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A critical review from our regional partners

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South Africa aims to be sustainable, but ultimately they rely heavily on fossil fuels ( Coal)

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sustainable systems

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Table of Contents

1. What Is Sustainable Eating?

2. Sustainable Food Practices

3. Sustainable Eating Habits

4. How to Eat Sustainably

5. Sustainable Food Choices and Best Practices

6. Examples of Sustainable Foods

Does the way we eat affect the environment? Scientists say yes. Diets high in animal protein and certain crops can increase water usage, contribute to soil depletion, and release methane and other fossil fuel emissions into the atmosphere. Large-scale agriculture and livestock husbandry rely on highly resource-intensive farming practices. However, eating a sustainable diet can mitigate these impacts and help lessen the impact of agriculture on the environment.

The more individuals adopt the principles of food sustainability, the more it can help reduce the impact of climate change on the environment as well as on our health and well-being.

What Is Sustainable Eating?

Sustainable eating means choosing foods based on the impact of their production on soil, water consumption, pesticides, land clearing, greenhouse gasses, and fossil fuel usage. People who try to eat sustainably choose foods that are produced by farming practices that are the least harmful and the most beneficial to the environment.

Choosing to eat sustainably doesn't just have an environmental impact. It's also widely recognized as more nutritious than a conventional diet.

Components of a Sustainable Diet

A sustainable diet consists mainly of vegetables, legumes, whole grains, certain nuts, and fruits. It avoids most processed foods such as sugar and refined grains. Eating sustainably can include meat and fish that are grown and harvested in environmentally conscious ways. However, red meat, primarily beef, is not considered sustainable, since it contributes heavily to methane emissions and land deforestation. Dairy farming is also considered unsustainable due to methane emissions.

Benefits of a Sustainable Diet

Eating sustainably is less expensive than a diet rich in meat, since legumes and grains are less costly to produce than livestock and require fewer resources. These foods are high in nutrients. They can help people avoid chronic illnesses such as high blood pressure, which has been linked to a diet high in red meat and processed foods.

Sustainable Food Practices

Sustainable food practices start with understanding the impact of modern agriculture on climate change and the environment. Only then can people make informed choices about the food they buy and consume. As with any new practice, it can be difficult to know where to begin. It can also be hard to know if adopting sustainable eating as part of the solution to climate change can make a difference.

It's not possible to discuss sustainable food practices without talking about sustainable agriculture. Some sustainable choices, such as eating little to no red meat, can reduce methane emissions by reducing demand for beef. Conventionally grown vegetables, fruits, and nuts also require a lot of water and pesticides.

The Scope of the Problem

Agriculture accounts for 40% of the world's methane emissions, according to the United Nations' Global Methane Assessment. This largely comes from raising livestock and rice cultivation. Methane is one of the leading causes of global warming. One result of a warmer climate? Rising temperatures reduce crop yields, which can increase food insecurity around the world.

In 2020, U.S. agriculture emitted 669.5 million metric tons of carbon dioxide, nitrous oxide, and methane, according to the Environmental Protection Agency (EPA). Cattle, corn, and soybeans make up the top three farm products in the U.S., all of which are resource-intensive and have a high carbon footprint. Cattle and soybean production are also the largest drivers of deforestation in the Amazon basin, which increases carbon in the atmosphere.

Another example is almond farming in California. Almond production is a major user of water in the state. Producers use bees to pollinate their trees, and bees are under environmental pressures from pesticides and other factors, causing die-offs. Climate change-caused drought is causing conflict between agriculture and other water users. Almond producers are adopting sustainable practices, which may help to ease some of these effects.

Can sustainable food production, also known as climate-smart agriculture, meet the demand in a world that's expected to reach a global population of 8.6 billion in 2030? The answer may be: It's going to have to.

Sustainable Farming

Sustainable agriculture dates back thousands of years. Cultures around the world developed best practices for their regions based on soil and water characteristics. When scientists conduct experiments on the effectiveness of these practices, the results are promising. They can help reduce the carbon footprint of agriculture and counter the threat of a warming planet.

When farmers take sustainability into account, they can incorporate many farming practices that add biodiversity to the environment; reduce pesticides, fertilizers, and water usage; and decrease their carbon footprint. Not all these practices work for every farm, of course. Some of these practices include:

Reducing reliance on chemical fertilizers. Farmers are using methods such as mixing manure or compost directly into the soil, reducing the need for man-made fertilizers, which can pollute groundwater.

Planting crops that add nutrients to the soil. Farmers can plant clover or legumes to add nutrients to the soil, increasing the crop yields.

Planting cover crops. Cover crops slow erosion, act as natural pesticides, and improve water use.

Implementing agroforestry. This involves planting crops in forests, allowing the trees to provide shade and improve biodiversity.

Sustainable fishing. Sustainable agriculture practices also include harvesting fish to prevent overfishing and reducing bycatch.

Raising beef on grass. Raising cattle on grass until slaughtered can reduce the impact of finishing cattle with high-resource-grown feed. It also produces leaner, healthier meat.

Sustainable Choices

Based on this information, individuals can make choices at the grocery store or farmers market that support sustainable food production. As more people approach food buying with this knowledge in mind, it may encourage a shift toward sustainable farming. With that in mind, here are some tips for grocery shopping.

Smart shop the grocery aisle. Navigate toward plant foods, choose meat sparingly, and avoid processed foods.

Bring bags from home. Reusable totes or upcycled bags help reduce plastic waste.

Buy in bulk. Grains, legumes, nuts, and dried fruits can be cheaper in bulk and can be portioned out later.

Read labels. Was the fish sustainably harvested? Is the beef grass fed? Where does the food come from?

Don't overbuy. Try to avoid food waste and only buy as much as necessary so it can be consumed before it goes bad.

Sustainable Eating Habits

Adopting sustainable eating habits means taking a well-rounded approach to food. Besides being mindful of how food is produced, it's important to take food storage and food waste into consideration. It can mean being adventurous about trying new foods and new recipes. Daily meals may require more thought and meal prep until the habit becomes ingrained.

Sustainable eating habits include:

Choose a Plant-Based Diet

A plant-based diet is more sustainable than a diet heavy in animal protein or processed sugars. This doesn't mean that everyone must become vegan or vegetarian. A sustainable diet can include sustainably harvested seafood, and beef and dairy in small quantities. A diet rich in vegetables, fruits, legumes, and nuts is high in nutrients and reduces risk of heart disease and cancer.

Buy Local and in Season

The general wisdom is that buying locally and in season are important parts of a sustainable diet. The real answer is more complex.

Emissions from food transportation are only a tiny part of food production's carbon footprint, so it's possible to eat sustainably without going to the local farmers market. The big exception is food that travels by air. These are often fresh berries and vegetables with a short shelf life.

Buying food in season tends to be more sustainable. Food grown outdoors in season requires less energy and water than food cultivated in artificial, controlled environments. It may often be more nutritious and tastier. Eating seasonably can also lead to a more varied diet as different fruits and vegetables become available.

Reduce Food Waste

The Food and Drug Administration (FDA) estimates that 30%-40% of all food produced in the U.S. is wasted - roughly 133 billion pounds of food in 2010. All the resources that went into producing that food also went to waste. Therefore, reducing food waste is a crucial habit. Methods include using vegetable scraps (and bones, if eating meat) to make soup stock or broth and freeze for later. Buying less at the grocery store can also prevent food waste. Understanding the difference between "use by" and "sell by" dates can help avoid throwing out perfectly good food.

Choose Sustainable Packaging

Styrofoam meat trays covered in plastic wrap are part of unsustainable food production. This packaging is made of fossil fuels and can't be recycled or composted, adding to climate change and environmental degradation. Sustainable food packaging can be made from microbial biodegradable polymers that keep food fresh and safe until consumed.

How to Eat Sustainably

Successfully transitioning to a sustainable diet can be a long process, but it doesn't have to be a difficult one. Not every change will work for a particular individual. Food choices are intensely personal. Food allergies and intolerances will impact sustainable options. Ready to get started with eating sustainably?

Start Small

Start with small changes. Commit to one meatless dinner a week, then daily. Identify recipes and meal plans that make sense for individual budgets and households. Research alternatives to old favorites.

Replace Red Meat

Maybe that means exchanging hamburgers with a veggie burger and topping it with favorite burger toppings. Remember that beans, lentils, and peas aren't the only sources of protein. Nuts and certain plants such as broccoli and asparagus are high in protein.

Note that there is some question on the sustainability of plant-based meat replacement products, especially with regard to water usage and emissions.

Reconsider Seafood

Salmon is a healthy fish chock full of omega-3 fatty acids and other nutritional goodness. However, it's mostly farmed, and has to be flown to most markets. Mussels, scallops, clams, and other shellfish are more environmentally sustainable than salmon and other fish that may be farmed or overfished.

