Prevalence and factors associated with excessive dietary sugar intake among adults in Kenya: Findings from STEPS Survey, 2015
Valerian Mwenda, 1, 2* Jane Githuku1, Gladwell Gathecha2, Zeinab Gura1

1.	Field Epidemiology and Laboratory Training Programme, Ministry of Health, Kenya
2.	Non-communicable disease division, Ministry of Health, Kenya
* Corresponding author, valmwenda@gmail.com
Background: The burden of non-communicable diseases (NCD) is increasing worldwide, with type 2 diabetes being a major contributor. High dietary sugar intake has been associated with rising type 2 diabetes prevalence and complications, both directly through insulin resistance and indirectly by contributing to the obesity epidemic.  Risk factor surveillance through population-based, regular and continuous surveys has been identified as an effective strategy to inform public health interventions in NCD control. The stepwise approach to surveillance (STEPS) survey is used globally to monitor physical, behavioural and biochemical NCD risk factors, with the behavioural component including dietary intake of sugar.  Kenya carried out the STEPs survey among adults aged 18 to 69 years in 2015.
Aims: To determine the prevalence, associated factors as well as knowledge, attitudes and practices on high dietary sugar intake from the findings of the Kenya STEPs survey, 2015.
Methods: The STEPS survey was a multi-cluster, household-based survey targeting individuals aged 18-69 years. We carried out secondary analysis on the dataset using STATA version 14. Excessive sugar intake was defined as addition of sugar to beverages already with sugar just before intake, intake of sugary soft drinks and intake of processed foods high in sugar, in most meals. We calculated means and standard deviation for continuous variables, proportions for categorical variables, prevalence and adjusted prevalence odds ratios (POR), with their 95% confidence intervals (CI), adjusted for survey design.
Results: A total of 4484 individuals were surveyed. Mean age was 40.5 years±0.6 years, females were 60% of the sample.  Excessive intake of sugar was reported by 13.7 % (11.7-15.8) of the respondents, with 27.7% (22.7-32.8) always adding sugar to beverages just before intake and 1.6% (0.8-2.4) reporting intake of processed foods high in sugar daily. Possession of knowledge on the health hazards of high dietary sugar was reported by 83.7 %( 80.5-86.9) of the respondents while 54.4% (52.8-55.9) regarded lowering of dietary sugar as very important. On sugar intake reduction, 53.6% (49.5-57.7) reported minimizing sugar use in beverages, 11.9% (9.6-14.1) were using sugar alternatives, 53.6% (49.5-57.7) were limiting consumption of soda and sugary drinks while 45.5% (40.0-50.9) were limiting consumption of processed foods.  Being an urban dweller (POR 1.4, 95% CI 1.1, 1.78) and having attained secondary education and above (POR 2.15, 95% CI 1.59, 2.9) were associated with high dietary sugar intake. 
Discussion: The prevalence of high dietary sugar intake in Kenya from the survey is high; its association with diabetes, obesity and cardiovascular disease could negatively impact NCD and diabetes control programmes in the country. Being an urban resident and highly educated were significantly associated with high dietary sugar intake; special focus of public health action should be targeted to these specific demographic groups, which could also be on the upward trend as a result of rapid urbanization, improving levels of education and livelihoods as well as rural to urban migration.. A majority of the respondents were taking steps to reduce dietary sugar intake; public health authorities should support these efforts through enhancing public awareness and policies that support healthy dietary practices. Further studies are required to evaluate the effect of high dietary sugar on diabetes type 2 prevalence as well as attainment of treatment targets in Kenya.
Key words: NCD, STEPS, survey, dietary sugar, diabetes
References
NCD Risk Factor Collaboration. Worldwide trends in diabetes since 1980: a pooled analysis of 751 population-based studies with 4· 4 million participants. The Lancet. 2016 Apr 15; 387(10027):1513-30.
World Health Organization. WHO STEPS surveillance manual: the WHO STEPwise approach to chronic disease risk factor surveillance.

Prevalence and factors associated with high dietary sugar among adults in Kenya: findings from STEPwise survey, 2015