Effect of Sugar-Sweetened Beverage Imports on the Prevalence of Overweight among Underfive Children in Nine Eastern Africa Countries

doi:10.21203/rs.3.rs-4697545/v1

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Effect of Sugar-Sweetened Beverage Imports on the Prevalence of Overweight among Underfive Children in Nine Eastern Africa Countries

https://doi.org/10.21203/rs.3.rs-4697545/v1

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Background

Overweighting among children under five years of age is increasingly becoming a global health concern. This has a connection with international trade and its influence on the increasing availability and consumption of sugar in different forms. This study seeks to identify the effects of the import of sugar-sweetened beverages on the prevalence of overweight among children under five years of age in nine Eastern Africa countries (EAC).

Methods

This study analyzed data from the UN Comtrade Database and World Development Indicators (WDI) of the World Bank (WB) spanning from 2000–2022. The East African countries selected are Burundi, Malawi, Mozambique, Rwanda, Tanzania, Uganda, Zambia, Madagascar and Zimbabwe. With these panel data, the fixed-effect estimation approach was employed as a technique to study the effect.

Results

The analysis revealed that the imports of sugar-sweetened beverages such as milk drinks, tea and coffee, and water, including mineral and aerated drinks, had a negative effect on the incidence of overweight among children under five years old in the EAC, but the difference was not statistically significant. However, GDP per capita was found to be positively related to the incidence of overweight.

Conclusions

This study did not find any evidence that SSB consumption in EACs contributes to the prevalence of overweight among children under five years old. Only GDP growth per capita was found to have a positive effect on the prevalence of child overweight. The findings suggest that international trade policies and agreements should consider the effect of economic growth on adverse health outcomes among children under five years of age in EACs and other similar developing countries.

sugar-sweetened beverages

overweight

underfive children

imports

eastern Africa

Globally, there is no country that is on the track to prevent the increase in overweight among children under 5 years of age (Branca et al., 2023). Studies have established a link between sugar intake and overweight or obesity (Magriplis et al., 2021; Yu et al., 2022; Kuhnle et al., 2015). The availability of sugar-sweetened commodities, especially through trade, has also been reported by several studies (Schram et al., 2015; Mendez Lopez et al., 2017; Lo et al., 2021; Mabeta & Smutka, 2023). A report from the 2023 World Obesity Federation revealed that almost 400 million children will be overweight or obese by 2035 (Lobstein et al., 2023). The same report indicates that the global increase in obesity incidence among children and adolescents will be the most pronounced, from 8–18% in girls and from 10–20% in boys from 2020 to 2035.

Consequently, there is an increasing economic impact of obesity globally. It is estimated that its cost will increase from US$1.96 trillion in 2020 to over US$4 trillion in 2035, at a constant US$ value. The impacts include healthcare costs, loss of productivity, and premature death. Due to overweight or obesity, the global gross domestic product (GDP) is expected to decrease by 2.4% in 2020 and then increase to 2.9% from that value (2.4%) by 2035 (Lobstein et al., 2023).

Overweight is no longer a health problem in high-income countries but has also dramatically risen in low- and middle-income countries, including countries in eastern Africa. Previous studies have reported that there has been a considerable increase in childhood obesity in Sub-Saharan Africa over the past two decades (Danquah et al., 2019). For instance, in their review, Danquah et al. (2020) reported that in SSA, childhood obesity or overweight has increasingly become a public health concern. This increase was also observed in West African countries (Diallo et al., 2023).

In sub-Saharan Africa (SSA), the prevalence of obesity among children and adolescents is expected to increase from 5–14% in girls and from 4–7% in boys between 2020 and 2035. By 2035, the yearly economic impact is projected to be more than US$50 billion or 1.6% of the region’s GDP (in constant 2019 dollars) (Lobstein et al., 2023).

Several studies have investigated the risk factors leading to overweight among underfive children (Saha et al., 2022; Tiruneh et al., 2021). The major contributors to overweight or obesity have been found to be the consumption of high-fatty products, high-sugars, and micro nutrient-poor diets (BA et al., 2004; Ruhara et al., 2021). Most of these products are easily imported in many countries, especially LMC. Additionally, the expanding scope of international trade agreements and policies has facilitated the sudden increase in imports of sugar-sweetened beverages (Ruhara et al., 2021).

