“Have milk, maas or yoghurt every day”: a food-based dietary guideline for South Africa

A national working group recently reached consensus that a guideline  message for milk consumption should form part of the set of revised food-based dietary guidelines (FBDGs) for South Africa. The message was formulated as: “Have milk, maas or yoghurt every day”. This paper provides scientific support for this FBDG, based on the nutrition and healthprofile of South Africans; addresses concerns about possible detrimental effects of milk consumption, such as lactose intolerance, saturated fat and trans-fat content, milk allergies and dental caries in children; and  identifies barriers to increased consumption. The guideline refers to milk, maas and yoghurt, and not all dairy products. This is based on the nutrient contribution of these products to a healthy diet. Milk (and some dairy products) has a low sodium-to-potassium ratio, as well as bioactive peptides, which may protect against the development of noncommunicable diseases. There is some evidence that the calcium in milk and dairy plays an important role in the regulation of body weight and bone mineral content in children. Available data show that milk and calcium intake in South Africans is low. Identified barriers include perceptions about lactose intolerance, taste, price, lack of knowledge on the nutritive value of milk and milk products, and possibly cultural taboos. As a result, increasing the consumption of milk, maas and yoghurt of South Africans will require active, multifaceted and multilevel promotion

Low rates of exclusive breastfeeding are still evident in four South African provinces

Objectives: Breastfeeding is one of the primary strategies used to enhance infant nutrition and improving child survival worldwide. The intention of globally increasing the rate of exclusive breastfeeding (EBF) to at least 50% of infants in the first six months of life was stated in the 2014 International Conference on Nutrition Rome Declaration on Nutrition and the Post-2015 Development Agenda. This study aimed to explore the infant-feeding practices of mothers and caregivers of infants aged ≤ 6 months in four provinces in South Africa.Setting and subjects: This cross-sectional study was conducted in four provinces in South Africa. In total, 40 health facilities were randomly selected in the four provinces and visited, including metropolitan and non-metropolitan health facilities over the geographical area of the provinces. The sample size comprised mothers and/or caregivers of babies aged ≤ 6 months.Design: Fixed-format interviews were used in this cross-sectional study on 580 mothers and/or caregivers. The mothers completed 24-hour recall based on the Food and Agriculture Organization of the United Nations dietary diversity list, consisting of 12 different food groups, to assess dietary intake and diversity.Results: The EBF rate for infants up to the age of six months was 12%. Mothers who delivered full-term babies were most likely to initiate breastfeeding within the first hour of delivery. More than a third of the mothers had ceased breastfeeding by one month (40%, n = 23). The introduction of complementary food took place in 17% of infants during this first month. The minimum standards of dietary diversity were met by one infant only. Different reasons found to influence mothers’ feeding practices included needing to return to work (29%) or their studies (12%), the mothers’ health status (25%), and perceptions of an “insufficient” milk supply (13%).Conclusion: Therefore, new strategies should address these gaps in knowledge with key breastfeeding awareness messages and a special focus on community involvement and participation. There is also a need for the whole nutrition fraternity, including government, academia and development industries, to intervene by developing more innovative approaches to increase the rate of EBF in South Africa.Keywords: exclusive breastfeeding, South Africa, low rates, infant feeding practice

Reducing the sodium content of high-salt foods: Effect on cardiovascular disease in South Africa

Background. Average salt intake in South African (SA) adults, 8.1 g/day, is higher than the 4 - 6 g/day recommended by the World Health Organization. Much salt consumption arises from non-discretionary intake (the highest proportion from bread, with contributions from margarine, soup mixes and gravies). This contributes to an increasing burden of hypertension and cardiovascular disease (CVD).Objectives. To provide SA-specific information on the number of fatal CVD events (stroke, ischaemic heart disease and hypertensive heart disease) and non-fatal strokes that would be prevented each year following a reduction in the sodium content of bread, soup mix, seasoning and margarine.Methods. Based on the potential sodium reduction in selected products, we calculated the expected change in population-level systolic blood pressure (SBP) and mortality due to CVD and stroke.Results. Proposed reductions would decrease the average salt intake by 0.85 g/person/day. This would result in 7 400 fewer CVD deaths and 4 300 less non-fatal strokes per year compared with 2008. Cost savings of up to R300 million would also occur.Conclusion. Population-wide strategies have great potential to achieve public health gains as they do not rely on individual behaviour or a well-functioning health system. This is the first study to show the potential effect of a salt reduction policy on health in SA

South Africa's salt reduction strategy: Are we on track, and what lies ahead?

