CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 4, July/August 2022 AFRICA 207 consumed as protein fell within the recommended range in these studies (between 10 and 35% of total energy), it was at the lower end of this range and as much as half of the protein consumed came from plant sources.91,92,94 Rural adults consumed a higher proportion of energy from carbohydrates and a lower proportion of energy from fat compared to their urban counterparts, with urbanisation being linked to higher total, saturated and monounsaturated fat intakes.91,92 In a study by Peer et al. (2018), which used cross-sectional data on semi-urban and urban adults from five of South Africa’s nine provinces, 47 to 55% of men and 38 to 48% of women regularly consumed high-fat foods, with more regular consumption in those between 45 and 54 years of age than those between 55 and 64 years of age.28 Steyn et al. (2016) also showed that, while the proportion of energy consumed as fat fell within the recommended range of 20 to 35% for urban adults from Cape Town, saturated fat intakes exceeded recommendations (> 7% total energy).91 Data from the PURE study assessed dietary intakes of urban adults according to alignment with the South African FoodBased Dietary Guidelines.90 The PURE data showed that higher intakes of dairy products, fruit and vegetables, legumes and fish, and lower intakes of meat and meat products (a dietary profile more aligned with the South African Food-Based Dietary Guidelines) was associated with lower energy, fat (saturated, mono-unsaturated and polyunsaturated fat) and sodium, but not fibre, carbohydrate and protein intakes.93 As demonstrated by Kolahdooz et al. (2013) and the CRIBSA study, national fortification of staple foods (maize and wheat flour) with key micronutrients (vitamin A, iron, zinc, folic acid, thiamine, riboflavin, niacin, and vitamin B6) since 2003 has contributed to adequate intakes of some, but not all of these vitamins and minerals.91,92 In a cross-sectional study of peri-urban middle-aged adults in KwaZulu-Natal, the most commonly consumed food items were identified as sugar, maize meal porridge, bread, tea, rice, hard margarine, legumes, cordial squash, non-dairy creamer and milk.96 Both this study and cross-sectional data on urban and rural adults from the Western Cape showed the variety and frequency of fruit and vegetable consumption to be low, with apples and bananas being the most commonly consumed fruit, and cabbage and mixed vegetables being the most commonly consumed vegetables.96,97 Data from Peer et al. (2018),28 as well as from the WHO-SAGE study,17 showed that between half and two-thirds of middle-aged adults consumed inadequate amounts of fruit and vegetables (less than five portions a day).27,28,39 Lower daily fruit and vegetable intakes were also associated with daily or weekly purchasing of sugar-sweetened beverages (SSBs) in one study of rural and urban adults from the Western Cape, with urban adults purchasing SSBs, snacks and sugar more commonly than those living at the rural site.97 In one study exploring seasonality in dietary intakes of women farm workers in the Western Cape, seasonal fluctuations in employment were associated with lower dietary diversity in the autumn and winter months, that is, the non-farming season.98 Salt consumption Using data collected from the food labels of packaged foods one year prior to implementation of salt regulations in 2016,91 research showed that approximately two-thirds of foods covered by the regulations were either below or meeting the upper limit of sodium content by the time the regulations were implemented100 Despite this, data collected from self-identified white, black and Indian South Africans prior to the implementation of the regulations demonstrated that 65% of adults consumed salt in excess of the WHO’s < 5 g/d recommendation101 In addition, findings from the WHO-SAGE study on salt-related knowledge and behaviour indicated that approximately 30% of South African middle-aged adults were not aware that high salt consumption could have an impact on their health, and 73% perceived the amount that they consumed to be ‘just the right amount’.109 In addition, discretionary salt intake was found to be high, with 79.9% of middle-aged adults adding salt to food during cooking either ‘often’ or ‘always’, and 32.9% regularly adding salt to their meals at the table.109 Peer et al. (2018) showed that in semi-urban and urban settings across South Africa, high intakes of salty foods were evident, with 41.8 to 54.7% of middle-aged men and 38.6 to 49.8% of women regularly consuming high-salt foods8 In addition, a higher percentage of those in the 45- to 54-year age group consumed high-salt foods than those in the 55- to 64-year age group.103 Data from WHO-SAGE has also shown that 91% of all adults fail to meet the daily dietary potassium requirements, and that dietary sodium-to-potassium molar ratios of > 2 are more strongly related to blood pressure as adults age than sodium intakes alone.104 This further emphasises the need for a greater focus on improving overall dietary patterns, rather than limiting research and interventions to single dietary components in isolation. As mentioned above, in 2003, national fortification of staple foods was introduced in South Africa to reduce the prevalence of micronutrient deficiencies at a population level.105,106 Since then, regulations aimed at minimising trans fatty acid intakes and reducing salt intakes were drafted and published in 2011 and 2013, respectively.101,107 The new regulations108,109 particularly focused on limiting the amount of trans fatty acids and salt in commercially prepared food products.30,110 In 2015, the Strategy for the Prevention and Control of Obesity in South Africa was introduced by the National Department of Health, with goals related to diet particularly focused on improving food environments (including ensuring availability and access to healthy food), as well as educating and mobilising communities and supporting obesity prevention in childhood.30 Sugar-sweetened beverage intake An SSB tax (the Health Promotion Levy or HPL) was implemented in 2018 at a rate of R0.021 per 1 g of sugar, over an initial tax-free threshold of 4 g/100 ml, in order to reduce the sugar content of SSBs and discourage consumer purchasing.103 In a recent longitudinal study, SSB and added sugar intakes of adolescents and adults (n = 617) living in Soweto, Johannesburg, were assessed before, at the time of, and one year after implementation of the HPL.111 Study findings showed that substantial reductions in SSB consumption occurred between 2017 (at the time the intention of an SSB tax was announced) and 2018 (at the time the SSB tax was implemented), particularly by those who consumed higher levels initially. These reduced intakes were maintained in the following year. This is
RkJQdWJsaXNoZXIy NDIzNzc=