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Recent Progress in Nutrition

(ISSN 2771-9871)

Recent Progress in Nutrition (ISSN 2771-9871) is an international peer-reviewed Open Access journal published quarterly online by LIDSEN Publishing Inc. This periodical is devoted to publishing high-quality papers that describe the most significant and cutting-edge research in all areas of nutritional sciences. Its aim is to provide timely, authoritative introductions to current thinking, developments and research in carefully selected topics. Also, it aims to enhance the international exchange of scientific activities in nutritional science and human health.

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Current Issue: 2025  Archive: 2024 2023 2022 2021
Open Access Review

Engaging with an Industrial Pandemic: Drivers of and Responses to the Expansion of Ultra-Processed Foods in East and Southern Africa

Rene Loewenson * ORCID logo

Training and Research Support Centre, Box CY651, Harare, Zimbabwe

* Correspondence: Rene Loewenson

Academic Editor: Ehab Salah Eshak Farag

Special Issue: Food, Diet, and Nutrition: Connecting Underlying Determinants of Health in the 21st Century

Received: January 14, 2025 | Accepted: August 19, 2025 | Published: August 29, 2025

Recent Progress in Nutrition 2025, Volume 5, Issue 3, doi:10.21926/rpn.2503018

Recommended citation: Loewenson R. Engaging with an Industrial Pandemic: Drivers of and Responses to the Expansion of Ultra-Processed Foods in East and Southern Africa. Recent Progress in Nutrition 2025; 5(3): 018; doi:10.21926/rpn.2503018.

© 2025 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.

Abstract

Intensified marketing and expanding consumption of ultra-processed foods (UPFs) that contain high sugar, salt, trans-fats and other additives and sugar sweetened beverages in Sub-Saharan Africa (SSA) are associated with rising obesogenic environments and non-communicable diseases, termed by some an ‘industrial pandemic’ due to its commercial drivers and cross border nature. This review paper addresses the question of how far SSA, positioned at an early point of a rising wave, is controlling this growing health challenge. The paper explores the public health responses to this expansion of UPFs in SSA, together with the issues and challenges faced. Drawing on existing analytic frameworks, the paper presents available evidence from 86 papers accessed from online searches and pertinent evidence from four United Nations databases. These sources are used to provide information on responses underway in SSA on (i) generating and sharing evidence and information as a form of discursive power; and on engaging (ii) on policy, regulation and other institutional measures; and (iii) at structural level, on taxes on UPFs and sugar sweetened beverages (SSBs) and investment measures, including to promote healthy food system alternatives, particularly in urban areas. While there is clear policy recognition of the need to respond effectively, widely, and more rapidly across SSA, and while a range of responses are underway, the findings suggest that the response is not yet matching the scale or pace of the challenge. The paper examines the challenges in implementing regulatory, policy, tax, and institutional interventions to prevent the health harms of UPFs and SSBs. It further examines the underlying political economy and power imbalances between powerful transnationals and SSA states that weaken health action. The paper argues that the learning raised on the assets for public health measures and opportunities for intervention in SSA, together with the health and wider costs of inaction, call for a strengthened African response to this industrial pandemic.

Keywords

Ultra-processed foods; commercial determinants; Sub-Saharan Africa; policy, law, tax, investment, food systems

1. Introduction

The second Sustainable Development Goal (SDG) commits to end hunger, achieve food security and improved nutrition, and promote sustainable agriculture. In contrast, the tenth SDG commits to reducing inequality within and between countries [1]. The interconnectedness, increased trade, investment and advances in technology through globalisation can facilitate innovation in production, goods and services. However, where globalisation has led to large corporations and agribusiness practices overtaking local food producers, and with liberalised trade, it has expanded consumption of processed foods in Sub-Saharan Africa (SSA), and can exacerbate inequality and add unhealthy foods and diets to pre-existing food insecurities. These features of globalisation are adding new challenges to achieving these SDGs [2,3,4,5,6]. The resulting consequences of unhealthy diets are apparent in SSA, with its double burden of undernutrition together with obesity, cardiovascular disease, and diabetes, with the increased production and marketing of ultra-processed foods (UPFs), and with rising UPF consumption in all age groups [2,3,4,5,6].

Ultra-processed foods (UPFs) refer to processed refined foods, with additives such as high sugar, salt, trans-fats or preservatives, flavours or colourants, and with limited or no whole food [7]. UPFs include sugar-sweetened beverages (SSBs) that contain ‘free sugars’ (such as glucose, fructose, sucrose, table sugar) added by manufacturers or producers [8,9,10]. Liberalised trade, expanded marketing, and rising urbanisation have shifted consumption towards imported UPFs at the expense of locally grown vegetables, fruits, and cereals that are rich in essential nutrients [11]. While SSB intake has fallen in higher-income countries, it is rapidly rising in SSA, particularly in urban residents with higher education levels [12,13,14].

