Low-income South African adults consume, on average, 40% of their calories from ultra-processed products, according to a new study published this month in Public Health Nutrition. Meanwhile, only 7% meet the World Health Organization’s recommendations for daily fruit and vegetable intake, and only 19% meet fiber recommendations.

Researchers at the University of the Western Cape in South Africa, the University of North Carolina at Chapel Hill, and the University of Sydney examined the diets of over 2,000 low-income South Africans reported in a 24-hour dietary recall collected in 2017–2018. They classified all the foods people reported eating according to their level of processing, using the NOVA classification system.

“South Africa is facing a rising tide of obesity and non-communicable diseases that is driven in part by the proliferation of ultra-processed products,” said Tamryn Frank, PhD, researcher and dietitian at the School of Public Health at the University of the Western Cape in South Africa and the study’s first author. “Consuming these ultra-processed products is associated with numerous health risks, such as obesity, diabetes, heart disease, certain cancers, and increased risk of early death. This puts a strain on our already burdened health care system.”

Of particular concern to the researchers is that younger consumers appear to be getting more of their calories from ultra-processed products than older consumers—a concerning trend given the increase in nutrition-related diseases in South Africa.Among 18- to 29-year-olds, ultra-processed products accounted for just over 40% of daily calories, compared to 22% for 40- to 50-year-olds.

South Africa is one of many countries actively working to implement policies that could help improve the food supply and the population’s dietary quality. In 2018, for example, the country began taxing soft drinks based on their sugar content under a Health Promotion Levy. This led to the beverage industry significantly reducing the amount sugar in products, as well as drops in purchases and intake of taxable beverages. For example, young adults in Langa, South Africa reduced their intake of taxed beverages by 37%, drinking 9 grams less sugar per person per day. In Soweto, Johannesburg, black adolescents and adults reported decreasing their frequency of drinking sugary beverages by 7 times per week among high-intake consumers and 2 times per week among medium-intake consumers.

To build on the success of the Health Promotion Levy, last year the National Department of Health released a draft front-of-package warning label regulation, designed and written based on scientific evidence from focus groups and randomized controlled trials in South Africa. The Department is currently reviewing public comments and working on finalizing the regulation. This policy aims to provide South Africans of all literacy levels with clear guidance on which products are high in nutrients of concern (sugar, saturated fat, and salt) or contain non-sugar sweetener. 

Research is also underway to identify how and to what extent ultra-processed, unhealthy foods are marketed to South Africans, particularly children and adolescents. Restricting such marketing is a policy approach prioritized by the World Health Organization.

South Africa faces the double challenge of limiting consumption of ultra-processed and nutritionally harmful foods while also ensuring low-income populations have enough to eat. Of those surveyed for this study, 14% reported experiencing moderate to severe hunger.

“This challenge of addressing both under- and over-nutrition will require a combination of policies to ensure equitable access, availability and affordability of healthy foods,” said Frank. “A start would be using revenue raised from the Health Promotion Levy to subsidize the cost of fruits and vegetables, particularly for low-income populations,” said Frank.

---

This study was funding by The International Development Research Centre (IDRC), Bloomberg Philanthropies, and US National Institutes of Health.

AUTHORS

Tamryn Frank
Shu Wen Ng
Caitlin M. Lowery
Anne-Marie Thow
Elizabeth C. Swart

---

Learn more about ultra-processed foods and the NOVA classification system.

---

MORE RESEARCH FROM
SOUTH AFRICA:

Nutrient warning labels work in South Africa: Results from a randomized controlled trial Read more…

---

Most South African breakfast cereal packages feature child-directed marketing Read more…

---

Beverage industry ad spend and airtimes in South Africa Read more…

The majority of breakfast cereals in South Africa feature child-directed marketing strategies on their packaging, according to a new study in Public Health Nutrition. In an analysis of over 200 breakfast cereals, researchers also found that breakfast cereals with child-directed marketing contained significantly more total sugar and less fiber than cereals without child-directed marketing.