Although some previous studies have indicated that trade has a positive impact on health outcomes, such as reducing infant mortality and improving life expectancy (Zhang et al., 2022), some trade policies, such as trade openness and trade and investment agreements, have also been proven to have adverse effects on health outcomes (Barlow et al., 2022). Trade liberalization, as a trade policy, tends to be conducive to the consumption of sugary drinks or sweetened beverages (Mendez Lopez et al., 2017), which can lead to chronic diseases (Lo et al., 2021; Teng et al., 2020). In particular, overweight or obese children are prone to experiencing an increased risk of having high blood pressure, high cholesterol concentrations, type 2 diabetes, asthma, joint problems, gallstones, anxiety, depression, insulin resistance, hypertension, hyperlipidemia, liver and kidney disease, and reproductive problems (Albataineh et al., 2019; Sahoo et al., 2015). These consequences are connected to the manufacturing, importing or purchasing and consumption of sugar-sweetened beverages and foods that contain high amounts of energy, fat, sugar, salt and low amounts of vitamins and minerals (WB & PAHO, 2020). The literature indicates factors associated with overweight in children in SSA (Choukem et al., 2020). Similarly, studies have attempted to use child overweight data relating to import data (Ferretti and Mariani, 2019; Schmidt & Fang, 2021).

Beverage waters sweetened or flavored ranked 281st in terms of global trade in 2021, with $12.6 billion in total trade. Exports of sweetened or flavored beverage waters increased by 24.7% between 2020 and 2021, from $10.1 billion to $12.6 billion. In general, trade in sweetened or flavored beverage waters constitutes 0.06% of global trade (OEC, 2023).

Analysis of the most recent Demographic and Health Survey (DHS) data showed that the prevalence of overweight among children under five years of age ranged from 3.2% in Kenya to 5.6% in Rwanda (KNBS & ICF, 2023; NISR et al., 2021). In addition, it varied from 1.4% in Burundi to 2% and 5.2% in Ethiopia and Zambia, respectively (EPHI & ICF, 2021; MPBGP et al., 2017).

While various factors contribute to overweight and obesity in Africa, economic risk factors play a major role in increasing incidence of childhood obesity, especially in the East African context. For example, a study performed in 175 countries between 1975 and 2016 showed that international trade openness was positively associated with country obesity, where an increase of 10% in trade openness was associated with an increase in the obesity rate of 0.80% (An et al., 2019).

A study performed in Kenya showed that 18% of children under five years of age were overweight, which was found to be associated with maternal overweight and obesity, higher education levels, a very large child at birth and stunting (Gewa, 2010). Another study performed in sub-Saharan Africa in 2022 showed that overweight and obesity in preschool children were strongly associated with the home food environment and high maternal BMI. The economic transition in many African countries, including East African countries, has led to a shift in dietary patterns and physical activity levels, which contributes to an increased prevalence of overweight in children and urbanization (Kwansa et al., 2022).

Urbanization and globalization, particularly the free trade of services such as the modern marketing food trade in food products, have brought about changes in food systems and marketing exchange practices. This has resulted in the proliferation of inexpensive, highly processed foods that are energy dense but nutrient poor; these foods are more accessible and affordable than healthier foods are, and as a result, this exacerbates the risk of childhood overweight in economically disadvantaged communities (Popkin et al., 2020).

Childhood overweight or obesity has been considered an epidemic (Paul, 2023; Tiruneh et al., 2021) and a pandemic in the Global South (Paul, 2023). Child overweight, according to the World Health Organization (WHO), is a condition in which the child’s weight is not proportional to his or her height (Jones et al., 2017; Ayele et al., 2022; Flynn et al., 2022). Overweight children have a weight-for-height greater than two (2) standard deviations (SDs) above the median of the WHO Child Growth Standards (WHO, 2024; de Onis, 2015; LBD Double Burden of Malnutrition Collaborators, 2020).

There is a connection between international trade, globalization of trade and public health. An increase in trade has noticeable effects on health outcomes (Bettcher et al., 2000; Loewenson et al., 2007; Cyrus, 2018). Recent trends have shown a concerning increase in the prevalence of overweight and obesity among children under five years of age in East African countries (S.A. Tiruneh, 2021). This escalation appears to be significantly influenced by the regular consumption of soft drinks, including both carbonated and noncarbonated sugar-sweetened beverages (SSBs). Several studies conducted in developed countries have investigated this health concern (Malik VS, Pan A, Willett WC et al., 2013; F.B. Hu, 2013; Ferretti and Mariani, 2019).

