The Local Food Environment and Body Mass Index among the Urban Poor in Accra, Ghana

10-year level, trends and socio-demographic disparities of obesity among Ghanaian adults-A systematic review and meta-analysis of observational studies

The double burden of malnutrition has assumed severer forms in Low and Middle Income Countries (LMICs) arising from sharper increases in prevalence rates of overweight and obesity in these countries compared to higher income countries. Considering that LMICs already have fragile health systems, the rising obesity levels may just be a ticking time bomb requiring expeditious implementation of priority actions by all global and national actors to prevent an explosion of cardiovascular disease related deaths. The aim of this systematic review and meta-analysis was to provide a current estimate of obesity and overweight prevalence among Ghanaian adults and assess socio-demographic disparities following the PRISMA guidelines. We searched Pubmed with Medline, Embase, Science direct and African Journals Online (AJOL) for studies on overweight and obesity published between 2013 and January 2023. Applying a quality effects model, pooled mean Body Mass Index (BMI) and prevalence of overweight and obesity were obtained from 42 studies conducted across all three geographical locations of Ghana with a combined sample size of 29137. From the analysis, the mean BMI of adults in Ghana was 24.7 kgm-2 while overweight and obesity prevalence was estimated as 23.1% and 13.3% respectively. Temporal analysis showed sharper increases in overweight and obesity prevalence from 2017/2018. Mean BMI (Females: 25.3kgm-2 vrs Males: 23.1 kgm-2), overweight (Females: 25.9% vrs Males: 16.5%) and obesity (Females: 17.4% vrs Males: 5.5%) prevalence were higher among females than males. Gender differences in mean BMI and obesity prevalence were both significant at p<0.001. Urban dwellers had higher mean BMI than their rural counterparts (24.9kgm-2 vrs 24.4kgm-2). Overweight (27.6% vrs 18.2%) and obesity (17.3% vrs 11.0%) prevalence were also higher in urban areas than in rural areas. Body weight indicators for the various geographical areas of Ghana were; southern sector: 25.4kgm-2, 28.9% and 15.4%, middle sector: 24.8kgm-2, 26.4% and 16.2% and northern sector: 24.2kgm-2, 15.4% and 8.5% for mean BMI, overweight and obesity prevalence respectively. The southern part of Ghana was similar to the middle part in terms of mean BMI, overweight and obesity but higher than the northern part. We conclude that overweight and obesity prevalence in Ghana has risen to high levels in recent years with women and urban dwellers disproportionately more affected. There is a possible implication for increased cardiovascular diseases and a generally poor quality of life for the people. Evidence-based public health interventions are needed to reverse the current situation.

The role of social support and the built environment on diabetes management among structurally exposed populations in three regions in Ghana

Sub-Saharan Africa is undergoing an epidemiological transition driven by rapid, unprecedented demographic, socio-cultural, and economic transitions. These transitions are driving increases in the risk and prevalence of diabetes and other non-communicable diseases (NCDs). As NCDs rise, several attempts have been made to understand the individual level factors that increase NCDs risks, knowledge, and attitudes around specific NCDs as well as how people live and manage NCDs. While these studies are important, and enhance knowledge on chronic diseases, little attention has been given to the role of social and cultural environment in managing chronic NCDs in underserved settings. Using purposive sampling among persons living with Diabetes Mellitus (PLWD) and participating in diabetes programs from regional and municipal hospitals in the three underserved regions in Ghana (n = 522), we assessed diabetes management and supportive care needs of PLWDs using linear latent and mixed models (gllamm) with binomial and a logit(log) link function. The result indicates that PLWDs with strong perceived social support (OR = 2.27, p ≤ 0.05) were more likely to report good diabetes management compared to PLWDs with weak perceived social support. The built environment, living with other health conditions, household wealth, ethnicity and age were associated with diabetes management. Overall, the study contributes to wider discussions on the role changing built and socio-cultural environments in the rise of diet-related diseases and their management as many Low- and Middle-Income Countries (LMICs) experience rapid epidemiological and nutrition transitions.

Dietary patterns among adults in three low-income urban communities in Accra, Ghana

OBJECTIVE

Dietary patterns describe the dietary behaviour and habits of individuals. Unhealthy dietary patterns provide individuals with limited nutrients while increasing the risk of nutrition-related diseases. Unhealthy dietary patterns are high in urban areas, especially among low-income urban residents. This study examined dietary patterns in three low-income urban communities in Accra, Ghana, between 2011 and 2013.

METHODS

This study used Wave 2 and 3 data from the Urban Health and Poverty Survey (EDULINK 2011 and 2013). The sample size was 960 in 2011 and 782 in 2013. Dietary pattern was examined using factor analysis and the NOVA food classification system. Summary statistics were computed for sociodemographic characteristics and diet frequency and pattern. Differences in dietary behaviours between 2011 and 2013 were also estimated. Three logistic regression models were computed to determine the predictors of dietary patterns.

RESULTS

The frequency of consumption of animal-source foods (ASF) and fruits was higher in 2013 compared with 2011. The intake of processed culinary ingredients (NOVA Group 2), processed foods (NOVA Group 3) and ultra-processed foods (NOVA Group 4) was higher in 2013 versus 2011. In 2013, 29% consumed ultra-processed foods compared to 21% in 2011. Three dietary patterns (rice-based, snack-based, and staple and stew/soup) were identified. About two out of every five participants consumed the food items in the rice (43%) and staple and sauce patterns (40%). The proportion of participants who consumed the food items in the snack pattern was 35% in 2011 but 41% in 2013. Respondents aged 25-34 and those with higher education often consumed the snack-based and rice-based dietary patterns. In 2013, participants in Ussher Town had a higher probability of consuming food items in the snack pattern than those living in Agbogbloshie.

CONCLUSIONS

This study found that between 2011 and 2013, more participants consumed ASFs, fruits, and processed foods. A complex interplay of personal and socio-cultural factors influenced dietary intake. The findings of this study mirror global changes in diet and food systems, with important implications for the primary and secondary prevention of NCDs. Health promotion programs at the community level are needed to address the increasing levels of processed food consumption.

Early childhood eating behaviors associated with risk of overweight and its socio-ecological determinants in Korean preschool children

BACKGROUND/OBJECTIVES

This study aimed to identify preschool children's eating behaviors associated with early childhood obesity and its multi-level, socio-ecological determinants.

