The new South African food-based dietary guidelines in perspective

The new South African food-based dietary guidelines in perspective

Prof HH (Esté) Vorster, Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa

Introduction: ‘optimal’ nutrition
Malnutrition, and especially the co-existence of under- and over-nutrition, leading to a double burden of infectious and non-communicable diseases (NCDs), is one of the most critical problems developing countries and specifically South Africa, are facing today. In addition to ensure food and nutrition security by making nutritious food available and affordable, there is a real need to inform, educate and empower consumers to make the right food and beverage choices that will lead to the consumption of healthy diets. Any healthy diet (and many food combinations may form such diets) will ensure that all nutrient and energy needs are met without leading to over-nutrition and consequent increased risk of NCDs. Healthy diets are therefore adequate regarding all nutrients, but also prudent and protective against NCD risk. Adequate diets are needed throughout the life cycle to ensure optimal physical and mental growth and development, health and well-being of humans; prudent diets are needed to ensure the lowest possible risk of NCDs and quality of life as people grow older.The nutrient profile of healthy diets is based on a huge body of scientific evidence about the different nutrients required by humans, their presence in foods, absorption, physiology, metabolism and excretion, genetic influences on these processes, human variability in needs, and the association of specific nutrients with disease: all leading to nutrient recommendations made by various scientific bodies around the world.

Food-based dietary guidelines (FBDGs)
People (consumers) eat foods and not nutrients: nutrition scientists therefore replaced nutrient-based recommendations to the public with food-based dietary guidelines (FBDGs) that will be understood by consumers. Country-specific FBDGs are dietary recommendations based on local foods and eatingpatterns.1,2 FBDGs cantherefore be defined as science-based policy recommendations in the form of guidelines for healthy eating.3 They are a translation of evidence-based nutrient recommendations into foods or dietary patterns that should guide the general population towards consuming a healthy, more optimal diet. The key concepts of FBDGs and the scientific evidence-based methodology for their preparation and use have been conceptualised and designed by the joint Food and Agriculture Organization and World Health Organization (FAO/WHO) Consultation held in Nicosia, Cyprus in 19951in response to the World Declaration and Plan of Action on Nutrition adopted by the 1992 International Conference on Nutrition.4 The action plan was to inter alia eliminate and reduce famine and famine related deaths, starvation, and specific nutritional deficiencies, and also to reduce nutrition-related NCDs. FBDGs thus became part of the FAO/WHO strategy to promote appropriate diets through recommendations of optimal dietary patterns and healthy lifestyles, calling on Governments to provide evidence-based advice to the public in the form of guidelines that they could understand, relate to and apply.

In the nutrition literature, the concept of FBDGs is often suggested as a tool to improve optimum nutrition and health. The ideal FBDG programme should therefore comply to the needs to effectively ‘market’ nutrition knowledge and motivate consumers towards changing behaviours to make the best possible choices within their budgets regarding their eating patterns.5 This ‘ideal’ FBDG programme must consist at least of a set of short, qualitative FBDG messages formulated in a way that will grab attention and that consumers will understand; the messages must be supported by a country-specific food guide that explains the food choices which collectively will lead to a healthy diet; some technical support information are needed that motivate the FBDG messages and food guide and give quantitative recommendations on how much and how often certain foods, beverages and their products should be eaten for optimal health.5

The implementation of the FBDG programme needsplans on the best way to market the FBDG messages, further development of specific education and promotional material targeted to specific groups of consumers, and plans on how to evaluate the outcomes of implementation.5Unfortunately, less is known about successes and/or failures of implementation and the impact of implementation on dietary behaviour and health in the short- or long-term. A possible reason for this may be because although the science of and supporting methodology for developing FBDGs have been documented to a certain extent,1-5many countries still lack the capacity to translate scientific evidence into FGBDs and to develop appropriate education and promotion material, implementation (intervention) programmes, as well as monitoring and evaluation strategies.6

Potential barriers to healthy eating: the challenge for developing FBDGs
It is generally known how difficult it is to change eating behaviour through trying to educate populations on healthy food choices. The barriers are numerous, from poverty and food insecurity (healthier choices are not available, accessible or affordable) to peer pressure and aggressive marketing of food and beverage products leading to intakes of energy-dense, micronutrient-poor convenience and ‘junk’ foods and drinks that are becoming more affordable and available in developing countries.When designing FBDG messages for a particular country, all these factors should be taken into account. A summary from the 2009 working document of the WHO5 of the desired characteristics of FBDG messages are given in Box1 below. It is clear that a thorough knowledge of the health profiles, eating patterns, the affordability and availability of foods and beverages, traditional and indigenous foods should be considered in designing FBDG-messages.