The estimation of sugar-sweetened beverage (SSB) imports has evolved over time, reflecting shifts in consumer behavior, policy interventions, and global trade dynamics. SSBs are any drinks that contain added sugar or sweeteners. These beverages contain free sugars, which include carbonated or noncarbonated soft drinks; 100% fruit/vegetable juices and drinks; liquid and powder concentrates; flavored water; energy and sports drinks; ready-to-drink tea; ready-to-drink coffee; and flavored milk drinks (Sousa et al., 2020; Malik & Hu, 2022).

Previous studies examining the link between SSBs and child nutrition outcomes range from systematic reviews to cross-sectional and ecological analyses, covering a broad spectrum of countries and regions. Key themes include the effectiveness of SSB taxation in reducing consumption and obesity rates (Itria et al., 2021), the role of SSB affordability in increasing obesity incidence (Ferretti and Mariani, 2019), and the global consumption patterns of SSBs among children and adolescents and their health implications (Ooi et al., 2022). The literature has also explored the broader impacts of global trade on health (Bettcher et al., 2000) and the determinants of obesity in East African children (Tiruneh et al., 2021). Each study contributes to a nuanced understanding of how SSB consumption, influenced by factors such as taxation, affordability, and global trade, is linked to the rising prevalence of obesity and related health issues.

Thus, understanding global evidence and providing region-specific data on the relationship between SSB imports and the prevalence of overweight are crucial for effectively informing the design and implementation of locally specific and relevant prevention and intervention programs. However, there remains a significant gap in the related literature within developing regions, especially in eastern African countries. Research on the linkage between international trade, trade policies and agreements and health outcomes such as overweight among children under the age of five years in Eastern African countries is scarce. In particular, there is a lack of specific knowledge on the effects of SSB imports on the increasing incidence of childhood overweight in these countries.

This study aimed to investigate the effect of the import of sugar-sweetened beverages (SSBs) on the prevalence of overweight in underfive children in nine Eastern African countries, namely, Burundi, Madagascar, Malawi, Mozambique, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe. This study focused on the effects of importing juices, milk drinks, tea and coffee, and water with mineral and aerated drinks, which are commonly called SSBs or sugary drinks (Bahl & Bird, 2020).

Data

This study used data from the World Development Indicators (WDI) of the World Bank (WB) and UN Comtrade for the period spanning from 2000–2022. The authors analyzed data for nine selected East African countries, namely, Burundi, Madagascar, Malawi, Mozambique, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe.

These countries were included in this study because they fulfilled the following criteria or conditions. These countries were selected because the prevalence of overweight is on the rise in low- and middle-income countries (LMICs). In the eastern part of Africa, underfive children tend to be overweight (Tiruneh et al., 2021). This region has persistent problems associated with malnutrition, as revealed in the 2022 Global Nutrition Report. The same report revealed that the average incidence of overweight was 4%, the lowest value compared with that in other subregions of Africa. In the same region, the UNICEF, WHO and World Bank (2023) reported that the prevalence of overweight among children under five years of age has not changed since 2015. According to the 2025–2030 World Health Assembly (WHA), the WHO and UNICEF suggest that child overweight status be reduced and will remain constant at less than 3% by 2030 (Chadare et al., 2022). However, this region is off track to meet the target. Moreover, these countries were also selected due to the availability of data.

Dependent Variable

The dependent variable of the study was the prevalence of overweight in children under five years of age. According to the WHO's 2006 Child Growth Standards, the prevalence of overweight children is defined as the percentage of children under the age of five whose weight-for-height ratio is more than two standard deviations above the median for the international reference population of the corresponding age. This variable indicates the nutritional status of the child.

We obtained data on the prevalence of overweight from the website of the World Bank Development Indicators (WDI). The data are expressed as percentages. It is a modeled estimate.

Independent variables

The independent variable of interest in this study is the amount of sugar-sweetened beverage (SSB) imports. These include the imports of juice, milk drinks, tea and coffee, and water, including mineral and aerated drinks. These SSBs have been associated with weight gain (Malik & Hu, 2022). The present study aimed to assess the effects of these variables on the prevalence of overweight among children under five years of age. Table 1 provides a description of the SSBs according to the WHO nutritional profile and their Harmonized systems (HS) classification in The United Nations Commodity Trade Statistics Database (UN Comtrade) (WHO Regional Office for Africa, 2018).

