Vegetables for Healthy Diets in Low- and Middle-Income Countries: A Scoping Review of the Food Systems Literature

Climate change-induced shifts in the food systems and diet-related non-communicable diseases in sub-Saharan Africa: a scoping review and a conceptual framework

OBJECTIVES

To determine the relationship between climate change, food systems and diet-related non-communicable diseases (DR-NCDs) in sub-Saharan Africa (SSA) and propose a conceptual framework for food systems in SSA.

DESIGN

A scoping review.

ELIGIBILITY CRITERIA

Studies included investigated the relationship between climate change and related systemic risks, food systems, DR-NCDs and its risk factors in SSA. Studies focusing on the association between climate change and DR-NCDs unrelated to food systems, such as social inequalities, were excluded.

SOURCES OF EVIDENCE

A comprehensive search was conducted in ProQuest (nine databases), Google Scholar and PubMed in December 2022.

CHARTING METHODS

Data extracted from studies included author, study type, country of study, climate change component, DR-NCD outcomes and risk factors, and impacts of climate change on DR-NCDs. A narrative approach was used to analyse the data. Based on the evidence gathered from SSA, we modified an existing food system conceptual framework.

RESULTS

The search retrieved 19 125 studies, 10 of which were included in the review. Most studies used a cross-sectional design (n=8). Four explored the influence of temperature on liver cancer through food storage while four explored the influence of temperature and rainfall on diabetes and obesity through food production. Cross-sectional evidence suggested that temperature is associated with liver cancer and rainfall with diabetes.

CONCLUSION

The review highlights the vulnerability of SSA's food systems to climate change-induced fluctuations, which in turn affect dietary patterns and DR-NCD outcomes. The evidence is scarce and concentrates mostly on the health effects of temperature through food storage. It proposes a conceptual framework to guide future research addressing climate change and DR-NCDs in SSA.

Zero fruits/vegetables consumption and associated factors among Children aged 6-23 months in Ethiopia: Mixed effect logistic regression analysis

BACKGROUND

The first two years of life is a vital period for promoting optimal growth, development and health. The lifelong nutritional habit and overall health of children is influenced by their early age feeding practice. Ethiopia is among the top five countries in Sub-Saharan Africa with the highest burden of zero fruits/vegetables consumption. This study aims to access factors associated with zero fruits/vegetables consumption among children aged 6-23 months in Ethiopia.

METHODS

The study analyzed Ethiopian Mini Demographic and Health Survey 2019 dataset with a total weighted sample of 1459 young children aged between 6-23 months and who were living with their mothers. Data cleaning, coding and labeling were done using STATA version 14 software. Multilevel mixed effect logistic regression model was employed to identify associated factors.

RESULTS

Exactly 69.3% of children aged 6-23 months in Ethiopia had zero fruits/vegetables consumption. In the multivariable multilevel binary logistic regression analysis a child from household with middle (AOR = 0.55, 95% CI: 0.35, 0.86) and rich (AOR = 0.37, 95% CI: 0.23, 0.60) wealth index, mothers who aged between 25-34 years old (AOR = 0.44; 95%CI = 0.29-0.69), mothers who were married/living with partner (AOR = 3.21; 95%CI: 1.58-6.52), children of mothers who follow Islamic religion (AOR = 0.34, 95% CI: 0.19, 0.61), mothers who had more than four ANC visits during their most recent pregnancy (AOR = 0.57; 95%CI: 0.39-0.83), children in age group of 12-18 month(AOR = 0.41, 95% CI: 0.28, 0.59), and 19-23 months (AOR = 0.26, 95% CI: 0.17, 0.40), health facility delivery (AOR = 1.52, 95% CI; 1.00-2.30), and small peripheral regions (AOR = 4.40, 95% CI; 1.39-13.97) were found to be significant factors associated with children's zero fruits /vegetables consumption. The Interclass correlation coefficient (ICC) value in the null model was 0.34, which indicates that 34% of the variation in children's zero fruits /vegetables consumption was attributed to the variation between clusters.