Large food transnational companies from the USA and Europe have dominated in Africa for many years. Recent decades have added companies from the Americas and Asia, and a growth in African companies, albeit with some of the latter acting as franchises of larger foreign companies to expand their operations on the continent [15]. Together with their promotion of export-oriented production and agribusiness, SSA has experienced an intensified marketing of poor quality, high-profit, and low-priced UPFs and SSBs, including through local informal vendors [16,17,18,19]. For example, imports of soft drinks into Southern Africa grew by 1200% from 1995 to 2010, and snack foods by 750% [19].

The food, beverage, and breastmilk substitute industries contribute to approximately 10-12 million yearly deaths linked to dietary factors in 195 countries studied in all regions globally [20]. SSA is not immune to these risks, and the nutritional transitions and obesogenic environments associated with the expansion of UPFs are already leading to a rise in non-communicable diseases (NCDs) in countries at various income levels [11,21,22,23]. In 2017, the intake of all healthy foods was lower than the optimal level in all global regions, including SSA, as was the higher-than-optimal consumption of sodium, trans fats, and sugar-sweetened beverages [20]. African countries are experiencing rising levels of non-communicable diseases (NCDs) such as obesity, cardiovascular disease, metabolic conditions, diabetes, and cancers [2,14], with consumption of UPFs from childhood leading to NCDs at earlier ages [24]. There are currently significantly higher levels of female obesity in rich than poor households in SSA, with a rich: poor ratio of 13:1, and female overweight prevalence 4 times higher in rich than in poor households [6,25,26]. However, experience in other global regions foretells a potential shift in consumption and adverse health outcomes towards lower wealth quintiles that may also apply in African countries [27]. In addition to their immediate consequences for physical well-being, these NCDs cost health services, households, and the economy in caring and lost income [17].

This rise in production and marketing of UPFs and their health consequences has been termed by some an ‘industrial epidemic’, that may also be termed a pandemic given its transnational nature [28,29]. The COVID-19 pandemic raised global attention to controlling the spread of infectious disease agents. However, less attention has been paid to this ‘industrial pandemic’ of expanding UPF consumption and NCDs, notwithstanding their widening population impact. Can SSA, positioned as it is at an early point of a rising wave, afford to delay its response to control this ‘industrial pandemic’? With this concern, this review paper explores the public health responses to this rise in UPFs and SSBs in SSA, together with the issues and challenges in and options for a more vigorous public health response.

The paper presents the methods and sources of evidence and their limitations. It presents the findings on the policy, legal, information, and other institutional dimensions of the public health responses to UPFs and SSBs in SSA. A subsequent section discusses the challenges and issues faced in implementing action to protect public health regarding UPFs and SSBs in SSA. Finally, the conclusions propose options for implementing a more vigorous public health response to UPFs and SSBs in Sub-Saharan Africa.

2. Methods

With its focus on public health responses, the paper drew on analytic frameworks on social and commercial determinants of health to explore the dimensions of and factors affecting public health action on UPFs as a particular commercial determinant of health [11,30,31,32,33]. Drawing on these frameworks, the paper explores actions that (i) generate and share evidence and information that challenge narratives that weaken public health or those that advance public health, as a form of discursive power; (ii) engage on agential power, through policy, regulation and other institutional measures; and that (iii) engage at structural level, such as in tax and investment measures, including to promote healthy food system alternatives.

This review paper includes publicly available evidence from regional (multi-country) evidence or reviews in English for 2010-2023 obtained through searches of published documents of journal papers and United Nations and Africa Regional and sub-regional organisation institutional documents sourced on Google, Google Scholar, PubMed, Semantic Scholar, and Medline databases, Scielo, and AJOL. The paper draws on searches captured and included public domain documents for 2010-2023 on SSA in several rounds from these sources:

  1. Published United Nations (UN) and continental policy documents relevant to food and nutrition for 2013-2023, implemented in 2023.
  2. Published documents covering continental or multi-country studies or reports on UPFs implemented within general searches on commercial determinants of health in SSA implemented in 2023 and within general searches on social determinants of health implemented in 2024. The search terms used only Africa or sub-regional terms, and country-specific searches were not included.
  3. Searches in international and regional standards and country laws covering food safety and health-promoting standards and provisions implemented in late 2022.
  4. Searches on SSBs and SSB taxes in SSA covering policy, legal measures, design, products taxed, levels, implementation, and impact. Implemented in 2023, and on UPF taxes and health-promoting urban food systems implemented in 2024.