Table 1

Sugar-sweetened beverages according to the WHO nutritional profile from the UN Comtrade website
Sugar-sweetened beverages	Harmonized System (HS) code	Description
Juices	2009	Fruit or nut juices (including grape must and coconut water) and vegetable juices, unfermented, not containing added spirit, whether or not containing added sugar or other sweetening matter
Milk drinks	0402	Milk and cream; concentrated or containing added sugar or other sweetening matter
Tea and coffee	210112	Preparations with a basis of extracts, essences or concentrates or with a basis of coffee
Water, including mineral and aerated drinks	2202	Waters, including mineral and aerated waters, containing added sugar or sweetening matter, flavored; other nonalcoholic beverages, not including fruit, nut or vegetable juices of heading no. 2009

We considered the value of imports (trade flows) expressed in United States dollars (USD) for the period from 2000–2022. The data were sourced for the nine selected countries as “Reporters”, while the “Partners” were the World. To obtain the data used in this study from the UN Comtrade website, we considered TOTAL Modes of Transport for “Mode of Transports”, and TOTAL customs procedure codes were considered for the “Customs code”. In addition, the “Set your query options” feature has the “Breakdown Mode”, which was considered to be Plus, while the “Aggregate by” feature remained with the value None.

In addition to SSBs, this study considered a number of control variables. The latter include trade openness and GDP per capita growth. Data on trade openness were obtained from the World Development Indicators (WDI) of the World Bank and from the website of our World in Data1. These data are expressed in terms of the annual percentage of GDP, that is, Trade in terms of % GDP. This trade openness index is computed by summing the imports and exports of goods and services, and this sum is divided by GDP.

We drew GDP per capita growth data from the WDI website. It is the annual percentage growth rate of GDP per capita based on constant local currency. This value is computed by taking annual GDP and dividing by the mid-year population. The annual percentage growth rate of GDP per capita is based on a constant local currency. The GDP per capita is the gross domestic product divided by the midyear population. Table 2 provides the description and summarizes the origin of the data.

Table 2

Description of variables and sources of data
Variable	Description	Unit	Source of data
Dependent variable
Prevalence of overweight	Prevalence of overweight children is the percentage of children under age 5	percentage	WDI
Independent variables
Imports of juice	Total value of imports of juice (USD)	USD	UN Comtrade
Imports of Milk drinks	Total value of imports of milk drinks (USD)	USD	UN Comtrade
Imports of Tea and Coffee	Total value of imports of Tea and Coffee (USD)	USD	UN Comtrade
Imports of water, including mineral and aerated drinks	Total value of imports of water, including mineral and aerated drinks	USD	UN Comtrade
Trade openness	The ratio from the sum of imports and exports divided by GDP	Import + export ratio to GDP expressed in annual percentage	WDI
GDP per capita growth	Annual percentage growth rate of GDP per capita based on constant local currency.	annual percentage	WDI

Data analysis methods

As an empirical estimation method, we used the fixed effects approach to investigate the effects of SSB consumption on the prevalence of overweight among children under five years of age in nine EAC countries. The fixed effect model indicates the relationship between dependent and independent variables within a country (considered an entity). With this approach, it is assumed that these entities may have individual observations or characteristics that may or may not have an effect on the outcome and/or predictor variables. These individual characteristics are not random and may influence the dependent or predictor variables. This issue has to be controlled for. Therefore, the impact of independent variables may not be influenced by those fixed observations. Moreover, this fixed effect approach assumes that there is no correlation between the entity’s error term and independent variables (predictors). The Hausman test, when performed, indicated the choice of the fixed effect model. The data included 9 countries (n = 9), and the time period was 22 years (2000–2022) (T = 22).

