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South African food-based dietary guidelines - guidelines for whom?
D Labadarios*, N P Steyn+
*Department of Human Nutrition University of Stellenbosch and Tygerberg Hospital Tygerberg, W Cape
+Chronic Diseases of Lifestyle Programme Medical Research Council Tygerberg, W Cape

S A J Clin Nutr 2001 Feb Vol 14 No 1

Since the international meetings of the World Health Organisation and the Food and Agriculture Organisation held in Cyprus in 1995,¹ 'food-based dietary guidelines' have become the nutrition buzzwords of the decade. To put it simply and in context, these organisations recommended the use of food-based guidelines in education programmes mainly because the man in the street thinks in terms of foods and not in terms of nutrients. After decades of promoting 'food groups', nutritionists have now 'succumbed' to food guidelines. In fact, the objective of 'food groups' originally was also to relate to foods and not to nutrients.² How will the public relate to these new food-based dietary guidelines, how will they interpret them, and what will we as health educators tell them?

The article on p. 9 of this issue of the SAJCN is an excellent attempt to bring South Africa on par with the latest developments in the field of nutrition education, worldwide. The authors should be congratulated on the approach they adopted to evaluate preliminary principles and concepts in this regard, as well as the innovative research methods they have used to evaluate the underlying feelings and perceptions held by women of different social and cultural backgrounds. Such an evaluation is truly fundamental to developing guidelines which will be user-friendly and practical for all groups of people in the country - something that is of course particularly difficult in a country like ours with such a wide diversity of nutritional disorders and food consumption patterns.

The guideline 'Enjoy a variety of foods' is meant to encourage diversification, with the belief that the more dietary variety one has, the better the possibility of attaining optimal nutrition. The basis of this guideline centres on the available evidence that dietary variety is associated with longevity.³ This guideline implies that everyone understands the meaning of 'variety' or, for that matter, that variety can be defined in objective/quantitative terms. In Northern Province, for example, it was found that the daily variety of food items may range between 10 and 20 items.⁴ When the overall diet was evaluated it became apparent that 65% of the food items were from carbohydrate sources, 20% were from fat sources and 15% were from protein sources.⁵ In terms of affordability and accessibility, fats were restricted to sunflower oil or hard margarine, protein to chicken and legumes, and carbohydrates to maize, sorghum, rice, potatoes, cabbage and pumpkin. The majority of the population in this province function within this framework, and one wonders what the word variety would imply to people consuming such a small variety of basic food items and how they would attempt to increase it. One wonders what the word 'variety' implies to someone who eats virtually the same diet every day. Could it possibly be two or more additional food items, and if so, how would one decide on these? The guideline 'Make starchy foods the basis of most meals' is easy to live with and is a fact of life for the majority of South Africans, particularly the poor living in rural areas. Do we really want to tell them this? Should we not rather encourage the use of more unrefined starches and in combination with a protein, e.g. legumes or meat? Starchy foods are already the basis of most meals and consequently, in many instances, the cause of poor diets with poor nutrient density.⁶

In theory 'eating plenty of fruit and vegetables' is an ideal way of overcoming micronutrient deficiencies, providing antioxidants and ensuring a diet high in fibre. In practice, however, fruit is an expensive item for the poor, particularly in remote arid areas. The National Food Consumption Survey (NFCS) of 1 - 9- year-old children in South Africa indicated that fruit is low down on the list of commonly consumed food items in many provinces.⁷ Should nutrition educators therefore not rather offer culturally appropriate and affordable alternatives to fruit? One suggestion would be to encourage the sustainable use of indigenous vegetables in the appropriate setting. The latter are widely distributed in most provinces and are still fairly popular in rural communities.⁸ One should guard against the exclusive promotion of 'exotic' fruits and vegetables, which could result in indigenous plants and their produce being regarded as inferior, even when many are nutritionally superior.⁹

Another guideline in need of clarification is 'Eat legumes regularly'. As found by Love et al.¹⁰ people tend not to have a clear understanding of the terms 'legumes' and 'regularly'. The latter term is too generalised and gives no indication of quantity or recommended frequency of usage. Would it not be more appropriate to give people a more concrete guideline, e.g. 'try to eat half a cup of cooked beans per day if you are an adult and half of this if you are a child'. Even so, and of particular interest in relation to the findings of the study by Love et al.,¹⁰ legumes appear to be seen as wasters of cooking fuel by the poor and have low popularity among the well to do. Reconciling these widely divergent aspects of affordability and preference will undoubtedly be a formidable challenge. The guideline that 'foods from animals can be eaten every day' could be seen as a truce between pleading for the prevention of coronary heart disease (CHD) on the one hand and preventing iron deficiency anaemia on the other. Perhaps this guideline needs to be more specific, e.g. 'If you are an overweight adult with a risk of CHD restrict your intake of red meat to less than three times per week. Children and women of childbearing age should have meat every day, if cost considerations allow for it.' This in itself underscores the care that is needed in imparting the correct nutrition education messages for the appropriate group of the population.

