Dietary behaviours in the context of nutrition transition: a systematic review and meta-analyses in two African countries

Socioeconomic inequalities in early child development in children aged under 36 months in South Asia: A systematic review

BACKGROUND

In South Asia, 89 million children under 5 are at risk of not reaching their developmental potential. Household socioeconomic position (SEP) is a determinant of early child development (ECD). However, synthesised evidence for the association between ECD and SEP in young children in South Asia is not available. Therefore, this review synthesises evidence on the relationship of household SEP with ECD in children under 36 months of age in South Asia.

METHOD

PubMed, Cochrane Library, MEDLINE and Scopus were systematically searched to identify studies from South Asian countries that reported evidence on the association between SEP and ECD. Search terms included items related to motor, cognitive, language and socioemotional development. Study quality was assessed using the QualSyst tool, with three quality levels (high/medium/low), and a narrative review for each ECD outcome was constructed (PROSPERO registration: CRD42019131533).

RESULTS

Twelve of the 950 publications screened met the inclusion criteria (nine from India, two Nepal and one Bangladesh). The majority (n = 10, 83%) reported language development on its own or alongside another ECD outcome. Fewer articles assessed cognitive (n = 6, 50%), motor (n = 7, 58%) or socioemotional development (n = 3, 25%). Higher SEP was associated with better ECD for one third of the associations reported. One ECD outcome (socioemotional development) was negatively associated (with socioeconomic status) based on low quality evidence. Mother's education and family income were the major SEP constructs associated with ECD. One, four and seven studies were rated as having a low, medium and high risk of bias, respectively.

CONCLUSION

This review reveals the scarcity of evidence exploring associations between household SEP and ECD in children under 36 months in South Asia, especially outside of India. Enhancing evidence for associations between ECD and SEP is needed for evidence-based policy making to reduce developmental delays associated with a disadvantaged SEP in the South Asian region.

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.

Food Insecurity and Dietary Deprivation: Migrant Households in Nairobi, Kenya

The current study focuses on food consumption and dietary diversity among internal migrant households in Kenya using data from a city-wide household survey of Nairobi conducted in 2018. The paper examined whether migrant households are more likely to experience inferior diets, low dietary diversity, and increased dietary deprivation than their local counterparts. Second, it assesses whether some migrant households experience greater dietary deprivation than others. Third, it analyses whether rural-urban links play a role in boosting dietary diversity among migrant households. Length of stay in the city, the strength of rural-urban links, and food transfers do not show a significant relationship with greater dietary diversity. Better predictors of whether a household is able to escape dietary deprivation include education, employment, and household income. Food price increases also decrease dietary diversity as migrant households adjust their purchasing and consumption patterns. The analysis shows that food security and dietary diversity have a strong relationship with one another: food insecure households also experience the lowest levels of dietary diversity, and food secure households the highest.

Disappearance and survival of fermented beverages in the biosphere reserve Tehuacán-Cuicatlán, Mexico: The cases of Tolonche and Lapo

Traditional fermented products are disappearing from the local foodscapes due to social pressures and ecological changes that affect their production; it is therefore crucial to document local knowledge, which is crucial to maintain and recover local biocultural heritage and to contribute to food security. This study aims to document and foster the production of local traditional beverages by registering recipes of fermented beverages in the Tehuacán-Cuicatlán biosphere reserve in central Mexico, a region recognized for its great biocultural diversity. We conducted a search of peer-reviewed literature. Additionally, we included ethnographic research and participatory methods to engage residents in different steps of the production process. We identified five main fermented beverages in the research area, the most common beverages are those produced by agave species which include, mescal, pulque and an almost extinct beverage known as lapo which involves sugar cane as main substrate. We also identified a fermented beverage produced with several cacti fruits known as nochoctli and a traditional a fermented beverage produced with fruits of Schinus molle known as tolonche. We highlight the production of lapo and tolonche since these involved the incorporation of foreign substrates into the region after the Spaniard conquest and to their restricted distribution and almost extinction. The beverages tolonche and lapo are nowadays almost lost and only a few producers still prepare them to follow modified versions of the original recipe. Lapo and tolonche were once important in the research area but almost became extinct until local people started to recently recover them. Traditional fermented beverages in Mexico play an important role in cultural identity and contribute to the local diet; nevertheless, several fermented beverages have not been recorded and have even become extinct. This work is an effort to promote and conserve traditional fermented beverages as valuable biocultural heritage by empowering people to make decisions about the use of locally available resources, which is crucial in times when food systems are highly vulnerable.

