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October 2017 Dietetics & Nutrition NEWS 1

Dietetics & NutritionNEWS

Newsletter of the Professional Board for Dietetics and Nutrition

2017

Health Professions Council of South Africa

Issue 01/10/

Dietetics & Nutrition NEWS October 20172

ContentsContentsChairperson’s Note .....................................3.

What does the Professional Board for Dietetics and Nutrition do for the Registered Professional? ............................4.

How to check if you are on the HPCSA Professional Board register or not: .............................................8.

HPCSA Online Renewal Registration .................................................9.

The labelling of Dairy Products in South Africa ...........................................................10.

The importance of having an Indemnity Cover .........................................12.

TPN, Vitamin and Enteral Feeds Prescription Rights ......................................12.

Benefits of Registering with HPCSA ...........13.

Nutrition at highest level on the International Agenda .................................14.

Low Carbohydrate Diets for Health and Weight Loss ..........................................15.

How to earn your CEUs...............................20.


We are already at the end of the second quarter , how time flies!

To bring you up to speed on the work done by the Board in the past year, I would like to share the following information with you. The Board is still two members short, it is supposed to have 10 members, however, the Board is operating with eight members. This complicates the work of the Board tremendously, as all members also have permanent jobs, without taking into consideration the amount of time and work we spend on Board issues.

In 2016, we assessed five Universities’ Dietetics programmes for accreditation. Each University’s accreditation assessment takes four working days for a panel of three members. Fifteen evaluators participated in this venture, of which five were previous Board members with experience in the assessment processes. The other 10 evaluators were members of the current Board, as a result, some members did more than one assessment. Three days was spent on the actual discussions, site visits and meetings with staff and University personnel. The fourth day was utilised to draft a preliminary assessment report, which was finalised within two weeks of the assessment visit.

The Board developed the strategic plan for the next five years (2015-2020)

• did a risk assessment based on the strategic plan,

• drafted a performance monitoring and self-assessment tool,

• finalised the Dietitian-Nutritionist outcomes and assessment document for Universities usage in drafting their new programmes,

• the Board also had a fruitful engagement with the National Department of Health and Department of Higher Education and Training.

The Board worked on the operational plan during March to align with the strategic plan. We also updated the accreditation assessment document for Universities to provide information that is of relevance, as well as a code of conduct for evaluators. Going forward, there will also be an evaluation form for Universities to assess the evaluators after visits have been concluded. Several Standard Operating Procedures were developed and are already in use.

Based on this information, I invite all Dietitians or Nutritionists with relevant questions or unresolved issues to contact the Board secretariat so that we can give urgent attention to those issues. Remember, you are all important to us and we are here to represent you in any way we can.

Chairperson: Professional Board for Dietetics and Nutrition

Professor Susanna Magrietha Hanekom

C H A I R P E R S O N ’ S NOTE


WHAT DOES THE PROFESSIONAL BOARD FOR DIETETICS AND NUTRITION DO FOR THE REGISTERED PROFESSIONAL?Prof. Susanna Magrietha Hanekom PhD Nutrition

We frequently hear the following question: “What does the HPCSA or the Professional Board for Dietetics and Nutrition (DNB)” do for us (registered professionals). To answer this question, I will keep my comments

to the questions relating to and which form part of the strategic plan of the DNB.

The vision and mission of the DNB states the following, and already should make the reader aware of what the Board stand for:

Vision:

A trustworthy, credible, transparent and accountable Board that serves the interest of the profession and the public.

Mission:

To protect and serve the public and guide the profession. Practical effect is given to the above through ensuring excellence of dietetic and nutrition service delivery and thereby protecting the South African public by:

• Maintaining and enhancing the quality ofpractice;

• Safeguarding the integrity of dietetics andnutrition professionals registered with theBoard;

• Promoting the nutritional health of all SouthAfricans;

• Being a Board that is willing and able to beefficientintheirsupportandservicedelivery;

• Communicatingeffectivelytoallstakeholders.

TheProcess:

The strategic plan is in line with the following:

1. The mandate of the Board in terms of the Amendment Act;

2. The strategic plan of Council (2016/2017-2020/2021);

3. The current ten-point plan of Department of Health;

4. The delivery agreement of the Department of Health’s Outcome: “A long and healthy life for all South Africans”;

5. The national plan for human resources for health for South Africa.

Strategicobjectives:1. Protecting the public:

a. Improve professional conduct turnaround times:

• Improve the responsiveness to the public and professionals with respect to professional conduct turnaround times (e.g. conduct teleconferences as and when required to address urgent matters);


b. Ensure the professionals are properly qualified to serve the public:

• Improve CPD compliance to improve professional competence and ensure the professionals are properly qualified to serve the public

c. Ensure accountability and professional conduct of professionals:

• Improve accountability and professional conduct of professionals through improvements in guidelines and protocols related to professional conduct (e.g. through Audits and improved internal controls);

2. Regulating and guiding the profession:

a. Scope of practice and/or scope of profession for registered professionals:

• Develop, review and finalise the scope of practice for registered professionals to meet the needs of the public;

b. Setting up of minimum competencies and skills:

• Ensure the quality assurance and accreditation of training institutions is done effectively and efficiently;

• Ensure that training is provided to evaluators of training institutions;

• Ensure that a sufficient number of identified evaluators are trained;

c. Create opportunities for CPD through e.g. articles and questionnaires:

• New CPD opportunities created;

d. Improve professional competence:

• Keeping professionals abreast with the current and future trends in the industry;

e. Review and update guidelines, rules and regulations (applicable to the Board):

f. Ensure the rules, regulations and guidelines applicable to the Board are relevant and in line with local and international best practices (This includes (but is not limited to): (1) Strengthening the verification of qualification and certificate of good standing / (2) Investigating and developing protocols to address the registration of persons from non-accredited training institutions / (3) Investigating guidelines for tariffs & fitness to practice):

g. Contribute towards Council’s


strategic review of the legislations and the regulations

• Review and clarify the relevance of existing legislation in line with Council’s objective

h. Strengthening of processes & timeframes pertaining to registration

• Evaluation and implementation of the processes and procedures relating to the:

vGeneral registration of students

vRegistration of foreign qualified applicants

vRestoration of practitioners

3. Advisory, Advocacy and Stakeholder Engagement:

a. Improve communication (including activities and decisions taken by the Board) with all stakeholders and the public

• Provide input and

contribute to Council’s stakeholder engagement initiative in order to enhance communication and improve on the image of the HPCSA

Ensure regular communication with all stakeholders through various media platforms (e.g. Journals, Websites, etc.)

b. Benchmarking with international best practice

Allowing the Board to confer and benchmark with international regulatory bodies in relation to evidence based standards of education, training and practice

c. Address the registration of state/government employed professionals

• Engagement with the State and provincial government

d. Address the registration of private practicing professionals

• Engagement with entities dealing with private practicing professionals

e.g. BHF

e. Develop and communicate Board position on key issues (Including but not limited to NDP, inter-sectoral stakeholder collaboration);

• Develop policy position statements and engagement across government departments e.g. sugar tax proposal

f. Facilitate the promotion of the profession to increase

• Employment opportunities

• Increased role within the public sector

• Increase the need for rural jobs, (by taking Nutrition to the rural areas and making people aware of their needs)

v Continued multi-stakeholder (government, training institutions, other) engagements

v Encourage post graduate studies into the development of the


professions

v Interact with NDoH to strengthen the number of dieticians and nutritionists servicing the public

g. Improve internal communication across Professional Boards

• Foster an enabling working environment between Professional Boards, Secretariat and Council.

4. Effective and Efficient Functioning of the Board

a. Ensure that Board Members are continually trained and competent

• Identify skills gaps of Board Members and ensure that Board Members are continuously trained

b. Improve consistency, transparency and decisiveness in Board functioning in line with the application of regulations

• Define, communicate and implement processes such that functions of the Board are clearly defined and executed

• Review by legal of concluded matters to ensure that regulations were applied consistently

• Critically evaluate important functions affecting the Board and ensure role clarification is communicated

• Review the terms of reference of the Board and its committees

c. Improved effectiveness and efficiency of the Board including meetings

Develop SOPs (and timelines) for:

vBoard activities, including high level processes for communication channels

vResolutions and communications thereof

vThe development of minutes and agendas of meetings including the potential simplification of minutes

vBoard member’s participation in feedback and input in documentation and reports.

d. Measure and improve Board performance

Measure the performance of the Board and its committees on an annual basis through self-evaluation and potential external 360 evaluations

e. Contribution to Council’s Digital Transformation Initiative

• Provide Secretariat with the required list of IT requirements

The above details may seem daunting, but this is what the DBN has set out to achieve in the next four years. I hope that by reading through the strategic goals, this will highlight what the current members (eight members and two vacancies to be filled) seek to achieve. You are welcome to address any questions on these strategic outcomes to the Board secretariat or the Chairperson and additional or urgent issues needing the attention of the DNB . It is also the responsibility of the registered professional (our eyes and ears) to keep us abreast of whatever is happening (good or bad) on grassroots level. Without your help, we will not be able to address any problems and correct them.

