The feasibility of implementing food-based dietary guidelines in the South African primary-school curriculum.

OBJECTIVE: To explore the perceptions of educators from the Western Cape Province about the feasibility of implementing South African food-based dietary guidelines (FBDG) in the national curriculum of primary schools. DESIGN: Combined quantitative and qualitative methods. We report on the quantitative component. SETTING: Twelve public primary schools of different socio-economic status in three education districts of the Western Cape: Metro Central, Metro East and Cape Winelands. SUBJECTS: Educators (n 256) participated in the self-completed questionnaire survey. RESULTS: Educators assessed that FBDG were appropriate to South African schoolchildren (94%), could be used as an education tool (97%) and fill gaps in the current curriculum about healthy dietary habits (91%). Besides Life Orientation, FBDG could be taught in other learning areas from grades 3 to 7 (9-13 years old). Important barriers to implementing FBDG in the curriculum were educators' workload (61%), insufficient time (46%), learners' disadvantaged background (43%) and educators' lack of knowledge (33%). Other approaches to teach children about FBDG included linking these to the National School Nutrition Programme (82%), school tuck shops (79%), parent meetings (75%), school nutrition policy (73%) and school assembly (57%). Educators in high-income schools perceived that learners' lifestyle was significantly worse (P < 0·001) and that tuck shops and the school assembly were the best means to teach pupils about FBDG (P < 0·001 and P < 0·05). CONCLUSIONS: Implementing FBDG in the national school curriculum is seen as important together with optimizing the school physical environment. Key factors required for successful implementation in the curriculum are sufficient educational materials, adequate time allocation and appropriate educator training.

A qualitative evaluation of exposure to and perceptions of the Woolworths Healthy Tuck Shop Guide in Cape Town, South Africa.

BACKGROUND: Both under- and over-nutrition pose a public health concern, especially for children in South Africa. Several initiatives exist in South Africa directed at promoting healthy eating and nutrition at schools. One of them is the Woolworths Making the Difference (MTD) Programme aimed at eliminating barriers to promoting healthy lifestyles that exist at schools, such as the availability of low-cost, unhealthy foods either from tuck shops (small food shops) or street vendors. The Healthy Tuck Shop Guide is a recent addition to the MTD Programme. The aim of this evaluation was to assess awareness, potential uptake, and perceptions of the Woolworths Healthy Tuck Shop Guide among parents and staff in a sample of schools that were exposed to the guide. METHODS: A qualitative study consisting of focus groups, interviews, and tuck shop observation was used to gather information on 13 schools and their exposure, comprehension, and use of the guide. A mix of schools was examined in terms of economic status and level of control over their tuck shop. Thematic analysis was used to extract findings. RESULTS: Findings show that despite overall positive attitudes about the guide several barriers to its implementation exist, including children's preferences for unhealthy foods, the higher cost of healthy foods, and other issues related to a lack of facilities, time and manpower. CONCLUSION: Findings suggest that the Woolworths Healthy Tuck Shop Guide would contribute more meaningfully to the creation of healthier food environments if executed within a larger support network to address barriers to implementation.

A proposed new food guide: why pyramids should stop at traffic lights.

Many food guides are used around the world, with most based on a graphical design to indicate how much of each food group should be eaten. However, the most recent versions of the food guides used in the United States (MyPyramid) and Canada (Eating Well with Canada's Food Guide) have moved away from using a graphical design. In this article, we evaluate the design of these various food guides and describe an alternative design for a food guide based on a traffic lights approach. Foods are classed as green (eat freely based on recommended amounts), amber (eat in limited amounts), and red (eat little or none). The food guide is accompanied by a set of simple rules for selecting an appropriate diet. This design has several advantages over conventional designs. In particular, the proposed design more closely reflects the actual composition of foods, namely that foods within each food group tend to fall into three distinct groups based on nutritional composition, a point which is much less clear with conventional food guide designs. The simplicity of the design may make it especially valuable in developing countries and among communities where educational standards are poor. Only a limited amount of research has been conducted on traffic lights food guides, mainly for its use in the treatment of childhood obesity. Further research is therefore required.

Consumer testing of the preliminary paediatric food-based dietary guidelines for healthy children aged 1-7 years, among English- and Afrikaans-speaking mothers in the city of Cape Town, South Africa.