Community perceptions on the factors in the social food environment that influence dietary behaviour in cities of Kenya and Ghana: a Photovoice study

OBJECTIVE

To explore communities' perspectives on the factors in the social food environment that influence dietary behaviours in African cities.

DESIGN

A qualitative study using participatory photography (Photovoice). Participants took and discussed photographs representing factors in the social food environment that influence their dietary behaviours. Follow-up in-depth interviews allowed participants to tell the 'stories' of their photographs. Thematic analysis was conducted, using data-driven and theory-driven (based on the socio-ecological model) approaches.

SETTING

Three low-income areas of Nairobi (n 48) in Kenya and Accra (n 62) and Ho (n 32) in Ghana.

PARTICIPANTS

Adolescents and adults, male and female aged ≥13 years.

RESULTS

The 'people' who were most commonly reported as influencers of dietary behaviours within the social food environment included family members, friends, health workers and food vendors. They mainly influenced food purchase, preparation and consumption, through (1) considerations for family members' food preferences, (2) considerations for family members' health and nutrition needs, (3) social support by family and friends, (4) provision of nutritional advice and modelling food behaviour by parents and health professionals, (5) food vendors' services and social qualities.

CONCLUSIONS

The family presents an opportunity for promoting healthy dietary behaviours among family members. Peer groups could be harnessed to promote healthy dietary behaviours among adolescents and youth. Empowering food vendors to provide healthier and safer food options could enhance healthier food sourcing, purchasing and consumption in African low-income urban communities.

Individual‐level drivers of dietary behaviour in adolescents and women through the reproductive life course in urban Ghana: A Photovoice study

Evidence on the individual‐level drivers of dietary behaviours in deprived urban contexts in Africa is limited. Understanding how to best inform the development and delivery of interventions to promote healthy dietary behaviours is needed. As noncommunicable diseases account for over 40% of deaths in Ghana, the country has reached an advanced stage of nutrition transition. The aim of this study was to identify individual‐level factors (biological, demographic, cognitive, practices) influencing dietary behaviours among adolescent girls and women at different stages of the reproductive life course in urban Ghana with the goal of building evidence to improve targeted interventions. Qualitative Photovoice interviews (n = 64) were conducted in two urban neighbourhoods in Accra and Ho with adolescent girls (13–14 years) and women of reproductive age (15–49 years). Data analysis was both theory‐ and data‐driven to allow for emerging themes. Thirty‐seven factors, across four domains within the individual‐level, were identified as having an influence on dietary behaviours: biological (n = 5), demographic (n = 8), cognitions (n = 13) and practices (n = 11). Several factors emerged as facilitators or barriers to healthy eating, with income/wealth (demographic); nutrition knowledge/preferences/risk perception (cognitions); and cooking skills/eating at home/time constraints (practices) emerging most frequently. Pregnancy/lactating status (biological) influenced dietary behaviours mainly through medical advice, awareness and willingness to eat foods to support foetal/infant growth and development. Many of these factors were intertwined with the wider food environment, especially concerns about the cost of food and food safety, suggesting that interventions need to account for individual‐level as well as wider environmental drivers of dietary behaviours.

Time constraints, eating at home, eating out, cooking skills, food preferences and food safety concerns were identified as key factors influencing dietary behaviours at the individual level in urban Ghana.

Ability to eat nutritious, safe food was largely mediated by income and wealth.

Biological factors, such as pregnancy/lactating status influenced behaviours through medical advice, nutrition knowledge and willingness to promote foetal/infant development.

Many individual‐level factors were intertwined with the wider food environment.

Factors influencing dietary behaviour at different levels need to be considered together when developing interventions/policies for healthier diets.

