Diet-related non-communicable diseases such as cancer, diabetes, and stroke account for a third of all deaths and half of all hospital admissions in Kenya. Unhealthy eating, and the growing number of people who are overweight and obese, is also a big problem in many other African countries, particularly in urban areas. This column reports on efforts to find government actions that can help to curb these trends.
Africa is experiencing a nutritional transition. Dietary patterns are changing as globalization contributes to food environments that are teeming with tempting but unhealthy choices that were unavailable a few decades ago.
The large and rapid shift of populations across the continent from rural to urban areas, where such foods are cheap and available on every corner, means that it is easier than ever before to overconsume unhealthy foods that are high in calories and low in nutrients. Habitually filling up on processed, nutrient-poor foods can lead to diet-related non-communicable diseases (NCDs), including medical conditions such as cancer, diabetes, and stroke.
According to the World Health Organization, deaths from NCDs are concentrated in low- and middle-income countries, and rates are steadily rising. Kenya, unfortunately, exemplifies this trend; NCDs account for a third of all deaths and half of all hospital admissions.
Being above a healthy weight is among the top risk factors for developing an NCD – and it is especially a risk among women. The proportion of women in Kenya who are overweight or obese has risen from 25% to 33% between 2008 and 2014. And roughly two in three women aged between 40 and 60 who are living in urban areas of the country are considered to be overweight.
New research by the African Population and Health Research Center (APHRC), the University of Ghana and the University of Sheffield is trying to find systematic ways for governments to curb the trends in overweight and obesity. Effective policies are needed both because of the public health concern and the financial toll that diet-related NCDs take on a population.
To that end, more than a dozen experts in health, nutrition, and NCDs gathered in Nairobi in July 2018 to participate in a workshop to review evidence and propose priority actions using a tool developed by the International Network for Food and Obesity/Non-Communicable Diseases Research, Monitoring and Action Support (INFORMAS) process.
INFORMAS has developed a healthy food environment policy index (Food-EPI) tool to help assess what governments are doing to make it easier for people to eat or drink healthily, such as improving food labeling, restricting adverts about processed foods, or controlling the price of unhealthy or healthy foods through taxes or subsidies. The Nairobi policy workshop is one component of the research work to expand the body of evidence on dietary transitions in African cities.
The research team compiled information on the extent to which policies exist in Kenya and are implemented across 13 domains, ranging from food promotion to labeling, to policies on food trade, to infrastructure, governance, and health. Examples include government actions such as earmarking funding for implementation. The domains, which were originally determined by a group of international experts through a comprehensive review in 2012, correspond to central features of food environments that have the potential to be shaped by government action.
The Healthy Food Environment Policy Index includes 13 domains under which experts reviewed and ranked policies and proposed government actions. (Figure source: www.informas.org)
The assembled experts were first asked to rate Kenya’s implementation of these policies in relation to international best practices, using a scale from very low or no progress to very good or excellent progress. Next, they scored how far along they believed implementation currently is, ranging from early to late stages of progress. Where there were no existing policies, no evidence of policy action, or both, participants selected ‘cannot rate’.
For example, the group ranked Kenya’s progress on food labeling against the good practice indicator of having standard and regulated food labeling that allows consumers to easily assess how healthy packaged food is. While there is a policy in Kenya that packaged foods should declare their levels of trans fatty acids, as these are strongly linked to heart disease, the evidence collated shows that there are currently no requirements for a single, consistent, easily interpreted, evidence-informed front-of-pack supplementary nutrition information label.
The experts contrasted this with current good practices in other countries, such as a requirement in Ecuador that all packaged foods must display a ‘traffic light’ label to communicate quickly and clearly levels of fats, sugar and salt, all indicated by red (high), amber (medium) or green (low). Evidence is mixed, however, on the effectiveness of food labels in influencing consumer behavior, although it has to be noted that there is as yet no evidence on the impact of labeling in low-income countries.
The final step was for the experts to rank their collectively proposed actions for the government, first in terms of importance (the extent of significance of the anticipated value of the action), and then in terms of achievability (how easily the action might be accomplished given political, budgetary and social realities).
Analysis is already underway, and the results will be used to benchmark and continue to monitor government policies to improve food environments to increase their accountability and action.
Kenya is only the second country in Africa (the other being South Africa) to complete the Food-EPI policy benchmarking. The research team adapted the model slightly to pilot a new element to reflect emerging evidence that infants who are breastfed have better protection against NCDs later in life.
The same Food-EPI policy benchmarking has been carried out in Accra under the leadership of APHRC’s counterparts at the University of Ghana in September 2018. As the number of participating countries increases, it is hoped that the pool of best practice policies will deepen and strengthen.