Introduction
Obesity has tripled since 1975, causing about 3 million deaths from obesity-related diseases worldwide each year (WHO, 2018). Health systems have a challenge in managing the health needs of people with obesity, reiterating the need to change perceptions of obesity as a matter of personal failure to its recognition as a disease for focused prevention and adequate resource allocation. There is global increase of trends of overweight and obesity,[1] with the fastest rise occurring in low- and middle-income countries (Moore et al., 2010). The increase in obesity cases is one of the most serious public health challenges of the twenty-first century (WHO, 2009) particularly in Sub-Saharan Africa where health systems are weak and least prepared for the future complications arising from childhood obesity and overweight (Bollyky et al, 2017). People with obesity spend 30 per cent more on medical care, thus straining the health systems. The cost of obesity to health systems varies between nations but may account for between 0.7-2.8 per cent of a country’s total health care costs (Withrow and Alter, 2011). In countries such as the US with a higher prevalence of obesity, expenditures are expected to double every decade, and will account for 16 to 18 per cent of total health care expenditures by 2030 (Wang et al., 2011). The COVID-19 pandemic has exacerbated overweight and obesity due to prevention measures that included lockdowns restricting movements, and closure of schools that limited physical activity in school-going children, among other effects by the measures.
Overweight and obesity is likely to be worsened by the current nutrition and physical activity transition characterized by availability of cheap high calorie dense foods, limited participation in physical activity and increased use of energy-saving devices (Onywera, 2010). Only 12.6 per cent of children in Kenya meet the 60 minutes or more recommendation of moderate or physical activity per day (Muthuri et al., 2014). Unhealthy eating habits are strongly associated with obesity, and this was alluded to by (Okeyo et al., 2019) that adolescents had inappropriate dietary practices. This increasing prevalence is associated with urbanization, access to and consumption of high-calorie diets, and decreased physical activity (Chowdhury et al., 2017). In addition, increased nature of sedentary jobs where people do not burn the required calories as they are at work contributes to obesity and overweight.
The Constitution of Kenya in Article 43(1) (a) guarantees all Kenyans the right to the highest attainable standards of health by access to all healthcare services. The overarching policy guiding multisector actions is the National Food and Nutrition Security Policy. In addition, the National Nutrition Action Plan has costed the activities for implementation by sectors with a nutrition role. A review of the Kenya Nutrition Action Plan reveals inadequate nutrition workforce, weak community engagement and participation for demand and uptake of nutrition services as challenges of nutrition service delivery for a healthy population. In scaling up of interventions on overweight and obesity, provision of budget in national allocations is critical for assured implementation of interventions.
Effects of Obesity and Overweight
Obesity and overweight are characterized by raised Body Mass Index (BMI), which is a major risk factor for non-communicable diseases such as cardiovascular diseases, diabetes, musculoskeletal disorders especially osteoarthritis, some cancers, among others. Obese children experience breathing difficulties, increased risk of fractures, hypertension, early markers of cardiovascular diseases, insulin resistance and psychological effects.
The number of children with overweight and obesity is increasingly affecting poorer children’s households and countries (UNICEF, 2020). Childhood obesity has been associated with higher chances of adult obesity, premature death, and disability (WHO, 2017). This would potentially result in children of the current generation having shorter life expectancy than that of their parents due to the increased burden of obesity-related diseases. Further, obese and overweight individuals face higher levels of stigmatization, self-worth, and reduced health-related quality of life regardless of race or ethnicity (Wallander et al., 2013).
Why Overweight and Obesity?
Environmental changes associated with development and lack of supportive policies in sectors that include health, agriculture, urban planning, transport, environment, education, food processing, distribution and marketing contribute to increased obesity and overweight. The brunt of overweight and obesity has been exacerbated by the current COVID-19 pandemic, underscoring the need for multisector interventions if the gains made on progressive improvement in the realization of national targets by 2022 are to be sustained.
Increased obesity and overweight experienced in the recent past are attributed to changing lifestyles and feeding practices influenced by fast-changing food systems where fast foods and high energy dense foods are preferred. The lack of public recognition of obesity and its adverse consequences present major challenges to the provision of obesity prevention and management services. Obesity associated bias and stigma is a barrier to health care (Puhl and Suh, 2015). Up to 45 per cent of physicians have negative views of people with obesity, and health professionals have been reported to hold prejudicial attitudes towards obese people, that they are unlikely to comply with recommendations aimed at achieving weight reduction. This underscores the need for refresher training of the health workforce for positive attitude and promotion of supportive care to people that are overweight and obese.