Box1: Summary of characteristics of FBDGs

(i) FBDGs recommend about foods and dietary patterns (not nutrients)
(ii) FBDGs should lead to nutritionally adequate diets
(iii) FBDGs should lead to diets associated with a low risk of NCDs
(iv) FBDGs must address country-specific nutrition and health problems
(v) FBDGs must be science and evidence-based
(vi) FBDGs should also advise on modern and new functional food products
(vii) FBDGs must be socio-cultural and ethnic sensitive
(viii) FBDGs should promote environmentally sustainable agriculture
(ix) FBDGs should promote the use of indigenous foods
(x) FBDGs must be realistic, affordable and attainable
(xi) FBDGs should emphasize enjoyment of foods
(xii) FBDG messages must be marketable
(xiii) FBDGs must consider all aspects of food safety
(xiv) FBDGs could also promote “other” healthy behaviors
(xv) FBDGs could form the basis for therapeutic and individualized diets
(xvi) FBDGs are aimed at defined target groups
(xvii) FBDGs should be “visionary” and open to reformulation and change

In summary, the characteristics the following:

FBDGs are short, simple, positive, marketable messages for everyone on how to choose a healthy diet (optimal, balanced, adequate, prudent)
They are about foods (not nutrients)
They address nutrition-related public health problems of the country
They are evidence-based (science background)
They must be realistic, do-able, promoting local indigenous and traditional foods

The South African process for developing and revising FBDG messages
The Nutrition Society of South Africa (NSSA) initiated the process of designing FBDGs for the general South African population in 19977 in partnership with the Department of Health, Directorate Nutrition, the Medical Research Council (MRC) and several other stakeholders from different United Nations’ agencies and food producer organisations in South Africa. This was a three-year process of a thorough review of the nutritional situation in South Africa by the academic members of the group, the changes needed in nutrient intakes and dietary behaviours based on the most recent science, and ways to promote these changes using FBDGs. A set of FBDG messages was accordingly designed and tested.

The testing of the developed messages in women of different population groups8 was funded by the United Nations Children’s Fund (UNICEF). The technical support papers, promoting the guidelines from scientific literature, and providing more information about the types and amounts of the different food groups to be eaten, were published in the South African Journal of Clinical Nutrition in 2001.9 The Department of Health formally adopted the set of FBDGs in 2003 to form the basis of nutrition communication to the public, with the addition of a guideline on sugar intake, based on the relationship between sugar consumption and dental caries. The final set of 11 guidelines is listed in Table I. These FBDGs were aimed at individuals aged seven years and older.

