Benchmarking food environment policies for the prevention of diet-related non-communicable diseases in Kenya: National expert panel's assessment and priority recommendations

Global, regional, and national burden of ischemic stroke, 1990-2021: an analysis of data from the global burden of disease study 2021

Background

Ischemic stroke remains a major contributor to global mortality and morbidity. This study aims to provide an updated assessment of rates in ischemic stroke prevalence, incidence, mortality, and disability-adjusted life-years (DALYs) from 1990 to 2021, specifically focusing on including prevalence investigation alongside other measures. The analysis is stratified by sex, age, and socio-demographic index (SDI) at global, regional, and national levels.

Methods

Data for this study was obtained from the 2021 Global Burden of Diseases, Injuries, and Risk Factors Study (GBD). To quantify temporal patterns and assess trends in age-standardized rates of ischemic stroke prevalence (ASPR), incidence (ASIR), mortality (ASDR), and DALYs, estimated annual percentage changes (EAPCs) were computed over the study period. The analyses were disaggregated by gender, 20 age categories, 21 GBD regions, 204 nations/territories, and 5 SDI quintiles. R statistical package V 4.4.2 was performed for statistical analyses and plot illustrations.

Findings

In 2021, the global burden of ischemic stroke remained substantial, with a total of 69,944,884.8 cases with an ASPR of 819.5 cases per 100,000 individuals (95% UI: 760.3-878.7). The ASIR was 92.4 per 100,000 people (95% UI: 79.8-105.8), while the ASDR was 44.2 per 100,000 persons (95% UI: 39.3-47.8). Additionally, the age-standardized DALY rate was 837.4 per 100,000 individuals (95% UI: 763.7-905). Regionally, areas with high-middle SDI exhibited the greatest ASPR, ASIR, ASDR, and age-standardized DALY rates, whereas high SDI regions had the lowest rates. Geospatially, Southern Sub-Saharan Africa had the highest ASPR, while Eastern Europe showed the highest ASIR. The greatest ASDR and age-standardized DALY rates were observed in Eastern Europe, Central Asia, as well as North Africa, and the Middle East. Among countries, Ghana had the highest ASPR, and North Macedonia had both the highest ASIR and ASDR. Furthermore, North Macedonia also exhibited the highest age-standardized DALY rate.

Interpretation

Regions with high-middle and middle SDI continued to experience elevated ASPR, ASIR, ASDR and age-standardized DALY rates. The highest ischemic stroke burden was observed in Southern Sub-Saharan Africa, Central Asia, Eastern Europe, and the Middle East.

Funding

None.

Food environment in Burkina Faso: priority actions recommended to the government using Food-EPI tool

Introduction

The food environment is an important factor in the efforts of countries worldwide to achieve a transition to sustainable food systems. The objective of this study is to formulate and prioritize actions to be addressed to the government of Burkina Faso for the creation of a healthy food environment, which will contribute to reducing malnutrition in all its forms and non-communicable diseases.

Methods

National experts were brought together to identify and prioritize actions to fill the gaps identified through a multi-step assessment process following the methodology of the Healthy Food and Environment Policy Index (Food-EPI).

Results

Up to 20 priority policy actions were recommended to the Burkina Faso government. Actions in the policy component focused mainly on regulation of food promotion and marketing, particularly to children, and others in the infrastructure support component focused largely on political leadership, i.e., strong and visible political support from the government to improve the food environment, population nutrition, diet-related non-communicable diseases and their inequalities.

Conclusion

The priority actions to be recommended to the government will strengthen advocacy for government decisions to create a healthier food environment in the country.

Identifying priority double-duty actions to tackle the double burden of malnutrition in infants and young children in Peru: Assessment and prioritisation of government actions by national experts

