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The cost of a healthy diet

Hettie Schönfeldt, Nicolette Gibson & Hester Vermeulen

School of Agricultural and Food Sciences

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The African Situation

Africa is the only continent where the nutrition situation has deteriorated in recent decades •Since 1990 the number of undernourished people in Africa has increased by nearly 20%

•Under nutrition is a major risk factor and contribute to 28% of deaths in Africa

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NORTHERN CAPENORTHERN CAPENORTHERN CAPENORTHERN CAPENORTHERN CAPENORTHERN CAPENORTHERN CAPENORTHERN CAPENORTHERN CAPE

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NelspruitNelspruitNelspruitNelspruitNelspruitNelspruitNelspruitNelspruitNelspruit

UpingtonUpingtonUpingtonUpingtonUpingtonUpingtonUpingtonUpingtonUpington

BloemfonteinBloemfonteinBloemfonteinBloem fonteinBloem fonteinBloemfonteinBloemfonteinBloemfonteinBloem fontein

Cape TownCape TownCape TownCape TownCape TownCape Tow nCape Tow nCape Tow nCape Town

BishoBishoBishoBishoBishoBishoBishoBishoBisho

PietersburgPietersburgPietersburgPieter sburgPieter sburgPietersburgPietersburgPietersburgPieter sburg

PietermaritzburgPietermaritzburgPietermaritzburgPietermaritzburgPietermaritzburgPietermaritzburgPietermaritzburgPietermaritzburgPietermaritzburg

EASTERN CAPEEASTERN CAPEEASTERN CAPEEASTERN CAPEEASTERN CAPEEASTERN CAPEEASTERN CAPEEASTERN CAPEEASTERN CAPE

Map produced by the Health GIS Centre,Medical Research Council of SA (2004)

Data Source: Municipal Demarcation Board

Current Provinces of South Africa with Provincial CapitalsProvince boundaries

International boundaries

● Population of 46 million people● Majority SA households live in poverty with limited food

variety (mainly staples) available in the homeWhite maize porridge, brown bread, sugar, milk & tea (NFCS, 1999)

● 30.9 % preschool children stunted (Short for their age)vs.

● 56.2% of the adult population overweight or obese (Demographic and Health

Survey, 2003) ● Rapid urbanization and acculturation

● Double burden of disease often evident within same households, and often even within the same

individual

South Africa

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Recent SA Health and Nutrition Developments to combat malnutrition

1. Food Based Dietary Guidelines2. Food Fortification and Supplementation

Program● Iodization of salt● Vitamin A supplementation● Food Fortification Program

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Food Based Dietary Guidelines

●Qualitative statements that express dietary goals in terms of foods

●Represent the best consensus of scientific knowledge and public health advice currently available

●Based on the relationship between diet and disease●Can be used as educational tools for promoting the

importance of nutrition to combat the growing double burden of malnutrition

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Food Based Dietary Guidelines

The FBDG’s are the result of a wide consultative process throughout the country, in line with the recommendations of the World Health Organisation (WHO) and the Food and Agriculture Organisation (FAO)

Eleven guidelines where formulated for healthy eating for South Africans older than 7 years

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Food Based Dietary Guidelines

The following 1st three guidelines provide general health messages to promote a healthy lifestyle:

● Enjoy a variety of foods● Be active● Drink lots of clean, safe water

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Food Based Dietary Guidelines

The following food-based dietary guidelines help us to plan good mixed meals:

● Make starchy foods the basis of most meals● Eat plenty of vegetables and fruit every day● Eat dry beans, split peas, lentils and soya

regularly● Chicken, fish, meat, milk or eggs can be eaten

daily

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Food Based Dietary Guidelines

The following dietary guidelines teach us about moderation and balance for healthy eating:

● Eat fats sparingly● Use salt sparingly● Use food and drinks containing sugar

sparingly and not between meals● If you drink alcohol, drink sensibly

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Food Based Programmes

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Canadian Healthy Eating Guidelines

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Food Groups & Recommended portion sizes

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Recommended balanced diet “Grocery List”“Grocery List”

Bread 1 R5.89Maize 5kg R16.99Soup bones 643g bag R3.34 Maas 1 carton R7.39Milk 2L R15.99Spinach Bunch R2.99Carrots Bunch R2.99Tomatoes 1 R1.61 Onion 1 R1.17 Apple 1 R1.49 Potato 1 R2.48Banana 1 R1.34Orange 1 R2.04