South Africa faces high levels of obesity and other diet-related such as type 2 diabetes, hypertension, cardiovascular disease, and cancer. In April 2023, the National Department of Health released draft regulation R3337, which includes mandatory front-of-package warning labels and restrictions on marketing for products high in nutrients of concern that can cause or worsen NCDs when consumed in excess. Under this regulation, products with warning labels will be banned from making health or nutrition claims, featuring characters on packaging, and using other direct and indirect marketing strategies to appeal to children and their parents.

Research shows that marketing is a key factor in promoting consumption of ultra-processed products high in salt, sugar, saturated and trans fats, and calorie density. Children and adolescents are developmentally vulnerable to advertising and other marketing tactics and are highly targeted, often for food and beverage companies’ least-healthy products. Food and beverage advertising has remained unregulated even though children’s rights are guaranteed in the South African Constitution.

In this study, researchers assessed the nutritional composition of 222 breakfast cereals as well as the presence of direct child marketing strategies on packaging (e.g., illustrations, characters, fantasy, role models), and indirect marketing to children’s parents (nutritional claims and health claims). Breakfast cereals with direct child marketing strategies had lower levels of protein and fiber and higher total sugar and carbohydrate content than those without direct marketing strategies. 

Key findings:

This research was funded by Bloomberg Philanthropies.

AUTHORS

Alice S. Khan
Tamryn Frank
Rina Swart

---

MORE RESEARCH FROM SOUTH AFRICA:

Nutrient warning labels work in South Africa: Results from a randomized controlled trial Read more…

---

Beverage industry ad spend and airtimes in South Africa Read more…

A new study published in the Journal of Public Health Research has found that in South Africa, sugar-sweetened beverage manufacturers spent USD 191 million (ZAR 3.7 billion) advertising SSBs across different media from 2013 to 2019. The bulk of this was spent on television (TV) advertising, particularly during children’s and family viewing times.

Researchers from PRICELESS South Africa, the SAMRC Centre for Health Economics and Decision Science at the University of Witwatersrand, and UNC-Chapel Hill measured the number of sugary beverage advertisements in South Africa from January 2013 to April 2019. They used Nielsen data from the top 10 manufacturers in South Africa to assess advertising expenditures across different media, including TV, print newspapers and magazines, radio, and internet. They examined data by drink category and media type and analyzed the number of ads aired on TV during child and family peak viewing times (between 3 p.m. and 7 p.m. on weekdays).

Key findings:

South Africa faces high levels of diet-related diseases such as obesity, type 2 diabetes, hypertension, cardiovascular disease, and cancer. Drinking excess sugary drinks increases the risk of developing these diseases and their risk factors. Research shows that marketing and advertising is a key factor in promoting the consumption of sugary drinks and other ultra-processed products and that children and adolescents are highly susceptible to food marketing.

To lower consumption of sugary drinks as well as foods high in sugar, salt, saturated fat, South Africa implemented a sugary drink tax in 2018 that has already led to decreased purchases and intake of sugary drinks. The country also recently issued a draft regulation for mandatory front-of-package warning labels, which includes a stipulation that products with warning labels (i.e., high in salt, fat, sugar, or containing artificial sweeteners) may not use certain marketing techniques on their packages.

Thus far, however, the country has not enacted policies to restrict marketing of non-essential foods or drinks beyond the proposed packaging restrictions. This study suggests that the sweetened beverage industry is capitalizing on the child and family market, particularly via television advertising. The study also finds that industry’s voluntary pledges to curb marketing aimed at children have not worked, further underscoring the need for statutory action.

---

This research was funded by Bloomberg Philanthropies and the South African Medical Research Council.

AUTHORS

Micheal Kofi Boachie
Susan Goldstein
Petronell Kruger
Shu Wen Ng
Karen J Hofman
Evelyn Thsehla

---

FACT SHEETS

Read more about the evidence for restricting marketing for non-essential foods and drinks high in sugar, salt, saturated or trans fats, or calorie density.

A new study from South Africa comparing three different front-of-package (FOP) labeling schemes found that a nutrient warning label helped more participants correctly identify unhealthy products and more strongly reduced their intention to purchase those products, compared to a “multiple traffic light” label and a Guideline Daily Amounts label.

These findings, published in Appetite, come at an important time as South African policymakers consider draft regulation for the country’s first mandatory front-of-package label. While research from other countries has found that nutrient warning labels are the stronger FOP label option for identifying and discouraging consumption of unhealthy foods, some studies find that other labels, such as the traffic light, can also be effective. This suggests that context plays an important role and underscores the importance of testing a label designed specifically for South Africa.