SUBJECTS/METHODS

In a cross-sectional study of 364 mothers of preschool children aged 3-5 years, these children's healthy eating behaviors were assessed using a validated preschool nutrition quotient (NQ-P) questionnaire. The children's overweight or obesity statuses were determined based on body mass index percentiles from the 2017 Korean National Growth Chart. The associations between the NQ-P score and risk of overweight or obesity were examined using multivariable logistic regression. The associations of individual, maternal, physical, and media environmental factors with the NQ-P score were also examined using multivariable linear regression.

RESULTS

Preschool children with greater NQ-P scores were at a significantly lower risk of overweight or obesity (P < 0.01). The NQ-P score had a significantly positive association with maternal body mass index and an inverse association with household income (all P < 0.05). Maternal parenting and feeding practices exhibited associations with the NQ-P score. Positive associations were observed with "warm," "structured," and "autonomy-supportive" parenting as well as monitoring feeding practices (all P < 0.05). In addition, the NQ-P score had a significantly positive association with the childcare center's anti-obesogenic environment, such as the provision of nutritional and physical-activity support and vicinity of the built food environment to the home, including access to good-quality food, fruits and vegetables, and low-fat foods (all P < 0.05). Regarding media environments, the NQ-P score demonstrated more significant associations with viewing and eating and/or cooking content displayed on online video platforms (all P < 0.05) than with that on television.

CONCLUSIONS

Our findings confirm the significance of healthy eating behaviors in early-childhood-obesity prevention and underscore the importance of multilevel maternal, physical, and media environmental interventions that effectively guide eating behaviors in preschool children.

Food availability and food habits among Ghanaians: Tracking the dietary transition in Ghana

Background: Although extreme hunger has reduced significantly, people are eating nutrient-poor cheap foods that are unhealthy and environmentally unsustainable. Even though dietary practices are changing in Ghana, there is minimal national-level analysis of the changes and their implication for population health. Aim: This study describes shifts in food availability and consumption in Ghana from 1983-2013. Methods: Data from the Food and Agriculture Organisation (FAO) food balance sheets and a scoping review were used. Descriptive analysis was conducted in excel for the FAO data, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews recommendation was followed for the scoping review. Results: The availability of total calories increased from 1527 kcal in 1983 to 3016 kcal in 2013, representing 608 kcal above the daily recommended allowance for women. Sugar and sweeteners was the food group with the highest increase of 1075%. Vegetables contributed the least to food availability, with less than 40 kcal a day. Rice contributed the most to food availability among cereals (56 kcal in 1983 to 304 kcal in 2013), replacing maise as the primary cereal. Conclusion: After the 1983 famine, there were significant increases in food availability in Ghana. The provision of rice, sugars and tubers meant to end hunger, changed dietary patterns and has resulted in low dietary diversity, high energy intake and overweight/obesity. Therefore, there is a need to intervene and increase the availability of other food groups.

Food Vendors and the Obesogenic Food Environment of an Informal Settlement in Nairobi, Kenya: a Descriptive and Spatial Analysis

Food environments of urban informal settlements are likely drivers of dietary intake among residents of such settlements. Yet, few attempts have been made to describe them. The objective of this study was to characterize the food environment of a densely-populated informal settlement in Nairobi, Kenya according to the obesogenic properties and spatial distribution of its food vendors. In July-August 2019, we identified food vendors in the settlement and classified them into obesogenic risk categories based on the types of food that they sold. We calculated descriptive statistics and assessed clustering according to obesogenic risk using Ripley's K function. Foods most commonly sold among the 456 vendors in the analytic sample were sweets/confectionary (29% of vendors), raw vegetables (28%), fried starches (23%), and fruits (21%). Forty-four percent of vendors were classified as low-risk, protective; 34% as high-risk, non-protective; 16% as low-risk, non-protective; and 6% as high-risk, protective. The mean distance (95% confidence interval) to the nearest vendor of the same obesogenic risk category was 26 m (21, 31) for vendors in the low-risk, protective group; 29 m (25, 33) in the high-risk, non-protective group; 114 m (88, 139) in the high-risk, protective group; and 43 m (30, 56) in the low-risk, non-protective group. Clustering was significant for all obesogenic risk groups except for the high-risk, protective. Our findings indicate a duality of obesogenic and anti-obesogenic foods in this environment. Clustering of obesogenic foods highlights the need for local officials to take action to increase access to health-promoting foods throughout informal settlements.

Availability of healthy and unhealthy foods in modern retail outlets located in selected districts of Greater Accra Region, Ghana

Background

Intake of unhealthy foods is linked to the onset of obesity and diet-related non-communicable diseases (NCDs). Availability of unhealthy (nutritionally poor) foods can influence preference, purchasing and consumption of such foods. This study determined the healthiness of foods sold at modern retail outlets- supermarkets and mini-marts in the Greater Accra Region of Ghana.

Methods

All modern retail outlets located in six districts of Greater Accra were eligible. Those < 200 m² of floor area and with permanent structures were categorized as mini-marts; and those ≥200 m² as supermarkets. Shelf length of all available foods were measured. Healthiness of food was determined using two criteria - the NOVA classification and energy density of foods. Thus, ultra-processed foods or food items with >225 kcal/100 g were classified as unhealthy. The ratio of the area occupied by unhealthy to healthy foods was used to determine the healthiness of modern retail outlets.

Results

Of 67 retail outlets assessed, 86.6% were mini-marts. 85.0% of the total SHELF area was occupied by foods categorized as unhealthy (ranging from 9,262 m² in Ashiaman Municipality to 41,892 m² in Accra Metropolis). Refined grains/grain products were the most available, occupying 30.0% of the total food shelf space, followed by sugar-sweetened beverages (20.1% of total shelf space). The least available food group-unprocessed staples, was found in only one high income district, and occupied 0.1% of the total food shelf space. Retail outlets in two districts did not sell fresh fruits or fresh/unsalted canned vegetables. About two-thirds of food products available (n = 3,952) were ultra-processed. Overall, the ratio of ultra-processed-to-unprocessed foods ranged from 3 to 7 with an average (SD) of 5(2). Thus, for every healthy food, there were five ultra-processed ones in the studied retail outlets.

Conclusion

This study reveals widespread availability of ultra-processed foods in modern retail outlets within the selected districts. Toward a healthier food retail environment, public health and food regulators, in partnership with other stakeholders need to institute measures that improve availability of healthy foods within supermarkets and mini-marts.