Add Mushrooms

Mushrooms are high in protein and other nutrients. They are also a source of umami, which adds extra flavor to foods. There are many dozens of varieties of mushrooms, and they can be bought fresh or dried for an extra flavor punch.

Remember Packaging

A great deal of food packaging is designed to catch the eye rather than preserve food from spoilage or contamination. Choosing compostable packaging and avoiding foods wrapped in plastic contribute to sustainable eating. Bring reusable bags to prevent plastic from entering the environment, where it can harm animals and plant life. Other packaging choices include reusable mugs instead of paper coffee cups and buying in bulk.

Be Adventurous

Eating sustainably should be tasty. Try new foods and new recipes and choose favorites. Spices and sauces open up a new world of food options. By shifting the focus of meals away from meat and toward other nutritious foods, sustainable eaters can enjoy a wide variety of cuisines.

Sustainable Food Choices and Best Practices

The following sustainable food practices can stretch food dollars, reduce food waste, and increase the nutritional bang for the buck.

Meal Plans

Before going to the grocery store, start with a meal plan. Meal planning is a way to save on costs and make sure food doesn't go to waste. Meal planning can also help prevent impulse buys. It makes it easier to cook at home rather than going out to dinner at the last minute, which can be twice as expensive as eating in.

Advance Meal Prep

Sometimes, the last thing someone wants to do at the end of a long day is cook dinner. That's where advanced meal preparation comes in. Slow cookers and multi cookers are efficient timesavers that help ensure food doesn't go to waste. Some other options are choosing one day to cook for the week and freezing meals. While this may seem more about efficiency than sustainability, remember that throwing food out is a huge problem and a terrible waste of resources.

Organic vs. Non-Organic: Which Is Better?

While many organic foods are sustainably grown or harvested, buying organic isn't always the answer. For instance, organic beef and organic dairy still produce more methane than plants grown with fertilizers and pesticides. A diet that avoids red meat and cheese can be sustainable without being organic.

Eat Leftovers, Use Food Scraps

When food ends up in landfills, it's a waste of not only the food itself but of the resources that went into producing it. Eating leftovers is an excellent way to prevent food and resource waste. Similarly, using food scraps and bruised or ugly produce in stocks and soups is an effective way to get all the nutrition from each food dollar.

Community-Supported Agriculture (CSA)

CSAs are organized by local farms that offer a subscription or share model to consumers. Households can choose a weekly or twice-monthly box. They either pick up their boxes or have their vegetables and foods delivered. The benefits of CSAs are that products are local and in season, both aspects of sustainable eating. CSAs also connect consumers with the source of their food, which is also an important part of sustainability.

Freeze and Preserve Food

Treat the freezer like a pantry. Freezing food can save it from spoiling before being used, reducing food waste. Frozen berries and vegetables can also be a great way to buy these products out of season. Learning to can and jar foods safely can extend the life of foods as well.

Examples of Sustainable Foods

Sustainability is an exercise in eating thoughtfully. It means looking at everything involved with the food on the plate - from where it was planted; to how it was fertilized, grown, and harvested; and finally to how it arrived at the grocery store or farmers market. It means growing food for the people of a region, rather than exporting it to other countries, reducing the food's carbon footprint.

Sustainability also recognizes tradeoffs. For many people, a vegan diet is not an option. Rather, a "flexitarian" diet, in which people eat mostly vegetables and some meat, is perfectly sustainable. And some foods are more sustainable than others and have a smaller carbon footprint. Every little bit helps.

Examples of sustainable foods include the following:

Grass-Fed Beef and Lamb

Even with the concerns regarding red meat, grass-fed beef in moderation can be part of a sustainable diet. This is also true for lamb. Well-maintained forage, using techniques such as rotating crops with pastureland, can preserve the health of the environment.

Mussels and Other Bivalves

These filter feeders transform waste into nutrients. Mussel fisheries also create microhabitats for other ocean wildlife. Mussels, clams, oysters, and scallops can be grown and harvested with very little environmental impact.

Local Fruits and Vegetables

CSAs are an excellent source of local fruits and vegetables. These items from local farms can be eaten in season or preserved and pickled. Local cultivation also means there's more opportunity to grow different varieties of common foods. These heirloom varieties speak to the diversity that at one time characterized the global food system. Eating locally can help support a return of these heirloom food varieties, increasing nutritional options.

Seaweed

Seaweed is a highly nutritious food and has promise as a fertilizer, animal feed, and a replacement for plastics. It can also be used to convert agricultural runoff into food and help prevent acidification of the oceans. In some regions, the cultivation of seaweed along with bivalves (muscles) can potentially provide an opportunity to shift away from fishing, easing overfishing.

Eat Sustainably and Help Protect Our Air, Soil, and Water

Modern agriculture has done much to feed a growing population, eliminating hunger in many parts of the world. However, livestock husbandry is a huge source of methane emissions. Monoculture has caused environmental degradation. The widespread use of chemical fertilizers and pesticides threatens to contaminate the shrinking water supply.

The advance of climate change means sustainable food practices are more essential than ever to reducing the carbon emissions and environmental impact of food production. Whether you choose sustainable eating for the health benefits or environmental impact, these choices mean a more positive future for the world.
Infographic Sources Environmental Protection Agency, "Preventing Wasted Food at Home" World Wildlife Fund, "Fight climate change by preventing food waste" Financial Times, "How methane-producing cows leapt to the frontline of climate change" Food and Agriculture Organization of the United Nations, "Key facts and findings" World Resources Institute, "6 Pressing Questions About Beef and Climate Change, Answered" The Beet, "These Plant-based Foods Are Terrible for the Planet. Here's What to Eat Instead"

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Guide to Sustainable Eating: Improving Your Health and the Planet

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What is sustainable eating and how can it help the environment? Find out how to make sustainable food choices that will improve your health and the planet.

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Regenerative Agriculture - Grass Fed vs Grain Fed

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“We need to treat the whole problem of health in soil, plant, animal and man as one great subject” - Sir Albert Howard

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South africa has sustainable food system, but does not consume sustainably

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Due to 95% of their beef and poultry production coming from feedlots, they are not sustainable. Feedlots produce methane and harmful gasses into the environment.

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Plant-based diets can reduce the amount of methane produced into the atmosphere by cutting down the amount of meat needed to feed the country. Instead of meat, especially red meat, eating more fresh fruits, grains, and vegetables can cut down on emissions.

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Food and Agriculture Organization of the United Nations

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Official name

Food-based dietary guidelines for South African.

Paediatric food-based dietary guidelines for South Africa.

Publication year

South Africa first published FBDGs in 2003. A revised version was launched in 2012.

Process and stakeholders

The South African guidelines were developed by the Nutrition Society of South Africa in partnership with the Department of Health, the Medical Research Council, academics, food producer organizations and United Nations agencies. They were adopted by the National Department of Health, Directorate of Nutrition.

A national working group revised the South African set of FBDGs (i.e. the draft paediatric FBDGs and the general FBDGs). A food guide and documentation have also been developed, in collaboration with the FAO, to support the revised FBDG messages.

Intended audience

The revised general FBDGs target people 5 years and older. The proposed paediatric FBDGs target children 0-5 years.

Food guide

The South African food guide displays seven food groups to be eaten regularly: starchy foods; vegetables and fruits, dry beans, peas, lentils and soya; chicken, fish, meat and eggs; milk, maas, yoghurt; fat and oil; and water.

It only shows food groupings (composed of local and affordable foods) that are necessary for healthy eating, and unlike other food guides, it does not include items whose consumption should be limited, such as highly processed foods high in sugar, fat and salt.

The size of each food group segment reflects the volume the group should contribute to the total daily diet.
Messages

Enjoy a variety of foods.

Be active!

Make starchy foods part of most meals.

Eat plenty of vegetables and fruit every day.

Eat dry beans, split peas, lentils and soya regularly.

Have milk, maas or yoghurt every day.

Fish, chicken, lean meat or eggs can be eaten daily.

Drink lots of clean, safe water.

Use fats sparingly. Choose vegetable oils rather than hard fats.

Use sugar and foods and drinks high in sugar sparingly.

Use salt and food high in salt sparingly.

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Official name Food-based dietary guidelines for South African. Paediatric food-based dietary guidelines for South Africa. Publication year South Africa first published FBDGs in 2003. A revised version was launched in 2012. Process and stakeholders The South African guidelines were developed by the Nutrition Society of South Africa in partnership with the Department of Health, the Medical Research Council, academics, food producer organizations and United Nations agencies.

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Nutrition is the biochemical and physiological process by which an organism uses food to support its life. It includes ingestion, absorption, assimilation, biosynthesis, catabolism and excretion.

The science that studies the physiological process of nutrition is called nutritional science (also nutrition science).

Organisms primarily provide themselves with carbon in one of two ways: autotrophy (the self-production of organic food) and heterotrophy (the consumption of existing organic carbon). Combined with the source of energy, either light ( phototrophy) or chemical ( chemotrophy), there are four primary nutritional groups for organisms.