CONCLUSION

This study found that zero fruits/vegetables consumption among children aged 6-23 months in Ethiopia is high. Therefore, efforts should be made by stakeholders who are concerned about optimal diet and health of children to improve fruits/vegetables consumption of children particularly those from poor households, young mothers (15-24), and peripheral regions of Ethiopia. This could be done during ANC follow up visits and during nutrition counseling.

Estimates and trends of zero vegetable or fruit consumption among children aged 6-23 months in 64 countries

Children require a diverse diet, that includes vegetables and fruits, to support growth and development and prevent non-communicable diseases. The WHO-UNICEF established a new infant and young child feeding (IYCF) indicator: zero vegetable or fruit (ZVF) consumption among children aged 6-23 months. We estimated the prevalence, trends, and factors associated with ZVF consumption using nationally representative, cross-sectional data on child health and nutrition in low-and-middle-income countries. We examined 125 Demographic and Health Surveys in 64 countries conducted between 2006-2020 with data on whether a child ate vegetables or fruits the previous day. Prevalence of ZVF consumption was calculated by country, region, and globally. Country trends were estimated and tested for statistical significance (p<0.05). Logistic regression analysis was used to examine the relationship between ZVF and child, mother, household, and survey cluster characteristics by world region and globally. Using a pooled estimate of the most recent survey available in each country, we estimate the global prevalence of ZVF consumption as 45.7%, with the highest prevalence in West and Central Africa (56.1%) and the lowest in Latin America and the Caribbean (34.5%). Recent trends in ZVF consumption varied by country (16 decreasing, eight increasing, 14 no change). Country trends in ZVF consumption represented diverse patterns of food consumption over time and may be affected by the timing of surveys. Children from wealthier households and children of mothers who are employed, more educated, and have access to media were less likely to consume ZVF. We find the prevalence of children aged 6-23 months who do not consume any vegetables or fruits is high and is associated with wealth and characteristics of the mother. Areas for future research include generating evidence from low-and-middle-income countries on effective interventions and translating strategies from other contexts to improve vegetable and fruit consumption among young children.

Healthy Eating for All? The Challenge of Adhering to Dietary Guidelines for Low-Income Groups in China

The Chinese Dietary Guidelines propose a balanced diet for healthy living, but the affordability of this diet needs to be considered, especially for low-income households. To investigate the affordability of a healthy diet, this study analyzes the daily retail prices of 46 food items in 36 Chinese cities from 2016 to 2021. This study compares expenditure, diet composition, and nutritional status in two scenarios aligned with the guidelines. The results show that the mean minimum cost of a balanced diet exceeds the current per capita food expenditure for at least 182.85 million urban households. This suggests that low-income people would need to increase their expenditure by at least 20-121% to achieve the recommended diets. This study also identifies affordable and nutrient-dense foods such as standard flour, eggs, black beans, and cabbage, which policymakers should focus on when monitoring food prices. The findings recommend a combination of social and food system policies to reduce prices and make healthy diets accessible. This study identifies the gaps in the Chinese Dietary Guidelines for ensuring accessibility for vulnerable groups and provides a template for policymakers and researchers to track diet affordability using available food price data in China, contributing to China's 2030 Health Plan and the UN's Sustainable Development Goals.

Factors affecting fruit and vegetable consumption and purchase behavior of adults in sub-Saharan Africa: A rapid review

