HEALTHY EATING
3.1 DEVELOPMENT PROCESS OF THE SOUTH AFRICAN FBDGs
3.1.4 Construction of the preliminary FBDGs
3.1.4.3 Content of the dietary guidelines
The content of the dietary guidelines, aimed at South Africans older than 5 years, was formulated by the SA FBDG Work Group based on the identified nutrition-related public health concerns and possible implicated dietary and lifestyle factors as cited in the scientific literature. The nutrition-related public health concerns considered a priority for South Africans older than 5 years were obesity, hypertension, hypercholesterolaemia, non- insulin dependent diabetes and cancer (see Table 3.4). Dietary goals and preliminary dietary information were than formulated to address these nutrition-related public health concerns (see Table 3.5).
At the third meeting of the SA FBDG Work Group (09-02-1998), a first draft set of FBDGs was compiled based on associations found between identified nutrition-related public health concerns, dietary consumption patterns and lifestyle factors of South Africans (see Table 3.5). The SA FBDG Work Group could not gain consensus on the following Issues:
(a) to have a separate dairy (calcium) guideline;
(b) to combine the fat and salt guidelines;
(c) to include the tea/coffee (caffeine) guideline; and
(d) if lifestyle advice (alcohol, smoking and stress) should be considered as part of food- based/dietary advice.
(SA FBDG Work Group 1998).
It was therefore agreed to present the first draft set of FBDGs to other nutrition and health professionals for fuller discussion. This took place at the biennial Nutrition Congress of the Nutrition Society of South Africa (NSSA) and the Association for Dietetics in South Africa (ADSA), in May 1998. The objective of the workshop was to develop a maximum of ten (10) food-based dietary guidelines based on, and with the aim of improving, current dietary practices and prevailing nutrition-related public health issues of South Africans.
The workshop was attended by 67 delegates (SA FBDG Work Group 1998).
Nutrition professionals debated each proposed guideline of the first draft set in terms of:
- Health relevance - Do the FBDGs address existing/potential nutrition-related public health issues facing South Africans?
- Scientific evidence - Are the FBDGs supported by credible scientific evidence?
- Practical application - Are the FBDGs achievable, sustainable, affordable, culturally sensitive and environmentally sensitive?
- Comprehension - Are the FBDGs understandable and able to be translated in a meaningful manner?
- Prudency (moderation) and adequacy - Do the FBDGs, as a set, address the nutrition transition of over- and under-nutrition?
(SA FBDG Work Gr,:mp 1998).
nutrition-related health concerns of South Africans older than 5 years of age (after SA FBDG Work Group 1998)
DIETARY GOALS & RATIONALE VARIETY
No single food or meal will meet all the requirements for essential and, as yet, unidentified nutrients.
MEALS
Blood glucose levels and appetite are balanced best through eating II minimum of three meals a day; breakfast being the most important. An increase in the number of meals eaten can increase the variety of the diet.
SNACKS
While in-between meal eating can assist in maintaining blood glucose levels, it can also result in a high intake of fats, salt, sugar and total energy depending on food selection.
Frequent contact of foods with the teeth can also promote the development of tooth decay.
BODY WEIGHTIEXERCISE Energy balance and body weight
management is to be encouraged through food choice and exercise. Rather than the setting of an upper limit on energy intake;
advise to exercise up to 30 minutes a day and more on most days of the week.
ENERGY
Diet to provide energy consistent with age, gender, activity and physiological
requirements, and the maintenance of a healthy body weight.
PRELIMINARY DIETARY INFORMATION Enjoy a variety of foods from what you have available and what you can afford.
Eating two meals a day is good - eating three meals a day is better.
To prevent obesity, eat snackfoods that are low infat.
Achieve and maintain a healthy weight by enjoying regular physical activity and healthy eating.
Eat enoughfood to meet your energy needs.
FIRST DRAFT SET OF FBDGs Enjoy as wide a variety of foods as is affordable and locally available.
It is best to eat smaller meals more often than one big meal each day, but have no more than 6 food intakes a day for the sake of your teeth, and make sure that you eat food in the morning.