From Ampesie to French fries: systematising the characteristics, drivers and impacts of diet change in rapidly urbanising Accra

Sub-Saharan Africa (SSA) is urbanising rapidly. One of the most visible outcomes of this urbanisation process is the change in the diets of urban residents. However, diet change in the context of rapid urbanisation is a complex and multi-dimensional phenomenon that encompasses multiple intersecting historical, environmental, socioeconomic, and political aspects. This study aims to unravel and systematise the characteristics, drivers and impacts of diet changes in Accra, through the interviews of multiple stakeholders and Causal Loop Diagrams. Diet change is characterised by the increased consumption of certain foodstuff such as rice, chicken, fish, vegetable oil, sugar, and ultra-processed food (UPF), and the decreased consumption of traditional foodstuff such as roots, tubers, and some cereals such as millet. These changes are driven by multiple factors, including among others, changes in income, sociocultural practices, energy access, and policy and trade regimes, as well as the proliferation of supermarkets and food vendors. Collectively, these diet changes have a series of environmental, socioeconomic, and health/nutrition-related impacts. Our results highlight the need to understand in a comprehensive manner the complex processes shaping diet change in the context of urbanisation, as a means of identifying effective interventions to promote healthy and sustainable urban diets in SSA. The development of such intervention should embrace a multi-stakeholder perspective, considering that the relevant urban actors have radically different perspectives and interests at this interface of urbanisation and diet change.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11625-022-01195-y.

Dietary Diversity and Dietary Patterns in School-Aged Children in Western Kenya: A Latent Class Analysis

Inadequate diet among children has both immediate and long-term negative health impacts, but little is known about dietary diversity and dietary patterns of school-aged children in rural Kenya. We assessed dietary diversity and identified dietary patterns in school-aged children in Western Kenya using a latent class approach. We collected dietary intake using a 24 h dietary recall among students in elementary schools in two rural villages (hereafter village A and B) in Western Kenya in 2013. The mean (SD) age was 11.6 (2.2) years in village A (n = 759) and 12.6 (2.2) years in village B (n = 1143). We evaluated dietary diversity using the 10-food-group-based women’s dietary diversity score (WDDS) and found a mean (SD) WDDS of 4.1 (1.4) in village A and 2.6 (0.9) in village B. We identified three distinct dietary patterns in each village using latent class analysis. In both villages, the most diverse pattern (28.5% in A and 57.8% in B) had high consumption of grains, white roots and tubers, and plantains; dairy; meat, poultry, and fish; and other vegetables. Despite variation for some children, dietary diversity was relatively low for children overall, supporting the need for additional resources to improve the overall diet of children in western Kenya.

Consumer demand for novel fruit and vegetable products with extended shelf lives in East Africa: a multinational multi-product analysis

OBJECTIVE

To evaluate the potential of products made out of underutilised fruits and vegetables for closing seasonal nutritional gaps among rural and urban consumers in East Africa.

DESIGN

The multinational analysis combines sensory testing and experimental auctions to assess consumers' perceptions and willingness to pay (WTP) for 6 different fruit and vegetable products.

SETTING

Open markets in rural and urban areas in Kenya, Tanzania and Uganda.

PARTICIPANTS

There were 939 male and female adults who were at least 18 years old.

RESULTS

Tobit models for each product show that besides sensory perception, similar socio-demographic characteristics influence consumers' WTP for these products in all 3 countries. The products are especially liked among younger, male and urban consumers.

CONCLUSION

We conclude that there is demand and a potential market for processed fruit and vegetable products based on indigenous raw material in East Africa. The products, thus, have promising potential to improve nutrition, especially during off-season conditions when access to fresh produce is limited.

Factors Influencing Adolescents' Dietary Behaviors in the School and Home Environment in Addis Ababa, Ethiopia

Background

Malnutrition affects many adolescents in Ethiopia. Over one-third of adolescent girls and two-thirds of boys are thin. Overweight and obesity in Ethiopia is mostly a concern in urban populations of higher wealth quintiles. Urbanization and globalization of diets is shifting food environments. The objective of this study was to assess whether food environments in and around schools in urban Ethiopia influence dietary diversity, quality, BMI status or perceptions of adolescents.

Methods

Twelve high schools were selected in Addis Ababa (private/government). From each school, 20 pupils aged 15–19 years were randomly selected (n = 217) and interviewed about assets in their households, their diets (categorized into 10 food groups of the Minimum Dietary Diversity, the Global Dietary Recommendations scores and four categories of the NOVA classification based on level of processing) and their use of pocket money. In addition, food environment audits were conducted within the school compound and a 0.5 km radius around each school and types of food outlets.

