'Go beyond safety': Policies needed to create healthier food environments in South Asia – latest study

Researchers assessed food policies in South Asia, which included Bangladesh, India, Pakistan, and Sri Lanka, from 2020 to 2022.

The assessment was conducted using the Healthy Food Environment Policy Index (Food-EPI), a global tool that rates the level of implementation of policies on food environments by the government against international best practice.

They found that while undernutrition remains a significant public health problem in lower-middle income countries like those in South Asia, there is also an increasing shift towards overnutrition.

Historically, these countries have focused on policies to address food hygiene and undernutrition that are not suitable to prevent the increased availability of energy-dense processed foods associated with overnutrition.

For example, the increasing prevalence of diet-related non-communicable diseases in South Asia is concerning, with type 2 diabetes projected to rise to 68%, compared to the global increase of 44%.

Therefore, South Asia requires stronger policies promoting healthier food environments to encourage healthy diets. Such policies would restrict the availability, affordability, promotion, and attractiveness of unhealthy foods and beverages.

“We conclude that food policy in South Asia focuses on food safety and hygiene as evident by the moderate implementation of policies related to labelling, monitoring, and leadership. All other policies were weakly implemented or non-existent. The countries recognised the need to address the growing levels of overnutrition related non-communicable diseases. [So, we provided] a policy agenda focused on creating healthier food environments in South Asia,” ​wrote researchers in The Lancet Regional Health – Southeast Asia​.

These findings come from a research study commissioned by the National Institute for Health Research (NIHR) Global Health Research Units and Groups using UK aid from the UK Government.

The study​

A total of 104 stakeholders from South Asian government and non-governmental sectors assessed policy and infrastructure support implementation. There were 43 from academia, 15 from NGOs and other organisations, and 46 from the government.

There were seven policy domains being assessed – food composition, labelling, promotion, provision, retail, prices, food trade & investment.

Researchers also looked at six infrastructure support domains – leadership, governance, monitoring & intelligence, funding & resources, platforms for interaction, health in all policies.

The stakeholders were first instructed to individually assess the implementation level of each policy and infrastructure support indicator in comparison to the international best-practice policy examples.

The five-point Likert scale was used for the assessment – ‘1’ represented the policy did not exist (non-existent), ‘2’ indicated the implementation of the policy was weak, ‘3’ the implementation of the policy was moderate, ‘4’ the implementation of the policy was strong, and ‘5’ the implementation of the policy was very strong.

The stakeholders’ assessment showed that implementation of food environment policies and infrastructure support was predominantly weak. Labelling, monitoring, and leadership policies received a moderate rating, with a focus on food safety, hygiene, and quality rather than obesity prevention.

For instance, with the exception of India, food retail policies for all countries were rated as non-existent, as stakeholders could not identify zoning laws and policies that controlled the availability of unhealthy foods nor to promote the availability of healthy products. There was also insufficient funding being invested to prevent diet-related non-communicable diseases – no government funded research targeted for improving food environments and no statutory health promotion agency in place.

Only India was reported to have food policies and infrastructure support in place for all Food-EPI domains – 43% of the indicators were rated as weak and 57% as moderate.

In Bangladesh, for 62% of the indicators, the degree of implementation relative to international best practices was rated as weak, 13% as moderate, and 26% were non-existent.

All indicators in the policy domains were rated with weak implementation.

For leadership in the infrastructure support domain, the government appears to have developed strategies and put initiatives in place to ensure food safety and nutrient goals to improve the nutrition of the population. For monitoring, the evidence indicates that there is regular monitoring of adult and child nutritional status and obesity prevalence.

In Pakistan, only 2% of the indicators were rated as moderate, whilst 75% of the indicators were rated as weak and 23% were non-existent.

In Sri Lanka, 19% of the indicators were rated as moderate, 64% of the indicators were rated as weak and 17% as non-existent.

Recommended actions​

Based on these assessment results, the stakeholders formulated recommended actions for improving food environments, which are ranked according to importance.

Factors that affected ranking include the effectiveness on improving food environments and diets, and the effects on reducing diet-related health issues.

Among the top recommendations, actions related to prices, promotion, retail, and labelling were consistently recognised by all countries as both important and achievable. In particular, food price actions were highlighted as fiscal policies, including subsidies for healthy foods and taxes on unhealthy food and beverages.

Actions related to food promotion include banning or restricting unhealthy food advertisements for children and adolescents.

This also included policies aimed at regulating unhealthy food items sponsored by food industry, such as banning of toys associated with the acquisition of unhealthy foods. This further extends to retail recommended actions, which include policies that encourage supermarkets to promote in-store availability of healthy foods, and to regulate the sale of unhealthy foods around schools.

For labelling, all four countries prioritised introducing front of pack labelling to strengthen consumer choice – e.g. the traffic light system.

In addition, Pakistan and India recommended with very high importance actions related to provision, namely by raising the awareness of non-communicable diseases among teachers, students, and parents through school-based awareness programmes, and establishing food programmes that provide food for the population at low cost or free.

The most highly recommended actions are related to monitoring, platforms, and leaderships. In terms of monitoring, recommendations focused on strengthening the monitoring and surveillance mechanisms to regularly monitor the health status of the population and food environments, as well as implementing regular assessments on the impact of regulations that may control the unhealthy food environments such as taxation or limiting promotion of unhealthy foods in schools.

The other area of focus was leadership, specifically the prioritisation of government initiatives on the prevention of diet-related non-communicable diseases, and coordination across departments and levels of government, industry, and civil society.

“Our findings underline the critical need for targeted policies to combat obesity and diet-related non-communicable diseases, extending beyond the current focus on food safety and hygiene. It suggests prioritising the enhancement of food labelling, the introduction of fiscal policies to promote healthy eating, the implementation of stricter regulations on food promotions, and the improvement of nutritional standards in schools,”​ said the researchers.

Addressing these areas with comprehensive strategies and ensuring the necessary support and resources are allocated is essential for the significant improvement of public health outcomes in the region, said the researchers.