An introduction to the Food-Based Dietary Guidelines for the Elderly in South Africa

Food-based dietary guidelines (FBDGs) are not a new concept and are being used in many countries to promote healthy eating and the prevention of diet-related chronic diseases. The Food and Agriculture Organization (FAO) recommended FBDGs as an approach to prevent malnutrition and promote healthy dietary behaviours in populations, taking into consideration local conditions, traditional dietary practices and socioeconomic and cultural factors whilst at the same time using evidence-based scientific principles. South Africa (SA) currently has two sets of guidelines, namely the paediatric food-based dietary guidelines and the South African FBDGs for the population aged seven years and older. The recognition that elderly malnutrition remains a major public health concern in SA led to the formulation of a specific set of guidelines for this vulnerable population group based on existing nutrition-related health issues, local dietary habits and barriers to food intake experienced by those aged 60 and above. This introductory paper on the development of the elderly food-based dietary guidelines (EFBDGs) will be followed by six technical papers motivating why these guidelines are suited to address nutrition-related issues among the elderly in SA.


Introduction
The world is ageing; it is projected that between the years 2015 and 2050, the population of those aged 60 years and above will rise from 900 million to 2 billion (increase of 10%). 1 Southern African countries, such as SA, are actually an exception with a relatively small percentage of the population in the older age groups. 2 Currently, 8.2% of the South African population are over the age of 60 and 5.2% are over the age of 65. Although SA has a relatively small percentage of the population in the age range 60+ compared with higher income countries, by 2025 the total population aged over 60 is expected to be over 10.5%. In 2015, South African males 60 years of age had a life expectancy of 73½ years. Women of the same age had a life expectancy of 78 years. 3 Ageing is an inevitable, natural process associated with higher prevalence of non-communicable diseases (NCDs). NCDs contribute to 51% of deaths in SA. 4 Good food choices and optimal nutrition are important for the prevention and treatment of NCDs throughout the life span. 5 A whole-diet approach is essential for the prevention and treatment of frailty in the elderly as people do not eat single nutrients, but food and meals. 6 Furthermore, research has indicated the importance of adequate dietary intakes of energy, protein, clean water and micronutrients in the elderly and the impact thereof on NCDs and frailty. Malnutrition, both under-(for example, micronutrient deficiencies) and over-nutrition (for example, obesity), exacerbates the risk of immobility and frailty. 6 Eating difficulties, often observed in the elderly due to loose teeth, ill-fitting dentures, sensory changes, dry mouth and food-drug interactions, may also affect food choices and dietary intakes that can lead to malnutrition and dehydration. In addition, cultural food preferences and dietary intake habits and experiences throughout the lifetime impact on food choices and should be considered when planning interventions for the elderly. 7 An important goal during ageing is maintaining health and functional independence. Many of the health problems experienced during old age can be prevented or controlled by healthy lifestyle behaviours such as regular physical exercise and consuming a balanced, healthy diet. 8 The Food and Agriculture Organization (FAO) recommended food-based dietary guidelines (FBDGs) as an approach to prevent malnutrition and promote healthy dietary behaviours in populations, taking into consideration local conditions, traditional dietary practices, and socioeconomic and cultural factors whilst at the same time using evidence-based scientific principles. 9 The current global COVID-19 pandemic is of huge public health concern and the majority of deaths are occurring in the elderly, specifically those suffering from two or more comorbidities. 10 Nutritional deficits are most prevalent in older populations, contributing to the weakening of the immune system and negatively impacting on antibody production, making the elderly susceptible to infections. 10 This paper aims to describe the process followed in developing FBDGs for the elderly (EFBDGs). The testing of the developed guidelines has been described in a previous paper by Napier and co-authors. 11 Background to food-based dietary guidelines The International Conference on Nutrition (ICN) convened by the FAO in Rome in 1992 adopted 'Promoting appropriate diets and healthy lifestyles' as one of its plans of action. Governments were called upon to provide dietary guidelines to the public. The FAO and the World Health Organization (WHO) in an international consultation recommended the development and implementation of FBDGs by governments 9 and provided guidelines for the development of the guidelines. SA agreed to this strategy and the first set of South African FBDGs for South Africans older than five years was completed in 2000 and adopted by the Department of Health in 2003; 12 the paediatric food-based dietary guidelines (PFBDGs) were completed and published in 2007. 13 The SAFBDGs were further updated in 2012 for intended use by people seven years and older (refer Table 1). Consequent to these FBDGs, the South African Food Guide was developed in 2012 and is illustrated in Figure 1. 13