Nutrients are substances used by an organism to survive, grow, and reproduce. The seven major classes of relevant nutrients for animals (including humans) are carbohydrates, dietary fiber, fats, proteins, minerals, vitamins, and water. Nutrients can be grouped as either macronutrients (carbohydrates, dietary fiber, fats, proteins, and water needed in gram quantities) or micronutrients (vitamins and minerals needed in milligram or microgram quantities).

In nutrition, the diet of an organism is the sum of foods it eats, which is largely determined by the availability and palatability of foods.

Human nutrition deals with the provision of essential nutrients from food that are necessary to support human life and good health. In humans, poor nutrition can cause deficiency-related diseases such as blindness, anemia, scurvy, preterm birth, stillbirth and cretinism, or nutrient excess health-threatening conditions such as obesity and metabolic syndrome; and such common chronic systemic diseases as cardiovascular disease, diabetes, and osteoporosis. Undernutrition can lead to wasting in acute cases, and stunting of marasmus in chronic cases of malnutrition.

Animal nutrition focuses on the dietary nutrients needs of animals, often in comparison (or contrast) to other organisms like plants. Carnivore and herbivore diets are contrasting, with basic nitrogen and carbon proportions vary for their particular foods. Many herbivores rely on bacterial fermentation to create digestible nutrients from indigestible plant cellulose, while obligate carnivores must eat animal meats to obtain certain vitamins or nutrients their bodies cannot otherwise synthesize. Animals generally have a higher requirement of energy in comparison to plants.

Plant nutrition is the study of the chemical elements that are necessary for plant growth. There are several principles that apply to plant nutrition. Some elements are directly involved in plant metabolism. However, this principle does not account for the so-called beneficial elements, whose presence, while not required, has clear positive effects on plant growth.

A nutrient that can limit plant growth according to Liebig's law of the minimum is considered an essential plant nutrient if the plant cannot complete its full life cycle without it. There are 16 essential plant soil nutrients, besides the three major elemental nutrients carbon and oxygen that are obtained by photosynthetic plants from carbon dioxide in the air, and hydrogen, which is obtained from water.

Plants uptake essential elements from the soil through their roots and from the air (consisting of mainly nitrogen and oxygen) through their leaves. Green plants obtain their carbohydrate supply from the carbon dioxide in the air by the process of photosynthesis. Carbon and oxygen are absorbed from the air, while other nutrients are absorbed from the soil. Nutrient uptake in the soil is achieved by cation exchange, wherein root hairs pump hydrogen ions (H⁺) into the soil through proton pumps. These hydrogen ions displace cations attached to negatively charged soil particles so that the cations are available for uptake by the root. In the leaves, stomata open to take in carbon dioxide and expel oxygen. The carbon dioxide molecules are used as the carbon source in photosynthesis.

Although nitrogen is plentiful in the Earth's atmosphere, very few plants can use this directly. Most plants, therefore, require nitrogen compounds to be present in the soil in which they grow. This is made possible by the fact that largely inert atmospheric nitrogen is changed in a nitrogen fixation process to biologically usable forms in the soil by bacteria.

Plant nutrition is a difficult subject to understand completely, partially because of the variation between different plants and even between different species or individuals of a given clone. Elements present at low levels may cause deficiency symptoms, and toxicity is possible at levels that are too high. Furthermore, deficiency of one element may present as symptoms of toxicity from another element and vice versa.[citation needed ]

Carpenter, Kenneth J. (1994). Protein and Energy: A Study of Changing Ideas in Nutrition. Cambridge University Press. ISBN 978-0-521-45209-0.

Curley, S., and Mark (1990). The Natural Guide to Good Health, Lafayette, Louisiana, Supreme Publishing

Galdston, I. (1960). Human Nutrition Historic and Scientific. New York: International Universities Press.

Gratzer, Walter (2006) [2005]. Terrors of the Table: The Curious History of Nutrition. Oxford University Press. ISBN 978-0-19-920563-9.

Mahan, L.K.; Escott-Stump, S., eds. (2000). Krause's Food, Nutrition, and Diet Therapy (10th ed.). Philadelphia: W.B. Saunders Harcourt Brace. ISBN 978-0-7216-7904-4.

Thiollet, J.-P. (2001). Vitamines & minéraux. Paris: Anagramme.

Walter C. Willett; Meir J. Stampfer (January 2003). "Rebuilding the Food Pyramid". Scientific American. 288 (1): 64-71. doi:10.1038/scientificamerican0103-64. PMID 12506426.

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Nutrition is the biochemical and physiological process by which an organism uses food to support its life. It includes ingestion, absorption, assimilation, biosynthesis, catabolism and excretion. The science that studies the physiological process of nutrition is called nutritional science (also nutrition science).

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Freshwater is a critical resource that we all depend on, and yet only three percent of the Earth's water supply is freshwater, found in glaciers, water bodies and groundwater, with only a half a percent of that available for our use. In other words, if the world's water supply were 26 gallons, our useable supply of freshwater would be half a teaspoon.

Climate change has severely impacted our water supply. Saltwater intrusion and competition from new water users has further exacerbated conditions. America's farmers and ranchers are struggling to keep production going and growing to feed an increasing population here in the U.S. and around the world, despite these challenges. Today and in the future, they will be called on to do more with less water.

USDA's Natural Resources Conservation Service (NRCS) can help. NRCS works one-on-one with farmers, ranchers, and foresters to help them implement conservation practices and approaches that conserve water while at the same time improving the health of their lands, helping each drop of water go further.

Check out these examples:

Irrigation Pipeline

Farmers can conserve water by making improvements to their irrigation systems. An irrigation pipeline carries water, either for storage or for applying on the land. Steve Burke in Sheridan, Montana, uses this practice on his cattle, hay, and grain operation. By replacing his old method of flood irrigation with a new irrigation pipeline and gravity sprinkler system, Steve uses half the water he used to, and can water his crops in a fraction of the time.

See how irrigated pipelines work:

Cover Crops

Cover crops improve the health of soils by keeping the soil covered, cooling the surface, and reducing water lost to evaporation. They increase the organic matter in the soil, which improves soil structure, prevents soil erosion, and ensures water and nutrients stay where they should be, in the soil. Healthy soils help plants better utilize water, meaning less is needed. Farmers plant covers, like grass, small grain, or legumes in the time periods between growing their cash crops.

See how cover crops work:

Residue and Tillage Management (No-Till)

No-till is the practice of creating a narrow furrow just large enough for a seed to be placed, typically using a no-till planter. By not plowing or disking, prior cash and cover crop residues stay on the surface, protecting the soil and keeping it healthier than it would be using conventional tillage. When it breaks down into organic matter it helps improve soil structure. Fields managed using high-residue no-till for multiple years generally have higher levels of organic matter, higher infiltration rates and a higher water holding capacity than conventionally tilled fields. That means water received gets and stays in the field instead of running off the land or moving below plant roots.

See how no-till works:

There are currently more than 160 conservation practices available to help farmers and ranchers with natural resource concerns on their lands, including conserving water. NRCS staff is available at service centers across the country to help answer questions and provide one-on-one advice and assistance. To find a local service center, visit farmers.gov/service-center-locator

To find out more about conservation practices that conserve water, visit farmers.gov/conservation.

Erika Cross manages strategic communications at USDA. She can be reached by email at  erika.cross@usda.gov.

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Freshwater is a critical resource that we all depend on, and yet only three percent of the Earth's water supply is freshwater, found in glaciers, water bodies and groundwater, with only a half a percent of that available for our use.

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South Africa has a healthy and nutritious reccomended diet, that contains foods that can be obtained locally, while excluding food that should be consumed with moderation like processed foods.

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Irrigation Pipeline: A pipeline and appurtenances installed to convey water for storage or application as part of an irrigation water system

Cover Crops: plants that are planted to cover the soil rather than for the purpose of being harvested. Cover crops manage soil erosion, soil fertility, soil quality, water, weeds, pests, diseases, biodiversity and wildlife in an agroecosystem—an ecological system managed and shaped by humans.

Residue and Tillage Management: Limiting soil disturbance to manage the amount, orientation and distribution of crop and plant residue on the soil surface year around.

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Do the people of South Africa follow dietary restrictions?

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Do the people of South Africa follow dietary restrictions?

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The government's plan in theory is nutritious, but economic disparities in the country limit the population's access to nutritious food, therefore meaning the general population typically doesn't follow these guidelines and are not nutritious.

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Abstract

Objective:

To determine the level of adherence and to assess the association between higher adherence to the South African food based dietary guidelines (SAFBDG) and breast cancer risk.

