Afr. J. Food Agric. Nutr. Dev. 2022; 22(2): 19702-19726 https://doi.org/10.18697/ajfand.107.21830 PROCESS AND LESSONS LEARNED IN THE DEVELOPMENT OF FOOD-BASED DIETARY GUIDELINES IN GHANA Aryeetey R1* and AI Ramos2 Richmond Aryeetey *Corresponding author email: raryeetey@ug.edu.gh 1University of Ghana School of Public Health, Legon, Ghana 2Food and Agriculture Organization, Rome, Italy https://doi.org/10.18697/ajfand.107.21830 19702 ABSTRACT Food-based dietary guidelines (FBDGs) are used, globally, as a tool for promoting awareness of healthy diets and, thereby, to improve dietary behaviour. It is also used as a policy framework for creating a health-promoting food environment. In sub-Saharan Africa, only a few countries have developed FBDGs. In 2016, Ghana commenced the process for developing a national FBDG. Four years down the line, significant progress has been achieved towards developing dietary guidelines for persons living in Ghana. The process for developing Ghana's FBDGs has, generally, follow the plan proposed by the 1998 FAO/WO consultative meeting on development of FBDGs, but with minor deviations. These deviations have been occasioned by the need to adapt the process to accommodate context-relevant circumstances relating to local capacity and financial resources constraints. The first step in developing Ghana’s FBDGs was to set up a national Multisectoral Technical Task Team (MTTT) under the policy direction of the Ministry of Food and Agriculture. Thereafter, an evidence review exercise was carried out, involving systematic review of existing literature, complemented by primary data collection, all aimed at understanding the priority foods, nutrition and health issues to be addressed by recommendations in the FBDGs. The key issues identified in the evidence review were validated by the MTTT and subsequently prioritized using an online survey, as well as a prioritization workshop that convened key stakeholders in nutrition and health in Ghana. Subsequently, the priority issues served as the basis for the crafting of technical recommendations. The aim of this paper is to describe the processes, people, data, and resources that have facilitated progress towards development of Ghana’s FBDGs. The challenges, and limitations of the process, as well as the solutions that have been employed to overcome them, have also been highlighted here. For the benefit of future FBDGs development in Ghana and elsewhere, the key lessons that have been learned in the development of Ghana’s FBDGs have been presented, including lessons on political will, planning and time management, resources, capacity development, and multi-sectoral action. Key words: Food-based dietary guidelines, Ghana, diet, food system, evidence review https://doi.org/10.18697/ajfand.107.21830 19703 BACKGROUND The Republic of Ghana is located on the coast of West Africa and is considered a model country for several reasons[1]. With a per capita gross domestic product of about 2200 United States Dollars[2], Ghana is a stable democracy[3] and is among the best performing economies in the West Africa sub-region. Since 2010, Ghana has been classified by the World Bank as a lower middle income country (LMIC)[4]. In addition, the country has experienced sustained economic growth and reduction in income poverty[5, 6]. Indeed, Ghana was the first country in sub-Saharan Africa (SSA) to achieve the Millennium Development Goals’ poverty reduction target [5, 7]. In addition, there is evidence of significant improvement in availability and access to health services, information technologies, roads, water, and other infrastructure and basic amenities[8]. However, this relatively strong economic and human development performance has not translated into robust health and wellbeing outcomes [9, 10]. Undernutrition, particularly among young children remains at unacceptably high [11, 12]. Anemia, a proxy for chronic micronutrient deficiency, remains high among vulnerable populations (women of reproductive age, and young children) [11]. In addition, there is increasing prevalence of overweight and other diet-related non-communicable diseases[11, 13, 14]. Globally, sub-optimal diets, across the entire lifecycle, constitute an important driver of malnutrition[15]. Currently, child breastfeeding and complementary feeding remain suboptimal in Ghana and does not show any signs of improving [11, 12, 16]. Although the FAO food balance sheet data demonstrate a situation of low prevalence of undernourishment (indicative of food availability)[17, 18], household food insecurity remains high with wide equity gaps among sub-population groups across the country [19, 20]. Food-based dietary guidelines (FBDGs) constitute an important evidence-informed tool and a framework for promoting consumption of healthy diets, as well as guidance for living healthier lifestyles[21, 22]. Traditionally, FBDGs have been designed in a way that enables lay populations to learn about health-promoting food groups, optimal dietary patterns, and lifestyles[21, 23]. In addition, FBDGs can also guide food-related government policies and programs. Because of the important role of FBDGs for populations, the process for design is important[22, 23]. Key aspects of the FBDGs development process, across the globe, are the need to rely on solid evidence as a basis for the guidance, that an open system of broad consultation is implemented across expert stakeholders, and the involvement of end-user groups to improve their effectiveness, ensure appropriateness, and acceptability and to engage the public. This rigorous process is intended to ensure an evaluation of the key nutrition problems, as well as review and use of the best accessible evidence on healthy diets and their relationships with human health and wellbeing. However, there is a considerable lack of national FBDGs in the Africa sub-region[22]. Currently, the Food and Agriculture Organization’s