Sodium content of processed foods
frequently consumed by children in
early childhood development centres in
the North-West Province
M Korff
orcid.org 0000-0002-1789-9927
Mini-dissertation submitted in partial fulfilment of the
requirements for the degree
Masters of Science in Nutrition
at
the Potchefstroom Campus of the North West University
Supervisor:
Dr Mariaan Wicks
Co Supervisor:
Dr Tertia Van Zyl
Co Supervisor:
Dr Bianca van der Westhuizen
Graduation May 2018
ACKNOWLEDGEMENTS
This Master’s dissertation would not have been possible without the following persons. Each one played such a HUGE part in the completion of this project. I appreciate all their support so much, and would like to give my sincere thanks to:
My supervisors, Dr Mariaan Wicks and Dr. Bianca van der Westhuizen, for all their support, especially the motivational talk at the end. I have personally learned so much from them. My co-supervisor, Dr Tertia Van Zyl for the privilege of working with her and the opportunity to learn from her.
The Centre for Excellence of Nutrition, for giving me the opportunity to do my Master’s project. I appreciate all the doors that have been opened for me!
The George Institute and Discovery Vitality, for making it financially possible to do this degree.
Cecile Cooke and Herman Myburgh for all their support and advice during my laboratory time frame. I have learned a lot from them.
My best friend as well as fellow-student, Claudine, special thanks for all the tears, jokes and just being there to talk to. Claudine, Are you up for Ph.D. next?
My little sister, Charlize, who, even though she didn’t always understand what I was talking about, played such a huge role in this degree with all her motivational pep talks. I love her to bits!
My parents, Tom and Ria, for being so supportive during this roller coaster ride of my life. I want to let them know that I love them with all my heart.
The love of my life, Cobus, for all his support and motivation and for always keeping me calm.
“I can do all things through Him who gives me strength”
ABSTRACT
Introduction: Childhood obesity is a major public health concern for South Africa (SA). Children who are obese often suffer from cardiovascular diseases such as high blood pressure, which can continue later in their lives. Evidence is emerging regarding the crucial role of sodium in regulating the blood pressure of children. While many factors contribute to childhood obesity and its related diseases, processed foods which are high in fat, sugar and/or sodium have been identified as a key contributing factor. The setting of the study was early childhood development centres (ECDs) situated in the Tlokwe municipality of SA.
Objectives: The aim of the study was to determine the true sodium content of processed foods frequently consumed by children aged two to five years and living in the Tlokwe municipality. Specific objectives included (i) identifying processed foods frequently consumed by children aged two to five years attending ECDs (ii) determining whether processed foods frequently consumed by children aged two to five years, with identified high sodium content, is included in the sodium regulation (R.214), (iii) determining the true sodium content of foods frequently consumed by children aged two to five years and lastly (iv) comparing the declared sodium value of the most frequently consumed processed food, against the true sodium value.
Methods: A list of ECDs were collected from the Department of Social Development (DSD) in North West Province. From this list, a random sample of 40 ECDs was selected. A non-probability sample of the parents were included in the study. Eight ECDs were specifically targeted to conduct 24-Hour Dietary Recall (24HDR) interviews with. The 32 remaining ECDs were targeted for the Unquantified Food Frequency Questionnaire (UFFQ) interviews. The data from the 24HDR were used to compile the UFFQ. This cross-sectional study used an UFFQ specifically developed to determine the processed foods frequently consumed by children aged two to five years in the Tlokwe region, SA.
Furthermore, the sodium content of the top 75th percentile of the most frequently consumed processed foods, contributing to sodium intake, was analysed by means of the atomic absorption spectrometry (AAS).
Results: In total, 15 processed food categories were identified as frequently consumed, three food products per food category were analysed by means of AAS sequential to microwave digestion to determine the true sodium content. The majority of the identified food products were included in the sodium regulation (R.214); only 13.33% were not included. The sodium measured in the different food categories varied from 4.1% to 40.7%, when comparing the nutrition information panel with the true sodium value. The findings provide valuable information
to support future studies on larger varieties of processed foods frequently consumed by children.
Conclusion: The valuable data collected here can support future studies on larger varieties of processed foods that children frequently consume, to establish whether the R.214 should be adjusted accordingly. Our findings showed however that the majority of the food product consumed by children is included in the regulation
OPSOMMING
Inleiding: Kinders vetsug is 'n groot openbare gesondheid probleem vir Suid-Afrika (SA). Kinders wat vetsugtig is, ly dikwels aan kardiovaskulêre siektes soos hoë bloeddruk, wat later in hul lewens kan voortduur. Bewyse neem toe oor die belangrike rol van natrium in die regulering van die bloeddruk in kinders. Alhoewel baie faktore bydra tot die vetsug van kinders en die verwante siektes, word geprosesseerde voedsel wat hoog is in vet, suiker en/of natrium, geïdentifiseer as 'n belangrike bydraende faktor.
Doelwitte: Die doel van die studie was om die ware natrium-inhoud van geprosesseerde voedsel te bepaal wat gereeld deur kinders tussen die ouderdom van twee en vyf jaar geëet word wat in die Tlokwe-munisipaliteit woon. Spesifieke doelwitte sluit in: (i) die identifisering van geprosesseerde voedsel wat gereeld verbruik word deur kinders tussen die ouderdomme van twee tot vyf jaar wat vroeë kinderontwikkelingsentrums bywoon; (ii) bepaal of geprosesseerde voedsel wat gereeld verbruik word deur kinders tussen twee en vyf jaar, met geïdentifiseerde hoë natriuminhoud, in die natriumregulasie (R.214) ingesluit word, (iii) die bepaling van die ware natriuminhoud van voedsel wat gereeld deur kinders tussen twee en vyf jaar geëet is en laastens (iv) die verklaarde natriumwaarde van die mees gereelde verbruikte voedsel, teen die ware natriumwaarde, te vergelyk.
Metodes: 'n Lys van vroeë kinderontwikkelingsentrums is by die Departement van Maatskaplike Ontwikkeling (DSD) in die Noordwes Provinsie ingesamel. Uit hierdie lys is 'n ewekansige steekproef van 40 vroeë kinderontwikkelingsentrums gekies. 'n Nie-waarskynlikheidsmonster van die ouers is in die studie ingesluit. Agt vroeë kinderontwikkelingsentrums is geïdentifiseer om 24-uur dieet herroep (24HDR) onderhoude mee te voer. Die 32 oorblywende vroeë kinderontwikkelingsentrums was geteiken vir die Ongekwantifiseerde Voedselfrekwensvraelys (UFFQ) onderhoude. Die data van die 24HDR is gebruik om die UFFQ op te stel. Hierdie dwarsdeursnit studie het 'n UFFQ gebruik om die geprosesseerde voedsel wat gereeld geëet word deur kinders tussen twee en vyf jaar in die Tlokwe-streek, SA, te bepaal.
Daaropvolgend is die natriuminhoud van die boonste 75ste persentiel van die mees gereelde verbruikte geprosesseerde voedsel, wat bydra tot natriuminname, deur die atoomabsorpsiespektrometrie (AAS) geanaliseer.