Results

On average there were 436 food outlets and 246 food or drink advertisements around each school. The majority of the advertisements (89.9%) were of ultra-processed foods, mostly sugar-sweetened beverages (SSBs). Most were positioned on food outlets (89.1%). SSBs or sweets were visibly on display in 26.3% of the outlets and fresh fruits and vegetables in 17.9% of outlets. Dietary diversity of adolescents was poor with an average of 3.6 food groups out of 10 consumed in the last 24 h. Ultra-processed foods and beverages were consumed by 23.5% of adolescents. The majority of adolescents spent their pocket money on SSBs, sweets or fried foods. Our analysis found that higher assets in adolescents' households were associated with higher dietary diversity and consumption of healthy food groups. We found no association between the food environment and dietary indicators or the BMI-z-score.

Conclusion

While the school food environments investigated were not conducive with promoting healthy dietary behaviors, we cannot conclude that these environmental factors directly influence adolescents' diets. The pervasive advertising and availability of unhealthy foods and beverages requires policy action for healthy school food environments.

Barriers and Facilitators in Preparation and Consumption of African Indigenous Vegetables: A Qualitative Exploration From Kenya

Malnutrition and food security continue to be major concerns in sub-Saharan Africa (SSA). In Western Kenya, it is estimated that the double burden of malnutrition impacts 19% of adults and 13–17% of households. One potential solution to help address the concern is increased consumption of nutrient-dense African Indigenous Vegetables (AIVs). The objectives of this study were to: (i) document current methods used for preparation and consumption of AIVs; (ii) identify barriers and facilitators of AIVs consumption and preparation; and (iii) identify a package of interventions to increase the consumption of AIVs to promote healthy diets. This study used qualitative data collected from 145 individual farmers (78 female and 67 male) in 14 focus group discussions (FGDs) using a semi-structured survey instrument. Most farmers reported that they prepared AIVs using the traditional method of boiling and/or pan-cooking with oil, tomato, and onion. However, there were large discrepancies between reported cooking times, with some as little as 1–5 min and others as long as 2 h. This is of importance as longer cooking times may decrease the overall nutritional quality of the final dish. In addition, there were seasonal differences in the reported barriers and facilitators relative to the preparation and consumption of AIVs implying that the barriers are situational and could be modified through context-specific interventions delivered seasonally to help mitigate such barriers. Key barriers were lack of availability and limited affordability, due to an increase cost, of AIVs during the dry season, poor taste and monotonous diets, and perceived negative health outcomes (e.g., ulcers, skin rashes). Key facilitators included availability and affordability during peak-season and particularly when self-produced, ease of preparation, and beneficial health attributes (e.g., build blood, contains vitamins and minerals). To promote healthy diets within at risk-populations in Western Kenya, the findings suggest several interventions to promote the preparation and consumption of AIVs. These include improved household production to subsequently improve affordability and availability of AIVs, improved cooking methods and recipes that excite the family members to consume these dishes with AIVs, and the promotion of the beneficial heath attributes of AIVs while actively dispelling any perceived negative health consequences of their consumption.

Development of Decision Support System Platform for Daily Dietary Plan

Background:

Solving many health issues needs accurate and significant information in food consumption. Recently, data analysis and communication provided outstanding and robust approaches to fulfill the necessity of scientific information and help in decision making in many fields. Many evidence reported that with little information better decisions can be achieved.

Objective:

This research aimed to develop the Decision Support System (DSS) for the daily dietary plan to practically help users in food consumption and health care.

Methods:

The system consists of 1,940 cuisine items, including Thai and English menus. In this system, the user can set the daily dietary plan by selecting menu items with food specific and total calories. Overall calories of selected menu items would be calculated automatically. The user can see the normal range of calories required based on gender with the help of the baseline (normal office person).

Results:

This system can help users to become familiar with a better daily dietary plan, food calories, and health care easily. Furthermore, experts (doctors) can improve their learning experiences by formulating and adjusting the Decision Support System (DSS) for patients in special need. The easiness and usefulness of this system were evaluated by 119 users on Likert scale (1=least, 5=most). The result on average was 4.58.

Conclusion:

The Decision Support System (DSS) for the daily dietary plan was developed. The accessibility to the system is via personal computer (PC), smartphone, and tablet with internet connection. For future work, this DSS can improve by connecting the platform with health care providers via sharing the data for more online support.

Assessing the readiness of small cities in Ghana to tackle overweight and obesity

The rapid rise in the prevalence of overweight and obesity, and the associated health problems, is an emerging challenge in Ghana, and for women in particular. This study contributes to the understanding of this emerging phenomenon in Ghana by analyzing it from a community perspective, applying the Community Readiness Model in two small cities in Ghana. A series of Key Informant Interviews were undertaken and analyzed, using the model’s scoring structure and supplementary textual analysis. We find that communities are aware of overweight and obesity as a health issue, but that it is not prioritized or championed. Furthermore, the diet counseling and keep-fit programs put the responsibility on individuals to address, rather than considering the upstream and structural causes and solutions.

