
 
Figure 13: Daily vegetables consumption over a one-week period 
 
 
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Tomato
Okro
Kontomire with agushie
Kontomire
Beans
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
1-2 times 3-4 times 5-6 times never
 
Figure 14: Daily stew consumption over a one-week period 
 
Okro
Groundnut
Palm
Light
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
1-2 times 3-4 times 5-6 times never
 
Figure 15: Daily soups consumption over a one-week period 
 
4.5.3 Pattern of consumption of protein-rich foods 
The most consumed fish was salmon (>50%), herring was the least consumed fish (<30%). A 
little over half of the participants had consumed meats like goat and cow meat and almost 
60% had consumed chicken as illustrated in figure 16. Eggs were consumed by most of the 
participants at least once/twice in a week. Less than 20% of the participants had consumed 
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bush meat, offal, crabs and shrimps. Less than half of the participants consumed milk and 
milk products as shown in figure 17. Evaporated milk consumption was most frequent 
amongst the participants compared to powdered milk. Cheese was the least consumed milk 
product. 
 
 
Sausages
Eggs
Offals
Goat/cow meat
Chicken
Herrings
Cras/shrimps
Tilapia
Salmon
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
1-2 times 3-4 times 5-6 times never
 
Figure 16: Daily meat, poultry, fish and egg consumption over a one-week period 
 
Cheese
Brukina
Powdered milk
Evaporated milk
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
1-2 times 3-4 times 5-6 times never
 
Figure 17: Daily milk and milk products consumption over a one-week period 
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4.5.4 Pattern of consumption of foods high in fats 
Most of the participants had not consumed spreads during the period of data collection. 
Although margarine was most frequently consumed, just about a quarter of the participants 
had consumed it as shown in figure 18. The frequency of consumption of deep-fried foods 
was also low. Even though fried about 40% of participants consumed fried plantain, it was 
mostly consumed once/twice weekly. As illustrated in figure 19, more than 60% of 
participants had consumed white bread (cake bread, tea bread, sugar bread and butter bread) 
and most (about 40%) of them consumed it once/twice in the week. Biscuit was the second 
most consumed pastry with about half of the participants reporting that they had consumed it 
during the week of assessment. The most reported rate of consumption of pastries was 
once/twice in a week. Doughnuts were the least consumed pastry. 
Fried plantain
Fried yam
Koose
Groundnut paste
Margarine
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
1-2 times 3-4 times 5-6 times never
 
Figure 18: Daily deep-fried foods and spreads consumption over a one-week period 
 
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Chips
Biscuits
Wheat bread
White bread
Plantain chips
Doughnuts
Cakes
Meat pie
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
1-2 times 3-4 times 5-6 times never
 
Figure 19: Daily pastries consumption over a one-week period 
 
 
4.5.5 Pattern of consumption of carbohydrate-rich foods 
As shown in figure 20, for the common breakfast meal options (beverages and porridges) 
assessed, more than half of the participants had not consumed them. However, the most 
consumed beverage and porridge was cocoa and millet porridge respectively where majority 
of participants had consumed these foods at least once/twice within a week. Rice, wheat and 
oats porridges were the least (<20%) consumed among participants. 
Except for banku, plain rice and jollof, more than half of the participants had not consumed 
the major staples in the country. Gari was the least consumed starchy food followed by 
plantain. Although noodles and spaghetti are not traditional staples in Ghana, its consumption 
is almost at par with traditional staples like yam, fufu and kenkey.  Almost 90% of the 
participants had eaten plain rice during the week of assessment with most of them eating it 
once/twice weekly followed by those who ate rice almost every day. Figure 22 shows that 
consumption of sugar-sweetened (soda) was very common among participants (60%) with a 
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consumption rate mostly once/twice weekly. This was followed by fruit juice consumption. 
Alcohol consumption beverages represented less than 10% of the participants. 
Rice porridge
Corn porridge
Wheat/oats
Millet porridge
Cocoa
Tea
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
1-2 times 3-4 times 5-6 times never
 
Figure 20: Daily beverages and porridges consumption over a one-week period 
 
Gari
Noodles/ spaghetti
Kenkey
Jollof rice
Plain rice
Plantain
Yam
Fufu
Banku
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
1-2 times 3-4 times 5-6 times never
 
Figure 21: Daily starchy foods consumption over a one-week period 
 
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Vitamilk
Alcoholic drinks
Sobolo
Fruit juice
Soda
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
1-2 times 3-4 times 5-6 times never
 
Figure 22: Daily soft drinks and alcoholic beverages consumption over a one-week 
period 
 
4.6 Association between Nutrition Knowledge and Nutritional Status 
A chi-squared test was conducted to determine the association between nutritional knowledge 
and nutritional status and the results presented in Table 14. A p˃0.05 was obtained; therefore, 
we do not reject the null hypothesis. 
 Table 14: Association between nutritional status and nutritional knowledge 
Overall nutritional Nutritional knowledge ranking     
status 
Low High  Total p-value 
Malnourished 9 33 42   
0.196 
Well-nourished 17 112 129 
Total  26 145 171 
 