Enjoy eating enough food and doing regular (daily) physical activity to achieve and maintain a healthy body weight.
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Continuation o/Table 3.5 Dietary goals and rationale, preliminary dietary information and eventual first draft of food-based dietary guidelines (FBDGs) to address nutrition-related health concerns of South Africans older than 5 years of age (after SA FBDG Work Group 1998)
DIETARY GOALS & RATIONALE CARBOHYDRATE
50-60% total daily energy; emphasise unprocessed to achieve adequate intakes of fibre (20-30g/day), vitamins and minerals (vitamins C and B6, beta-carotene, folate, iron, potassium).
PROTEIN
10-20% total daily energy (meat-based diet 8-10%; plant-based diet 10-12%); vitamins A
PRELIMINARY DIETARY INFORMATION Include high fibre breads, cereals and grain products in every meal.
Eat a variety of fruits and vegetables every day, especially those that are dark green, dark orange or yellow.
When cooking vegetables or fruit, cookfor a short time in very little water so that the $!oodness is not destroyed.
Eat legumes (dry beans, lentils, split peas) at least twice a week.
I
and B 12, iron, zinc, calcium.I
Eat small portions of lean meat, fish and chicken.FAT
<35% total daily energy for children, active adults, non-obese adults, elderly experiencing weight/muscle mass loss.
<30% total daily energy for all, excluding above.
*
Trans fatty acids - limit*
Saturated fatty acids - < 1 0% total daily energy (TE)*
Poly-unsaturated fatty acids - <10% TE*
Mono-unsaturated fatty acids - <10% TE*
Cholesterol - <300mg/day SODIUM<3g sodium/day
<5g salt/day
Eat at least one low fat dairy product every day.
Eat foods and meals made with little or no fat.
Eat foods and meals made with little or no salt.
FIRST DRAFT SET OF FBDGs Make starchy foods the basis of most meals - maize, bread, rice, sorghum, pasta or potatoes. Some of these foods should be minimally processed.
Eat plenty of raw or lightly cooked vegetables and fruits every day in meals and for snacks - dark green, yellow and dark orange ones are good choices.
Eat more legumes - dry beans, peas, lentils, soya products and nuts.
Foods from animals can be eaten every day - milk and milk products, fish, chicken, eggs and lean meat.
Eat low fat meals and foods, and use fat sparingly when preparing foods.
Eat foods and meals made with little or no salt.
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(FBDGs) to address nutrition-related health concerns of South Africans older than 5 years of age (after SA FBDG Work Group 1998)
DIETARY GOALS & RATIONALE PRELIMINARY DIETARY INFORMATION FIRST DRAFT SET OF FBDGs WATER Drink clean, safe water to quench your thirst. Drink lots of clean, safe water to quench your thirst.
At least 1 litre/day.
ALCOHOL
If
you drink alcohol, keep intake to less than 2 alcoholic If you drink alcohol, drink sensibly.Males: <22units/week; females: beverages every second day.
<12units/week; pregnancy/lactation:
Ounits/week. Drinking alcohol whilst pregnant or breastfeeding is not advisable.
TEA/COFFEE
If
you drink regular tea and/or coffee, keep intake to 4-5 If you drink tea and/or coffee, keep intake to 4-5 cups or Concerns regarding high caffeine intakes. cups or less per day. less per day.SMOKING Smoking is addictive and harmful to your health - it is Smoking is addictive and harmful to your health - it is Concerns related to incidence of cancer and never too late to give it up. never too late to give up.
heart disease.
STRESS Control stress. Make time to relax. Laugh a little, smile Control stress - make time to relax.
Concerns related to incidence of heart a lot.
disease.