The searches on food laws and SSB taxes were used to inform separate discussion papers [34,35]. Additional searches were made and documents included by snowballing from references or article texts. One synthesis review on promising practices in urban food systems provided valuable information from within-country case studies to complement the continental-level searches [24]. This review paper is explicitly not a systematic review. Documents were included if they covered SSA, UPFs, or SSBs and included information on one or more of the dimensions of responses above, and any issues on their implementation. A grounded thematic analysis was implemented on the evidence from the 86 papers included within the key categories of response noted above and on factors affecting implementation. A further 6 papers are cited as relevant to the introduction and conclusions.

In addition, pertinent evidence relating to food patterns, diets and related non-communicable diseases was extracted for SSA from four datasets, viz: the World Health Organization (WHO) Obesity Evidence Hub dataset [36], the Global Database on the Implementation of Nutrition Action (GINA) [37], the Health Inequality Data Repository [26] and the United Nations SDG database [25]. The WHO Obesity Evidence Hub dataset provided valuable evidence on SSB taxes, while UN datasets enabled standard data definitions across countries and standardised indicators.

As limitations, drawing from reviews at continental or sub-regional levels may miss specific country information, as do searches in English. Examples from countries identified in the review and some local case studies are included. Still, specific country analyses and searches in other languages in SSA would be helpful and require follow-up research. With the pace of expansion of UPFs, it is likely that many changes on the ground are not yet well captured in published literature. Further, in the UN databases, 2021 was the most recent year for much data captured at the time of the capture, with limited disaggregations available, affecting equity analysis. Information on SSB and UPF taxes was likely to be incomplete for more recent country data, and developments in policies, laws, taxes, and innovations may have taken place since the searches for this paper were implemented. However, in presenting information more consistently provided across several sources, and citing sources and years for evidence presented, we consider the information in the paper to be sufficiently robust to point to responses and to support interpretation.

2.1 Ethics Statement

Given the use of public domain secondary evidence, an ethical review was not required.

3. Results: Public Health Responses to Ultra-Processed Foods in SSA

Countries in SSA have a time-bound opportunity to address the shift to UPF consumption and its impact on rising food-related NCDs. As noted in the methods, action on such commercial determinants of health to control health risks and promote healthy alternatives can use policy, legal, tax and investment, and information measures, that address discursive, agential/institutional and structural issues [11]. This section outlines within these dimensions of action the nature and levels of public health responses to the expansion of UPFs and their health impacts in SSA. The following section discusses issues and challenges in their application.

3.1 Policy Recognition and Legal Standards as a Basis for Wider Actions

Various platforms in SSA express policy recognition of the need for health-promoting food systems. An African Union Strategic Framework for Food Systems Transformation and a road map of the African Year of Nutrition 2025, together with the 2022 Abidjan Declaration on Nutrition commit governments to accelerate investment, implementation and coordination to improve nutrition and food security and end all forms of malnutrition [38,39]. In 2023, the WHO Regional Committee for Africa (AFRO) endorsed a 2019-2025 Strategic plan to reduce the double burden of poor nutrition from food insecurity and poor quality diets. The plan includes 14 priority interventions covering policy, legislation and regulation, partnerships and multi-sectoral action, service delivery, data innovation and research [40]. The 2003 FAO/WHO Food Safety and Quality Guidelines cover tax and regulatory measures on food production, transportation, and marketing, food safety and labelling, food quality and consumer protection, with measures to integrate risk analysis and prevention throughout the production, processing, and marketing chain as a shared responsibility of different stakeholders [41]. WHO has produced a Nutrient Profile Model as a tool for controlling obesogenic environments and the marketing of UPFs and SSBs to children [42].

Translating these policy commitments into laws and standards provides a foundation for other forms of public health action. African country food laws generally include provisions to prevent and protect against public health risks, including through food labelling. However, a review found that few country laws contain specific provisions regulating UPFs, fortified foods, food supplements and additives, or include standards for urban agriculture in food systems [34]. More recent biosafety acts in some countries do regulate the promotion, advertisement, and sales of ‘novel’ foods, which may include some UPFs [34]. In other examples, Kenya, Uganda, and Tanzania have adopted nutrition profile modelling and food labelling standards to inform regulations covering the marketing of food and non-alcoholic beverages. At the same time, Burkina Faso, Mali, and Sierra Leone have strengthened nutrition labelling rules to reduce risk factors for diet-related NCDs [43]. In 2013, South Africa regulated the amount of sodium the food industry can use in its products at the manufacturing level, with a timescale for affected industries to reconfigure recipes and technical adaptations to decrease sodium levels [44]. While industry often resists regulation, as discussed later, such legal processes can help to build partnerships with the food industry on less risky alternatives, draw evidence from the academic sector, and raise social campaigns to raise public awareness about health risks [44].