Ihopeyouallhaveawonderfulandfruitfulyear.


Go to the landing page of the HPCSA: www.hpcsa.co.za

Scroll down to the bottom of the page until you get to “Search the Register” (Magnifying glass):

• Click on the magnifying glass (this may take some time, please WAIT)

• Next screen: Select search criteria and fill in the required field

• Click “Search” to find your name.

• Next screen: Click on “VIEW” to see the details of your search. Read through the results. It stipulates if you are an active member or removed from the register.

If you cannot find your details when using your DT/NT number, use one or more of the other criteria. It may be that when using just your surname, you will not find your name. Use your ID or DT/NT number for best results. If you get no results, follow the tip on the screen and contact the information centre for assistance.

REGISTRATIONHow to check if you are on the register or not:Prof. Susanna Magrietha Hanekom PhD Nutrition


HPCSA’s Online Renewal of Registration is an interactive system, applying intelligence to the Renewal and payment process for the Health Professions of South Africa. The system guides the user to create an account, login, update their profile, renew the registration and complete the process by making the payment for their yearly renewal of annual fees.

The system is intuitive and usable. To assist you as the user, an easy to follow guide has been created with real graphics and an easy to use interactive index.

The process starts with creating an account and is finalised when a payment is made. The user can also generate a practicing card, view the HPCSA documents as well as invoices and statements. Please see the website. https://practitionerssso.hpcsa.co.za/identity/login?signin=48caed057a366059ccf477320da7691a

HPCSA ONLINE RENEWAL AND PAYMENT PORTAL


THE LABELLING OF DAIRY PRODUCTS IN SOUTH AFRICAPenny Campbell Masters Degree in Public Health

The consumption of dairy products has enormous nutritional and health benefits. The intake thereof is promoted as essential components of a healthy diet worldwide. South Africa is no exception and there is

strong evidence that for the vast majority of the population, dairy intake is less than optimal. In conveying intake requirements to a client, Dietitians and Nutritionists rely on the labelling of these products to ensure that appropriate choices are made. Therefore, labelling is of critical importance and this article will attempt to briefly outline the regulatory framework of labelling using dairy products as an example.

There are pieces of legislation administered by different government departments that impact on dairy product labelling:

• Department of Agriculture, Forestry and Fisheries (DAFF) – Agricultural Product Standards Act, 1990 (Act 119 of 1990) and its Regulations

• Department of Trade and Industry - National Regulator for Compulsory Specifications (NRCS) and the application of the relevant regulations in terms of the Trade Metrology Act, 1973 (Act 77 of 1973)

• Department of Health (DoH) – The Foodstuffs, Cosmetics and Disinfectants Act, 1972 (Act 54 of 1972) and its Regulations

The Agricultural Products Standards Act, 1990 (Act 119 of 1990) controls and promotes specific product standards for meat, dairy products, cereals, fruit, canned fruit and vegetables destined for local and export markets. These are in the main related to the quality and compositional aspects of these products. In March 2016, new requirements for dairy and imitation dairy products took effect through the gazetted regulations relating to the classification, packing and marking of dairy products and imitation dairy products intended for sale in the Republic of South Africa (R 260 of 2015). Through these regulations, producers of such products are required to provide consumers with:

• products of consistent quality

• correct classification and grading

• accurate and relevant information through prescribed marking requirements

• an informed and personal choice

Practically, these regulations ensure that important nutritional principles or characteristics are described using specific terms, e.g. full-fat yoghurt versus low-fat yoghurt. They also provide for secondary dairy products classification or categorization e.g.

• Pasteurised and ultra-pasteurised milk

• Long life or ultra-high temperature treated (UHT) milk

• Condensed and evaporated milk

• Pasteurised and UHT cream

• Yoghurt

• Buttermilk and buttermilk powder

• Maas and other fermented milk

• Whey and whey powder

• Cheese

• Butter

• Milk powder


The National Regulator for Compulsory Specifications (NRCS), separate from South African Bureau of Standards (SABS) handles food safety and labelling issues related to canned meat containing more than 10% meat, frozen and canned fish and fishery products. The NRCS is also responsible for administering the Trade Metrology Act of 1973 (Act 77 of 1973) which relates to weights and measures and thus the net weight on product labels as well as weighing and measuring instruments are regulated.

Through the Foodstuffs, Cosmetics and Disinfectants Act, 1972 (Act 54 of 1972) and its Regulations, DoH is responsible for food safety and regulatory nutrition, including food labelling, salt iodization, food fortification, trans fats, sodium reduction, hygiene requirements and product safety.

The Regulations Relating to the labeling and advertising of foodstuffs (R146 of 2010) are more general in that they cover all foodstuffs and some of the important provisions included in the regulations are:

• Foodstuffs should be described in such a manner that the information related to the contents and/or composition of a product is indicated in close proximity to the name on the main panel of the packaging in letter sizes as prescribed by the regulations. The description should be legible and the contents should not be misleading and/or aimed at deceiving consumers. This provision relates to for example, products such as quick frozen chicken portions to which a brine-based mixture has been added as an ingredient.

• The inclusion of date markings such as ‘best before’; ‘sell by’; and ‘use by’ on the packaging of pre-packaged foodstuffs, to inform consumers of the freshness/quality and suitability status of foodstuffs at the time of purchase. There is however, no prohibition of the sale of foodstuffs past their minimum date of durability.

• Details of the country and/or countries of origin, or where the foodstuffs have been produced.

• Criteria for certain nutritional claims such as for example, ‘high in fibre’; ‘low fat’; ‘sugar free’; etc., as well as in these instances, the mandatory inclusion of a nutritional table in a prescribed format to substantiate/support such claims.

• The inclusion of information referred to as: ‘Quantitative Ingredient Declaration’, or QUID, which will ensure that consumers are made

aware of the amount of a certain ingredient or ingredients emphasised on the label of a foodstuff, are present therein.

• The approval by the Director-General of endorsement entities, such as Weigh Less, CANSA, Diabetes SA, etc., to allow industry to include the logos of these entities on the labels of their products, in support of or to promote certain nutritional or diet related characteristics of the products concerned.

• The inclusion of requirements regarding the declaration of common food allergens such as peanuts, tree nuts, soya and dairy products, wheat gluten, etc., present in foodstuffs, including as an ingredient in processed foodstuffs, as well as detailed guidelines to assist industry in this regard.

Consumers have a right to know what is in their food and food labeling remains the primary means of communication between the producer, seller and the consumer. Labeling regulations provide a fair playing field to assure that consumers are not bamboozled by false and misleading marketing activities by the industry, whilst ensuring that they can make informed nutritional choices.


The Minister of Health on the 22 October 2010 repealed the regulations relating to indemnity cover for registered health practitioners promulgated on 30 August 2010.

No new/amended regulations have since been promulgated and therefore it is not a legal requirement for a Dietitian and Nutritionist to obtain indemnity cover.

Regulations relating to indemnity cover for registered health practitioners http://www.hpcsa.co.za/Uploads/editor/UserFiles/downloads/dietetics/Indemnity_Cover.pdf

Dietitians and Nutritionists are regarded as experts in nutrition, as a result, they are involved in the

provision of expert nutrition advice/counselling to the healthy and those affected by diseases.

Today the field of nutrition is flooded with nutrition products that are to be administered orally and/or via enteral tube or parenterally. The difference between nutritional products and pharmaceutical products is becoming difficult to identify, as many products are said to give pharmaceutical benefits and nutritional benefits at the same time. Some of these products

require to be administered at high dosages to realize the benefits. This blurred line has necessitated the development of guidelines to help healthcare professionals know which products Dietitians can prescribe and for which benefits/purpose.

Nutrition solutions that are administered parenterally are particularly affected by the review of legislation by Medicine Control Council. The review is understood to be preventing dietitians and nutritionists from prescribing these solutions by rescheduling them.

