Abstract
Background: Obesity and nutrition-related non-communicable diseases (NR-NCDs) are increasing throughout Africa, driven by urbanisation and changing food environments. Policy action has been limited - and influenced by high income countries. Socio-economic/political environments of African food systems must be considered in order to understand what policy might work to prevent NR-NCDs, for whom, and under what circumstances. Methods: A realist synthesis of five policy areas to support healthier food consumption in urban Africa: regulating trade/foreign investment; regulating health/nutrition claims/labels; setting composition standards for processed foods; restricting unhealthy food marketing; and school food policy. We drew upon Ghana and Kenya to contextualise the evidence base. Programme theories were generated by stakeholders in Ghana/Kenya. A two-stage search interrogated MEDLINE, Web of Science and Scopus. Programme theories were tested and refined to produce a synthesised model. Results: The five policies operate through complex, inter-connected pathways moderated by global-, national- and local contexts. Consumers and the food environment interact to enable/disable food accessibility, affordability and availability. Consumer relationships with each other and retailers are important contextual influences, along with political/ economic interests, stakeholder alliances and globalized trade. Coherent laws/regulatory frameworks and government capacities are fundamental across all policies. The increasing importance of convenience is shaped by demographic and sociocultural drivers. Awareness of healthy diets mediates food consumption through comprehension, education, literacy and beliefs. Contextualised data (especially food composition data) and inter-sectoral collaboration are critical to policy implementation. Conclusion: Evidence indicates that coherent action across the five policy areas could positively influence the healthiness of food environments and consumption in urban Africa. However, drivers of (un)healthy food environments and consumption reflect the complex interplay of socio-economic and political drivers acting at diverse geographical levels. Stakeholders at local, national, and global levels have important, yet differing, roles to play in ensuring healthy food environments and consumption in urban Africa.
Highlights
Many African countries are experiencing a nutrition transition with shifting dietary patterns, related to rapid urbanisation and changing food systems.[1]
We focused on evidence relating to five ‘good preventative policy’ actions from those identified internationally[20,21] and locally[12,13] to improve the healthiness of food systems: regulation of trade in goods/services and foreign direct investment (FDI); regulation of food health/ nutrition claims; setting food composition standards/targets for processed foods; restricting the promotion of unhealthy food; and clear/consistent healthy food promotion policy in schools
As a starting point we focused on the seven policy domains and associated good practice indicators identified in the Healthy Food Environment Policy Index (Food-EPI): a tool developed by INFORMAS (International Network for Food and Obesity/Noncommunicable Diseases Research, Monitoring and Action Support) for monitoring government action to improve food environments.[16]
Summary
Many African countries are experiencing a nutrition transition with shifting dietary patterns, related to rapid urbanisation and changing food systems.[1] obesity and nutrition-related non-communicable diseases (NR-NCDs) are rapidly increasing; becoming an important public health challenge.[2] Ghana and Kenya exemplify trends in rapid urbanisation and shifting dietary patterns.[3,4,5] Rising overweight and obesity sit alongside persistent and significant burdens of under-nutrition and multiple micronutrient deficiencies in many African countries[3]; and this “multiple burden of malnutrition”[3,6] presents a considerable challenge within African food systems, within urban food environments.[7] The food environment merits particular attention as the interface that mediates people’s food acquisition and consumption within the wider food system, that is influenced by policy and governance.[8] Preventive policy action to address obesity and NR-NCDs within African urban food systems has been limited. Research in Ghana and Kenya has, for example, identified gaps in policy implementation to promote healthy food environments, in relation to food advertising (except marketing breastmilk), food trade, food retail, food prices, food provision (except schools).[12,13] At the same time, evidence to inform action within food systems tends to be
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