3.2 Applying Tax Disincentives to Discourage Health Risks

While UPFs and SSBs are often sold at low prices, the chronic diseases they lead to raise costs to households, health services, and economies [45]. There is new attention to lifting fee barriers and to service and outreach models that ensure early detection and care. However, these measures are still unevenly applied in and across SSA countries [45].

A broader population impact may be achieved from economic measures that incentivise manufacturers to reduce harmful ingredients, shifting the burden from households and care to risk prevention. In contrast, many African countries give tax concessions and reduced tax rates to multinational corporations to encourage investment [46]. These companies often use their economic power to resist national tax measures, and SSA states face deficits in tax capacities, and transnationals may profit shift to lower-tax countries [47]. Some SSA countries have, however, explored excise taxes as one option to tackle the public health risks, and to earmark funds for control programmes.

In SSA, this has more commonly been applied to SSBs, with WHO and UNICEF promoting taxes to control SSB consumption [48]. Both the World Trade Organization and the African Continental Free Trade Area Agreement trade rules allow for such taxes when applied to protect public health. An SSB tax that increases prices by 20% was observed by WHO to reduce consumption by 20% [2]. Applying an SSB tax was, however, noted to require careful thinking about the design, introduction and implementation of the tax, to address capacities, employment and equity impacts [49,50]. WHO recommended that excise taxes increase the price of all taxed foods and beverages by the same (absolute) amount to reduce the incentive to substitute a cheaper taxed product, and to make the tax more straightforward to implement and less susceptible to price manipulation [49]. Basing SSB excise taxes on sugar content, including sugar substitutes, while more administratively demanding to implement, may encourage consumers to substitute for healthier untaxed substitutes and the industry to reduce sugar content [49].

SSB taxes have been applied in half of the SSA countries, with their introduction expanding between 2016 and 2022 (Table 1) [35]. The taxes are used on a range of SSBs in different forms and at various levels, with 15 countries applying an ad valorem excise tax, 8 countries a specific excise tax, 3 countries a mixed regime and one combining VAT and a specific excise tax. Specific excise taxes are mainly applied per volume and content and four countries use tiered SSB taxes [35].

Table 1 SSA countries applying/not applying SSB taxes, 2023.

While relatively widely introduced, SSB excise taxes appear to be primarily applied to enhance revenue, or to protect domestic producers [17,35,37]. Some countries, such as South Africa, Zambia, and Uganda, have linked the tax to health goals and reduced consumption of SSBs, particularly when challenged on their introduction by industry, but have not ring-fenced or earmarked them for specific health programmes [22,51]. In introducing an SSB tax in 2022, the Zimbabwe government proposed ring-fencing this for the treatment and support of cancer, diabetes, and hypertension in an NCD Fund [52]. However, there is no available report on implementation. Very low shares of the SSB tax collection (less than 2% of the SSB tax in Uganda) have thus been documented to be spent on health programmes, mainly not focused on food-related NCDs, and there has been debate on the use of the SSB tax revenue for health programmes in South Africa [53,54,55].

There has been a recent global debate on applying excise taxes to UPFs. However, by 2024, only 21 countries globally applied these, and only four in Africa [56] (Table 2). In 2024, after reducing the SSB tax on cordials, arguing unfairness in using the sugar levels of concentrates when these would be diluted, the Zimbabwe government imposed a ‘fast foods tax’ of 0.5% on the value of selected processed foods sold by fast food retail outlets and restaurants to “encourage operators to adopt culinary (sic) that promote healthy eating” ([52], p. 204). While the application of excise taxes on UPFs or foods high in saturated fats, sugar and sodium is reported to show an association with reduced UPF purchases and consumption, the limited level of application and evaluation of their impact makes it difficult to draw clear conclusions, particularly given the variation in tax type, levels and the included tax base [56].

Table 2 Excise taxes (percentages) on UPFs or foods high in saturated fats, sugar and sodium, SSA May 2024.