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4.7 Association between Inflammatory Biomarker and Nutritional Status 
A linear regression showed that weight was a predictor for IL-6 levels such that a unit change 
in weight will lead to a 0.66 decrease in IL-6 levels (F (1, 166) = 4.93 ; p = 0.03). After 
adjusting for height, the results are presented in the table below (F (2, 165) = 2.97; R2- 0.03 p 
= 0.05). 
Table 15: Strength of association between IL-6 levels and weight 
Variable  Coefficient (confidence interval) p-value 
Weight -0.589 (-1.194 – 0.016) 0.06 
Height  -0.340 (-1.007 – 0.327) 0.32 
 
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CHAPTER FIVE 
5.0 DISCUSSION 
5.1 Socio-demographic Characteristics of Participants 
Historically, people with SCD were known to have a shorter life expectancy compared to 
non-SCD individuals. However, due to improvements in care, the life expectancy of these 
individuals has increased. A recent report by Asare stated that most (86%) of the patients at 
the Ghana Institute of Clinical Genetics were between the ages of 13-39 years (Asare et al., 
2018). Similarly, this study also had majority (91.2%) of participants within the age range of 
16-39 years. More females than males (1.6:1) participated in this study which is also in 
agreement to the report by Asare et al. (2018). Generally, more females attended the clinic 
compared to males in a ratio of 1.6:1 and this was attributed to the better health seeking 
behaviour of females than males (Asare et al., 2018). In agreement to the current study, 
Nyante, Oppong and Bonney (2019) also found the prevalence of females (60%) with SCD to 
be higher than males (40%). Another explanation given by Asare et al. (2018) was that 
Ghanaian women had a higher life expectancy compared to males based on a WHO report.  
 
Individuals with sickle cell anaemia represented a larger number of the participants. Aside 
sickle cell anaemia, the Hb SC subtype also represented 30% of the participants. A 
preliminary study conducted at a hospital in the Volta region of Ghana also reported a higher 
percentage of Hb SS to Hb SC patients in a ratio of 1:0.4. Sickle cell anaemia (Hb SS) and 
Hb SC were the reported genotypes probably because Hb S and Hb C are the commonest 
variants found in Africans with the Hb C variant being almost exclusive to West Africa 
(Makani et al., 2013). Even though individuals with SCD suffer from periodic crisis and may 
be absent during school hours, this did not deter them from pursuing formal education as this 
study shows that almost all participants had some level of formal education with most of 
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them attaining at least a Secondary or Vocational or Technical certificate. Opposing to this 
study, Nyante et al. (2019) reported that most (47.2%) of their participants had attained 
tertiary education. Most Ghanaians in secondary or vocational school are in their teenage 
years (13-18years) and this may explain why this study recorded a higher percentage for 
secondary or vocational level whereas Nyante and colleagues reported a higher percentage 
for tertiary education because their study did not include persons below 18 years. 
 
5.2 Source of Nutrition Information 
Due to the frequent reports on the nutritional challenges faced by individuals with SCD, there 
have been proposals to involve experts like dietitians and nutritionists in the standard care 
protocol (Hyacinth et al., 2013). Findings from this study suggest that this proposal has not 
fully been implemented since nutrition experts are the least consulted for nutrition 
information. This study revealed that the services of the nutritionists are not frequently sort 
after although there is a consulting nutritionist at the institute every Tuesday and Friday. A 
survey by a group of scientists showed many young adults could not afford the fee (GH₵ 10 - 
GH₵ 30) needed to consult a dietitian because of their limited income (Quaidoo et al., 2018). 
Given the mean age of this study’s participants, it is likely that most of them faced similar 
challenges and hence could not schedule an appointment with a dietitian or nutritionist.  
 
A study among healthy young adults in Accra reported that health professionals were the 
least consulted for nutrition information whereas the internet, radio, television, family and 
friends were the most consulted (Quaidoo et al., 2018). This trend was attributed to the  
preference for self-care practices by people in developing countries (Obasola & Agunbiade, 
2016). A similar trend for self-care practices can also be seen in this study as family and 
friends were the most consulted source of nutrition information whereas radio, television and 
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internet were most consulted compared to dietitians. For individuals with SCD the quest for 
self-care may have negative consequences on them due to probability of misinformation. 
 
Although Quaidoo et al., (2018), documented health professionals as the least consulted for 
nutrition information, this study reports that doctors are the most consulted health 
professional for nutrition counsel. The differences in the findings may be due to study 
participants. Whilst the study by Quaidoo et al. (2018) was among healthy individuals, this 
current study was among individuals with a chronic condition who visit the clinic and interact 
with doctors and nurses very often.  It is therefore not surprising that doctors and nurses were 
the most consulted health professionals for nutrition information because they are the primary 
providers of health care for these individuals. People with SCD need a comprehensive 
nutrition management due to the nutritional challenges they face and doctors and nurses are 
not equipped to provide such care. Hence, doctors and nurses should refer cases that require 
nutrition attention to the appropriate professionals since they are well equipped to provide 
information and other strategies that can improve nutritional status. 
 
