Role of Sugar-sweetened beverages for increasing non-communicable diseases

Role of Sugar-sweetened beverages for increasing non-communicable diseases. Undernutrition and food insecurity have historically been, and remain, significant public health problems in Kenya. Consequently, there are many policies addressing these issues but few include actions to address unhealthy diet and over-nutrition. A policy gap has emerged due to the nutrition transition related to increasing urbanization.

Kenya is experiencing increasing levels of obesity and related non-communicable diseases (NCDs), including diabetes, cardiovascular diseases, and cancer.

Nutrition related-NCDs (NR-NCDs) are higher among urban than rural communities, and women are particularly vulnerable. For instance, obesity among women increased by almost 10-fold (25% to 33%) from 2008 to 2014.

An estimated 4% of rural and 21% of Kenyan urban children are overweight/obese. Furthermore, NCDs account for about one-third of all deaths and half of all hospital admissions in the country.

Kenya’s health policy and the national strategy for the prevention and control of NCDs (2015–2020) emphasize the need for action to reverse and address the NCD burden.

The World Health Organization (WHO) recommends the taxation of sugar-sweetened beverages (SSBs) as a population-level and cost-effective intervention to control the rising burden of obesity and NR-NCDs.

SSBs refer to any beverage with added sugar or other sweeteners, such as sucrose or high fructose corn syrup, which have high levels of calories and little nutritional value. Examples of SSBs include regular soda, fruit drinks, sports drinks, energy drinks, sweetened waters, and coffee and tea beverages with added sugars.

Fiscal interventions such as SSB taxes have the potential to not only reduce obesity and related NCDs but to also raise additional revenue, which can be further directed towards health promotion or health care delivery for prevention and management of NCDs.

Despite their low-cost and efficacy, the adoption and implementation of such policies in Kenya have not occurred. An analysis of NCD prevention policies in Kenya, conducted in 2017, showed that, although some policies addressing NR-NCDs existed, they did not adequately reflect the ‘best buy interventions’ for unhealthy foods.

Previous analyses of the policy landscape in Kenya identified the lack of political commitment and inadequate resources in government as hampering the implementation and adoption of comprehensive NCD prevention policies. The political economy of fiscal measures and ensuing tension between Government and industry is complex.

Kenya is one of the world’s largest producers of tea and hot drink, which constitute the largest segment of the non-alcoholic drinks market. Coca-Cola has a strong presence in the country and is consumed by approximately half the population.

Locally, there is a robust network of financial and human resources, and a growing global experience of tactics, that can be used against over-burdened and under-resourced Government departments when industry profits are threatened. The government’s political and governance environment is subject to resource and capacity constraints.

This study addresses the policy and stakeholder environments influencing NR-NCD and SSB action in Kenya. It identifies gaps in the evidence and data and provides an analysis of the policy context and nature of the SSB industry in Kenya. Understanding the broader NCD policy landscape and the relevant politico-economic factors that impact policy-making is a key step in the development of feasible and context-specific policy and action against SSBs.

Study design

This study was nested in a broader study of seven countries in East and Southern Africa, which shared the same methodology. The study design was a qualitative policy analysis, which entailed a desk review of existing nutrition-related policies and evidence related to NCDs and SSBs in Kenya. We reviewed Kenyan 15 policy documents across sectors implicated in NCD prevention and SSB taxation, including documents from the departments of health, agriculture and finance.

The desk review was complemented by interviews with 10 knowledgeable policy actors from government ministries, with responsibilities related to fiscal policy and/or nutrition, health; civil society organizations with interests in NR-NCDs and SSB, industrial associations and academics.

The semi-structured interviews were designed to explore the policy and political context, as well as to identify enablers of, and barriers to, policy change with regard to NR-NCDs and SSBs.

Organizations were purposively selected from the different sectors, based on the document review and the likely roles of their institutions in the formulation and implementation of NCD prevention policies and SSB taxation.

Snowball sampling was then used to identify potential respondents within the selected institutions, who were formally invited to participate.

The interviews were conducted using an open-ended interview guide that was tailored to the expertise of the respondent, in order to understand the gaps and opportunities to strengthen NR-NCD and SSB tax-related policies. It also included the potential of policies regarding the use of revenue to increase access to healthy food and the barriers to and facilitators of policy reforms on the same. Interviews were conducted in English and were audio-recorded with the respondent’s consent.

Data processing and analysis

Interviews were transcribed verbatim, anonymized, and stored in digital format. They were coded manually, by two researchers, using pre-determined data matrices.