“It was important to create a warning label for South Africa that can help people from different language backgrounds and literacy levels make informed decisions on what to buy and eat,” said Makoma Bopape (left), first author and Senior Lecturer in Human Nutrition and Dietetics at the University of Limpopo. “We achieved this using a triangle shape and exclamation mark that are associated with ‘warning’ in South Africa and by including icons for each nutrient, for example a saltshaker for sodium.”

In a randomized controlled trial, researchers from the University Limpopo, the University of the Western Cape, the University of Antwerp, and the University of North Carolina at Chapel Hill compared how well the different label types helped South African consumers:

• Identify products high in sugar, salt, or saturated fat;
• Identify unhealthy products; and
• Reduce intention to purchase unhealthy products.

Participants were randomly selected from the general South African population, which resulted in a representative sample of nearly 2,000 households. They first answered questions about a set of fictional products with no FOP labels, as a control condition. Next, they were randomly assigned to one of the three FOP label conditions and shown another set of products featuring that label. They then answered the same questions about the labeled products.

Researchers measured how many participants in each group correctly identified products high in nutrients of concern (sugar, salt, and saturated fat), how many correctly identified products as unhealthy, and whether participants’ intention to purchase the unhealthy products changed after seeing them with a specific FOP label.

“These findings are consistent with a rapidly growing body of evidence from around the world showing that warning labels are the most effective label type for helping consumers rapidly identify unhealthy foods — and perhaps more importantly, discouraging consumers from buying them,” said Lindsey Smith Taillie (right), co-author and Associate Professor of Nutrition at the University of North Carolina at Chapel Hill.

This research comes on the heels of another study by Bopape, Taillie, and Rina Swart, senior author and professor in Dietetics and Nutrition at the University of the Western Cape, in which they examined how the same warning labels impacted parents’ food purchasing decisions and perceptions of unhealthy foods. When shown images of products with warning labels, parents said they would buy less of the foods with warning labels and switch to non-labeled, healthier options. Parents in the study also expressed that their children’s health was their top priority. Warning labels made them think about future health impacts if their children continued eating ultra-processed foods high in sodium, sugar, and saturated fat.

Like many countries worldwide, South Africa faces high rates of obesity and other diet-related diseases including type 2 diabetes, hypertension, and heart disease — all exacerbated by consuming a diet high in sugar, sodium, or saturated fat. In addition to helping consumers easily and more accurately identify foods high in nutrients of concern and discourage purchases of those products, requiring FOP warning labels on the least-healthy foods and drinks could incentivize industry to offer healthier product choices.

Policies using similar FOP nutrient warning labels have already been implemented or passed in ten other countries — most in the last three years. Evidence of their impact in Chile, where FOP warning labels have been required on unhealthy packaged foods and drinks since 2016, suggests that findings from experiments like this one in South Africa can translate into real, population-level changes in shopping behavior once a policy is implemented. In its first year, Chile’s FOP warning label policy was associated with a 24% drop in sugary drink purchases and declines in sodium (–37%), total calories (–24%), calories from sugar (–27%), and calories from saturated fat (–16%) purchased from all foods and beverages.

“If South Africa adopts the labels used in this study into the current draft regulations, ours will be the first African country and second country in the world after Israel to use a mandatory warning label with icons for different nutrients,” said Swart (left). “In addition to helping guide South African consumers toward healthier choices on what to buy, eat, and feed their families, this could provide important evidence for other countries that have diverse languages and literacy levels.”

---

This research was funded by Bloomberg Philanthropies.

For inquiries, contact Emily Busey.

Read the full paper in Appetite:

---

AUTHORS

Makoma Bopape
University of Limpopo,
University of the Wester Cape

Jeroen De Man
University of Antwerp

Lindsey Smith Taillie
UNC-Chapel Hill

Shu Wen Ng
UNC-Chapel Hill

Nandita Murukutla
Vital Strategies, New York

Rina Swart
University of the Western Cape

---

RESOURCES

Read more about the evidence for front-of-package labels.

View different front-of-package labeling policies around the world.