Resultate: In totaal is 15 verwerkte voedselkategorieë geïdentifiseer as gereeld verbruik, drie voedselprodukte per voedselkategorie is geanaliseer met behulp van AAS in samewerking met mikrogolfvertering om die ware natriuminhoud te bepaal. Die meerderheid van die geïdentifiseerde voedselprodukte is ingesluit in die natriumregulasie (R.214); slegs 13.33% is nie ingesluit nie. Die natrium wat in die verskillende voedselkategorieë gemeet is, het gewissel van 4.1% tot 40.7%, wanneer die voedingsinligtingspaneel met die ware natriumwaarde
vergelyk word. Die bevindinge verskaf waardevolle inligting om toekomstige studies te ondersteun oor groter rasse van geprosesseerde voedsel wat gereeld deur kinders verbruik word.
Gevolgtrekking: Die waardevolle data wat hier ingesamel word, kan toekomstige studies ondersteun om ʼn weier verskeidenheid geprosesseerde voedsel produkte wat kinders gereeld verbruik, te toets om vas te stel of die R.214 natrium regulasie aangepas moet word. Ons bevindings het egter getoon dat die meerderheid van die voedselproduk wat deur kinders verbruik word, reeds in die regulasie ingesluit word.
LIST OF DEFINTIONS
Nutrition transition: Populations have adopted modern lifestyles as a result of economic and social development, urbanisation and acculturation, which have led to changes in dietary patterns and nutrient intakes (Popkin, 2002; Vorster, 2002; Vorster et al., 2011).
HFSS foods: Foods high in fat, sugar and/or salt (WHO, 2015).
Sodium regulation (R.214): Limits the sodium content in certain food products, in order to reduce the sodium consumption of the South African population (R.214:March 2013, 2013). Frequently consumed foods: Will be classified as foods consumed three to five times per week or more, or by 5% of the population (Brekke et al., 2007).
Electronic Unquantified Food Frequency Questionnaire: The participants can complete the questionnaire electronically, food quantities consumed are not required only the frequency over a seven day period (one week).
24 Hour Dietary recall: It is a structured interview which has been designed to capture detailed information on what the participant consumed (foods and beverages) in the past 24 hours (Thompson & Byers, 1994).
Urbanisation: Populations have adopted a diet that is high in fat and saturated fat, added sugar and sodium, while there is a decrease in fibre intake (Vorster, 2002).
Obesogenic environments: Environments that are created by advertising and promoting unhealthy foods and beverages (Moodley et al., 2015).
Ultra-processed foods: Addition of salt, preservatives and other additives (e.g. flavourings, colourants) to food products (Monteiro et al., 2010).
Hypertension: Increased blood pressure that leads to increase cardiovascular diseases and mortality rates (Falkner, 2010).
LIST OF ABBREVIATIONS
24HDR 24 Hour Dietary Recall
AAS Atomic Absorption Spectrometry
BP Blood Pressure
CVD Cardiovascular Diseases CV Coefficient of variance
DALYs Disability-Adjusted Life Years DSD Department of Social Development ECDs Early childhood development centres GBD Global Burden of Disease
GDP Gross Domestic Product
HFSS foods High Fat, Sugar and/or Salt foods HREC Health Research Ethics Committee ICP Inductively Coupled Plasma
MSc Master of Science
Na Sodium
NCDs Non-Communicable Diseases NFCS National Food Consumption Survey
NIST National Institute of Standards and Technology R.214 Sodium reduction regulation
RSD Relative Standard Deviation
SADoH South African Department of Health SAMRC South African Medical Research Council
SANHANES South African National Health and Nutrition Examination SAPFBDG South African Paediatric Food-Based Dietary Guidelines UFFQ Unquantified Food Frequency Questionnaire
TABLE OF CONTENTS
1.1 General introduction ... 1
1.1.1 Obesity and non-communicable disease: A global and national problem ... 1
1.1.2 Changing food environment ... 2
1.1.3 The role of sodium in the development of high blood pressure ... 2
1.1.4 NCD and obesity prevention strategies ... 3
1.2 Rationale for this study ... 3
1.3 Research aim ... 4
1.4 Research objectives ... 4
1.5 Ethics ... 5
1.6 Financial Support ... 5
1.7 Contributions of members of the research team... 6
1.8 Structure of the mini-dissertation ... 6
2.1 Global perspective of childhood obesity and non-communicable disease ... 8
2.2 National perspective of childhood obesity and NCD ... 9
2.2.1 Obesity, sodium and cardiovascular disease ... 9
2.3 Obesity in urban areas ... 11
2.4 Rise in childhood NCDs ... 11
2.5 Characteristics of high blood pressure ... 12
2.6 Contributing factor to the childhood obesity and NCDs ... 13
2.8 The contribution of processed foods in obesogenic environments ... 14
2.9 Foods high in fat, sugar and salt ... 16
2.10 Food choices ... 16
2.10.1 Food preference development ... 16
2.11 The role of sodium in the body ... 17
2.12 Sodium consumption and development of high blood pressure ... 17
2.13 The measurement of sodium in processed foods ... 18
2.14 Obesity and NCD prevention strategy ... 20
2.15 Conclusion ... 22
4.1 Overall discussion ... 53
4.2 Strengths and limitations of the study ... 53
4.2.1 Strengths ... 53
4.2.2 Limitations ... 54
4.3 Results ... 55
4.4 Recommendations for future research ... 55
LIST OF TABLES
Table 1-1: Food categories included in the sodium regulation (R.214) ... 3 Table 2-1: The different groups of processed foods, adapted from da Costa
Louzada et al. (2015) ... 15 Table 2-2: Sampling method of different food matrices ... 19 Table 2-3: The suggested paediatric FBDGs for children 12 - 36 months and 3 - 5
LIST OF FIGURES
Figure 2-1: The ranking of different contributors to DALYS in South Africa (Adapted from the Strategy for the prevention control of obesity in South Africa
2015-2020) ... 10 Figure 2-2: Comparison of changes in risk factors of death for all South Africans
CHAPTER 1: GENERAL INTRODUCTION
“Be strong and courageous. The Lord your God will be with you wherever you go”
Joshua 1:9
This chapter provides background information on the study, highlights the importance of this study, states the aim and objectives as well as the structure of the mini-dissertation and sets out the role of each member of the research team.
1.1 General introduction
1.1.1 Obesity and non-communicable disease: A global and national problem
The progressive increase in overweight and obesity in both adults and children is a public health concern in South Africa (Mchiza & Maunder, 2013; Van Niekerk et al., 2014). Overweight and obesity significantly increase the risk of developing non-communicable diseases (NCDs) such as hypertension, diabetes and various forms of cancers (National Heart Lung and Blood Institute., 2012; Prospective Studies Collaboration, 2009).