Characteristics of FBDGs
FBDGs are messages that can be used to guide consumers and educators on the best foods and drinks to consume to manage NCD risk. 14 Unlike other types of recommendations, FBDGs are framed in terms of the food being consumed and not individual nutrients, making the message easy for the consumer to conceptualise and understand. 12 FBDGs are intended to be used in health promotion, nutrition education and dietary guidance for the general public and therefore should be culturally sensitive and take into consideration appropriate customary dietary patterns for various population groups. These guidelines should further address public health concerns (such as those described above) in specific population groups 14 such as the elderly. The key principles for developing food-based dietary guidelines include: . Dietary patterns: Total diet and food patterns should be reflected rather than nutrients and numerical nutrient goals.
. Practicality: Recommended foods should be affordable, widely available and accessible and these guidelines should be flexible for use by various population and age groups.
. Comprehensibility: Levels of literacy must be considered when developing the guidelines, with good visual presentation, and testing of the guidelines is of importance.
. Cultural acceptability: Foods chosen and colours used in illustrations should be appropriate in terms of culture and religion. Appropriate language should be used with positive messages encouraging the enjoyment of appropriate diets. 9,14 Food-based dietary guidelines for the elderly globally There are several countries with developed FBDGs for the elderly as a tool to address old-age related health challenges. Table 2 presents the guidelines developed by Australia, 15 New Zealand, 16 Singapore, 17 the United Kingdom 18 and the United States of America. 19 These guidelines were consulted in the development of the EFBDGs.

Development of food-based dietary guidelines for the elderly in South Africa
Vorster et al. 12 recommended the development of FBDGs for vulnerable groups in SA. A working group was assembled in 2012 to develop FBDGs for elderly South Africans. The working group met in the same year to discuss their mandate and it was agreed to develop FBDGs for South African elderly aged 60 years and above 11 and to use the FAO/WHO consultation guidelines on the development of FBDGs and adapt it for local conditions. 14 The decision to develop separate EFBDGs to promote health for SA elderly was based on their specific dietary needs for healthy ageing and specific diet-related public health issues as highlighted earlier in this paper. The EFBDGs developed are based on the current SAFBDGs. 11 A recent global review of FBDGs from 90 countries, seven in Africa including SA, indicated that the SAFBDGs adhere to the WHO Healthy Diet Fact Sheet, 20 therefore it was prudent to base the EFBDGs on the SA guidelines. The Nutrition Society of South Africa (NSSA) then endorsed the development of the EFBDGs as a NSSA project.
The key objectives of the working group were to: . Find and expand on common dietary health issues based on the public health profiles of the elderly in SA.   Use less salt and sauces and cut down on salted and preserved foods . If you drink alcohol: Men should not drink more than 2 standard drinks a day and women, no more than 1 standard drink a day . Agree on the role of nutrients and dietary patterns in healthy ageing.
. Develop appropriate guidelines based on the current SA FBDGs for South Africans seven years and older.
. Test the consumer understanding and appropriateness of the guidelines in five of the official SA languages.
. Write scientific papers for each guideline in support of its formulation, background and aims.
. Develop support educational material for the guidelines for the layperson.
. Develop support material for nutrition educators. 11 Members of the working group reviewed international and SA literature to identify public health problems related to nutrition in the elderly and to develop preliminary EFBDGs. Twelve guidelines were developed addressing the main elderly health and wellness concerns and these were closely aligned with the current SA FBDGs. 11 In May 2013 the literature reviews and preliminary guidelines were circulated to international and local expert advisers who previously agreed to assist with the review process, for input into the initial/draft motivations and guidelines with the literature reviews as support information. Once the feedback was received from the advisers the working group met again later in 2013 to discuss the feedback and reviewed the EFBDGs considering the input from the expert advisers. Consensus was reached, and the guidelines updated to 13 (see Table 3). 11 The next stage of the development was to test the guidelines in a community setting. This consisted of two phases, with the first phase testing understanding of the English EFBDGs in the various age groups, and phase two testing understanding of the adapted and translated EFBDGs. The detailed development and testing process was published in the South African Journal of Clinical Nutrition in 2017 11 and a snapshot of the process is presented below.

