The whole-food plant-based diet: what does it entail and what lessons can it offer South African dietitians?

No abstrac

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 recommended 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 (stroke, ischaemic heart disease and hypertensive heart disease) and non-fatal CVD events 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. Conclusions. 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

Editorial

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

Liking, salt taste perception and use of table salt when consuming reduced-salt chicken stews in light of South Africa's new salt regulations

This study investigated the impact of salt reduction on liking, salt taste perception, and use of table salt when consuming chicken stew in light of South Africa's new salt recommendations. In total, 432 South- African consumers (aged 35.2 ± 12.3 years) consumed a full portion of a chicken stew meal once at a central location. Four stock cube powders varying in salt content were used to prepare chicken stews: 1) no reduction e 2013 Na level; regular salt level as currently available on the South African market (24473 mg Na/100 g), 2) salt reduction smaller than 2016 level, i.e. 10%-reduced (22025 mg Na/100 g), 3) 2016 salt level, as per regulatory prescriptions (18000 mg Na/100 g), 4) 2019 salt level, as per regulatory prescriptions (13000 mg Na/100 g). Consumers were randomly allocated to consume one of the four meals. Liking, salt taste perception, and use of table salt and pepper were measured. Chicken stews prepared with reduced-salt stock powders were equally well-liked as chicken stews with the current salt level. Moreover, a gradual reduction of the salt in the chicken stews resulted in a reduced salt intake, up to an average of 19% for the total group compared to the benchmark 2013 Na level stew. However, 19% of consumers compensated by adding salt back to full compensation in some cases. More salt was added with increased reductions of salt in the meals, even to the point of full compensation. Further investigation into the impacts of nutrition communication and education about salt reduction on salt taste perception and use is needed. This research provides new consumer insights on salt use and emphasises the need for consumer-focused behaviour change approaches, in addition to reformulation of products.http://www.elsevier.com/locate/appet2017-01-31hb201

Association of dairy consumption with metabolic syndrome, hypertension and diabetes in 147 812 individuals from 21 countries

Objective: Our aims were to assess the association of dairy intake with prevalence of metabolic syndrome (MetS) (cross-sectionally) and with incident hypertension and incident diabetes (prospectively) in a large multinational cohort study.Methods: The Prospective Urban Rural Epidemiology (PURE) study is a prospective epidemiological study of individuals aged 35 and 70 years from 21 countries on five continents, with a median follow-up of 9.1 years. In the cross-sectional analyses, we assessed the association of dairy intake with prevalent MetS and its components among individuals with information on the five MetS components (n=112 922). For the prospective analyses, we examined the association of dairy with incident hypertension (in 57 547 individuals free of hypertension) and diabetes (in 131 481 individuals free of diabetes).Results: In cross-sectional analysis, higher intake of total dairy (at least two servings/day compared with zero intake; OR 0.76, 95% CI 0.71 to 0.80, p-trend\u3c0.0001) was associated with a lower prevalence of MetS after multivariable adjustment. Higher intakes of whole fat dairy consumed alone (OR 0.72, 95% CI 0.66 to 0.78, p-trend\u3c0.0001), or consumed jointly with low fat dairy (OR 0.89, 95% CI 0.80 to 0.98, p-trend=0.0005), were associated with a lower MetS prevalence. Low fat dairy consumed alone was not associated with MetS (OR 1.03, 95% CI 0.77 to 1.38, p-trend=0.13). In prospective analysis, 13 640 people with incident hypertension and 5351 people with incident diabetes were recorded. Higher intake of total dairy (at least two servings/day vs zero serving/day) was associated with a lower incidence of hypertension (HR 0.89, 95% CI 0.82 to 0.97, p-trend=0.02) and diabetes (HR 0.88, 95% CI 0.76 to 1.02, p-trend=0.01). Directionally similar associations were found for whole fat dairy versus each outcome.Conclusions: Higher intake of whole fat (but not low fat) dairy was associated with a lower prevalence of MetS and most of its component factors, and with a lower incidence of hypertension and diabetes. Our findings should be evaluated in large randomized trials of the effects of whole fat dairy on the risks of MetS, hypertension, and diabetes

Development of a model for the monitoring and evaluation of nutrition and nutrition-related programmes in South Africa

