Browsing by Author "Holdsworth, M."

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The African urban food environment framework for creating healthy nutrition policy and interventions in urban Africa
(PLOS ONE, 2021) Osei-Kwasi, H.A.; Laar, A.; Zotor, F.; Pradeilles, R.; Aryeetey, R.; Green, M.; Griffiths, P.; Akparibo, R.; Wanjohi, M.N.; Rousham, E.; Barnes, A.; Booth, A.; Mensah, K.; Asiki, G.; Kimani-Murage, E.; Bricas, N.; Holdsworth, M.
This study developed, validated, and evaluated a framework of factors influencing dietary behaviours in urban African food environments, to inform research prioritisation and inter vention development in Africa. A multi-component methodology, drawing on concept map ping, 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.
Conference on ‘Nutrition dynamics in Africa opportunities and challenges for meeting the sustainable development goals’
(Proceedings of the Nutrition Society, 2017) Aryeetey, R.; Colecraft, E.; Holdsworth, M.; et al.
Although a substantial amount of nutrition research is conducted in Africa, the research agenda is mainly donor-driven. There is a clear need for a revised research agenda in Africa which is both driven by and responding to local priorities. The present paper summarises the proceedings of a symposium on how evidence can guide decision-makers towards context-appropriate priorities and decisions in nutrition. The paper focuses on lessons learned from case studies by the Evidence Informed Decision Making in Nutrition and Health Network implemented between 2015 and 2016 in Benin, Ghana, and South Africa. Activities within these countries were organised around problem-oriented evidence-informed decision-making (EIDM), capacity strengthening and leadership, and horizontal collaboration. Using a combination of desk-reviews, stakeholder influence-mapping, semi-structured interviews and convening platforms, these country-level studies demonstrated a strong interest in partnership between researchers and decision-makers, and the use of research evidence for prioritization and decision-making in nutrition. Identified capacity gaps were addressed through training workshops on EIDM, systematic reviews, cost-benefit evaluations, and evidence contextualization. Investing in knowledge partnerships and the development of capacity and leadership are key to driving the appropriate use of evidence in nutrition policy and programming in Africa.
Dietary behaviours in the context of nutrition transition: a systematic review and meta-analyses in two African countries
(Public Health Nutrition, 2020-03-11) Aryeetey, R.; Rousham, E.K.; Pradeilles, R.; Akparibo, R.; Bash, K.; Booth, A.; Muthuri, S.K.; Osei-Kwasi, H.; Marr, C.M.; Norris, T.; Holdsworth, M.
Objective: To synthesise evidence of urban dietary behaviours (macronutrients, types of foods, dietary diversity and dietary practices) in two African countries in relation to postulated changes in the context of nutrition transition. Design: Systematic review and meta-analyses, including six online databases and grey literature, 1971–2018 (Protocol CRD42017067718). Setting: Urban Ghana and Kenya. Participants: Population-based studies of healthy adolescents and adults. Results: The forty-seven included studies encompassed 20 726 individuals plus 6526 households. Macronutrients were within WHO-recommended ranges: mean energy intake was 1867 kcal/d (95 % CI 1764, 1969) and the proportions of macronutrients were carbohydrate 61·2 % (58·4, 64·0), fat 25·3 % (22·8, 28·0) and protein 13·7 % (12·3, 15·1). The proportion of population consuming fruit and vegetables was 51·6 %; unhealthy foods, 29·4 %; and sugar-sweetened beverages (SSBs), 39·9 %. Two-thirds (68·8 %) consumed animal-source proteins. Dietary diversity scores were within the mid-range. Meal patterns were structured (typically three meals per day), with evidence lacking on snacking or eating out. Conclusions: Population-level diets fell within WHO macronutrient recommendations, were relatively diverse with structured meal patterns, but some indications of nutrition transition were apparent. The proportion of population consuming fruit and vegetables was low compared to healthy-eating recommendations, and consumption of SSBs was widespread. A paucity of evidence from 1971 to 2010 precluded a longitudinal analysis of nutrition transition. Evidence from these two countries indicates which aspects of dietary behaviours may be contributing to increasing overweight/obesity, namely a low proportion of population consuming fruit and vegetables and widespread consumption of SSBs. These are potential targets for promoting healthier diets
Factors influencing dietary behaviours in urban food environments in Africa: a systematic mapping review
(Public Health Nutrition, 2020-05-26) Laar, A.; Booth, A.; Mohindra, A.; Wanjohi, M.; Graham, F.; Pradeilles, R.; Cohen, E.; Holdsworth, M.
Objective: To identify factors influencing dietary behaviours in urban food environments in Africa and identify areas for future research. Design: We systematically reviewed published/grey literature (protocol CRD4201706893). Findings were compiled into a map using a socio-ecological model on four environmental levels: individual, social, physical and macro. Setting: Urban food environments in Africa. Participants: Studies involving adolescents and adults (11–70 years, male/female). Results: Thirty-nine studies were included (six adolescent, fifteen adolescent/adult combined and eighteen adult). Quantitative methods were most common (twentyeight quantitative, nine qualitative and two mixed methods). Studies were from fifteen African countries. Seventy-seven factors influencing dietary behaviours were identified, with two-thirds at the individual level (45/77). Factors in the social (11/77), physical (12/77) and macro (9/77) environments were investigated less. Individual-level factors that specifically emerged for adolescents included selfesteem, body satisfaction, dieting, spoken language, school attendance, gender, body composition, pubertal development, BMI and fat mass. Studies involving adolescents investigated social environment-level factorsmore, for example, sharing food with friends. The physical food environment was more commonly explored in adults, for example, convenience/availability of food.Macro-level factors associated with dietary behaviours were food/drink advertising, religion and food prices. Factors associated with dietary behaviour were broadly similar for men and women. Conclusions: The dominance of studies exploring individual-level factors suggests a need for research to explore how social, physical and macro-level environments drive dietary behaviours of adolescents and adults in urban Africa. More studies are needed for adolescents and men, and studies widening the geographical scope to encompass all African countries
How ready are communities to implement actions to improve diets of adolescent girls and women in urban Ghana?