This study estimated the following econometric model, also known as the health production function, with the prevalence of overweight as the response variable:

$$\:overweigh{t}_{it}={\beta\:}_{0}+{\beta\:}_{1}Juic{e}_{it}+{\beta\:}_{2}Mil{k}_{it}+{\beta\:}_{3}TCoffe{e}_{it}+{\beta\:}_{4}Wate{r}_{it}+{\beta\:}_{5}{X}_{it}+{ϵ}_{it}$$

where overweight represents the incidence of overweight children under five years of age, for i = 1, 2, …, N indicates the number of countries, and t = 1,2..,T indicates the time periods. Betas are coefficients. Juice represents the total value of imports of juices. Milk represents the total value of imports of milk drinks. TCoffee represents the total value of imports of tea and coffee. Water represents the total value of water, including mineral and aerated drinks. X represents control variables such as Trade openness and GDP per capita growth.

ε _it represents the error term for country i at time t and is calculated as follows:

$$\:{ϵ}_{i}{,}_{t}={\mu\:}_{i}+{\gamma\:}_{t}$$

µ _i = country-specific fixed effects constant in time, $\:{\gamma\:}_{t}$= time-specific fixed effects

Additionally, to analyze the data, we used Stata version 15 MP. Moreover, because some countries have missing data, interpolation techniques were used to construct a complete dataset. This technique is more reliable than extrapolation because it provides a valid estimate. We performed log-transformation for easy interpretation in terms of elasticity: when the independent variable increases by 1% over time, the dependent variable (y) changes by 𝛽% or elasticity.

Moreover, the study performed OLS regression analysis with the Stata command reg and panel regression analysis with the xtreg command. This command is generally employed for panel data. The study used the reghdfe command, which estimates regressions with multiple levels of fixed effects.

Table 3 presents the summary statistics for the study variables. The analysis was based on balanced panel data; however, for certain variables, data for certain periods of the year (2000–2023) were missing for all 9 countries. The descriptive analysis revealed that the average incidence of overweight among children under 5 years of age was approximately 5.1% in nine East African countries during the period of 23 years (2000–2022).

Table 3

Average magnitude of the study variables.
Variable	n	Mean	Std. Dev.	Min	Max
Prevalence of overweight	207	0.051	0.022	0.015	0.122
Juices	207	4269802.3	2444619.6	484204.13	7759806.9
Milk drinks	207	7165305.4	3078010.6	2271723.9	13083675
Tea Coffee	207	191383.1	159065.32	14479.625	591932.5
Water mineral drinks	207	4918825.4	2965123.6	834614.33	10090190
Trade openness	198	0.537	0.059	0.413	0.62
GDP per capita growth	207	0.017	0.045	-0.183	0.199

During the study period, the average total value of imports of juices in these countries was 4,269,802.3 USD. This amount was 7,165,305.4 USD for milk drinks, 191,383.1 USD for tea and 4,918,825.4 USD for water, including mineral and aerated drinks.. The average trade openness (import + export ratio to GDP) in the nine selected (9) EACs was 0.537 (53.7%), while the average annual percentage growth rate of GDP per capita based on constant local currency was 0.017 (1.7%).

Table 4

Correlations between child overweight and the selected study variables
Variables	(1)	(2)	(3)	(4)	(5)	(6)	(7)
ln of prevalence of overweight (1)	1.000
Juices (2)	-0.374	1.000
Milk drinks (3)	-0.350	0.882	1.000
Tea and coffee (4)	-0.360	0.802	0.767	1.000
Water mineral drinks (5)	-0.371	0.971	0.812	0.806	1.000
Trade openness (6)	-0.287	0.776	0.888	0.546	0.674	1.000
GDP per capita growth (7)	0.219	0.047	0.073	-0.069	0.013	0.112	1.000

The results in Table 4 indicate that the incidence of overweight among children under five years of age in the nine EACs during the period 2000–2022 and the imports of juice are negatively correlated. The same relationship was also observed for the imports of milk drinks, tea and coffee, and water, including mineral and aerated drinks. In contrast, there was a positive correlation between GDP per capita growth and the incidence of overweight. The results reveal that, except for GDP per capita growth, the other study variables were strongly correlated with each other, all of which were considered together.

Relationships between under five years of overweight and the selected variables

Table 3 shows the results of the fixed effect regression analyses. The results suggest that the import of sugar-sweetened beverages (SSBs) did not contribute to an increase in the prevalence of overweight in children under the age of 5 years in the nine EAC. Column (1) of Table 3 shows the results from the pooled ordinary least squares (OLS) regression, column (2) shows the fixed-effect regression results, and column (3) shows the results of a multiway fixed regression (regditional). Overall, the coefficients are similar, though robust standard errors are different.