On 2 September 2016, 25 local and international participants from various sectors met in Cape Town to take stock of South Africa (SA)’s progress in salt reduction and develop a roadmap for action. SA is centre stage on salt reduction globally, being the first country to mandate salt reduction across a wide range of processed foods. Excessive salt intake contributed by processed foods and discretionary sources motivated SA to implement a public awareness campaign in parallel with legislation to reduce salt intake to the World Health Organization target of 5 g per day. Five priority areas were identified for continued action on salt reduction, including obtaining research funds for continued monitoring and compliance of salt reduction targets. Determining the contribution of foods eaten out of home to total salt intake and implementing strategies to address this sector were also highlighted as key actions. Lastly, implementing the next stage of the Salt Watch awareness campaign to change

Estimating the changing burden of disease attributable to high sodium intake in South Africa for 2000, 2006 and 2012

Background. Elevated sodium consumption is associated with increased blood pressure, a major risk factor for cardiovascular and chronic kidney disease. Objectives. To quantify the deaths and disability-adjusted life years (DALYs) attributed to high sodium intake in persons aged ≥25 years in South Africa (SA) for 2000, 2006 and 2012. Methods. Comparative risk assessment (CRA) methodology was used and population attributable fractions (PAFs) of high sodium intake, mediated through high blood pressure (BP), for cardiovascular and chronic kidney disease were estimated. This was done by taking the difference between the PAF for elevated systolic BP (SBP) based on the estimated SBP level in the population and the PAF based on the estimated SBP that would result if sodium intake levels were reduced to the theoretical minimum risk exposure level (1 g/day) according to population group and hypertension categories. A meta-regression based on data from nine national surveys conducted between 1998 and 2017 was used to estimate the prevalence of hypertension by age, sex and population group. Relative risks identified from international literature were used and the difference in PAFs was applied to local burden estimates from the second South African National Burden of Disease Study. Age-standardised rates were calculated using World Health Organization (WHO) standard population weights. The attributable burden was also estimated for 2012 using an alternative target of 2 g/day proposed in the National Strategic Plan for the Prevention and Control of Non-communicable Diseases (NSP). Results. High sodium intake as mediated through high SBP was estimated to cause 8 071 (95% uncertainty interval (UI) 6 542 - 15 474) deaths in 2012, a drop from 9 574 (95% UI 8 158 - 16 526) in 2006 and 8 431 (95% UI 6 972 - 14 511) in 2000. In 2012, ischaemic heart disease caused the highest number of deaths in persons (n=1 832), followed by haemorrhagic stroke (n=1 771), ischaemic stroke (n=1 484) and then hypertensive heart disease (n=1 230). Ischaemic heart disease was the highest contributor to deaths for males (27%), whereas for females it was haemorrhagic stroke (23%). In 2012, 1.5% (95% UI 1.3 - 2.9) of total deaths and 0.7% (95% UI 0.6 - 1.2) of total DALYs were attributed to high sodium intake. If the NSP target of <2 g/day sodium intake had been achieved in 2012, ~2 943 deaths and 48 870 DALYs would have been averted. Conclusion. Despite a slight decreasing trend since 2006, high sodium intake mediated through raised BP accounted for a sizeable burden of disease in 2012. Realising SA’s target to reduce sodium intake remains a priority, and progress requires systematic monitoring and evaluation

Household, community, sub-national and country-level predictors of primary cooking fuel switching in nine countries from the PURE study