Phase 1: testing of English guidelines and various SA language groups
A study population of IsiZulu, Afrikaans, IsiXhosa, English and Sesotho speaking elderly were selected to be included in the focus groups for testing of the English guidelines as these five languages are the most spoken languages in SA. 11 The aim of the focus groups, consisting of six to eight women and men in each language category, was to establish whether the guidelines were understood, interpreted correctly and culturally acceptable.
The study population included was made up of elderly individuals aged 60 years and older in Durban, Vereeniging, Pretoria, East London and rural Qwa-Qwa (KwaZulu-Natal, Gauteng, Eastern Cape and Free State provinces, respectively). 11 From the testing it was evident that three guidelines were not clear and some members of the focus groups found them confusing. These were the guidelines on including legumes, meat, fish and chicken, and whole grains. The confusion, however, was related to the English words used.

Phase 2: translation of guidelines and testing of translated guidelines
Once the results of the first phase focus groups were analysed, the guidelines were again reviewed by the working group and adapted to address language barriers as well as unfamiliar words in the English guidelines. The EFBDGs were then translated into IsiZulu, Afrikaans, IsiXhosa and Sesotho. After translation the guidelines were again tested in focus groups to assess whether the participants understood the guidelines as translated into their home languages. 11 The final translated EFBDGs were understood and were accepted as presented in Table 3.

Obesity
Obesity has become a global epidemic in recent years and is now responsible for 2.8 million deaths per year. 21 The South  African National Health and Nutrition Examination Survey (SAN-HANES-1) indicated that the prevalence of obesity tended to increase with age in both men and women. Older adults usually are less active and thus need to reduce energy intake due to the decrease in basal metabolic rate (BMR). However, this does not always happen and thus body weight increases during old age due to an energy imbalance. 22 The proportion of obese women aged 55-64 and 65 years and older were 56.3% and 52.2% respectively in SA. 23 According to the South Africa Demographic and Health Survey (SADHS) 2016, the majority of men (54.4%) and women (75.4%) aged 65 years or above were either overweight or obese. 24 Moreover, a cohort study among the elderly in Sharpeville showed a consistent prevalence of overweight/obesity of more than 83.7% in women. 23 In addition, a study among elderly in Umlazi showed a prevalence of 82.0% overweight/obesity among women. 25 Obesity has the potential to increase risk of hypertension, coronary heart diseases (CHDs) and cancer.

Cardiovascular diseases
With increasing age, many older adults have dyslipidaemias, more so than in younger adults. In SA, 13.2% of older adults within the age range of 55-64 years, and 15.5% who were 65 years or above had high blood cholesterol. 5 However, in a smaller study conducted among women aged 18-90 years old in the Vaal region, the prevalence of dyslipidaemia was 34.3%. 26 In a cohort study among the elderly in Sharpeville, a consistently high prevalence of dyslipidaemia, specifically low high-density lipoprotein-cholesterol (HDL-C) (> 70%) and high triglyceride (> 34%) levels, was observed. 27 It has been proposed that pre-menopausal women have a lower risk of developing cardiovascular disease (CVD) compared with men of the same age group, due to the protective effect of the female hormone oestrogen. After menopause, however, postmenopausal women become more prone to CVD, due to the reduced levels of oestrogen. 28 Hypertension Several studies done in sub-Saharan Africa (SSA) concluded that age is strongly associated with increased prevalence of hypertension, and the prevalence rate of hypertension in adults aged 50 and older was found to be significantly higher than in the rest of the adult population. The SADHS reported that the prevalence of hypertension in adults had doubled from 25% to 46% in women and 23% to 44% in men between 1998 and 2016. However, hypertension was more prevalent among older adults aged 65 and above (84%). 24 In a smaller study in SA, the hypertension prevalence among adults above 50 years old was also found to be very high (77%). 29,30 Important to note is that many older adults are not aware that they have hypertension as only 38% were aware of their condition. 31

