Editorial: \'Big is beautiful\' - and unhealthy and confusing?

No abstract. South African Journal of Clinical Nutrition Vol. 18 (1): 4-

“Enjoy a variety of foods”: As a food-based dietary guideline for South Africa

Eating a diverse diet is an internationally accepted recommendation for a healthy diet. The food-based dietary guideline (FBDG) “Enjoy a variety of foods” aims to encourage people to consume mixed meals, to increase variety by eating different foods from various food groups, and to alter food preparation methods. This position paper suggests ways of measuring dietary variety, addresses the consequences of poor dietary variety in South Africa, and provides results pertaining to dietary variety in South African children and adults. The literature reveals that dietary diversity is best calculated by means of different food groups, which are based on the traditional eating patterns of the population under  investigation. Ideally, the recall period should be three days. Two national surveys in South Africa have provided data on dietary diversity scores(DDS) in adults and children, of 4.02 and 3.6 respectively. It was shown that in children, DDS positively relates to weightfor-height z-scores, with a z-score above zero being achieved when DDS is > 4. However, an energy-dense diet is cheaper and lower in micronutrients and also positively associated with increased body mass index in women. Hence, dietary variety is essential in improving the micronutrient intake of the diet, and is also important in preventing obesity. Household food insecurity in South Africa remains a constraint on the implementation of this guideline. This FBDG should be used in conjunction with the other South African FBDGs, to ensure the sufficient intake of food that contains protective factors and the limited intake of food that is known to increase the risk of noncommunicable diseases

Sugar and health: A food-based dietary guideline for South Africa

The intake of added sugar appears to be increasing steadily across the South African population. Children typically consume approximately 40-60 g/day, possibly rising to as much as 100 g/day in adolescents. This represents roughly 5-10% of dietary energy, but could be as much as 20% in many individuals. This paper briefly reviews current knowledge on the relationship between sugar intake and health. There is strong evidence that sugar makes a major contribution to the development of dental caries. The intake of sugar displaces foods that are rich in micronutrients. Therefore, diets that are rich in sugar may be poorer in micronutrients. Over the past decade, a considerable body of solid evidence has appeared, particularly from large prospective studies, that strongly  indicates that dietary sugar increases the risk of the development of obesity and type 2 diabetes, and probably cardiovascular disease too. These findings point to an especially strong causal relationship for the consumption of sugar-sweetened beverages (SSBs). We propose thatan intake of added sugar of 10% of dietary energy is an acceptable upper limit. However, an intake of < 6% energy is preferable, especially in those at risk of the harmful effects of sugar, e.g. people who are overweight, have prediabetes, or who do not habitually consume fluoride (from drinking fluoridated water or using fluoridated toothpaste). This translatesto a maximum intake of one serving (approximately 355 ml) of SSBs per day, if no other foods with added sugar are eaten. Beverages with added sugar should not be given to infants or to young children, especially in a feeding bottle. The current food-based dietary guideline is: “Use foods and drinks containing sugar sparingly, and not between meals”. This should remain unchanged. An excessive intake of sugar should be seen as a public health challenge that requires many approaches to be managed, including new policies and appropriate dietary advice

Who is the nutrition workforce in the Western Cape?

Objectives: The aim of the present study was to determine the current nutrition staffing profile of the Integrated Nutrition Programme (INP) inDepartment of Health in the Western Cape, and establish whether it is adequate to meet the objectives of the INP.Method: Self-administered questionnaires compiled in English were used as the main data collection instrument for nutrition staff in districtsand at hospitals (n = 647). Eight individual questionnaires, one per staff category, were developed and utilised in the study.Results: Foodservice workers were the largest group of nutrition personnel (n = 509; 79%), followed by dietitians (n = 64; 10%), managers(n = 31; 5%), auxiliary workers (n = 28; 4%), and administrative workers (n = 15; 2%). Sixty-two per cent of the nutrition workforce waslocated in urban areas and 38% in rural districts. Hospital and district dietitians experienced common problems, as well as specific differences.Regarding problems, both categories referred to limited resources, inadequate number of available posts, and lack of acknowledgementand support from administrative and supply chain management. District dietitians were also hampered by lack of space for consultations,poor referrals from doctors, insufficient posts for nutrition advisers, and difficulty in communicating with Xhosa-speaking patients. Hospitaldietitians were hampered by insufficient interaction with district dietitians and lack of dietitians for specialised units. They also mentioned thatpoor salaries were affecting morale.Conclusion: Recommendations such as additional posts for dietitians, improved conditions of service and salaries, increased advocacy fornutrition, and a number of human resources recommendations were made, and should be considered if the INP objectives are to be met

Characteristics and factors influencing fast food intake of young adult consumers in Johannesburg, South Africa