Design:

Population-based, case-control study (the South African Breast Cancer study) matched on age and demographic settings. Validated questionnaires were used to collect dietary and epidemiological data. To assess adherence to the SAFBDG, a nine-point adherence score (out of eleven guidelines) was developed, using suggested adherence cut-points for scoring each recommendation (0 and 1). When the association between higher adherence to the SAFBDG and breast cancer risk was assessed, data-driven tertiles among controls were used as cut-points for scoring each recommendation (0, 0·5 and 1). OR and 95 % CI were estimated using multivariate logistic regression models.

Setting:

Soweto, South Africa.

Participants:

Black urban women, 396 breast cancer cases and 396 controls.

Results:

After adjusting for potential confounders, higher adherence (>5·0) to the SAFBDG v. lower adherence (<3·5) was statistically significantly inversely associated with breast cancer risk overall (OR = 0·56, 95 % CI 0·38, 0·85), among postmenopausal women (OR = 0·64, 95 % CI 0·40, 0·97) as well as for oestrogen-positive breast cancers (OR = 0·51, 95 % CI 0·32, 0·89). Only 32·3 % of cases and 39·1 % of controls adhered to at least half (a score >4·5) of the SAFBDG.

Conclusions:

Higher adherence to the SAFBDG may reduce breast cancer risk in this population. The concerning low levels of adherence to the SAFBDG emphasise the need for education campaigns and to create healthy food environments in South Africa to increase adherence to the SAFBDG.

Keywords: Breast cancer prevention, Diet and cancer, Dietary guidelines, Black urban women, South Africa

South Africa, an upper-middle income country, is undergoing a rapid nutrition transition characterised by shifts in dietary-and-lifestyle patterns. Nutritious traditional meals and active lifestyles are being replaced with frequent consumption of highly processed foods, often being energy dense and nutrient poor, and high levels of physical inactivity and sedentary behaviour. Concurrent to these dietary-and-lifestyle shifts is the continuously increasing rate of obesity, especially among South African women. Obesity and overweight are important risk factors for different cancer types, especially postmenopausal breast cancer. Breast cancer is the leading diagnosed cancer among South African women and contributes to current public health challenges in South Africa. The age-standardised incidence rate of breast cancer in South Africa is 52·6 per 100 000 women, while the age-standardised mortality rate is 16·0 per 100 000 women. Incidence rates of breast cancer are lower in black South African women (age-standardised rate of 20·8) compared with other ethnic groups (white, coloured and Indian), but evidence suggests that black women have higher mortality rates compared with other races. Based on data from 2020, incidence rates of all cancer cases, including breast cancer, are predicted to rise with 47 % by 2040. This is worrisome since higher incidence rates may simultaneously increase mortality rates, especially in resource poor countries such as South Africa. It is therefore important to identify specific, modifiable risk factors that could be used to implement preventive actions, especially for black South African women.

The FAO of the UN and WHO recommend country-specific food based dietary guidelines (FBDG) to promote healthy dietary patterns. The aim of country-specific FBDG is to reduce nutrition deficiencies and to assist in preventing the development of non-communicable diseases. The South African food based dietary guidelines (SAFBDG) were initially published in 2003 and revised in 2012. These recommendations consist of eleven short, simple and clear nutrition messages that promote a varied and adequate diet and consider foods that are available, culturally sensitive, affordable and environmentally sustainable. However, the level of adherence to the SAFBDG and the association thereof with breast cancer in black women from Soweto are not yet known.

A similar study, conducted in black women from Soweto, South Africa, recently showed that higher adherence to the 2018 World Cancer Research Fund/American Institution for Cancer Research's (WCRF/AICR) Cancer Prevention Recommendations was associated with a lower breast cancer risk in this population. Although the SAFBDG promote similar dietary guidelines as the 2018 WCRF/AICR Cancer prevention guidelines (i.e. increase consumption of fruit, vegetable, beans, lean meats and limit foods high in saturated fat and added sugar), there are some important differences between the two sets of recommendations to consider. Compared with the 2018 WCRF/AICR Cancer Prevention Recommendations, the SAFBDG are guidelines specifically developed for South Africa based on prevailing dietary patterns which aim to address current nutrition-related health problems within South Africa. On the other hand, the 2018 WCRF/AICR Cancer Prevention Recommendations are more lifestyle orientated and include cancer-specific recommendations, based on robust evidence from mostly higher income countries. Investigating the association between adherence to the SAFBDG and breast cancer risk will complement the previous work of Jacobs and colleagues (2021) by providing additional country-specific or context-specific insight into the diets (and variety thereof) of black women from Soweto, South Africa. The current study aims to first investigate the level of adherence to the SAFBDG (overall and for each individual SAFBDG recommendation) and second to assess whether higher adherence to the SAFBDG (overall and for each individual SAFBDG recommendation) is associated with a reduced breast cancer risk in black South African women from Soweto.

Methods and study population

The database from the South African Breast Cancer (SABC) study, a population-based, case ( n 396) control ( n 396) study conducted among black urban women from the greater Soweto population from 2014 to 2017, was used to conduct the current study. Breast cancer cases were newly diagnosed, prior to any cancer treatment from the Chris Hani Baragwanath Academic Hospital. Cases were recruited as soon as possible after the cancer diagnoses. Controls were healthy and unrelated to the breast cancer cases with no history of cancer diagnoses and matched by age (± 5 years) and area of residence to the cases. Information regarding inclusion and exclusion criteria of breast cancer cases and controls and recruitment of breast cancer cases was previously described elsewhere. The sample size had a sufficient power of 80 % (when type II error rate = 10 %) for OR ≥ 1·5 and type I error set at 5 %. "This study was conducted according to the guidelines laid down in the Declaration of Helsinki, and all procedures involving research study participants were approved by the International Agency for Research on Cancer, the University of the Witwatersrand and North-West University. Written informed consent was obtained from all subjects/patients."

Determining habitual dietary intake

A validated and reproducible culture-specific Quantitative FFQ (QFFQ) was used together with household utensils, food portion pictures and food models to determine habitual dietary intake. For validation/reproducibility of the QFFQ (in previous studies), spearman rank correlation coefficients of 0·14-0·59 were obtained when macro- and micronutrients intakes and food groups were compared with a 7 d weighed food record and foods captured by a QFFQ. In 2011l, reproducibility of the QFFQ was evaluated again in the Prospective Urban and Rural Epidemiological-SA study, and correlations for energy, macro- and micronutrients were good (between 0·59 and 0·76), which indicated that the validity of the QFFQ stayed consistent over time. The QFFQ was administered by registered dietitians, a nutritionist and registered nurse who all received training by nutritionists with over 30 years of experience in dietary assessment to ensure consistency among the different interviewers. Nutrient content information (macro- and micronutrients) was obtained using the South African Food Composition Tables. The dietary intake frequency included the amount of times foods were consumed per d/week/month or never. Life size colour photographs of thirty-seven foods (in three portion sizes) were displayed in the food portion picture booklet. Participants were asked about their habitual dietary intake over the past month. Daily intakes of the different foods included in the QFFQ were calculated by two nutritionists to ensure accurate and quality processing of the QFFQ, using a stepwise approach. A stepwise approach was used to calculate daily intakes. Consumption frequencies were converted into number of days per month, and the amount of each portion consumed (for each individual) was converted into grams, using standardised tables to convert household measurements into grams. The daily consumption was calculated by multiplying the frequency of consumption (d/month) by the portion sizes (converted to grams) divided over 30 d. The daily energy and nutrient intakes were determined by multiplying the daily intake of each food item (as consumed) by the nutrient and energy content (per 100 g), derived from the South African Food Composition tables, and then adding together the contributions from all food items.

Non-dietary assessments

Trained investigators and fieldworkers conducted face-to-face interviews. Detailed information on demographic factors and socio-economic status - ethnicity, history of health, family history of breast cancer, reproductive risk factors (age/year at full-term pregnancy, breastfeeding history, age at menarche and at menopause for postmenopausal women, use of oral contraceptives and hormone replacement therapy), family history of cancer, breast health (previous breast lumps by breast laterality and breast pains), smoking habits and physical activity (recreational, transportation, occupational and household) - were collected. Weight, height, sitting height, hip circumference and waist circumference were measured according to standardised procedures. Measurements were always done in duplicate and redone if there was discordance. Measurements were done by the same person throughout the study to avoid inter-user variation, and all equipment was calibrated regularly. All questionnaires used to collect the anthropometry and lifestyle information were validated and proven reproducible in studies conducted in South Africa and elsewhere.

Construction of the South African food based dietary guidelines adherence score

To determine the level of adherence to the South African food based dietary guidelines (overall and for each individual South African food based dietary guideline recommendation)

To determine the level of adherence to the SAFBDG, an adherence score was developed since no standardised scoring algorithm currently exists to measure adherence to the SAFBDG. Table 1 provides a detailed layout of the construction of the adherence score with recommended intakes/adherence levels, methods and definitions used for each recommendation to determine adherence to the SAFBDG. Each of the participants' adherence to the SAFBDG was calculated for overall adherence as well as for each individual SAFBDG recommendation. Recommendations regarding salt (use salt and foods high in salt sparingly) and water (drink lots of clean, safe water) consumption were excluded from the overall adherence score as the required information to assess adherence to these recommendations were not gathered during data collection.