The highest NCD-related mortality levels, roughly about 80% of total deaths, appear to be in low- and middle-income countries (LMICS) (World Health Organisation (WHO), 2012). Aside from adult obesity, childhood obesity has rapidly increased and is a major cause for concern, especially in those low- and middle-income countries undergoing urbanisation (Fitch et al., 2013). Approximately 41 million children worldwide under the age of 5 years have been classified as overweight and obese (Unitated Nations Children's Funds (UNICEF), 2015). In South Africa, the most recent data report that the number of overweight children between the ages of 2 and 5 years has increased from 10.6% (Labadarios et al., 2007) to 18.1% (Shisana et al., 2013) in the last decade. Research has shown that childhood obesity increases the risk of developing a number of NCDs and that childhood obesity carries over into adult life, also increasing the risk of developing NCDs later in life (Park et al., 2013). Furthermore, obesity together with hypertension appears to increase the risk of cardiovascular disease proceed throughout life (Feber and Ahmed, 2010). One of the major contributors to the increasing childhood obesity rates and obesity-related NCDs is the changing food environment (Swinburn et al., 2011). Therefore, urgent measures must be put in place to address the effect of NCDs on mortality and the burden of disease (Shisana
1.1.2 Changing food environment
Populations have adopted modern lifestyles as a result of economic and social development, urbanisation and acculturation, which have led to changes in dietary patterns and nutrient intakes; these changes in dietary patterns are defined as nutrition transition (Popkin, 2002; Vorster, 2002; Vorster et al., 2011). The accessibility and availability of high fat, sugar and/or salt (sodium) (HFSS) foods have contributed to the obesogenic environment currently observed, affecting not only adults but children as well.
Because of financial constraints and the shift in dietary patterns, the diets of a majority of consumers consist largely of affordable, highly processed foods and drinks (Naidoo, 2013). Food companies generally manipulate certain ingredients, specifically fat, salt and sugar, to improve the taste of these foods (Monteiro et al., 2013; Roberto et al., 2015); therefore, processed foods are usually HFSS foods. For the purpose of this research project, special attention will be given to the changes in the salt or sodium content of processed foods in this ever-changing food environment.
1.1.3 The role of sodium in the development of high blood pressure
A meta-analysis of controlled trials has shown that the sodium intake of children influences the risk of developing hypertension in adulthood (He & MacGregor, 2006).
In children, high blood pressure (BP) is characterised by systolic and/or diastolic BP above the 95th percentile for age, gender and height; pre-hypertension is characterised by systolic and/or diastolic BP above the 90th percentile but below the 95th percentile (Falkner, 2010; Ingelfinger, 2014).
Sodium is an essential element that maintains the plasma volume, acid-base balance and cell function normality (WHO, 2012) and is required only in small quantities. Studies indicate that there is a direct link between increased sodium consumption and high BP (He & MacGregor, 2007; He & MacGregor, 2009). He and MacGregor (2006) have reported that children who consume a low sodium diet present with lower BP. To our knowledge, there is little information in the literature regarding the sodium consumption of children.
In South Africa, 41% of the low-income adult population is hypertensive (Schutte et al., 2017). Because of the increased prevalence of high BP amongst South African adults, various prevention strategies and regulations have been put in place by the South African government to combat this burden of disease. It is not known, however, whether these strategies and regulations will also protect the children of this country against high BP.
1.1.4 NCD and obesity prevention strategies
In South Africa, the double burden of under- and over-nutrition is observed in young children (Vorster et al., 2013). Early dietary interventions and the promotion of healthy dietary patterns are of great importance during childhood. For these reasons, the South African Food-Based Dietary Guidelines (SAFBDGs) (Vorster et al., 2013), which have a specific guideline for sodium, The Strategy for the Prevention and Control of Obesity in South Africa
2015-2020 (Department of Health, 2015) and the sodium regulation (R.214) (Act 54 of
1972), which limits sodium content in certain food products, were developed. These strategies were put in place to reduce obesity and NCDs of the South African population, including adults and, possibly, children. The targeted categories included in the sodium (R.214) regulation are explained in Table 1-1.
Table 1-1: Food categories included in the sodium regulation (R.214)
Food category 2016 target
(Na/100mg)
2019 target (Na/100mg)
Bread 400 380
All breakfast cereals 500 400
All fat and butter spreads 550 450
Savoury snacks, excluding salt-and-vinegar flavoured 800 700 Flavoured potato crisp, excluding salt-and-vinegar 650 550 Flavoured ready-to-eat savoury snack and potato crisp,
salt-and-vinegar only
1000 850
Processed meat – uncured 1300 1150
Processed meat – cured 850 650
Raw processed meat sausages 800 600
Dry soup powder (not instant type) 5500 3500
Dry gravy powders and dry instant savoury sauces 3500 1500 Dry savoury powders with dry instant noodles to be mixed with a
liquid
1500 800
Stock cubes/ powder/ granules/ emulsions/ pastes /jellies 18000 13000 Na: sodium
1.2 Rationale for this study
One of the major risk factors for the development of cardiovascular diseases (CVD) is hypertension (Lloyd-Sherlock et al., 2014). With hypertension levels continuing to rise, it is
considered a global public health concern. In the past, NCDs were observed only in adults, but are now commonly observed in children (Beaglehole et al., 2013; Daniels, 2006).
The evidence is mounting regarding the crucial role sodium plays in the regulation of BP in children (O'Halloran et al., 2016). There is a significant association between childhood and adulthood BP (Reilly & Kelly, 2011; Riedel et al., 2014; Williams & Goulding, 2009). The increased accessibility and availability of processed foods in South Africa can strengthen the risk of hypertension as these foods can generally be classified as HFSS foods (Feeley & Norris, 2014). South Africa has a mandatory sodium reduction regulation (R.214) which focuses on the lowering of the true sodium content in certain processed foods.
Literature regarding the processed food consumption of South African children aged two to five years is limited, while information on the sodium content of the processed foods frequently consumed by children is also scarce. Moreover, it is unclear whether the sodium reduction regulation (R.214) includes the foods frequently consumed by children. This study will, therefore, identify the processed foods frequently consumed by children aged two to five years, focusing specifically on the sodium content of these frequently consumed foods and the inclusion of these foods in the sodium reduction regulation (R.214).
1.3 Research aim
The primary aim of the current study is to determine the true sodium content of processed foods frequently consumed by children aged two to five years living in the Tlokwe municipality, South Africa, by means of atomic absorption spectrometry (AAS) analysis. 1.4 Research objectives
To identify processed foods frequently consumed by children aged two to five years attending early childhood development centres in the Tlokwe municipality using an Unquantified Food Frequency Questionnaire (UFFQ).
To determine whether processed foods with identified high sodium content, frequently consumed by children aged two to five years, are included in the sodium regulation (R.214).
To determine the true sodium content of foods frequently consumed by children aged two to five years, using AAS analysis.
To examine the declared sodium value of the most frequently consumed processed foods that are included in the sodium regulation (R.214) against the true sodium value determined by AAS.