Multiple forms of malnutrition coexist in infants and young children (IYC) in Peru. The World Health Organization has proposed double-duty actions (DDAs) to simultaneously address undernutrition and overweight/obesity. We assessed current implementation of- and priority for- government-level actions to tackle multiple forms of malnutrition in IYC in Peru. Mapping of current policy activity was undertaken against 47 indicators of good practice for five DDAs (exclusive breastfeeding, complementary feeding, food marketing, maternal nutrition, preschool nutrition; assessed by 27 indicators) and for the enabling policy environment, i.e., 'infrastructure support' (health in all policies, platforms for interactions, financing, monitoring, governance, leadership; assessed by 20 indicators). Interviews with 16 national experts explored views on the level of and barriers to implementation of DDAs and infrastructure support, as well as their prioritisation based on likely impact and feasibility. The level of implementation of actions was categorised into two groups (agenda setting/formulation vs. implementation/evaluation). Mean scores were generated for prioritisation of DDAs and infrastructure support. Deductive qualitative analysis was undertaken to identify barriers that influence policy implementation. Only 5/27 DDA indicators were reported as fully implemented by all national experts (international code that regulates the marketing of breastmilk substitutes, iron supplementation for IYC, micronutrient powders in IYC, iron/folic acid supplementation in pregnant women, paid maternity leave). Only 1/20 infrastructure support indicator (access to nutrition information) was rated as fully implemented by all experts. Barriers to implementing DDAs and infrastructure support included: legal feasibility or lack of regulations, inadequate monitoring/evaluation to ensure enforcement, commercial influences on policymakers, insufficient resources, shifting public health priorities with the COVID-19 pandemic and political instability. The experts prioritised 12 indicators across all five DDAs and eight infrastructure support indicators. Experts highlighted the need to improve implementation of all DDAs and identified ways to strengthen the enabling policy environment.

The health and economic impact and cost effectiveness of interventions for the prevention and control of overweight and obesity in Kenya: a stakeholder engaged modelling study

BACKGROUND

The global increase in mean body mass index has resulted in a substantial increase of non-communicable diseases (NCDs), including in many low- and middle-income countries such as Kenya. This paper assesses four interventions for the prevention and control of overweight and obesity in Kenya to determine their potential health and economic impact and cost effectiveness.

METHODS

We reviewed the literature to identify evidence of effect, determine the intervention costs, disease costs and total healthcare costs. We used a proportional multistate life table model to quantify the potential impacts on health conditions and healthcare costs, modelling the 2019 Kenya population over their remaining lifetime. Considering a health system perspective, two interventions were assessed for cost-effectiveness. In addition, we used the Human Capital Approach to estimate productivity gains.

RESULTS

Over the lifetime of the 2019 population, impacts were estimated at 203,266 health-adjusted life years (HALYs) (95% uncertainty interval [UI] 163,752 - 249,621) for a 20% tax on sugar-sweetened beverages, 151,718 HALYs (95% UI 55,257 - 250,412) for mandatory kilojoule menu labelling, 3.7 million HALYs (95% UI 2,661,365-4,789,915) for a change in consumption levels related to supermarket food purchase patterns and 13.1 million HALYs (95% UI 11,404,317 - 15,152,341) for a change in national consumption back to the 1975 average levels of energy intake. This translates to 4, 3, 73 and 261 HALYs per 1,000 persons. Lifetime healthcare cost savings were approximately United States Dollar (USD) 0.14 billion (USD 3 per capita), USD 0.08 billion (USD 2 per capita), USD 1.9 billion (USD 38 per capita) and USD 6.2 billion (USD 124 per capita), respectively. Lifetime productivity gains were approximately USD 1.8 billion, USD 1.2 billion, USD 28 billion and USD 92 billion. Both the 20% tax on sugar sweetened beverages and the mandatory kilojoule menu labelling were assessed for cost effectiveness and found dominant (health promoting and cost-saving).

CONCLUSION

All interventions evaluated yielded substantive health gains and economic benefits and should be considered for implementation in Kenya.

The Africa Food Environment Research Network (FERN): from concept to practice

Background:

Africa is contending with unhealthy food environments that are, in part, driving increasing rates of overweight, obesity and diet-related non-communicable diseases, alongside persistent undernutrition. This current paradigm requires expanded efforts – both in the volume and nature of empirical research, as well as the tools and capacity of those who conduct it. High quality and context-relevant research supports the development and implementation of policies that create healthy food environments.

Aim and approach:

This paper sets out the concept of the Africa Food Environment Research Network (FERN) initiative recently established by the Measurement, Evaluation, Accountability, and Leadership Support for non-communicable diseases (NCDs) (MEALS4NCDs) prevention project. Central to the Africa FERN initiative are: 1) building research capacity for innovative food environment research in Africa; 2) improving South–South, South–North partnerships to stimulate robust food environment research and monitoring in Africa and 3) sustaining dialogue and focusing priorities around current and future needs for enhanced food environment research and monitoring in Africa.