3.3 Public Information, Evidence to Promote Health

Within SSA, there have been efforts to strengthen narratives, challenge false narratives, provide evidence from surveys, and promote health information on various commercial determinants of health, including promoting transparency and accountability of multinationals. Health promotion activities in SSA now include information on NCDs and their contributors, but health promotion outreach on NCDs is seen to need wider application, including through primary health care approaches [11,40]. WHO AFRO noted, for example, the slow progress in the promotion of safe and healthy diets, with only half of 47 AFRO Member States having adopted at least one of seven priority policy actions to deliver sustainable, healthy and safe diets [40]. As noted earlier, SSA laws include food labelling and consumer information provisions, but provide less specific controls on advertising and sponsorships of UPFs in media or near places frequented by children [34]. Front-of-pack labelling can guide consumers towards healthier diets and encourage producers to reduce harmful ingredients. However, by 2022 only South Africa in SSA had formally begun developing a system for this for UPFs [57]. Further, without media and information outreach and without clearly understood visual labels on levels of harmful food additives, consumers may not understand these ingredient labels. As a result, they may be poorly organised to enforce them. For example, a 2014 study in urban and rural adults in Zimbabwe found that while 77% of adults read food labels, especially women, younger, more educated and employed people, only 41% of these people understood the information on the labels. Most respondents (81%) called for education on the meaning of food labels and for simplified labelling [58].

Survey evidence has helped to inform policy and measures on UPFs, but it is often ad hoc. The institutionalised application of Health Impact Assessments (HIAs) and routine data in this area could provide more consistent information and evaluation of measures taken [59]. While Environmental Impact Assessment is now required by law in most African countries, the expansion of commercial risks to health is seen to demand a similar scale-up of HIA [59]. For example, in SSA, Zimbabwe’s 2018 Public Health Act provides powers for the health minister to specify the projects and activities which require a HIA to be conducted before licensing or implementation; as well as the HIA procedure and contents and any penalties or remedial measures resulting [60]. There is, however, limited reporting of HIA in the commercial food sector in SSA.

3.4 Promoting Healthy Food System Alternatives

Public health measures that control the production, advertising and marketing of UPFs need to be accompanied by measures that provide affordable, safe, nutritious foods, through multi-sectoral approaches that promote healthy food systems and their link to climate change and economic benefit [3,11,61,62] Agricultural policies and investment in the processing of locally grown foods can provide healthy alternatives. This is particularly pertinent in urban areas where dietary shifts to UPFs are most pronounced in SSA [63]. Equally, the opportunity to promote healthy local foods is suggested by surveys indicating that over a fifth of households in cities in eastern and southern Africa source food from urban agriculture [63].

Practices promoting healthy urban food systems in SSA are often reported at the local level. For example, in urban sites in Kenya, Malawi, Uganda, Zimbabwe and Zambia, urban local authorities and a range of non-state actors have linked reduction and recycling of organic waste to produce organic fertilisers and reclaim green spaces for urban agriculture, boosting healthy food local vegetable, grain and fruit production [24,64,65]. Some sites have applied water harvesting and other water conserving approaches to support urban farming. In Kampala, Uganda, Community Led Agriculture Banks set up in local communities provide information, demonstration sites, training and seed and equipment to support innovative techniques for urban farming in small spaces [66]. In Lusaka, Zambia, vendors in a local food market segregate food and other organic waste to take to a bio-digester that provides energy generated from bio-waste for local lighting, including energy for a school [67]. In a range of urban settings, such initiatives in multiple SSA countries have boosted availability of healthy foods and incomes, particularly in vulnerable and informal sector residents, demonstrating the link between healthy alternatives in urban food systems, climate adaptation and inclusive local economies [24].

SSA countries possess abundant agricultural resources, genetic diversity, and a youthful population as untapped assets for healthy food systems. Practices that promote local production and processing of nutritious foods and healthy food choices as alternatives to UPFs are reported to involve relationships between urban retailers and farmers in supply chains; training and incentives, local technology innovation for processing; support for local seed stocks; and links between communities and local governments and involvement of young people, and between urban and rural areas [24,68,69]. Knowledge-sharing platforms and stakeholder collaborations that bridge gaps and facilitate the dissemination of best practices are reported to have played a key role in this. In a review of 12 food hubs in SSA countries, collaborative platforms engaged communities to promote healthy food systems by addressing local needs, connecting local farmers and producers with consumers to ensure access to nutritious food, and improving linkages between rural and urban areas [69]. In Mbale, Uganda, a Good Food Council and Good Food Parliament provide multi-stakeholder platforms that widen shared understanding of food system issues and promote the local production for sale of nutritious foods, fruit in local markets [70].

Beyond the national cross sectoral responses detailed earlier, the promotion of healthy alternatives to UPFs thus needs also to take place at local level, empowering people, especially women, youth and marginalised communities, with information, knowledge, skills, resources, appropriate technologies and production inputs, to produce and market alternatives for healthy and affordable food [24,68,69].

4. Discussion: Challenges and Issues Facing Public Health Actions

The public health interventions described in the findings were not without challenges, and there is documented learning on what promotes their implementation, from local to national and international levels.