Obesity and overweight that was previously linked to wealth is increasingly becoming a condition of the poor, reflecting greater availability of cheap calories from fatty and sugary foods. Policies that increase taxes on sugary foods with a view to disincentivising processors and restricting deceptive marketing of the foods are required.
Despite COVID-19 bringing to focus the critical role of nutrition for healthy lives, the nutrition sector has inadequate workforce that is far much below the recommended nutritionists’ density per 100,000 population, being at 3.8. The situation will not improve soon as counties are autonomous. Decisions on nutrition workforce to be recruited will vary from county to county, making it difficult to have consistent efforts for improved nutrition of the population. Legal frameworks require strengthening to compel counties to maintain staffing levels that are appropriate for this critical cadre.
Clinical nutrition focusing on optimal nutrition care as an intervention in disease management recognizes integration as an important component of health care. Dieticians support the nutrition and hydration needs of acutely and chronically ill people and monitor the nutrition status of populations at risk. Even after patients leave hospital, dieticians have a role in rehabilitation, reducing risk of complications and shortening recovery time. Clinical nutrition and dietetics need to be complemented through follow up, and linkages at the community level and include promotive, preventive and nutrition rehabilitative services.
With the COVI-19 pandemic, schools closed for 7 and 10 months for the examination classes, and the rest of the classes, respectively. This period saw minimal physical activity among learners. The COVID-19 protocols of staying at home to keep safe, working from home, partial lockdowns, restricted movements, and closure of markets generally saw increased reduction of physical activity, thus increasing the risk of weight gain.
Despite evidence of high prevalence and adverse health outcomes associated with overweight and obesity in Kenya, there is paucity of information examining the nationwide demographic characteristics and health-related behaviours associated with the condition. Like in other Low Middle Income Countries, predictors for overweight and obesity include living in urban areas, high income, and high levels of education. Studies conducted among slum dwellers also provide evidence of high rates of overweight and obesity among low-income groups due to consumption behaviour. In urban areas, one study found that high-income women had a higher prevalence of overweight and obesity and were more likely to consume high-caloric, high-fat, and high-protein foods associated with higher risk of overweight and obesity (Steyn et al., 2011). Other predictors among women include increased age, increased parity, being divorced or widowed, higher alcohol intake, insufficient intake of fruits and vegetables, and decreased physical activity (Mbochi et al., 2012). Some studies report that obesity is higher among those living in urban areas, women, and individuals with high income (Steyn et al., 2011; Pawloski et al., 2012).
Changing Food Systems
Urbanization and the movement of populations searching for employment in towns has exacerbated shifting food systems. Increase of ready-to-eat foods in supermarkets, and unregulated advertising has led to inappropriate food choices by urban dwellers, compounded by lack of time to cook, which is occasioned by frequent traffic snarl ups particularly in Nairobi city. Shoppers are buying foods prepared on the streets with little consideration of safety for consumption. Mothers’ knowledge of childcare and feeding practices determine the state of nutrition of children. Parenting has changed, child rights championed, and thus some children make food choices without considering nutritional value with little control by parents. Strengthening supply and demand for better food that improves children’s food environment initiatives are required. The Government has a role of promoting healthy food environments in schools and limiting sale and advertising of sugar sweetened foods in proximity to schools or playgrounds. Further, choice of diverse healthy foods rich in nutrients is a challenge even in the 3-5th wealth quintile as there are high obesity levels. This requires an analysis of consumption patterns to understand drivers of obesity and overweight.
Multi-sector Interventions
Using multisector approach, continuous health advocacy and communication with audience-specific structured nutrition education awareness messages to the public in all channels of communication for behaviour change will sustainably reduce obesity. The Ministry of Social Protection needs to provide safety nets for access to foods by the vulnerable while the Ministry of Agriculture, Fisheries, Livestock and Cooperatives educate communities on diversification in foods production for availability of all food groups. The Ministries responsible for Water and Sanitation and irrigation initiatives could target to increase the proportion of the population producing food through irrigated agriculture and increase measures for sustained household production especially in areas with low rainfall, the arid and semi-arid lands. The education sector requires strengthened nutrition education delivery in the curriculum through mobilization of resources allocated to adequately implement sector initiatives.