5.3 Food Consumption Patterns of Individuals with Sickle Cell Disease 
The food consumption patterns of the study participants were similar to that of healthy 
individuals in Ghana. For fruits, banana was the most consumed followed by citrus this is 
contrary to findings by Asante et al. (2015) who reported a citrus as the most frequently 
consumed fruit followed by banana. The monthly consumption also showed similar trends, 
banana was the most consumed fruit in each month followed by oranges except for October 
and December where pawpaw and apple consumption recorded the second highest 
frequencies respectively. Based on the article by Banson, Sun and Banson (2016), banana is 
available all year round, this may account for it being the most consumed fruit in all the 
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months. The period of data collection may explain why the frequency of orange consumption 
was the second highest in January and February because oranges are available from January-
March and June-September (Banson et al., 2016). Although apples and grapes are exotic 
fruits, consumption of apples was more frequent than grapes and this agrees with the study 
conducted by Asante and colleagues (Asante et al., 2015). 
 
In accordance with the study by Asante and colleagues this study also found that 
consumption of fresh vegetables was low. This is because Ghanaians prefer consuming their 
vegetables in the form of stews and soups. Fruits and vegetables are the main sources of 
vitamins and minerals in our diet, assessment of nutrition knowledge showed that participants 
did not know the importance of micronutrients to the body.  This may also explain the low 
frequency of consumption of these foods.  
 
For the starches, rice consumption was the most frequent probably due to the busy urban 
lifestyle and this is in accordance to a study conducted in the Ashanti region which also 
reported frequent consumption of rice compared to other staples like “banku” and 
“fufu”(Frimpong, 2013). Asante et al. (2015) also documented that preferred breakfast 
options for Ghanaians in Accra were corn and millet porridge but in this study cocoa 
beverages were the most preferred choice of breakfast followed by millet porridge. Eggs and 
salmon were the most frequently consumed protein-rich food compared to chicken and meat. 
Tanabe et al. (2010) mentioned that individuals with SCD do not consume fatty foods as a 
coping strategy to prevent crises. Since meats are often perceived to fatty, it is likely that 
participants preferred consuming salmon which is seen to be less fatty. Although participants 
knew sugar-sweetened beverages and pastries were not healthy snacks, they still consumed 
them in relatively high frequencies. 
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Fruits and vegetables are very important in the diets of individuals. This is because they 
contain vitamins and minerals which are very essential to human living. For example, vitamin 
A, C and E are antioxidant vitamins and this property has been shown to help reduce the 
frequency of crisis and disease severity in people with SCD (Hyacinth et al., 2010). Given the 
numerous nutrient deficiencies that people with SCD present with, it is necessary that they 
consume adequate amounts to help reduce incidence of these nutrient deficiencies. From the 
food consumption data gathered, it is seen that the consumption of these group of foods is 
very low among participants. It is therefore necessary, that in the nutritional management of 
people with SCD, dietitians and nutritionists emphasize on the need for these persons to 
consume adequate amounts of fresh fruits and vegetables since these foods contains the 
minerals and vitamins that most SCD patients that will help improve the numerous 
complications that they face.  
 
5.4 Nutritional Status of Participants  
The average body fat level of both males and females were within the normal range with the 
mean levels of females and males being 30.6±7.04 and 11.9±5.82 respectively. Two studies 
have also reported the mean body fat levels of males with SCD to be 8.9% and 10.8% (Eke, 
Chukwu, Ikefuna, Ezenwosu, & Emodi, 2015 & VanderJagt, Harmatz, Scott-Emuakpor, 
Vichinsky, & Glew, 2002). However, these studies report significantly lower levels of body 
fat in females with body fat levels of 25.7 % and 14.7% compared to the 30.6% reported in 
this study. For muscle mass, Eke et al. (2015) also reported higher levels (33.1%) among 
females compared to this study (28.1%) and vice versa for the  males. A correlation analysis 
showed that body fat increased with age and muscle decreased with age this could explain the 
differences observed between the two studies since Eke and colleagues assessed the body 
composition of adolescent whereas this study was conducted among adolescents and adults. 
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In healthy populations, there is muscle loss with increasing age due to many factors like 
reduced activity, lower concentration of growth hormones and insulin-like growth factor 
(Seene & Kaasik, 2012). This age-related sarcopenia coupled with the hypermetabolic nature 
of the disease may contribute to the reduced %MM reported. In contrast, although 
VanderJagt et al. (2002) also conducted their study among adolescents, the percentage muscle 
mass of both genders (males - 91.1% and females – 72.1%) were significantly higher than the 
present study. It is worth noting that the study by VanderJagt and colleagues was conducted 
in the United States which is a developed country unlike Ghana and Nigeria which are still 
developing. Hence, individuals with SCD in the developed countries are more likely to 
receive better health care compared to Ghana. The body composition of females is quite 
worrying because a high percentage body fat has been shown to increase cardiovascular 
disease risk (Valentino et al., 2015). Almost 40% of the females had high and very high 
percentage body fat levels and this may put them at risk of cardiovascular diseases which will 
put another metabolic stress on the body in addition to the SCD. 
 