Objectives: To determine fast food consumption patterns, socio-economic characteristics and other factors that influence the fast food intake of young adults from different socio-economic areas in Johannesburg, South Africa. Methods: A descriptive, cross-sectional study was undertaken, using an interviewer-administered, validated questionnaire to elicit the characteristics of the study population (adults aged from 19 to 30 years), their reasons for and frequency of fast food consumption, their specific fast food choices, and their attitudes towards health. Results: The study population (n = 341) consisted primarily of young working adults (n = 242) with at least a secondary education. Almost half (42%, n = 102) of the employed participants earned less than R5 000 per month, but spent more than R200 on fast food per month. Twenty-one per cent of all participants had fast food at least once a week, while 27.6% had it two to three times a week. Socio-economic group (SEG) and gender were significantly related to fast food intake (p < 0.01), with a larger proportion of participants (65%, n = 76) in the lower socio-economic group (LSEG) showing more frequent use. Males consumed fast food more frequently than females. The most popular fast foods consumed were burgers (69.5%), pizza (56.6%) and fried chicken (38.4%). Soft drinks were the most popular beverage consumed (56%). The main reasons for choosing fast food were time limitations (58.9%), convenience (58.2%) and taste (52.5%). The majority of the participants were concerned about their health (93.3%) and indicated a fear of becoming overweight (44.3%). Seventy-eight per cent of all the participants would have chosen a healthier option if it had been available on the menu. Television was reported to be the most effective medium influencing their food choices. Conclusion: Fast food intake appears to be very common in this group of young South African adults. Various factors that influence fast food intake were identified that provide health educators and policy makers with useful information for health promotion. Keywords: fast food intake; nutrition; young adults; food outlets; socio-economic area

Nutrition interventions in the workplace: Evidence of best practice

Aim: The aim of this desktop study was to review all workplace interventions having a nutrition component, published in peer-reviewed literature between 1995 and 2006 by WHO, and to document activities that were successful, as well as possible barriers to their success.Methodology: A systematic review of workplace studies revealed 41 interventions, of which 30 complied with the predetermined search criteria. The following outcome measures were considered in the evaluation of the interventions: (i) changes in nutritional knowledge, attitudes, self-efficacy, intentions and stage of change; (ii) changes in dietary behaviours; (iii) changes in clinical/physical markers, such as: body weight or body-mass index (BMI), blood pressure (BP) or serum cholesterol concentrations; and (iv) process and/or policy outcomes.Results: A large number of diverse workplace interventions were successful in changing outcomes positively in the interventions evaluated. The following were key success factors: i) there was a nutrition and physical activity component; ii) dietitians were involved in nutrition education; iii) changes occurred in the cafeteria/canteen, which increased the availability of healthy food options and advertised them accordingly; iv) tailored feedback on diet (and clinical values) was given to subjects; v) employees were involved in planning and managing programmes; vi) the reduced prices (of healthy food items) in vending machines encouraged employees to buy healthier options; and vii) the stages of change theory was most commonly associated with best practice outcomes.Conclusions: Numerous workplace interventions have shown significant improvements in employees’ health and behaviours. However, it is necessary to plan intervention programmes based on the existing evidence of best practice

A review of school nutrition interventions globally as an evidence base for the development of the HealthKick programme in the Western Cape, South Africa

Aim: The aim of this study was to review all school interventions having a nutrition component, published in peer-reviewed literature between 1995 and 2006, and to document activities that were successful as well as those that were possible barriers in order to develop a best practice school intervention for the Western Cape Province, South Africa.Methodology: A systematic review of school studies revealed 85 interventions that complied with the predetermined search criteria. The following outcome measures were considered in the evaluation of the interventions: (i) changes in nutritional knowledge, attitudes and  selfefficacy and stage of change; (ii) changes in dietary behaviours; (iii) changes in clinical/physical markers such as body weight or body mass index, blood pressure or serum cholesterol concentrations; and (iv) process and/or policy outcomes.Results: Key success factors of school-based interventions appeared to be the following: A nutrition-based curriculum offered at school by trained teachers generally improved behavioural outcomes. A physical activity programme and parental component were associated with most of the best practice clinical and behavioural outcomes. Furthermore, all best practice studies were grounded on a firm theory of behaviour, such as social cognitive, social marketing or stages of change. Most of the interventions that included a food service component had best practice behavioural outcomes.Conclusions: Numerous school-based nutrition interventions have shown significant improvements in children’s nutritional behaviours. Consequently, it is necessary to plan programmes based on existing evidence of best practice. The lessons learnt from this review have beenapplied in the development of the HealthKick programme initiated in  schools in the Western Cape in 2007

How diverse is the diet of adult South Africans?