An iterative approach was adopted in the analysis of data from the desk review and from the qualitative interviews. Kingdon’s framework was used to draw together data sources that provided an understanding of the ‘problem’ of NCDs and SSBs, the ‘solutions’ (including an SSB tax), the existing policy landscape, and stakeholder politics.

Ethical considerations

The study was approved by the Amref Health Africa – Ethical and Scientific Review Committee (Amref-ESRC), Ethics number: P593/2019. Written informed consent to participate, and consent to record the interviews were obtained from all respondents. Confidentiality was assured and maintained.

NR-NCDs are gaining recognition and there are Government efforts to identify and implement effective interventions to prevent and control them. The findings from this study are consistent with those from a 2014 policy review. However, concerns about the slow progress in the implementation of the policies were evident, with the main hurdle being the poor allocation of resources to address NCDs.

Other studies have documented poor funding as a challenge in the implementation of NCDs policies in Kenya, and have reported that the health sector in Kenya is curative rather than preventive-focused. Similar to this study, Anyona et al. (2014), observed the preference of infectious diseases over NCDs in resource allocation in Kenya and posited that the non-immediate impact of NCD interventions was less appealing politically as infectious diseases had quick visible results. Policies that enhance equitable access to both preventive and curative healthcare are recommended to address NCDs.

Although SSB taxation is recommended as a cost-effective intervention to prevent NCDs, the existing excise tax on beverages does not differentiate between healthy and unhealthy beverages. The excise tax is also not based on any public health evidence; is primarily a revenue collection strategy. No local impact case for SSB taxation has been presented to the Kenyan Government, to demonstrate the potential gains of SSB tax.

Preparing this case is especially difficult, given that information about the beverages industry is opaque. Consumption and sales data about soft drinks was not accessible to us as researchers. Although Kenya is collecting NCD data, these data have not been adequately applied to advocate for SSB taxation.

The tobacco taxation policy was introduced in Kenya in 2014, and lessons learned during that process may be applicable to SSB taxation, especially with regard to understanding industry strategy and influence, the need for continuous stakeholder engagement and advocacy, adequate resource allocation, and political leadership and coordination mechanisms.

An additional hurdle in the implementation of an SSB tax is the lack of public information about the ill health effects of SSBs, especially in urban communities that place an aspirational value on western diets. Both policymakers and the general public require more information on the health impacts of SSBs and their contribution to NR-NCDs.

Advocacy and public education about NR-NCDs are critical if the current excise tax on soft drinks is to change to SSB taxation. Public education on the health impact of SSB consumption could be done through existing structures such as the education system, the community health structure, and the media.

The existing stakeholders and the policy framework provide a platform for this work. Local investment in the sugar and SSB industry should be critically examined to understand how this may undermine the Government’s commitment to addressing NCDs through regulations limiting the production and consumption of unhealthy foods and beverages. Furthermore, there is a need for additional evidence to support an explicit SSBs taxation policy and wide stakeholder engagement, especially that of the Ministry of Agriculture, Trade, and Industrialisation, which are driving the agenda for the sugar and SSB industries in Kenya.

Lack of local evidence on the potential impact of SSB tax was cited as a challenge to lobbying for SSB taxation in Kenya. Researchers should focus on understanding the potential impact of the existing excise tax on SSBs and sugar consumption, and public health, thereby generating ‘practice-based evidence. However, as consensus is being strengthened around SSB taxation, the existing excise tax creates a window of opportunity for sustained advocacy to gradually increase the tax as more evidence on the impact of SSB consumption is generated.

Limitations

We targeted to interview representatives from various institutions, including the Government, non-governmental organizations, and industries associations. However, industry representatives who were requested to participate in the study were not forthcoming. In addition, obtaining data from the sugar and SSB industry was a challenge; information on industry operations was not readily available on the companies’ websites and formal data requests to the industries were not successful. The findings of this study are therefore limited by the data that were publicly available and accessible at that time of the study.

Conclusion

The current policy landscape for NR-NCD prevention in Kenya provides some basis for the adoption of an SSB tax, although this is not an explicit policy of the Government. NR-NCDs prevention policies should reflect a continuum of issues, from undernutrition to food security, nutrition transition, and the escalation of nutrition-related non-communicable diseases. A local advocacy case for sugar-sweetened beverage taxation has not been made, to do this, data such as the cost of illness associated with SSBs and the cost of inaction is needed. Public and policymaker education is critical to challenge the prevailing attitudes towards sugar-sweetened beverages and the western diet.