Available online at www.sciencedirect.com Review of policy action for healthy environmentally sustainable food systems in sub-Saharan Africa Michelle Holdsworth1, Simon Kimenju2, Greg Hallen3, ] ]] ]]]]]]] Amos Laar4 and Samuel O Oti3 Many sub-Saharan African (SSA) countries are experiencing diet-related non-communicable diseases (DR-NCDs). multiple burdens of malnutrition. Rising overweight/obesity Rising overweight, obesity and DR-NCDs coexist coexist alongside persistent burdens of under-nutrition and alongside persistent and significant burdens of under- multiple micronutrient deficiencies. Poverty and social inequity nutrition and multiple micronutrient deficiencies [1••]. remain key drivers of unhealthy diets and malnutrition. Diets in Poverty and social inequity remain key drivers of un- SSA are increasingly transitioning towards unhealthy (energy- healthy diets and malnutrition. dense, nutrient-poor and unsafe) and environmentally unsustainable diets. Healthy, sustainable food systems are required to deal with these considerable challenges equitably, This multiple burden of malnutrition is driven largely by so policy action needs to balance the health, environmental and transitions to food systems that are increasingly un- economic dimensions of diets and food systems. We review healthy and environmentally unsustainable. Food sys- evidence in recent literature for which policy actions have the tems have been conceptualised to encompass the entire best chance of success in SSA by appraising their likely impact, range of activities involved in the production, proces- relevance, cost/affordability and feasibility to help guide sing, marketing, consumption and disposal of goods that policymakers and researchers in their development and originate from agriculture, forestry or fisheries, including evaluation. the inputs needed and the outputs generated at each of these steps. Food systems contribute particularly to the Addresses burden of DR-NCDs by enabling the consumption of 1 UMR MoISA (Montpellier Interdisciplinary Centre on Sustainable Agri- unhealthy foods that are highly processed, energy-dense food systems), CIRAD, CIHEAM-IAMM, INRAE, Institut Agro, IRD, and of low nutritive value. At the same time, food sys- Montpellier, France tems are the single-largest cause of global environmental 2 Kula Vyema Centre of Food Economics, Kiambu, Kenya 3 change. For example, agriculture occupies about 40% of International Development Research Centre (IDRC), Ottawa, Canada 4 Department of Population, Family & Reproductive Health, School of global land, and up to 30% of global greenhouse-gas Public Health, University of Ghana, Accra, Ghana emissions come from food production [2]. The un- sustainable nature of global food systems and their im- Corresponding author: Holdsworth, Michelle pact on climate change creates a vicious cycle [3,4]. (michelle.holdsworth@ird.fr) Unsustainable food systems contribute to climate change, which over time will affect food production and Current Opinion in Environmental Sustainability 2023, 65:101376 ultimately human health. In addition to health and en- This review comes from a themed issue on Sustainable Food vironmental dimensions of sustainability, social equity systems needs to be also accounted for, including the afford- Edited by Maria J. Darias, Mafaniso Hara, Israel Navarrete and ability of food. Eric O. Verger The food environment — the interface that mediates people’s food acquisition and consumption within the Available online xxxx wider food system [5••] — merits particular policy at- Received: 8 December 2022; Revised: 11 September 2023; tention. This is because it is shaped by policy actions Accepted: 26 September 2023 that span various sectors, including agriculture, nutrition, https://doi.org/10.1016/j.cosust.2023.101376 trade and health. Hence, identifying which policy ac- 1877–3435/© 2023 The Authors. Published by Elsevier B.V. This is an tions are most likely to be successful that can sustainably open access article under the CC BY license (http:// improve food environments and the wider food system is creativecommons.org/licenses/by/4.0/). crucial. In this paper, we discuss evidence from global recommendations of policy actions for equitable healthy (nutritious/safe), environmentally sustainable food sys- Introduction tems, to appraise which of these policy actions have the Many sub-Saharan African (SSA) countries are experi- best chance of success of preventing multiple forms of encing multiple burdens of malnutrition, including malnutrition in SSA. www.sciencedirect.com Current Opinion in Environmental Sustainability 2023, 65:101376 2 Sustainable Food Systems In this paper, we review evidence in recent literature Type and scope of review (mainly 2020 onwards) for which policy actions have the We undertook a narrative literature review incorporating best chance of ensuring healthy environmentally sus- international reports and scientific literature. We looked tainable and equitable food systems in SSA by ap- for evidence in the literature for how successful these 13 praising their likely impact, relevance, feasibility and policy actions would be in SSA