Table 1.

Recommendation

Suggested intake/measure of adherence

Method used to measure adherence to the individual SAFBDG recommendation

Foods included in food groups to measure adherence to the guideline/Exclusions and definitions

1) Enjoy a variety of foods

DDS > 4 (out of 9)
A DDS score <4 was considered a low dietary diversity.

Calculating a DDS with nine food groups, using the FAO guidelines, with nine being the highest DDS and zero (0) the lowest DDS.

1·1) Cereals, roots and tubers: rice, corn, sorghum, oats, samp, sweet potatoes, potatoes, fortified and unfortified maize meal and bread, products made with wheat flour or any other grain flour such as pasta, porridges and tortillas
Excluded: sweet biscuits and cakes as they are classified under "sweets" (not measured as part of the DDS in the current study).

1·2) Meat, poultry and fish: organ meat, chicken (fresh and frozen), fish and seafood (fresh, frozen and canned), red meat (beef, pork, goat, mutton, venison), processed meat (salami, sausage/vienna, ham, polony, corned beef, bacon) and dried meat (biltong, mopani worms).

1·3) Dairy: milk (whole, low-fat and skimmed milk) and milk products (custard, hard and soft cheese, processed cheese and yoghurt).

1·4) Eggs: scrambled, fried and boiled/poached.

1·5) Vitamin A-rich fruit and vegetables (for plant foods - 60 RAE per 100 g & for liquids- 30 RAE per 100 g): carrots, pumpkin, red pepper, sweet potato (yellow flesh), spinach, apricots, melon (orange flesh), mango, pawpaw, apricot juice and peaches. Vegetables mixed with potatoes were separated according to standardised recipes from the Condensed Food Composition Tables of South Africa.

1·6) Legumes/pulses: beans (dried, cooked, raw and canned), peanuts, peanut butter, lentils and soya products.

1·7) Other fruit: banana, fig, grapes, guava, raisins, naartjie/tangerine, orange, blueberry, plum, strawberry, melon (green flesh), watermelon, pineapple, pear, apple, litchi, pomegranate, avocado and kiwifruit.

1·8) Other vegetables: beetroot, onions, broccoli, cauliflower, lettuce, cabbage, green beans, brinjal, cucumber, mushroom, tomato, gem squash, peppers and okra. Mixed vegetable dishes were separated according to standardised recipes from the Condensed Food Composition Tables of South Africa.

1·9) Fats and oils: butter, tallow, margarine, mayonnaise, vegetable oil, shortenings and sour cream.

2) Be active.

At least 150 min of moderate and vigorous physical activity/week

Calculating the sum of light, moderate and vigorous physical activity (min/week).

Due to low levels of moderate and vigorous physical activities in both breast cancer cases and controls, light physical activities were included in the analysis.

3) Make starchy food part of most meals

No specific suggestion.
General guideline of ten minimally processed/whole grains/root vegetables exchanges/units/day (based on 8 500 kJ intake/d).

Exchange quantities for one unit:
+ maize meal porridge, + soft/maltabella/oats = 125 g
+ maize meal porridge, stiff = 60 g
+ maize meal porridge, crumbly = 45 g
+ bread = 35 g
+ potatoes/sweet potatoes = 100 g +cooked, pasta/samp/whole grains = 75 g, +unsweetened breakfast cereals = 25 g
+ cooked rice = 65 g

Included: carbohydrates in the form of minimally/unprocessed or whole grains and root vegetables such as potatoes and white fleshed sweet (roasted, boiled, mashed, sautéed in sunflower oils, no added sugar or saturated fats) potatoes, fortified white and brown bread, whole wheat bread, fortified and unfortified maize meal, white and brown rice, plain pasta (macaroni, spaghetti), sorghum, bulgur wheat, oats and minimally processed breakfast cereals without added sugar (see definition of added sugar in table below).
Excluded: highly processed/refined starchy foods (provita's, biscuits, cookies, cakes, tarts, pies), deep fried potatoes/French fries, vetkoek (deep fried dough) and legumes (legumes are included in the individual SAFBDG recommendation "Eat dry beans, split peas, lentils and soya regularly").

4) Eat plenty of vegetables and fruit every day.

Calculating the sum of all fruit and vegetables consumed in g/d, using the food composition tables of South Africa

Vegetables: spinach, green beans, green leafy vegetables, beetroot, carrot, onions, broccoli, cauliflower, lettuce, cabbage, brinjal, baby marrow, okra, cucumber, corn, mushrooms, tomato, gem squash, green pepper.
Excluded: potato and white fleshed sweet potato (included in the individual SAFBDG recommendation "Make starchy foods part of most meals".

Fruit: banana, apple, apricot, melon (orange and green flesh), figs, guava, raisins, mango, tangerines/naartjies, orange, pawpaw, peach, blueberry, peach, plum, strawberry, watermelon, pineapple, pear, fruit salad, prune, litchi, pomegranate, avocado, kiwifruit and 100 % pure fruit juice.

5) Eat dry beans, split peas, lentils and soya regularly

No specific indication.
At least 2 to 3 portions/week. One portion equals ½ cup or 75 g of dry beans/peas/cooked lentils or 30 g of soya mince.

Calculating the sum of all legumes consumed in g/d, using the food composition tables of South Africa.

Beans, split peas, lentils (dried, canned, raw and cooked) and soya products.

6) Have milk, maas or yoghurt every day.

Milk, maas or yoghurt at least >400 ml/d.

Calculating the sum of milk, maas or yoghurt in ml/d, using the food composition tables and food quantities table of South Africa.

Milk (either fresh or powdered), unsweetened yoghurt and maas (traditional fermented milk).
Excluded: sweetened, full-fat and processed milk products and cheeses to prevent intake of SFA, Na and sugar.

7) Fish, chicken, lean meats or eggs can be eaten daily.

2 to 3 fish servings/week
Approximately 4 Eggs/week
Lean meat ≤90 g/d

Calculating the sum of fish, chicken, lean meats and eggs consumed in g/d, using the food composition tables of South Africa

Fish and seafood, especially oily fish such as sardines, pilchards, tuna, anchovies and mackerel (fresh, frozen and canned), chicken (white and dark meat), lean meat and eggs (scrambled, fried, boiled/poached).
Lean meat is defined as meat with a fat percentage between 5 % and 10 % can be labelled as lean or trimmed.

8) Use fats sparingly. Choose vegetable oils rather than hard fats.

≥20 % Total fat intake ≤30 % of total energy intake/d.
Saturated fat <10 % of total energy intake/d.

Using the total amount of fat as a percentage of total energy intake and total amount of saturated fat as a percentage of total energy intake. Measured by the food composition tables of South Africa

Total fat measured in all single foods consumed in breast cancer cases and controls.
Total fat includes trans fatty acids, SFA, MUFA and PUFA (including essential fatty acids such as n-3, n-6).
Hard fats refer to all animal fats and vegetables oils such as palm kernel and coconut oil.

9) Use sugar and foods and drinks high in sugar sparingly.

Added sugar intake <10 % of total energy intake.
Added sugar intake <6 % for further health benefits.

Total amount of added sugar as a percentage of total energy intake, measured by the food composition tables of South Africa

Added sugar measured in all single foods consumed in breast cancer cases and controls.
Added sugar refer to "any sugar added to foodstuffs during processing and includes but is not restricted to sugar as defined by Regulations Relating to the Use of Sweeteners in Foodstuffs under the Act, honey, molasses, sucrose with added molasses, coloured sugar, fruit juice concentrate, deflavoured and/or deionized fruit juice and concentrates thereof, high-fructose corn syrup and malt or any other syrup of various origins".

A maximum overall adherence score of nine (to the SAFBDG) was therefore possible. To determine the level of adherence to the SAFBDG, overall and for each individual SAFBDG recommendation, suggested portions sizes/d or week and percentages of total energy intake per day were used as cut-points (as currently suggested in the technical support papers of the SAFBDG). As an example, it is advised to consume 400 g fruit and vegetables and to have <10 % of total energy from saturated fat intake/d.

To calculate adherence to the individual SAFBDG recommendation "Enjoy a variety of foods", a Dietary Diversity Score (DDS), based on nine food groups, was used. The nine food groups were based on the FAO of the UN guidelines and included (1) cereals, roots and tubers; (2) meat, poultry and fish; (3) diary; (4) eggs; (5) vitamin A-rich vegetables and fruit; (6) legumes; (7) other vegetables than vitamin A-rich; (8) other fruits than vitamin A-rich and (9) fats and oils. The lowest possible DDS score was zero (0) and the highest possible DDS nine (9). A DDS score below four (4) was considered as having a low dietary diversity.