Conclusion:

The FERN initiative presents an opportune platform for researchers in Africa and the global North to weave the threads of experience and expertise for research capacity building, collaboration and advocacy, to advance food environment research.

Benchmarking policy goals and actions for healthy food environments in Ethiopia to prevent malnutrition in all its forms using document analysis

OBJECTIVE

Unhealthy diets resulting in overweight and obesity and diet-related non-communicable diseases are of increasing concern in Ethiopia, alongside persistent undernutrition, and have been linked to unhealthy food environments. Little is known about the policy response to unhealthy food environments in Ethiopia. The objective of this study was to assess how different food environment domains have been addressed in Ethiopian policy goals and action over time and how this compares with global good practice benchmarks.

SETTING

Ethiopia.

PRIMARY AND SECONDARY OUTCOME MEASURES

We analysed intentions and plans of the government to act, using policy documents (outputs of decision-making in the form of published strategies, plans or policies) related to improving diets and nutritional status through healthy food environments in Ethiopia between 2008 and 2020. Our coding framework was guided by the policy component (n=7 domains) of the Healthy Food-Environment Policy Index, which was modified to include food quality and safety as an eighth domain.

RESULTS

From the 127 policy outputs identified, 38 were retained, published by 9 different government ministries and institutions. Our results show that eight food environment domains have been addressed to some extent, but gaps remain compared with global best practice, especially in food promotion, processing, retail, price and trade. From 2018, policy began to embrace the wider food system, with more explicit food environment interventions becoming apparent.

CONCLUSIONS

Policy efforts achieved in food safety, food processing, marketing and labelling are important stepping stones to building future policy actions addressing the food environment domains of food retail, food provision and food trade. Benchmarking of food environment policy actions should also consider actions on food fortification, agro-processing and informal markets in the context of multiple forms of malnutrition.

Evaluation and prioritization of actions on food environments to address the double burden of malnutrition in Senegal: perspectives from a national expert panel

OBJECTIVE

To evaluate the extent of implementation of public policies aimed at creating healthy eating environments in Senegal compared to international best practice and identity priority actions to address the double burden of malnutrition.

DESIGN

The Healthy Food Environment Policy Index (Food-EPI) was used by a local expert panel to assess the level of implementation of 43 good practice policy and infrastructure support indicators against international best practices using a Likert scale and identify priority actions to address the double burden of malnutrition in Senegal.

SETTING

Senegal, West Africa.

PARTICIPANTS

A national group of independent experts from academia, civil society, non-governmental organizations and United Nations bodies (n =15) and a group of government experts from various ministries (n =16) participated in the study.

RESULTS

Implementation of most indicators aimed at creating healthy eating environments were rated as "low" compared to best practice (31 on 43, or 72%). The Gwet AC2 inter-rater reliability was good at 0.75 (CI 0.70 - 0.80). In a prioritization workshop, experts identified forty-five actions, prioritizing ten as relatively most feasible and important and relatively most effective to reduce the double burden of malnutrition in Senegal (example: Develop and implement regional school menus based on local products (expand to 14 regions) and measure the extent of the promotion of unhealthy foods to children).

CONCLUSIONS

Significant efforts remain to be made by Senegal to improve food environments. This project allowed to establish an agenda of priority actions for the government to transform food environments in Senegal to tackle the double burden of malnutrition.

Perspective: Food Environment Research Priorities for Africa-Lessons from the Africa Food Environment Research Network