THE IMPORTANCE OF HAVING AN INDEMNITY COVER

TPN, VITAMIN AND ENTERAL FEEDS PRESCRIPTION RIGHTS Tshilidzi Nageli BSc Dietetics


The role of the HPCSA, apart from guiding the professions, is to:

Conferprofessionalstatus

• The right to practice your profession

• Ensuring no unqualified person practises your profession

• Recognising you as a competent practitioner who may command a reward for service rendered

Setstandardsofprofessionalbehaviour

• Guiding professionals on best practices in healthcare delivery

• Contributing to quality standards that promote the health of all South Africans

• Acting against unethical practitioners

Ensure your Continuing Professional Developmentthrough:

• Setting and promoting the principles of good practice to be followed throughout the career

Practitioners who are not practising their profession may in terms of section 19(1)(c) of the Health Professions Act 1974 (Act 56 of 1974) request that their name be removed from the relevant Register on a voluntary basis. A written request should reach Council before 31 March of the year in which the practitioner wishes his or her name to be removed from the Register.

http://www.hpcsa.co.za/Registrations/VoluntaryRemoval

http://www.hpcsa.co.za/PBDieteticsNutrition/Restoration

BENEFITS OF REGISTERING WITH HPCSA

Practitioners practising any of the health professions falling within the ambit of the HPCSA are obliged to register with Council as a Statutory body.


On 1 April 2016 the United Nations General Assembly agreed a resolution proclaiming the UN Decade of Action on Nutrition from 2016 to 2025. The resolution aims to ‘trigger intensified action to end hunger and eradicate malnutrition worldwide, and ensure universal access to healthier and more sustainable diets – for all people, whoever they are and wherever they live. It calls on governments to set national nutrition targets for 2025 and milestones based on internationally agreed indicators’.

This means that the governments also agree to endorse the Rome Declaration on Nutrition and Framework for Action adopted by the Second International Conference on Nutrition (ICN2) in November 2014.

The FAO and WHO will lead the implementation of the Decade of Action on Nutrition on behalf of the UN in collaboration with the World Food Programme (WFP), the International Fund for Agricultural Development (IFAD) and the United Nations Children’s Fund

(UNICEF), and involving coordination mechanisms such as the United Nations System Standing Committee on Nutrition (SCN) and multi-stakeholder platforms such as the Committee on World Food Security (CFS).

‘The Framework for Action commits governments to exercise their primary role and responsibility for addressing undernourishment, stunting, wasting, underweight and overweight in children under five years of age, anaemia in women and children - among other micronutrient deficiencies. It also commits them to reverse the rising trends in overweight and obesity and reduce the burden of diet-related non-communicable diseases in all age groups’

The new resolution invites international partners, civil society, private sector and academia to actively support governments to ensure full implementation of the steps outlined in the Rome Declaration and Framework for Action.

Nutrition at highest level on the International Agenda

SixActionAreashavebeenidentifiedfortheimplementation:

ActionArea1–Sustainable,resilientfoodsystemsforhealthy diets Creating sustainable, resilient food systems for healthy diets

ActionArea2–Alignedhealthsystemsprovidinguniversalcoverageofessentialnutritionactions Accelerating nutrition improvement in sub-Saharan Africa: Scaling up nutrition interventions in three countries

ActionArea3–Socialprotectionandnutritioneducation Ensuring healthier diets, better nutrition and strengthened food systems: The role of social protection policies and programmes

ActionArea4–Tradeandinvestmentforimprovednutrition Why policies on trade and markets matter during the Nutrition Decade

ActionArea5–Safeandsupportiveenvironmentsfornutritionatallages Implementing food-based dietary guidelines for policies, programmes and nutrition education

ActionArea6–Strengtheninggovernanceandaccountabilityfornutrition Progress in defining and promoting respect for human rights in the food and nutrition-relevant business sector

Formoreinformationvisit:• http://www.who.int/nutrition/decade-of-action/en/• http://www.who.int/nutrition/decade-of-action/

workprogramme-doa2016to2025-en.pdf• https://www.unscn.org/en/topics/un-decade-of-action-

on-nutrition


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NSSA Newsbits

2016;29(2)S Afr J Clin Nutr

Joint Statement on Low Carbohydrate Diets for Health and Weight Loss

by Nutrition Society of South Africa (NSSA) and Association for Dietetics in South Africa (ADSA)

Any diet recommended for the short or long term should be nutritionally sound, not harmful to health or the environment, practical, affordable, and suit the individual’s taste preferences and psychosocial environment. The current available evidence does not support an extreme low carbohydrate diet for reducing risk of disease. Low carbohydrate diets may enable some people to lose weight by reducing their energy intake and achieving an energy deficit. However, achieving a nutritionally adequate and healthy dietary pattern becomes problematic with extreme low carbohydrate diets that emphasise high fat intake from predominantly animal foods and restrict and eliminate many nutrient- and fibre-rich foods. The commercialisation of low carbohydrate diets is substantial and consequently many versions of this diet continue to be sold.

In recent years in South Africa, there have been many conflicting public messages provided about healthy eating, and what constitutes an appropriate diet for health and weight loss. This nutrition debate has received a lot of media attention, and while this heightened awareness and focus on the importance of optimal nutrition is positive, many members of the public are confused because the healthy eating and weight loss messages are not always consistent. This Joint Statement therefore aims to present explanations of key concepts and an overview of recent scientific evidence on low carbohydrate diets for health and weight loss. This statement is intended for use by health professionals.

Introduction

Low carbohydrate diets that restrict a variety of foods continue to receive media attention with ensuing intensified public interest and commercial benefits for marketers and retailers. Versions of these diets (e.g. Atkins, South Beach, Banting) make claims about weight loss and prevention and treatment of a range of diseases, such as diabetes, cancer, tuberculosis and Alzheimer’s. They are typically promoted via books, magazines, courses, websites and social media, along with food or supplement products, as part of a multibillion dollar industry. This continues despite a considerable body of systematically synthesised scientific evidence showing that current dietary recommendations, which endorse a range of carbohydrate, protein and fat intakes and healthy dietary patternsa, promote adequate nutrition and reduce disease risk.1 Additionally, this evidence indicates that a number of different diets result in

weight loss over the short term if energy intake deficit is achieved, although some dietary patterns may be more beneficial than others for sustaining long term cardio-metabolic health.2-4

a Dietary patterns can be defined as the quantities, proportions, variety, or combination of different foods, drinks, and nutrients (when available) in diets, and the frequency with which they are habitually consumed.1

Carbohydrate restriction

The currently recommended intake of carbohydrates ranges from 45 to 65% of total dietary energy,5-8 and diets with less than 45% of energy from carbohydrates are regarded as being low in carbohydrates, as they fall below this recommendation. Commercial low carbohydrate diets generally cover a spectrum from extreme restriction, for example 5% of total energy, to more moderate, such as 30%. This restriction may be indicated as a daily quota expressed in grams, for example, 25 grams.

Implications

Carbohydrate restriction can result in an unbalanced and restrictive diet. Our total daily energy intake is derived from macronutrients (carbohydrate, fat and protein) in the diet. For a given level of energy intake (e.g. 8400 kilojoules), increasing the proportion of one macronutrient necessitates decreasing the proportion of one or both of the others. Thus when foods rich in carbohydrates such as grains, cereals and legumes are avoided and other carbohydrate sources such as dairy, fruits and vegetables are restricted, they are replaced with high fat and high protein foods, such as meats, cheese, butter, cream and oils. Diets rich in meat and dairy products pose a significant threat to environmental sustainability.9,10 Furthermore, as most foods consist of varying combinations of carbohydrates, fats and proteins, compliance with a daily quota of less than 25 grams of carbohydrate, as an example, would permit only one medium-sized apple (about 180 g) with meats, fish and pure fats per day. Any further intake of fruit, vegetables, dairy, nuts, legumes, cereal foods [or grains], would lead to this quota of carbohydrates being exceeded. These foods are not only sources of carbohydrate, but also of other essential nutrients such as vitamins, minerals, water, fibre and phytonutrients. One needs to consider the complete ‘nutrient package’ of a food before excluding it from one’s diet. Extreme carbohydrate restriction therefore makes a varied, nutrient- and fibre-rich diet near impossible to achieve.