No specific portion size was stated in the SAFBDG to measure adherence to the individual SAFBDG recommendation "Make starchy foods part of most meals". To assess adherence to this recommendation, a general guideline (consume ten starchy exchanges/units/d, based on 8500 kJ intake/d) was used. Starchy exchanges/units included minimally processed starches, whole grains and root vegetables (potato, white fleshed sweet potato). With regard to measuring adherence to the SAFBDG recommendation "Eat dry beans, spilt peas, lentils and soya regularly", no specific amount (percentage of total energy) or portion size was stated in the SAFBDG. To establish the recommended portion size to measure adherence to this guideline, legume consumption was compared with the legume consumption in other South African studies (Prospective Urban and Rural Epidemiologica, SANHANES) and guidance from the Nutrition Information Centre of the University of Stellenbosch was followed. Sensitivity analysis was conducted without the recommendation "Eat dry beans, spilt peas, lentils and soya regularly" and "Make starchy foods part of most meals" but did not change the overall adherence result (results not shown).

Adherence scores to each individual SAFBDG recommendation, using recommended portion sizes, were calculated as follows: one (1) point when adhering to the recommendation and zero (0) points for non-adherence to the recommendation. Two sub-categories were developed to measure adherence to the recommendations "Fish, chicken, lean meat or eggs can be eaten daily" and "Use fats sparingly. The two sub-categories for the recommendation "Fish, chicken, lean meat or eggs can be eaten daily" included: (1) fish, chicken and lean meat consumption can be eaten daily and (2) egg consumption can be eaten daily. The two sub-categories to measure adherence to the recommendation "Choose vegetable oils rather than hard fats" included (1) keep total fat intake between the recommended range (≥20 % and ≤30 % of total energy intake) and (2) limit saturated fat intake <10 % of total energy intake. Adherence to these individual SAFBDG recommendations with two sub-categories, mentioned above, was scored as follows: zero (0) points for non-adherence and half a point (0·5) for adherence. To measure adherence to the individual SAFBDG recommendation "Use sugar & food & drinks high in sugar sparingly", three sub-categories, non-adherence (0 points), partial adherence (0·5 point) and adherence (1 point) were developed. This was based on the fact that the SAFBDG, in accordance with the WHO's healthy diet indicator, advise an added sugar intake of <10 % of total energy intake, while an added sugar intake of <6 % of total energy may have additional health benefits.

Assessing the association between adherence to the South African food based dietary guidelines (overall and for each individual South African food based dietary guideline recommendation) and breast cancer risk

The distribution of adherence to five (out of nine) of the individual SAFBDG recommendations resulted in highly skewed categories (adherence/non-adherence to an individual SAFBDG recommendation ≥73 % for both breast cancer cases and controls). Therefore, data-driven tertiles (33rd and 66th percentiles) were used to determine the cut-off points for assessing the association between adherence to the SAFBDG (overall and for each individual SAFBDG recommendation) and breast cancer risk. Cut-off points for each individual SAFBDG recommendation, using data-driven tertiles, were calculated as follows: one (1) point when adhering to the recommendation (highest tertile); half (0·5) a point for partial adherence to the recommendation (middle tertile) and zero (0) points for non-adherence to the recommendation (lowest tertile) (see online Supplemental Table 1). Each individual SAFBDG recommendation contributed equally to the total adherence score. The recommendations, "Use fats sparingly" and "Choose vegetable oils rather than hard fats" had two sub-recommendations that were scored individually and were divided by two to determine an average score (0; 0·25 and 0·5). Finally, tertiles of control participants (33rd and 66th percentiles) were used to determine adherence to the overall score and the association with breast cancer risk, with ≤3·5 being the lowest adherence tertile and >5·0 the highest adherence tertile.

Statistical analysis

A total of 399 breast cancer cases and 399 matched controls were recruited in the SABC study. Of those, three breast cancer cases and three matched controls were excluded due to missing dietary data information. Descriptive analyses were performed, and differences between cases and controls were assessed using paired sample t-test (normal distributed data presented as mean ± s d) and Wilcoxon signed rank test (not normal data, presented as median, 25th and 75th percentiles) for continuous variables and paired χ ² test for categorical variables (presented as percentages). Specifications of the WHO were used to calculate BMI, using measured height and weight (kg/m ²).

Assessing the association between adherence to the South African food based dietary guidelines and breast cancer risk: overall and individual guidelines

Conditional logistic regression models were used to compute OR and associated 95 % CI to determine the association between breast cancer risk and adherence to the SAFBDG (overall and each individual SAFBDG recommendation). Adherence scores (overall and for each individual SAFBDG recommendation) were stratified by hormonal breast cancer receptor subtypes, menopausal status (pre v. post) and obesity (BMI ≥ 30 kg/m ²). For the two latest variables, unconditional logistic regression was used. Additional analysis was conducted to determine significant interactions among strata (menopausal status, hormonal breast cancer receptors and obesity).

The following confounders were examined for adherence to the overall- and individual SAFBDG recommendation (chosen a priory from known breast cancer risk factors): individual income (R1-R3000, R3001-R6000 and R6001+), ethnicity (Zulu/Pedi/Swazi, Xhosa, Sotho, Tshwane, Venda, Tsonga and Ndebele), level of education (none/primary school, high school and college/postgraduate/diploma), smoking (smokers and non-smokers), height (continuous), waist circumference (continuous data), age at menarche (continuous), full-term pregnancy (yes/no), age at first pregnancy (<24 v. >24 years of age), age at menopause (<48 v. >48 years of age), parity (≤ three children v. > three children), duration of exclusive breast-feeding (months), use of exogenous hormones (hormonal birth control to avoid pregnancy: oral contraceptives and injections), or hormone replacement therapy after menopause), family history of breast cancer (yes/no), HIV status (positive v. negative), total energy intake in kJ (continuous), alcohol intake in gram (continuous) and under reporting (under reporting, plausible reporting and over reporting). Under reporting (13·1 % of breast cancer cases and 11·6 % of controls) and over reporting (24·0 % of breast cancer cases and 27 % of controls) cut-off points were calculated using the Goldberg and Black principle to determine over-and-under reporting of energy intake. Menopausal status, ethnicity, total energy intake, alcohol intake, individual income/month and waist circumference altered the crude OR by more than 10 % when assessing adherence to overall and individual SAFBDG recommendations and were included in our final model.

An additional confounder, habitual physical activity per day (active v. less active), was examined when adherence to the individual SAFBDG recommendations was assessed. This was done as physical activity was part of the overall score and as such not included as a confounder in the overall score analyses.

Results

Selected descriptive characteristics amongst cases and controls are reported in Table 2. Ethnicity differed significantly between cases and controls with breast cancer cases having more Ndebele-speaking people and controls having more Sotho-speaking people. Breast cancer cases had a significant lower waist circumference (93·3 cm ± 13·8 cm) compared with controls (95·8 cm ± 13·7 cm) and had less HIV-positive (16·5 %) cases than controls (22·6 %). Controls had a higher percentage of alcohol consumers but consumed less ethanol (4·6 g/d) on average than cases (5·4 g). Hormone-responsive breast cancers, ER+ (75·3 %) and PR+ (66·4 %) were the dominant breast cancer subtypes, while triple negative breast cancer accounted for 16·2 % (not stratified by menopausal status).

Table 3 presents the level of adherence to the SAFBDG (overall and for each individual SAFBDG recommendation) between cases and controls, using suggested portion sizes or percentages of total energy intake as cut-points for all the SAFBDG recommendations. Regarding overall adherence to the SAFBDG, only 32·3 % of breast cancer cases and 39·1 % of controls adhered to at least half (4·5) of the SAFBDG (nine out of the eleven were measured).

Both cases and controls showed adherence levels <50 % to the following individual SAFBDG recommendations: "Be active", "Make Starchy foods part of most meals", "Eat plenty of fruit and vegetables every day", "Eat dry beans, spilt peas and lentils regularly", "Have milk, maas or yoghurt every day" and "Use sugar & foods & drinks sparingly". Fewer cases adhered to the individual SAFBDG recommendation "Enjoy a variety of foods" (measured by a DDS score), with only 39·1 % of cases having a dietary diversity score above four (out of nine) compared with 51·1 % of controls. Both cases (17·2 %) and controls (22·7 %) showed low adherence to the individual SAFBDG recommendation "Eat dry beans, spilt peas and lentils regularly". In addition, both cases (82·1 %) and controls (73 %) showed high adherence to the sub-category for fish, chicken and lean meat consumption (<90 g/d), while controls (46·7 %) were more likely to adhere to the sub-category on egg consumption (at least four eggs/week) than breast cancer cases (39·2 %). Although adherence to the individual SAFBDG "Use fats sparingly. Choose vegetable oils rather than hard fats" was low, breast cancer cases (52·5 %) were more likely to adhere to the total fat sub-recommendation (total fat >20 % and <30 % of total energy intake) than controls (45·2 %).