with respect to five groups cost/affordability, to help guide policymakers and re- of criteria (detailed in Table 3): i. Expected impact on the searchers in their development and evaluation. healthiness and environmental sustainability of diets, ii. Expected reach to disadvantaged population groups, in- cluding social equity; iii. Relevance to the African context in Methods terms of healthiness and sustainability of current food Selecting the shortlist of policy actions consumption/availability patterns; iv. Cost and affordability We identified an initial list of 42 policy actions to orient of policy actions to assess economic viability and v. Fea- food systems towards healthier diets, adapted from [6] sibility of implementing the policy actions in SSA. and recommendations in 14 global reports/articles (Supplementary file 1). The following 5 specific criteria were applied to shortlist this policy subset for SSA: likely Published scientific literature and global nutrition impact on improving nutrition/health, environmental reports sustainability and social equity and number of parts of We searched for evidence at the level of SSA, Africa, the food system targeted, and whether government low- and middle-income countries (LMICs) and then could implement changes. Environmental sustainability globally for the 13 policy actions, until we found evi- scoring was based on the balance between the following dence. The need to incorporate evidence from outside pathways (Figure 1): reducing versus increasing demand of Africa was useful in informing the potential impact of for food/biodiversity, animal source foods, ultra-pro- the different policy actions, where data were lacking cessed foods or food waste. An overall score for all 5 from within Africa. However, including insights from criteria was produced by summing the scores (Table 1). further afield is a drawback due to differing contexts. We All policy actions scoring ≥ 7 points and having ≥ 1 point searched for recent systematic reviews in MEDLINE for environmental sustainability were retained, leaving and Google Scholar as a starting point. We then under- 13 policy actions for review (Table 2). took hand-searches of reference lists of these reviews Figure 1 Current Opinion in Environmental Sustainability Pathways of impact for diet on environmental sustainability. *(integrating evidence from [3–6,21,53]). Current Opinion in Environmental Sustainability 2023, 65:101376 www.sciencedirect.com Policy for sustainable food in sub-Saharan Africa Holdsworth et al. 3 Table 1 Criteria used to select the policy subset for the review. Criteria Scoring process Score (max)a Criteria 1: What impact could the action have 1 point attributed for each of 5 pathways that policy Maximum of 5 points on nutrition and health? could impact: availability, accessibility, affordability, appeal and safety. Criteria 2: What impact could the action have Scoring was based on the balance between the A score of ≥ 1 was required for inclusion on environmental sustainability? following trade-offs: reducing versus increasing in the final policy list, that is, demand for food/biodiversity, animal source foods, environmental benefits exceeded any ultra-processed foods or food waste. trade-offs. Criteria 3: Could the action have an impact on The actions were appraised for their likely impact on Maximum of 3 points improving equity (SES, gender and/or facilitating equity of access to a nutritious diet for each children)? of SES/gender/children. Criteria 4: Which part(s) of the food system 1 point was given for each component of the food Maximum of 4 points would the action target? system that the different policies target: food supply, food environment, individual factors and consumer behaviour. Criteria 5: Does the action require government Each policy action was categorised as Yes/No to Yes = 1, No= 0 involvement in developing, implementing and/ whether it relied mainly on government/public or monitoring policies to ensure healthy and decision-making. This was seen as a measure of sustainable food systems? feasibility. a All policy actions scoring ≥ 7 points and having ≥ 1 point for Criteria 2 were retained. and also for subsequent included literature. We also evidence, having a peer-review process, tackling nutri- identified recent (2019–2021) global nutrition reports tion and environmental sustainability of diets in a global that met our inclusion criteria for citing research and/or LMIC context and proposing specific actions on Table 2 Policy actions included in the review (adapted from [5]). Action Trade 1. Design trade policies to prioritise sustainable food systems that supply nutritious, safe foods over less-nutritious processed foods (high in fats, sugars and salt), taking account of the benefits of local and international supply chains in different contexts, the protection of smallholder farmers, food price stability and the availability of complementary policies. Supply chain infrastructure actions 2. Maintain and upgrade markets selling nutritious foods to low-income communities and ensure they have access to infrastructure to enhance food safety and reduce food losses, including available clean water, public toilets and waste removal. Financial actions 3. Redirect agriculture subsidies from staple crops to increasing production of more nutritious foods (fruit, vegetables, nuts and seeds and pulses). 