Measures of continuity of physical activity in the context of pandemics by increasing social amenities such as open playgrounds in urban areas and stadium, and social halls are necessary. Measures of exercising at workplaces provided in Occupational Safety and Health Act, 2017 promote well-being. Increasing walkways to enable physical activityis reflected in infrastructure expansion and plans need to be integrated into master development plans.
Possible Solutions
The Agenda 2030 on sustainable development recognizes Non-Communicable Diseases as a major challenge in realizing sustainable development. Sustainable Development Goal 2 targets to end all forms of malnutrition, including overweight and obesity (WHO, 2018). In realizing this, strengthening these initiatives and provision of an enabling environment for nutrition interventions will reduce overweight and obesity. As countries strive to control the COVID-19, there is need to increase nutrition resources and proactively plan to prevent the drivers of malnutrition. Learning from the pandemic, and forecasting into the future would require well-coordinated, funded, and functional preventive public health strategies on food, nutrition, health, and social protection.
Continued structured nutrition education in learning institutions with mentors or champions that include teachers and peer clubs need to be strengthened to promote knowledge on dietary choices for well-nourished communities. In addition, physical activity enables learners to refresh and enhance their health. Despite evidence of limited exercise during school closure occasioned by the COVID-19 pandemic, little focus has been given to corrective measures in the context of pandemics. The experience of the pandemic was forgotten fast, with parents obtaining new uniforms for their overgrown children and little reflection on the health and economic consequences of obesity/overweight by policy makers. Measures of remote learning may keep the learners engaged with breaks between sessions where they are reminded to exercise.
The Government will need to enforce compliance on labelling of food products to ensure non-deceptive marketing and health on nutritional value of foods, so that that buyers can make informed choices on nutrition. There should also be disincentives for industry from processing fast high energy dense foods by increasing taxes to minimize foods with little nutritional value.
The lapsing of 5 to 10 years period before a nutrition survey is done gives results that do not enable taking of corrective measures in safeguarding the health of the population. The damage of overweight for five or so years that is not tamed early has long-term health and economic implications in terms of management of non- communicable diseases.
The World Health Assembly targets to reduce obesity and overweight by the year 2025 as Sustainable Development Goals are cognizant of increased obesity. The Occupational Safety and Health Act 2007 under Part II General duties by employer in section 6(1)e requires the provision and maintenance of working environment for every person employed that is safe without risks to health, and adequate as regards to facilities and arrangements for the employees welfare at work. Employees require to participate in physical activity for psychosocial health and well-being.
Preventive strategies through identification of risk factors, education interventions and behaviour change may be effective at reducing risk throughout the population. Linking of community measures with the learning in schools would ensure continuum of nutrition education. Evidence on the risk factors and morbidities associated with childhood obesity would enable designing of interventions with optimum outcomes.
National infrastructure development plans need to holistically incorporate sustainable functional utilities for replication by the counties. In facilitating physical activity, the Nairobi Metropolitan Services plans on infrastructure expansion to promote healthy and exercising patterns by increasing walkways and cyclist lanes require to be consistently implemented and adhered to in all infrastructure developments as provided for in the master plans. County infrastructure master plans require to be sustainable in availing access of future generations to social amenities, playgrounds, social halls, and recreational facilities.
Employers need to strategize on how to engage workforce in exercising in the new normal of COVID-19, while keeping social distance. In addition, the public could be engaged using social media on nutrition education and awareness in a sustained manner, and leveraging on existing structures such as church health and education departments and community health workers’ forums.
Conclusion
Strengthened supportive environments and structured communities’ engagement enable healthier food choices and physical activity, thus reducing obesity and overweight. Effective implementation of policies will create supportive environments that reinforce educational and behaviour interventions tailored for individuals, thus improving outcomes for the populations.
References
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[1]Overweight and obesity are defined based on age using a simple index of weight- for- height. In under 5 children, overweight and obesity are defined as weight for height greater than 2 and weight for height greater than 3 Standard Deviation above World Health Organization Child Growth Standards Median, respectively. For adults overweight and obesity refers to a Body Mass Index (BMI) greater than or equal to 25 and BMI greater than or equal to 30, respectively.
Author: Geoffrey Kebaki, Senior Policy Analyst-National Information Platform for Food Security and Nutrition