The original publication is available at http://www.nutritionj.com/content/10/1/33Abstract. Background. The objective of the current study was to measure dietary diversity in South Africans aged 16 years and older from all population groups as a proxy of food security. Methods. A cross-sectional study representative of adults from all specified ages, provinces, geographic localities, and socio-economic strata in South Africa was used (n = 3287). Trained interviewers visited participants at their homes during the survey. Dietary data was collected by means of a face validated 24 hour recall which was not quantified. A dietary diversity score (DDS) was calculated by counting each of 9 food groups. A DDS <4 was regarded as reflecting poor dietary diversity and poor food security. Results The provinces with the highest prevalence of poor dietary diversity (DDS <4) were Limpopo (61.8%) and the Eastern Cape (59.6%). By contrast, only 15.7% of participants in Western Cape had a low score. Participants in tribal areas (63.9%) and informal urban areas (55.7%) were by far the worst affected. There were significant differences in DDS by Living Standards Mean (LSM) analysis (p < 0.05) with the lowest LSM group having the lowest mean DDS (2.93).The most commonly consumed food groups were cereals/roots; meat/fish; dairy and vegetables other than vitamin A rich. Eggs, legumes, and vitamin A rich fruit and vegetables were the least consumed. Conclusion. Overall the majority of South Africans consumed a diet low in dietary variety. The tribal areas and informal urban areas were worst affected and eggs, legumes and vitamin A rich fruit and vegetables, were the least consumed.Publishers' versio

The association between nutrition and physical activity knowledge and weight status of primary school educators

The purpose of this study was to investigate primary school educators’ health status, knowledge, perceptions and behaviour regarding nutrition and physical activity.Thus, nutrition and physical activity knowledge, attitudes,  behaviour and risk factors for the development of non-communicable diseases of 155 educators were assessed in a  cross-sectional survey. Height, weight, waist circumference, blood pressure and random glucose levels were  measured. Twenty percent of the sample had normal weight (body mass index (BMI, kg/m²) &lt; 25), 27.7% were  overweight (BMI 25 to < 30) and 52.3% were obese (BMI < 30). Most of the participants were younger than 45  years (54.2%), females 78.1%, resided in urban areas (50.3%), with high blood pressure ( 140/90 mmHg:  50.3%), and were inactive (48.7%) with a high waist circumference (&gt; 82 cm: 57.4%). Educators’ nutrition and  physical activity knowledge was poor. Sixty-nine percent of educators incorrectly believed that eating starchy foods  causes weight gain and only 15% knew that one should eat five or more fruit and/or vegetables per day. Aspects of poor nutritional knowledge, misconceptions regarding actual body weight status, and challenges in changing health behaviours, emerged as issues which need to be addressed among educators. Educators’ high risk for developing chronic non-communicable diseases (NCDs) may impact on educator absenteeism and subsequently on school  functioning. The aspects of poor nutrition and physical activity knowledge along with educators’ high risk for NCD development may be particularly significant not merely in relation to their personal health but also the learners they teach.Keywords: body weight, educators, health, knowledge, non-communicable diseases, nutrition, perceptions, physical activity, primary schools, risk factor

The National Food Consumption Survey (NFCS): South Africa, 1999

Objective: The aim of the National Food Consumption Survey (NFCS) in South Africa was to determine the nutrient intakes and anthropometric status of children (1-9 years old), as well as factors that influence their dietary intake. Design: This was a cross-sectional survey of a nationally representative sample of all children aged 1-9 years in South Africa. A nationally representative sample with provincial representation was selected using 1996 Census information. Subjects: Of the 3120 children who were originally sampled data were obtained from 2894, a response rate of 93%. Methods: The sociodemographic status of each household was assessed by a questionnaire. Dietary intake was assessed by means of a 24-hour recall and a food-frequency questionnaire from the caregivers of the children. Food purchasing practices were determined by means of a food procurement questionnaire. Hunger was assessed by a modified hunger scale questionnaire. Nutritional status was determined by means of anthropometric measurements: height, weight, head circumference and arm circumference. Results: At the national level, stunting (height-for-age below minus two standard deviations (&lt; -2SD) from the reference median) was by far the most common nutritional disorder, affecting nearly one in five children. The children least affected (17%) were those living in urban areas. Even with regard to the latter, however, children living in informal urban areas were more severely affected (20%) compared with those living in formal urban areas (16%). A similar pattern emerged for the prevalence of underweight (weight-for-age &lt; -2SD), with one in 10 children being affected at the national level. Furthermore, one in 10 (13%) and one in four (26%) children aged 1-3 years had an energy intake less than half and less than two-thirds of their daily energy needs, respectively. For South African children as a whole, the intakes of energy, calcium, iron, zinc, selenium, vitamins A, D, C and E, riboflavin, niacin, vitamin B6 and folic acid were below two-thirds of the Recommended Dietary Allowances. At the national level, data from the 24-hour recalls indicated that the most commonly consumed food items were maize, sugar, tea, whole milk and brown bread. For South African children overall, one in two households (52%) experienced hunger, one in four (23%) were at risk of hunger and only one in four households (25%) appeared food-secure. Conclusion: The NFCS indicated that a large majority of households were food-insecure and that energy deficit and micronutrient deficiencies were common, resulting in a high prevalence of stunting. These results were used as motivation for the introduction of mandatory fortification in South Africa. © The Authors 2005.Conference Pape