1.5 Ethics
The projects in the mini-dissertation obtained ethical approval from the Health Research Ethics Committee (HREC) of the North-West University, South Africa, with the following reference number: NWU-00033-17-A1-02. All the studies that are included followed the guidelines of the Declaration of Helsinki. Written informed consent was obtained from each participant before commencing with the research. The dietary data collection forms part of the larger study and sub-study one. Sub-study one titled “The healthiness of processed foods frequently consumed by children in early childhood development centres in the North West Province” will also focus on the overall “healthiness” of the processed foods frequently consumed. The sodium analyses of the processed foods frequently consumed forms part of the current study (sub-study two).
1.6 Financial Support
The study itself was funded by the South African medical research council (SAMRC). The funders had no role in the design, analysis or writing of the article.
The post-graduate student was supported by Discovery Vitality and The George Institute for Global Health. Any opinions, findings, conclusions and/or recommendations in the mini-dissertation are those of the authors, and Discovery Vitality therefore does not accept any liability in this regard.
1.7 Contributions of members of the research team
Affiliation Name Qualification Relevant Expertise Role in study
North-West University
Dr Mariaan Wicks
PhD Dietetics Expert in dietary analysis with a vested interest in children. Experience in nutrient profiling Supervisor of MSc student and co-principal investigator of the larger study. Monitoring of study. North-West University Dr Tertia van Zyl PhD Dietetics Experience in dietary assessment methodology, (24HDR, FFQ), nutrient profiling, dietary patterns. Co-supervisor of MSc student and principal investigator of the larger study. Monitoring of study. North-West University Dr Bianca van der Westhuizen
PhD Nutrition Expert in sodium food analysis with vested interest in sodium consumption in children. Measuring and preparing food samples to determine sodium content in different food matrices. Co-supervisor of MSc student.
Supervising the AAS analyses (sodium analyses) North-West University Ms Nadia Theron
BSc Nutrition Full time MSc student
Recruitment of
participants, conducting 24 HDR; developing the UFFQ and conducting the UFFQ, compiling a list and analysis of frequently consumed packaged food North-West University Ms Marlise Korff
BSc Nutrition Full time MSc student
Recruitment of
participants, conducting 24 HDR and UFFQ, AAS analyses (sodium analyses) North-West University Mrs Marike Cockeran
Biostatistician Statistics and data analysis
Statistics and data analysis
1.8 Structure of the mini-dissertation
This mini-dissertation is divided into five chapters. Chapter 3 is presented in article format and the referencing of this chapter is done according to the guidelines of the respective journals, which are attached as an addendum.
Chapter 1: Provides background information on the study, highlights the importance of this study, and states the aim and objectives as well as the structure of the mini-dissertation and sets out the role of each member of the research team.
Chapter 2: Explores the relevant and available literature on the sodium content of processed foods children frequently consume, including topics such as global perspectives of childhood obesity and NCDs, national perspectives of childhood obesity and NCDs, contributing factors to the childhood obesity and NCD epidemic, food choices, the measurement of sodium in processed foods, obesity and NCD prevention strategy.
Chapter 3: Consists of the manuscript titled “Sodium content of processed foods frequently consumed by children in early childhood development centres in the North West province of South Africa” and written according to the guidelines of the Public Health Nutrition Journal.
Chapter 4: Summarises the findings of the study, the difficulties faced, as well as recommendations for future studies.
Chapter 5: Bibliography of Chapters 1, 2 and 4. Chapter 3 references are included as part of the chapter.
CHAPTER 2: LITERATURE REVIEW
“Cast your cares on the Lord and He will sustain you” Psalm 55:22
This chapter explores the relevant and available literature on the sodium content of processed foods children frequently consume. Topics include: global perspectives of childhood obesity and NCDs, national perspectives of childhood obesity and NCDs, contributing factors to the childhood obesity and the NCD epidemic, food choices, the measurement of sodium in processed foods and obesity and NCD prevention strategies. 2.1 Global perspective of childhood obesity and non-communicable disease
The prevalence of childhood obesity globally has increased rapidly over the past four decades, especially in low- and middle-income countries (Lobstein et al., 2015). Malnutrition problems include concerns about the increasing prevalence of overweight and obesity in children (Steyn et al., 2016). Childhood obesity has increased rapidly and is a major cause of concern, especially in those low- and middle-income countries undergoing urbanisation (Fitch et al., 2013). In 2013 there were already 43 million children under the age of 5 years worldwide classified as overweight and obese (De Onis et al., 2010). The risk for various NCDs namely hypertension, diabetes, coronary heart disease are significantly increased by overweight and obesity (National Heart Lung and Blood Institute, 2012; Prospective Studies Collaboration, 2009)
Hypertension is a major long-term health effect as well as one of the leading causes of premature death amongst adults; it is also classified as a NCD (Chobanian et al., 2003). Globally, one of the foremost preventable risk factors for deaths in adults is high BP or hypertension, with roughly 13% of deaths worldwide caused by this disease (WHO, 2009). Hypertension rates increased from approximately 594 million in 1975 to 1.13 billion in 2005, of which 597 million were men and 529 million were women (NCD Risk Factor Collaboration, 2017). High BP is more commonly observed in children and adolescents as well (Falkner, 2010; Falkner et al., 2004), especially in children who are overweight or obese (Kaelber & Pickett, 2009; Ramos & Barros, 2005; Salvadori et al., 2008). This high BP can be coupled with a family history of hypertension, obesity and other lifestyle factors (Falkner, 2010). Owing to the high prevalence of childhood obesity, the prevalence of high BP in children is bound to increase (Chockalingam et al., 2006; Falkner, 2010; Flynn, 2013; Lo et al., 2013). Hansen et al. (2007) reported that the prevalence of high BP in children aged 3-18 years in
northeast Ohio was 3.6%, while 3.4% were pre-hypertensive. When looking at the rates of hypertension among children and adolescents in the USA (>3%), as well as asymptomatic rates (>3%), it is quite clear that high BP in childhood must be treated as a long-term health problem (Falkner, 2010).
2.2 National perspective of childhood obesity and NCD
2.2.1 Obesity, sodium and cardiovascular disease
In South Africa, unfortunately, the progressive increase in overweight and obesity in both adults and children is also one of the major public health concerns (Mchiza & Maunder, 2013; Van Niekerk et al., 2014). Even though overweight and obesity rates are increasing in countries with varied income and educational levels, the absolute rates remain higher in countries with low income and low educational levels (Mitchell et al., 2011). This suggests that the gap between socioeconomic levels is getting smaller (SADoH, 2015). Low- and middle-income countries appeared to have the highest NCD-related mortality levels: roughly about 80% (WHO, 2012). It has been suggested that the incidence of hypertension is higher in LMICs than in high-income countries (Lloyd-Sherlock et al., 2014).