At both local and national levels, participation and multi-stakeholder partnerships are reported to leverage resource contributions and co-creation, and to raise trust, ownership, and accountability. Multi-stakeholder approaches are also noted to take time and to demand updated national policy or legal frameworks, tender, contracting, and procurement policies that would bring domestic financial support to the activities [24,69]. Locally developed technology innovations support relevance, climate-adapted approaches, and local economies, but lack national investment in research and development within countries to generate, test, and apply them. While local interventions to grow and process healthy foods generate local earnings for often low-income communities, they face challenges of inadequate and inconsistent project funding, usually insufficient for the scale-up needed to provide alternatives to large company UPF sales [24].

Clarity on the health impacts of different categories of UPFs, generally and SSA, would help in public health messaging and controls. While this is not an explicit focus of this paper and as a developing field requires its focused investigation, the lack of clear and implementable criteria to assign individual products to UPF-related risks means that most policies target threshold levels of saturated fats, sugars, sodium, and sometimes energy, rather than specific UPF products [56]. As noted earlier, in 2017, there was higher than optimal consumption of sodium, trans-fats, and sugar-sweetened beverages in SSA [20]. The WHO Nutrient profile model for children in the African Region in its nutrient threshold approach identifies UPFs as more harmful if as single foods they contain sodium (mg) to energy (kcal) in a ratio greater than 1:1; free sugars and total fats greater for each than 10% of total energy and transfats greater than 1% total energy [42]. While the model lists a range of different foods available in SSA, including chocolate, confectionery, bread products, breakfast cereals, savoury snacks, sweetened fruit and dairy-based drinks, deserts, and processed meats and sauces, their level of harm demands specific testing of these threshold levels in their constituents [42]. More explicitly, but without evidence on the distribution of their uptake in SSA, the Global Food Research Programme highlights a category of ‘NOVA Group 4’ UPFs that are not simply foods that meet the processing and additive criteria for UPFs, but that include additives that heighten their appeal and durability, raising potentially addictive qualities [71]. Their distribution in SA in marketing and diets in SSA is an important area for further investigation.

Public health messages on the harms of UPFs face the counter-challenge of wide corporate marketing, reaching into homes, suburbs, schools, and even informal vendor carts [21,72,73,74]. While social media may represent an asset to share information on the harms of UPFs and to promote healthier alternatives for an increasingly socially connected urban population in Africa, the pace and content of public health messaging may not match the pace and messaging from UPF producers and markets, including through the expanding online sales and home delivery of fast foods and attractive options such as ‘Munchy Mondays’.

The findings point to a range of policies, model laws, and guidance that support public health action on UPFs, but a gap in their slow implementation on the continent, in both law and institutional practice. Weak protections against advertising and promotion of UPFs to children and in schools in law and practice present as an essential gap, given the role long-term exposure to UPFs can play in the earlier onset of NCDs [21,28]. Some states have begun to apply legal and tax measures, supported by UN agency messages. Food laws in SSA cover product labelling, but not always in accessible formats or with outreach to support understanding. SSB taxes are expanding in application, albeit with limited use for health interventions and limited evaluation of their positive impact on products and health. As evidenced from reversals and variable application of SSB taxes in the findings, the lack of evidence on effects makes the tax measures vulnerable. The experiences reported point to the role legal and tax reforms can play in generating partnerships, evidence, and public awareness. However, there are limited reports of these opportunities being effectively tapped.

Multinational food corporations are also resistant to such regulation or tax measures, preferring less effective voluntary measures [22,55,75,76], sometimes using threats of disinvestment, trade disputes, and litigation over controls [21,22,77]. For example, when the Zambian government applied and maintained a 25% excise tax on soft drinks in 1998, Coca-Cola’s threats to pull out from the country led to the tax being repealed in 2015, ostensibly for economic reasons [22]. The variability in laws and tax measures across countries, the lack of harmonised regional standards, porous cross-border trading, and trade liberalisation, including as promoted in the African Continental Free Trade Agreement, give companies an advantage in terms of threats to shift to countries that offer more favourable terms.

Hence, while the expansion of UPFs and their consequence for rising NCDs are widely recognised in policy in SSA, there are gaps in the measures needed for their control. As reported in the findings, SSA states face significant imbalances in power and resources in their interactions with the often transnational actors promoting UPFs and the obesogenic health-harming conditions outlined in this paper [11,21,22,78]. Ideas and narratives that frame for-profit commerce and consumption of its products as a sign of economic status, and free markets as essential for wellbeing; and the growth of agro-industrial practices and investments in SSA economies generate public anxiety around alternatives, and weaken health sectors in facing finance ministries [11,18,19,79]. This is reinforced when the dominant understanding of NCD causation is kept in global and national forums within narrow and often behavioural boundaries [80,81], and when there is limited application of health impact assessment and monitoring of policy measures or commercial activities, as noted in the findings.

