Towards a responsible food-based dietary guideline for alcohol consumption for South Africa

Abstract

Alcohol abuse in South Africa is a major problem. It has negative social and health consequences. The social effects include a contribution to high levels of crime, road accidents, intentional and unintentional violence, irresponsible sexual behaviour associated with the HIV/AIDS pandemic, as well as the high prevalence of foetal alcohol syndrome and poverty. The health consequences are many, including malnutrition, some cancers and liver cirrhosis. Reported intakes amongst South Africans are high, but it is especially the pattern of intake, binge drinking, that is of concern. The recommendation about alcohol intake in the South African food-based dietary guidelines (FBDGs), state that "if you drink alcohol, drink sensibly". Clearly, this guideline is not having the intended effects. The first objective of this study was to review alcohol consumption patterns, its negative effects, but also its putative beneficial effects in the South African population, with a focus on Africans. The second objective was to analyse the FBDGs from 75 different countries to assess how alcohol recommendations in other countries are made. The third objective was to examine the relationships between alcohol intake and health effects in Africans in transition, using the results from the THUSA-study. The last objective was to integrate all these findings to make a recommendation on how the South African FBDG for alcohol could be re-formulated to be more effective. The literature shows that the Colonial and Apartheid past of South Africa probably contributed to a pattern of drinking in African men which is reflected in the high intakes and binge drinking of the present. No evidence that the beneficial cardio-protective effect of moderate alcohol consumption, described for many European populations, could be found for Africans. The analysis of the THUSA data showed that the expected beneficial effects of alcohol consumption on HDL-cholesterol levels were seen, but that intakes were associated with a significant increase of serum ferritin levels in African men and women. Using serum ferritin as indicator of negative or positive iron balance, 23% of female drinkers compared with 11 % of non-drinkers, and 46% of male drinkers compared to 25% of non-drinkers were in positive iron balance, having a risk of iron-overload. Because both drinkers and non-drinkers had high HDL-cholesterol levels (means between 1.07 and 1.30 mmol/L) it was argued that the negative health effects of alcohol consumption in this African population outweighed possible beneficial effects. It was concluded that there is little evidence that moderate alcohol consumption has beneficial or cardioprotective effects in black South Africans. It was further concluded that the negative effects on iron status as well as all the other reported social and health consequences of alcohol misuse or abuse, indicate that the South African FBDG on alcohol should be revisited. Three possibilities are discussed, namely to avoid making a recommendation, to recommend "not to drink at all" or to change the present qualitative guideline into a more explicit quantitative one, giving information that could motivate more responsible drinking. It is recommended that these options should be considered by a multi-sectorial stakeholder group to reach consensus about a possible new guideline, and that this guideline should be aggressively marketed, using social marketing principles to change alcohol consumption behaviour of South Africans. One of the limitations of this thesis is that no data were available on the awareness and knowledge of the South African population about the FBDG on alcohol. It is recommended that a study to assess this is done urgently.