4. Focus social protection programmes such as cash transfer, food voucher and food delivery on increasing the availability, affordability and appeal of nutritious foods and limiting the appeal of foods high in fats, sugars and salt. 5. Implement taxes to decrease affordability and incentivise reformulation of sugary drinks and foods high in fats (especially saturated and trans-fats), sugars and salt. Public institution actions 6. Implement comprehensive school food programmes, incorporating food and meals, nutrition standards, nutrition education, school gardens, food personnel training, food skills and literacy. 7. Adopt a public food procurement policy that applies nutritional guidelines (limiting sugar, fat and salt) to food procured for public institutions and prioritises purchasing from smallholders, local, family and/or sustainable food producers. Business incentives 8. Provide incentives to fast-food outlets, street food vendors and food service trucks (including investment funds and technical support) to reformulate their recipes, sell and promote nutritious and sustainable foods in place of foods high in fats, sugar and salt. Regulations and laws 9. Set mandatory limits in processed packaged foods on trans-fats, sugar, salt/sodium and/or saturated fat. 10. Regulate health claims on foods and require nutrition labelling on packages/menus to indicate if foods are high in calories, fats (including saturated and trans-fats), sugars and/or salt and/or in positive nutrients 11. Restrict all forms of marketing, advertising and in-store promotions, toys, giveaways or other incentives of high fat, sugary/salty foods and beverages, particularly to children. 12. Use zoning laws to restrict numbers of large-scale/formal ’fast food’ (unhealthy) outlets and vendors in select geographic areas. National guidelines 13. Align all food system policies and programmes with culturally appropriate FBDGs that integrate health and environmental sustainability and widely communicate the guidelines to the general public. www.sciencedirect.com Current Opinion in Environmental Sustainability 2023, 65:101376 4 Sustainable Food Systems Table 3 Criteria applied to each of the policy actions to appraise likely ‘success’ in Africa. Criteria Criteria definition Impact on diets Will it work? Expected impact on improving/ensuring the healthiness and environmental sustainability of diets and food systems. Reaching vulnerable groups Will it reach disadvantaged population groups? For example, lower SES and adolescent girls/women, children to ensure social and gender equity. Relevance to Africa Is it relevant to the African context in terms of healthiness and sustainability of current food consumption/ availability patterns and food systems? Cost and affordability Is it affordable? Cost and affordability of the different policies to assess economic viability. This includes costs or economic consequences resulting from implementing or rolling out the policy, to the state, local authorities and health services. Feasibility Can it be implemented? politically, technically and in terms of legislation, human capacity and technically co- operation of agencies, across departments and sectors, supported by government and so on; acceptability by citizens — social, cultural and individual acceptability. food systems or food environments. These reports were likely to act on improving the food supply and food screened to identify the evidence/literature they had environment as entry points, with less policies focusing utilised to make their recommendations (Supplementary directly on individual factors, consumer behaviours or Table 1). While there exist a number of specific SSA diets. country-focussed nutrition reports, we do not include them in this review as they did not meet the above The findings from the scientific literature are integrated criteria. below in terms of their likely impact, reach relevance, cost and feasibility. Findings: the likely impact, reach, relevance, cost and feasibility of policy actions in sub- Likely impact of policy actions on healthy, sustainable Saharan African diets in sub-Saharan African Mapping policy actions onto the different parts of the We found recent evidence for the impact on nutrition on food system (Figure 2) illustrates that they are most 6 policies: school food programmes, taxing unhealthy Figure 2 Current Opinion in Environmental Sustainability Policy actions for SSA with most evidence for success across the food system. Current Opinion in Environmental Sustainability 2023, 65:101376 www.sciencedirect.com Policy for sustainable food in sub-Saharan Africa Holdsworth et al. 5 food/beverages, subsidising healthy foods, controlling incentives to fast-food or street food vendors and zoning food/beverage marketing, implementing food-based policy. Some of the evidence comes from within Africa, dietary guidelines (FBDGs) and social protection mea- but it is mainly from HICs. The lack