Women and Diabetes in the Spotlight this November

Over the past decades, the rise of diabetes around the world has been so prevalent and extreme, it is sometimes referred to as the epidemic of our modern times. In 2017, the diabetes focus theme is Women and Diabetes. Globally, diabetes is the ninth leading cause of death in women, resulting in 2.1 million deaths each year. It is estimated that there are currently more than 199 million women living with diabetes, and by 2040, this total is expected to reach over 310 million.

Registered dietitian and ADSA (the Association for Dietetics in South Africa) spokesperson, Ria Catsicas says, “According to the latest mortality report for South Africa released earlier this year, diabetes is ranked as the leading cause of death in women, and the most important risk factor for developing Type 2 diabetes is obesity. At this time, more than 60% of South African women are either overweight or obese, putting them at higher risk than men of developing diabetes in the future.”

Gender also means that women experience additional health risks due to obesity. As Ria notes: “Almost 17% of pregnant South African women experience gestational diabetes which is directly related to obesity. This condition puts them at risk of experiencing high blood pressure during their pregnancy, miscarriages and still birth. In addition, the babies of mothers-to-be with gestational diabetes tend to be large which can contribute to complications during birth and are themselves at a higher risk of developing type-2 diabetes later in life. Obesity also plays a role in increasing the risks of female infertility.”

Optimal nutrition is key for the person with diabetes; it is also crucial for those who may not have diabetes yet, but are insulin-resistant and those with a family history of diabetes, as genetics are also a risk. Optimal nutrition is also essential for all women – up to 70% of cases of Type 2 diabetes can be prevented by following a healthy lifestyle.

Type 1 diabetes is managed by medication (injectable insulin and or tablets),a controlled diet and exercise; but when it comes to Type 2 diabetes, good nutrition along with other healthy lifestyle changes are usually the first line of treatment to manage diabetes, and if medication is required, a healthy diet can complement and often influence the medicine, to help avoid experiencing the life-threatening complications of diabetes. Tabitha Hume, also a registered dietitian and ADSA spokesperson, points out that common-sense healthy lifestyle changes can be a vital safeguard. “Balanced meals that are made up of a combination of high fibre, low-GI carbohydrates, lean protein and healthy plant fats with generous helpings of vegetables and salads and some fruit (in controlled portions) can be a general guide. However, plasma glucose control is very individual, depending on the severity of the diabetes, and the type and dosage of medication being used. Diabetics will need the help of a registered clinical dietitian who can support them in translating these guidelines into the practical meal plans that best suit their food culture, their taste preferences, daily routines and lifestyles.’’

ADSA spokesperson, Nasreen Jaffer agrees, “There is no ‘one size fits all’. In order to make a sustainable change to a healthier eating plan, all aspects of a person’s life must be taken into account. A working mom with kids at school does not have the same amount of time for food planning and preparation compared to a stay-at-home mom. It is the role of the dietitian to help tailor an eating plan that is healthy – as well as practical, affordable and do-able for the individual.”

All three experts agree that this year’s World Diabetes Day focus on women is relevant to the adoption of healthy lifestyles across South Africa’s population.   While many men play a prominent nurturing role in the home, and many are becoming increasingly interested in the impact of nutrition on health and physical performance, it is still common for women to take the dominant role in the nourishing of the family, and ensuring health and disease prevention.

Tabitha points out: “Since women are most often the home chef, the grocery shopper, and the planner of meals and snacks for children and the family, if nutrition education is targeted at women, there is a higher chance that healthy nutrition guidelines filter through the whole family and have the biggest impact. Family traditions, practices and cultures most often derive from the mother in a family which is why children often adopt the religion and language of the mother. This is where the ‘Mother Tongue’ phrase originates. South African women are encouraged to develop a ‘Mother Meal’ concept moving forward, helping to instil healthy eating habits in children from a young age.”

World Diabetes Day on 14 November aims to shine a light on the risks for developing diabetes; as well as the needs for regular screening, access to information, self-management education, treatments and support, which includes optimal nutrition.