Table 3

Regression analyses of the influence of the selected factors on child overweight in EACs
	Full Model			Reduced model
	(1)	(2)	(3)	(1)	(2)	(3)
VARIABLES	Using -reg-	Using -xtreg-	Using -reghdfe-	Using -reg-	Using -xtreg-	Using -reghdfe-
Juices	-0.0693	-0.0693	-0.0693	-0.0424	-0.0424	-0.0424
	(0.0573)	(0.0556)	(0.0556)	(0.0259)	(0.0253)	(0.0253)
Milk drinks	-0.0723	-0.0723	-0.0723	-0.0132	-0.0132	-0.0132
	(0.104)	(0.101)	(0.101)	(0.0206)	(0.0202)	(0.0202)
Tea and Coffee	-0.0500	-0.0500	-0.0500	-0.0961*	-0.0961*	-0.0961*
	(0.0430)	(0.0418)	(0.0418)	(0.0490)	(0.0481)	(0.0481)
Water Mineral drinks	-0.0807	-0.0807	-0.0807	-0.0506	-0.0506	-0.0506
	(0.0488)	(0.0474)	(0.0474)	(0.0302)	(0.0296)	(0.0296)
Trade openness	0.373	0.373	0.373
	(0.322)	(0.313)	(0.313)
GDP per capita growth	0.0187**	0.0187**	0.0187**
	(0.00689)	(0.00669)	(0.00669)
Constant		1.232	1.232		-0.360	-0.360
		(1.684)	(1.684)		(0.715)	(0.715)
Observations	148	148	148	207	207	207
R-squared	0.907	0.644	0.907	0.863	0.538	0.863
Country Fixed Effects	YES	YES	YES	YES	YES	YES
Robust standard errors in parentheses
* p < 0.01, p < 0.05, * p < 0.1

The results based on the full model indicate that the imports of juice, imports of milk drinks, imports of tea and coffee, and imports of water are negatively correlated with the prevalence of overweight in children under five years of age, and these effects are not statistically significant.

Unlike the other variables considered, this study revealed that GDP per capita has a positive effect on overweight children under five years of age. The results indicate that when the GDP per capita increases by 1% over time, the incidence of overweight increases by 1.87%.

The reduced model did not include the variables of trade openness or GDP per capita. The results based on the reduced model showed that the imports of tea and coffee had a statistically negative effect on the prevalence of overweight in individuals under five years old. An increase in the USD in imports of tea and coffee is associated with a decrease in the prevalence of overweight under five years of age by 9.61% over time. When we include the country fixed effect and perform all three models, we observe a decrease in robust standard errors of coefficient estimates.

This study aimed to investigate the effect of the import of sugar-sweetened beverages on the prevalence of overweight among children under five (U5) in nine (9) East African countries. These countries include Burundi, Malawi, Mozambique, Madagascar, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe. We found that the variables of interest, including the imports of juice, milk drinks, tea and coffee, and water (including mineral and aerated drinks), were not significantly different, despite their negative effect on the prevalence of overweight in children under five years old in those countries.

This study revealed that the GDP growth per capita in these countries has a positive effect on the prevalence of overweight among children under five years of age. Several studies have established that there is a positive relationship between GDP per capita and overweight or obesity (Hu et al., 2020). These findings corroborate prior evidence of the relationship between economic development and the nutritional status of children, such as obese or overweight children (Egger et al., 2012; Bu et al., 2021). It has been suggested that the prevalence of overweight depends on the increase in economic growth in developing countries (Seyde et al., 2016). The increase in overweight people around the world is attributed to important economic factors, such as economic development, urbanization and women’s empowerment (Fox et al., 2019), as well as trade (Giuntella et al., 2020).

However, because SSBs are related to overweighting under five children in the context of EAC and because of the negative effects of SSBs, our study aimed to be similar to other studies that have attempted to establish a relationship between trade and health outcomes. Our study also relates to the work of Agüero and Ukil (2022), which assessed the effect of Chinese imports on birth weight gain as an infant health outcome in sub-Saharan African countries. These authors found that a significant increase in birth weight was associated with greater exposure to Chinese imports based on a sample of more than 350,000 births from 22 sub-Saharan African nations. Other studies have indicated that there is a positive relationship between SSB consumption and overweight (Yu, et al., 2022; Freire et al., 2018 and Ferretti & Mariani, 2019).