In South Africa, the childhood obesity rates are, unfortunately, quite similar to those of other developing countries. International and regional comparisons of childhood obesity rates have indicated that South Africa has a major problem with obesity in pre-school aged girls and boys (Shisana et al., 2013). The 2013 South African National Health and Nutrition Examination Survey (SANHANES) indicated that the overweight rates in both girls and boys in the age group of 2 to 5 years have increased from 10.6% (Labadarios, 2007) to 18.1% (Shisana et al., 2013). Nationally, there are 17.5% and 18.9% boys and girls aged 2 to 5 years, respectively, classified as overweight (Shisana et al., 2013). In many developing countries, the prevalence of underweight in children has remained constant, while in South Africa the prevalence of overweight and obesity has increased (Popkin, 2001; De Klerk et
al., 2004; Gonzalez-Suarez et al., 2009; Motlagh et al., 2011; Van Niekerk et al., 2014). The
SANHANES report also indicated that 39.2% of women and 10% of men were classified as obese (Shisana et al., 2013). The absolute obesity rates remain highest in women from urban areas (42%) (Shisana et al., 2013). These results possibly suggest that childhood obesity is carried over into adulthood.
In South Africa, obesity is also a major contributing factor to years lost due to ill-health, or disability-adjusted life years (DALYS) (Norman et al., 2007). The different contributors to DALYS are outlined in Figure 2-1 and, as can be seen, obesity is ranked fifth (2.90%) and
hypertension eighth (2.40%), which indicates that these two components are contributors to early death in South Africa.
Figure 2-1: The ranking of different contributors to DALYS in South Africa (Adapted from the Strategy for the prevention control of obesity in South Africa 2015-2020)
The estimated prevalence of hypertensive adults in South Africa is between 14% and 33% (Crowther & Norris, 2012; Mayosi et al., 2009). An individual that is classified as hypertensive usually lacks the appropriate systematic vascular resistance that can bring BP back to normal when plasma volume and cardiac output increase (Bloch, 2016) and, in South Africa, this is one of the leading causes of death (Nojilana et al., 2016).
Sodium is an essential element that maintains plasma volume, acid-base balance and normality in cell function; it also assists in carrying nerve impulses (WHO, 2012). Sodium is, however, required only in small quantities in the human body (Wentzel-Viljoen et al., 2013). As regards salt intake, the WHO recommend a sodium intake of 2g/day (5g of salt) for adults, which is exceeded worldwide (Brown et al., 2009; WHO, 2012). Adults in South Africa consume an average of 3.072g sodium (7.8g salt) daily (Swanepoel et al., 2016), indicating that the sodium intake in South Africa is high. Thirty percent of South Africa’s population consume 4g sodium (10g salt), which is double the daily sodium recommendation (Swanepoel et al., 2016). Increased sodium intake has a direct effect on increased BP (He & MacGregor, 2007; He & MacGregor, 2009). The increase in hypertension in South Africa
and the associated risk of a high sodium diet motivated the SADoH to implement a salt reduction strategy from 2013 to June 2016. This strategy includes a sodium reduction regulation (R.214) which regulates the sodium content in certain processed foods and their related products (R.214:March 2013, 2013).
2.3 Obesity in urban areas
The increasing rates of childhood obesity are causing concern, especially in countries undergoing urbanisation (Fitch et al., 2013). The prevalence of the double burden of under- and over-nutrition is increasing in children (Vorster et al., 2013). High obesity prevalence tends to occur first in groups of high socio-economic status in the urban areas of low- and middle-income countries (Abubakari et al., 2008; Swinburn, 2011). In South Africa, the population’s diet has shifted from a traditional diet to a more westernised diet (which is high in fat, sugar and/or salt), which leads to a higher prevalence of obesity in the urban population (Bourne et al., 2002). Furthermore, a study conducted by Peer et al. (2016) confirmed the findings that increased urbanisation rates in the African population in South Africa have a great influence on the increasing obesity rates in the population. As a result of rapid acculturation and urbanisation, children are now raised in an environment that encourages weight gain (Swinburn, 2011). Sales of processed food products also seem to increase with urbanisation and the rate of sales is rapidly growing in lower-income countries (Popkin, 2016). The rapid raise of obesity rates in children also increase the risk of developing NCDs as a child and/or even later in life (Park et al., 2013).
2.4 Rise in childhood NCDs
People of all ages, including children, are affected by NCDs and their risk factors (Shisana et
al., 2013). What is more, childhood obesity is a strong predictor of adult obesity (Kelsey et al., 2014), which increases the risk of developing obesity-related NCDs even further. There
are four key NCDs strongly linked with children, namely CVD, cancer, chronic respiratory disease and diabetes (Shisana et al., 2013). Increasing body weight is also strongly associated with the development of NCDs (Raymond et al., 2006). This is one of the reasons why the increasing rates of childhood overweight and obesity are of such great concern. Additionally, it is very important to note that these NCD risk factors that develop in childhood proceed throughout life (SADoH, 2015). Childhood BP has an association with adulthood BP, suggesting that children with high BP are at high risk of developing hypertension and related risk factors later in life (Chen & Wang, 2008; WHO, 2012).
2.5 Characteristics of high blood pressure
In South Africa, hypertension contributes particularly to mortality amongst older black women, with a prevalence of 78% (Lloyd-Sherlock et al., 2014). From 1998 to 2008 there has been a significant increase in hypertension, which can in turn lead to increases in strokes and heart attacks (Bradshaw et al., 2011). Worldwide assessments in 2015 by the Global Burden of Disease (GBD) indicated that, from 2005 to 2015, ischaemic heart disease remained second on the list (Figure 2-2). This result indicates that in the past decade not much has been done to lower this risk factor.
Figure 2-2: Comparison of changes in risk factors of death for all South Africans (Adapted from GBD, 2015)
Among adults, hypertension is usually characterised by a diastolic pressure higher than 140 mmHg and a systolic pressure higher than 90 mmHg (Norman et al., 2007). In children, high BP is characterised by systolic and/or diastolic BP above the 95th percentile for age, gender and height; pre-hypertension is characterised by systolic and/or diastolic BP above the 90th percentile but still below the 95th percentile (Falkner, 2010; Ingelfinger, 2014).
Two studies that analysed childhood BP trends (Din-Dzietham et al., 2007; Munter et al., 2004) indicated that childhood BP prevalence is increasing. Various studies also found that the BP prevalence is higher in the group that has high rates of childhood obesity (Kaelber & Pickett, 2009; Munter et al., 2004; Ramos & Barros, 2005; Salvadori et al., 2008). As already mentioned, the increased childhood obesity rates are associated mainly with the changing food environment (Swinburn et al., 2011). Children’s food environments have changed substantially during the last decades as the affordability, palatability and supply of
HFSS foods have increased extensively, leading to increased obesity rates and its related risk factors in young children.
2.6 Contributing factor to the childhood obesity and NCDs
One of the major identified drivers of overconsumption of energy-dense (HFSS) foods (Steyn
et al., 2016) and nutrient-poor foods and beverages is the globalisation of food systems
(Swinburn et al., 2011). Populations have adopted modern lifestyles as result of economic and social development, urbanisation and acculturation, which have led to changes in dietary patterns and nutrient intakes; this situation can be defined as the nutrition transition (Popkin, 2002; Vorster, 2002; Vorster et al., 2011). These transitions have been happening at a rapid pace over the past decades, and for this reason, the double burden of disease is experienced by numerous countries (Swinburn et al., 2011). Nutrition transition has led to increasing levels of overweight, obesity and related diseases in South Africa (Naidoo, 2013). This transition has also indirectly led to an increase in sodium consumption (WHO, 2012), which is in turn associated with increases in NCDs (Vorster, 2002). Popkin and Gordon-Larsen (2004) have emphasised that in developing countries transitioning is happening rapidly and at earlier stages of economic and social development.