Table 4 provides results on the association between overall adherence to the SAFBDG, using data-driven tertiles for each SAFBDG recommendation, and the association with breast cancer risk. After adjusting for potential confounders, higher adherence (>5·0) v. lowest adherence (≤3·5) to the SAFBDG showed a significant inverse association with breast cancer risk overall (OR = 0·56, 95 % CI (0·38, 0·85), P = 0·006), among postmenopausal women (OR = 0·64, 95 % CI (0·40, 0·97), P = 0·034) as well as in oestrogen receptor positive (ER+) breast cancer (OR = 0·51, 95 % CI (0·32, 0·89), P = 0·004). No significant association with breast cancer risk was observed in premenopausal or obese women.

The association between higher adherence to individual SAFBDG recommendations, using data-driven tertiles for each individual SAFBDG recommendation, with breast cancer risk is presented in Table 5. After adjustment for potential confounding factors, higher adherence to the recommendation "Enjoy a variety of foods" (measured by a dietary diversity score) showed an inverse association with breast cancer risk overall (OR = 0·46, 95 % CI (0·29, 0·70), P < 0·001), in postmenopausal women (OR = 0·48, 95 % CI (0·30, 0·77), P = 0·003) and in participants with ER+ and progesterone receptor positive (PR+) breast cancers (OR = 0·42, 95 % CI (0·26, 0·68), P < 0·001 and OR = 0·51, 95 % CI (0·31, 0·85), P = 0·010, respectively). With regard to the recommendation "Make starchy food part of most meals", higher adherence showed an inverse association with ER+ breast cancer (OR = 0·65, 95 % CI (0·42, 0·99), P = 0·047). Furthermore, higher adherence to the recommendation "Eat plenty of vegetables and fruit everyday" showed an inverse association with breast cancer risk overall (OR = 0·58, 95 % CI (0·38, 0·86), P = 0·008), in postmenopausal women (OR = 0·62, 95 % CI (0·39, 0·99), P = 0·046) and in participants with ER+ and PR+ breast cancers (OR = 0·51, 95 % CI (0·32, 0·81), P = 0·005 and OR = 0·59, 95 % CI (0·37, 0·94), P = 0·028, respectively). Higher consumption of milk, maas or yoghurt showed an inverse association with breast cancer risk overall (OR = 0·69, 95 % CI (0·47, 0·97), P = 0·025), in postmenopausal women (OR = 0·69, 95 % CI (0·43, 0·98), P = 0·039) and in participants with ER+ breast cancers (OR = 0·54, 95 % CI (0·35, 0·84), P = 0·006). Higher adherence to the recommendation "Fish, chicken, lean meat or eggs can be eaten daily" showed an inverse association with breast cancer risk overall (OR = 0·67, 95 % CI (0·46, 0·95), P = 0·036) and in participants with ER+ breast cancer (OR = 0·56, 95 % CI (0·36, 0·87), P = 0·010).

Discussion

To our knowledge, this is the first study investigating the relationship between adherence to the SAFBDG and breast cancer risk. The results indicate that higher adherence to the SAFBDG, using data-driven cut-points, may reduce the risk of developing breast cancer in this population overall, in postmenopausal women and for women with ER+ breast cancer. The strongest inverse associations with breast cancer risk were seen for higher adherence to the following individual SAFBDG recommendations "Enjoy a variety of foods", "Eat plenty of fruit and vegetables every day", "Have milk, maas or yoghurt every day" and "Fish, chicken, lean meat or eggs can be eaten daily". The study results further indicate a concerning low level of adherence to the SAFBDG, whether adherence was measured as overall adherence or individual recommendation adherence.

Higher adherence to the SAFBG (measured with data-driven cut-points) may protect against the development of breast cancer in this population. Studies investigating the association between adherence to the SAFBDG (and other dietary guidelines) and nutrition-related diseases in this South African population are still limited. However, our findings are in line with results from international studies investigating adherence to national Food Based Dietary Guidelines in association with non-communicable disease and obesity risk. Although national Food Based Dietary Guidelines may differ, based on the population, Food Based Dietary Guidelines generally promote similar healthy eating behaviour/patterns globally. A Danish Cohort study of 54 305 participants showed that higher adherence to the Danish Food Based Dietary Guidelines had an inverse association with Type 2 diabetes and CVD. A Dutch Cohort study showed that higher adherence to the Dutch Food Based Dietary Guidelines was inversely associated with overall mortality and non-communicable diseases such as Type 2 diabetes and colorectal cancer. The European Prospective Investigation into Cancer and Nutrition study (EPIC-Granada study conducted in Spain) showed that higher adherence to the Spanish Dietary Guidelines was associated with a lower risk of being obese. These global findings highlight the importance of adhering to national Food Based Dietary Guidelines to reduce non-communicable diseases such as breast cancer.

Associations and adherence to individual South African food based dietary guideline recommendations

"Enjoy a variety of foods"

Higher adherence to the individual SAFBDG recommendation "Enjoy a variety of foods", using data-driven cut-points, showed an inverse association with breast cancer risk. This indicate that consumption of a variety of foods may play an important role in breast cancer prevention. However, more than 60 % of cases and nearly half of controls did not adhere to this recommendation when suggested adherence cut-points were used. Similar results from the South African National Health and Nutrition Examination Survey showed that 50 % of the black South African population had a DDS below four. This is a concern as the low DDS in the current study indicates that a variety of foods and thus a variety of micronutrients, which may protect against breast cancer, are not consumed.

"Eat plenty of fruit and vegetables every day" and "eat dry beans, split peas, lentils and soya regularly"

Higher adherence to the individual SAFBDG recommendation "Eat plenty of fruit and vegetables every day", using data-driven cut-points, was inversely associated with breast cancer risk in the current study. Worrisome, however, is that adherence to the SAFBDG recommendation "Eat plenty of fruit and vegetables every day" (using suggested adherence cut-points) was low in both cases and controls in our study. The Prospective Urban and Rural Epidemiology cohort study, conducted in the North-West Province of South Africa, showed that only 31·5 % of urban women ( n 355) adhered to this recommendation. Low fruit and vegetable consumption was also observed in other South African regions. In addition, concerning low levels of adherence to the individual SAFBDG recommendation "Eat dry beans, split peas, lentils and soya regularly" was observed when suggested adherence cut-points were used in the analysis and is in line with other studies reporting low legume consumption in South Africa. Low adherence to these respective recommendations is of concern as high fibre foods such as fruit, vegetables and legumes have been linked to a decreased risk of colorectal cancer and can help maintain a healthy weight necessary to decrease the risk for postmenopausal breast cancer.

"Having milk, maas or yoghurt every day and "fish, chicken, lean meats or eggs can be eaten daily"

Higher adherence to the individual SAFBDG recommendations "Having milk, maas or yoghurt every day and "Fish, chicken, lean meats or eggs can be eaten daily" showed inverse associations with breast cancer risk when data-driven cut-points were used. However, both cases and controls showed worrying low levels of adherence to the SAFBDG recommendation "Have milk, maas or yoghurt everyday" (using suggested adherence cut-points). The Prospective Urban and Rural Epidemiologica study, mentioned above, showed similar low adherence levels (11·5 %) to this recommendation amongst urban women (400 g of milk, maas or yoghurt or 50 g hard cheese/d). Low adherence to this recommendation is concerning since the evidence suggests that dairy products and diets high in Ca may decrease the risk of premenopausal breast cancer.

"Make starchy foods part of most meals"

Almost 60 % of both cases and controls did not adhere to the SAFBDG recommendation "Make starchy foods part of most meals" when suggested adherence cut-points were used. This finding was unexpected since staple foods, such as fortified maize meal, bread, rice, etc., promoted in this recommendation, cost less per unit of energy than animal products, fruit and vegetables and is therefore considered affordable. Despite the low consumption of minimally processed starchy foods, total carbohydrate intake for both cases (61·4 %) and controls (64·0 %) was within the recommended macronutrient distribution range (45-65 % of total energy intake). This finding indicates that not all starchy foods consumed are of high nutritional value and reflect the changes in dietary carbohydrate consumption, from high fibre and nutrient dense starchy staple food intakes to higher consumption of refined starches, lacking nutrients and having a high added sugar content.

"Use fats sparingly. Choose vegetable oils rather than hard fats" and "use sugar and foods and drinks high in sugar sparingly"

Adherence to the SAFBDG recommendations: (1) "Use fats sparingly. Choose vegetable oils rather than hard fats" and (2) "Use sugar & foods & drinks sparingly" also showed low levels of adherence in both cases and controls when suggested portions were used as adherence cut-points. Similar, low levels of adherence to the SAFBDG recommendation regarding total fat intake were observed in Cape Town, South Africa. With regard to added sugar intake, a review of dietary surveys in the adult South African population from 2000 to 2015 and cross-sectional studies showed that added sugar intake was greater than the recommended 10 % of total energy intake in various provinces of South Africa (North-West, KwaZulu-Natal, Western Cape, Free state). Diets high in saturated fat and added sugar are concerning because diets high in saturated fat and added sugar have been linked to a higher risk of being overweight or obese, which is a known risk factor for postmenopausal breast cancer.