Exploring the Motivations of Family Caregivers Caring for Older Persons in Urban Poor Accra, Ghana

There is a general paucity of studies on family caregivers' motivations for providing care to older persons in the urban poor context in Ghana. This study seeks to explore family caregivers' motivations for providing care to older persons in urban poor Accra, Ghana. A qualitative descriptive design was used and in-depth interviews were conducted with thirty-one family caregivers. The QSR NVivo 10 software was used to analyze the data thematically. We found that autonomous motivation inspired family caregivers to provide care. Empathy and affection intrinsically motivated some caregivers to provide care to their care recipients, while others were extrinsically motivated by filial responsibility, reciprocity, and obligation to provide care. These findings showed that family caregivers were autonomously motivated to provide care to older persons. We recommend the need for future studies to explore changes in family caregivers' motivations to provide care over time.

Mapping food and physical activity environments in low- and middle-income countries: A systematised review

This systematised literature review synthesised evidence on approaches to mapping food and physical activity (PA) environments in low- and middle-income countries (LMICs). Of the 60 articles included, 25 and 35 mapped food and PA environments respectively. All studies were cross-sectional with researcher-led data collection. Three types of mapping tools were identified - maps (n = 18), GPS (n = 10), and GIS (n = 37). Our findings point to a paucity of research mapping food and PA environments, overall and particularly subjective domains. We highlight a need for future studies that utilise innovative, inexpensive and participatory research methods to understand dynamic exposures to obesogenic environment features in resource-constrained contexts undergoing rapid urbanisation.

Changing Dietary Habits: The Impact of Urbanization and Rising Socio-Economic Status in Families from Burkina Faso in Sub-Saharan Africa

(1) Background: Sub-Saharan Africa is experiencing the fastest urbanization worldwide. People in rural areas still have a traditional and rural lifestyle, whereas the Westernization of diet and lifestyle is already evident in urban areas. This study describes dietary habits of families in Burkina Faso living at different levels of urbanization. (2) Methods: Data on lifestyle, socio-economic conditions, health status and anthropometry were collected from 30 families living in rural villages, a small town and the capital city. A food frequency questionnaire and a 24 h recall diary were used to estimate dietary habits and macronutrients intake. (3) Results: The urban cohort showed a more diversified diet, with a higher intake of animal protein and, especially in children, a higher consumption of simple sugars. Fiber intake was significantly higher in the rural and semi-urbanized cohorts. As expected, overweight and obesity gradually increased with the level of urbanization. In semi-urbanized and urban families, we observed coexistence of under- and over-nutrition, whereas in rural families, a portion of children were wasted and stunted, and adults were underweight. (4) Conclusions: These three cohorts represent a model of the effect on diet of rural-to-urban migration. Rural diet and traditional habits are replaced by a Western-oriented diet when families move to urbanized areas. This dietary transition and increased socio-economic status in newly developing urban areas have a major impact on disease epidemiology, resembling the past evolution in Western countries.

Lay knowledge of cardiovascular disease and risk factors in three communities in Accra, Ghana: a cross-sectional survey

OBJECTIVES

Cardiovascular disease is a major cause of morbidity and mortality in Ghana, and urban poor communities are disproportionately affected. Research has shown that knowledge of cardiovascular disease (CVD) is the first step to risk reduction. This study examines knowledge of CVD and risk factors and determinants of CVD knowledge in three urban poor communities in Accra, Ghana.

METHODS

Using the Cardiovascular Disease Risk Factors Knowledge Level Scale, which has been validated in Ghana, we conducted a cross-sectional survey with 775 respondents aged 15-59 years. CVD knowledge was computed as a continuous variable based on correct answers to 27 questions, and each correct response was assigned one point. Linear regression was used to determine the factors associated with CVD knowledge.

RESULTS

The mean age of the participants was 30.3±10.8 years and the mean knowledge score was 19.3±4.8. About one-fifth of participants were living with chronic diseases. Overall, 71.1% had good CVD knowledge, and 28.9% had moderate or poor CVD knowledge. CVD knowledge was low in the symptoms and risk factor domains. A larger proportion received CVD knowledge from radio and television. The determinants of CVD knowledge included ethnicity, alcohol consumption, self-reported health and sources of CVD knowledge. CVD knowledge was highest among a minority Akan ethnic group, those who were current alcohol consumers and those who rated their health as very good/excellent, compared with their respective counterparts. CVD knowledge was significantly lower among those who received information from health workers and multiple sources.

CONCLUSION

This study underscores the need for health education programmes to promote practical knowledge on CVD symptoms, risks and treatment. We outline health systems and community-level barriers to good CVD knowledge and discuss the implications for developing context-specific and culturally congruent CVD primary prevention interventions.

A Direct Assessment of the External Domain of Food Environments in the National Capital Region of India

Data on food environments in India and other low- and middle-income countries are scarce. The objective of this study was to assess the four dimensions of the external domain of food environments (availability, price, vendor and product properties, and marketing) in food establishments in the National Capital Region of India. The assessment focused on fruits, vegetables, and ultra-processed foods. The 60 food establishments surveyed were categorized as stores, restaurants, or mobile food vendors. Only 13.3% of food establishments sold fruits and vegetables. Stores were more likely to sell vegetables than mobile food vendors (14.8 vs. 6.2%, respectively) and sold a greater variety of both fruits and vegetables as compared to mobile food vendors [mean (SD) of 8.6 (3.2) fruits and 18.6 (9.2) vegetables available at stores vs. 5.5 (5.7) fruits and 25 vegetables available at the one mobile food vendor who sold vegetables]. However, these healthy food items were more expensive at stores. The availability (100% of stores, 12.5% of mobile food vendors, and 12.5% of restaurants) and variety (156 types) of ultra-processed foods across food establishments were higher than fruits and vegetables. A greater percentage of food establishments displayed advertisements for ultra-processed foods as compared to unprocessed or minimally processed foods such as fruits and vegetables. The National Capital Region of India has an unhealthy food environment. Regulations that limit the availability of ultra-processed foods and improve the availability and affordability of fruits and vegetables are needed to reverse the rising tide of chronic non-communicable diseases in this setting.