of evidence does sures. While some evidence came from within not mean that they would not have an impact, but may Africa, most was from high-income countries (HICs). be due to the challenge of demonstrating causality of policy impacts that are intertwined with other food Firstly, there is widespread and consistent evidence that system components. comprehensive school food policies can promote healthy food consumption by controlling the availability of food/ There is some evidence that trade regulation can reduce beverages, introducing nutrition standards for school imports of ‘unhealthy’ foods/beverages, for example, meals, offering free or subsidised fruit and vegetables, higher tariffs on sugar and confectionery products and by engaging with family and the school community and fats/oils can reduce obesity [24]. However, evidence for by providing school nutrition/health services that in- the impact of trade on dietary outcomes is limited. A clude water and sanitation [7•–9]. Evidence showing meta-analysis of 114 articles on the impact of front-of- that bundled interventions are more effective than pack labels found that although labels help consumers single interventions is mainly from HICs or LMICs identify healthier products, their impact in changing outside of Africa [7•,10,11]. Current research evidence in behaviours is limited [25]. Whilst nutrition labelling may schools in Africa (and LMICs in general) mainly focuses have insufficient impact on dietary behaviours, it could on school food provision, but the moderation aspects stimulate product/menu reformulation [5••]. Whilst (sugar, fat, salt and fibre) of school meals are in- there is convincing evidence that consumption of highly sufficiently addressed [7•,8,10]. processed energy-dense/nutrient-poor foods, has nega- tive impacts on diet quality and health globally and in Evidence for the expected impact of taxation comes Africa [26–28••], we found limited evidence of whether from reviews integrating evidence in LMICs, which in- mandatory fat/sugar/salt limits in processed packaged dicate that well-designed taxes can reduce purchase/ foods impact on diet. consumption of unhealthy foods/beverages [12–15]; most evidence is for sugar-sweetened beverages (SSBs). We found a lack of evidence on three policies that tackle Taxation can also encourage reformulation of high-sugar/ the retail food environment. Firstly, we did not find salt/fat products [12]. There is also evidence that food evidence to indicate that providing incentives to fast- subsidies can be effective in promoting healthy diets food or street food vendors would encourage re- [16]. Plentiful evidence [8] from HICs demonstrates that formulation of recipes or sales of more nutritious foods in food marketing influences food preferences, purchase Africa. Evidence for whether incentives to fast-food or behaviour and pester power/purchase requests (of chil- street food vendors would work mainly comes from dren) [17]. Although a recent scoping review synthe- HICs, where evidence is from the formal fast-food sising 55 studies, mainly in HICs, found limited sector. We found no evidence of studies assessing the evidence of whether exposure to outdoor food marketing impact of zoning policy in SSA. Evidence of studies influences eating behaviour [18]. assessing impact is inconclusive, coming mainly from the United States/United Kingdom, one systematic review A modelling study of FBDGs of 85 countries worldwide of 31 studies [29] found mixed evidence of the impact of (including SSA) has predicted that adopting national the proximity/density of food outlets around schools on FBDGs could lead to reductions of an average of 15% in children’s weight. premature mortality from DR-NCDs and a reduction in greenhouse gas emissions of 13% [19]. However, the Reach of policy actions to vulnerable groups in sub- impact of introducing FBDGs within Africa is likely to Saharan African be less, as the expected reduction in mortality was only A number of policies could reach vulnerable groups, estimated at 6% because of the higher communicable with evidence identified in particular for school pro- disease burden. There is also evidence from systematic grammes, social protection measures, upgrading markets reviews that social protection measures (mainly cash in low-income communities, subsidies on fruit and ve- transfers) can improve nutritional outcomes, especially getables and public procurement policy. those tied to nutrient-rich food [20–23]. However, evi- dence in SSA for impact on consumption of nutritious- Agricultural subsidies on nutritious foods can make diverse diets appears to be sparse and inconsistent [21]. these foods cheaper, which can benefit people on low incomes [30]. Whether subsidising healthy foods is more On the contrary, less recent evidence was found for equitably fiscal than taxing unhealthy foods is debatable. impact of 7 policies: food procurement, trade regulations, Evidence for which socio-economic groups are reached food labelling, setting mandatory nutrient limits in pro- by taxation is contentious, with some authors citing a cessed packaged foods, upgrading market infrastructure, greater