ReprintedwithpermissionfromtheNutritionSocietyofSouthAfricaandAssociationforDieteticsinSouthAfrica


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NSSA Newsbits


Diet for health vs. Diet for weight loss

Simplistically, diets can be thought of as supporting health or weight loss. A diet for health focusses on preventing nutrient deficiencies and excesses, and reducing non-communicable disease risk. Such diets have a long time horizon with many years of exposure before outcomes, such as disease and death, emerge. By contrast, a diet aimed primarily at managing overweight and obesity has a shorter time horizon as weight change occurs over a relatively short time. Although these two types of diet have different objectives and time-frames, both should be nutritionally sound and avoid doing harm. Thus, diet for weight loss and diet for health are equally important.

Dietary Recommendations for Health

Dietary recommendations developed by governments and associated scientific bodies related to macronutrients, micronutrients, foods and dietary patterns for health aim to: (1) optimise physiological and mental functions and address clinical or subclinical nutrient deficiencies, and (2) reduce the risk of non-communicable diseases. These recommendations are informed by the totality of evidence emerging from various types of research including systematic reviews, randomised controlled trials, large cohort studies, controlled feeding studies and depletion/repletion nutrition studies. In deciding on the strength of specific recommendations careful consideration is given to the potential risk of bias, consistency of effects, generalizability of findings and other elements relating to the available research. While recommendations are usually made for healthy people,4,5,7,8,11-13 disease-specific dietary guidelines also exist, such as those for people with diabetes or kidney disease.

Comprehensive, systematic and transparent assessments of the evidence, combined with wide consultation of stakeholders, underpin various dietary guidelines produced in Nordic countries,8 the United States1,4 and the United Kingdom14 While the basic foundations of these guidelines have remained relatively stable over time; shifting patterns of disease and new evidence have resulted in some changes in emphasis and application as recommendations have been updated. More recent recommendations incorporate a wider range of macronutrient goals,5-8 place a greater emphasis on the quality of macronutrient food sources; and focus to a greater extent on the total diet or dietary pattern rather than on isolated nutrients, than has been the case in the past.

Currently recommended macronutrient goals are shown in Table 1. These macronutrient ranges are known to be associated with reduced disease risk and provide adequate intakes of essential nutrients. Within the various ranges there is room for flexibility from lower to higher intakes of carbohydrate, fat and protein. However, extreme restriction or excess can be expected to result in an imbalance of macronutrient intake, suboptimal micronutrient intake and increased disease risk.7

Quality of foods and dietary patterns

A healthy diet involves more than ensuring intake of the required amount of nutrients to prevent deficiencies. The quality and variety of foods eaten and dietary patterns over time are equally important.1,15 Foods provide a complex mixture of nutrients and other compounds that may have a synergistic effect on health.

Carbohydrates, fat and protein are not homogenous entities. Food structure, food source and processing influence their physiologic effects and the amounts that optimise nutrient status and reduce disease risk.5,7 There is consistent evidence that reducing saturated fats (found predominantly in animal sources, coconut and palm oil) and trans fat (processed fats) by partially replacing them with unsaturated fats reduces the risk of cardiovascular events and coronary deaths. For every 1 percent of energy from saturated fats replaced with polyunsaturated fats, the incidence of coronary heart disease is reduced by 2 to 3 percent.16-19 A recent Cochrane review 20 concluded: “there is a large body of evidence, including almost 60,000 people who have been in studies assessing effects of reducing saturated fat for at least two years each.” The authors report that together, these studies show that reducing saturated fat and replacing it with polyunsaturated fats reduces our risk of cardiovascular disease. Analysis of the results suggested that the degree of reduction in cardiovascular events was related to the degree of reduction of serum total cholesterol, and the data suggested greater protection with greater saturated fat reduction or greater increase in polyunsaturated and monounsaturated fats. The evidence quoted refers to clinical disease endpoints (e.g. cardiovascular events, stroke) and is important in terms of effects on burden of disease. Dietary advice that encourages intake of saturated fat therefore may present a real risk for cardiovascular events, especially in at-risk patients. The evidence for replacement of saturated fat by monounsaturated fat or carbohydrate is not as clear, and this likely depends on type and source, but replacing saturated fat with refined carbohydrates may be harmful.21 Thus, in contrast to the previous focus on absolute amounts, current recommendations now emphasise the type of fat (replacement of unhealthy fats with healthy fats), and the type of carbohydrate (encouraging consumption of minimally processed or unrefined grains and cereals higher in fibre, as well as beans, lentils, peas, fruit and root vegetables and discouraging highly refined carbohydrates and added sugars).22,23 Notably, risks from saturated fat or refined carbohydrates are not mutually exclusive, but co-exist in diets, along with other risks related to, for example, sodium intake, fibre intake and total energy intake.

Healthy dietary patterns

Current evidence supports links between certain dietary patterns and risks of obesity and chronic diseases, particularly cardiovascular disease, hypertension, type 2 diabetes and certain cancers.1,4

Table 1: Recommended ranges of macronutrient goals from selected governmental bodies globally

Nordic countries8 USA, Canada7 Australia, New Zealand5 Europe6

Carbohydrate (% of total energy) 45 – 60 45 – 65 45 – 65 45 - 60

Fat (% of total energy) 25 – 40 20 – 35 20 - 35 20 - 35

Protein (% of total energy) 10 – 20 10 - 35 15 – 25 ---


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For example, systematic reviews of large long-term studies show that several dietary patterns are equally and consistently associated with a reduced risk of future type 2 diabetes.24-26 These dietary patterns vary in their actual macronutrient composition but share several common components, including whole grains, fruit, vegetables, nuts, legumes, healthy vegetable oils, proteins such as lean meat and seafood, little or moderate alcohol, and reduced intake of red and processed meats and sugar-sweetened beverages.

Recommendations from different countries based on best evidence have been consistent in what they have identified as healthy dietary patterns (Box 1). The following is an extract from the Nordic report8: “Decrease energy density, increase micronutrient density, and improve carbohydrate quality. Diets dominated by naturally fibre-rich plant foods will generally be lower in energy density compared to diets dominated by animal foods. Energy density is generally high in food products high in fat and added sugar. Whole grains and whole-grain flour are rich in dietary fibre and have lower energy density compared to refined grains and sifted flour”.4

These guidelines also highlight the importance of achieving and maintaining a healthy weight by maintaining energy balance.

Low carbohydrate dietary pattern

It should be clear from the above, that the dietary pattern associated with carbohydrate restriction (especially the extreme form), is not aligned with healthy variety supported by the evidence. This is especially true for the animal-fat-based versions of low carbohydrate diets. At present, there is a lack of conclusive evidence regarding the health effects of low carbohydrate diets over the long term. However, preliminary data from cohort studies are available which point to an association between low carbohydrate intake and increased risks of heart disease and mortality.28-31 There is also evidence of adverse effects, such as higher heart disease risk, from diets that emphasise animal fat16-19 (e.g. butter and lard), and animal-derived foods.1,11 Furthermore, elimination and restriction of many foods as recommended by low carbohydrate diets reduces dietary variety, which if maintained over time, can result in essential nutrient deficiencies. Promoting such restrictions is particularly concerning in South Africa where poor dietary diversity32 and low vegetable and fruit intake33 are prevalent. Various studies confirm that low carbohydrate diets are linked to poor vitamin C, B1, B3, B6, folate, magnesium and dietary fibre intake.34,35

In South Africa, low carbohydrate and high fat diets have been promoted by some as being appropriate for infants and young children, without sufficient examination of potential negative consequences of such recommendations. Exclusion of certain foods/food groups from the diet, as is recommended in low-carbohydrate high fat diet regimes, increases the risk for nutrient deficiencies. This is a serious concern in infants and young children as such deficiencies could compromise growth, cognitive development and health in general, during a vulnerable life stage.36-38 Furthermore, fostering a healthy relationship with food during childhood is important, and balance, variety and moderation are important components that contribute to this relationship. Introducing a culture of ‘dieting’ or being placed on a diet in childhood is inappropriate and could lead to an unhealthy relationship with food later in life. Restrictive diets for infants should

only be followed in specific medical conditions and under strict medical supervision.39

Culture, availability of foods and income are factors which should be taken into consideration when formulating public health guidelines intended for a population. Cost of food (affordability/economic accessibility), in particular, is considered a major barrier to following dietary advice, and price is the major factor influencing food purchases. Food insecurity is a public health issue in South Africa, with research showing varying levels of household food insecurity in different population groups. In some informal settlements in SA, household food insecurity is as high as 70%.40. Many people consume carbohydrate-based staples because that is all they can afford. For this reason, South Africa implemented the Regulations relating to the fortification of certain foodstuffs in 2003 to ensure that certain commonly consumed staples are fortified with a minimum quantity of specific micronutrients.41

Dietary recommendations for weight loss

The aetiology of overweight and obesity is complex. Various biological, psychological, social and economic vulnerabilities appear to be layered on relatively stable genetic and behavioural susceptibilities, all of which are poorly understood at present.42,43 At the centre of this complexity is the physiologic principle that change in bodyweight results from an imbalance between the energy content of food consumed and the energy used by the body.44 Sustained energy deficit results in weight loss and sustained energy excess results in weight gain.