The Supply of Calories, Proteins, and Fats in Low-Income Countries: A Four-Decade Retrospective Study

Over the past decades, both the quantity and quality of food supply for millions of people have improved substantially in the course of economic growth across the developing world. However, the number of undernourished people has resumed growth in the 2010s amid food supply disruptions, economic slowdowns, and protectionist restrictions to agricultural trade. Having been common to most nations, these challenges to the food security status of the population still vary depending on the level of economic development and national income of individual countries. In order to explore the long-run determinants of food supply transformations, this study employs five-stage multiple regression analysis to identify the strengths and directions of effects of agricultural production parameters, income level, price indices, food trade, and currency exchange on supply of calories, proteins, and fats across 11 groups of agricultural products in 1980-2018. To address the diversity of effects across developing nations, the study includes 99 countries of Asia, Europe, Latin America, the Middle East, and Africa categorized as low-income, lower-middle-income, and upper-middle-income economies. It is found that in low-income countries, food supply parameters are more strongly affected by production factors compared to economic and trade variables. The effect of economic factors on the food supply of higher-value food products, such as meat and dairy products, fruit, and vegetables, increases with the rise in the level of income, but it stays marginal for staples in all three groups of countries. The influence of trade factors on food supply is stronger compared to production and economic parameters in import-dependent economies irrelevant of the gross national income per capita. The approach presented in this paper contributes to the research on how food supply patterns and their determinants evolve in the course of economic transformations in low-income countries.

The African urban food environment framework for creating healthy nutrition policy and interventions in urban Africa

This study developed, validated, and evaluated a framework of factors influencing dietary behaviours in urban African food environments, to inform research prioritisation and intervention development in Africa. A multi-component methodology, drawing on concept mapping, was employed to construct a framework of factors influencing dietary behaviours in urban Africa. The framework adapted a widely used socio-ecological model (developed in a high-income country context) and was developed using a mixed-methods research approach that comprised: i. Evidence synthesis consisting of a systematic review of 39 papers covering 14 African countries; ii. Qualitative interview data collected for adolescents and adults (n = 144) using photovoice in urban Ghana and Kenya; and iii. Consultation with interdisciplinary African experts (n = 71) from 27 countries, who contributed to at least one step of the framework (creation, validation/evaluation, finalisation). The final framework included 103 factors influencing dietary behaviours. Experts identified the factors influencing dietary behaviours across all the four levels of the food environment i.e. the individual, social, physical and macro levels. Nearly half (n = 48) were individual-level factors and just under a quarter (n = 26) were at the macro environmental level. Fewer factors associated with social (n = 15) and physical (14) environments were identified. At the macro level, the factors ranked as most important were food prices, cultural beliefs and seasonality. Factors ranked as important at the social level were household composition, family food habits and dietary practices. The type of food available in the neighbourhood and convenience were seen as important at the physical level, while individual food habits, food preferences and socioeconomic status were ranked highly at the individual level. About half of the factors (n = 54) overlap with those reported in an existing socio-ecological food environment framework developed in a high-income country context. A further 49 factors were identified that were not reported in the selected high-income country framework, underlining the importance of contextualisation. Our conceptual framework offers a useful tool for research to understand dietary transitions in urban African adolescents and adults, as well as identification of factors to intervene when promoting healthy nutritious diets to prevent multiple forms of malnutrition.

The Importance of a Food Systems Approach to Low and Middle Income Countries and Emerging Economies: A Review of Theories and Its Relevance for Disease Control and Malnutrition