Small area variations and factors associated with blood pressure and body-mass index in adult women in Accra, Ghana: Bayesian spatial analysis of a representative population survey and census data

BACKGROUND

Body-mass index (BMI) and blood pressure (BP) levels are rising in sub-Saharan African cities, particularly among women. However, there is very limited information on how much they vary within cities, which could inform targeted and equitable health policies. Our study aimed to analyse spatial variations in BMI and BP for adult women at the small area level in the city of Accra, Ghana.

METHODS AND FINDINGS

We combined a representative survey of adult women's health in Accra, Ghana (2008 to 2009) with a 10% random sample of the national census (2010). We applied a hierarchical model with a spatial term to estimate the associations of BMI and systolic blood pressure (SBP) and diastolic blood pressure (DBP) with demographic, socioeconomic, behavioural, and environmental factors. We then used the model to estimate BMI and BP for all women in the census in Accra and calculated mean BMI, SBP, and DBP for each enumeration area (EA). BMI and/or BP were positively associated with age, ethnicity (Ga), being currently married, and religion (Muslim) as their 95% credible intervals (95% CrIs) did not include zero, while BP was also negatively associated with literacy and physical activity. BMI and BP had opposite associations with socioeconomic status (SES) and alcohol consumption. In 2010, 26% of women aged 18 and older had obesity (BMI ≥ 30 kg/m2), and 21% had uncontrolled hypertension (SBP ≥ 140 and/or DBP ≥ 90 mm Hg). The differences in mean BMI and BP between EAs at the 10th and 90th percentiles were 2.7 kg/m2 (BMI) and in BP 7.9 mm Hg (SBP) and 4.8 mm Hg (DBP). BMI was generally higher in the more affluent eastern parts of Accra, and BP was higher in the western part of the city. A limitation of our study was that the 2010 census dataset used for predicting small area variations is potentially outdated; the results should be updated when the next census data are available, to the contemporary population, and changes over time should be evaluated.

CONCLUSIONS

We observed that variation of BMI and BP across neighbourhoods within Accra was almost as large as variation across countries among women globally. Localised measures are needed to address this unequal public health challenge in Accra.

Metabolic syndrome among individuals living with hypertension in Accra, Ghana

Metabolic syndrome (MetS) is a major risk factor to cardiovascular diseases. In this study, we investigate the prevalence and associated risky behaviour of MetS in resource-poor urban communities in Accra, Ghana. We analysed data on 111 persons with hypertension, screened and recruited for a therapeutic lifestyle intervention program in August 2015. MetS was measured using the International Diabetes Federation (IDF) and the World Health Organization definitions. The prevalence of MetS was 58.4% and 16.8% by the IDF and WHO definitions respectively. More women (61.8%) compared to men (31.8%) had MetS (p = 0.011). Approximately 31% of the hypertensive patients were engaged in moderate-intensity physical activity; 9.0% were current smokers, 42.0% consumed excess alcohol over the past month prior to the interview and 41.0% discontinued taking their antihypertensive medications without consulting with a doctor. About 42.0% and 37.0% of respondents always consumed fruits and vegetables respectively at least two times a day. The binary logistic regression showed that compared to women, men had lower odds of consuming two or more servings of vegetable in a day (OR: 0.2; 95% CI; 0.1, 0.8). Increase in age was associated with higher odds of consuming fruits at least twice a day (1.0; 1.0, 1.1) but with lower odds of engaging in moderate intensity physical activity (0.9; 0.8, 1.0). Being married was associated with higher odds of engaging in moderate physical activity (2.8; 1.0, 8.2). Therapeutic methods essential for the management of patients with hypertension and MetS should include non-pharmacological remedies targeting the promotion of medication adherence, Dietary Approaches to Stop Hypertension (DASH) and physical activities; these are vital to changing unhealthy lifestyle which worsens the underlying pathology.

Reverse thinking: taking a healthy diet perspective towards food systems transformations

Food systems that deliver healthy diets without exceeding the planet’s resources are essential to achieve the worlds’ ambitious development goals. Healthy diets need to be safe, accessible, and affordable for all, including for disadvantaged and nutritionally vulnerable groups such as of smallholder producers, traders, and consumers in low- and middle-income countries. Globally, food systems are experiencing rapid and drastic changes and are failing to fulfil these multiple duties simultaneously. The international community therefore calls for rigorous food systems transformations and policy solutions to support the achievement of healthy diets for all. Most strategies, however, are essentially supply- and market-oriented. Incorporation of a healthy diet perspective in food system transformation is essential to enable food systems to deliver not only on supplying nutritious foods but also on ensuring that consumers have access can afford and desire healthy, sustainable, and culturally acceptable diets. This paper argues that this should be guided by information on diets, dietary trends, consumer motives, and food environment characteristics. Transformational approaches and policies should also take into account the stage of food system development requiring different strategies to ensure healthier diets for consumers. We review current knowledge on drivers of consumer choices at the individual and food environment level with special emphasis on low- and middle income countries, discuss the converging and conflicting objectives that exist among multiple food-system actors, and argue that failure to strengthen synergies and resolve trade-offs may lead to missed opportunities and benefits, or negative unintended consequences in food system outcomes. The paper proposes a menu of promising consumer- and food-environment- oriented policy options to include in the food systems transformation agenda in order to shift LMIC consumer demand towards healthier diets in low- and middle income countries.

Food Security in Ghanaian Urban Cities: A Scoping Review of the Literature

Urbanisation in Ghana could be negatively impacting the state of food security, especially in economically vulnerable groups. Food supply, safety, and quality are all aspects of food security which could be impacted. We conducted a scoping literature review to understand the nature and magnitude of evidence available on the urban food security situation in Ghana. A literature search was conducted in Medline, CINAHL, Embase, Global Health, Scopus, Web of Science, Africa Wide Information and Google Scholar to identify relevant peer-reviewed and grey literature. 45 studies, mainly cross-sectional surveys/food samples analysis, met the inclusion criteria. The majority of studies were concentrated in the Greater Accra Region (n = 24). Most studies focused on food safety and quality (n = 31). Studies on supply and stability were, however, scarce. Qualitative research methods were uncommon in the included studies. The existing literature on food security are concentrated in two regions: The Greater Accra and Ashanti regions. Future studies exploring food security in urban Ghana should focus on exploring the lived experiences and perceptions of food insecurity and food stability by urban-dwellers using qualitative methods. The evidence suggesting that the safety/quality of foods sold in Ghanaian markets is poor should be a concern to consumers and policy makers.