Box 1: Healthy dietary patterns as described in dietary guidelines from selected governmental bodies globally

United States of America’s 2015 Dietary Guidelines Advisory Committee (DGAC)4: “The overall body of evidence examined by the 2015 DGAC identifies that a healthy dietary pattern is higher in vegetables, fruits, whole grains, low- or non-fat dairy, seafood, legumes, and nuts; moderate in alcohol (among adults); lower in red and processed meats; and low in sugar-sweetened foods and drinks and refined grains.”

Nordic Nutrition Recommendations 20128: “Typical features of a healthy dietary pattern as described in NNR 2012 include plenty of vegetables, fruit and berries, pulses, regular intake of fish, vegetable oils, whole grains, low-fat alternatives of dairy and meat, and limited intake of red and processed meat, sugar, salt and alcohol.”

Australian Dietary Guidelines 201312: “A variety of foods should be consumed from each of the five food groups – vegetables and legumes/beans; fruit; grain (cereal) foods mostly wholegrain and/or high cereal fibre varieties; lean meats and poultry, fish, eggs, nuts and seeds, and/or legumes/beans; and milk, yoghurt, cheese and/or alternatives. Mostly reduced fat milk, yoghurt and cheese products are recommended for adults. Limit intake of foods containing saturated fat, added salt, added sugars and alcohol.”

Brazilian Dietary Guidelines 201413: “Natural or minimally processed foods, in great variety, mainly of plant origin, are the basis for diets that are nutritious, delicious, appropriate, and supportive of socially and environmentally sustainable food systems.”

South African Food-based Dietary Guidelines, 201227: “The food-based dietary guideline ‘Enjoy a variety of foods’ aims to encourage people to consume mixed meals, to increase variety by eating different foods from various food groups, and to alter food preparation methods. A healthy diet contains sufficient water, energy, macronutrients and micronutrient to meet requirements.”


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Weight loss diets

Strong evidence demonstrates that, as part of a comprehensive lifestyle intervention offered by multidisciplinary teams of professionals, overweight and obese adults can achieve weight loss through a variety of dietary patterns if they achieve a sustained energy deficit. Although these dietary patterns will all result in weight loss over a 6-months to 2-year period, long-term effects on cardio-metabolic health may be negative with some dietary patterns.2-4 Current dietary approaches appear to be insufficient to achieve adequate weight loss in most patients with severe obesity and bariatric surgery provides the only solution for these individuals.45 Different weight loss approaches work for different people as long as they are able to achieve a reduction in energy intake.

The available evidence strongly suggests that adherence to diets is the key to weight loss success, and may explain a large part of whether people are able to achieve energy deficit for weight loss, especially in the long run.44 Clinical trials have shown greater weight loss in groups that had better adherence to weight loss diets, regardless of whether diets were low carbohydrate or low fat.3,46,47 Thus, ease of adherence is a critical consideration when recommending weight loss diets.

Dietary patterns that tend to be relatively low in total fat and moderate (not high) in carbohydrate are consistent with reduced risk of excess weight gain.12 In this regard, evidence from a systematic review (including 33 randomised controlled trials (73 589 participants) and 10 cohort studies) showed that lower total fat intake leads to small but statistically significant and clinically meaningful, sustained reductions in body weight in adults in studies with baseline fat intakes of 28 to 43% of energy intake and durations from six months to over eight years. Evidence supports a similar effect in children and younger people.48

Low carbohydrate diets and weight loss

The renewed public interest in low carbohydrate diets has been precipitated in part by selective reporting of publications that suggest beneficial effects, especially on weight loss.49-51 These studies have mostly been small, short (<2 years) trials comparing the effect of diets differing in macronutrient compositions on changes in weight and surrogate health outcomes of chronic diseases, such as blood lipid levels. Systematic reviews of all relevant trials have demonstrated no differences between the various diets52,53 or very small differences after 6 months that disappear after 12 months.49,50 It is, therefore, reasonable to conclude that any diet which supports a sustained dietary energy deficit results in weight loss, regardless of carbohydrate, fat and protein composition.44,52,54 Low carbohydrate diets likely enable some people to lose weight by reducing their energy intake. Carbohydrate is the largest nutrient class, and greatest source of energy. Therefore, when people reduce carbohydrates, they tend to reduce total energy intake by eating less food.55,56 Also, the associated higher protein57 and fat intake58 is known to decrease hunger leading to less food consumption and reduced energy intake. Finally, dietary free sugarsb are a type of carbohydrate. Synthesised evidence from randomised trials and cohort studies54,59 shows that weight change that occurs when intake of free sugars is increased or decreased results from the concomitant changes in energy

intake. Reducing free sugar intake, especially from sugar-sweetened beverages, is seen as an important part of a multi-pronged, transversal strategy to reduce risk of overweight, obesity and dental caries.60 b Free sugars are defined as ‘mono- and disaccharides added to foods by the manufacturer, cook or consumer, and sugars naturally present in honey, syrups, fruit juices and fruit concentrates’.

Conclusions

Although obesity is acknowledged as a complex issue, many debates about its causes and solutions focus on exceedingly simple dichotomies presenting apparently competing perspectives, such as carbohydrate versus fat as the villain. Other examples of dichotomies include personal versus collective obligations for action, supply versus demand-type justifications for intake of unhealthy food, government regulation versus industry self-regulation.43 In the recent Lancet series on obesity,61 an exploration of the dichotomy of individual versus environmental drivers of obesity concludes that “people bear some personal responsibility for their health, but environmental factors can readily support or undermine the ability of people to act in their own self-interest”.43 The authors propose a reframing of obesity that stresses the reciprocal nature of the interaction between the environment and the individual.

Dietary patterns have and are rapidly changing in most countries, particularly in emerging economies, such as South Africa with natural or minimally processed foods of plant origin being displaced with industrialised food products. Aggressively marketed, ultra-processedc, highly palatable, energy-dense foods now dominate our food systems. These foods contain less protein and fibre, more free sugars, total, saturated and trans fats, sodium and, for solid products, more energy per volume, than whole or minimally processed foods.13,62,63

c Ultra-processed foods are made from processed substances extracted or refined from whole foods e.g. oils, hydrogenated oils and fats, flours and starches, variants of sugar, and cheap parts or remnants of animal foods, with little or no whole foods.

Genuine progress in addressing the global obesity epidemic lies beyond the standoff between entrenched dichotomies, and includes changing our societal approach to food, beverages, and physical activity, as well as better accountability on the part of all actors involved.43,64 Debates about the ‘ideal’ macronutrient-focused diet, while shedding little light on workable solutions to ameliorate the persisting problem of obesity; sends out mixed messages and creates public confusion. The opinions that low carbohydrate diets are the best and the solution for obesity (and many other illnesses), arise from good marketing and public relations, rather than good science. While giving attention to the multiple underlying factors involved in obesity, we need to ensure that dietary recommendations for the public are informed by the best, available up-to-date evidence and centred on healthy foods and dietary patterns rather than isolated nutrients, such as carbohydrates.4,8,12,13

This manuscript has not been peer reviewed and reflects the collective position of the Nutrition Society of South Africa and The Association of Dietetics in South Africa on the subject matter. The SAJCN will not accept any responsibility of any claims or dispute(s) arising from the contents of the manuscript.


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12. Australian National Health and Medical Research Council. Australian Dietary Guidelines. Canberra: Australian Government, Department of Health and Aging, National Health and Medical Research Council, 2013.

13. Ministry of Health of Brazil; Secretariat of Health Care; Primary Health Care Department. Dietary Guidelines for the Brazilian population. Brazil: Ministry of Health of Brazil, 2014.

14. Scientific Advisory Committee on Nutrition. Draft carbohydrates and health report. London: Public Health England, 2014.

15. United Nations Standing Committee on Nutrition. Nutrition Targets and Indicators for the Post-2015 Sustainable Development Goals: Accountability for the Measurement of Results in Nutrition: A techincal note. United Nations 2015.