The overall nutritional status based on BMI show that majority of the respondents were well-
nourished with a few malnourished cases. Historically, individuals with SCD were mostly 
reported to be underweight; however, due to improvements in the standard of care, there is a 
shift from underweight to normal as reported in this study. This study also reports cases 
overweight and obesity almost close to prevalence underweight. Cox et al. (2011), did not 
report any case of overweight or obesity in their study among Hb SS individuals in Tanzania. 
Conversely, Akodu, Diaku-Akinwumi and Njokanma (2012) documented a 2.5% prevalence 
of obesity in their study conducted in Nigeria. A lower prevalence rate was reported 
compared to this study because Akodu et al. (2012) conducted their study among individuals 
with SCD aged 2-15 years old whilst the current study was conducted among individuals 
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aged 16 years and above. Unlike the study carried out in Nigeria, studies in Ghana conducted 
among children have not reported any case of overweight or obesity (Boadu, 2016; Bonsu, 
2017; Osei-Yeboah et al., 2011). One of such studies, explained that dietary energy and 
nutrient intake of these Ghanaian children were sub-optimal (Boadu, 2016).  
 
The prevalence of overweight and obesity among individuals with SCD in developed 
countries is higher than what has been reported in developing countries. An overweight and 
obesity prevalence rate of 44% was reported among African-Americans with SCD in the 
United States and the BMI was higher in Hb SC individuals compared to Hb SS (Kaufman et 
al., 2018). An equally higher prevalence (54%) of overweight and obesity was documented in 
another study conducted in the United States among SCD patients aged 16 years and above 
(Farooqui et al., 2014). Farooqui et al. (2014), states that these high rates are reflections of 
the rapid increase of obesity in the general population of developed countries. These findings 
on the prevalence of overweight and obesity suggests that whilst health professionals focus 
on ensuring almost all underweight patients attain a normal weight, care should be taken to 
prevent patients from gaining excessive weight.  
 
5.5 Serum Vitamin E and Interleukin-6 levels of Participants 
Low circulating levels of antioxidant vitamins has been reported in individuals with SCD. 
This study also reported lower levels of vitamin E as compared to the reference range. This 
shows participants are at risk of vitamin E deficiency since the reference range is 5.5-
17µg/ml (Wallach, 1996). A similar study by Hasanato records mean vitamin E levels as low 
as 2 mg/L (Hasanato, 2006). This is worrying because participants are given multivitamins to 
supplement their dietary intake and help prevent these nutrient deficiencies. The low vitamin 
E level is also suggestive that even in steady state; there is an increased demand for nutrients 
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to compensate the hypermetabolic activities like subclinical inflammation taking place. 
Inflammation is likely to be more pronounced in persons with lower levels of vitamin E 
because they will not benefit from the ability of this vitamin to prevent oxidative stress and 
reduce rate of haemolysis. 
 
Evidence of the hypermetabolism is the elevated IL-6 levels recorded even in steady state. 
Keikhaei et al. (2013) reported elevated IL-6 among SCD subjects compared to controls with 
a mean 12.1±1.98 pg/ml. Similarly, Pierrot-Gallo et al. (2015) also reported higher IL-6 
levels among SCD subjects with a mean level of 15.9±9.1 pg/ml. These are not extremely 
different from the levels recorded in this study. Some studies have documented extremely 
high IL-6 levels in steady state SCD individuals. One of such studies reports mean levels of 
71±40 pg/ml (Hibbert et al., 2005).  A recent report by Elzubeir and colleagues also reported 
extremely high circulating IL-6 levels in steady state SCD individuals (Elzubeir et al., 2017). 
These findings suggest that even in study state, inflammation is ongoing in this group of 
people.  
 
This chronic inflammatory response may be responsible for the low body weight recorded in 
some participants. An independent t-test showed that individuals with sickle cell anaemia had 
a significantly lower body weight and elevated IL-6 compared to those with Hb SC. This is 
because a negative correlation existed between IL-6 levels and body weight (r = -0.1698, p 
=0.03). Interleukin-6 is a pro-inflammatory cytokine that has been implicated in cancer 
cachexia for causing weight loss and reducing appetite (Carson & Baltgalvis, 2010). Thus 
chronic elevated levels will lead to a reduction in body weight. A linear regression 
demonstrated that for every unit increase in weight, IL-6 levels will decrease by 0.66. After 
adjusting for height, weight was not a significant predictor of IL-6 levels. 
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5.6 Association between nutrition knowledge and nutritional status 
Contrary to reports that nutrition knowledge was associated with nutritional status such that a 
high nutritional knowledge will lead to a good nutritional status and vice versa, this study 
reported no association between these two variables. This buttresses the statement by Hakli et 
al. (2016) that nutrition knowledge alone may not be enough to improve nutritional status if 
not translated into dietary behaviour and practices. In this study, although almost all the 
participants knew that sugar-sweetened beverages and pastries were not healthy snacks, the 
consumption rate was high. This lack of translation of knowledge to behaviour may explain 
the result obtained. 
Unlike healthy individuals, persons with SCD are in a hypermetabolic state and this is 
reinforced by the elevated IL-6 levels recorded even in steady state. This increases the energy 
and nutrient requirements of affected persons. Therefore, having a high nutritional knowledge 
will not automatically translate into a good nutritional status if adequate energy and nutrients 
are not consumed to support the hypermetabolism and growth. Hence, nutrition experts 
should not only focus on providing nutrition information during counselling sessions but also 
have a means of assessing nutrition behaviour and practices. There is also a need for frequent 
monitoring to ensure that the nutrition counsel provided is being adhered. For individuals 
who may be struggling with underweight especially persons with Hb SS, laboratory tests can 
be requested to ascertain the intensity of inflammation and the appropriate dietary counsel 
that can meet metabolic demands and support growth given. 
5.7 Limitations 
Some limitations of this study include: 
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1. The dietary assessment tool used in this study may have some levels of under- or 
over-reporting.  
2. It is also possible that eating habits were modified to impress the researcher and these 
may affect the results. 
3. The results of the study cannot be generalized because of the sampling technique 
used. 
 
