Nutrient profiling to develop a model for regulating health and

nutrient claims: Experiences and lessons

learned from South Africa

Edelweiss Wentzel-Viljoen

Centre of Excellence for Nutrition

North-West University

South Africa

Acknowledgements

• Prof Johann Jerling

• Prof Esté Vorster

• Mariaan Wicks – M student

• Sarie Lee - M student

• DoH, Directorate: Food Control

• Stakeholders

• WHO

• FSANZ

Outline

• Background

• SA Process

• Nutritional recommendations

• FSANZ model

• Validations

• The way forward

• Challenges

SA Dept of Health: Food Control

published draft Regulations Governing the

Advertising and Labelling of Foodstuffs,

No R. 642 (20 July 2007)

Promote healthier eating habits through improved

labelling of foods

Background

Regulations Governing the Advertising

and Labelling of Foodstuffs, No R. 642

General appreciation and support from most

role players

Annexure 6 - Widely commented on by

scientific community and food industry

Background

Annexure 6

"Foodstuffs not considered essential

for a healthy diet and for which NO

nutrient content, GI, certain

comparative, health, slimming or any

other claim with a health or

nutritional message will be

permitted”

Process

• EFSA meeting

• Report on existing models

• DoH: Food Control

• WHO guidelines & involvement

• Decision to use FSANZ

• Validation of the model for SA

• Stakeholder meeting

• FSANZ involvement

• Final report to DoH: FC

Context

NPM to provide an evidence-

based approach to determine

the eligibility of a food to carry a

nutrient and/or health claim

Nutrient Profile Model

UK Model – Mike Rayner

FSANZ Model – D Mackerras

SA Model

Nutritional recommendations

Nutrient UK Model Australian & NZ

reference values*

South Africa

WHO guidelines

Energy 2130 kcal(8916kJ) 8750kJ Maintain healthy

body weight

Saturated fat 11% TE (26g) Aus: 10% TE(26g)

NZ: 12% TE

<10% TE

Total sugar 21% TE

Non-milk: 11% TE

NZ: no more than

15% TE sucrose &

free sugars

<10% free sugars

Sodium 2400mg UL = 2300mg <2000mg

Protein 45g for women RDI = 46g 10-15% TE

Fibre 20 – 24g AI = 25g >25g

Fruit and

vegetables

380g/day (excl

potato)

Aus: 300g fruit;

375g vegetables

(incl potato)

≥400g/dag

SA FBDG: >400g

* Moderately active women (19-50 yrs)

FSANZ model

Based on 100g food product

Energy (kJ)

Saturated fat (g)

Total sugars (g)

Sodium (mg)

Fruit/vegetable/legume/nuts (%)

Protein (g)

Fibre (g)

FSANZ model 3 Categories

Cat 1: Beverages (including milk)

Cat 2: Any food other than those in Cat 1 / 3

Cat 3: Cheese and processed cheese with a

calcium content >320mg/100g; edible oil;

edible oil spreads; margarine; butter

NP score must be less than

Cat 1: <1

Cat 2: <4

Cat 3: <28

for a food item to be eligible

Determining eligibility of a food to carry a nutrient and/or health claim

Determine the category of food item

(category 1,2 or 3)

Calculate baseline points

(Energy (kJ), sat fat, total sugar and sodium per 100g/ml)

Calculate modifying points

(Protein, fibre & fvln)

Calculate final score of food item

Assess final score & determine eligibility of food item to carry a nutrient and/or health claim

Important:

Certain conditions

(baseline points ≥ 13)

Cat 1 < 1

Cat 2 < 4

Cat 3 < 28

Suitability for South Africa

WHO “Guiding principles and framework manual for the

development or adaptation of nutrient profile models”

Workshop – NWU

WHO

DoH: FC

Final decision to use FSANZ as basis

5 Validations

WHO guidelines

1.Content validity – SAFBDG

2.Convergent validity – Ranking

3.Construct validity – Diet quality

4.Construct validity – Linear programming

5.Construct validity – Diet quality – improvement of diet

Validations

1. SAFBDG

2. Ranking

Scarborough, P., Boxer, A., Rayner, M. & Stockley, L. 2007a. Testing nutrient profile models using data from a survey of nutrition professionals. Public health nutrition, 10(4):337-345

Scarborough, P., Rayner, M., Stockley, L. & Black, A. 2007b. Nutritional professionals’ perception of the ‘healthiness’ of individual foods. Public health nutrition, 10(4):346-353

3. Diet quality – Diet quality index

Arambepola, C., Scarborough, P. & Rayner, M. 2008. Validating a nutrient profile model. Public health nutrition, 11(4):371-378

4. Linear programming

Darmon, N., Vieuz, F., Maillot, M., Volatire, J. & Martin, A. 2009. Nutrient profiles discriminate between foods according to their contribution to nutritional adequate diets: a validation study using linear programming and the SAIN,LIM system. American journal of clinical nutrition, 89:1227-1236

5. Diet quality – Diet quality index – Improvement of diet

Assumptions

1. Use the SA Food Composition Database (FCDB) and labels

2. Total sugar definition – difference between FSANZ (including intrinsic sugars), SA FCDB, label information and new R146 requirements

3. Dietary fibre definitions

4. Fruit, vegetable, legume and nut content – info limited

5. Correctness of nutrient composition on in the SA FCDB and labels

6. Dietary intake data set – PURE2005

Validation 1 – SA FBDG

Aim

To identify a small number of 'indicator'

foods and assess whether the NPM

produces results which appear to

contradict the FBDGs

Validation 1 – SA FBDG

Food Based Dietary Guideline

Meat, chicken, fish, milk and eggs could be eaten daily

Eat dry beans, split peas, lentils and soya regularly

Make starchy foods the basis of most meals

Eat plenty of vegetables and fruits daily

Use food and drinks containing sugar sparingly and not

between meals

Use salt sparingly

Eat fats sparingly

Validation 1 – SA FBDG

Results

Overall a substantial agreement between

the way the NPM and FBDG classify the

individual food items (kappa statistic = 0.73)

