CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 5, June 2012
AFRICA
249
of dietary consumption observed is likely to have been a major
contributor to the pattern of sub-optimal health outcomes (i.e.
premature mortality and recurrent morbid events) found in these
patients from Soweto with HF.
8
High salt intake, particularly in men, was a major problem
in this black urban patient group. This, related to a high
consumption of bread, processed and take-away foods and the
use of high-salt stock cubes and sauces, consistent with North
American findings where salt in bread and pre-prepared and
cereal foods contributed to around one-quarter of total salt
intake.
33
Possible barriers to adherence to a healthy, low-salt
diet in this black population were: lack of knowledge regarding
high-salt foods and healthy affordable alternatives, perceptions
that meals prepared without added salt were tasteless and boring,
and lack of support for dietary change from family members.
34
Although a salt restriction (2–3 g/day) is standard therapy
for HF,
35
black Sowetans with HF commonly consumed 5–7 g
per day.
36
This indicates the need for higher levels of dietetic
education to achieve sodium-restricted diets. At Chris Hani
Baragwanath Hospital, 10 registered dieticians currently provide
a nutritional service to 2 500 patients; clearly an inadequate ratio
of 1:250, instead of the more acceptable ratio of 1:50.
37
In contrast to the rural areas of South Africa where more
‘traditional’ food patterns still apply, in the urban areas
undergoing very rapid epidemiological transition, poor quality
‘Westernised’ diets are common.
26,38
The South African Dietary
Guideline (SADG) addresses these nutritional issues, although
compliance with recommendations is not readily achieved by
disadvantaged urban populations.
38
The SADG for example
recommend servings of ‘meat, fish, chicken or eggs’ should be
eaten daily as nutrient-rich sources of high-quality protein. As
selection of fatty meats and full-fat dairy foods can increase
cardiovascular disease risk, Scholtz and colleagues
39
suggest a
safe daily intake would comprise: 400–500 ml milk, two to three
servings of fish and four eggs, and no more than 560 g of meat
per week.
In this group of CHF patients, median intake is less than
half this amount, presumably as these foods are not affordable.
Nevertheless, the proportion of dietary protein was within
accepted levels (13%E), although the majority came from plant
rather than animal sources, with implications for micronutrient
intake. Calcium intake, particularly in women was inadequate.
Some more affordable sources of plant protein, notably legumes,
rich in many nutrients, were not selected in quantity, suggesting
lack of familiarity with preparing meals using these foods.
The total fat intake seen in this HF cohort was within
recommended levels (
<
30%E) but saturated fat intake was
excessive, particularly in men, and was related to choice of
poor-quality fatty meat, high-fat dairy foods, cakes and biscuits,
and take-away foods. This is consistent with the trend for higher
total fat and saturated fat consumption seen with urbanisation
throughout South Africa.
40
This patient group continued to eat
more traditional carbohydrate foods such as maize porridge, oats
and mabella, but also consumed highly refined carbohydrate
foods such as cakes, biscuits, cold drinks, sweets, chocolates
and added sugar, liable to increase triglycerides and to promote
Fig. 1. Proportion of men and women consuming more than the recommended daily intake of sodium or with less
than the daily recommended intake of selected micronutrients. Significant difference between men and women, *
p
<
0.01, **
p
<
0.001.
100
80
60
40
20
0
Vit D
Vit C
Vit E
Ca
Folate
Iron
Vit B6
Niacin
Sodium
Percent
Men
Women
90%
6%
87%
37%
67%
40%
66% 66%
57% 53%
125%
50%
108%
8%
113%
4%
470% 294%
Fig. 2. Percentage of men and women consuming the 10 foods contributing most to mean sodium intake in HF patients.
100
80
60
40
20
0
Salt added
to cooked
food
Processed
meat
Margarine Sauces &
condiments
Take-away
foods
Packet
soup
Bread Salted
snacks
Stock
cubes
Breakfast
cereal
Percent
Men
Women