(BMC Public Health, 2019-05-15) Laar, A.; Pradeilles, R.; Marr, C.; Holdsworth, M.; Zotor, F.; Tandoh, A.; Klomegah, S.; Coleman, N.; Bash, K.; Green, M.; Griffiths, P.L.
Background: Ghana has reached an advanced stage of nutrition transition, contributing to an increase in nutrition-related non-communicable diseases, particularly amongst urban women. Community involvement is an important factor in the success of efforts to promote healthy eating. The readiness of populations to accept a range of interventions needs to be understood before appropriate interventions can be implemented. Therefore, this study assessed how ready urban communities are to improve diets of women of reproductive age in Ghana. Methods: Using the Community Readiness Model (CRM), in-depth interviews were conducted with 24 key informants from various sectors in low income communities across two cities in Ghana: Accra and Ho. The CRM consists of 36 open questions addressing five readiness dimensions (community knowledge of efforts, leadership, community climate, knowledge of the issue and resources). Interviews were scored using the CRM protocol with a maximum of 9 points per dimension (from 1 = no awareness to 9 = high level of community ownership). Thematic analysis was undertaken to gain insights of community factors that could affect the implementation of interventions to improve diets. Results: The mean community readiness scores indicated that both communities were in the “vague awareness stage” (3.35 ± 0.54 (Accra) and 3.94 ± 0.41 (Ho)). CRM scores across the five dimensions ranged from 2.65–4.38/9, ranging from denial/resistance to pre-planning. In both communities, the mean readiness score for ‘knowledge of the issue’ was the highest of all dimensions (4.10 ± 1.61 (Accra); 4.38 ± 1.81 (Ho)), but was still only at the pre-planning phase. The lowest scores were found for community knowledge of efforts (denial/resistance; 2.65 ± 2.49 (Accra)) and resources (vague awareness; 3.35 ± 1.03 (Ho)). The lack of knowledge of the consequences of unhealthy diets, misconceptions of the issue partly from low education, as well as challenges faced from a lack of resources to initiate/sustain programmes explained the low readiness. Conclusions: Despite recognizing that unhealthy diets are a public health issue in these urban Ghanaian communities, it is not seen as a priority. The low community readiness ratings highlight the need to increase awareness of the issue prior to intervening to improve diets.
Implementation of healthy food environment policies to prevent nutritionrelated non-communicable diseases in Ghana: National experts’ assessment of government action
(Food Policy, 2020-05-19) Laar, A.; Barnes, A.; Aryeetey, R.; Tandoh, A.; Bash, K.; Mensah, K.; Zotor, F.; Vandevijvere, S.; Holdsworth, M.
Nutrition-related non-communicable diseases (NR-NCDs) are a global health problem, increasingly recognised as driven by unhealthy food environments. Yet little is known about government action to implement food environment- relevant policies, particularly in low-and lower-middle income countries. This study assessed government action, implementation gaps, and priorities to improve the food environment in Ghana. Using the Healthy Food-Environment Policy Index (Food-EPI), a panel comprising government and independent experts (n = 19) rated government action to improve the healthiness of food environment in Ghana against international best practices and according to steps within a policy cycle. Forty-three good practice indicators of food environment policy and infrastructure support were used, with ratings informed by systematically collected evidence of action validated by government officials. Following the rating exercise, the expert panel proposed and prioritized actions for government implementation. Three-quarters of all good practice indicators were rated at ‘low’/‘very little’ implementation. Restricting the marketing of breast milk substitutes was the only indicator rated “very high”. Of ten policy actions prioritized for implementation, restricting unhealthy food marketing in children’s settings and in the media were ranked the highest priority. Providing sufficient funds for nationallyrelevant research on nutrition and NCDs was the highest priority infrastructure-support action. Other priority infrastructure-support actions related to leadership, monitoring and evaluation. This study identified gaps in Ghana’s implementation of internationally-recommended policies to promote healthy food environments. National stakeholders recommended actions, which will require legislation and leadership. The findings provide a baseline for measuring government progress towards implementing effective policies to prevent NR-NCDs.
Review of policy action for healthy environmentally sustainable food systems in sub-Saharan Africa
(Current Opinion in Environmental Sustainability, 2023) Holdsworth, M.; Kimenju, S.; Hallen, G.; Laar, A.; Oti, S.O.
Many sub-Saharan African (SSA) countries are experiencing multiple burdens of malnutrition. Rising overweight/obesity coexist alongside persistent burdens of under-nutrition and multiple micronutrient deficiencies. Poverty and social inequity remain key drivers of unhealthy diets and malnutrition. Diets in SSA are increasingly transitioning towards unhealthy (energy dense, nutrient-poor and unsafe) and environmentally unsustainable diets. Healthy, sustainable food systems are required to deal with these considerable challenges equitably, so policy action needs to balance the health, environmental and economic dimensions of diets and food systems. We review evidence in recent literature for which policy actions have the best chance of success in SSA by appraising their likely impact, relevance, cost/affordability and feasibility to help guide policymakers and researchers in their development and evaluation.
Unhealthy eating practices of city-dwelling Africans in deprived neighbourhoods: Evidence for policy action from Ghana and Kenya
(Global Food Security, 2020) Holdsworth, M.; Pradeilles, R.; Tandoh, A.; et al.
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 di etary 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.