 
 
 
  
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CHAPTER SIX 
6.0 CONCLUSION AND RECOMMENDATIONS 
6.1 Conclusion 
Although, almost all participants (90%) had not received counselling from a dietitian or 
nutritionist, majority had a high nutritional knowledge. However, nutritional knowledge did 
not influence nutritional status. Even though majority of the participants were well nourished 
(had a normal BMI), this study also found that the prevalence of overweight and obesity is 
almost equal to that of underweight.  Haemoglobin SS participants were more likely to have a 
lower BMI compared to other SCD types. 
Food consumption patterns of participants was similar to the healthy Ghanaian population 
with low frequency of consumption of fruits and vegetables was low and high consumption 
of sugar-sweetened beverages and pastries. 
Serum interleukin 6 levels were significantly elevated in individuals with sickle cell anaemia 
compared to those with Hb SC. Also, IL-6 levels were slightly higher in participants with a 
normal nutritional status compared to those who were malnourished. Serum vitamin E levels 
of participants with a normal nutritional status were lower than those who were 
malnourished. However, the difference between the groups was not significant. 
 
6.2 Recommendations 
1. Since nutritional knowledge did not influence nutritional status, there is a need for 
dietitians to assess dietary practices and habits of individuals during counselling 
sessions. 
2. There is a need to educate participants on the micronutrients and the importance of 
these nutrients to the body. 
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3. Patients at risk of being overweight or obese should be referred to dietitians for 
nutrition therapy to prevent these persons from developing non-communicable 
diseases like diabetes and dyslipidemia in addition to their present condition. 
4. Future research should engage in interventional studies that will improve the dietary 
habits and intake of participants.  
  
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Sickle Cell Disease : New Opportunities and Challenges in Africa. The Scientific World 
Journal, 2013, 1–16. https://doi.org/http://dx.doi.org/10.1155/2013/193252 
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Mandese, V., Marotti, F., Bedetti, L., Bigi, E., Palazzi, G., & Iughetti, L. (2016). Effects of 
Nutritional Intake on Disease Severity in Children with Sickle Cell Disease. Nutrition 
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Marwah, S. S., Blann, A. D., Rea, C., Phillips, J. D., Wright, J., & Bareford, D. (2002). 
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146. https://doi.org/10.1002/ajh.10033 
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Behaviors in Children with Sickle Cell Disease. Journal of Pediatric Psychology, 29(4), 
315–320. 
Mitchell, M. J., Kawchak, D. A., Stark, L. J., Zemel, B. S., Ohene-frempong, K., & Stallings, 
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Bioelectrical Impedance Analysis of the Body Composition of Children and Adolescents 
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Impedance Analysis of the Body Composition of Nigerian Children with Sickle Cell 
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Wayne, W. D. (1999). Biostatics: A Foundation for Analysis in the Health Sciences (7th ed.). 
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Oral Glutamine Supplementation Decreases Resting Energy Expenditure in Children 
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and Adolescents with Sickle Cell Anemia. Journal of Pediatric Hematology/Oncology, 
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Ninth World Health Assembly, 1–5. 
  
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APPENDICES 
APPENDIX I 
UNIVERSITY OF GHANA 
SCHOOL OF BIOMEDICAL AND ALLIED HEALTH SCIENCES 
INFORMED CONSENT  
My name is Faustina Ofosua Mintah and I wish to conduct research on the topic 
“Assessing Nutrition Knowledge and Nutritional Status of Sickle Cell Disease Patients”. 
I am a Dietetic student of the School of Biomedical and Allied Health Sciences, College of 
Health Sciences, University of Ghana.  
General Information about Research: The aim of the study is to assess nutrition 
knowledge and the nutritional status of sickle cell disease (SCD) patients. This study will 
help us know your nutritional status. It will also help us understand the relationship between 
your nutrition knowledge and nutritional status.  
You will be required to fill a questionnaire that will provide information on your nutrition 
knowledge. You will also be required to give information on what you eat and how much you 
eat. Your body height and weight will be measured to determine your nutritional status. A 
small amount (about half of a teaspoon) of your blood that was taken for SickleGenAfrica 
will be taken for some blood tests. This will help us know if you have some nutritional 
problems or not. All these processes will take about 45 minutes.  
Possible risks and Discomforts: There is no risk involved in taking part in this study.  
Possible benefits: There is no direct benefit to you. However, the results will be used to plan 
nutrition and health intervention programmes to improve your care and SCD patients in 
general.  
Confidentiality: The information you provide will be kept confidential by the researcher. 
You will not be identified by your name. You will be given codes as a form of identification.  
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Voluntary Participation: Participating in this study is voluntary without any costs. You are 
free to withdraw from the study at any point in time and your care at the clinic will not be 
affected. 
Contacts for Additional Information: The researcher will however be available and willing 
to answer any further questions about the research, now or during the course of the project. 
You can contact me through this number should you have any questions or concerns, 
0248568483.  
VOLUNTARY AGREEMENT  
I agree that the research project named above has been read and explained to me. I have also 
been given the opportunity to ask questions about the research and I have been answered to 
my satisfaction. I therefore agree to take part in this study. I understand that I am agreeing 
with my signature/thumbprint on this form to take part in this research project.  
Name of participant / parent ……………………………………..   
 
