Dietary habits are transitioning in urban Africa and nutrition-related non-communicable diseases (NR-NCDs) are becoming an important public health problem, particularly amongst women. Energy-dense nutrient-poor (EDNP) food and beverage consumption is associated with increased energy consumption and lower micronutrient intake. The overconsumption of EDNP products is therefore implicated in the onset of NR-NCDs and contributes to micronutrient deficiencies. This DFC Dietary transitions in Ghana project 1) investigates the factors in the social and physical food environments that drive consumption of EDNP food and beverages in women and adolescent girls, and 2) harnesses this understanding to develop context-relevant interventions to improve diets.
Setting: Two Ghanaian cities of different demographic transition stages: Ho: population>270,000; Accra: population>1.8 million.
Study populations: n=192 women/adolescent girls throughout the reproductive life course (13-49 years). Community informants (n=24) and national stakeholders will also be interviewed 2017-2019.
Tools: Socio-ecological approach using innovative qualitative and quantitative methods. So far, we have:
The next phase integrates these findings on drivers into developing priorities for context-specific interventions by using innovative methods to consult with local community informants (Community Readiness Model); and national stakeholders (the Food-EPI tool across the seven domains of food environments in the INFORMAS framework for benchmarking policy in relation to healthy food environments).
Findings and Interpretations
Preliminary findings indicate that drivers of food choice act across all socio-ecological levels. Food safety, encompassing microbiological safety, food handling, toxicity from pollutants, and the sanitary environment around food outlets emerged as key drivers of food choice. The cost of food and financial access were also identified by participants, especially in Ho. GIS mapping has indicated that a diverse range of both healthy and unhealthy foods and beverages are available in both cities. Sugar sweetened beverages are widely advertised in Accra and Ho (over half in Accra and one-third in Ho of food advertisements). All drivers have been incorporated into the development of an evidence-informed conceptual framework to illustrate the social and physical environmental drivers of EDNP food and beverage consumption that have emerged, which will be further developed and validated. The framework will identify the key drivers that could be targeted so that culturally appropriate interventions can be developed. The adaptation of a nutrient profiling tool is underway to classify the 144 foods consumed as EDNP (or not) using nine nutrients to encourage and three to avoid. Forty potentially relevant policies to prevent NR-NCDs were identified in Ghana across the seven domains of food environments in the INFORMAS framework.
The use of these novel qualitative and quantitative methods in this context has allowed us to shed light on how food environments are shaping food choices. The triangulation of findings and building of an evidence-informed framework will allow us to identify drivers that are important and specific to African cities. Using methods that give communities a voice (PhotoVoice and the Community Readiness Model) allow unique context relevant insights. The Food-Epi assessment of the food policy environment has indicated that there is already a lot of relevant policy activity in Ghana. An important challenge is to ensure that such policy does no harm on other forms of malnutrition, therefore the double-duty nature of such actions will be assessed during the prioritization process.