Workshop participants queried the ability of the general public to correctly interpret some of the terminology and concepts used, namely variety, frequently, meals, snacks, healthy body weight, starchy foods, legumes, foods from animals. Questions also arose regarding how consumers categorise dairy products (together or separate from meat products), whether they perceive alcohol as a factor influencing dietary intake, and if their water supply is safe and clean. To keep the number of guidelines to a minimum, workshop participants agreed to exclude the guidelines regarding tea and coffee (caffeine), smoking and stress on the basis that:
- caffeine intake was not a priority in terms of the identified nutrition-related public health problems
- the Department of Health was already adequately addressing the smoking issue with its anti-smoking campaign
- stress referred to lifestyle, not dietary, change (SA FBDG Work Group 1998).
A second draft set of FBDG resulted from the workshop (see Table 3.6), and was reviewed at a fourth meeting of the SA FBDG Work Group (01-08-1998). In keeping with the F AO/WHO criteria for FBDGs, namely, action-oriented, positive, simple guidelines, it was agreed that the final set of FBDGs should preferably comprise no more than ten guidelines which are positive and concisely written, and which are accompanied by explanatory consumer text. A third draft of eleven preliminary FBDGs resulted from these deliberations (see Table 3.6) (SA FBDG Work Group 1998; WHO 1998).
According to the recommended F AO/WHO FBDGs development process the next step, following the formulation of a draft set of FBDGs, is the preparation of technical support papers for each FBDG statement. At the fifth meeting of the SA FBDG Work Group (22/01/1999), it was agreed that the third draft set of FBDGs should first be subjected to consumer testing and, once refined, technical support papers could be prepared. This was regarded as a time saving step. It was also agreed that sub-committees should be formed to address the adaption of the proposed FBDGs for other priority groups (HIV, pregnancy, breastfeeding, paediatrics, elderly, chronic illness) (SA FBDG Work Group 1999).
To increase the credibility of the FBDGs testing phase, it was decided that consumer testing should take the form of formal research studies. It was also agreed that such studies should be conducted in as many of the nine provinces of South Africa as resources would permit so as to access the different ethnic groups within the country (SA FBDG Work Group 1999).
Results of the consumer testing studies from the KwaZulu Natal and Western Cape provinces were reported at the sixth meeting of the SA FBDG Work Group (18-01-2000).
Results from the consumer testing produced similar findings, namely, that consumers:
- considered fruit an expensive commodity compared to vegetables - were familiar with the term "legumes", but regarded it as uncommon - misunderstood the phrase "foods from animals"
- understood the word "fat" to include cooking fats, but not fatty foods and spreads - were confused by the guideline "Eat healthier snacks"
(Love, Maunder, Green, Ross, Smale-Lovely & Charlton 2001).
First Draft Set of Food-Based Dietary Second Draft Set of Food-Based Dietary Third Draft Set of Food-Based Dietary Guidelines for South Africans (>5years) Guidelines for South Africans (>5 years) Guidelines for South Africans (>5 years) Enjoy as wide a variety of foods as is affordable and Enjoy as wide a variety of foods as is affordable and Enjoy a variety of foods.
locally available. locally available.
It is best to eat smaller meals more often than one big Eat meals more often and eat in the morning. Eat healthier snacks.
meal each day, but have no more than 6 food intakes a day for the sake of your teeth, and make sure that you eat food in the morning.
Enjoy eatin~ enough food and doing regular (daily) Eat enough food for physical activity and to maintair. Be active!
physical activity to achieve and maintain a healthy a health body weight.
body weight.
Make starchy foods the basis of most meals - maize, Make starchy foods the basis of most meals. Make starchy foods the basis of most meals.
bread, rice, sorghum, pasta or potatoes. Some of these foods should be minimally processed.
Eat plenty of raw or lightly cooked vegetables and Eat vegetables and fruits as frequently as possible/at Eat plenty of fruits and vegetables every day.
fruits every day in meals and for snacks - dark green, least 5 a day.
yellow and dark orange ones are good choices.
Eat more legumes - dry beans, peas, lentils, soya Eat legumes regularly/as frequently as possible. Eat legumes regularly.
products and nuts.
Foods from animals can be eaten every day - milk Foods from animals can be eaten every day. Foods from animals can be eaten every day.
and milk products, fish, chicken, eggs and lean meat.
Eat low fat meals and foods, and use fat sparingly Eat low fat meals and foods, and use fat sparingly Use fat sparingly.
when preparing foods. when preparing foods.