Signature /mark of participant / parent …………………………….  
Tel No: ………………… 
Date …………………………  
If volunteers cannot read the form themselves, a witness must sign here:  
I was present while the benefits, risks and procedures were read to the patient. All questions 
were answered and the patient has agreed to take part in the research.  
Name of witness …………………………………………………..  
Signature of witness …………………………... Date …………………………   
 
I certify that the nature and purpose, the potential benefits, and possible risks associated with 
participating in this research have been explained to the above individual.  
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Name of Person Who Obtained Consent …...................................................  
 
Signature of Person Who Obtained Consent …...................................................  
 
Date …………………………….. 
 
 
 
  
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APPENDIX II 
CHILD ASSENT FORM 
INFORMATION SHEET  
My name is Faustina Ofosua Mintah and I wish to conduct a research on the topic 
“Assessing Nutrition Knowledge and Nutritional Status of Sickle Cell Disease Patients”. 
I am a Dietetic student of the School of Biomedical and Allied Health Sciences, College of 
Health Sciences, University of Ghana.  
I am asking you to take part in this study because I am trying to learn more about the 
relationship between your nutrition knowledge and nutritional status. This will take about 45 
minutes.  
General information: If you agree to be part of this study, your height and weight will be 
measured. We will also ask you questions about what you eat and how much you eat. A little 
amount of the blood that was taken for SickleGenAfrica will be collected for some blood 
tests. Your participation in this study will give us important information to help plan a 
programme to improve your care and health.  
Possible risk and discomforts: You will not experience any pain for taking part in this 
study.  
Voluntary Participation and Right to Leave the Research: You can stop participating in 
this study at any point and nobody will get angry with you.  
Confidentiality: The information you provide will be kept confidential. Your name will not 
be written against any response you give.  
Contact for Additional Information: You can also call me on 0248568483 or contact me 
anytime you see me.  
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Please talk to your parents before you decide whether or not to be part of this study. I will 
also ask your parents for permission before you are chosen for the study. Even if your parents 
say “yes” you can still decide not to participate in the study.  
 
VOLUNTARY AGREEMENT  
By marking or thumb printing below, it means that you understand and know the issues 
concerning this study. If you do not want to be part of the study, please do not mark or 
thumbprint. A copy of this form will be given to you and your parents after you have marked/ 
thumb printed it.  
This assent form which describes the risks, benefits and procedures of the research project 
named above has been explained to my satisfaction. I have been given the opportunity to 
have any questions about the research answered to my satisfaction. I agree to take part in this 
study.  
NAME OF CHILD…………………………………………………………………….  
DATE…………………………… 
MARK/THUMBPRINT………………………………….......  
NAME OF RESEARCHER……………………………………………………………….  
DATE……………………….. SIGNATURE …………………………  
TELEPHONE NUMBER ………………………………………………………  
If child cannot read the form themselves, a witness must sign here:  
I was present while the benefits, risks and procedures were read to the child. All questions 
were answered and the child has agreed to take part in the research.  
Name of witness …………………………………………………..  
Signature of witness …………………………... Date ………………………… 
  
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APPENDIX III 
QUESTIONNAIRE 
                                                                                          Participant’s code ……….. 
SOCIO-DEMOGRAPHIC DATA 
1. Age of participant …………. 
2. Gender:       0- Male                       1- Female   
3. Body measurements  pa pa
ck ck
Height (cm)  
s s 
Weight (kg) (1 (1
0
BMI (kg/m2)  0
0 0
BF (%) pc pc
MM (%) s  s 
pe pe
VF r  r 
RM pa pa
ck ck
 
) ) 
4. Sickle cell genotype:   0 - SS                 1- SC                   2- SF                  Other………   
5. Place of residence.....................p..a........................p..a.............  pa
ck ck ck
6. Ethnicity: …………………………….  
s s s 
7. Religion (1 (1 (1
0- Christian               1- Muslim 
0                 2- Tra0ditionalist          0     
  
0 0 0
Other (specify) …pa………    pa pa
pc pc pc
ck ck ck
8. Educational background s s s 
s s s 
pe
0- No formal ed(u1cation              
p  e 1- P pe(r1imary                  2- JSS    (  1            
r  r r  
0 pa 0 pa 0 pa
             3- SSS                     4- Tertiary 
p
0   
a        0     5- Voc
paational/Technicapla0  ck ck  ckck ck ck 
pa pc s papc s pc ps 
9. Occupation:       s 0 - Public serva
)n t                          
)1 - Civil Servant)   s                                                     ck (1 ck s (1 ( a1
2- Trader      s      p  e   3- Seam0 stress / Hs apierpdaresser  0                   4- Unpe emp0claoyed  
(p1a r 
 