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17. Hooper L, Summerbell CD, Thompson R, Sills D, Roberts FG, Moore HJ, Davey Smith G. Reduced or modified dietary fat for preventing cardiovascular disease. Cochrane Database Syst Rev. 2012;5:CD002137.

18. Mozaffarian D, Micha R, Wallace S. Effects on coronary heart disease of increasing polyunsaturated fat in place of saturated fat: a systematic review and meta-analysis of randomized controlled trials. PLoS Med. 2010;7(3):e1000252.

19. Jakobsen MU, O’Reilly EJ, Heitmann BL, Pereira MA, Balter K, Fraser GE, Goldbourt U, Hallmans G, Knekt P, Liu S, Pietinen P, Spiegelman D, Stevens J, Virtamo J, Willett WC, Ascherio A. Major types of dietary fat and risk of coronary heart disease: a pooled analysis of 11 cohort studies. Am J Clin Nutr. 2009;89(5):1425-32.

20. Hooper L, Martin N, Abdelhamid A, Davey Smith G. Reduction in saturated fat intake for cardiovascular disease. Cochrane Database Syst Rev. 2015;6:CD011737.

21. Jakobsen MU, Dethlefsen C, Joensen AM, Stegger J, Tjonneland A, Schmidt EB, Overvad K. Intake of carbohydrates compared with intake of saturated fatty acids and risk of myocardial infarction: importance of the glycemic index. Am J Clin Nutr. 2010;91(6):1764-8.

22. Threapleton DE, Greenwood DC, Evans CE, Cleghorn CL, Nykjaer C, Woodhead C, Cade JE, Gale CP, Burley VJ. Dietary fibre intake and risk of cardiovascular disease: systematic review and meta-analysis. BMJ. 2013;347:f6879.

23. Ye EQ, Chacko SA, Chou EL, Kugizaki M, Liu S. Greater whole-grain intake is associated with lower risk of type 2 diabetes, cardiovascular disease, and weight gain. J Nutr. 2012;142(7):1304-13.

24. Alhazmi A, Stojanovski E, McEvoy M, Garg ML. The association between dietary patterns and type 2 diabetes: a systematic review and meta-analysis of cohort studies. J Hum Nutr Diet. 2014;27(3):251-60.

25. Esposito K, Chiodini P, Maiorino MI, Bellastella G, Panagiotakos D, Giugliano D. Which diet for prevention of type 2 diabetes? A meta-analysis of prospective studies. Endocrine. 2014.

26. Koloverou E, Esposito K, Giugliano D, Panagiotakos D. The effect of Mediterranean diet on the development of type 2 diabetes mellitus: A meta-analysis of 10 prospective studies and 136,846 participants. Metabolism. 2014;63(7):903-11.

27. Steyn NP, Ochse R. “Enjoy a variety of foods”: as a food-based dietary guideline for South Africa. S Afr J Clin Nutr. 2013;26(3 (Supplement)):S13-S7.

28. Lagiou P, Sandin S, Lof M, Trichopoulos D, Adami HO, Weiderpass E. Low carbohydrate-high protein diet and incidence of cardiovascular diseases in Swedish women: prospective cohort study. BMJ. 2012;344:e4026.

29. Noto H, Goto A, Tsujimoto T, Noda M. Low-carbohydrate diets and all-cause mortality: a systematic review and meta-analysis of observational studies. PLoS One. 2013;8(1):e55030.

30. Sjogren P, Becker W, Warensjo E, Olsson E, Byberg L, Gustafsson IB, Karlstrom B, Cederholm T. Mediterranean and carbohydrate-restricted diets and mortality among elderly men: a cohort study in Sweden. Am J Clin Nutr. 2010;92(4):967-74.

31. Schwingshackl L, Hoffmann G. Low-carbohydrate diets impair flow-mediated dilatation: evidence from a systematic review and meta-analysis. Br J Nutr. 2013;110(5):969-70.

32. Labadarios D, Steyn NP, Nel J. How diverse is the diet of adult South Africans? Nutr J. 2011;10:33.

33. Naude CE. “Eat plenty of vegetables and fruit every day”: a food-based dietary guidelines for South Africa. S Afr J Clin Nutr. 2013;26(3 (Supplement)):S46-S56.

34. Dangelo KN. Nutrient Adequacy of Low versus High Carbohydrate Diets for Older Adults: University of Cincinnati; 2009.

35. Gardner CD, Kim S, Bersamin A, Dopler-Nelson M, Otten J, Oelrich B, Cherin R. Micronutrient quality of weight-loss diets that focus on macronutrients: results from the A TO Z study. Am J Clin Nutr. 2010;92(2):304-12. 8

36. du Plessis LM, Kruger S, Sweet L. Complementary feeding: a critical window of opportunity from six months onwards. S Afr J Clin Nutr. 2013;26(3):S129-S40.

37. Pan American Health Organization/World Health Organization. Guiding Principles for Complementary Feeding of the Breastfed Child. Pan American Health Organization/World Health Organization, 2003.

38. World Health Organization. Global Strategy for Infant and Young Child Feeding. Geneva: World Health Organization 2003.

39. Shaw V. Clinical Paediatric Dietetics. 4th ed. London, United Kingdom: Wiley Blackwell; 2014.

40. Naicker N, Mathee A, Teare J. Food insecurity in households in informal settlements in urban South Africa. S Afr Med J. 2015;105(4):268-70.

41. Department of Health. Regulations relating to the fortification of certain foodstuffs (No. R. 504 of 7 April 2003). . Pretoria: Government Gazette, Republic of South Africa; 2003.

42. World Health Organization. Technical Report Series 894. Obesity, Preventing and Managing the Global Epidemic. Report of a WHO consultation. Geneva: World Health Organization 2000.

43. Roberto CA, Swinburn B, Hawkes C, Huang TT, Costa SA, Ashe M, Zwicker L, Cawley JH, Brownell KD. Patchy progress on obesity prevention: emerging examples, entrenched barriers, and new thinking. Lancet. 2015.

44. Hall KD, Sacks G, Chandramohan D, Chow CC, Wang YC, Gortmaker SL, Swinburn BA. Quantification of the effect of energy imbalance on bodyweight. Lancet. 2011;378(9793):826-37.

45. Colquitt JL, Pickett K, Loveman E, Frampton GK. Surgery for weight loss in adults. Cochrane Database Syst Rev. 2014;8:CD003641.

46. Alhassan S, Kim S, Bersamin A, King AC, Gardner CD. Dietary adherence and weight loss success among overweight women: results from the A TO Z weight loss study. Int J Obes (Lond). 2008;32(6):985-91.

47. Dansinger ML, Gleason JA, Griffith JL, Selker HP, Schaefer EJ. Comparison of the Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart disease risk reduction: a randomized trial. JAMA. 2005;293(1):43-53.

48. Hooper L, Abdelhamid A, Moore HJ, Douthwaite W, Skeaff CM, Summerbell CD. Effect of reducing total fat intake on body weight: systematic review and meta-analysis of randomised controlled trials and cohort studies. BMJ. 2012;345:e7666.

49. Bueno NB, de Melo IS, de Oliveira SL, da Rocha Ataide T. Very-low-carbohydrate ketogenic diet v. low-fat diet for long-term weight loss: a meta-analysis of randomised controlled trials. Br J Nutr. 2013;110(7):1178-87.

50. Hession M, Rolland C, Kulkarni U, Wise A, Broom J. Systematic review of randomized controlled trials of low-carbohydrate vs. low-fat/low-calorie diets in the management of obesity and its comorbidities. Obes Rev. 2009;10(1):36-50.

51. Shai I, Schwarzfuchs D, Henkin Y, Shahar DR, Witkow S, Greenberg I, Golan R, Fraser D, Bolotin A, Vardi H, Tangi-Rozental O, Zuk-Ramot R, Sarusi B, Brickner D, Schwartz Z, Sheiner E, Marko R, Katorza E, Thiery J, Fiedler GM, Bluher M, Stumvoll M, Stampfer MJ, Dietary Intervention Randomized Controlled Trial G. Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet. N Engl J Med. 2008;359(3):229-41.

52. Naude CE, Schoonees A, Young T, Senekal M, Garner P, Volmink J. Low carbohydrate versus isoenergetic balanced diets for reducing weight and cardiovascular risk: a systematic review and meta-analysis. PLoS One. 2014 9(7):e100652.