Table 1: First set of South African food-based dietary guidelines, 2003

Enjoy a variety of foods.
Be active.
Make starchy foods the basis of most meals.
Eat dry beans, peas, lentils and soy regularly.
Chicken, fish, meat or eggs can be eaten daily.
Drink lots of clean, safe water.
Eat plenty of vegetables and fruit every day.
Eat fats sparingly.
Use salt sparingly.
If you drink alcohol, drink sensibly.
Use foods and drinks containing sugar sparingly, and not between meals.
Paediatric FBDGs for South Africa
A similar process was initiated by the NSSA, who established a paediatric working group to develop FBDGs for infants and children younger than seven years of age, which was published in Maternal and Child Nutrition in 2007.10-11 The paediatric guidelines were specific to the following age groups: birth to 6 months; > 6 months to < 12 months; and > 1 to < 7 years. They paralleled the FBDGs for children aged seven years and older, with the introduction of the same messages to target the younger ages. However, these paediatric FBDGs were not officially adopted by the Department of Health as because of funding constraints, the messages had not been fully tested. Revision of the South African FBDGs The majority of South Africans are experiencing a rapid process of economic development, urbanisation, acculturation and modernisation of their dietary habits. This phenomenon of a rapid nutrition transition, together with new knowledge about the relationships between dietary intakes and health, led to the recommendation that the 2003 FBDGs should be “reviewed and adapted accordingly” on a regular basis.7 In 2011, the Department of Health, Directorate of Nutrition, embarked on a process to develop a new, more appropriate country-specific food guide for South Africa. As part of this process, it was decided to review the existing FBDGs.A national working group was convened, and during a workshop that took place on 30 March 2011, several expert working groups including a paediatric working group, were formed to review the new literature and revise the guidelines. The expert and paediatric working groups reported their findings and made suggestions to the national working group during a meeting on 27 July 2011. During this meeting, consensus was reached on: (i) the formulation of a set of FBDGs for the general population of individuals older than five years of age;(ii) a separate set of paediatric guidelines for infants and children younger than five years of age;(iii) the inclusion of a milk guideline in the general FBDGs;(iv) a focus on the quality of fats in the fat guideline; and (v) small changes in the wording of some of the other guideline messages. (vi) it was also agreed that the alcohol guideline created much confusion, especially the words: “drink sensibly”. As there are many other initiatives in South Africa that address alcohol abuse, it was decided to delete this guideline message. (However, a technical support paper on alcohol consumption has been written to provide assistance to nutritionists and dietitians on how to deal with alcohol recommendations); (vii) special attention was given to the words “eat”, “consume” and “use”. The word “use” was restricted to the salt, sugar and fat guidelines, because salt and sugar, and at times fats and oils, were seen as ingredients that are added in the preparation of food;(viii) Debate on the use of the words “regularly”, “sparingly” and “moderately” led to slight reformulation of some guidelines. Each expert working group took responsibility for writing the technical support paper according to a specific terms-of-reference document, and information in the technical support paper focused on the needs of infants and children under five years of age, where relevant. These technical support papers are to be published in a special September issue of the South African Journal of Clinical Nutrition.Final consensus on the wording of each guideline and the information that should be included in the technical support papers was obtained during a meeting of the national working group on 26 June 2012. The revised set of general FBDG messages for South African adults and children aged five years and older is listed in Table 2. It is important that these messages should be seen in context. They are designed as short, qualitative ‘sound-bites’ to grab the attention of consumers. But they should be explained to consumers in terms of food choices using the food guide to show possible replacements, exchanges and options that will suit different budgets. Furthermore, the technical support papers, motivating each guideline, and giving optimal quantities (portion or serving sizes) as well as optimal frequencies of consumption and potential barriers to implementation, should be used to develop appropriate education material for specific target groups (pregnant and lactating mothers, mothers of small children, school children, adolescents, adults, the aged, etc.). Table 2: Revised general food-based dietary guidelines for South Africans, 2012 Enjoy a variety of foods. Be active! Make starchy foods part of most meals. Eat plenty of vegetables and fruit every day. Eat dry beans, split peas, lentils and soya regularly. Have milk, maas or yoghurt every day. Fish, chicken, lean meat or eggs can be eaten daily. Drink lots of clean, safe water. Use fats sparingly. Choose vegetable oils, rather than hard fats. Use sugar and foods and driks high in sugar sparingly. Proposed new paediatric FBDGs The paediatric FBDGs are still to be adopted by the South African Department of Health and therefore given here as ‘proposed’ guidelines, shown in Table 3. The new South African Food Guide The food guide, illustrating the food groups that should be eaten regularly, developed in parallel to the revision of the FBDGs, is shown in Figure 1. This food guide has been developed for South Africans with support from the FAO. It is unique in the sense that it only shows food groupings that are necessary for healthy eating, and does not, like many other food guides, such as the widely used food pyramid, include items such as sugar, sweetened foods and drinks, nor salt. It also focuses on traditional foods in our multicultural society and specifically on affordable choices that form a large part of habitual intakes of poorer people. The proportional size of the food group circles symbolically reflect the proportional volume that the group should contribute to the total daily diet.

Figure 1: The South African food guide (Department of Health, Directorate Nutrition

The food guide should be seen as an ideal tool to explain to individuals and target groups how to choose a healthier diet.