The guideline that is perhaps of greatest concern is that relating to fat intake, i.e. 'use fat sparingly'. The majority of the population in South Africa, particularly black children, have a fat intake which is too low and results in a diet which is low in energy, one of the main causes of stunting in South Africa.⁷ We should be encouraging children from poor families, particularly in rural areas, to increase their fat intake appropriately. Whether this message should be age-related and population-specific is to be debated. Certainly, sending out a message on decreasing fat intake should be done very selectively and with serious consideration to the target population. For instance, 'Use fat sparingly, if you are an overweight child or adult, or have a history of heart disease in your family' may afford the desired specificity on the widely varying needs of the population.

Another guideline that may cause some concern is 'eat healthier snacks'. Both 'healthier' and 'snacks' are open to varied interpretations from the social and cultural point of view as well as in terms of income, as was found by Love et al.¹⁰ Once again, one should consider making the guideline more specific and self-explanatory, e.g. 'If you eat between meals, select a healthy food like brown bread, fruit or nuts' - a message that could be understood at all levels.

A review of the literature on European countries and the USA has shown that nearly all developed countries have nutrient guidelines, generally given as a percentage contribution of macronutrients to energy intake. With the exception of the Mediterranean countries,¹¹ most developed countries also have food-based dietary guidelines, generally formulated within the last 5 - 10 years. Except for Germany,¹² these countries have not allocated recommended food portion sizes. A few countries, such as Denmark¹³ and Italy,¹⁴ have recommended specific quantities for total fruit and vegetables only, ranging from 400 to 600 g per day. In addition to the food-based dietary guidelines, nearly all countries use some type of pictorial scheme to explain their guidelines. This includes the use of a pyramid (USA,¹⁵ Denmark¹³), a circle (Germany¹²) and a plate (UK¹⁶).

Generally speaking and in comparative terms, South Africa has adopted the same guidelines used by developed countries (the ones that are unique to the South African scenario, as indicated by Love et al.,¹⁰ being 'Eat legumes regularly'; 'Foods from animals can be eaten every day'; 'Drink lots of clean, safe water' and 'Eat healthier snacks'). While certain developed countries have developed their own food-based dietary guidelines, all such countries have recommended increasing fruits and vegetables and grains/carbohydrates and decreasing fat intake. In contrast to these countries, South Africa has not advocated decreasing sugar intake. This can be seen as an enlightened decision in relation to the latest consensus on the subject as summarised by the FAO and the WHO,¹⁷ namely that prevention programmes to control and prevent dental caries should focus on fluoride and adequate oral hygiene and not on sucrose intake alone, and to the documented low energy intake of young children in this country.⁷ Additionally, like those of the majority of developed countries, the South African guidelines also include salt reduction, dietary variety, sensible alcohol intake and increased physical activity. The crucially important issue raised by Love's paper¹⁰ regarding the dietary guidelines for South Africans relates to the appropriateness of the guidelines for a population as diverse as ours. The fundamental question in urgent need of an answer is the practicality of using one set of dietary guidelines in a country where both under- and overnutrition coexist to the extent that they do in South Africa.⁷ The four dietary guidelines that are unique to South Africa ('Eat legumes regularly'; 'Foods from animals can be eaten every day'; 'Drink lots of clean, safe water' and 'Eat healthier snacks') are aimed at the lower socio-economic groups, while the majority of the other guidelines are aimed at the more affluent groups. Perhaps a more practical and appropriate approach in dealing with this formidable challenge might be to have two sets of dietary guidelines, one aimed very specifically at those at risk of undernutrition and deficiency disorders and the other aimed at those predisposed to chronic diseases of lifestyle. Irrespective, Love's paper¹⁰ underscores the excellent start of a process, the conclusion of which will be based on continued evaluation, wisdom, time, and experience.

References

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