R70.10R70.10

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Recommended balanced diet Current cost per portionCurrent cost per portion

Bread 3 slices R0.87 3 portionsMaize 500 g cooked R0.50 5 portionsSoup bones 450g R2.44 2 portionsMaas 1 carton R7.39 2 portionsSpinach 100 g raw (±4 leaves) R0.66 1 portionCarrots 1 R0.32 1 portionTomatoes 1 R1.61 1 portionOnion 1 R1.17 1 portionApple 1 R1.49 1 portionPotato 1 R2.48 1 portionBanana 1 R1.34 1 portionOrange 1 R2.04 1 portion

R22.31/dayR22.31/day

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South Africa Financial demographics

●Half of the 10 to 11 million households in South Africa can be classified as low-income households

–Have less than ZAR800 per month to spend (Prahalat & Hart, 2006)

●Most households have 5 members:–ZAR5.33 /person /day to meet all needs

●Substantially lower than the international poverty line indicator of US$1.25/day (ZAR11.13)

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THE REALITY

daily nutritionally adequate diet

R22.31VS

R5.33 available per person per day

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Recommended balanced diet

Portions:•8 grains•8 fruits & veggies•2 meat•2 dairy

R22.31/dayR22.31/day

Have available R5.33

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R7.20R7.20

R7.39R7.39

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R5.89R5.89 R5.92R5.92

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1 bread (R5.89) VS

1 potato, 1 orange, 1 tomato (R6.13)

R5.89R5.89

R6.13R6.13

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R1.38R1.38

R1.49R1.49

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Cooked white maize porridge, brown bread, sugar, tea, whole milk and– 5 most often consumed

(NFCS, 2000)

Cereal flours contribute between 50-75% of energy intake of populations in sub-Saharan Africa…

and milling refinement of wheat or maize removes about two-thirds of the vitamins and minerals

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National Food Fortification Program includes the compulsory addition of 8 micronutrients to all maize meal and wheat flours

The fortification cocktail and the addition rates based on National Food Consumption Survey (NFCS), 1999 & South African Vitamin A Consultancy Group Survey (SAVACG), 1994

33,3% of SA children (6-71 months) are vitamin A deficient (SAVACG, 1994)

1 in 2 children consume less than half the recommended level for vitamin A, riboflavin, niacin, vitamin B6, folic acid, calcium, iron and zinc (NFCS, 1999)

General Food Fortification and Supplementation Program in 2003

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Food Fortification Program (2003)

Envisaged Results? Vitamin A and Fe fortification in maize meal and

wheat flour over 5-years could: 1. Prevent one out of four childhood deaths2. Lower maternal deaths by one third3. Increase the working capacity of the labour force

by up to 40%4. Raise the population IQ by 10 to 15 points5. Increase the GDP by 5% at a cost of 0.3%6. Alleviate the iron deficiency cost, which is

predicted to be near US$1-bn/year (SA DoH)

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Food Fortification Program (2003)

●Successful?–National Food Consumption Survey fortification

Baseline (2005) performed 2 years after NFFP was implemented

–Findings: >2 out of 3 children and 1 out of 4 women had a

poor vit A status>1 out of 7 children and 1 out of 5 women had

poor iron status>45% of children had inadequate zinc status

Indicate increases in deficiencies when compared to previous data – regardless of fortification

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Food fortification

● Most nutrients are added to contribute 25% of RDA in 200g raw product– Translates into 370g brown bread–Dependent on consistency of porridge: 530g stiff porridge &

1450g soft porridge

● 2005 study indicated that the average daily intake of maize porridge was 532g/person (345 stiff, 124 soft, 83 crumbly), while brown bread intake was only about 150g/person/day

(Duvenhage & Schonfeldt, 2007)

Effect of inflation on portion size?