Table 3: Proposed paediatric food-based dietary guidelines, still to be tested

0 – 6 months

Give only breast milk, and no other foods or liquids, to your baby for the first six months of life.
6 – 12 months

At six months, start giving your infant small amounts of complementary foods, while continuing to breastfeed to two years and beyond.
Gradually increase the amount of food, number of feeds and variety as the child gets older.
Feed slowly and patiently, and encourage your baby to eat, but do not force them.
From six months of age, give your child meat, chicken, fish or egg every day, or as often as possible.
Give your child dark-green leafy vegetables and orange-coloured vegetables and fruit every day.
Start spoon feeding with thick foods, and gradually increase to the consistency of family food.
Hands should be washed with soap and clean water before preparing or eating food.
Avoid giving tea, coffee and sugary drinks and high-sugar, high-fat salty snacks.
12-36 months

Continue to breastfeed to two years and beyond.
Gradually increase the amount of food, number of feedings and variety as the child gets older.
Give your child meat, chicken, fish or egg every day, or as often as possible.
Give your child dark-green leafy vegetables and orange-coloured vegetables and fruit every day.
Avoid giving tea, coffee and sugary drinks and high-sugar, high-fat salty snacks.
Hands should be washed with soap and clean water before preparing or eating food.
Encourage your child to be active.
Feed the child five small meals during the day.
Make starchy foods part of most meals.
Give your child milk, maas or yoghurt every day.
3-5 years

Enjoy a variety of food.
Make starchy foods part of most meals.
Lean chicken or lean meat or fish or eggs can be eaten every day.
Eat plenty of vegetables and fruit every day.
Eat dry beans, split peas, lentils and soya regularly.
Consume milk, maas or yoghurt every day.
Feed your child regular small meals and healthy snacks.
Use salt and foods high in salt sparingly.
Use fats sparingly. Choose vegetable oils, rather than hard fats.
Use sugar and food and drinks high in sugar sparingly.
Drink lots of clean, safe water and make it your beverage of choice.
Be active!
Hands should be washed with soap and clean water before preparing or eating food.
Concluding remarks
FBDGs for a specific country have many potential uses. In addition to educating consumers on healthy diets, it must impact on policies guiding the production of food and beverages (e.g. agriculture), the import and distribution of food (e.g. economics, the food industry, etc.), and all institutions providing meals to consumers (e.g. retailers, restaurants, hostels the army, prisons, schools, etc.). FBDGs are science-based recommendations on healthy eating, and should help to get clear, unbiased and authoritative messages across on how to plan and choose healthier diets for better development and optimal health.

References
1. Food and Agriculture Organization of the United Nations/World Health Organization. Preparation and use of FBDGs. Geneva: WHO; 1996.
2. Food and Agriculture Organization of the United Nations/World Health Organization. Preparation and use of FBDGs. Geneva: WHO; 1998.
3. European Food Safety Authority. FBDGs: Scientific opinion of the panel on dietetic products, nutrition and allergies. EFSA Journal. 2008;1-44.
4. Food and Agriculture Organization of the United Nations. World declaration and plan of action for nutrition. Rome: FAO/WHO International Conference on Nutrition; 1992.
5. WHO Procedural Manual for the development and implementation of regional and country-specific food-based dietary guidelines (FBDGs). Draft, 2009:1-49.
6. Smitasiri S, Uauy R. Beyond recommendations: implementing food-based dietary guidelines for healthier populations. Food Nutr Bull. 2007;28:S141-S151.
7. Vorster HH, Love P, Browne C. Development of food-based dietary guidelines for South Africa – the process. S Afr J ClinNutr. 2001;14(3):S3-S6.
8. Love P, Maunder E, Green M, et al. South African food-based dietary guidelines: testing of the preliminary guidelines among women in KwaZulu-Natal and the Western Cape. S Afr J ClinNutr. 2001;14(1):9-19.
9. Vorster HH, ed. South African food-based dietary guidelines. S Afr J ClinNutr. 2001; 14(3):S1-S80.
10. Aggett P, Moran VH, eds. Food-based dietary guidelines for infants and children: the South African experience. Matern Child Nutr. 2007;3(4):223-333.
11. Bourne LT. South African paediatric food-based dietary guidelines. Matern Child Nutr. 2007;3(4):227-229.