53. Schwingshackl L, Hoffmann G. Long-term effects of low-fat diets either low or high in protein on cardiovascular and metabolic risk factors: a systematic review and meta-analysis. Nutrition Journal. 2013;12.

54. Te Morenga L, Mallard S, Mann J. Dietary sugars and body weight: systematic review and meta-analyses of randomised controlled trials and cohort studies. BMJ. 2013;346:e7492.

55. Brehm BJ, Seeley RJ, Daniels SR, D’Alessio DA. A randomized trial comparing a very low carbohydrate diet and a calorie-restricted low fat diet on body weight and cardiovascular risk factors in healthy women. J Clin Endocrinol Metab. 2003;88(4):1617-23.

56. Sondike SB, Copperman N, Jacobson MS. Effects of a low-carbohydrate diet on weight loss and cardiovascular risk factor in overweight adolescents. J Pediatr. 2003;142(3):253-8.

57. Yang D, Liu Z, Yang H, Jue Y. Acute effects of high-protein versus normal-protein isocaloric meals on satiety and ghrelin. Eur J Nutr. 2014;53(2):493-500.

58. Little TJ, Horowitz M, Feinle-Bisset C. Modulation by high-fat diets of gastrointestinal function and hormones associated with the regulation of energy intake: implications for the pathophysiology of obesity. Am J Clin Nutr. 2007;86(3):531-41.

59. Malik VS, Pan A, Willett WC, Hu FB. Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis. Am J Clin Nutr. 2013;98(4):1084-102.

60. World Health Organization. Draft guidelines on free sugars released for public consultation, 5 March 2014. Geneva: World Health Organization 2014.

61. Kleinert S, Horton R. Rethinking and reframing obesity. Lancet. 2015.

62. Monteiro CA, Levy RB, Claro RM, de Castro IR, Cannon G. Increasing consumption of ultra-processed foods and likely impact on human health: evidence from Brazil. Public Health Nutr. 2011;14(1):5-13.

63. Monteiro CA, Moubarac JC, Cannon G, Ng SW, Popkin B. Ultra-processed products are becoming dominant in the global food system. Obes Rev. 2013;14 Suppl 2:21-8.

64. Swinburn B, Kraak V, Rutter H, Vandevijvere S, Lobstein T, Sacks G, Gomes F, Marsh T, Magnusson R. Strengthening of accountability systems to create healthy food environments and reduce global obesity. Lancet. 2015.

Pleasenote:Thismanuscripthasnotbeenpeer-reviewedandreflectsthecollectivepositionoftheNutritionSocietyofSouthAfricaandThe

AssociationforDieteticsinSouthAfricaonthesubjectmatter.TheSAJCNwillnotacceptanyresponsibilityofanyclaimsordispute(s)arisingfromthe

contentofthemanuscript.


HOW TO EARN YOUR CEUs1. Complete your personal details below

2. Read the “Joint Statement on Low Carbohydrate Diets for Health and Weight Loss by Nutrition Society of South Africa (NSSA) and Association for Dietetics in South Africa (ADSA)” as reprinted from (SAJCN 2016, 29 (2): 103-107 on pages 14 to 17 and answer the questions on pages 21 to 22.

3. Indicate the answers to the questions by marking an “x” in the appropriate block on page 20.

4.Youwillearn1CEUifyouanswer70%ormoreofthequestionscorrectly.Ascoreoflessthan70%willunfortunatelynotearnyouanyCEUs.

5. Make a photocopy for your own records in case your answers do not reach us or wishes to enquire.

6. Scan and email or post your answers to:

Email: [email protected]

Postal Address: Mrs HE Koornhof, 10 Grey Street, Welgemoed, 7530

Pleasenote:Theanswersshouldnotreachuslaterthan31October2017.Answersheetsreceivedafterthisdatewillnotbeprocessed.

CPDReferencenumber:DT/A01/2017/00094

HPCSAnumber:………………………………………………………………………………………………………………...

(NTorDTwith7digits)

Initials:…………………………………………………………………………………………………………………………….

SurnameasregisteredwiththeHPCSA:…………………………………………………………………………………...

Contactnumber:……………………………………………………………………………………………………………….

E-mailaddress:…………………………………………………………………………………………………………………

PLEASEANSWERALLTHEQUESTIONSANDMARKTHEAPPROPRIATEBLOCKWITHAN“X“

1. A B C

2. A B C

3. A B C

4. A B C

5. A B C

6. A B C

7. A B C

8. A B C

9. A B C

10. A B C


C) All of the above

Choosethecorrectoption:A)orB)orC)

5. A) Strict compliance with a low carbohydrate diet that allows 25 grams of carbohydrate would permit a person only one portion of vegetables and one portion of fruit per day, plus meats, fish and pure fats per day.

B) Strict compliance with a low carbohydrate diet that allows 25 grams of carbohydrate would permit a person only two portions of vegetables or one portion of fruit per day, plus meats, fish and pure fats per day

C) Strict compliance with a low carbohydrate diet that allows 25 grams of carbohydrate would permit a person one portion of fruit of about 180 gram per day, plus meats, fish and pure fats per day


6. A) Dietary recommendations developed by governments and relevant international scientific bodies are related to macronutrients, micronutrients, foods and dietary patterns and intend to promote optimal health by (1) optimising physiological and mental functions and addressing clinical or subclinical nutrient deficiencies, as well as (2) reducing the risk of non-communicable diseases

B) Dietary recommendations developed by governments only relate the needs of country and are not based on the good evidence from a relevant international scientific bodies to promote optimal health and reduce the risk of non-communicable diseases.

C) All of the above


7. A) It depends on the goal of a diet whether you need to also consider the micronutrient adequacy and risk of doing harm.

B) Whether a goal of a diet is weight loss or optimal health and wellness, it should always be nutritionally sound and avoid doing harm.

C) All of the above

1. A) There is a limited amount of systematically synthesised scientific evidence providing support for the current dietary recommendations, which recommend a range of carbohydrate, protein and fat intakes and healthy dietary patterns promote adequate nutrition and reduce disease risk

B) There is a considerable body of systematically synthesised scientific evidence which shows that the current dietary recommendations, which recommend a range of carbohydrate, protein and fat intakes and healthy dietary patterns, promote adequate nutrition and reduce disease risk.

C) There is a no scientific evidence to promote the current dietary recommendations, which recommend a range of carbohydrate, protein and fat intakes and healthy dietary patterns to promote adequate nutrition and reduce disease risk.


2. A) The current healthy diet recommendation for carbohydrate intake ranges from 45 to 65% of total dietary energy, and diets with less than 45% of energy from carbohydrates is regarded as being low in carbohydrates.

B) Even though the current healthy diet recommendation for carbohydrate intake ranges from 45 to 65% of total dietary energy, only diets with less than 30% of energy from carbohydrates is regarded as being low in carbohydrates.

C) None of the above


3. Diets rich in meat and dairy products pose a significant threat to environmental sustainability. Choose the correct option: A. TRUE B. FALSE

4. A) One needs to consider the complete ‘nutrient package’ of a food before including any specific carbohydrate food source in one’s diet as the carbohydrate content is more important than the other essential nutrients such as vitamins, minerals, fibre and phytonutrients.

B) One needs to consider the complete ‘nutrient package’ of a food before excluding it from one’s diet as carbohydrate restriction makes a varied, nutrient- and fibre-rich diet near impossible to achieve.


unsaturated fats reduces the risk of cardiovascular events and coronary deaths

B) A recent Cochrane review concluded: “there is a large body of evidence, including almost 60,000 people who have been in studies assessing effects of reducing saturated fat for at least two years each.” The authors report that together, these studies show that reducing saturated fat and replacing it with polyunsaturated fats reduces our risk of cardiovascular disease.

C) All of the above


10. A) Presently there is a dearth of conclusive evidence regarding the health effects of low carbohydrate diets over the long term.

B) Presently preliminary data from cohort studies point to an association between low carbohydrate intake and decreased risks of heart disease and mortality.

C) All of the above



8. A) Even though dietary recommendations for optimal health are based on comprehensive, systematic and transparent assessments of the evidence, including consultation with stakeholders in the country for which they are produced, the basic foundations of these guidelines remained relatively stable over time, except for some changes in emphasis, mostly on the quality of macronutrient food sources and total diet or dietary pattern.

B) Since dietary recommendations for optimal health are based on comprehensive, systematic and transparent assessments of the evidence, as well as consultation of stakeholders in the country for which they are produced, the basic foundations of these guidelines have changed a lot over time with an emphasis on the quantity of macronutrient food sources and a focus on specific nutrients.