In order to achieve the Sustainable Development Goals, considerable dietary shifts, including an increase in the consumption of fruit and vegetables (FV) will be required. However, worldwide consumption of FV is far below international recommendations, including in many low- and middle-income countries (LMICs), particularly in Africa. Understanding what, where, when, and how people choose to eat requires an understanding of how individuals are influenced by factors in their social, physical, and macro-level environments. In order to develop effective interventions to increase fruit and vegetable consumption, the factors influencing consumer behavior need to be better understood. We conducted a rapid review to assess and synthesize data on individual, social, physical, and macro-level factors that enable or constrain fruit and vegetable consumption and purchase among adults living in sub-Saharan Africa. Our conceptual framework is based on a socio-ecological model which has been adapted to settings in LMICs and Africa. We systematically searched four electronic databases including Scopus, Medline (PubMed), PsycInfo, and African Index Medicus, and screened Google Scholar for gray literature. We included a total of 52 studies and narratively summarized the existing evidence for each identified factor across the different levels. We found that most studies assessed demographic factors at the individual level including household or family income, socio-economic status and education. Furthermore we identified a variety of important factors that influence FV consumption, in the social, physical, and macro environment. These include women's empowerment and gender inequalities, the influence of neighborhood and retail food environment such as distance to market and price of FV as well as the importance of natural landscapes including forest areas for FV consumption. This review identified the need to develop and improve indicators both for exposure and outcome variables but also to diversify research approaches.

The feasibility of implementing food-based dietary guidelines and food graphics in Ethiopia

This study aimed to test the acceptability, cultural appropriateness, consumers' understanding, and practicality of the Ethiopian food-based dietary guideline's messages, tips, and food graphics. A qualitative study design was applied with focus group discussions and key informant interviews. Four different participant groups were included: 40 consumers, 15 high-level nutrition experts, 30 frontline community health extension workers (HEWs), and 15 agriculture extension workers (AEWs) to incorporate different stakeholder perspectives. Data collection was conducted using 7 focus group discussions (FGDs) and 30 key informant interviews (KIIs). Collected data were coded and analyzed using QSR International NVivo V.11 software. Most of the study participants were highly interested in implementing the dietary guidelines once these guidelines are officially released. Based on the participants' views, most of the messages align with the current nutrition education materials implemented in the country except the messages about physical activity and alcohol intake. However, participants suggested defining technical terms such as ultra-processing, whole grain, safe and balanced diet in simpler terms for a better understanding. Practicality, affordability, availability, and access to the market were the major barriers reported for adherence to the guidelines. To be more inclusive of cultural and religious beliefs, findings show that the guideline should address fasting and traditional cooking methods. In conclusion, the dietary guidelines were well received by most stakeholders. They are thought to be feasible once feedback on wording, affordability, availability, and access is considered in the messages, tips, and graphic designs.

Optimal complementary feeding practices of children aged 6–23 months in three agro-ecological rural districts of Jimma zones of southwest Ethiopia

Despite the critical importance of complementary feeding, large proportions of children in developing countries are sub-optimally fed during 6–23 months of age. In Ethiopia, even though the government has been rolling out infant and young child feeding (IYCF) guidelines, the proportion of mothers adhering to the recommended optimal practices and its associated factors have not been assessed in different agro-ecological areas. Hence, the present study aimed to determine optimal complementary feeding practices and associated factors in three agro-ecological rural districts (high, mid and lowland) of southwest Ethiopia. A community-based cross-sectional study was carried out among 845 mothers-index young children 6–23 months Jimma zone. Multistage sampling was employed to select the study participants. Structured and pretested questionnaires were used to collect data and entered into Epi Data V.1.4.4.0. The data were analysed using SPSS version 20. Binary and multivariable logistic regressions were used to identify factors associated with optimal child-feeding practices. The significance of the association was determined at P < 0⋅05. The overall proportion of optimal complementary feeding practice (OCFP) was 9⋅4 % at 95 % CI (7⋅19, 11⋅08). The timely initiation of complementary feeding, minimum meal frequency, minimum dietary diversity and minimum acceptable diet was 52⋅2, 64⋅1, 17⋅2 and 12⋅2 %. Multivariable logistic regression showed that being in the highland districts, having good maternal knowledge, and mothers having primary school education, having a family size of less than six were positively associated with optimal complementary feeding practices. The findings showed that OCFP was low, especially in the midland agro-ecological districts.