What we eat at our place of work has a huge impact on our overall diet and influences our productivity. The prevalence of overweight and obesity combined is now 65% for females and 31% for males (2012 South African Health and Nutrition Examination Survey – SANHANES) and unhealthy workplace eating behaviour is believed to be playing a role in South Africa’s growing obesity problem.

The Association for Dietetics in South Africa (ADSA) has partnered with National Nutrition Week since the late 1990s to highlight important nutrition messages to South Africans. “In line with our continued efforts to support South Africans in living healthier lifestyles and to promote dietitians as the go-to experts for nutrition advice, the issues around healthy eating in the workplace are close to our hearts and something our dietitians deal with on a daily basis”, says ADSA President, Maryke Gallagher.

Employees consume at least half of their meals and snacks during work hours, making this an important place to promote healthy eating. Registered Dietitian, Alex Royal, says that healthy eating at work can be a challenge as there are often too many temptations: the vending machine, the sweets trolley, colleagues who have bad habits that influence others. “During a busy day we don’t have time (or forget) to prepare healthy meals or even forget to eat. So blood glucose levels drop, resulting in an energy dip and potentially cravings, especially for highly processed and sugary foods. This fuels the cycle of unhealthy eating at work”, Royal concludes.

The question is what can employers do to create a healthier food environment at work? Suggestions include changing meal options available at work to be in line with the guidelines for healthy eating, offering a variety of foods, controlling portion sizes, overhauling vending machines and kiosks to include healthy snack options, offering drinks that are not sugar-laden and changing the menu of food provided during meetings. Cath Day, Registered Dietitian and ADSA spokesperson, also offers some tips for employees:

  • Before grabbing a snack, first ask yourself if you are really hungry or if you rather need to take a break from what you are doing. Going for a short walk or getting some fresh air – may be all you need.
  • Don’t skip meals or healthy snacking between meals. Skipping meals and snacks results in dips in blood glucose (sugar) levels and thus you will be more likely to crave unhealthy foods.

We often talk about school lunchboxes, but what about work lunchboxes? These go a long way in giving employees more control over what they eat during the day. According to Registered Dietitian Kelly Schreuder the goals of a healthy work lunchbox include: Variety and balance of foods, providing a variety of nutrients, including protein, carbohydrates, fat and micronutrients. Real food, as opposed to processed snacks and those that are high in added sugar, excess salt and poor quality fat, and portion control.

And what about fluids – what should we be drinking while we are at work? “The simple answer is that water should be the main beverage we are drinking while working but there are many other healthy options to choose from as well. People often forget that beverages can contain a large amount of energy (and many beverages contain too much sugar such as sugar sweetened beverages and fruit juice) so we need to be more mindful about what we are drinking”, say ADSA spokesperson Catherine Pereira.

Being active in the workplace is also important and employees should try to be as physically active as possible. Durban-based dietitian, Hlanzeka Mpanza says that it is not impossible to include some physical exercise in the workday. Use the steps instead of the lift; form an exercise club with colleagues and try to fit in a 15 minute walk during the lunch hour; wear a pedometer during the day to keep track of activity levels and as a motivator; and stretch your legs by walking over to your colleagues’ desk instead of sending them an email.

What we eat affects our mood, how alert we are and our overall productivity. We asked dietitian Maryke Bronkhorst why food influences us in this way. “Some foods contain nutrients that are used to manufacture certain brain chemicals that may enhance mental tasks like memory, concentration, and reaction time.   Protein foods enhance the brain’s production of dopamine, a natural brain chemical that helps one to feel alert. Large quantities of carbohydrates, on the other hand, result in the production of serotonin, a natural brain chemical that can cause drowsiness, but glucose in the bloodstream is the brain’s main source of energy. So it’s important that you eat at regular intervals and choose low glycaemic index options to prevent your blood sugar levels from dropping too low”, says Bronkhorst. Lean biltong, a small handful nuts, a piece of fresh fruit e.g. blueberries, vegetable crudités with a dip like hummus and plain yoghurt flavoured with handful of berries are great ‘go-to’ snacks.