C) All of the above


9. A) There is consistent evidence that reducing saturated fats (found predominantly in animal sources, coconut and palm oil) and trans fat (processed fats) by partially replacing them with

Pleasenote:Theanswersshouldnotreachuslaterthan31October2017.Answersheetsreceivedafterthisdatewillnotbeprocessed.

2016DnB NEWS

World Breastfeeding Week (WBW) takes place from 1-7 August annually and there is a website that contains information

and resources relevant to the theme that can be used throughout the year.

In particular, the theme for this year is highly relevant and topical, and the information that has been provided can be used not only during WBW, because

it focuses on how breastfeeding can contribute to each of the 17 Sustainable Development Goals (SGDs). One of the materials that is already available and can be used throughout the year is a WBW 2016 Calendar, available here. There is also a Facebook page that you can like for regular updates, called WABA World Breastfeeding Week.

Source:ADSA’sinternalcommunication

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The Dietetics and Nutrition News is a newsletter practitioners registered with the Professional Board for Dietetics and Nutrition. Its is produced by the Public Relations and Service Delivery department, HPCSA building, 2nd floor, Madiba Street, Arcadia, Pretoria. Dietetics and Nutrition practitioners are encouraged to forward their contributions to Fezile Sifunda at [email protected] The copyright in the compilation of this newsletter, its name and logo is owned by the Health Professions Council of South Africa. You may not reproduce this newsletter, or its name or the logo of the Health Professions Council of South Africa that appears in this newsletter, in any form, or for commercial purposes or for purposes of advertising, publicity, promotion, or in any other manner implying their endorsement, sponsorship of, or affiliation with any product or service, without the Health Professions Council of South Africa’s prior express written permission. All information in this newsletter, is provided in good faith but is relied upon entirely at your own risk. By making use of this newsletter and its information you agree to indemnify the Health Professions Council of South Africa, Employees and Service Providers from all liability arising from its use.

Copyright and Disclaimer

GENERAL INFORMATION

For any information or assistance from the Council direct your enquiries to the Call CentreTel: 012 338 9300/01Fax: 012 328 5120Email: [email protected]

Where to find us:553 Madiba StreetCorner Hamilton and Madiba Streets Arcadia, Pretoria P.O Box 205Pretoria 0001 Working Hours :Monday – Friday : 08:00 – 16:30Weekends and public holidays – Closed Certificate of Good Standing/ Status, certified extracts verification of licensureSusan Ndwalane Tel: 012 338 3995Email: [email protected] Continuing Professional Development (CPD)Helena da SilvaTel: 012 338 9413Email: [email protected]

Raylene SymonsTel: 012 338 9443Email: [email protected]

Change of contact detailsEmail: [email protected] Ethics and professional practice, undesirable business practice and human rights of Council:Sadicka ButtTel: 012 338 3946Email: [email protected] Service DeliveryEmail: [email protected]: 012 3389301 Complaints against practitionersLegal ServicesFax: 012 328 4895Email: [email protected] Statistical Information and Registers: Yvette DaffueTel: 012 338 9354Email: [email protected]

Professional Board for Dietetics and Nutrition

Communication with the BoardTel: (+27) 12 338 3964/ 3992/ [email protected]


2016DnB NEWS

World Breastfeeding Week (WBW) takes place from 1-7 August annually and there is a website that contains information

and resources relevant to the theme that can be used throughout the year.

In particular, the theme for this year is highly relevant and topical, and the information that has been provided can be used not only during WBW, because

it focuses on how breastfeeding can contribute to each of the 17 Sustainable Development Goals (SGDs). One of the materials that is already available and can be used throughout the year is a WBW 2016 Calendar, available here. There is also a Facebook page that you can like for regular updates, called WABA World Breastfeeding Week.

Source:ADSA’sinternalcommunication

1413

The Dietetics and Nutrition News is a newsletter practitioners registered with the Professional Board for Dietetics and Nutrition. Its is produced by the Public Relations and Service Delivery department, HPCSA building, 2nd floor, Madiba Street, Arcadia, Pretoria. Dietetics and Nutrition practitioners are encouraged to forward their contributions to Fezile Sifunda at [email protected] The copyright in the compilation of this newsletter, its name and logo is owned by the Health Professions Council of South Africa. You may not reproduce this newsletter, or its name or the logo of the Health Professions Council of South Africa that appears in this newsletter, in any form, or for commercial purposes or for purposes of advertising, publicity, promotion, or in any other manner implying their endorsement, sponsorship of, or affiliation with any product or service, without the Health Professions Council of South Africa’s prior express written permission. All information in this newsletter, is provided in good faith but is relied upon entirely at your own risk. By making use of this newsletter and its information you agree to indemnify the Health Professions Council of South Africa, Employees and Service Providers from all liability arising from its use.

Copyright and Disclaimer

GENERAL INFORMATION

For any information or assistance from the Council direct your enquiries to the Call CentreTel: 012 338 9300/01Fax: 012 328 5120Email: [email protected]

Where to find us:553 Madiba StreetCorner Hamilton and Madiba Streets Arcadia, Pretoria P.O Box 205Pretoria 0001 Working Hours :Monday – Friday : 08:00 – 16:30Weekends and public holidays – Closed Certificate of Good Standing/ Status, certified extracts verification of licensureSusan Ndwalane Tel: 012 338 3995Email: [email protected] Continuing Professional Development (CPD)Helena da SilvaTel: 012 338 9413Email: [email protected]

Raylene SymonsTel: 012 338 9443Email: [email protected]

Change of contact detailsEmail: [email protected] Ethics and professional practice, undesirable business practice and human rights of Council:Sadicka ButtTel: 012 338 3946Email: [email protected] Service DeliveryEmail: [email protected]: 012 3389301 Complaints against practitionersLegal ServicesFax: 012 328 4895Email: [email protected] Statistical Information and Registers: Yvette DaffueTel: 012 338 9354Email: [email protected]

Professional Board for Dietetics and Nutrition

Communication with the BoardTel: (+27) 12 338 3964/ 3992/ [email protected]

The Dietetics and Nutrition Newsletter is a newsletter for practitioners registered with the Professional Board for Dietetics and Nutrition. It’s produced by the Public Relations and Service Delivery Department, Health Professions Council of South Africa (HPCSA) building, 2nd floor, Madiba Street, Arcadia, Pretoria. Dietetics and Nutrition practitioners are encouraged

to forward their contributions to Mamokete Mabusela at [email protected] .The copyright in the compilation of this newsletter, its name and logo is owned by the HPCSA. You may not reproduce this newsletter, or its name or the logo of the HPCSA that appears in this newsletter, in any form, or for commercial purposes or for purposes of advertising, publicity, promotion, or in any other manner implying their endorsement, sponsorship of, affiliation with any product or service, without the HPCSA’s prior express written permission. All information in this newsletter, is provided in good faith but is relied upon entirely at your own risk. By making use of this newsletter and its information you agree to indemnify the HPCSA, Employees and Service Providers from all liability arising from its use.

CopyrightDisclaimer

ForanyinformationorassistancefromtheCouncildirectyourenquiriestotheCallCentre

Tel: 012 338 9300/01

Fax: 012 328 5120


Wheretofindus:

553 Madiba Street

Corner Hamilton and Madiba Streets

Arcadia, Pretoria

P.O Box 205

Pretoria 0001

WorkingHours:

Monday – Friday : 08:00 – 16:30

Weekends and public holidays – Closed

CertificateofGoodStanding/Status,certifiedextractsverificationoflicensure

SusanNdwalane

Tel: 012 338 3995


ContinuingProfessionalDevelopment(CPD)

HelenadaSilva

Tel: 012 338 9413


RayleneSymons

Tel: 012 338 9443


Changeofcontactdetails


Ethicsandprofessionalpractice,undesirablebusinesspracticeandhumanrightsofCouncil:

NtsikeleloSipeka

Tel: 012 338 9304


ServiceDelivery


Tel: 012 3389301

ComplaintsagainstpractitionersLegalServices

Fax: 012 328 4895


StatisticalInformationandRegisters:

YvetteDaffue

Tel: 012 338 9354


CommunicationwiththeBoard

Tel: 012 338 3964/ 3992/ 3906


MmakgosiMaifadi

Tel: 012 338 3964

MamoketeMabusela

Tel: 012 338 3992

AbegailNkosi

Tel: 012 338 3906


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