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Current consumption patterns

Studies Ethnic GroupsAverage portion consumed (g)Maize Bread Milk Sugar

Adult Food Consumption studies 1983– 2002 All 848 165 204 27Lebowa Study 1991 Black, rural, 10yrs+ 858 153 40.6 19.7Dikgale study 1998 Black, rural, 19yrs+ 891 121 121 26.8THUSA Bana Study 1996 – 1998 Black, urban + rural,10yrs+ 532 115 72.4 20.5Duvenage Study 2005 Black, informal urban,20yrs+ 532 150 56 22

1. Limited amount of money available to spend on food results in a very limited food basket

2. Increase in food prices results in decrease in portion sizes

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Recommended intake: 10 000 kJ/day

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Food inflation in South Africa - Nutrition implications

●Already nutrition dilemma with low vit A, Fe, prot and kJ intake – with decrease in portion sizes = continual decrease

●High risk of food diversity - promoted by dietary guidelines - to decline even more

●Fortification programs are not calculated based on these low consumption values

●Households could, due to inflation, move significantly closer to FAO “Hunger threshold” of 308kCal / 1 260kJ per day

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What should be done?

Food Security

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Possible solutions

Combined effort between government and private sector1. Food Stamp system (Retail & Government)>Awarded free to those most in need (affordability) >Increase availability of certain nutritionally adequate foods

to the poor2. Development of an in-store balanced food basket

(Retail & Producers)>Provides a balanced diet in one basket / bag (nutritionally

adequate) (different content depending on the retailer)>At a reduced price (affordability)>In the shops where the poor consumer would anyway

purchase staple foods (availability)

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Thank You

nicolette.gibson@up.ac.za012 – 361 2333

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1. Food Stamp Program

● The USDA Food Stamp Program – Federal assistance program that provides food to low income people

living in the US – Most food stamp benefits are now distributed using

Electronic Benefit Transfer (EBT) cards but for most of its history the program has used paper vouchers

● Stamps used to purchase any prepackaged edible foods regardless of nutritional value (for example soda and candy could be purchased on food stamps)

● Both consumer and retailer needs to apply for eligibility to receive / accept these EBT cards

● Screening tools are available on the web – to screen for eligibility for food stamps

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1. Food Stamp Program

● Consumer application for Food Stamps must be made at local Food Stamp Office– Criteria

> earnings> rent or mortgage> utility bills> child support> day care expenses>medical bills (if you are 60 or older, or disable)>Child support payments

● Store Eligibility– must sell food for home preparation and consumption and meet at least one of

the criteria below>Offer for sale at least three different varieties of food in each of the following

four staple food groups, with perishable foods in at least two categories, on a daily basis:   Bread & Grains, Dairy, Fruits & Vegetables, Meat, Poultry, Fish    

>At least 50% of the total sales (e.g., food, non-food, services, etc.) at your store must be from the sale of staple food

35http://www.fns.usda.gov/fsp/

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2. Balanced Budget Basket

●Basket / bag containing low cost produce providing all the nutrients required per person per day

●Set at a constant low price with variable contents suiting the retailer and the supplier

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Balanced Budget Basket

●Providing a bag / basket containing foods containing all the nutrients required per person per day

●Variety of products based on the 5 food groups and portions●Could use surplus perishables that would normally not be

sold / removed from the shelves●Does not need to contain the same products every day –

only maintain the requirement:–Provide 8 portions starches–Provide 8 portions fruit and veg–Provide 2 portions meat and meat alternatives–Provide 2 portions dairy and alternatives–Should be sold at a constant reduced price (e.g R10)

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Proposal

●Available all year round at retailer●Containing the most inexpensive products to retailer as

bought from the producer for that day / week●Does not need to be the best and highest quality produce–Could be that which other wise would have been removed from

shelf and not sold (e.g. with marks)– E.g windfalls program for apples in England

●Each basket may be different, as long as it contains the required– E.g indivdual: 8prt starches, 8prt veggies & fruit, 2prt meats and

2prt dairy–OR family pack (For four ppl)–OR weekly basket (For either)

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Balanced Budget Basket

●Will contain the most affordable options: –8 portions starch >500g starch, (e.g. half bread 350g + 150g raw maize meal)

–2 portions dairy >100g cheese OR container maas OR 250 ml canned milk OR

500ml milk OR 500 ml sour milk or 1½ cup yogurt etc… –2 portions meat and meat alternatives >±200g made up from Soup bones (greater weight needed) OR

oval OR gizzards OR eggs (2 eggs) OR legumes OR nuts etc…–8 portions fruits and vegetables >800g made up of a variety of the most affordable fruits and

vegetables including at least one vitamin A rich vegetable and one green vegetable