Over the last 2 decades, many African countries have undergone dietary and nutrition transitions fueled by globalization, rapid urbanization, and development. These changes have altered African food environments and, subsequently, dietary behaviors, including food acquisition and consumption. Dietary patterns associated with the nutrition transition have contributed to Africa's complex burden of malnutrition-obesity and other diet-related noncommunicable diseases (DR-NCDs)-along with persistent food insecurity and undernutrition. Available evidence links unhealthy or obesogenic food environments (including those that market and offer energy-dense, nutrient-poor foods and beverages) with suboptimal diets and associated adverse health outcomes. Elsewhere, governments have responded with policies to improve food environments. However, in Africa, the necessary research and policy action have received insufficient attention. Contextual evidence to motivate, enable, and create supportive food environments in Africa for better population health is urgently needed. In November 2020, the Measurement, Evaluation, Accountability, and Leadership Support for Noncommunicable Diseases Prevention Project (MEALS4NCDs) convened the first Africa Food Environment Research Network Meeting (FERN2020). This 3-d virtual meeting brought researchers from around the world to deliberate on future directions and research priorities related to improving food environments and nutrition across the African continent. The stakeholders shared experiences, best practices, challenges, and opportunities for improving the healthfulness of food environments and related policies in low- and middle-income countries. In this article, we summarize the proceedings and research priorities identified in the meeting to advance the food environment research agenda in Africa, and thus contribute to the promotion of healthier food environments to prevent DR-NCDs, and other forms of malnutrition.

Providing Measurement, Evaluation, Accountability, and Leadership Support (MEALS) for Non-communicable Diseases Prevention in Ghana: Project Implementation Protocol

Background: This study describes the rationale, adaptation, and final protocol of a project developed to address the increase in obesity and nutrition-related non-communicable diseases (NR-NCDs) in Ghana. Code-named the Measurement, Evaluation, Accountability, and Leadership Support for NCDs (MEALS4NCDs) project, it aims to measure and support public sector actions that create healthy food marketing, retail, and provisioning environments for Ghanaian children using adapted methods from the International Network for Food and Obesity/NCDs Research Monitoring and Action Support (INFORMAS).

Methods: The protocol for this observational study draws substantially from the INFORMAS' Food Promotion and Food Provision Modules. However, to appraise the readiness of local communities to implement interventions with strong potential to improve food environments of Ghanaian children, the MEALS4NCDs protocol has innovatively integrated a local community participatory approach based on the community readiness model (CRM) into the INFORMAS approaches. The setting is Ghana, and the participants include health and nutrition policy-makers, nutrition and food service providers, consumers, school authorities, and pupils of Ghanaian basic schools.

Results: The study establishes a standardized approach to providing implementation science evidence for the prevention of non-communicable diseases (NCDs) in Ghana. It demonstrates feasibility and the innovative application of the INFORMAS expanded food promotion and food provision modules, together with the integration of the CRM in a lower-middle income setting.

Conclusion: The research will facilitate the understanding of the processes through which the INFORMAS approach is contextualized to a lower-middle income African context. The protocol could be adapted for similar country settings to monitor relevant aspects of food environments of children.

Sodium Content and Labelling Completeness of Packaged Foods and Beverages in Kenya

Increased consumption of unhealthy processed foods, particularly those high in sodium, is a major risk factor for cardiovascular diseases. Nutrition information on packaged foods can help guide consumers toward products with less sodium, however the availability of nutrition information on foods sold in Kenya is currently unknown. The aims of this study were to estimate the proportion of packaged foods and beverages displaying nutrition information for sodium and determine the amount of sodium in packaged foods available for sale in Kenya. Data was collected in 2019 from five retail supermarkets in Nairobi. The availability of sodium information provided on packaged products and the sodium content were recorded. As secondary analyses, we compared sodium content labelling of products in Kenya by manufacturing location and the sodium content of products available in Kenya and South Africa. A total of 6003 packaged products in 56 food categories were identified. Overall, 39% of products displayed sodium content, though the availability of labelling varied widely between food categories, with coverage in main categories ranging from 0% (yoghurts and yoghurt drinks) to 86% (breakfast cereals). Food categories with the highest median sodium content were herbs and spices (9120 mg/100 g), sauces (1200 mg/100 g) and meat alternatives (766 mg/100 g) although wide variabilities were often observed within categories. Imported products were more likely to provide information on sodium than locally produced products (81% compared to 26%) and reported higher median sodium levels (172 mg/100 g compared to 96 mg/100 g). Kenyan products reported a higher median sodium content than South African products in six categories while South African products had higher median sodium in 20 categories, with considerable variation in median sodium content between countries in some categories. These findings highlight considerable potential to improve the availability of sodium information on packaged products in Kenya and to introduce reformulation policies to reduce the amount of sodium in the Kenyan food supply.