proportional impact on health of low-income www.sciencedirect.com Current Opinion in Environmental Sustainability 2023, 65:101376 6 Sustainable Food Systems populations in HICs [13•,14]. In LMICs, higher socio- Many studies in Africa have identified the cost of food as economic status (SES) groups tend to consume more a major driver on dietary behaviour [34], making in- SSBs, and other highly processed foods and beverages itiatives to reduce the cost of healthier foods, such as compared with lower SES groups [31], so the impact of subsidies and social protection measures extremely re- the tax on lower-income populations is harder to predict. levant, considering evidence from SSA that healthy diets Introducing mandatory limits on fats, sugar and salt in are unaffordable for many [35]. The majority of food is processed foods could reach lower- income groups, who provided by the informal sector in SSA [28••], hence it is are increasing their purchase of processed food in SSA highly relevant to improve market infrastructure to [28••]. Literature rarely considered which population provide clean water and hand washing facilities to make groups might be affected by trade regulations, but it food safer for a large proportion of the population [36]. seems likely that the most vulnerable will be dis- Incentives to fast-food and street vendors appear re- proportionately affected in negative ways [8]. levant, considering evidence that many fast-food/street food vendors increasingly sell unhealthy foods/beverages For labelling on packaged foods to work, consumers [28••,37]. Low incomes and a busy urban life push many need to be educated to improve nutritional knowledge consumers towards fast food, therefore, zoning regula- and to understand food labels [8], but it needs to be tions are relevant, considering evidence of the rapid accompanied by population literacy if it is to reach the spread of international fast-food outlets [38]. poorest and women, who are more likely to be illiterate, with literacy rates of 59% women versus 72% of men in Introducing mandatory nutrient limits on processed SSA (World bank, 2020 literacy data). foods and regulating health claims/nutrition labelling is therefore also pertinent, given the rapid spread of pro- Upgrading markets could have a positive impact on so- cessed packaged foods in SSA [28••,39]. Actions to cial equity because economic access is a major obstacle disincentivise unhealthy food consumption through to purchasing safe (and nutritious) food, therefore, en- taxation are relevant because there is widespread con- suring that food is safer for everyone will contribute to sumption of unhealthy foods/beverages [40]. Indeed, reducing these inequalities. Poorer people use markets availability of SSBs is widespread in SSA, with a large for more of the food they purchase and consume in SSA proportion of adolescents consuming them daily [41]. than wealthier citizens. In addition, street food vendors Related is the pertinence of advertising controls on in markets tend to live on very low, precarious incomes SSBs, which are heavily advertised in SSA [37,42–44]. and are predominately women [32]. Within SSA, zoning Advertising controls on high-fat, sugary/salty foods is also regulations for large-scale fast-food outlets would be relevant as fast-food consumption is spreading rapidly more likely to impact on higher-income groups, who use [28••]. Less-explicit marketing activities also need ad- these outlets more. However, zoning regulations around dressing that is often introduced under the guise of schools is a priority in social equity terms given that it is corporate social responsibility initiatives by transnational targeting children. Indeed, school-based interventions food companies [39]. have the potential to reduce social inequalities as they can reach poorer children and free or subsidised school Trade regulations that incorporate nutritional quality, meals are an indirect social protection measure. There is and implementing FBDGs, are clearly relevant, con- evidence that procurement policies could have social sidering the increasing consumption of (imported) un- equity benefits by ensuring business/income generation healthy foods and multiple burdens of malnutrition in for local (potentially low-income and/or female) farmers SSA [28••]. Lastly, school nutrition programmes are or enterprises meeting fair trade criteria and ensuring highly relevant, considering the vulnerability of children employment in local communities; procurement policy and their right to good nutrition and the presence of through a comprehensive school programme can also multiple forms of malnutrition in children/adolescents in reach vulnerable school-going children with healthy SSA. Although school meals are relatively widespread in food [9,33]. SSA, more research is needed on their nutritional quality [10]. Relevance of policy options in sub-Saharan African Only one of the policy actions lacked evidence for its Cost and affordability of policy actions in sub-Saharan relevance in Africa (public procurement) beyond the African school setting. In Africa, the vast majority of food served The