Our review explores the changing food production, distribution and consumption environment in low and middle-income countries and emerging economies as a basis for framing how to study food systems in order to address public health issues of food safety and nutrition. It presents the state of knowledge on existing food systems science and its use in terms of sustainable actions for food safety and public health. The review identifies a knowledge gap in food system mapping and governance, with value chain mapping of key commodities often missing. Despite a number of initiatives, the application of food systems methods is highly variable in scope and quality. Most analyses concentrate on specific commodities, rarely taking into account the need for a whole diet approach when looking at nutrition or the assessment of a range of infectious agents and their interactions when looking at food safety. Of the studies included in the review there is a growing observation of “informal” food systems, a term used inconsistently and one that requires revision. “Informal” food systems link to the formal sector to provide food security, yet with trade-offs between economic efficiencies and food safety. Efforts to improve food safety are hampered by inadequate food safety capacities and a lack of policy coherence leading to: inadequate investment; fragmented food quality control systems; weak or non-existent traceability mechanisms; weak foodborne disease surveillance; obsolete food regulation; and weak regulatory enforcement. In-depth food systems assessments can complement risk analysis to identify risky behaviors and understand institutional settings in order to improve codes of practice and enforcement. Methods for looking at food safety from a food systems perspective are emerging, yet existing nutrition and food systems science are not advancing sufficiently in response to nutritional public health problems. There is an urgency for improved understanding of the structure and drivers of the food systems, for better planning of changes that leads to nutrients access and healthy levels of eating. It is proposed that countries and international institutions provide an atlas of food system maps for the key commodities based on an agreed common methodology and developed by multidisciplinary teams.

The Processed food revolution in African food systems and the Double Burden of Malnutrition

African consumers have purchased increasing amounts of processed food over the past 50 years. The opportunity cost of time of women and men has increased as more of them work outside the home, driving them to buy processed food and food prepared away from home to save arduous home-processing and preparation labor. In the past several decades, this trend has accelerated with a surge on the supply side of the processing sector and small and medium enterprises (SMEs) and large private companies making massive aggregate investments. Packaged, industrialized, ultra-processed foods and sugar-sweetened beverages (SSBs) are a growing proportion of the processed food consumed. Also, in the past several decades, overweight and obesity have joined the long-standing high levels of stunting and wasting among children and extreme thinness among women of childbearing age. Together these phenomena have formed a double burden of malnutrition (DBM). The DBM has emerged as an important health problem in sub-Saharan Africa. The rise of the DBM and the increase in ultra-processed food consumption are linked. Policy makers face a dilemma. On the one hand, purchases of processed food are driven by long-term factors, such as urbanization, increased income, and employment changes, and thus policy cannot change the pursuit of convenience and labor-saving food. Moreover, much processed food, like packaged milk, is a boon to nutrition, and the processed food system is a major source of jobs for women. On the other hand, the portion (some 10-30%) of processed food that is ultra-processed is a public health challenge, and policy must address its detrimental effects on disease burden. The global experience suggests that double duty actions are most important as are selected policies focused on healthy weaning foods for addressing stunting and taxes on SSBs, nutrition labeling, and other measures can steer consumers away from unhealthy ultra-processed foods to addressing obesity and possibly child nutrition and stunting. We recommend that African governments consider these policy options, but note that the current extreme fragmentation of the processing sector, consisting of vast numbers of informal SMEs in sub-Saharan Africa, and the limited administrative/implementation capacity of many African governments require pursuing this path only gradually.

Improving nutritional status among urban poor children in sub-Saharan Africa: An evidence-informed Delphi-based consultation

In sub‐Saharan Africa (SSA), rapid urbanisation coupled with the high prevalence of infant and young child (IYC) undernutrition in low‐income settings means that interventions to support IYC nutrition are a priority. Little is known about how urbanisation influences IYC feeding (IYCF) practices, and evidence‐based interventions to improve IYC health/nutrition in the urban poor are lacking. Therefore, this research aimed to (a) systematically review evidence on interventions for improving the nutritional status of IYC aged 6–23 months living in urban poor areas (PROSPERO CRD42018091265) and (b) engage stakeholders to identify the highest ranking evidence gaps for improving IYCF programmes/policies. First, a rapid systematic review was conducted. This focused on the literature published regarding nutrition‐specific and nutrition‐sensitive complementary feeding interventions in urban poor areas, specifically low‐income informal settlements, in low‐ and middle‐income countries (LMICs). Six intervention studies met the review inclusion criteria. Intervention adherence was generally high, and indicators of maternal knowledge and IYC nutritional intake typically increased because of the interventions, but the impact on anthropometric status was small. Second, stakeholders working across SSA were engaged via a Delphi‐based approach to identify priority areas for future intervention. Stakeholders reported that a situational analysis was required to better understand IYCF in urban poor areas, particularly the causes of IYC undernutrition, and highlighted the need to involve local communities in defining how future work should proceed. Together, these findings indicate a need for more evidence regarding IYCF and the factors that drive it in urban poor areas across LMIC settings, but particularly in SSA.