The influence of the urban food environment on diet, nutrition and health outcomes in low-income and middle-income countries: a systematic review

INTRODUCTION

Diet and nutrition are leading causes of global morbidity and mortality. Our study aimed to identify and synthesise evidence on the association between food environment characteristics and diet, nutrition and health outcomes in low-income and middle-income countries (LMICs), relevant to urban settings, to support development and implementation of appropriate interventions.

METHODS

We conducted a comprehensive search of 9 databases from 1 January 2000 to 16 September 2020 with no language restrictions. We included original peer-reviewed observational studies, intervention studies or natural experiments conducted in at least one urban LMIC setting and reporting a quantitative association between a characteristic of the food environment and a diet, nutrition or health outcome. Study selection was done independently in duplicate. Data extraction and quality appraisal using the National Heart Lung and Blood Institute checklists were completed based on published reports using a prepiloted form on Covidence. Data were synthesised narratively.

RESULTS

74 studies met eligibility criteria. Consistent evidence reported an association between availability characteristics in the neighbourhood food environment and dietary behaviour (14 studies, 10 rated as good quality), while the balance of evidence suggested an association with health or nutrition outcomes (17 of 24 relevant studies). We also found a balance of evidence that accessibility to food in the neighbourhood environment was associated with diet (10 of 11 studies) although evidence of an association with health outcomes was contradictory. Evidence on other neighbourhood food environment characteristics was sparse and mixed. Availability in the school food environment was also found to be associated with relevant outcomes. Studies investigating our other primary outcomes in observational studies of the school food environment were sparse, but most interventional studies were situated in schools. We found very little evidence on how workplace and home food environments are associated with relevant outcomes. This is a substantial evidence gap.

CONCLUSION

'Zoning' or 'healthy food cart' interventions to alter food availability may be appropriate in urban LMIC.

PROSPERO REGISTRATION NUMBER

CRD42020207475.

Institutional mortality rate and cause of death at health facilities in Ghana between 2014 and 2018

BACKGROUND

The epidemiological transition, touted as occurring in Ghana, requires research that tracks the changing patterns of diseases in order to capture the trend and improve healthcare delivery. This study examines national trends in mortality rate and cause of death at health facilities in Ghana between 2014 and 2018.

METHODS

Institutional mortality data and cause of death from 2014-2018 were sourced from the Ghana Health Service's District Health Information Management System. The latter collates healthcare service data routinely from government and non-governmental health institutions in Ghana yearly. The institutional mortality rate was estimated using guidelines from the Ghana Health Service. Percent change in mortality was examined for 2014 and 2018. In addition, cause of death data were available for 2017 and 2018. The World Health Organisation's 11th International Classification for Diseases (ICD-11) was used to group the cause of death.

RESULTS

Institutional mortality decreased by 7% nationally over the study period. However, four out of ten regions (Greater Accra, Volta, Upper East, and Upper West) recorded increases in institutional mortality. The Upper East (17%) and Volta regions (13%) recorded the highest increase. Chronic non-communicable diseases (NCDs) were the leading cause of death in 2017 (25%) and 2018 (20%). This was followed by certain infectious and parasitic diseases (15% for both years) and respiratory infections (10% in 2017 and 13% in 2018). Among the NCDs, hypertension was the leading cause of death with 2,243 and 2,472 cases in 2017 and 2018. Other (non-ischemic) heart diseases and diabetes were the second and third leading NCDs. Septicaemia, tuberculosis and pneumonia were the predominant infectious diseases. Regional variations existed in the cause of death. NCDs showed more urban-region bias while infectious diseases presented more rural-region bias.

CONCLUSIONS

This study examined national trends in mortality rate and cause of death at health facilities in Ghana. Ghana recorded a decrease in institutional mortality throughout the study. NCDs and infections were the leading causes of death, giving a double-burden of diseases. There is a need to enhance efforts towards healthcare and health promotion programmes for NCDs and infectious diseases at facility and community levels as outlined in the 2020 National Health Policy of Ghana.

Foodscapes in urban spaces of Africa: implications for food and nutrition security among the urban poor

Food security has been a global development agenda for several decades, and rightly so: nearly 945 million people were food insecure in 2005 and a decade later, this number declined to 784 million in 2014, only to rise to 821 million three years later in 2017. These global figures, however, mask variations in the extent of progress in different regions of the world. Progress towards achieving food security has been much slower in sub-Saharan Africa, and the region continues to be the worst hit by food insecurity. Furthermore, it is increasingly being recognised that food insecurity is prevalent in urban, and not just rural areas, and that the urban poor rather than the rural poor are particularly vulnerable, and at increased risk of being food insecure. Additionally, nutrition insecurity, a closely related component of food insecurity, is common among the urban poor and contributes to malnutrition. While several factors have been explored in trying to address the issue of food security, the potential role of foodscapes in urban spaces of Africa has been less researched. Recent evidence, however, indicates that foodscapes in urban areas of sub-Saharan Africa potentially contribute to food and nutrition insecurity, particularly among the urban poor. Addressing food and nutrition insecurity in sub-Saharan Africa will thus first require reframing the discourse about these issues from solely a rural to also an urban problem, and secondly improving access, especially availability of healthy and nutritious options that are also economically accessible, for vulnerable and at-risk groups; in particularly, the urban poor.

Between the City and the Farm: Food Environments in Artisanal Mining Communities in Upper Guinea

Objective:

Artisanal and small-scale mining (ASM) is a widespread livelihood in low- and middle-income countries; however, many in ASM communities face high levels of poverty and malnutrition. The food environments in ASM communities have non-agricultural rural characteristics that differ from those in urban and agricultural rural areas examined in much existing food environment literature.

Design:

We examine these complex external and personal food environments in ASM communities via a study using qualitative and quantitative methods. Market surveys and a cross-sectional household survey, plus qualitative mining site non-participant observations and in-depth structured interviews, were conducted in three waves.

Setting:

Eighteen study sites in ASM communities in northern Guinea.

Participants:

Surveys covered mothers in mining households with young children (n 613); in-depth interviews engaged caregivers of young children (n 45), food vendors (n 40) and young single miners (n 15); observations focused on mothers of young children (n 25).