OBJECTIVE: The aim of this qualitative study was to test the comprehensibility of the preliminary food-based dietary guidelines (FBDG) for healthy South African children aged 1-7 years. Objectives included assessing exposure to FBDG, comprehension of the proposed paediatric FBDG (PFBDG) and whether the guidelines can be used in meal planning. DESIGN: Focus group discussions were used to collect data. Discussions were facilitated by the investigator in either English or Afrikaans, according to a predetermined discussion schedule. Focus groups were formed on the basis of language and socio-economic status (SES). SETTING: Areas within the City of Cape Town representing lower, middle and upper SES groups. SUBJECTS: A total of seventy-six English- and Afrikaans-speaking mothers were contacted via randomly selected consenting preschool groups to participate voluntarily. RESULTS: Most mothers reported that they do not use guidelines. They had a good grasp of the concepts of and need for PFBDG. They suggested slight alterations to wording/phrasing of the guidelines. The most problematic guidelines were those regarding starch, milk and sweet treats/drinks. No substantial differences were found between English and Afrikaans data. Differences were found between SES groups, with the upper SES groups comprehending the guidelines better. CONCLUSION: The proposed PFBDG were well received. The target population that would benefit the most from these guidelines would be the less educated, lower SES groups. The present study shows that once the guidelines have been modified, they may be used as a comprehensive guide for nutritional education.

National fortification of staple foods can make a significant contribution to micronutrient intake of South African adults.

BACKGROUND: A national survey found that micronutrient deficiencies are prevalent in South African children, particularly calcium, iron, zinc, riboflavin, niacin, vitamin B6, folate, vitamin A, E and C. Mandatory fortification of maize meal and wheat flour were introduced in 2003 to combat some of the deficiencies found in children. To date however, there has not been a national survey on dietary intake in adults. OBJECTIVES: The main objectives of this study were to evaluate the micronutrient intake of the diet consumed by the average adult South African by means of secondary data analyses and secondly to evaluate the effects of fortification on selected nutrient intakes. STUDY DESIGN: Secondary data analysis was carried out with numerous dietary surveys on adults to create a database that included sampling (and weighting) according to ethnic/urban-rural residence in line with the population census, of which 79% were black Africans and the majority resided in rural areas. The effect of fortification was evaluated by substituting fortified foods in the diet for the unfortified products. SUBJECTS: The combined database used in this study comprised 3229 adults. RESULTS: Mean calcium, iron, folate and vitamin B6 intakes were very low particularly in women. Mean intakes of most micronutrients were lower in rural areas. Fortification of maize meal and wheat flour (bread) raised mean levels of thiamine, riboflavin, niacin, vitamin B6 and folate above the recommended nutrient intakes (RNIs). In women, despite fortification, mean iron intakes remained below the RNIs, as did calcium since it was not in the fortification mix. CONCLUSION: The average dietary intake of adults was of poor nutrient density, particularly in rural areas. Fortification of maize meal and wheat flour (bread) considerably improved mean vitamin B6, thiamine, riboflavin, niacin, folate and iron intakes as well as the overall mean adequacy ratio of the diet.

South African paediatric food-based dietary guidelines.

South African efforts to address both under- and overnutrition , and other nutrition-related public health issues, utilizing food-based dietary guidelines (FBDGs) as an educational tool, are introduced. However, the focus is placed on the development of paediatric FBDGs for infants and young children, from birth up to the age of 7 years, and how these were made compatible with scientific and local public health evidence on the one hand, and existing South African FBDGs for children over the age of 7 years, adolescents and adults, on the other. Members of the Working Group and other stakeholders are gratefully acknowledged.

The process followed in the development of the paediatric food-based dietary guidelines for South Africa.

In 1996, a Food and Agricultural Organization/World Health Organization expert panel proposed the development of food-based dietary guidelines (FBDGs) that would be unique and specific to the needs of the populations of different countries. In 1997, a South African FBDG Working Group was initiated to develop a single set of FBDGs aimed at optimal nutrition for all South Africans older than 5 years. Thereafter, additional working groups investigated the development of FBDGs for specific priority groups including HIV/AIDS sufferers, the elderly, pregnant and lactating women and children under 5 years. This resulted in the formation of an expert paediatric FBDG Working Group in 2000, in Cape Town with the task to develop paediatric FBDGs (PFBDGs) for children younger than 5 years. However, it was decided to raise the 5-year-age limit to 7 years, which corresponds to one of the recommended dietary allowance (RDA) cut-offs for both genders and that would cover most pre-schoolers. Ultimately, three age subcategories were identified for developing specific PFBDGs, i.e. 0-6 months, 6-12 months and 12-84 months. In May 2003, after thorough review of the relevant literature, discussions with various stakeholders and pre-testing for comprehensibility, a set of preliminary PFBDGs for each of the subcategories was approved by the Working Group to be subjected to consumer testing. The proposed guidelines were considered to be the most appropriate ones for each age group, based on scientific and local evidence, and were evaluated utilizing qualitative methodologies. The results of these data are presented and discussed below. However, further testing is required for the diverse groups in the country.

Addressing malnutrition in young children in South Africa. Setting the national context for paediatric food-based dietary guidelines.