best evidence we found for cost-effectiveness was in public settings or purchased by government funds is for taxation policy and school programmes, and for probably in schools, so contextualised evidence is lim- mandatory limits on processed foods. Schools are eco- ited. Evidence was found for the relevance of the other nomically efficient platforms for delivering interven- 12 policy actions in the SSA context. A number of these tions, as they provide pre-existing infrastructure. Indeed, actions are relevant because they address the challenge the WHO integrates schools into two of its best-buys and of changing diets and nutrition transition evident in SSA. recommended actions: i. reducing salt in public Current Opinion in Environmental Sustainability 2023, 65:101376 www.sciencedirect.com Policy for sustainable food in sub-Saharan Africa Holdsworth et al. 7 institutions (includes schools) [45]; and ii. nutrition governments implement subsidies to increase intake of education to increase fruit and vegetables, including fruit and vegetables, which is supported by modelling schools. In SSA, school meals provision often lacks stable data of impressive benefits for health, environment and funding [8]. economic sustainability if subsidies are realigned to sustainable healthy diets [21]. Lastly, it has been esti- The WHO estimates taxing SSBs is a cost-effective in- mated that the economic value from a population tervention in LMICs [45], although others have cau- adopting FBDGs could amount to 10–25% of national tioned against generalising cost-effectiveness to gross domestic product [19], with roughly 10–13% in the different contexts [46]. Concerns about economic con- African region. Increasing investment in some of the sequences of taxation have been raised, with lobbying other policy actions that require or implement FBDGs from industries that would be impacted financially by a would have an even greater economic value and impact tax [13•], which may reduce political feasibility. The on nutritional and environmental sustainability. desire to support the economic competitiveness of the sugar industry and protect employment is a potential Feasibility of policy actions in sub-Saharan African economic constraint to implementing taxation in SSA. Two policy actions were identified as the most feasible: However, strategies to develop positive public opinion social protection measures and school programmes. towards SSB taxation have been identified, thanks to Politically, social protection measures are feasible for two advocacy from Civil Society and academics in SSA reasons. Firstly, social protection is well-entrenched in [13•,47]. Advocacy is crucial to garner political feasibility many SSA countries. Secondly, there are efforts to make from potential strong opposition. There are economic different programmes nutrition-sensitive, with legal re- concerns that governments may have to account for, as cognition on the right to food in many SSA countries. processed food offers employment in food processing, There is evidence of political feasibility of school nu- wholesale, transport and retail sectors, especially for trition programmes, albeit with a focus on school meals. women and adolescents [28••]. Local, regional and national government need resources to work together to implement school nutrition policies. Mandatory nutrient limits on processed packaged foods encompasses three interventions that the WHO re- Three policies have particular challenges regarding fea- commends: firstly, to reduce salt intake through re- sibility: public procurement policy (including that in formulation. Secondly, the elimination of trans-fats schools), incentives for fast-food outlets and street ven- through legislation. Lastly, reformulation so that trans- dors and zoning laws. A public procurement regulatory fats and saturated fats are replaced with unsaturated fats framework, including identifying legal mechanisms, has [45]. The WHO recommends that governments imple- been identified as essential [33] to ensure compliance for ment nutrition labelling to stimulate reductions in en- maximum impact. This may prove challenging in SSA ergy, fats, sugars and sodium [45]. contexts with unregulated food systems. Technical fea- sibility of implementing zoning restrictions may be There is a lack of evidence on the cost-effectiveness of a hindered by the required legislation and the human number of policy actions on nutritional outcomes: trade capacity and resources for implementation. One tech- policy, marketing or advertising controls, zoning restric- nical challenge of incentives to fast- food/street food tions or implementing FBDGs. We found no evidence vendors is it requires monitoring of their compliance. on cost of providing incentives for fast-food outlets/ street vendors, but we highlight the need to consult with Other policies are likely to be feasible under certain street food vendors on the economic impact of such a conditions and circumstances: trade regulations, up- policy, as the majority are from low-income households. grading markets and introducing subsidies/taxation. We did not find evidence on the cost of upgrading