"Be active"

Apart from low adherence to the nutrition-related SAFDG recommendations, adherence to the SAFBDG recommendation "Be active" also showed worrying low adherence levels in both breast cancer cases and controls in the current study. This low physical activity level is not a new finding and is in line with several studies conducted amongst black South African women. The finding is alarming as physical activity may protect against breast cancer development and being overweight or obese.

Level of adherence to the overall South African food based dietary guidelines

A modelling study, reviewing global adherence to national food based dietary guidelines in 85 countries, showed that South Africa is among the countries with the lowest adherence to the national food based dietary guidelines. In line with the above review, the results of our study clearly showed low adherence to the overall and individual SAFBDG recommendations.

Poverty, influencing purchasing power, and a growing obesogenic food environment are considered key barriers to healthier eating patterns in South Africa. Additionally, the Strategy for the Prevention and Control of Obesity in South Africa states that high crime rates and gender-based violence, especially in urban South African areas, contribute to the perception of it being unsafe to exercise outdoors and could also contribute to low physical activity levels (all ethnicities). A lack of exercise space due to small plots and size of physical buildings in low-income households may also be considered a potential limitation to physical activity. Also, the many challenges associated with measuring self-reported physical activity levels in epidemiological studies such as recall bias of participants may further contribute to low physical activity levels. Furthermore, a lack of knowledge (especially in resource poor settings), education and skills regarding food preparation methods (especially for beans/lentils); length of preparation time; taste preferences (unsweetened products v. sweetened products) and perceptions towards a healthy diet and social and cultural influences may also contribute to the low adherence levels observed. Given the effect of the COVID-19 pandemic, resulting in a higher unemployment rate and higher food prices, adherence to the SAFBDG may decrease even further. Low adherence to the recommendation "Eat dry beans, split peas, lentils and soya regularly" is not likely to be influenced by economic status since beans and other legumes are affordable in South Africa. However, the cost occurred as a result of the length of preparation of beans and other legumes may influence the consumption thereof. Therefore, more research is required to understand the drivers of consumption of specific food groups such as beans and other legumes in this population.

Results of our study suggest that dietary intake that is not well aligned with the SAFBDG recommendations is associated with an increased risk of developing breast cancer in this black female population of Soweto, South Africa. It is therefore critical to also create sustainable and healthy food environments that support the affordability, availability and accessibility of healthy foods and safe environments that support physical activity in order to enable adherence to the SAFBDG in this population. However, creating sustainable and healthy food environments in South Africa is not an easy task and requires multi-sectoral and transdisciplinary public health engagement, beyond those already in place.

Furthermore, results of our study are in line with a recent study, conducted in the same black female population of Soweto, South Africa, which investigated the association between adherence to the 2018 WCRF/AICR Cancer Prevention Recommendations and breast cancer risk. Both sets of recommendations showed that higher consumption of fruit and vegetables may reduce breast cancer risk in this population. The 2018 WCRF/AICR Cancer Prevention Recommendations emphasised the importance of following an overall healthy lifestyle (being physically active, a healthy weight and following healthy diet) for breast cancer prevention. Results of the current study complement these findings of Jacobs and colleagues (2021) by (1) highlighting the potential benefits of specific foods (milk, maas, yoghurt, lean meats and eggs) and (2) emphasising the importance of following a diverse diet for breast cancer prevention in this population. While the findings of both studies provide valuable insights in the lifestyle and diets of black women from Soweto, more research is required to understand how the 2018 WCRF/AICR Cancer Prevention Recommendations and the SAFBDG could be used as key nutrition intervention/tool in breast cancer prevention studies.

Strengths of the current study include the fact that cases were recruited prior to any breast cancer treatment and that the questionnaires used to obtain data were proven to be validated and data used in the analysis were standardised and administered by trained personnel. Limitations include the relatively limited sample size of the current study, the nature of the case-control study design which is prone to differential biases of cases and the use of a QFFQ to collect dietary data which relies on the memory of participants and is therefore more prone to recall bias. Dietary intake and physical activity were measured over the past month when habitual dietary intake of case participants could have changed due to illness and may contribute to random misclassification and under estimation of dietary intake. In addition, although dietary intakes were captured throughout the year (in different participants) and that breast cancer cases and controls were recruited little time apart, seasonal variability of foods (not adjusted for) may have influenced usual reporting of dietary intakes. It is also noteworthy that QFFQ are not ideal for measuring absolute dietary intakes as their main goal is to measure relative dietary intakes, allowing the ranking of people according to their dietary intakes. Therefore, comparison with fixed cutoffs is not recommended, especially in a population with highly skew data, which motived the use of data-driven tertiles for dividing the participants according to their dietary intakes and to measure adherence to the SAFBDG. Using such an alternative method may have influenced the overall results.

The methodology used in the current study is one of the first attempts to measure quantitative adherence to the SAFBDG and requires more investigation to establish a standardised adherence algorithm. We followed the exact recommendations as stated in the technical support papers of the revised SAFBDG. But, precise recommendations were not always stated such as in the case of measuring adherence to the recommendations "Make starchy foods part of most meals" and "Eat dry beans, split peas, lentils and soya regularly". To measure adherence to these two recommendations, assumptions were made, based on previous studies in South Africa or consulting with nutrition experts in South Africa. Such assumptions made the operationalisation of the current study challenging.

In conclusion, higher adherence to the SAFBDG showed inverse associations with breast cancer risk overall, in postmenopausal women and for women with ER+ breast cancer. In particular, the increased consumption of a variety of foods, fruit and vegetables, milk, maas or yoghurt and lean meat or eggs showed strong inverse associations with breast cancer risk. However, the black female population included in the current study showed concerning low levels of adherence to the SAFBDG. It is therefore necessary to promote adherence to the SAFBDG in both preventative education campaigns/actions and the creation of sustainable and healthy food environments that enhances the affordability, availability and accessibility of healthier foods, together with safe environments that support increased physical activity in order to enable adherence to the SAFBDG.

Acknowledgements

Acknowledgements: The authors would like to thank the participants of the SABC study and the medical staff of the Chris Hani Baragwanath Academic Hospital and Chris Hani Baragwanath Breast Unit. The authors would also like to thank the fieldworkers involved in the current study: Phindile Mathe, Yvonne Chaka, Victor Shandukani, Siphesihle Sibiya and Maria Sihlo and the SABC study project coordinators from the International Agency for Research on Cancer, Tracy Lignini and Robyn Smith. We also acknowledge the contribution towards dietary data collection, coding of QFFQ's and scientific input of prof H.H. Vorster (posthumous) in the current study. Financial support: The current study was supported by a research grant secured from the WCRF, international grant number 2012/591. The WCRF had no role in the study design, analysis or writing of this article. Authorship: The authors' contributions were as follows: I.J. formal statistical analysis and writing original draft; C.T.-K. writing-review and editing, involved in conceptualisation, investigation and supervision of the study; M.W. writing-reviewing and editing; J.M.B. writing-reviewing and editing. H.C. South African principle investigator of SABC study, co-responsible for methodology and resources; M.J. involved in the South African project administration of the SABC study; R.L. formal analysis of dietary intake; I.R. head principal investigator of SABC, writing-reviewing and editing; C.B. oversaw formal statistical analysis; M.J.G. writing-reviewing and editing; S.R. supervision of the overall SABC study project, review and editing. I.H. writing-review and editing. Ethics of human subject participation: "This study was conducted according to the guidelines laid down in the Declaration of Helsinki, and all procedures involving research study participants were approved by the International Agency for Research on Cancer, the University of the Witwatersrand and North-West University. Written informed consent was obtained from all subjects/patients."

Conflict of interest:

The authors declare that there are no conflicts of interest.

Supplementary material

For supplementary material accompanying this paper visit https://doi.org/10.1017/S1368980021004675.

References

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Supplementary Materials

For supplementary material accompanying this paper visit https://doi.org/10.1017/S1368980021004675.

Articles from Public Health Nutrition are provided here courtesy of Cambridge University Press

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Adherence to the South African food based dietary guidelines may reduce breast cancer risk in black South African women: the South African Breast Cancer (SABC) study

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To determine the level of adherence and to assess the association between higher adherence to the South African food based dietary guidelines (SAFBDG) and breast cancer risk. Population-based, case-control study (the South African Breast Cancer ...

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Some vegetables require less water than others

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Some vegetables, such as beans, are adapted to drought conditions at a very basic, cellular level.

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The country is plagued with resource constraints such as severs energy and water scarcity.

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