Primarily, obesity affects the middle-aged population (with a majority of women) in low-income countries while affecting the whole population in high-low-income countries (Swinburn et
al., 2011). This leads to a shifting of patterns of obesity (Popkin & Gordon-Larsen, 2004)
and other NCDs to the poor (Vorster et al., 2011). The increasing gross domestic product (GDP) is responsible for the economic transition as well as various other transitions, such as demographic, health, technological and nutritional transitions (Popkin, 1998). For low-income countries, economic growth is extremely important for development, whereas for high-income countries, the rising GDP does not increase quality of life, it only increases the consumption of products (Swinburn, 2011).
The main problem with the changing food environment is that schoolchildren, both at junior and high school level, spend the majority of their day away from home (Neinstein & Kaufman,2002; Wenhold et al., 2015), consequently increasing nutritional vulnerability (Steyn et al., 2016). Children of this age group are known for the poor food choices they make (Steyn et al., 2016). The majority of schools in South Africa have tuck shops that are located on school grounds; these shops are more likely to sell food products that are energy-dense (HFSS foods) and low in micronutrients (de Villiers et al., 2012). Various studies (Labadarios et al., 2005; Steyn et al., 2006a; Steyn et al., 2006b; Steyn et al., 2008a; Steyn
mostly of carbohydrate-rich foods and are low in fruit and vegetable intake. These results could be due to urbanisation and increased incomes (Naidoo, 2013), which can be a risk factor for increasing obesity rates (Steyn et al., 2016).
2.7 The role of urbanisation as obesogenic environment
Along with urbanisation, populations have adopted a diet that is high in fat and saturated fat, added sugar and sodium, while there is a decrease in fibre intake (Vorster, 2002). Most populations have shifted from a traditional diet that contains complex carbohydrates, fibre, whole grains, vegetables and fruit to a western diet that contains high portions of fat, salt and added sugar (Drewnowski, 2000; Drewnowski & Popkin, 1997). This occurs because populations have become more urban and are generating more money (Drewnowski, 2000; Drewnowski & Popkin, 1997). This rapid and uncontrolled urbanisation and its associated risk factors can be considered one of the leading contributors to the increasing obesity epidemic (Minos, 2016). In developing countries, food that is high in fat is usually cheaper (Cutler et al., 2003; Naidoo, 2013) than healthy foods (Minos, 2016). This can lead to the assumption that dietary habits are formed according to the availability of certain food products (Minos, 2016).
The greater accessibility and availability of food high in fat, salt and added sugar has led to an obesogenic environment. Obesogenic environments can be defined as environments that are created by the advertising and promoting of unhealthy foods and beverages. These advertisements are usually accompanied by the absence of the promotion of healthy foods and lifestyles (Day & Pearce, 2011; Lesser et al., 2013; Moodley et al., 2015). Therefore, increased income and discretionary spending, coupled with the increased marketing, advertising and availability of high-energy processed foods and beverages, play a crucial role in the obesity trend (Moodley et al., 2015; Shisana et al., 2013).
2.8 The contribution of processed foods in obesogenic environments
Specifically in middle-income countries, sales of processed, convenience and pre-prepared foods have increased along with obesity rates (Monteiro et al., 2013). The increasing purchase of processed foods by households is linked with the increasing obesity trends (Canella et al., 2014; da Costa Louzada et al., 2015), because households are replacing their traditional dietary patterns (meals prepared with minimally processed or unprocessed foods) with meals that contain more highly processed foods. For this reason, the food choices of the population are high in energy, unhealthy fats, sugar and/or salts, and low in dietary fibre (Canella et al., 2014; Da Costa Louzada et al., 2015). Furthermore, the World
Health Organisation (WHO) indicates that processed food consumption is associated with the development of NCDs (WHO, 2005).
Certain types of processing are essential, beneficial or harmless whereas other types can have a negative impact on health and well-being (Monteiro et al., 2010). Food processing is an important part of human evolution and is used to increase the durability and acceptability of certain foodstuffs (Monteiro et al., 2010). Because of financial constraints faced by consumers, diets consist largely of affordable, highly processed foods and drinks (Naidoo, 2013). Industries manufacture ultra-processed foods, also known as ready-to-eat products, by using substances derived from foods or synthesised from other organic sources (Monteiro
et al., 2010). The manner in which these foods are processed makes it difficult for the body
to regulate intake (Roberto et al., 2015). Most of the time, food companies manipulate certain ingredients namely, fat, salt and sugar, to increase the taste of the food (Roberto et
al., 2015) with the result that processed foods are highly appetising (Roberto et al., 2015).
Protein and fibre, the two components that are mainly responsible for slow absorption into the bloodstream, are not present in much ultra-processed food (Roberto et al., 2015). In table 2-1, the different types of food processing are described, the method of processing is stated and examples of foods subjected to each type of food processing are also given. Table 2-1: The different groups of processed foods, adapted from da Costa Louzada et al. (2015) Explanation Method of processing Examples of foods Group 1: Minimally processed foods
Whole foods submitted to some process but the nutritional properties are unaltered. Cleaning, removing inedible fractions, portioning, refrigeration and freezing.
Fresh meat and milk, grains, legumes, nuts fruits, vegetables, roots and tubers Group 2: Substances extracted from whole foods Ingredients used in domestic preparation and cooking are made up mainly from
fresh/minimally processed foods.
Extraction Oils, fats, flours, pastas, starches and sugar
Group 3: Ultra-processed foods
Usually made up from a group of substances to which none or small amounts of the foods of the group are added.
Addition of salt, preservatives and other additives (e.g. flavourings, colourants) Bread, cookies, chocolates, breakfast cereals, cereal bars, chips, savoury and sweet snacks, sugared, soft drinks; nuggets, meat patties sausages made from processed of meat
Like many other sources, the WHO define processed foods as products high in fat, sugar and/or salt (WHO, 2015), and these will be investigated in more detail in the following paragraph.
2.9 Foods high in fat, sugar and salt
Mayosi et al. (2009) reported that in South Africa, among the black population residing in urban areas, an increase in dietary fat intake from 16.4% to 26.6% from 1994 to 2008 has been observed. The largest change in food consumption was observed in the food group’s sugar-sweetened beverages, sauces, dressings and condiments, sweet and savoury snacks, meats, fats and oils. Convenience, health and nutrition, as well as indulgence, were the main drivers of the increase in consumption of processed foods and beverages; these changes in food consumption are worrying as they relate to increased fat, sugar and/or salt intake, which is a public health concern (Ronquest-Ross et al., 2015).