0 rc k r 5 – Student               6 – Other ……(1……………0  … ………. kc0k pa
0ck p
 a pc 0 pas pcpa pa psc  ck
10. How much d0o yps c
oaku earn mos nthly? 0 ck(1 s ck ck s(1 s 
pcck0-GH¢ 100 - (G1H)¢  299     p  e        1- G
pcH)¢ 0300- GHpe¢s 4 99     v          2- 
)G pH10e¢500 - (G1H¢ 699  
s  s 0  pr 
s 0 r (1  a  0  r 0 pa
            3- GH¢ 700 -p (10eGH¢ 899    p pc a k          4- 
e≥GpHc ¢ 900p  a  0              
    5- No inpc0paocme    0 ck
rp 
0
c ck r s ck 0 pa  psa pa cp
sk pc
p 0sa ) pa pe ) pc ck pc) e pa
s 
c(k1 ck s (1
c pcpke ck r s s ck0s  84 s
  rs  pe 0
 ) 
s  
r ) pa pe (1
 
pa s (01 (1 r pe 0
pa 0 ck r0 
0 cek (1
 par pc  pc
ck 0 00 ) pas 0
)r  ck
pa 0 s ) ck pcppce  pc
p
 ) pe
University of Ghana http://ugspace.ug.edu.gh
 
11. What is your marital status?  
0- Single                   1- Married                    2- Divorced/Widowed  
12. How long hpaave you known your spicakle cell status?  …………………pyaear 
ck ck ck
13. Do you have any disease aside sickle cell?  Yes                  No 
s s   s 
14. If yes, name( 1them…………………(1…………………pa……………p…a …(1………………. 
0 0 ck ckFEEDING BEHAVIOUR AND GENERAL NUTRITION INFORM0ATION 
0 0 s s 0
(1
1. Do you readpicly accept meals offerpecd to you? (1 pc
s s 0 0 s 
0- Yes                       1- No 
p e  pe 0 0 pe
2. How manyp atri mes do you eat inp aa dar y?   pc pc r 
ckpa ck pa s s pa
0- Once                  1- Twice                 2- Thrice               3- > 3x sc  k s ck p e pe c k
3. Do you tak(pe1a) d ietary suppleme(np1tas? )       Yes             p  a r     No  pa  r ) 
4. If yes, namc0ek them   0ck cpa p
ka pack
0s 
 
0s 
 s 2 s  
………………………………………………c…k ……ck……………c…k …………………
p(c1 p(c1 (1) pas ) 
(1
……………0……………………0 ……………………0 ……………ck……0 ……………… s s (1   
 p0e p0e 0 s 00
pc pc pc (1 pc
5. What is your r source of nutritiorn  information?0  Tick as many that apply 
psa pas s 0 s pc
        Doctors  c p k e             Nurses     c  p k e             Dietitian /p Neutritionist 
0 pe
s  
)r  pa pa)r  r 
pc
par pe
            Family andp fariends                   Rp adio/ Television pproagrammes  s ck ck  ckpa
c 
r 
k  s pa sc k ck
pe ck
pa pas 
Other ………) …………ck…………(1 (1) 
… ) r ) 
ck ck(1
  0 s 
pa
0 s  )  0  
0 (1
ck(1
NUTRITION KNOWLEDGE QUE0STIONNAIRE  (Adapted from Ta
0
) ndoh, 2015) 
pc 0 pc 0pc
1. Cassava, Yams  and Ga0ri are ricsh  sources of:   0 s 
1- Protein   2p-e Carbohpycdratesp  e  3- Fats       4- Iron      5- Don’t knpocpwe   
 r s r s r 
2.  Chicken, Eggs and Fpiseh are rich sources of:  pa pa pepa
1- Protein    2- Carbohry drates    3- Fats      4- Iron      5- Don’t know  ck ck rc k
 
) pa ) pa) 
3.  Which of the following is a rich source of fat?  
ck ck
1- Orange    2 - Margarine           3- Carrot     4- Rice     5- Don’t know  ) )   
4.  Milk and milk product s are rich in   
1- Sodium     2- Calcium      3- Iron      4- Zinc      5- Don’t know  
 
5.  Which of the following is a rich source of iron?  
1- Liver       2- Tomatoes       3- Carrot     4- Rice     5- Don’t know  
 
6. Which of the following is a rich source of dietary fibre/roughage?  
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1- Beans      2- white rice       3- Groundnut     4- Beef      5- Don’t know  
 
 
7. Inadequate intake of …………… will make you look very thin.  
1-Protein   2- Carbohydrates     3- Vitamin A     4- Vitamin K    5- Don’t know  
 
8. Rickets/ bow legs are caused by lack of  
1- Vitamin K      2-Vitamin D       3-Vitamin E      4-Vitamin A       5- Don’t know  
 
9. Anaemia is caused by lack of:  
1- Iodine     2- Iron       3- Calcium      4- Sodium      5-Don’t know  
 
  
10.  Bleeding of gums is caused by inadequate intake of:  
1-Vitamin C       2- Vitamin K      3- Vitamin E       4- Vitamin A      5- Don’t know  
 