These studies revealed that these SSBs are typically imported and consumed as part of a meal (Freire et al., 2018). However, Freire et al. (2018) indicated that the affordability of SSBs, which include noncarbonated drinks (such as ready to drink tea, coffee, and juice, as well as sports/energy and Asian drinks) and soft drinks, has a positive influence on the prevalence of overweight among individuals of both sexes (BMI ≥ 25) who are older than 18 years in 150 countries worldwide.

In addition, several studies and reports indicate that increased consumption of SSBs is linked to a greater incidence of overweight (Keller & Bucher Della Torre, 2015; Rousham et al., 2022; Yu et al., 2016). The same evidence was found in East African countries. Using data from demographic and health surveys (DHS), Tiruneh et al. (2021) reported that overweight was affected by overweight in children under five years old living in affluent households in East African countries such as Malawi, Mozambique, Rwanda, Tanzania, and Uganda. However, in our study, we examined the association between SSB imports and consumption among children under 5 years of age in 9 African countries and found that SSB imports have a negative but not statistically significant effect. However, it was found that GDP per capita has a positive effect on the incidence of overweight in children under five years of age.

This study revealed that the imports of juices, milk drinks, tea, coffee, and water, including mineral and aerated drinks, have a negative relationship with the prevalence of overweight in individuals under five years of age. However, the causal mechanisms through which SSB imports negatively affect the prevalence of overweight were not identified.

This study examined the effect of the import of sugar-sweetened beverages (SSBs) on the prevalence of overweight among underfive children in nine selected EACs, namely, Burundi, Malawi, Mozambique, Rwanda, Tanzania, Uganda, Zambia, Madagascar and Zimbabwe. This study bridges the gap in the literature on the potential influence of SSB imports on the prevalence of child overweight within developing regions, especially in eastern African countries. The findings revealed that the underfive overweight population in the study countries cannot be directly explained by the volume of SSB imports, such as juice, milk drinks, tea and coffee as well as mineral water and aerated drinks. The study did not find any evidence that SSB imports in EACs contribute to the prevalence of overweight among children under five years of age. However, GDP growth per capita was accompanied by an increase in the prevalence of child overweight. These findings suggest that the import of SSBs has a significant adverse effect on child health outcomes when access increases considerably. Therefore, trade policies should be enacted considering the effect of economic growth on adverse health outcomes among children under five years of age in EACs.

Ethics approval and consent to participate

Not applicable

Consent for publication

Not applicable

Availability of data and materials

All the data were obtained from the World Development Indicators (WDI) of the World Bank (WB) and UN Comtrade and are freely accessible through the following link: https://osf.io/a896w/

Competing interests

The authors declare that they have no competing interests.

Funding

This research did not receive funding for data collection or manuscript publication. The authors received financial support from the University of Rwanda (UR) World Trade Organization Chairs Programme (WCP) at the University of Rwanda to organize the manuscript writing meetings. No other funding was obtained for this study.

Authors' contributions - provide individual author contribution

FN, LK, OD, and FU contributed to the study's conceptualization, data analysis, and manuscript writing. LK acquired the study data and performed the data management and analysis. All the authors read and approved the final version of the manuscript.

Acknowledgments

The authors would like to thank Emmanuel Ndagijimana, College of Medicine and Health Sciences, University of Rwanda, for proofreading the manuscript.

Authors' information

Prof. François NIRAGIRE

Department of Applied Statistics, College of Business and Economics, University of Rwanda, Kigali, Rwanda

Email: [email protected]

ORCID: https://orcid.org/0000-0003-0473-387X

Mr. Lambert KWIZERA

Department of Economics, College of Business and Economics, University of Rwanda, Kigali, P.O. Box 4285, Kigali, Rwanda

Email: [email protected]

ORCID: https://orcid.org/0000-0002-4044-4568

Mrs. Olive DUSHIMIMANA

Department of Epidemiology, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda

Email: [email protected]

Mr. Florent UWACU

Business Research Centre, Rwanda Private Sector Federation (PSF), Kigali, Rwanda

Email: [email protected]

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Effect of Sugar-Sweetened Beverage Imports on the Prevalence of Overweight among Underfive Children in Nine Eastern Africa Countries

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