Unhealthy eating practices of city-dwelling Africans in deprived neighbourhoods: Evidence for policy action from Ghana and Kenya

Growing urbanisation in Africa is accompanied by rapid changes in food environments, with potential shifts towards unhealthy food/beverage consumption, including in socio-economically disadvantaged populations. This study investigated how unhealthy food and beverages are embedded in everyday life in deprived areas of two African countries, to identify levers for context relevant policy. Deprived neighbourhoods (Ghana: 2 cities, Kenya: 1 city) were investigated (total = 459 female/male, adolescents/adults aged ≥13 y). A qualitative 24hr dietary recall was used to assess the healthiness of food/beverages in relation to eating practices: time of day and frequency of eating episodes (periodicity), length of eating episodes (tempo), and who people eat with and where (synchronisation). Five measures of the healthiness of food/beverages in relation to promoting a nutrient-rich diet were developed: i. nutrients (energy-dense and nutrient-poor -EDNP/energy-dense and nutrient-rich -EDNR); and ii. unhealthy food types (fried foods, sweet foods, sugar sweetened beverages (SSBs). A structured meal pattern of three main meals a day with limited snacking was evident. There was widespread consumption of unhealthy food/beverages. SSBs were consumed at three-quarters of eating episodes in Kenya (78.5%) and over a third in Ghana (36.2%), with those in Kenya coming primarily from sweet tea/coffee. Consumption of sweet foods peaked at breakfast in both countries. When snacking occurred (more common in Kenya), it was in the afternoon and tended to be accompanied by a SSB. In both countries, fried food was an integral part of all mealtimes, particularly common with the evening meal in Kenya. This includes consumption of nutrient-rich traditional foods/dishes (associated with cultural heritage) that were also energy-dense: (>84% consumed EDNR foods in both countries). The lowest socio-economic groups were more likely to consume unhealthy foods/beverages. Most eating episodes were <30 min (87.1% Ghana; 72.4% Kenya). Families and the home environment were important: >77% of eating episodes were consumed at home and >46% with family, which tended to be energy dense. Eating alone was also common as >42% of eating episodes were taken alone. In these deprived settings, policy action to encourage nutrient-rich diets has the potential to prevent multiple forms of malnutrition, but action is required across several sectors: enhancing financial and physical access to healthier foods that are convenient (can be eaten quickly/alone) through, for example, subsidies and incentives/training for local food vendors. Actions to limit access to unhealthy foods through, for example, fiscal and advertising policies to dis-incentivise unhealthy food consumption and SSBs, especially in Ghana. Introducing or adapting food-based dietary guidelines to incorporate advice on reducing sugar and fat at mealtimes could be accompanied by cooking skills interventions focussing on reducing frying/oil used when preparing meals, including 'traditional' dishes and reducing the sugar content of breakfast.

Investigating foods and beverages sold and advertised in deprived urban neighbourhoods in Ghana and Kenya: a cross-sectional study

OBJECTIVES

The aim of this study was to characterise the local foods and beverages sold and advertised in three deprived urban African neighbourhoods.

DESIGN

Cross-sectional observational study. We undertook an audit of all food outlets (outlet type and food sold) and food advertisements. Descriptive statistics were used to summarise exposures. Latent class analysis was used to explore the interactions between food advertisements, food outlet types and food type availability.

SETTING

Three deprived neighbourhoods in African cities: Jamestown in Accra, Ho Dome in Ho (both Ghana) and Makadara in Nairobi (Kenya).

MAIN OUTCOME MEASURE

Types of foods and beverages sold and/or advertised.

RESULTS

Jamestown (80.5%) and Makadara (70.9%) were dominated by informal vendors. There was a wide diversity of foods, with high availability of healthy (eg, staples, vegetables) and unhealthy foods (eg, processed/fried foods, sugar-sweetened beverages). Almost half of all advertisements were for sugar-sweetened beverages (48.3%), with higher exposure to alcohol adverts compared with other items as well (28.5%). We identified five latent classes which demonstrated the clustering of healthier foods in informal outlets, and unhealthy foods in formal outlets.

CONCLUSION

Our study presents one of the most detailed geospatial exploration of the urban food environment in Africa. The high exposure of sugar-sweetened beverages and alcohol both available and advertised represent changing urban food environments. The concentration of unhealthy foods and beverages in formal outlets and advertisements of unhealthy products may offer important policy opportunities for regulation and action.