11.  Which of these foods would give you blood? 
1- Kontomire   2- Oranges 3- Banku  4- Fish     5- Don’t know 
 
12.  Do you think fruits and vegetables must be eaten frequently?  
1- Yes                 2- No                     3- Don’t know 
      13. Which of the following snack options is healthy? 
            1- Coca-cola       2- Ice-cream     3- Banana and groundnut   4- Biscuit  
            5- Don’t know 
      14. Which of these foods is balanced? 
        1- Corn dough porridge with bread               2- Boiled yam with kontomire stew and fish 
     3- Kenkey with pepper sauce                    4 - Fufu with palm-nut soup        
           5- Don’t know 
 
 
 
 
 
 
 
 
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      FOOD FREQUENCY QUESTIONNAIRE  
    For the past one week, how often has you have eaten the following foods? (Please tick one) 
Food/Dish Once a More than 1-2x a 3-4x a 5-6x a Rarely Never 
day once daily week week week 
BEVERAGES        
Tea         
Cocoa e.g. Milo         
PORRIDGES         
Corn porridge        
Millet porridge         
Oats/wheat        
Rice porridge         
Tombrown         
MILK AND MILK        
PRODUCTS  
Evaporated         
Powdered         
Brukina 
       
Cheese/ wagashie        
SPREADS          
Margarine         
Peanut butter         
BREAD         
Wheat bread        
White bread         
DEEP FRIED        
FOODS  
Fried yams         
Fried plantain         
Beans cake(koose)        
FISH AND        
SEAFOOD  
Salmon        
Herrings        
Tilapia         
Crab/Shrimps        
VEGETABLES         
Carrots        
Green pepper        
Cabbage/lettuce        
Cucumber        
 
 
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Food/Dish Once More than 1-2x a 3-4x a 5-6x a Rarely Never 
  a day once daily week week week 
MEAT AND MEAT        
 PRODUCTS  
Meat (beef, goat meat)        
 
Chicken        
 Offals         
Sausages         
 
Cow’s skin (wele)        
 Game (Bush meat)        
Eggs         
 
STARCHES         
 Banku        
 Kenkey  
       
Fufu         
 
Plantain         
 Yam         
Gari         
 
Cocoyam         
 Plain Rice         
Jollof        
 
Indomie/ spaghetti         
 LEGUMES & NUTS        
 Black/ red-eyed beans  
       
Baked beans         
 
Soy Beans        
 SOUPS         
Palm soup         
 
Groundnut soup         
 Light soup         
Okro soup         
 
STEWS         
 Kontomire stew (no        
 agushie) 
Kontomire stew (plus        
 
agushie) 
 Okro stew        
Ghanaian gravy         
 
 
 
 
 
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Food/Dish Once a More than 1-2x a 3-4x a 5-6x a Rarely  Never 
day once daily week week week 
FRUITS         
Pawpaw         
Pineapple         
Mango         
Banana         
Citrus fruits (Orange,        
tangerine) 
Apples         
Watermelon         
Avocado pear         
Grapes         
Guava         
Coconut         
DRINKS         
 Fanta, coke, sprite        
etc.. 
Fruit juices        
Vitamilk        
Sobolo        
Beer        
Wine/spirits        
SNACKS         
Meat pie        
Cake        
Doughnuts        
Chips        
Plantain chips         
Biscuits         
Roasted groundnut         
 
  
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APPENDIX IV 
INTERPRETATION OF BODY FAT AND MUSCLE MASS PERCENTAGES 
 
Body fat level interpretation for males 
  16years 17years 18-39 years 40-59 years 
Low  < 10.4% < 10.1% <   8.0%   < 11.0% 
Normal 10.4 - 24.7% 10.1 - 24.2% 8.0 - 19.9% 11.0 - 21.9% 
High  24.8 - 27.7% 24.3 - 26.8% 20.0 - 24.9% 22.0 - 27.9% 
Very high ≥27.8% ≥26.9% ≥25.0% ≥28.0% 
 
Body fat level interpretation for females 
  16years 17years 18-39 years 40-59 years 
Low  < 15.8% < 15.4% < 21.0% < 23.% 
Normal 15.8 - 34.5% 15.4 - 34.7% 21.0 - 32.9% 23.0 - 33.9% 
High  34.6 - 37.1% 34.8 - 37.3% 33.0 - 38.9% 34.0 - 39.9% 
Very high ≥ 37.2% ≥ 37.4% ≥39.0% ≥ 40.0% 
 
Muscle mass level interpretation for males 
  18-39 years 40-59 years 
Low  < 33.3% < 33.1% 
Normal 33.3 - 39.3% 33.1 - 39.1% 
High  39.4 - 44.0% 39.2 - 43.8% 
Very high ≥44.1% ≥43.9% 
 
Muscle mass  level interpretation for females 
  18-39 years 40-59 years 
Low  < 24.3% < 24.1% 
Normal 24.3 - 30.3% 24.1 - 30.1% 
High  30.4 - 35.3% 30.2 - 35.1% 
Very high ≥35.4 % ≥35.2 % 
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APPENDIX V 
ETHICAL CLEARANCE 
 
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