Introduction. Switchingfrom polluting (e.g. wood, crop waste, coal)to clean (e.g. gas, electricity) cooking fuels can reduce household air pollution exposures and climate-forcing emissions.While studies have evaluated specific interventions and assessed fuel-switching in repeated cross-sectional surveys, the role of different multilevel factors in household fuel switching, outside of interventions and across diverse community settings, is not well understood. Methods.We examined longitudinal survey data from 24 172 households in 177 rural communities across nine countries within the Prospective Urban and Rural Epidemiology study.We assessed household-level primary cooking fuel switching during a median of 10 years offollow up (∼2005–2015).We used hierarchical logistic regression models to examine the relative importance of household, community, sub-national and national-level factors contributing to primary fuel switching. Results. One-half of study households(12 369)reported changing their primary cookingfuels between baseline andfollow up surveys. Of these, 61% (7582) switchedfrom polluting (wood, dung, agricultural waste, charcoal, coal, kerosene)to clean (gas, electricity)fuels, 26% (3109)switched between different polluting fuels, 10% (1164)switched from clean to polluting fuels and 3% (522)switched between different clean fuels

Use salt and foods high in salt sparingly : a food-based dietary guideline for South Africa

Increased salt intake leads to an increase in blood pressure and decreased sodium intake relative to the usual or increased intake results in lowered blood pressure in adults, with or without hypertension. Blood pressure is a strong proxy indicator for the risk of cardiovascular disease, coronary heart disease and strokes. Hypertension is estimated to have caused 9% of all deaths in South Africa in 2000. In 2008, 42% of men and 34% of women aged 35-44 years, and 60% of men and 50% of women aged 45-54 years, were hypertensive. More than 70% of both men and women older than 65 years of age were hypertensive in 2008. Multilevel and multisectorial strategies are required to lower salt intake at population level, including the legislation of food supply, clearer labelling and signposting of food packaging, and improved consumer education on behavioural change regarding salt usage practices. A comprehensive national strategy that focuses on salt reduction is needed to reduce national blood pressure levels in the future. Legislating the levels of salt in processed food is only one part of this national strategy. All health professionals and educators should also provide appropriate nutritional recommendations that will educate, motivate and enable consumers to change their nutritional behaviour to reduce salt intake to less than 5 g per day, as recommended. The aim of this review is to revise the current food-based dietary guideline for salt, the implementation of which would contribute to lowering population salt intake, and blood pressure and cardiovascular disease, in South Africa

Food and nutrition labelling : the past, present and the way forward

CITATION: Koen, N., Blaauw, R. & Wentzel-Viljoen, Edelweiss. 2016. Food and nutrition labelling : the past, present and the way forward. South African Journal of Clinical Nutrition, 29(1):13-21.The original publication is available at http://www.sajcn.co.zaCurrent global mortality from noncommunicable diseases (NCDs) remains unacceptably high and is increasing. A major reduction in the burden of NCDs should come from population-wide interventions, including the promotion of a healthy diet through the provision of adequate nutrition information on food labels. However, in order for this type of intervention to be successful, it is important to have a better understanding of the consumer. This review focuses on the need for food and nutrition labelling (the section of information on a food label that specifically declares nutrient content) within the context of NCDs, as well as consumer nutrition label use, and understanding and the impact of nutrition labelling on purchasing behaviour. It provides a summary of the latest global nutrition labelling trends, the current situation in South Africa and the way forward. Consumer knowledge, use and understanding of nutrition labelling has been investigated extensively in the international literature. However, the majority of these investigations were conducted in developed countries. Therefore, additional research on the impact of nutrition labelling in developing countries is necessary, and should be a priority. There have been many developments in South Africa in terms of food and nutrition labelling in the last decade. Although the food industry, health professionals and consumers face many changes, challenges and opportunities with regard to food, and specifically to nutrition labelling, this is also the ideal time to promote the use and understanding of nutrition information on labels by health professionals to consumers.http://www.sajcn.co.za/index.php/SAJCN/article/view/1076Publisher's versio