South Africa’s health promotion Levy on pricing and acquisition of beverages in small stores and supermarkets

In response to concern over rising sugar-sweetened beverage (SSB) consumption, in April 2018, South Africa became the first Sub-Saharan African (SSA) country to implement an SSB tax. We assess changes in pricing and acquisition of beverages from local supermarkets and small stores among 18–39-year-old adults living in one township in the Western Cape, before and after tax implementation. This study is among the first evaluations of an SSB tax on the local food environment in a low-income township

Determining food industry compliance to mandatory sodium limits: Successes and challenges from the South African experience

To provide an update on the compliance to the Na reduction regulation (R.214) and to highlight some challenges and successes experienced by South Africa in the implementation of a mandatory Na regulation. The study design was observational. Nutritional information of packaged food (specified in the R.214 regulation) was collected between February 2019 and September 2020, before and after the implementation date of the final Na targets in the regulation. Six supermarket chains that accounted for more than 50 % of the grocery retailer market share in South Africa were included. The Na content (per 100 g) of products was extracted from photographs. Products were classified according to the thirteen food categories included in R.214. The percentage of targeted food categories that met the pre and post-regulation targets as well as the percentage by which Na limits were exceeded was calculated

Applying and comparing various nutrient profiling models against the packaged food supply in South Africa

This study aimed to apply the newly developed Chile Adjusted Model (CAM) nutrient profiling model (NPM) to the food supply in South Africa (SA) and compare its performance against existing NPM as an indication of suitability for use to underpin food policies targeted at discouraging consumption of products high in nutrients associated with poor health.Cross-sectional analysis of the SA-packaged food supply comparing the CAM to three other NPM: SA Health and Nutrition Claims (SA HNC), Chilean Warning Octagon (CWO) 2019, and Pan-American Health Organisation (PAHO) NPM.The SA-packaged food supply based on products stocked by supermarkets in Cape Town, SA

Child-directed marketing on packaged breakfast cereals in South Africa

Abstract Objective: Childhood obesity is on the rise in South Africa (SA) and child-directed marketing (CDM) is one of the contributing factors to children’s unhealthy food choices. This study assessed CDM on packaged breakfast cereals available in SA supermarkets and their nutritional quality. Design: Photographic images were examined in a descriptive quantitative study. A codebook of definitions of CDM was developed for this purpose. REDCap, an online research database, was used for data capturing and SPSS was used for data analyses including cross tabulations and one-way ANOVAs. Setting: The current study was set in the Western Cape province of SA. Subjects: Photographic images of all packaged breakfast cereals sold in major retailers in the Western Cape province of SA in 2019 were studied. Results: CDM strategies were classified as direct (to the child) or indirect (through the parent). A total of 222 breakfast cereals were studied, of which 96.9% had a nutritional or health claim, 95.0% had illustrations, 75.2% had product and consumption appeals, 10.8% had characters, 10.8% consisted of different appeals, 8.6% alluded to fantasy and 7.7% had role models. In breakfast cereals with direct CDM the protein and fibre content were significantly lower than in breakfast cereals without direct CDM. This study found a significantly higher total carbohydrate and total sugar content in breakfast cereals with direct CDM than those without direct CDM. Conclusion: CDM was highly prevalent in breakfast cereals sold in SA. Regulations to curb the marketing of packaged foods high in nutrients of concern is recommended

Taxed and untaxed beverage intake by South African young adults after a national sugar-sweetened beverage tax: A before-and-after study

Background In an effort to prevent and reduce the prevalence rate of people with obesity and diabetes, South Africa implemented a sugar-content-based tax called the Health Promotion Levy in April 2018, one of the first sugar-sweetened beverage (SSB) taxes to be based on each gram of sugar (beyond 4 g/100 ml). This before-and-after study estimated changes in taxed and untaxed beverage intake 1 year after the tax, examining separately, to our knowledge for the first time, the role of reformulation distinct from behavioral changes in SSB intake. Methods and findings We collected single-day 24-hour dietary recalls from repeat cross-sectional surveys of adults aged 18–39 years in Langa, South Africa. Participants were recruited in February–March 2018 (pre-tax, n = 2,459) and February–March 2019 (post-tax, n = 2,489) using door-to-door sampling. We developed time-specific food composition tables (FCTs) for South African beverages before and after the tax, linked with the diet recalls. By linking pre-tax FCTs only to dietary intake data collected in the pre-tax and post-tax periods, we calculated changes in beverage intake due to behavioral change, assuming no reformulation. Next, we repeated the analysis using an updated FCT in the post-tax period to capture the marginal effect of reformulation. We estimated beverage intake using a 2-part model that takes into consideration the biases in using ordinary least squares or other continuous variable approaches with many individuals with zero intake. First, a probit model was used to estimate the probability of consuming the specific beverage category. Then, conditional on a positive outcome, a generalized linear model with a log-link was used to estimate the continuous amount of beverage consumed. Among taxed beverages, sugar intake decreased significantly (p < 0.0001) from 28.8 g/capita/day (95% CI 27.3–30.4) pre-tax to 19.8 (95% CI 18.5–21.1) post-tax. Energy intake decreased (p < 0.0001) from 121 kcal/capita/day (95% CI 114–127) pre-tax to 82 (95% CI 76–87) post-tax. Volume intake decreased (p < 0.0001) from 315 ml/capita/day (95% CI 297–332) pre-tax to 198 (95% CI 185–211) post-tax. Among untaxed beverages, sugar intake increased (p < 0.0001) by 5.3 g/capita/day (95% CI 3.7 to 6.9), and energy intake increased (p < 0.0001) by 29 kcal/capita/day (95% CI 19 to 39). Among total beverages, sugar intake decreased significantly (p = 0.004) by 3.7 (95% CI -6.2 to -1.2) g/capita/day. Behavioral change accounted for reductions of 24% in energy, 22% in sugar, and 23% in volume, while reformulation accounted for additional reductions of 8% in energy, 9% in sugar, and 14% in volume from taxed beverages. The key limitations of this study are an inability to make causal claims due to repeat cross-sectional data collection, and that the magnitude of reduction in taxed beverage intake may not be generalizable to higher income populations. Conclusions Using a large sample of a high-consuming, low-income population, we found large reductions in taxed beverage intake, separating the components of behavioral change from reformulation. This reduction was partially compensated by an increase in sugar and energy from untaxed beverages. Because policies such as taxes can incentivize reformulation, our use of an up-to-date FCT that reflects a rapidly changing food supply is novel and important for evaluating policy effects on intake