The high number of commercial advertisements and the improved availability and affordability of highly processed foods have been directly linked to the increased consumption of these products (Moodley et al., 2015). The food and beverage industry marketing has a strong influence on long-term food and beverage preference; this success relies on children's ability to recognise and choose according to familiar brands (Arredondo
et al., 2009; Hawkes, 2007; Lesser et al., 2013; Moodley et al., 2015). In these modern food
environments, nutrient-poor and energy-dense (HFSS foods (Steyn et al., 2016)) foods are more commonly seen (Roberto et al., 2015). The fact that many dietary patterns originate during childhood possibly explains why the majority of South Africans have poor dietary habits (Moodley et al., 2015; Shisana et al., 2013).
2.10 Food choices
2.10.1 Food preference development
Food preferences are developed in different ways; for instance, some food preferences are innate (e.g. infants prefer sweetness) (Ventura & Mennella, 2011), and some food preferences are adopted and learned over time (Birch, 1998; Wardle & Cooke, 2008). The adoption of certain food preferences is a lifelong journey which starts from before birth and is changed during early feeding practices (Mennella et al., 2001). One of the major contributors to food preferences is the familiar flavour (taste), which goes together with the experience or consequences of consumption of the food product (Hawkes et al., 2015). Various studies have shown that frequent exposure to the taste of certain foods results in a child liking it more, which leads to increased consumption of a specific food (Harris, 2008;
Remington et al., 2012). For this reason, He and MacGregor (2006) proposed that the salt taste receptors are suppressed when a high sodium diet is consumed. This can increase children’s preference for saltier foods later in life.
Parents and caregivers of children have a great impact on the children’s food preferences through the food that they provide during feeding (Kral & Faith, 2009; Savage et al., 2007). The preference for energy-dense foods is adopted at home, and therefore the diet at home plays a crucial role in food preferences (Fildes et al., 2014). Furthermore, food preferences can be influenced by information. Marketing of food products using familiar and positive associations has a direct influence on food preferences (Boyland & Halford, 2013). It has been seen that food companies in low- and middle-income countries work hard to make their products available and affordable in order to change the preferences and habits of the population (Hawkes, 2002).
2.11 The role of sodium in the body
Sodium is the essential regulator of extracellular fluid volume, it is also a main cation, it manage acid-base balance and is crucial to neural transmission and muscle contraction (Dötsch et al, 2009). The intestinal tract absorb sodium, where after it is carried to the kidneys, which will clean all the sodium out of the circulation. There after the kidneys will only send out the correct amount of sodium into the circulation that will be used by the body. Normally the sodium amount ingested is the same as the amount excreted. In a case where the blood sodium levels are high the thirst signal will be activated to recover the sodium-to-water ratio. In this situation the kidneys will discharge, both sodium and sodium-to-water together (Guyton & Hall, 2016; Rolfes, 2014).
2.12 Sodium consumption and development of high blood pressure
As mentioned and discussed previously, the dietary patterns of children have changed substantially over the years. Nowadays, a large part of the child’s diet consists of processed and fast foods (Marrero et al., 2014). The National Food Consumption Survey (NFCS-1999) conducted in 1999 indicated that the top five foods most commonly consumed by South African children (aged 1-9 years) were maize, white sugar, tea, whole milk and brown bread (Labadarios et al., 2005). This was the first and only national survey that looked at what children are eating (Labadarios et al., 2005; Steyn et al., 2006a; Steyn et al., 2006b; Steyn
et al., 2008a; Steyn et al., 2007; Steyn et al., 2008b). A more recent study of Sowetan
adolescents (data from the birth to 20 years cohort study were used, and only the 17-18 year old data were used) indicated that the top four most commonly consumed foods were fried
chips, soft drinks, sweets and crisps (potato/maize) (Feeley & Norris, 2014). The above-mentioned studies are the only studies we know of on what South African children eat. Not only do these results indicate the crucial role that urbanisation and globalisation play in forming the dietary patterns of young people, it is also evident that there is a gap in the literature on what children in South Africa eat.
On the other hand, the maximum daily sodium intake recommendation for children aged 3-4 years and 5-8 years is 0.788g (2g salt) and 1.182g (3g salt) respectively (Marrero et al., 2014). To our knowledge, there are currently no data on the contribution that processed foods make to the sodium consumption of children in South Africa. As mentioned earlier, processed foods usually contain high amounts of fats, sugar and/or salt. A high consumption of sodium increases the risk of developing hypertension (Khaw et al., 2004). In a western diet, processed foods contribute to the majority of sodium consumption (Anderson
et al., 2010; Garriguet, 2007)
It has been reported that children who consume a low sodium diet present with a lower BP when compared with children on a high sodium diet (He & MacGregor, 2006). A meta-analysis conducted by He and MacGregor (2006) included 10 randomised controlled trials conducted in children and adolescents and showed significant changes in BP when sodium was reduced for a time period of four weeks. A more recent meta-analysis conducted by Aburto et al. (2013) confirmed that BP decreases in both children and adults when sodium intake is reduced. The reduction of salt intake not only plays an important role in lowering BP, but also in reducing obesity as well as cardiovascular diseases (Feber and Ahmed, 2010). This indicates how crucial it is that the sodium content of certain processed food products is measured.
2.13 The measurement of sodium in processed foods
The Minister of Health in South Africa, under section 15(1) of the foodstuffs, cosmetics, and disinfectants Act, 1972 (act 54 of 1972), gazetted the regulations relating to the reduction of sodium in certain foodstuffs (R.214). In the regulation, the specific method for sodium determination is stipulated as “suitable sodium potentiometric method or elemental analysis, with either flame AAS or ICP, for determining typical total sodium content which shall be applied for monitoring”. The permitted tolerance for nutrient declaration in the labelling of sodium cannot be more than 20% in excess of the target sodium value.
For measurement of the sodium content in processed foods, there are several techniques that can be used, namely flame AAS, flame atomic emission spectrometry, inductively
coupled plasma (ICP) atomic emission spectrometry, ICP mass spectrometry, and photometric and ion-selective detection (Capar & Cunningham, 2000; de Brätter et al., 1995; Dolan & Capar, 2002). It is important that, when the samples are prepared for sodium analysis, the sample matrices are sampled correctly and digested. Therefore, the sampling method for different food matrices of Greenfield and Southgate (2003) will be used (This is summarised in Table 2-2). Microwave digestion has been shown to be a rapid technique for preparing a complex food matrix for sodium analysis (Dolan & Capar, 2002). This technique is usually accomplished by adding acid (HNO3 and/or H2S2) to the food sample in a closed Teflon vessel and raising the pressure and temperature through microwave irradiation. The AAS is a technique where a small quantity of the extracted sample is injected into a flame, where the ions are reduced to elements and vaporised. The elements present in the sample absorb light at specific wavelengths in the visible or the ultraviolet spectrum. A light beam with a single specific wavelength for the element being measured (sodium) is directed through the flame to be detected by a monochromator. The light absorbed by the flame containing the extract is compared with the absorption from known standards to quantify the elemental concentrations.
