We developed the NOURISHING framework to highlight where governments need to take action to promote healthy diets and reduce overweight and obesity.
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The evidence suggests people who want to eat well use nutrient lists to choose healthier options. Interpretative labels help them when they find the labels hard to understand. Nutrition labels also create incentives for food manufacturers to reformulate their products, so helping populations more broadly by increasing the availability of food of higher nutritional value.
Clear standards are also needed on the use of nutrient and health claims. Evidence shows these claims alter the perception people have of these products – making it essential that they do not mislead.
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Section 15(1) of the Foodstuffs, Cosmetics, and Disinfectants Act (by means of regulation of 2010, effective from March 2012) defines the nutrient content claims permitted in South Africa and establishes rules for their use (eg levels of fat permitted in a food product bearing a low fat claim). Nutrient content claims must be substantiated by nutritional information, and the use of terms such as "health", "healthy", "wholesome" or "nutritious" is not allowed. Although nutrition content claims need to meet certain criteria set out in the regulation, there are no generalised nutritional criteria which restrict their use on "unhealthy" food.
We know from the evidence that making fruit and vegetables available in schools increases consumption. There is also evidence that food standards to restrict availability have the effect of reducing consumption of the restricted food.
For these actions to be effective for all children, they need to be sustained over time and accompanied by complementary behaviour change communication techniques, such as "modelling", school gardens, and communication to all stakeholders involved in the provision and consumption of school food. Worksites and healthcare also present strong potential for improved eating among adults.
The South African Department of Basic Education, in cooperation with the Provincial Education Departments, runs the voluntary National School Nutrition Programme (NSNP), which evolved out of the Primary School Nutrition Programme introduced in 1994. The Programme provides one daily meal which is based on the South African Food Based Dietary Guidelines (2012). Fresh fruit and vegetables should be served every day and soya no more than twice a week. As part of the school nutrition programme, voluntary guidelines for Tuck Shop Operators (2014) were developed which advise to only sell healthy food (eg fresh fruit, nuts, fish, brown bread sandwiches) and beverages in containers not exceeding 250ml (eg plain water, 100% fruit juice, unsweetened milk). Schools are encouraged to set up vegetable gardens to teach children to grow food and use the harvested produce for school meals. NSNP is implemented in the neediest public schools, and most schools use the opportunity offered to them.
Empirical estimates show that food prices influence, to a varying degree, how much food people buy. Targeted subsidies have been shown to help overcome affordability barriers to healthy food for people on low incomes. Incentives, like financial rewards or price discounts, have also been shown to encourage people to switch to healthier options.
Emerging evidence from implemented taxes, as well as modelling studies, indicate the potential for effectiveness to reduce consumption. Given food choices are influenced by a whole host of factors, especially in modern, complex food markets, taxes must be designed very carefully to maximise effectiveness.
Please note, $ refers to USD.
In December 2017, the South African government passed the Rates and Monetary Amounts and Amendment of Revenue Laws Act 2017 - Act No. 14 which introduced a Sugary Beverages Levy. The Levy is fixed at 2.1 cents ($0.17) per gram of sugar content in a sugary beverage that exceeds 4g per 100mL. The first 4g of sugar content in sugary beverages are not subject to the Levy. Sugary beverages include mineral waters and aerated waters, containing added sugar or other sweeteners or flavours, and other non-alcoholic beverages (excluding fruit or vegetable juices).
We are all influenced by the food that is available and affordable when we grow up, and the habits of the people around us. That’s why people in different countries and communities consume differently. We know that when the food supply changes, so does what people eat. This is why we need to improve the quality of the food supply. Evidence from salt reduction indicates that people’s tastes can change.
In 2013, the South African Department of Health adopted targets for salt reduction in 13 food categories by means of regulation (Foodstuffs, Cosmetics and Disinfectants Act). There is a stepped approach, with food manufacturers given until June 2016 to meet one set of category-based targets and another three years, until June 2019, to meet the next.
Peters SAE et al. (2017) The sodium content of processed foods in South Africa during the introduction of mandatory sodium limits. Nutrients 9(4):404
In February 2011, Regulation 127 relating to trans fat in foodstuffs amended Section 15(1) of the South African Foodstuffs, Cosmetics, and Disinfectants Act to prohibit the sale, manufacturing and importation of any oils or fats, alone or as part of processed food, that exceed 2g per 100g of oil or fat. This applies to retail, catering businesses, restaurants, institutions and bakeries. The regulations came into effect in August 2011.