Diabetes mellitus
The prevalence of diabetes as reported by the SADHS (2016) was slightly higher in women (13%) than in men (8%). However, the survey found that 64% of women and 66% of men had prediabetes and were therefore at a greater risk for diabetes. 24 At present the global age-specific mortality rate for diabetes is the highest in Africa, but very little research has been done among the elderly in SSA. 28 Diabetes, especially type 2 diabetes (T2D), which is often a result of lifestyle behaviours, negatively influences the quality of life in older adults in SA. A study found that 9.2% of the older adults had diabetes in SA; 32 however, in a recent cohort study among the elderly in Sharpeville, consistently high serum glucose levels were observed in more than 30%. 27

Metabolic syndrome
The prevalence of high levels of diabetes, obesity, high cholesterol and low HDL-C in SA 27 provides a combination of factors that could lead to a diagnosis of metabolic syndrome (MetS). Not much is documented concerning the prevalence rate of MetS in SA and only a few studies have reported MetS prevalence, ranging from an overall 30.2% in rural women (23) to 60.6% among coloured women in Cape Town. These rates indicate a high prevalence of MetS in SA, but limited information regarding the prevalence of MetS in the elderly exists for SA. 27

Malnutrition
Data from 12 countries, including SA, showed that nearly 14% of elderly individuals residing in nursing homes and nearly 6% of community-dwelling elderly individuals were malnourished. 33 Though the nationwide prevalence of malnutrition amongst the elderly population is currently unknown, SA's growing elderly population and radically unequal quality of (health) care likely indicate that a sizeable portion of the older adult population faces malnutrition. 34,35 Age-specific changes in protein intake, energy expenditure and micronutrient metabolism also play a role in the risk of malnutrition in the elderly. 36

Micronutrient deficiencies
Dietary diversity is a proxy indicator for micronutrient adequacy of the diet. 37 In fact, inadequate dietary diversity could cause micronutrient deficiencies. 22 Nutrient deficiencies not only impact adversely on physical and cognitive development but also contribute to decreased work productivity, increased risk of infection and various diseases as well as premature death. 38,39 Several studies indicated that the most common nutrient deficiencies in SA included calcium, iron, zinc, iodine, riboflavin, niacin and folate as well as vitamins A, E, C and B6. [40][41][42][43][44] Interestingly, the national anaemia prevalence for elderly men (> 65 years) is the highest (25.9%) compared with the overall national prevalence of 17.5%. Elderly women had an anaemia prevalence of 17%. 20 Several studies among the elderly in Sharpeville, Umlazi and other areas in SA showed poor dietary intake of multiple micronutrients. Studies undertaken among the Sharpeville elderly indicated iron-deficiency anaemia, folate and vitamin B12 deficiencies, suboptimum vitamin A and E status and a high prevalence (76.3%) of zinc deficiency, with women having higher prevalence rates than men. 27,45,46 Other common problems experienced in the elderly