Despite various national nutrition and primary healthcare programmes being initiated in South Africa over the last decade, child health has deteriorated. This is seen by the rise in infant and child mortality rates, the high prevalence of preventable childhood diseases, e.g. diarrhoea and lower respiratory tract infections, and the coexistence of under-nutrition along with HIV/AIDS. Poor dietary intake, food insecurity and poor quality of basic services prevail within this precarious causal web. The national Integrated Nutrition Programme is a comprehensive nutrition strategy that focuses on children below 6 years old, at-risk pregnant and lactating women, and those affected by communicable and non-communicable diseases. Focus areas relevant to pre-school children include disease-specific nutrition treatment, support and counselling; growth monitoring and promotion (GMP); micronutrient malnutrition control; breastfeeding promotion, protection and support; contributions to household food security; nutrition interventions among HIV-infected children; and nutrition promotion, education and advocacy. Progress towards this includes the Baby-Friendly Hospital Initiative; mandatory fortification of maize meal and wheat flour with multiple micronutrients; vitamin A supplementation coverage and mandatory iodization of salt by legislation; the provision of free road-to-health charts for GMP; and the National School Nutrition Programme. Since 2003, the basis of the nutrition education strategy has been the locally developed food-based dietary guidelines (FBDGs), directed at adults and school-going children. This review sketches the backdrop to and motivation for the introduction of specifically targeted paediatric FBDGs, for mothers and caregivers of children from birth to age 7 years, as a national initiative.

Feeding the 1 to 7-year-old child. A support paper for the South African paediatric food-based dietary guidelines.

Young children embark on a transitional nutritional journey, progressing from total reliance on caregivers to independence, autonomy and self-determination. Appropriate nutritional intake in young children is a diverse concept, incorporating suitable nutritional choices and feeding behaviours. Lessons learnt in childhood will have long-term effects on the individual and society overall. Since South African children are raised in a country where under- and over-nutrition exist simultaneously, a careful balance should be achieved in any national public health message. The South African paediatric food-based dietary guidelines for children younger than 7 years strive to facilitate the education of carers of young children in the adoption of healthy eating practices. The guidelines address issues regarding variety in the diet that has been shown to improve both micro- and macronutrient intakes. Specific reference is made to starchy foods, vegetables, fruit and water along with protein sources, which should be consumed regularly. Milk, has been emphasised in these guidelines because of the poor calcium intake in South African children. The only guideline that limits intake is the sweet treats or drinks message, because of public health concerns such as obesity and dental caries. Other messages pertaining to eating habits take cognisance of the child's physiological limitations in gastric capacity and suggest small regular meals. Clean, safe drinking water is the beverage of choice. Non-food-based guidelines are also included, which recognize the importance of active play, for developmental and health purposes, as well as regular clinic attendance.

Water: a neglected nutrient in the young child? A South African perspective.

Water is considered an essential nutrient because the body cannot produce enough water itself, by metabolism of food, to fulfil its need. When the quantity or quality of water is inadequate, health problems result, most notably dehydration and diarrhoea. As a result of contaminated water and poor hygiene, related infections are still a serious problem. Indeed, in the South African setting water availability and sanitation are critical issues because of the prevalence of childhood diarrhoea and also the HIV/AIDS crisis. Though considerable efforts have been made to improve the water and sanitation problems in South Africa - especially with regard to water supply infrastructure - there is still room for much improvement. Water is a healthy alternative to calorie-dense, non-nutritive beverages, such as artificial fruit drinks and soda. The latter should be avoided as they contribute little other than energy and may contribute to overweight and obesity. Also, they displace more nutritious foods from the child's diet. Consumption of fruit juice should also be limited. These issues highlight the need for a specific guideline relating to water intake in the paediatric food-based dietary guidelines.

Nutrition and HIV/AIDS in infants and children in South Africa: implications for food-based dietary guidelines.

The implications for food-based dietary guidelines (FBDGs) that are being developed in South Africa are reviewed in relation to HIV-exposed and -infected children. The nutritional consequences of HIV infection and nutritional requirements along with programmes and guidelines to address undernutrition and micronutrient deficiency in these children are also investigated. Based on studies for HIV-infected children in South Africa, more than 50% are underweight and stunted, while more than 60% have multiple micronutrient deficiencies. Nutritional problems in these children are currently addressed through the Prevention-of-Mother-to-Child Transmission Programme (PMTCT), the Integrated Nutrition Programme and Guidelines for the Management of HIV-infected Children which include antiretroviral (ARV) therapy in South Africa. Evaluations relating to the implementation of these programmes and guidelines have not been conducted nationally, although certain studies show that coverage of the PMTCT and the ARV therapy programmes was low. FBDGs for infants and young children could complement and strengthen the implementation of these programmes and guidelines. However, FBDGs must be in line with national and international guidelines and address key nutritional issues in these infants and young children. These issues and various recommendations are discussed in detail in this review.