Unhealthy eating practices of city-dwelling Africans in deprived neighbourhoods: Evidence for policy action from Ghana and Kenya

Growing urbanisation in Africa is accompanied by rapid changes in food environments, with potential shifts towards unhealthy food/beverage consumption, including in socio-economically disadvantaged populations. This study investigated how unhealthy food and beverages are embedded in everyday life in deprived areas of two African countries, to identify levers for context relevant policy. Deprived neighbourhoods (Ghana: 2 cities, Kenya: 1 city) were investigated (total = 459 female/male, adolescents/adults aged ≥13 y). A qualitative 24hr dietary recall was used to assess the healthiness of food/beverages in relation to eating practices: time of day and frequency of eating episodes (periodicity), length of eating episodes (tempo), and who people eat with and where (synchronisation). Five measures of the healthiness of food/beverages in relation to promoting a nutrient-rich diet were developed: i. nutrients (energy-dense and nutrient-poor -EDNP/energy-dense and nutrient-rich -EDNR); and ii. unhealthy food types (fried foods, sweet foods, sugar sweetened beverages (SSBs). A structured meal pattern of three main meals a day with limited snacking was evident. There was widespread consumption of unhealthy food/beverages. SSBs were consumed at three-quarters of eating episodes in Kenya (78.5%) and over a third in Ghana (36.2%), with those in Kenya coming primarily from sweet tea/coffee. Consumption of sweet foods peaked at breakfast in both countries. When snacking occurred (more common in Kenya), it was in the afternoon and tended to be accompanied by a SSB. In both countries, fried food was an integral part of all mealtimes, particularly common with the evening meal in Kenya. This includes consumption of nutrient-rich traditional foods/dishes (associated with cultural heritage) that were also energy-dense: (>84% consumed EDNR foods in both countries). The lowest socio-economic groups were more likely to consume unhealthy foods/beverages. Most eating episodes were <30 min (87.1% Ghana; 72.4% Kenya). Families and the home environment were important: >77% of eating episodes were consumed at home and >46% with family, which tended to be energy dense. Eating alone was also common as >42% of eating episodes were taken alone. In these deprived settings, policy action to encourage nutrient-rich diets has the potential to prevent multiple forms of malnutrition, but action is required across several sectors: enhancing financial and physical access to healthier foods that are convenient (can be eaten quickly/alone) through, for example, subsidies and incentives/training for local food vendors. Actions to limit access to unhealthy foods through, for example, fiscal and advertising policies to dis-incentivise unhealthy food consumption and SSBs, especially in Ghana. Introducing or adapting food-based dietary guidelines to incorporate advice on reducing sugar and fat at mealtimes could be accompanied by cooking skills interventions focussing on reducing frying/oil used when preparing meals, including 'traditional' dishes and reducing the sugar content of breakfast.

Implementation of healthy food environment policies to prevent nutrition-related non-communicable diseases in Ghana: National experts' assessment of government action

Nutrition-related non-communicable diseases (NR-NCDs) are a global health problem, increasingly recognised as driven by unhealthy food environments. Yet little is known about government action to implement food environment-relevant policies, particularly in low-and lower-middle income countries. This study assessed government action, implementation gaps, and priorities to improve the food environment in Ghana. Using the Healthy Food-Environment Policy Index (Food-EPI), a panel comprising government and independent experts (n = 19) rated government action to improve the healthiness of food environment in Ghana against international best practices and according to steps within a policy cycle. Forty-three good practice indicators of food environment policy and infrastructure support were used, with ratings informed by systematically collected evidence of action validated by government officials. Following the rating exercise, the expert panel proposed and prioritized actions for government implementation. Three-quarters of all good practice indicators were rated at 'low'/'very little' implementation. Restricting the marketing of breast milk substitutes was the only indicator rated "very high". Of ten policy actions prioritized for implementation, restricting unhealthy food marketing in children's settings and in the media were ranked the highest priority. Providing sufficient funds for nationally-relevant research on nutrition and NCDs was the highest priority infrastructure-support action. Other priority infrastructure-support actions related to leadership, monitoring and evaluation. This study identified gaps in Ghana's implementation of internationally-recommended policies to promote healthy food environments. National stakeholders recommended actions, which will require legislation and leadership. The findings provide a baseline for measuring government progress towards implementing effective policies to prevent NR-NCDs.