On Tuesday, 13th October ADSA (@ADSA_RD) is hosting a #WorkplaceNutrition twitter talk from 1pm to 2pm. The talk will focus on healthy eating and healthy living in the workplace providing employees with tips, ideas and advice about achieving a better nutrition balance during work hours. Dietitians and National Nutrition Week partners will be answering questions such as:

  • What are challenges employees face with healthy eating at work?
  • What can employees or workplace do to improve healthy eating during the workday?
  • What should be included in a work lunchbox?
  • What should we be drinking while we are working?
  • How do we stay active while working?
  • What are the go-to snacks that give energy needed to work well?

Join the conversation live on Twitter, follow the @ADSA_RD handle or track the hashtag #WorkplaceNutrition to get some great ideas and tips on how to eat healthily at work.

Raising Superheroes – Book Review*

In the newly released book, “Raising Superheroes”, Prof Tim Noakes, Jonno Proudfoot and Bridget Surtees advocate for what could be considered broadly as a healthy, balanced diet for infants and children. Fresh and real foods are promoted, which include red meat, chicken, fish, eggs; full cream dairy; vegetables and fruit; and grains such as quinoa, oats and millet. The ‘golden rules’ of “Raising Superheroes” echo principles stated in dietary guidelines generally advocated, such as “steering clear from added sugar and highly processed starchy foods”. The book showcases recipes that include fresh ingredients and the healthier version to some old time classics. It is not a “Banting” for children book, as what might have been expected, although the book has similar branding to the “Real Meal Revolution” and uses many of the same arguments.

The revised South African (SA) paediatric food-based dietary guidelines (SA-PFBDGs) are cited (Reference 36) in the book, however, reference is also made to “national guidelines” which include other country’s guidelines (e.g. UK, USA, Canada). It is therefore not always clear which guidelines are referred to, causing confusion about statements made in the book concerning dietary guidelines in general. In reference to the SA-PFBDGs specifically, it is stated that the guidelines are “still to be tested”. It should be noted that the proposed SA-PFBDGs will be field-tested for understanding and feasibility before they can be accepted as the official infant and young child feeding (IYCF) guidelines for the country. This process is currently underway with studies being conducted by Stellenbosch University researchers in collaboration with other academics. The statement that the promotion of these guidelines has not reversed the epidemic of obesity and diabetes (p318) is therefore unsubstantiated. It is important to note that the “Raising Superheroes dietary guidelines” proposed from page 319 has not been tested in rigorous research for understanding and feasibility in the SA context and population, which is considered a major shortfall of these proposed guidelines.

Some information and advice provided in the introduction to the different chapters are based on current best practice and international guidelines; while some information and advice is considered lacking a solid evidence base and posing potential harm. In the chapter covering pregnancy to 6 months period, it is stated on page 34 that “we don’t necessarily advise that pregnant or breastfeeding women should be following a fully ketogenic Banting diet. In other words, we’re not recommending that you exclude carbohydrates from your daily intake to such a degree that your body’s energy source switches completely from glucose to ketone bodies. (The scientific evidence on a fully ketogenic diet during pregnancy is insufficient to make definitive calls, though we suspect it would be perfectly fine.)”. It is not responsible to state “we suspect it would be perfectly fine” when providing advice, especially during vulnerable periods, such as during pregnancy. In fact, ketogenic diets during pregnancy have been linked to amniotic fluid insufficiency, bone mineral loss and calcium excretion, putting both mother and baby at risk of complications and/or deficiencies. The arguments of a ketogenic diet during pregnancy and the benefits of ketones for infant brain growth are taken further in the last chapter. A statement is made that “A key benefit of breastfeeding is that it maintains a state of ketosis in the newborn baby for as longs as it continues”. This blanket statement is not evidence-based and is made out of context when considered against the reference cited.