Eat foods and meals made with little or no salt. Eat foods and meals made with little or no salt. Use salt sparingly.
Drink lots of clean, safe water to quench your thirst. Drink lots of clean, safe water to quench your thirst. Drink lots of clean, safe water.
If you drink alcohol, drink sensibly. If you drink alcohol, drink sensibly. If you drink alcohol, drink sensibly.
If you drink tea and/or coffee, keep intake to 4-5 cups or less per day.
Smoking is addictive and harmful to your health - it is never too late to give up.
Control stress - make time to relax.
Based on these findings and to reflect consumer perceptions and understanding, changes were proposed to specific FBDG statements, namely, that:
_ "vegetables" should be listed before "fruits" as fruits are considered more expensive and less frequently available
_ "legumes" should be replaced with actual food examples i.e.: "dry beans, peas, lentils and soya"
- "foods from animals" should be replaced with actual food examples i.e.: "meat, fish,
chicken, milk or eggs"
- "use fat" sparingly should be replaced with "eat fats" sparingly, as the former implied
only fat used for cooking (oil, Holsum), and excluded fats in the form of spreads (margarine, butter) and fatty foods
- the "Eat healthier snacks" guideline should be omitted, but with information on wise snacking to be included in the explanatory text.
These changes resulted in the formulation of a fourth draft set ofFBDGs (see Table 3.7).
(SA FBDG Work Group 2000).
Table 3.7 Fourth draft set of food-based dietary guidelines for South Africans (>5 years)
(after SA FBDG Work Group 2000)
I. Enjoy a variety of foods.
2. Be active!
3. Make starchy foods the basis of most meals.
4. Eat plenty of vegetables and fruits every day.
5. Eat dry beans, peas, lentils and soya regularly.
6. Meat, fish, chicken, milk or eggs can be eaten every day.
7. Eat fats sparingly.
8. Use salt sparingly.
9. Drink lots of clean, safe water.
10. If you drink alcohol, drink sensibly.
The fourth draft set of FBDGs (as listed in Table 3.7) and consumer testing results from KwaZulu Natal, Western Cape and Northern Province were presented at the biennial Nutrition Congress :n August 2000, where discussions took place regarding the South African FBDGs development process. Comments from the Nutrition Congress were considered at the seventh meeting of the SA FBDG Work Group (18-lO-2000). It was agreed that, once approved as national dietary guidelines, supporting documentation should be made available regarding the FBDGs, and that this documentation should be structured on three levels:
• consumers - via pamphlets that provide practical information on how to apply the FBDGs, taking into consideration the diverse cultural eating habits that exist and levels of literacy
• health care workers/nutrition educators - via a training manual that provides justification for each of the FBDGs and practical instruction on how to use the FBDGs
for nutrition education
• health professionals - via published technical support papers that provide scientific evidence to justify the existence of each of the FBDGs
(SA FBDG Work Group 2001).
A draft copy of the explanatory consumer text is attached as Appendix 3. A draft copy of the health care worker training manual has also been compiled (but is not included in this document due to its length). The technical support papers providing scientific evidence for each of the proposed FBDGs have been published in the South African Journal of Clinical Nutrition, September 2001: 14(3): supplement S I-S80. The scientific evidence for inclusion of each ofthe proposed South African FBDGs is summarised in Table 3.8, and is further validated when reading the scientific evidence of similar dietary guidelines for other countries (DGAC 2000; NHMRC 1998).
Following the publication of the technical support papers, an editorial comment was made that "one should consider making the guidelines more specific and self-explanatory", for example, that the consumption of unrefined starchy foods should be encouraged. The editorial comment also questioned the ability of one set of guidelines to address the co- existence of under- and overnutrition in South Africa (Labadarios & Steyn 2001).
As explained in the SA FBDG Work Group's response to the editorial, the proposed FBDGs are an attempt at providing consistent nutrition messages in a non-segregating manner, aimed at thuse who are under-, over- or adequately nourished. In order to achieve this, each FBDG conveys a dietary principle in a succinct manner, using positive, broad terminology. Hence the consistent recommendation that all FBDGs should be accompanied by an explanatory consumer text which would elaborate on specific activities and strategies to apply the FBDGs (Love 2001).