Dietary intake and barriers to dietary compliance in black type 2 diabetic patients attending primary health-care services.

OBJECTIVE: To determine the dietary intake, practices, knowledge and barriers to dietary compliance of black South African type 2 diabetic patients attending primary health-care services in urban and rural areas. DESIGN: A cross-sectional survey. Dietary intake was assessed by three 24-hour recalls, and knowledge and practices by means of a structured questionnaire (n = 133 men, 155 women). In-depth interviews were then conducted with 25 of the patients to explore their underlying beliefs and feelings with respect to their disease. Trained interviewers measured weight, height and blood pressure. A fasting venous blood sample was collected from each participant in order to evaluate glycaemic control. SETTING: An urban area (Sheshego) and rural areas near Pietersburg in the Northern Province of South Africa. SUBJECTS: The sample comprised 59 men and 75 women from urban areas and 74 men and 80 women from rural areas. All were over 40 years of age, diagnosed with type 2 diabetes for at least one year, and attended primary health-care services in the study area over a 3-month period in 1998. RESULTS: Reported dietary results indicate that mean energy intakes were low (< 70% of Recommended Dietary Allowance), 8086-8450 kJ day(-1) and 6967-7382 kJ day(-1) in men and women, respectively. Urban subjects had higher (P < 0.05) intakes of animal protein and lower ratios of polyunsaturated fat to saturated fat than rural subjects. The energy distribution of macronutrients was in line with the recommendations for a prudent diet, with fat intake less than 30%, saturated fat less than 10% and carbohydrate intake greater than 55% of total energy intake. In most respects, nutrient intakes resembled a traditional African diet, although fibre intake was low in terms of the recommended 3-6 g/1000 kJ. More than 90% of patients ate three meals a day, yet only 32-47% had a morning snack and 19-27% had a late evening snack. The majority of patients indicated that they followed a special diet, which had been given to them by a doctor or a nurse. Only 3.4-6.1% were treated by diet alone. Poor glycaemic control was found in both urban and rural participants, with more than half of subjects having fasting plasma glucose above 8 mmol l(-1) and more than 35% having plasma glycosylated haemoglobin level above 8.6%. High triglyceride levels were found in 24 to 25% of men and in 17 to 18% of women. Obesity (body mass index > or = 30 kg m(-2)) was prevalent in 15 to 16% of men compared with 35 to 47% of women; elevated blood pressure (> or = 160/95 mmHg) was least prevalent in rural women (25.9%) and most prevalent in urban men (42.4%). CONCLUSIONS: The majority of black, type 2 diabetic patients studied showed poor glycaemic control. Additionally, many had dyslipidaemia, were obese and/or had an elevated blood pressure. Quantitative and qualitative findings indicated that these patients frequently received incorrect and inappropriate dietary advice from health educators.

Where does the black population of South Africa stand on the nutrition transition?

OBJECTIVE: To review data on selected risk factors related to the emergence of noncommunicable diseases (NCDs) in the black population of South Africa. METHODS: Data from existing literature on South African blacks were reviewed with an emphasis placed on changes in diet and the emergence of obesity and related NCDs. DESIGN: Review and analysis of secondary data over time relating to diet, physical activity and obesity and relevant to nutrition-related NCDs. SETTINGS: Urban, peri-urban and rural areas of South Africa. National prevalence data are also included. SUBJECTS: Black adults over the age of 15 years were examined. RESULTS: Shifts in dietary intake, to a less prudent pattern, are occurring with apparent increasing momentum, particularly among blacks, who constitute three-quarters of the population. Data have shown that among urban blacks, fat intakes have increased from 16.4% to 26.2% of total energy (a relative increase of 59.7%), while carbohydrate intakes have decreased from 69.3% to 61.7% of total energy (a relative decrease of 10.9%) in the past 50 years. Shifts towards the Western diet are apparent among rural African dwellers as well. The South African Demographic and Health Survey conducted in 1998 revealed that 31.8% of African women (over the age of 15 years) were obese (body mass index (BMI) > or = 30kg m(-2)) and that a further 26.7% were overweight (BMI > or = 25 to <30 kg m(-2)). The obesity prevalence among men of the same age was 6.0%, with 19.4% being overweight. The national prevalence of hypertension in blacks was 24.4%, using the cut-off point of 140/90 mmHg. There are limited data on the population's physical activity patterns. However, the effects of the HIV/AIDS epidemic will become increasingly important. CONCLUSIONS: The increasing emergence of NCDs in black South Africans, compounded by the HIV/AIDS pandemic, presents a complex picture for health workers and policy makers. Increasing emphasis needs to be placed on healthy lifestyles.