Thesis (Ph.D. (Dietetics))--North-West University, Potchefstroom Campus, 2004.Evaluation research or programme evaluation was developed mainly for general use in social science, notably education and psychology, for understanding and addressing social problems. Rossi eta/. (1999) defined programme evaluation or evaluation research as "... the use of social research procedures to systematically investigate the effectiveness of social intervention programmes that are adapted to their political and organisational environments and designed to inform social action in ways that improve social conditions". There are different types of evaluation, namely the evaluation of need, implementation evaluation, impact evaluation and efficiency evaluation. Several authors and international organisations developed tools and guidelines for measuring performance of nutrition programmes. However, a comprehensive model or framework, based on the existing theory of evaluation research to evaluate nutrition programmes in South Africa, is lacking. The national Primary School Nutrition Program (PSNP) was introduced as one of the 100 day Presidential Lead Projects of the South African Reconstruction and Development Programme in 1994. This programme is implemented in all nine provinces of South Africa and costs the taxpayer approximately R500 million per year. The focus area of the PSNP is school feeding, nutrition education and health promotion through interventions such as parasite control and micronutrient supplementation. An evaluation component was never part of the design of the PSNP. However, in the beginning of 2000 the North West Province, and later in 2000, the National Department of Health, commissioned evaluation of the PSNP. Aims The aim of this study was, therefore, to develop a framework or model for the monitoring and evaluation of nutrition and nutrition-related programmes in South Africa, based on the theory of evaluation research and incorporating the researcher's experience gained in the evaluation of the PSNP. Methods The results of an in-depth study of available literature on evaluation research are synthesized and presented in Chapter 2. This formed the theoretical basis for the development of an evaluation framework. A tender for the evaluation of the PSNP in the North West Province was allocated to the Potchefstroom University for CHE. The researcher acted as project leader and was responsible for the development of the evaluation framework and the execution thereof. The researcher was also part of the core team for the national evaluation of certain aspects of the PSNP and involved in the development of the evaluation framework, the gathering of data, the analysis and interpretation of the data as well as feedback to the relevant stakeholders. For both studies, an evaluation framework was developed based on the tender specifications. Once this was done, appropriate instruments and measuring methods were developed. The fieldwork was done at national, provincial and school level. Once the relevant data were gathered, the data were coded, captured, analysed and interpreted. A final report of the evaluation, including conclusions and recommendations regarding the programme, was written for each evaluation. Consultation with the appropriate stakeholders was held and continuous feedback was given to the North West Province and the National Department of Health for the two evaluations respectively (Chapters 3 and 4). Results A comprehensive framework for the evaluation of nutrition and nutrition-related programmes was developed and discussed in Chapter 5. It is suggested that the theory based evaluation (TBE) approach is followed for the evaluation of these. Weiss (1972; 1988; 1997) described theory-based evaluation as follows: "TBE aims to surface the theoretical underpinnings of the programme in advance and use the theories to help structure the evaluation. It aims to describe the actual mechanisms that are related to good outcomes". The evaluation is expected to collect data to see how well each step of the sequence in fact comes out. The developed framework of the evaluation shows that at least the following four principal components, namely: inputs, outputs, outcomes and impacts should be included. A very important and unique development in the framework is that it links all the steps of the evaluation process to all the phases in the development of a nutrition programme design, protocol and implementation. Conclusions It was possible to develop a framework for the evaluation of nutrition and nutrition-related programmes in South Africa based on TBE and the researcher's experience with the development of an evaluation framework for the PSNP. This framework could serve as a guideline to assist evaluators with the evaluation of nutrition programmes in the future. Recommendations Monitoring and evaluation should form an integral part of any nutrition and nutrition related intervention programme. Especially in South Africa, a developing country with scarce resource, where its serious malnutrition and HIVIAIDS problems are addressed by multi-sectorial, mutli-level and multi-site intervention programmes, appropriate evaluation should be conducted. The evaluation component should be developed as part of the development of the programme. Billions of Rands are spend on these programmes and the funders should demand responsibility and accountability from the programme developers and implementers through appropriate evaluations.Doctora

Assessing the construct validity of nutrient profiling models for restricting the marketing of foods to children in South Africa