Determining food industry compliance to mandatory sodium limits: Successes and challenges from the South African experience

Abstract Objective: To provide an update on the compliance to the sodium reduction regulation (R.214) and to highlight some challenges and successes experienced by South Africa in the implementation of a mandatory sodium regulation. Design: The study design was observational. Nutritional information of packaged food (specified in the R.214 regulation) was collected between February 2019 and September 2020, before and after the implementation date of the final sodium targets in the regulation. Six supermarket chains that accounted for more than 50% of the grocery retailer market share in South Africa were included. The sodium content (per 100g) of products was extracted from photographs. Products were classified according to the 13 food categories included in R.214. The percentage of targeted food categories that met the pre and post regulation targets as well as the percentage by which sodium limits were exceeded were calculated. Setting: Low-and-middle-income suburbs in Cape Town, South Africa. Participants: N/A Results: A total number of 3278 product were analysed. After the final implementation date, none of the categories targeted by the R.214 regulation fully complied. However, nine out of the 13 food categories targeted by R.214 were above the 70% compliance mark. Conclusions: The compliance to R.214 in South Africa is good, although not 100% compliant. This research also highlights the complexities regarding the monitoring and evaluation of a national regulation. Findings from the current study could aid by providing valuable information to countries in the process of implementing a sodium reduction strategy

A fit-for-purpose nutrient profiling model to underpin food and nutrition policies in South Africa

South Africa (SA) is facing a rising prevalence of obesity and diet-related chronic diseases. The government is seeking to develop effective, evidence-based policy measures to address this. A well-designed, fit-for-purpose nutrient profiling model (NPM) can aid policy development. The aim of this study was to develop a fit-for-purpose NPM in SA. Steps included: (1) determining the purpose and target population; (2) selecting appropriate nutrients and other food components to include; (3) selecting a suitable NPM type, criteria and base; and (4) selecting appropriate numbers and thresholds. As part of the evaluation, the nutritional composition of packaged foods containing nutritional information (n = 6747) in the SA food supply chain was analyzed, a literature review was undertaken and various NPMs were evaluated. Our findings indicated that it is most appropriate to adapt an NPM and underpin regulation with a restrictive NPM that limits unhealthy food components. The Chile 2019 NPM was identified as suitable to adapt, and total sugar, saturated fat, sodium and non-sugar sweetener were identified as appropriate to restrict. This NPM has the potential to underpin restrictive policies, such as front-of-package labelling and child-directed marketing regulations in SA. These policies will support the fight against obesity and NCDs in the country

Taxed and untaxed beverage intake by South African young adults after a national sugar-sweetened beverage tax: A before-and-after study.

BackgroundIn an effort to prevent and reduce the prevalence rate of people with obesity and diabetes, South Africa implemented a sugar-content-based tax called the Health Promotion Levy in April 2018, one of the first sugar-sweetened beverage (SSB) taxes to be based on each gram of sugar (beyond 4 g/100 ml). This before-and-after study estimated changes in taxed and untaxed beverage intake 1 year after the tax, examining separately, to our knowledge for the first time, the role of reformulation distinct from behavioral changes in SSB intake.Methods and findingsWe collected single-day 24-hour dietary recalls from repeat cross-sectional surveys of adults aged 18-39 years in Langa, South Africa. Participants were recruited in February-March 2018 (pre-tax, n = 2,459) and February-March 2019 (post-tax, n = 2,489) using door-to-door sampling. We developed time-specific food composition tables (FCTs) for South African beverages before and after the tax, linked with the diet recalls. By linking pre-tax FCTs only to dietary intake data collected in the pre-tax and post-tax periods, we calculated changes in beverage intake due to behavioral change, assuming no reformulation. Next, we repeated the analysis using an updated FCT in the post-tax period to capture the marginal effect of reformulation. We estimated beverage intake using a 2-part model that takes into consideration the biases in using ordinary least squares or other continuous variable approaches with many individuals with zero intake. First, a probit model was used to estimate the probability of consuming the specific beverage category. Then, conditional on a positive outcome, a generalized linear model with a log-link was used to estimate the continuous amount of beverage consumed. Among taxed beverages, sugar intake decreased significantly (p ConclusionsUsing a large sample of a high-consuming, low-income population, we found large reductions in taxed beverage intake, separating the components of behavioral change from reformulation. This reduction was partially compensated by an increase in sugar and energy from untaxed beverages. Because policies such as taxes can incentivize reformulation, our use of an up-to-date FCT that reflects a rapidly changing food supply is novel and important for evaluating policy effects on intake