Results:

The external food environment in these ASM communities combines widespread availability of commercially processed and staple-heavy foods with lower availability and higher prices for more nutritious, non-staple foods. Within the personal food environment, miners are constrained in their food choices by considerable variability in daily cash income and limited time for acquisition and preparation.

Conclusions:

We demonstrate that ASM communities have characteristics of both urban and rural populations and argue for greater nuance and appreciation of complexity in food environment research and resultant policy and programming.

Household food sources and diarrhoea incidence in poor urban communities, Accra Ghana

Diarrhoeal diseases remain a significant cause of morbidity and mortality, particularly in poor urban communities in the Global South. Studies on food access and safety have however not considered the sources of discrete food categories and their propensity to harbour and transmit diarrhoeal disease pathogens in poor urban settings. We sought to contribute to knowledge on urban food environment and enteric infections by interrogating the sources and categories of common foods and their tendency to transmit diarrhoea in low-income communities in Accra. We modelled the likelihood of diarrhoea transmission through specific food categories sourced from home or out of home after controlling for alternate transmission pathways and barriers. We used structured interviews where households that participated in the study were selected through a multi-stage systematic sampling approach. We utilized data on 506 households from 3 low-income settlements in Accra. These settlements have socio-economic characteristics mimicking typical low-income communities in the Global South. The results showed that the incidence of diarrhoea in a household is explained by type and source of food, source of drinking water, wealth and the presence of children below five years in the household. Rice-based staples which were consumed by 94.5% of respondents in the week preceding the survey had a higher likelihood of transmitting diarrhoeal diseases when consumed out of home than when eaten at home. Sources of hand-served dumpling-type foods categorized as "staple balls" had a nuanced relationship with incidence of diarrhoea. These findings reinforce the need for due diligence in addressing peculiar needs of people in vulnerable conditions of food environment in poor urban settlements in order to reap a co-benefit of reduced incidence of diarrhoea while striving to achieve the global development goal on ending hunger.

Shaping Physical, Economic, and Policy Components of the Food Environment to Create Sustainable Healthy Diets

Background:

Sustainable healthy diets are those dietary patterns that promote all dimensions of individuals’ health and well-being; have low environmental pressure and impact; are accessible, affordable, safe, and equitable; and are culturally acceptable. The food environment, defined as the interface between the wider food system and consumer’s food acquisition and consumption, is critical for ensuring equitable access to foods that are healthy, safe, affordable, and appealing.

Discussion:

Current food environments are creating inequities, and sustainable healthy foods are generally more accessible for those of higher socioeconomic status. The physical, economic, and policy components of the food environment can all be acted on to promote sustainable healthy diets. Physical spaces can be modified to improve relative availability (ie, proximity) of food outlets that carry nutritious foods in low-income communities; to address economic access certain actions may improve affordability, such as fortification, preventing food loss through supply chain improvements; and commodity specific vouchers for fruits, vegetables, and legumes. Other policy actions that address accessibility to sustainable healthy foods are comprehensive marketing restrictions and easy-to-understand front-of-pack nutrition labels. While shaping food environments will require concerted action from all stakeholders, governments and private sector bear significant responsibility for ensuring equitable access to sustainable healthy diets.

Determinants of dietary and physical activity behaviours among women of reproductive age in urban Uganda, a qualitative study

OBJECTIVE

To explore determinants of dietary and physical activity behaviours among women of reproductive age.

DESIGN

Data were collected through focus group discussions (FGD). The FGD guide was based on a modified theoretical framework; theory of planned behaviour was incorporated with constructs of health belief model, precaution adoption process model, social cognitive and social support theory. Discussions were audio recorded, transcribed verbatim and analysed thematically.

SETTING

Kampala, Uganda.

PARTICIPANTS

Women were categorised into young adults; 18-34 years and adults; 35-45 years.

RESULTS

Separate FGD with independent participants were conducted for dietary and physical activity behaviours until data saturation was achieved. Six FGD were conducted per behaviour. Determinants of dietary behaviours at intra-individual level included gaps in food skills, knowledge and self-efficacy, food safety concerns, convenience, finances and physiological satisfaction. The social-cultural norms were relationship between vegetable consumption and low social status, consideration of fruits as a snack for children and not food and habitual orientation towards carbohydrate foods. At environment level, social networks and increased availability of energy-dense, nutrient poor, street and processed foods influence dietary behaviour. For physical activity, intra-individual determinants were knowledge gaps and self-efficacy, while socio-cultural norms included gender stereotypes. Home (limited space and sedentary entertainment like social media and TV) and physical environment (cheap motorised transportation) influence physical activity.

CONCLUSION

The existing cultural beliefs promote dietary and physical activity behaviours which are divergent from healthy recommendations. Therefore, a comprehensive intervention is needed to address socio-cultural misconceptions, financial and time limitations in urban Uganda.

Correlates of over- or under-estimation of body size among resource-poor urban dwellers in a sub-Saharan African city

BACKGROUND

Individual perception of body size has implications for lifestyle behaviours including dietary habits and weight management practices.

AIM

To examine factors related to respondents' estimation of their body sizes compared to their body mass index (BMI).

SUBJECTS AND METHODS

This cross-sectional survey comprised a sample of 917 adults in urban poor Accra, Ghana. Silhouette figure ratings were used to assess perceived body size and ideal body size at a community level. Logistic regression analysis was used to determine correlates of respondents overestimating or underestimating their body sizes.

RESULTS

Approximately, 69% of respondents either underestimated or overestimated their body sizes. About a quarter of respondents perceived being overweight as the preferred ideal body size in their communities. The mean BMI of females and males who underestimated their body sizes were within the overweight category and normal weight category, respectively. Gender, educational level, employment status, the community of residence, and ethnicity were associated with how respondents correctly estimated, over- or under-estimated their body sizes. There was evidence of ethnicity mediating the association between the community of residence and body size estimation.

CONCLUSION

Weight management interventions must be mindful of the socio-demographic and cultural proclivities of the targeted populace for optimum impact.

The association between dietary consumption, anthropometric measures and body composition of rural and urban Ghanaian adults: a comparative cross-sectional study

Background

Overweight and obesity have become threats to public health in all regions across the globe including sub-Saharan Africa where prevalence used to be low. Policies to regulate the food environment and promote healthy food consumption look promising to reducing the prevalence of obesity but in Ghana there is not enough data to elicit a policy response. This study assessed the association between dietary consumption, anthropometric measures, body composition and physical activity among rural and urban Ghanaian adults.