Awareness is one precursor to eating well. The evidence suggests that public campaigns can boost awareness. To influence consumption, they need to be sustained and use multiple channels.
Food-based dietary guidelines are an information and communication tool involving the translation of recommended nutrient intakes or population targets into recommendations of the balance of food that populations should be consuming for a healthy diet. They typically promote increased intake of fruit and vegetables and limited intake of salt/sodium and sugar. They may also include guidance on physical activity and healthy weight, and provide guidelines for different population groups. Countries use various formats of presenting the guidelines including cooking pots (Guatemala, Paraguay), pineapples (Fiji), pyramids (Australia, India, US), plates (Colombia, UK), pagodas (China), spinning top (Venezuela), traditional African house (Benin) and circles (Argentina). Some countries have started to include sustainability criteria in their dietary guidelines (eg Germany in 2013, Finland and Brazil in 2014, Sweden and Qatar in 2015, the Netherlands and UK in 2016). Brazil’s revised dietary guidelines, launched in 2014, present food- and meal-based recommendations that take into account cultural dimensions and promote the consumption of minimally processed food as well as health, wellbeing and sustainable food systems, and recommend avoiding ultra-processed food. Details on the content of national dietary guidelines can be found on the FAO database on Food-based dietary guidelines.
Governments in these countries manage, or are involved in, fruit and vegetable campaigns that promote the consumption of a certain number of fruit and vegetable portions a day, often "5 a day" (eg Argentina, Chile, Germany, Mexico, New Zealand, South Africa, Spain, Tonga) but also "6 a day" (Denmark), "Go for 2&5" (Western Australia), “Fruits & Veggies – More Matters” (United States) or 5–10 (France).
Capacci S, Mazzocchi M (2011) Five-a-day, a price to pay: An evaluation of the UK program impact accounting for market forces. Journal of Health Economics 30(1), 87-98
Carter OBJ et al. (2011) ‘We’re not told why – we’re just told’: qualitative reflections about the Western Australian Go for 2&5® fruit and vegetable campaign. Public Health Nutrition 14(6), 982-988
Pollard CM et al. (2008) Increasing fruit and vegetable consumption: success of the Western Australian Go for 2&5® campaign. Public Health Nutrition 11(3), 314-320
People with elevated risk factors for cancer and other non-communicable diseases – such as heavy bodyweight, high cholesterol or glucose intolerance – can benefit from advice provided by their healthcare provider. Such advice can also be given to people at low risk for prevention into the future.
There is potentially a wide range of mechanisms for integrating nutrition advice into primary care, including counselling, self-help materials and computer-tailored messages. Randomised controlled trials suggest they can be effective if carefully designed and well targeted. The most positive outcomes appear to be for people already at risk.
The South African Integrated Nutrition Programme was implemented in 1995 and focuses on children under the age of 6, pregnant and lactating women and all people living with chronic diseases, and targets malnutrition in South Africa. It is located in the primary healthcare framework and includes protocols and guidelines on nutrition education and counselling.
The standardised curriculum to train community health workers in South Africa, dating from July 2012, contains a mandatory lesson on healthy lifestyle and eating, providing information on overweight and obesity, non-communicable diseases and undernutrition, as well as how nutrition affects health.
The reason for nutrition education is to improve knowledge and the ability to put that knowledge into practice. Studies have demonstrated that nutrition knowledge and healthy dietary behaviour are positively correlated. Higher levels of general education have been found to increase the ability of individuals to obtain and understand the health-related information needed to develop health-promoting behaviours.
The evidence shows that interventions to provide education can be effective, but this depends on the pre-existing attitude, knowledge and habit strength of the targeted group. Education should thus be accompanied by changes in the food environments to effect longer-lasting change.
In South Africa, the inclusion of nutrition is compulsory in the Life Orientation curriculum in schools.
The EduPlant programme is endorsed by the South African Department of Education. It supports the development of school gardens, where children learn to grow fruit and vegetables, eat some of the produce and sell the rest to raise funds. Schools receive support for two years until they can manage on their own.