The Built Environment and the Risk of Obesity among the Urban Poor in Accra, Ghana

Abstract

BACKGROUND: Obesity has become a major public health problem globally. Once more common in developed countries, the prevalence of obesity has been observed to be increasing in developing countries as well. In the past, obesity was attributed to factors such as individual genetic make-up and lifestyle behaviours. These factors however, do not exclusively explain the global increase in the prevalence of obesity over the last three decades. Rather, a built environment that encourages excess calorie consumption and physical inactivity has been proposed as a more likely explanation. OBJECTIVES: The influence of the built environment on obesity has been extensively documented in developed countries but continues to remain a grey area in developing countries, especially in the sub-Saharan Africa region. This study examines the built environment in an urban poor Ghanaian context and investigates how the built environment influences the risk of obesity for residents of these urban poor settings. METHODOLOGY: This study was conducted in three urban poor communities (James Town, Ussher Town and Agbogbloshie) in Accra, Ghana. The study involved the collection of primary data at two levels: the individual and community levels. At the individual level, data were collected on socio-demographic characteristics, lifestyle behaviours and anthropometric measures including weight, height and waist circumference through a survey. At the community level, Geographic Positioning System (GPS) technology was used to gather data on the features of the built environment including the location and number of out-of-home cooked foods, convenience stores, fruit and vegetable sales points and physical activity spaces. Qualitative data on community norms and perceptions about ideal body size and dietary and physical activity behaviours were also collected through focus group discussions. A mix of spatial, qualitative and quantitative analysis tools were used to analyse the data. The dependent variable for the study was obesity which was measured using body mass index (BMI) and waist-to-height ratio while the features of the built environment were used as the main independent variables. RESULTS: The built environment in the study area is suggestive of one that is “obesogenic”. There were more options for out-of-home cooked foods and convenience stores but fewer options for fruits and vegetables and physical activity spaces. Each additional out-of-home cooked food place located in the community was associated with an approximate 0.1 kg/m2 decrease in BMI while each additional convenience store was associated with a 0.2 kg/m2 increase in BMI after controlling for population density, crime level, social cohesion, trust among community members, perception about community ideal body size and individual socio-demographic characteristics and lifestyle behaviours. Also, the presence of a physical activity space in the community was associated with a 0.4 kg/m2 reduction in BMI although statistical significance was not achieved. The results of sex stratified models show a 0.1 kg/m2 reduction in BMI for each additional out-of-home cooked food place among females (at P<0.10) but not among males. The features of the built environment did not show a significant influence on waist-to-height ratio in the general model and sex stratified models although contributing to the variance. CONCLUSIONS: This study demonstrates the existence of a built environment that influences the risk of obesity in an urban poor Ghanaian context. The influence of the built environment on obesity differs depending on the measure of obesity and also differs for males and females. There is the need to expand the scope of obesity research in the sub-Saharan African region by examining the contribution of the built environment.