Conclusion

Classification of food products by the NPM

supported the FBDGs and no major

contradictions were found

Validation 2 – Ranking

Aim

To develop a representative dataset and

rank the food items

•NPM

•Dietitians

•128 food items

Validation 2 – Ranking

Conclusion

There are a large degree of agreement

between classification of food products by

the NPM and the dietetic professionals of

South Africa

Validation 3 -DQI

Aim

To examine the relationship between the

way the NPM categorizes foods and the

'healthiness' of diets in South Africa using

the Diet Quality Index

Diet quality index (DQI) Dietary recommendation Score Cut-point

Reduce total fat intake to ≤30% of energy 0 ≤30%

1 >30-40%

2 >40%

Reduce saturated fatty acid intake to <10% of

energy

0 <10%

1 10-13%

2 >13%

Reduce cholesterol intake to <300 mg/day 0 <300 mg

1 300-400 mg

2 >400 mg

Eat five or more servings daily of a combination of

vegetables and fruits

0 ≥5 servings

1 3-4 servings

2 0-2 servings

Eat six or more servings daily of breads, cereals,

and legumes

0 ≥6 servings

1 4-5 servings

2 0-3 servings

Maintain protein intake at moderate levels (lower

than twice the RDA¥)

0 ≤100% RDA

1 >100-150% RDA

2 >150% RDA

Limit total daily intake of sodium to ≤2,400 mg 0 ≤2400 mg

1 >2400-3400 mg

2 >3400 mg

Maintain adequate calcium intake (approximately

DRI§ levels)

0 ≥DRI

1 2/3 DRI-<DRI

2 <2/3 DRI

Validation 3 -DQI

Conclusion

Construct validity was thus confirmed by

providing evidence that the better the diet

quality of the respondents the larger the

proportion of foods categorised as ‘being

eligible to carry a nutrient and/or health

claim’ and vice versa

Validation 4 – linear programming

Aim

To assess if a plausible theoretical healthy

diet can be constructed from only healthy

foods and that no such plausible

theoretical diet can be constructed from

only healthy foods

Validation 4 – linear programming

Conclusion

It is concluded that a plausible theoretical

healthy diet can be constructed from only

foods eligible to carry a nutrient and/or

health claim and that no such plausible

theoretical diet can be constructed from

only foods that would be ineligible to carry

a nutrient and/or health claim

Validation 5 – Improvement of diet

Aim

To assess if the quality of a diet can

improve when foods not eligible to carry a

health claim are replaced by foods that

would be eligible a health claim as defined

by the NPM

Validation 5 – Improvement of diet

Conclusion

The NPM showed good construct validity

by proving that the quality of the diet can

be improved when foods not eligible to

carry a nutrient and/or health claim are

replaced by foods that would be eligible to

carry a nutrient and/or health claim

Stakeholder meeting

57 individuals; 34 organisations

Government

Food Industry

MRC

SAAFoST

NSSA

ADSA

Prof Dorothy Mackerras - Chief Public Health

Nutrition Advisor at Food Standards Australia

New Zealand

WHO

Conclusion

The prevention of non-communicable disease, in

line with the WHO Strategy for the Prevention of

Non-Communicable Disease, underpins the

suggested NPM – providing the scientific

evidence

NPM is intended to be used as a screening tool

to determine whether foods could be eligible to

carry any form of nutrient and/or health claim

All the validations suggested that there is no

reason to tweak the NPM to be applicable to the

South African environment

The stakeholders support the use of the NPM

Way forward

Phase 1 completed = R146

Phase 2 of R146

Screening tool: assess eligibility

to carry a nutrient and/or health

claim

Evidence for nutrient and/or

health claim

Phase 3 – Advertising to children

Challenges

Assumptions

Codex

Definitions of nutrients

Analysis methodology i.e. fibre

Incomplete food composition data

Information of % fruit, veg, legumes, nuts

Dry products like soup powders

Foods eaten in very small quantities

Pre-packed foods

Per 100g or per serving

Products to which milk is added (Cat ?)

Specialized foods i.e. sports drinks

New products on the market

New products on the market

Impact?

Regulated Claims

‘Healthier diets’

Improved Public Health

Prevention of

NCD’s

Nutrient

Profiling Model

Regulated

claims

www.respond.za.net

Category 2 - Corn flakes Average energy content (kJ) per 100g 1569 4

Saturated fatty acids (g) per 100g 0.2 0

Total sugars (g) per 100g 5 0

Sodium (mg) per 100g 898 9

Baseline points 13

% concentrated fruit, vegetable and legumes 0 0

% fruit, vegatables, nuts and legumes 0 0

Protein (g) per 100g 7.5 0

Fibre (g) per 100g 3 3

Final score 10

YES/NO NO

Category 2 - Corn flakes Average energy content (kJ) per 100g 1569 4

Saturated fatty acids (g) per 100g 0.2 0

Total sugars (g) per 100g 5 0

Sodium (mg) per 100g 500 5

Baseline points 9

% concentrated fruit, vegetable and legumes 0 0

% fruit, vegatables, nuts and legumes 0 0

Protein (g) per 100g 7.5 4

Fibre (g) per 100g 3 3

Final score 2

YES/NO YES