Furthermore, the advice provided in the section on foods to avoid during pregnancy, states that mothers should “Watch out for – Alcohol.” Furthermore, “the safest option is to abstain from drinking, though recent research appears to show that a very limited intake is fine.” No guide is provided to indicate what is meant with a “very limited intake” of alcohol. The one reference cited was written in the context specific to the United Kingdom and can therefore not be extrapolated to SA. Moreover, this advice is contradictory to what is advocated in SA by various authorities, including Department of Health. To refer very casually and jokingly to drinking during pregnancy as “not getting drunk” (page 39) is an irresponsible and insensitive statement in a country such as SA with the highest prevalence of Foetal Alcohol Spectrum (FAS) disorder in the world.

The guideline on breastfeeding rightly states that “breastfeeding is the gold standard of nutrition for your child, and it comes with a range of health benefits, as we cover elsewhere”. The benefits of exclusive and continued breastfeeding are reiterated, in summary, in the book. However, the actual detail provided on breastfeeding in the mentioned chapter, states that “From a purely nutritional point of view, you should be aiming to exclusively breastfeed until 4-6 months, and continue breastfeeding in combination with solid foods for longer – until two years, at least.” The guideline advocated by the World Health Organisation and which has been adopted by the SA Department of Health (DOH) states very clearly: “As a global public health recommendation, infants should be exclusively breastfed for the first six months of life to achieve optimal growth, development and health. Thereafter, to meet their evolving nutritional requirements, infants should receive nutritionally adequate and safe complementary foods while breastfeeding continues for up to two years of age or beyond.” The guideline on 4-6 months of exclusive breastfeeding is outdated and confusing in the SA context where the 6-month message is being strongly promoted. In a country where very poor breastfeeding practices are evident, especially in as far as the exclusivity is concerned, it is unacceptable and irresponsible to state this outdated recommendation. There is good evidence as to why exclusive breastfeeding for 0-6 months should be promoted, protected and supported and why the 4-6 month guideline should not be advocated as a broad public health message.

Furthermore, poor breastfeeding practices have a knock-on effect which leads to poor complementary feeding practices. The battle is therefore lost if a sound foundation of appropriate breastfeeding practices is not established. This fact is not emphasised sufficiently in the “Raising Superheroes” book. In the detailed section on breastfeeding, breastfeeding is described in negative words and language (including: first biggest challenge; intimidating; many experience a plethora of problems; common problems; for many women breastfeeding is difficult and can be extremely disheartening; hurdles; painful; incorrect; problem; insufficient), and this does not encourage breastfeeding as the most natural and healthful first food for infants and young children.

The paragraph to end the breastfeeding section disappointingly states: “But if you’ve done everything you can to breastfeed and it’s just not working, or if your lifestyle prevents you from breastfeeding for as long as you ideally might, then take heart; there are alternatives.” The need for strengthening the Mother Baby Friendly Initiative; breastfeeding friendly communities; maternity benefits; breastfeeding policies in the workplace which supports mothers to continue breastfeeding and/or express breastmilk; are not mentioned. Instead, what follows is a jump from the most healthful first food (breastmilk and breastfeeding) to an ultra-processed product (UPP) i.e. formula milk which is described as “practical and viable” and suggested as an alternative to breastfeeding. This is in stark contrast to statements elsewhere in the book that warn against “ultra-processed products” and promote real food. Formula milk should not be seen as an alternative to breastfeeding/breastmilk; it can only be considered a substitute if a mother chooses to formula feed.

In the ‘Science’ section at the end of the book, the following remarks are made: “Breastfeeding is nutritionally superior to formula feeding, a point that may not be sufficiently stressed in major feeding guidelines” (pg. 319) and “They [current national feeding guidelines] fail to stress the importance of continuing breastfeeding beyond six months” (Pg 344). These statements are inaccurate within the South African context. The SA paediatric food-based dietary guideline (Reference 36) for complementary feeding contains as its first message: ‘From six months of age, start giving your baby small amounts of complementary foods, while continuing to breastfeed for up to two years and beyond’ as does the first paper in the series. Furthermore, the SA DOH’s Infant and Young Child Feeding Policy (2013) states as a key component ‘continued breastfeeding for two years and beyond’, a recommendation provided in many other national policies.

