In small Ugandan cities food insecurity and diets lacking diversity are twinned with high levels of both obesity and non-communicable diseases.

Take note: Urban environment policymakers; Municipal health planners; Community health workers; Agricultural officers; those involved in urban agriculture; those involved in food and nutrition education; Urban residents.

Smaller cities such as Mbarara (pictured) may contain more space for urban food production, be closer to rural farms or family, and they may also have healthier urban food environments than larger cities. Yet this study suggests that such smaller cities already experience challenges associated with diabetes, hypertension and obesity. Predictions that such smaller cities will experience the greatest population growth and development pressure within Sub-Saharan Africa in the coming decades suggest that smaller cities deserve greater attention.

Own food production is still common practice in many Ugandan cities, particularly for better-off households. Yet food insecurity persists and dietary diversity is relatively low. Typical urban food environments such as this, with a heavy focus on starchy staples such as maize and matooke, were apparent when we studied Mbale and Mbarara. Nevertheless such smaller cities already have an adult population that is affected by the contemporary health challenge of obesity and other non-communicable diseases such as diabetes and hypertension. The often-assumed switch to urban fast foods, highly processed diets, and eating out was not found to be at all common for our surveyed households. Therefore such food environments may not necessarily be driving current health challenges in smaller cities. Insecure food access, irregular eating patterns, low dietary diversity, and a food/farming culture focused on carbohydrates may be other drivers of non-communicable disease. Detailed understanding of urban food and health environments is necessary so that proactive steps can be taken to reduce labour productivity losses, healthcare expenses and community suffering. In light of this, securing access to a balanced array of food groups and facilitating physical activity should be priorities in the support of healthier urban lives.

We already know: A number of studies in cities of the global South show a rise in obesity and other non-communicable diseases, concurrent with ongoing undernutrition, stunting and wasting (known as the double burden of malnutrition). Most studies have focused on the largest cities. Linkage between adult non-communicable diseases-burden with earlier childhood undernutrition has been suggested by medical studies. Agriculture is generally assumed by planners and policymakers to be less relevant as cities grow. However research has shown this to be less so, particularly in the African context.

What this study adds: This study presents evidence that double burden malnutrition is already apparent in smaller cities. Findings also suggest that the changes in food and nutritional environments commonly assumed to cause these health changes, are not yet very evident in Mbale and Mbarara. Nevertheless non-communicable diseases such as diabetes and hypertension, and concerning levels of obesity were found. The implication is that there are other important drivers of such diseases in these urban contexts. Our study also deepens the understanding of agriculture in relation to urban residents, describing not only an urban agriculture, but the interaction of urban-based households with rural lands and peoples.

Implications for city policy and practice: This study highlights the need for a more locally based understanding of the role of agriculture for urban residents. Local food perceptions and eating patterns as well as of attitudes to, and barriers towards, healthy and desirable urban lifestyles are important. There are strong implications for urban planning. Gardens and other spaces for agriculture are important. City infrastructure that is known to encourage walking or other physical activity such as safe pavements and recreational spaces are desirable. An immediate implication for public health practice is the importance of raising awareness among community health workers of the growing non-communicable disease dimension to malnutrition, and of the importance in continuing to promote dietary balance. The biggest barrier to such balance is low household incomes, and insecure employment. Policies and strategies supporting food security would be beneficial, but improving attitudes towards the consumption of fruit and vegetables could be an affordable first step. School-feeding programmes could also provide a beneficial long-term preventive strategy, together with improving employment opportunities.

Full article: Doing things their way? Food, farming and health in small Ugandan cities

Authors: Heather Mackay, Frank Mugagga, Lydia Kakooza, Linley Chiwona-Karltun
Editor: Marcus Grant