Methods

This was a cross-sectional study involving 565 Ghanaian adults. Structured interviewer administered questionnaires were used to collect information on socio-demographics. Dietary consumption was assessed using household food frequency questionnaire and 24-h recall. Height, weight, BMI, waist circumference and body composition of all participants were determined. The World Health Organization’s Global Physical Activity Questionnaire (GPAQ) was used to assess physical activity levels. Mann-Whitney U test was used to analyze differences in anthropometric measures, body composition and consumption among rural and urban participants. Principal component analysis was used to analyze household food frequency data and nutrient analysis template was used to analyze 24-h recall. Chi-square was used to measure differences in obesity prevalence by community and gender. Multinomial logistic regression was used to model the risk factors associated with obesity.

Results

The prevalence of overweight and obesity using BMI were 29.9 and 22.9% respectively. Use of waist circumference measurement resulted in the highest overall obesity prevalence of 41.5%. Prevalence of obesity was higher among females compared to males across all measures with the exception of visceral fat that showed no significant difference. Four different patterns were derived from principal component analysis. Among urban participants, the staple pattern showed a significant negative correlation with visceral fat (r − 0.186, p-value 0.013) and BMI (r − 0.163, p-value 0.029). Multinomial logistic regression revealed that males (AOR 19.715, CI 9.723–39.978, p-value < 0.001) had higher odds of being of normal weight compared to females.

Conclusion

Prevalence of overweight and obesity continue to rise in Ghana, especially among females. Public education and screening as well as interventions that regulate the food environment and make affordable and available healthy food options are needed to control the rise in obesity prevalence.

Determinants of dietary and physical activity behaviours among women of reproductive age in urban sub-Saharan Africa: a systematic review

Urban sub-Saharan Africa is in a nutrition transition shifting towards consumption of energy-dense nutrient-poor diets and decreasing physical activity. Determinants of nutrition transition in sub-Saharan Africa are presently not well understood. The objective of this review was to synthesise available data on determinants of dietary and physical activity behaviours among women of reproductive age in urban sub-Saharan Africa according to the socio-ecological framework. We searched MEDLINE, Embase, Scopus, Web of Science and bibliographies of included articles for qualitative, observational and randomised controlled studies published in English from January 2000 to September 2018. Studies conducted within general populations of women aged 18–49 years were included. Searches were according to a predefined protocol published on PROSPERO (ID = CRD42018108532). Two reviewers independently screened identified studies. From a total of 9853 unique references, twenty-three studies were retained and were mainly from South and West Africa. No rigorous designed quantitative study was identified. Hence, data synthesis was narrative. Notable determinants of dietary behaviour included: convenience, finances, social network, food skills and knowledge gaps, food deserts and culture. Cultural beliefs include strong relationship between high social status and weight gain, energy-dense confectionery, salt or fat-rich foods. Physical activity is influenced by the fast-changing transport environment and cultural beliefs which instigate unfavourable gender stereotypes. Studies with rigorous qualitative and quantitative designs are required to validate and develop the proposed frameworks further, especially within East Africa. Nevertheless, available insights suggest a need for comprehensive skill-based interventions focusing on socio-cultural misconceptions and financial limitations.

Food Environment Research in Low- and Middle-Income Countries: A Systematic Scoping Review

Food environment research is increasingly gaining prominence in low- and middle-income countries (LMICs). However, in the absence of a systematic review of the literature, little is known about the emerging body of evidence from these settings. This systematic scoping review aims to address this gap. A systematic search of 6 databases was conducted in December 2017 and retrieved 920 records. In total, 70 peer-reviewed articles met the eligibility criteria and were included. Collectively, articles spanned 22 LMICs, including upper-middle-income countries (n = 49, 70%) and lower-middle-income countries (n = 18, 26%). No articles included low-income countries. Articles featured quantitative (n = 45, 64%), qualitative (n = 17, 24%), and mixed-method designs (n = 11, 8%). Studies analyzed the food environment at national, community, school, and household scales. Twenty-three articles (55%) assessed associations between food environment exposures and outcomes of interest, including diets (n = 14), nutrition status (n = 13), and health (n = 1). Food availability was associated with dietary outcomes at the community and school scales across multiple LMICs, although associations varied by vendor type. Evidence regarding associations between the food environment and nutrition and health outcomes was inconclusive. The paucity of evidence from high-quality studies is a severe limitation, highlighting the critical need for improved study designs and standardized methods and metrics. Future food environment research must address low-income and lower-middle-income countries, and include the full spectrum of dietary, nutrition, and health outcomes. Improving the quality of food environment research will be critical to the design of feasible, appropriate, and effective interventions to improve public health nutrition in LMICs.

Neighborhood physical food environment and cardiovascular risk factors in India: Cross-sectional evidence from APCAPS

There has been increasing interest in associations between neighborhood food environments and cardiovascular risk factors. However, results from high-income countries remain inconsistent, and there has been limited research from low- and middle-income countries. We conducted a cross-sectional analysis of the third wave follow-up of the Andhra Pradesh children and parents study (APCAPS) (n = 5764, median age 28.8 years) in south India. We examined associations between the neighborhood availability (vendor density per km2 within 400 m and 1600 m buffers of households) and accessibility (distance from the household to the nearest vendor) of fruit/vegetable and highly processed/take-away food vendors with 11 cardiovascular risk factors, including adiposity measures, glucose-insulin, blood pressure, and lipid profile. In fully adjusted models, higher density of fruit/vegetable vendors within 400 m of participant households was associated with lower systolic blood pressure [-0.09 mmHg, 95% confidence interval (CI): -0.17, -0.02] and diastolic blood pressure (-0.10 mmHg, 95% CI: -0.17, -0.04). Higher density of highly processed/take-away food vendors within 400 m of participant households was associated with higher Body Mass Index (0.01 Kg/m2, 95% CI: 0.00, 0.01), waist circumference (0.22 mm, 95% CI: 0.05, 0.39), systolic blood pressure (0.03 mmHg, 95% CI: 0.01, 0.06), and diastolic blood pressure (0.03 mmHg, 95% CI: 0.01, 0.05). However, within 1600 m buffer, only association with blood pressure remained robust. No associations were found for between neighborhood accessibility and cardiovascular risk factors. Lower density of fruit/vegetable vendors, and higher density of highly processed/take-away food vendors were associated with adverse cardiovascular risk profiles. Public health policies regarding neighborhood food environments should be encouraged in south India and other rural communities in south Asia.