The ‘Raising Superheroes’ book refers to complementary foods (or the introduction of solids) as “weaning” throughout the book. This is an outdated term, which implies and is interpreted as the cessation of breastfeeding. The term is therefore not used in the literature globally, when optimal infant and young child feeding is discussed. The authors clearly criticise the use of baby cereals or grains for children when complementary foods are introduced. It needs to be acknowledged that South Africa is a country with high levels of household food insecurity. Often, families cannot afford or access animal protein and vegetables or fruit daily. In such situations, grains such as oats and millet, appropriately fortified staples, such as maize and brown bread, and commercially produced enriched complementary foods, such as infant cereals, may provide cost-effective food options.

In the chapter for 1-3 years of age, nothing is mentioned about the continuation of breastfeeding up to two years of age and beyond, although it is mentioned in the last chapter. The importance of continued breastfeeding during the introduction of complementary foods is also omitted. The protective effect of breastfeeding against food allergies, in particular is not mentioned. It is also not explained that food allergies are related to certain proteins in foods (e.g. protein in cow’s milk, fish, peanuts, egg white, soy and gluten) and that elimination diets (including the elimination of carbohydrates) are not routinely recommended for infants and young children, as they can negatively affect a child’s growth.

Furthermore, it is not appropriate to introduce a culture of ‘dieting’ or being placed on a diet in childhood. Fostering a healthy relationship with food during childhood is important, and balance, variety and moderation are important components that contribute to this relationship. In addition, many families in South Africa would struggle to sustain the recommendations made in this book, from a practical and cost point of view.

Several sections of the ‘Science’ chapter of the book are written from the point of view of the authors and, in particular, Prof Tim Noakes’ personal opinion and experience. Expert opinion and personal experience can be valuable when backed up by a solid evidence base and tested in rigorous research. In the case of this book, however, Prof Noakes often expresses his own views and opinions in a colloquial way and makes statements that have not been tested.

To summarize, this book provides many ideas for parents to incorporate fresh ingredients, an array of vegetables and fruit, incorporate various protein rich foods; and to cut down on sugar (with some clever party food ideas). Drawbacks of this book include conflicting messages about the inclusion of certain foods, e.g. whole grains and legumes or ‘unrefined carbohydrates’ are stated as being acceptable, but rarely used in recipes; the use of ‘fresh’ and ‘real’ food are often referred to while numerous recipes include high salt ‘processed’ and ‘cured’ meat such as bacon and ham. Furthermore, even though the evidence-based guidelines refer to grains and legumes as being acceptable, very few recipes include these ingredients. Although vegetables and fruit are recommended, the authors state that “The message of five or more vegetables a day has been overplayed by official guidelines” which is inaccurate. There is substantial evidence to support the recommendation of five-a-day and recent research suggests that it may not be enough.

In general, the target market of the book is vague. It is mentioned that a real meal revolution was started in SA and the intention is to take it to the rest of the world. The last statement in the book reads: “In summary, if the parents of newborn and young South Africans were all to follow the advice in this book we would revolutionise the long-term health of all South Africans. And that continues to be the goal of our eating revolution.” The stated aims of the “Real meal revolution” and “Raising Superheroes” point to a broad public health approach. However, the guidelines and advice, as well as recipes provided do not take into consideration the public health problems and issues of SA, and specifically those related to infant and young child nutrition. Culture, availability of foods and income are factors which should be taken into consideration when formulating broad guidelines intended for a population. Cost of food, in particular is considered a major barrier to following dietary advice. The advice and recipes in the book are clearly not targeted at the average South African, but rather the higher income market, which does not align with a public health approach. There appears to be a constant conflict between these approaches (individual VS population) in the book, which raise many unanswered questions from a public health nutrition perspective.

*This review was compiled by Lisanne du Plessis, with inputs from Catherine Day, Maryke Gallagher, Catherine Pereira, Sasha Watkins and Marlene Ellmer (Registered Dietitians and ADSA spokespeople).


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