South African paediatric food‐based dietary guidelines

Abstract

South African efforts to address both under‐ and overnutrition , and other nutrition‐related public health issues, utilizing food‐based dietary guidelines (FBDGs) as an educational tool, are introduced. However, the focus is placed on the development of paediatric FBDGs for infants and young children, from birth up to the age of 7 years, and how these were made compatible with scientific and local public health evidence on the one hand, and existing South African FBDGs for children over the age of 7 years, adolescents and adults, on the other. Members of the Working Group and other stakeholders are gratefully acknowledged.

The global burden of diet‐related diseases and the concern that nutrient‐based guidelines are not effective in promoting dietary and lifestyle behavioural changes, have resulted in a number of countries developing localised food‐based dietary guidelines (FBDGs). These are qualitative statements and generally less technical and more easily understood than nutrient recommendations. South Africa is such a country, having developed and tested guidelines for individuals over the age of 7 years that became available through the national and provincial Departments of Health in 2003.

The multisectorial South African Working Group that developed and tested those FBDGs had followed the process recommended by a joint FAO/WHO consultation (World Health Organization 1998). A set of technical support papers was published (Voster 2001) to reflect how existing under‐ and overnutrition could jointly be addressed by the guidelines, and to provide the rationale and scientific evidence for the guidelines. Furthermore, it also described how the guidelines had been based on prevailing eating patterns and diet‐related public health issues.

The recognition by the South African Working Group that stunting in preschool children is a major public health issue, led to the decision that caregivers and mothers of local African infants and young children required a special emphasis, a real focus and a specific set of guidelines. Consequently, a diverse multisectoral Working Group of health professionals with a paediatric focus was formed, with linkages to the original core Working Group under the auspices of the South African Nutrition Society and with support from the Association for Dietetics in South Africa, and also included liaison and support from the Nutrition Directorships of the National and Provincial Departments of Health.

The Paediatric Food‐Based Dietary Working Group based the development of draft guidelines on both the ‘core’ guidelines for school‐going children, adolescents and adults, as well as prevailing paediatric nutrition‐related public health issues and local dietary habits. To illustrate this, the Table 1 sets out the various guidelines, recognizing changes through the lifecycle as well as age categories that may coexist in the household and in the community.

Table 1.

South African food‐based dietary guidelines representing parallels of guidelines during the life cycle

Birth to 6 months	>6 months to <12 months	>1 to <7 years	Children >7 years, adolescents, adults
1. Enjoy time with your baby	1. Enjoy time with your baby
2. Breastfeeding is best for your baby for the first 6 months	4. Keep breast feeding your baby
	6. Teach your baby to drink from a cup
	2. From 6 months start giving your baby small amounts of solid foods
	3. Increase your baby's meals to five times a day	2. Feed children five small meals a day
		1. Encourage children to enjoy a variety of foods	1. Enjoy a variety of foods
3. Clean your baby's mouth regularly	5. Offer your baby clean, safe water regularly	8. Offer children clean, safe water regularly	9. Drink lots of clean, safe water
4. Take your baby to the clinic every month	7. Take your baby to the clinic every month	6. Take children to the clinic every 3 months
		7. Encourage children to be active every day	2. Be active
		3. Make starchy foods the basis of a child's main meals	3. Make starchy foods the basis of most meals
		4. Children need plenty of vegetables and fruits every day	4. Eat plenty of vegetables and fruits every day
		5. Children need to drink milk every day	5. Eat dry beans, peas, lentils and soy regularly
		9. Children can eat chicken, fish, meat, eggs, beans, soya or peanut butter every day	6. Chicken, fish, milk, meat or eggs could be eaten daily
			7. Eat fats sparingly
			8. Use salt sparingly
			10. If you drink alcohol, drink sensibly
		10. If children have sweet treats or drinks, offer small amounts with meals	11. Use food and drinks containing sugar sparingly and not between meals

This special issue includes a set of papers that provides the scientific basis and rationale for the draft paediatric FBDG (PFBDG) statements and initial results of testing. The Working Group decided to utilize a thematic approach in setting out the papers, as the roles of breastfeeding, growth monitoring, oral health, as well as the promotion of optimal nutrition are seen as pervasive to growth and development in the preschool child. Maternal/child interaction and its relationship with feeding, as well as regular clinic attendance were also identified as important public health issues that relate to the nutritional status of infants and young children in South Africa, while not being specifically food‐based.

In formulating these PFBDGs for mothers and caregivers, the Working Group considered the ‘normal’ healthy child – i.e. accepting that children with clinical conditions and special needs require specialized treatment after diagnosis. Nevetheless, it was recognized that a large and growing proportion of young South African infants and children are HIV‐positive and PFBDGs must be modified and tested for this purpose. Given the high prevalence of HIV infection in South Africa, it is essential that PFBDGs inform and support decisions around safe infant feeding, as well as optimal complementary feeding, which takes into account the increased energy requirements of HIV‐infected infants and children. Diets should be optimized for children on anti‐retroviral therapy while acknowledging the existing research gaps needed to address the metabolic derangements associated with treatment.

The development and evolution of these guidelines was a dynamic process, characterized by lively discussion and debate from many perspectives. The Working Group recognizes that the wording of the guideline statements requires further testing and refinement, but is happy to assist with protocols that have been developed for this purpose. However, it is hoped that the technical rationale, from both local and international evidence that has been taken into account and presented in this special issue, will be of value to expedite the process. Furthermore, it is hoped that this information will be a useful resource to health professionals in other developing country settings.

Lastly, the Working Group recognizes the important advocacy role that lies ahead and that once the guideline statements are finalized, and appropriately and clearly worded, consumer material needs to be developed with appropriately phrased supportive information, featuring illustrations of culturally acceptable, affordable foods that are easily available at local level.