The underlying political economy of food production in SSA plays a role in this power imbalance in the broader application of policies, laws, and measures outlined in the findings to protect public health regarding UPFs. Globalisation and trade liberalisation led to countries ‘producing what we don’t consume, and consuming what we don’t produce, ’ with rising primary crop food exports and processed food imports [82]. The growth of mono-cropping, such as of sugar cane for biofuels, has expanded corporate land acquisition, displacing or undermining incomes in local food producers [79]. Significant corporate and investor finances, including nearly US$6 billion since 2004 from the Bill and Melinda Gates Foundation, are being applied to advancing a ‘Green Revolution’ model promoting mono-cropping, commercialised technologies such as genetically-modified seeds, synthetic fertilisers and pesticides and imported technologies that strengthen corporate hegemony in food systems, ignoring the knowledge that local farmers possess [18,19,83]. The significant role multinationals and liberalised trade play in economies and food systems in SSA raises their economic power on issues such as control of UPFs. Their role also gives foundations associated with these multinationals a seat in many agenda-setting forums in SSA. Part of the Bill and Melinda Gates Foundation (BMGF), US$6 billion on its agriculture programme, is reported to be used to influence policy and to support groups that lobby policymakers. The Foundation is also included in the Advisory Group of the Committee on World Food Security and the CGIAR System Council, providing a seat at key policy tables [18,19,84].

The challenges outlined in this section can disrupt the partnership, trust, social engagement, and information flows at national and continental levels that emerged in the findings as essential for promoting healthy domestic food alternatives to UPFs. There are national and continental forums that bring evidence, ideas, and voice on food systems from communities, civil society, and academia to national and SSA forums [85,86]. The Alliance for Food Sovereignty in Africa, for example, represents more than 200 million farmers, fishers, pastoralists, indigenous people, women, consumers and others across all but five African countries, and advocates a model of agroecology, based on farmers’ land rights, local seed banks, investment in local food production, short supply chains and climate-resilient and ecologically-sustainable farming [8,87,88]. While such voices for healthy alternatives exist in SSA, the economic models, power imbalances and influences and the gaps in public action noted in this discussion can generate distrust, protest, and litigation, rather than the public-public interest alliances between states and civil society that play a role in successful public health action [11,83,89].

5. Conclusions

In the introduction to this paper, the question is raised: Can SSA, positioned as it is at an early point of a rising wave, afford to delay its response to control this ‘industrial pandemic’? The findings indicate policy recognition of the need to respond effectively, widely, and more rapidly across SSA. The findings also point to a range of responses underway. However, the evidence presented suggests that the response is not yet matching the scale or pace of the challenge. The findings and challenges point to some options for the ‘more vigorous public health response’ referred to in the introduction.

The findings and discussion of challenges note the presence of policy commitments and model laws and guidance that support public health action on UPFs, and measures such as tax disincentives to discourage health risks, but point to variability and gaps in their application.

5.1 One Key Option for a More Vigorous Response Is to Amplify Implementation of Existing Measures

There are interventions outlined in the findings that are already recognised in policy. They need the level of attention an ‘industrial pandemic’ deserves, including through updated food law to regulate these new risks, expanding public health literacy and implementation of accessible visual food labelling; using regulation and tax measures to control harmful food additives, including above-target levels of transfats, free sugars and sodium, preferably at manufacturing stage; and regulation of advertising and sale of UPFs, particularly in schools and to children. There is precedent for implementing these measures by drawing on how commercial risks were similarly addressed in tobacco control.

The findings note the power and resource imbalances that policy actors in SSA face in their interactions with transnational actors when taking actions to protect public health. While this is further discussed later, it points to a demand for regional co-operation to support action at the country level, including to avoid companies threatening to shift to African countries that offer more favourable terms.

To support the implementation of literacy, tax and regulatory measures, model laws and guidelines could be more rapidly expanded and disseminated. Opportunities for negative trade, tax, and production competition could also be closed by more active regional exchange of information and by harmonising laws and tax measures in regional economic communities in SSA.

Regional initiatives can support the design, econometric analysis, universal introduction, and regular national review of SSB and UPF tax measures in SSA countries, particularly those measures applied at the manufacturing level that encourage industries to lower the content of sugars, trans-fats, sodium, and similar additives. Regional approaches can enable information sharing on commodity and service pricing and tariff and tax systems that can prevent a ‘race to the bottom’ competition between countries [90]. They can also learn from initiatives in other regions, such as the initiatives currently underway in Colombia and Chile on UPF taxes [56].