There is evidence that trade policy is politically feasible markets in Africa. However, there are potential eco- in Ghana/Kenya, with evidence of intention or action to nomic benefits for vendors as customer numbers rise as design trade policies with nutritious goals [47,48]. There they are attracted to safer street food vendors [32]. If the are also indications of legal and technical feasibility. introduction of safer markets reduces foodborne dis- Implementation of trade regulations will require strong eases, this is likely to have an impact on economic government infrastructural capacity, clear policy framing, output through reducing the days lost to illness and use coherence across sectors and public support [8,47,48] of healthcare. and a commitment to prioritise public health alongside economic objectives, as political will may be constrained There was less evidence available for initiatives to make by economic policies and industry lobbying [28••]. In healthier foods more accessible. The FAO estimates that LMICs, targeted subsidies on fruit or vegetables are rare cash transfers may be more cost-efficient than ‘in-kind’ compared with staple foods [30]. Policymakers in SSA transfers because of the cost of procurement and logistics identify a lack of convincing evidence of impact on in distributing food [30]. The WHO recommends that health of introducing SSB taxes in their country as an www.sciencedirect.com Current Opinion in Environmental Sustainability 2023, 65:101376 8 Sustainable Food Systems obstacle to implementation [13•]. Evidence that taxation A review of FBDG implementation in Africa found that can be implemented comes from countries where large only seven of the 47 countries in the WHO Africa region food processors dominate, unlike in most of SSA, where have developed FBDGs [53], with none addressing en- informal food processing/retail are still widespread vironmental sustainability. Financial, technical and [28••], thereby reducing the feasibility of enforcing human resources were identified as a major barrier to a tax. implementation. Other factors reducing feasibility in- cluded a lack of collaboration among sectors, conflicting Politically, there is evidence that maintaining and up- agendas between public health and market economies, grading markets is feasible, but complying with local food industry lobbying and the challenge of counter- authorities’ regulations might be infeasible for small acting prolific marketing of unhealthy foods/bev- vendors; there is evidence from Kenya [49] that such erages [54]. regulations are likely to have limited impact due to weak institutional capacities for monitoring. Participatory re- search consulting with market users and food vendors is Conclusions recommended to find ways to effectively improve in- We reviewed evidence to appraise a subset of 13 policy frastructure [21,32], working alongside civil society to actions that were considered as having the best chance of represent the interests of the least powerful [50]. leading to healthy environmentally sustainable food systems in SSA. We considered recent evidence that Several policy actions require food composition tables or sheds light on their expected impact, reach, relevance, nutrition profiling systems for their implementation: ad- cost/affordability and feasibility in SSA. Ensuring fi- vertising/marketing controls, food labelling, FBDGs and nancial access to a nutritious and safe diet that benefits limits on processed packaged foods and taxation/sub- the most socially and economically deprived commu- sidies. Effective implementation of advertising and mar- nities needs to be integrated across policy action and in keting controls requires robust planning, technical settings that reaches these groups (e.g. in informal capacity and resources. Ideally, accurate and compre- markets, schools). Considering the environmental and hensive food composition data need to be available to economic sustainability of policy action, alongside nu- develop nutrient profiling models adapted at country- trition and health, is a challenge that needs to be seized level, to identify foods for taxation/subsidies and provide if SSA countries are to be successful in shifting towards information on the nutrition content of school meals. sustainable food systems. Under half of SSA countries have food composition ta- bles, whilst useful they do not include all foods (espe- To this end, a complementary mix of low and high cially processed foods) and lack data on target nutrients agency policy actions have been identified that, based on (sugars/saturated fat) [40]. However, the introduction of the available evidence, are likely to have been most an African nutrient profiling model [51] has enhanced successful in SSA. All of these actions have the potential feasibility, as broad food groups are already categorised for to contribute towards healthy sustainable food systems, prohibiting marketing if thresholds exceed values. Whilst but together, they will have a greater combined effect. this provides a list of example foods that fit into each Low agency interventions require individuals to invest category, these need