Mapping Obesogenic Food Environments in South Africa and Ghana: Correlations and Contradictions

In sub-Saharan Africa, urbanisation and food systems change contribute to rapid dietary transitions promoting obesity. It is unclear to what extent these changes are mediated by neighbourhood food environments or other factors. This paper correlates neighbourhood food provision with household consumption and poverty in Khayelitsha, South Africa and Ahodwo, Ghana. Georeferenced survey data of food consumption and provision were classified by obesity risk and protection. Outlets were mapped, and density and distribution correlated with risk classes. In Khayelitsha, 71% of households exceeded dietary obesity risk thresholds while 16% consumed protective diets. Obesogenic profiles were less (26%) and protective more prevalent (23%) in Ahodwo despite greater income poverty in Khayelitsha. Here, income-deprived households consumed significantly (p < 0.005) less obesogenic and protective diets. Small informal food outlets dominated numerically but supermarkets were key household food sources in Khayelitsha. Although density of food provision in Ahodwo was higher (76/km2), Khayelitsha outlets (61/km2) provided greater access to obesogenic (57% Khayelitsha; 39% Ahodwo) and protective (43% Khayelitsha; 16% Ahodwo) foods. Consumption and provision profiles correlate more strongly in Ahodwo than Khayelitsha (rKhayelitsha = 0.624; rAhodwo = 0.862). Higher obesogenic food consumption in Khayelitsha suggests that risky food environments and poverty together promote obesogenic diets.

Urban food environments in Africa: implications for policy and research

Africa is currently experiencing rapid urbanisation impacting on people's food environments and dietary habits. Such changes are associated with higher prevalence of obesity coexisting with undernutrition. The present paper provides an overview of the healthiness of African urban food environments. We discuss the ways that food environments can be characterised and summarise the methods that can be used to investigate and intervene in the food environment. Data for Africa over a 50-year period (1961–2013) suggest an increasing availability of energy, animal products, fruit and vegetables, vegetable oils, sugar and sweeteners but a decrease in animal fats. There is a lack of evidence about how social, physical and macro-environments drive dietary habits in urban Africa, as most research has focused on the individual level. Examining how food consumption is embedded in everyday life, by investigating social environments is crucial to developing effective interventions. The informal food sector plays an important role in the retail food environment. Macro-level food price changes are an important factor influencing nutritional quality of African diets. The rapid expansion of food/beverages advertising in Africa threatens traditional food habits. Liberalisation of food trade is already impacting on the nutritional quality of food available. Improving African food environments represents a pressing public health concern and has the potential to prevent all forms of malnutrition. Hence, by conducting research into the role of urban social, physical and macro-environments, emerging interventions and policies are likely to positively impact on nutritional status, thereby enhancing social and economic development.

Food beliefs and practices in urban poor communities in Accra: implications for health interventions

BACKGROUND

Poor communities in low and middle income countries are reported to experience a higher burden of chronic non-communicable diseases (NCDs) and nutrition-related NCDs. Interventions that build on lay perspectives of risk are recommended. The objective of this study was to examine lay understanding of healthy and unhealthy food practices, factors that influence food choices and the implications for developing population health interventions in three urban poor communities in Accra, Ghana.

METHODS

Thirty lay adults were recruited and interviewed in two poor urban communities in Accra. The interviews were audio-taped, transcribed and analysed thematically. The analysis was guided by the socio-ecological model which focuses on the intrapersonal, interpersonal, community, structural and policy levels of social organisation.

RESULTS

Food was perceived as an edible natural resource, and healthy in its raw state. A food item retained its natural, healthy properties or became unhealthy depending on how it was prepared (e.g. frying vs boiling) and consumed (e.g. early or late in the day). These food beliefs reflected broader social food norms in the community and incorporated ideas aligned with standard expert dietary guidelines. Healthy cooking was perceived as the ability to select good ingredients, use appropriate cooking methods, and maintain food hygiene. Healthy eating was defined in three ways: 1) eating the right meals; 2) eating the right quantity; and 3) eating at the right time. Factors that influenced food choice included finances, physical and psychological state, significant others and community resources.

CONCLUSIONS

The findings suggest that beliefs about healthy and unhealthy food practices are rooted in multi-level factors, including individual experience, family dynamics and community factors. The factors influencing food choices are also multilevel. The implications of the findings for the design and content of dietary and health interventions are discussed.

Socio-demographic and behavioural determinants of body mass index among an adult population in rural Northern Ghana: the AWI-Gen study

BACKGROUND

Obesity and associated cardiometabolic diseases are increasing in urban sub-Saharan Africa due to a complex epidemiological and nutritional transition. Related data on rural communities is scarce.

OBJECTIVES

The study characterized the socio-demographic and behavioural factors influencing body mass index (BMI) among adults in rural Northern Ghana Methods: A population-based cross-sectional study involving adults aged 40-60 years residing in the Kassena-Nankana districts was undertaken. Demographic, socio-economic and behavioural data were collected along with measures of anthropometry. We determined factors associated with BMI among women and men.

RESULTS

A total of 2014 adults were studied. The median age was 51 (IQR 45-57) years and 54% were women. The prevalence of overweight/obesity was higher among women than men (18.4% vs. 7.2%; p < 0.001), whilst underweight was more prevalent in men (18.3% vs. 13.1%; p = 0.001). Participants with the highest level of education and a high household socio-economic status had higher BMIs than those in the lowest strata in both men (β = 0.074, p = 0.028 and β = 0.072, p < 0.001, respectively) and women (β = 0.174, p = 0.001 and β = 0.109, p < 0.001, respectively). Men (β = -0.050; p < 0.001) and women (β = -0.073; p < 0.001) of the Nankana ethnic group had a lower BMI than the Kassena ethnic group. Among men, alcohol consumption (β = -0.021; p = 0.001) and smoking (β = -0.216; p < 0.001) were associated with lower BMI. Smokeless tobacco was associated with lower BMI among women. Pesticide exposure was associated with higher BMI (β = 0.022; p = 0.022) among men.

CONCLUSION

Age, sex, ethno-linguistic group and prevailing socio-demographic and behavioural factors within this rural community in Northern Ghana influence BMI. The observed positive association between pesticide use and BMI warrants further investigation.