Gastrointestinal problems
Ageing affects the motor and sensory functions of the gastrointestinal (GI) tract resulting in the elderly having a higher susceptibility to GI complications of co-morbid illnesses. 47 Specific age-related GI changes affect the oesophagus and colon specifically. These include reduced peristaltic pressure in the oesophagus leading to dysphagia, gastroesophageal reflux and reduction in colon motility causing constipation. 47 GI problems, such as diarrhoea and constipation, are common among the elderly. Rates of almost 50% for the elderly older than 55 years and 70% for those in nursing homes have been reported. Constipation is mainly caused by medication use, certain diseases such as diabetes and irritable bowel syndrome, blunted thirst mechanisms that may result in too low fluid intakes, less responsive intestinal muscle movement, declining cognitive function that may result in the elderly not recognising the urge to defecate, and low-fibre diets due to chewing problems. 48 The GI tract has an important role in maintaining homeostasis of many physiological processes such as ensuring adequate digestion and absorption of nutrients. 49 A healthy and well-functioning GI tract is associated with life satisfaction whereas diseases of the digestive system have been associated with a higher symptom burden that negatively affects the general health of elderly people. Furthermore, research has found a higher prevalence of anxiety and depression among those elderly who have GI symptoms. 50 Cognitive impairments T2D and MetS are major risk conditions for cognitive impairment and Alzheimer's disease due to disturbances in insulin signalling that can impair glucose delivery and use by the brain and nerve cells, leading to decreased function. This can result in structural changes in the memory of the hippocampus, leading to cognitive dysfunction and memory impairment. However, research has found hypometabolism of glucose in the brains of patients with Parkinson's disease and dementia. Although human studies are limited, a daily diet that includes an optimal balance of whole grain and other macro-and micronutrients, specifically the B-vitamins, is associated with lower risk of cognitive impairments, Alzheimer's disease and Parkinson's disease. 51

Dementia and depression
Dementia has become a significant economic burden in SSA but, because it is perceived as a normal part of growing old, many people are left undiagnosed. Furthermore, limited research has been undertaken among the elderly with dementia, resulting in a paucity of information. 19 However, in a systematic review exploring dementia and cognitive impairment in the elderly in SSA, higher dementia prevalence was observed in women (60-69 years) and men older than 70 years. 52 Underweight, Alzheimer's disease, cardiovascular diseases, diabetes and hypertension are associated with dementia. 30 A number of studies conducted in specific areas in SA highlighted the poor nutrition and health status of older adults. 11,53 For example, a study with 422 older adults aged 50 years and above showed that 42% of them suffered from depression. 53 Osteoporosis Bone health is a common health issue during ageing, especially for women. 54 Elderly people are more vulnerable compared with other-aged population groups in terms of osteoporosis. Osteoporosis is a bone health problem characterised by low bone mass and micro-architectural deterioration, and increases the risk of bone fragility and fracture. 55 There are many risk factors, which include both irreversible and modifiable factors, that contribute to low bone density. The risk of osteoporosis has a positive association with increased age, family history, female gender, oestrogen deficiency, amenorrhea, vitamin D deficiency, low intakes of calcium, chronic diseases, leading a sedentary lifestyle, and excessive smoking and alcohol consumption. Among the many factors that affect bone health and healthy ageing, healthy lifestyle behaviours (dietary intake and physical activity) are recognised as modifying factors to improve bone health in the elderly. Calcium intake is low among the elderly in SA. 31 The incidence of osteoporosis is more common among white, Asian and mixed-race populations compared with the black populations. 56 The way forward Technical support papers, based on recent and relevant scientific literature, were developed for each of the guidelines underpinning the science behind the guidelines selected and will be published in additional papers. Additional support material targeting the elderly is currently being developed and will address the needs of this group in the five languages. The following factors for the development of effective nutrition education messages will include: − household food security (the availability, accessibility and affordability of food); − nutrition-related public health concerns; − the consumer's socioeconomic circumstances; − the consumer's lifestyle and cultural eating habits; − the consumer's understanding of and ability to apply the information, which will be considered during the development process. 57,58 The next step will then be for the SA Department of Health to adopt these guidelines and to roll out the support material, which is being designed for the lay public as well as health professionals.

Conclusion
As age increases in the elderly, so does the risk of illness and malnutrition and in turn the prevalence of morbidity. 7 Nyberg et al. 7 further explains that appetite, smell, taste and eyesight deteriorate with age and are among the risk factors for poor dietary intake, nutritional status and specific drug use in the elderly. Preparing food for oneself is a sign of independence and is strongly associated with well-being and increased selfesteem. Community members need to be empowered and educated in ways to achieve an affordable yet balanced diet given their limited resources, mobility and knowledge. The EFBDGs will be a tool that can be used by healthcare workers to educate and empower the elderly regarding healthy food choices and lifestyle behaviours to prevent disease and improve health.

Author contributions
All authors assiduously contributed to the preparation of this manuscript and gave their respective approvals.
Disclosure statement -No potential conflict of interest was reported by the authors.