refining to include foods commonly fewer individual personal and psychological resources, consumed within a country. The use of lobbying [39] and and several of these emerged as priorities in SSA: food complexity arguments from industry [52] challenges the marketing restrictions, school food procurement, up- political feasibility of advertising controls by undermining grading informal markets, mandatory product nutrient regulation of unhealthy foods/beverages. reformulation, zoning regulations for fast-food vendors, social protection programmes, taxation on unhealthy Labelling can have a positive impact if it stimulates re- foods and subsidies on healthy foods and trade policy formulation or reduces portion size to remain within that prioritise nutrition. These need to be accompanied limits. However, as taste and convenience are strong by actions that require greater agency to access, under- drivers of food choice within the African region stand and apply information, through enhancing nutri- [28••,34], industry may not necessarily see the financial tion literacy and skills, that is, implementing FBDGs, benefit of reformulation in the absence of mandatory introducing incentives to street food vendors to provide regulations. Other challenges to feasibility relate to in- healthier foods, providing front-of- pack labelling and adequately resourced administrative infrastructure and a regulation of health claims. Comprehensive school food fragmented food-processing industry of many informal programmes can reach diverse socio-economic groups small and medium enterprises in SSA (around 80%), as and incorporate both low (e.g. school food standards/ well as large African-led companies and transnational procurement) and high agency components (e.g. nutri- industry [28••]. tion education), hence their broad appeal. Current Opinion in Environmental Sustainability 2023, 65:101376 www.sciencedirect.com Policy for sustainable food in sub-Saharan Africa Holdsworth et al. 9 Funding Hovmand PS, Howden M, Jaacks LM, Kapetanaki AB, Kasman M, The work was funded by the International Kuhnlein HV, Kumanyika SK, Larijani B, Lobstein T, Long MW, Matsudo VKR, Mills SDH, Morgan G, Morshed A, Nece PM, Pan A, Development Research Centre (IDRC) through a co- Patterson DW, Sacks G, Shekar M, Simmons GL, Smit W, Tootee funding partnership with the Rockefeller Foundation. A, Vandevijvere S, Waterlander WE, Wolfenden L, Dietz WH: The global syndemic of obesity, undernutrition, and climate Two of the authors are employed by the IDRC (GH/SO) change: the Lancet Commission Report. Lancet 2019, who contributed to discussions on the scientific scope 393:791-846, https://doi.org/10.1016/S0140-6736(18)32822-8 and methodology developed by MH/SK for the review, 4. Aldaya MM, Ibañez FC, Domínguez-Lacueva P, Murillo-Arbizu MT, as well as giving feedback on content. Rubio-Varas M, Soret B, Beriain MJ: Indicators and recommendations for assessing sustainable healthy diets. Foods 2021, 10:999, https://doi.org/10.3390/foods10050999 (2). CRediT authorship contribution statement Michelle Holdsworth: 5. HLPE: Food Security and Nutrition: Building a Global Narrative Conceptualisation, Methodology, •• Towards 2030. High Level Panel of Experts on Food Security and Data curation, Formal analysis, Writing – original draft. Nutrition of the Committee on World Food Security; 2020. Simon Kimenju: Conceptualisation, Methodology, This report is written by the High Level Panel of Experts on Food Security and Nutrition to inform the United Nations Committee on World Formal analysis, Writing – review & editing. Greg Food Security actions on food security and nutrition. This report sum- Hallen: Funding acquisition, Conceptualisation, Writing marises evidence about the current situation regarding food security and nutrition concepts, outcomes, drivers and policy directions need to – review & editing. Amos Laar: Validation, Writing – meet SDG 2 targets and Agenda 2030. review & editing. Samuel Oti: Funding acquisition, 6. Hawkes C, Walton S, Haddad L, Fanzo J: 42 Policies and Actions Conceptualisation, Methodology, Project administration, to Orient Food Systems Towards Healthier Diets for All. Centre Writing – review & editing. for Food Policy, City, University of London; 2020. 7. Downs S, Demmler KM: Food environment interventions Data Availability • targeting children and adolescents: a scoping review. Glob Food Secur 2020, 27:100403, https://doi.org/10.1016/j.gfs.2020. 100403. No data were used for the research described in the ar- The authors conducted a scoping literature review to examine influence of external and personal food environment interventions on the diets and ticle. nutrition of children and adolescents. Whilst most of the included stu- dies examined interventions in schools in high income countries, a few were from LMICs. Overall, personal food environment interventions Declaration of Competing Interest aimed at reducing the cost of food (for example through cash transfers) were associated with the most improvements in nutritional outcomes. The authors declare that they have no known competing 8. 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