Table 2-2: Sampling method of different food matrices
Foodstuffs category Sampling method
Bread
Take every fourth slice and one end slice and crumb thoroughly to form composite sample
All breakfast cereals and porridges, whether ready-to-eat, instant or cook-up, hot or cold
Quartered then crushed with a pestle to form composite sample
All fat spreads and butter spreads
Units will be softened over a warm water bath and then blended together gently to form the composite sample
Ready-to-eat savoury snacks, excluding salt- and vinegar-flavoured snacks
Quartered then crushed with a pestle to form composite sample
Flavoured potato crisps, excluding salt- and vinegar-flavoured potato crisps
Quartered then crushed with a pestle to form composite sample
Flavoured, ready-to-eat, savoury snacks and potato crisps, salt-and-vinegar only
Quartered then crushed with a pestle to form composite sample
Processed meats – uncured
The edible portion is chopped coarsely with a knife and mixed thoroughly to form the composite sample
Processed meat – cured
The edible portion is chopped coarsely with a knife and mixed thoroughly to form the composite sample
Foodstuffs category Sampling method
Raw processed meat sausages (all types) and similar products
The edible portion is chopped coarsely with a knife and mixed thoroughly to form the composite sample
Dry soup powders (not instant type) Unit will be mixed thoroughly and the combined mass quartered
Dry gravy powders and dry instant savoury sauces
Unit will be mixed thoroughly and the combined mass quartered
Dry savoury powders with dry instant noodles to be mixed with a liquid
Unit will be mixed thoroughly and the combined mass quartered
Stock cubes, stock powders, stock granules, stock emulsions, stock pastes or stock jellies
Unit will be mixed thoroughly and the combined mass quartered
It is important not only to measure the sodium content in certain processed foods, but also to implement interventions that can address these increasing obesity trends, especially since childhood obesity (and high BP) is carried over into adulthood.
2.14 Obesity and NCD prevention strategy
Interventions need to be implemented to address the double burden of stunting and rapid increase in overweight and obesity in children of South Africa (Mchiza & Maunder, 2013; Shisana et al., 2013). Early dietary interventions and the promotion of healthy dietary patterns during childhood are therefore of great importance. For these reasons, the South African Paediatric Food-Based Dietary Guidelines (SAPFBDG) were developed. The main purpose of the SAPFBDGs is to encourage the population, especially children, to adopt a healthy diet that meets the daily nutrient needs and helps to prevent the development of NCDs (Vorster et al., 2013). Different guidelines are set for the various age groups, but for the purpose of the current study the focus will be on the guidelines for the age group of 2-5 years (Table 2-3).
Table 2-3: The suggested paediatric FBDGs for children 12 - 36 months and 3 - 5 years
12 - 36 months Continue to breastfeed to two years and beyond.
Gradually increase the amount of food, number of feedings and variety as your child gets older.
Give your child meat, chicken, fish or egg every day, or as often as possible.
Give your child dark-green leafy vegetables and orange-coloured vegetables and fruit every day.
Avoid giving tea, coffee and sugary drinks and high-sugar, high fat, salty snacks to your child.
Hands should be washed with soap and clean water before preparing or eating food. Encourage your child to be active.
Feed your child five small meals during the day. Make starchy foods part of most meals.
Give your child milk, maas or yoghurt every day. 3 - 5 years Enjoy a variety of foods.
Make starchy foods part of most meals.
Lean chicken or lean meat or fish or eggs can be eaten every day. Eat plenty of vegetables and fruit every day.
Eat dry beans, split peas, lentils and soya regularly. Consume milk, maas or yoghurt every day.
Feed your child regular small meals and healthy snacks. Use salt and foods high in salt sparingly.
Use fats sparingly. Choose vegetable oil, rather than hard fats. Use sugar and food and drinks high in sugar sparingly.
Drink lots of clean, safe water and make it your beverage of choice. Be active!
Hands should be washed with soap and clean water before preparing or eating food (Vorster et al., 2013)
In April 2015, The Strategy for the Prevention and Control of Obesity in South Africa 2015-2020 was released as a result of the increasing prevalence of overweight and obesity in South Africa and because of the great strain placed by this prevalence on the economic and healthcare system (SADoH, 2015). This strategy aims to reform the “obesogenic” environments and enablers, while increasing opportunities for physical activity and healthy food options in healthcare facilities, early development centres, schools, workplaces and communities. In the South African Obesity Strategy, childhood obesity is singled out
because of the many perceived benefits that obesity prevention may have for a country. Globally, among the leading causes of mortality are NCDs, which lead to the majority of deaths, especially in low- and middle-income countries. Consequently, South Africa has implemented a Strategic Plan for the Prevention and Control of Non-Communicable Diseases 2013-17. One of the NCDs that the strategy specifically wants to address is cardiovascular disease, along with the four major risk factors for cardiovascular disease, namely physical inactivity, unhealthy diets, tobacco use and harmful use of alcohol (NDoH, 2012).
According to the WHO (2012), sodium regulations also need to be put in place for children aged 2-15 years in order to control blood BP. In order to reduce the sodium consumption of the South African population, the National Department of Health has implemented a sodium regulation (R.214) which limits the sodium content in certain food products (R.214:March 2013, 2013). These food categories, together with the two target dates, are described in Table 1.1. The regulation was amended on 6 September 2016, and therefore the amended target dates are included in the table. For this study, aim to identify processed foods frequently consumed by children, as well as to see what these processed foods contribution are to the sodium consumption of children.
Out of 57 countries, South Africa is one of the countries that have developed a sodium reduction strategy in order to meet the WHO target of 2g of sodium per day (WHO, 2012). South Africa is also the first country that has implemented sodium reduction targets for a large number of foodstuffs and made them mandatory.
2.15 Conclusion
A study of the literature makes it clear that the increasing rates of childhood obesity and its risk factors (obesity-related NCDs) are a major public health concern, globally as well as nationally. As seen in the literature, South Africa faces a double burden of disease, with childhood obesity increasing. It is also reported that childhood obesity is carried over into adulthood, which results in greater economic strain on the country. Studies have shown that these rapidly increasing obesity rates are a result of the urbanisation which the country is undergoing. This has led to the fact that the population consumes more processed foods since these foods are now more freely available and affordable. Processed foods are usually high in fat, sugar and/or salt. An examination of the literature reveals two important gaps: the first is that the latest research on what children (aged 2-5 years) eat is outdated (NFCS 1999) and the second is that there are no data regarding the contribution of processed foods to the sodium consumption of these children.
CHAPTER 3: ARTICLE
“Depend on the Lord in whatever you do, and your plans will succeed” Proverbs 16:3
This manuscript will be submitted to the Public Health Nutrition Journal and will be written according to the journal’s guidelines.
Title: Public Health Nutrition Impact factor: 2.483
Publisher: Cambridge University Press
Aim and scope: Address monitoring and surveillance of nutritional status and nutritional environments in communities or populations at risk
Identify and analyse behavioural, sociocultural, economic, political, and environmental determinants of nutrition-related public health
Develop methodology needed for assessment and monitoring
Inform efforts to improve communication of nutrition-related information
Build workforce capacity for effective public health nutrition action
Evaluate or discuss the effectiveness of food and nutrition policies
Describe the development, implementation and evaluation of innovative interventions and programmes to address nutrition-related problems
Relate diet and nutrition to sustainability of the environment and food systems