An additional outcome of the seventh meeting of the SA FBDG Work Group (18-10-2000) was that, once the technical support papers had been accepted for publication, the proposed FBDGs should be presented to the Department of Health for national approval and adoption (SA FBDG Work Group 2001).
The proposed FBDGs and technical support papers were presented to the Health Management Committee (HMC) meeting on 11 June 2001. The outcome of this meeting was that "the Health Management Committee noted, with appreciation, the work done in drafting the guidelines, but that the following needed consideration":
*
an explanation of the terms "sparingly" and "sensibly" (considered too vague)*
an explanation of the "meats" guideline (considered too open-ended)*
the inclusion of a guideline on "sugar" (to address dental caries) (DOHIFBDG Workshop 2001)(SAJCN 2001:14(3): supplement SI-S80)
FOOD-BASED DIETARY GUIDELINE Enjoy a variety of foods
Be active!
Make starchy foods the basis of most meals.
Eat plenty of vegetables and fruits every day.
SUMMARY OF PUBLISHED ARTICLE
No single nutrient is most important, and no single food supplies all the nutrients the body needs. Eating a variety of foods therefore makes it easier to obtain all the nutrients needed. Nutritionally, there are also no "bad" foods. What is important is how different foods are eaten to make a healthy diet. People should therefore strive to eat as wide a variety of foods as is affordable and acceptable.
When food is scarce or difficult to obtain due to poverty or inaccessibility, it is important to make the best possible food choices from what is available. Locally produced and traditional foods should not be forgotten as they can make a valuable contribution to a varied diet. It is suggested that prevailing low micronutrient intakes, low energy intakes as well as overconsumption of food and resultant chronic diseases of lifestyle will be addressed by this guideline. The challenge is to ensure that these goals are achieved within the context of high household food insecurity and increasing urbanisation (Maunder, Matji & Hlatshwayo-Molea 2001).
Implementing this guideline and the other nine that concern diet will assist in the achievement and maintenance of a healthy body weight, thereby preventing obesity and associated chronic diseases of lifestyle. Moderate exercise is recommended (40-60 minutes, 3-5 times a week) (Lambert, Bohlmann & Kolbe-Alexander 2001).
Starchy foods are good sources of carbohydrate. Minimally processed and fortified starchy foods are also good sources of fibre, vitamins (especially vitamin-B), and minerals. Starchy foods are also low in fats, depending on how they are prepared and what is added to them when they are eaten. Starchy foods are often economical, widely available foods, and can therefore contribute significant amounts of nutrients to the diet, particularly when unrefined varieties are chosen. Starchy foods should form the central part of each mixed meal and be eaten in larger amounts than the other foods at the meal. An increased carbohydrate (starchy food) intake can result in a decreased fat intake. Although starchy foods are an important part of the diet, they cannot provide all the nutrients needed by the body. For a healthy diet, other foods need to be added to starchy foods, such as vegetables, fruits, dry beans, soya, meat, fish, chicken, eggs, milk or milk products (Vorster & Nell 2001).
Vegetables and fruits provide a variety of different vitamins, such as folate, vitamin C and beta-carotene. When eaten with their skins/peels on, fruits and vegetables also provide fibre. Vegetables and fruits should be eaten as often as possible. Latest
recommendations suggest that at least 5 portions of vegetables or fruits be eaten everyday. Iffruit is expensive, more vegetables can be eaten. Edible wild fruits and vegetables can also be eaten. Vegetable gardens and fruit trees can also be planted at home to provide fresh vegetables and fruit for the family and even for sale. National and regional nutrition studies have shown that South Africans are not eating at least 5 portions of vegetables or fruit everyday. Affordability (lack of household income) is given as the main barrier, as well as lack of availability (especially fruits) and resistance from the children and, in some cases, the men in the household (Love & Sayed 200 I).
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