Background In an effort to combat childhood obesity the WHO has called on governments to restrict the marketing of unhealthy foods to children. Regulators have turned to nutrient profiling (NP) to provide the evidence for their decisions. This has resulted in the development of NP models, of which the validity of only a few have been established. The aim of this study was to assess the construct validity of various NP models for the purpose of restricting the marketing of unhealthy foods to children in South Africa by comparing the classification of foods by the models to the ranking of the same foods by registered dietitians. Methods Six current NP models were identified, then a representative food database of 120 foods was developed and each individual food was classified by each of the six models. Lastly dietitians were recruited to rank the healthfulness of the same 120 foods. Results Dietitians allowed 24% of the included foods for marketing to children, whereas the percentage of foods allowed by the included models ranged from 7 to 47%. Majority of pairwise comparisons between the NP models and dietitians yielded ҡ statistics >0.6, indicating substantial agreement. An almost perfect pairwise agreement was found between dietitians and the WHO Regional Office for Europe model. Conclusion The included NP models displayed good construct validity by agreeing with dietitians on what are ‘less healthy’ foods, thus the foods not allowed for marketing. The findings of this study contributes to the process of establishing validity of NP model

The development of a single health-endorsement logo for South Africa

CITATION: Koen, N., Wentzel-Viljoen, E. & Blaauw, R. 2018. The development of a single health-endorsement logo for South Africa. Public Health Nutrition, 21(8): 1444-1454, doi:10.1017/S1368980018000034.The original publication is available at https://www.cambridge.org/core/journals/public-health-nutritionObjective: To develop health-endorsement logos (HEL) for food products indicating healthy choices based on the South African nutrient profile model and to pilot test these logos with consumers. Design: Multistage mixed-methods design. Setting: Cape Town, South Africa. Subjects: Nine focus group discussions (FGD) were conducted with adult consumers to explore what types of HEL are preferred and why. Based on the findings, ten HEL were designed by a graphic design team. A modified Delphi technique, conducted with experts in the fields of nutrition and food science, was employed to eliminate lowest-scoring HEL and to improve the design of the remaining logos. Participants from the initial FGD participated in pilot testing the improved logos. Results: Participants from FGD (n 67) were positive about a single HEL, stating it would make food labelling less confusing as they did not understand the various HEL used. Participants indicated the logo should include wording related to ‘healthy choice’ or ‘better choice’ and pictures/symbols related to health and/or food. During two rounds of scoring and comments by experts (n 19), five logos were eliminated and the design of the remaining five improved. Three of five remaining logos received overall rankings of 3·08/5, 3·28/5 and 3·39/5, respectively, during FGD (n 36) in the pilot-testing phase. Conclusion: HEL were designed and consumer tested. Three designs were submitted to the national Department of Health to consider for implementation, after further testing, as a tool to assist in addressing the high incidence of non-communicable diseases in South Africa.Publisher's versio

Restricting the marketing of foods and non-alcoholic beverages to children in South Africa: are all nutrient profiling models the same?

The WHO has called for governments to improve children’s food environment by implementing restrictions on the marketing of ‘unhealthy’ foods to children. Nutrient profiling (NP) models are used to define ‘unhealthy’ foods and support child-directed food marketing regulations. The aim of the present study was to assess the suitability of the South African NP model (SANPM), developed and validated for health claim regulations, for child-directed food marketing regulations. The SANPM was compared with four NP models specifically developed for such regulations. A representative list of 197 foods was compiled by including all foods advertised on South African free-to-air television channels in 2014 and foods commonly consumed by South African children. The nutritional information of the foods was sourced from food packaging, company websites and a food composition table. Each individual food was classified by each of the five NP models. The percentage of foods that would be allowed according to the different NP models ranged from 6 to 45 %; the models also varied considerably with regard to the type of foods allowed for marketing to children. The majority of the pairwise comparisons between the NP models yielded κ statistics >0·4, indicating a moderate agreement between the models. An almost perfect pairwise agreement (κ=0·948) existed between the SANPM and the UK Food Standards Agency model (United Kingdom Office of Communication nutrient profiling model), a model extensively tested and validated for such regulations. The SANPM is considered appropriate for child-directed food marketing regulations in South Afric