news 14 March 2019 Country of Focus:Ghana Dietary transitions in Ghanaian Cities: Preliminary findings By Fiona Graham, PhD, Research Associate at the University of Sheffield’s School of Health and Related Research and Senam Klomegah, MPhil, Part-time Lecturer, School of Public Health, University of Health and Allied Sciences (UHAS) Ho. Obesity and diet-related diseases in Ghana are rising, particularly in urban areas. In these studies we set out to understand why and identify what communities and government can do to reverse this trend and improve health. Our research focused on three key areas: people in their communities, neighbourhoods and communities, and priorities for national action. Our studies involved adolescents and adults living in Accra (James Town) and Ho (Ho-Dome). People in their communities We wanted to determine what foods Ghanaians eat, how often they eat, where and with whom they eat. We conducted one-to-one interviews with individuals age 13 and above. We asked them to recall: all food and drink consumed inside/outside the home in the previous 24hr period, the time of day they ate/drank, how long it took them to consume it, where and with whom the food was consumed. Most people consumed three meals a day that were eaten quickly (less than 30 minutes). Shorter meals were more likely to have greater intakes of unhealthy foods and sugar-sweetened beverages, and were more commonly consumed during the morning, in schools and workplaces. Most meals were consumed with families at home; meals eaten outside the home were less common but often eaten with friends or alone. Neighbourhoods and communities We wanted to determine how neighbourhoods and people in their lives influence food choices in everyday life. We gave cameras to local residents and asked them to take photographs of: places where they eat, things that influence what they eat in their neighbourhood, someone who influences what they eat, things that make eating healthy easy or difficult. Factors in the physical environment influencing dietary behaviours Food hygiene was important when choosing where to eat “They keep that place very well. They sell by a gutter but, when they come, they clean the gutter very well before they sell. They have glass covering all their food. And the place they give you to sit if you are eating the food there, is very neat, there is soap, to use in washing your hands. When you eat, you enjoy it, even if the food is not so nice at times, you will enjoy it because of how the place is kept. How the place is neat, makes me want to eat over there.”(Female adolescent, 15-18 years, lowest SES, Ho) Environmental sanitation was a key consideration “As you can see the place is not neat… if you cook in a place like this and sell, I will not buy food from you to eat. That is why I took this picture. As you can see in this picture there are dirty rags on the ground and the place is littered with plastic rubbers. You can also see a bag full of empty sachet water rubbers.” (Female adult, 19-49 years, lowest SES, lactating, Accra) Food adulteration by street vendors was a common concern “Some food sellers also go and buy rotten and spoilt items to cook. I have also seen at the milling shop were rotten tomatoes, pepper and onion with maggots all over the container being milled together to be used to prepare food for people to buy and eat. These are happening in the larger markets like Makola so I prefer to cook at home to avoid all these things.” (Male adult, over 50 years, lowest SES, Accra) Financial access was a barrier to a healthy diet “When you have [money] then you can buy something to cook at home, and when you cook it, you can get some health from it. But if you don’t have money, and you go to the roadside to buy something…people do not take care of how they cook their food, when you eat, you can fall sick. So when you have money and you buy the foodstuff and cook at home, you will have nothing to worry about with regards to your health. So money is needed, everywhere.” (Female adult, 19-49 years, lowest SES, lactating, Ho) People in the community influence dietary behaviours Being in charge of the cooking of meals “This picture shows my mum… what she cooks at home is what I eat home. She is very selective of what we should eat because of my little brother and so she is mindful to cook what will be good for us for us to grow strong because at the end of the day when we get sick she will end up spending more money at the hospital so in order for her to prevent that she makes us eat good food, selecting the right nutrients.” (Female adult, 19-49 years, low-to-middle SES, Accra) Following family’s food preferences and needs “It is because of them that I eat a lot or eat a healthy food to get more breast milk for them to feed on. Because if I don’t eat a lot or eat a healthy food, they will not get the breast milk to feed on and they need to grow well…” (Female adult, 19-49 years, low-to-middle SES, lactating, Ho) Friends gather together for eating/cooking and have established practices “In the picture you can see some Banku there with my paddies (friends), showing we are about to eat. We normally eat this food with my boys sometimes every Tuesday or every Friday.” (Male adult, 19-49 years, low-to-middle SES, Accra.) We also wanted to characterise the food sold and advertised in James Town and Ho Dome. We conducted a survey of food outlets, and recorded what type of outlet it was, all items sold, whether there were any adverts and what they were advertising. Informal vendors (kiosks, local sellers, table tops) selling energy dense nutrient poor foods were more common in James Town, with shops more common in Ho Dome. Dried and processed foods and sugar-sweetened beverages were commonly available in both areas. Between 25%-39% of all outlets contained at least one advert, most commonly for sugar-sweetened beverages and alcohol. Regulating advertisements appears important for supporting healthy food choices, particularly in more formal outlets. To determine how ready these communities were to reduce unhealthy food and beverage consumption, we interviewed community members and leaders. This process revealed that community members had limited knowledge and some misconceptions about the diet-related health issues in the community. There was also limited awareness of local efforts and the resources that were available to address them. Although there were concerns about unhealthy food and beverage intake, they were not sufficient to motivate community members to action. Priorities for national action We wanted to understand what national experts in Ghana believe government policy priorities should be to address these dietary health issues. We used The Healthy Food Environment Policy Index to benchmark where Ghana is with regards to implementing evidence informed strategies to address the diet-related diseases. Nineteen experts rated the extent of government action and proposed and prioritised actions to improve the food environment. Policy actions identified as important and achievable were: legislation and regulation of food promotion/sponsorship / advertisements in schools and via the media, support nutrition advocates with the development food labelling system and implementation of the requirement for school caterers to pass a healthy meal planning course. In addition to policies, the government should support the development of a food composition database and dietary guidelines to promote healthy eating. Support for research on nutrition and diet-related diseases, was recommended plus regular surveillance and monitoring of the food environment. Our research has revealed the important influence the physical and social environment has on food choices. We also identified priorities for government policies to legislate and regulate unhealthy food and beverage promotion, sponsorship and advertisements in neighbourhoods, which will be important to improve dietary choices and health in Ghanaian cities. Acknowledgements The ‘Dietary transitions in Ghana’ project was funded by a grant from the Drivers of Food Choice (DFC) Competitive Grants Programme which is funded by the Bill & Melinda Gates Foundation and the Department for International Development (DFID), and managed by the University of South Carolina Arnold School of Public Health, USA. DFC supports new research on understanding food choice among the poor in low and middle-income countries, strengthening country-level leadership in nutrition and fostering a global community of food-choice researchers. The “Dietary Transitions in Ghanaian Cities” project is being delivered by the Universities of Sheffield, Loughborough, Liverpool, Ghana, Health and Allied Sciences and the CIRAD-Agricultural Research for Development in France. More details of the project can be found on our project website: https://scharr.dept.shef.ac.uk/dfc/. The TACLED project was funded by a Global Challenges Research Fund Foundation Award led by the MRC, and supported by AHRC, BBSRC, ESRC and NERC, with the aim of improving the health and prosperity of low and middle-income countries. The “TACLED (Dietary Transitions in African Cities: Leveraging Evidence for interventions and policy to prevent Diet-related noncommunicable diseases)” project is being delivered by the Universities of Sheffield, Loughborough, Liverpool, Ghana and the African Population and Health Research Center, Kenya (APHRC). More details of the project can be found on our project website: https://scharr.dept.shef.ac.uk/tacled/. We would like to thank all those in Ho and Accra who generously gave their time to participate in our studies.