The gaps reported in the findings in health promotion outreach, in public literacy on UPFs and NCDs, and public action are noted to undermine the public-public interest alliances between states and civil society to counter the challenges of transnational power and marketing of UPFs.

5.2 A More Vigorous Public Health Response Thus Calls for Increased Visibility and Public Awareness of Risks and Responses

Legal, tax, and other policy measures need to be seen as a vehicle for generating and using evidence and for building partnership, literacy, and public health outreach, in accessible, relevant ways to the public, to young people, and to influential voices and parliaments. For example, the front of mandatory product labelling on food packages can better simplify and use standard colour visual labelling to show contents and their health risks, with information outreach on the rationale and meaning to all social groups, accompanied by monitoring and review for improvements and adjustments [57].

As raised in the examples in Section 3.3 on public health information and evidence, the health sector contributes to this, contesting discourses that promote misleading information, providing evidence, ensuring disclosure and reporting of conflicts of interest, and public reporting of health, social, and ecosystem impacts. Health impact assessment should be a legal duty for licensing and recommending improvements to protect health in commercial activities in food systems that have a population impact. Research on the distribution, marketing, and dietary consumption in SSA of UPFs that have above threshold levels of free sugars, sodium, and trans-fats, and of the foods that are in the NOVA4 category of UPFs, can inform policy decisions and public awareness.

The findings point to responses underway in SSA and challenges faced in promoting healthy food system alternatives. The initiatives underway, including local technology development, provide a promising foundation for healthy options, albeit weakened by a lack of sustained resources.

5.3 Enabling Local Alternatives for Healthy Foods is thus Critical for a Stronger Public Health Response

The promotion of healthy alternatives to UPFs calls for the promotion of local production and processing of nutritious foods, including in green spaces for urban agriculture. Enabling healthy regional food systems implies land, agro-economic production, processing, marketing measures, including farmers’ land rights, and local seed banks. It means investment in local food processing, in research and development for technology innovators, and ecologically sustainable farming. It also means the effective use of state mechanisms such as procurement tenders, tariffs, taxes, and innovation funds to support healthy food systems.

These options within countries are noted in the paper to face the context of globalisation and trade liberalisation measures associated with the expanded trade, marketing, and consumption of UPFs and the increasing presence and power of transnational actors in the food sector.

5.4 Engaging in This Global Context Implies Strengthening Collaboration Across Sectors and Countries in SSA

The legal, tax, and other policy measures outlined in the paper go beyond the health sector and engage broader political economy and power structures that enable harmful practices or block alternatives. Experiences in SSA show that they demand political space and champions, given that these measures challenge powerful actors. Yet there is scope for addressing power imbalances in strengthened public interest alliances between politicians, policymakers, professional groups, civil society, communities, and investigative journalism, in the regional approaches raised earlier, and in engaging in these alliances around protecting healthy food systems at the global level.

The measures to regulate UPFs, control their harmful health impacts, and promote healthy alternatives demand improved cooperation across countries to engage effectively at the global level. SSA countries have already demonstrated impact on international tax, intellectual property, and other issues in international platforms, including through unified informed positions of regional economic communities, in the Africa Group of Diplomats, and the African Union [11,91,92,93]. Climate change and its intersection with the food-system trends outlined in this paper make it even more critical that SSA act on them [94,95].

The COVID-19 pandemic and the cross-border trade disruptions it brought exposed the risks of current trade and agribusiness policies for food security, stimulated people to grow and process foods locally, and to consume more local health-promoting foods. The pandemic raised the profile of public health in economic and political decision-making. It mobilised continental action and engagement on production and trade rules [96,97]. The expanding risk of UPFs and their impacts in SSA, the assets and opportunities for alternatives, and the gaps in responses call for a similarly strengthened response to this industrial pandemic.

Acknowledgments

The author acknowledges with gratitude contributors to prior searches and data capture, including Marie Masotya and Peter Binyaruka for data capture from UN databases, and Pascalina Chanda-Kapata, William Kasapila, Artwell Kadungure and Sue Godt for selected prior document searches. The author thanks Peter Piot and Doris Kirigia WHO AFRO for their leads on relevant policy information, and colleagues in the EQUINET community of practice in urban health and the EQUINET steering committee for background dialogue, experiences and insights shared on health in food systems.

Author Contributions

RL initiated, conceptualised and drafted the paper, carried out online searches, edited and produced the final draft. The author checked and approved the final draft.

Funding

No funding was used to produce this paper.

Competing Interests

The author declares that no competing interests exist.

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