repository of FBDGs shows only https://doi.org/10.18697/ajfand.107.21830 19704 seven countries that have developed and published national FBDGs. Ghana has never developed national food- based dietary guidelines. In 2010, the Ministry of Health (MoH) developed a document that was titled, Dietary and Physical activity guidelines[24]. However, this document was not intended for use by the general public. It was designed as a technical guide for training program managers. Also in 2009, the Ghana Health Service (GHS), in partnership with UNICEF, developed, Nutrition facts for Ghanaian families, a document intended to provide dietary messages aimed at improving health and wellbeing of Ghanaians[25]. However, similar to the MoH document, it was not designed for the general public, but instead, for extension workers involved in nutrition communication. While these two documents are the closest to FBDGs in Ghana, at the national level, neither of them meets the key quality criteria for a truly food-based dietary guideline[22, 23]. At the subnational level, there has been an attempt to develop district-level food-based dietary guidelines as part of a dietary study of young children[26]. In addition to these documents, multiple agencies have developed initiatives and policies that include guidance on improving diets, although these are not intended to be used as dietary guidelines (see Table 1). Therefore, there still remains an unmet need for evidence-informed recommendations on diets and behaviours, and which targets the general public with the aim of promoting health and well-being. A recent stakeholder review of existing government policies in Ghana has recommended the development of FBDGs in Ghana as a high priority and a feasibly high intervention to improve population diets and health[27]. The absence of national FBDGs has created opportunity for misinformation on diets[28]. In the last few years, there has been increased access to unsubstantiated and, often, inaccurate information promoted widely through various media (radio, television, social media) to unsuspecting and uninformed lay population[29]. Further, there is absence of contextually-appropriate and nationally-mandated standards for diet therapy by trained nutrition and dietetics professionals. As a result, nutrition and dietetics professionals rely on FBDGs from other countries. However, FBDGs from other countries have not been developed using foods and diets from the Ghanaian context; thus, the foods and food groups included are often not culturally suitable to the Ghanaian consumer. This creates a challenge for dietitians when translating such FBDGs for use in Ghana. In the Ghanaian context, FBDGs can be useful, not only as a communication tool for the public, but also as a guide for food and nutrition security program implementation across multiple government and non-government institutions. There are already existing population-based government initiatives across multiple agencies (both nutrition-sensitive and nutrition-specific) which are linked to food and diets. Some of the key food-related initiatives that can be influenced and guided by national FBDGs include the Livelihood Empowerment Against Poverty (LEAP) cash grant program[30, 31], school feeding program[32, 33], dietary aspects in basic and high school curriculum, national agriculture investment[34], food fortification[35], infant and young child feeding[36], nutrition information promotion through the health system, https://doi.org/10.18697/ajfand.107.21830 19705 and food regulation legislation (Table 1). The lack of national FBDGs limits consistency and coherence across these programs. This paper describes the processes employed in the development of Ghana’s first, truly food-based, dietary guidelines. This paper provides a basis for understanding the opportunities that have been leveraged for the FBDGs development as well as the challenges that needed to be surmounted in order to develop the FBDGs. This paper also outlines the lessons learned in the implementation of the FBDGs in a way that can serve as guidance for other African countries which will embark on a process of developing national FBDGs. Process for developing Ghana’s Food- based dietary guidelines The development of Ghana’s FBDGs basically followed the process outlined in the FAO/WHO guidance on development of FBDGs (Figure 1)[23, 37]. However, the actual implementation has involved some modifications to this approach, occasioned by an ongoing revision of the FAO FBDGs development process, as well as implementation-related situations and circumstances that were often unanticipated. A significant component of the FBDGs development process that required convening was carried out virtually as part of efforts to contain the SARS-COV-2 pandemic. The remainder of the paper will focus on describing how the process has been followed. In 2016, a delegation of three persons attended a workshop on FBDGs, organized by the FAO, in South Africa. Participation in this workshop represents one of the earliest indications of the Ghana government’s interest to develop a national FBDGs. In the same year, the Ghana Health Service published the National Nutrition Policy, which also indicated the government’s interest in developing dietary guidelines for the population[9]. Thereafter, in 2017, the University of Ghana’s School of Public Health (UGSPH) partnered with the University of Sheffield, Loughborough University, and the Africa Public Health Research Centre initiated a research project (TACLED) that prioritized FBDGs development as a deliverable. TACLED is an acronym for Dietary Transitions for African Cities: Leveraging Evidence for interventions and policy to prevent Diet-related noncommunicable diseases. TACLED was aimed at mapping the factors that are associated with food consumption patterns and how the evidence could be leveraged to address diet-related NCDs. With the funding provided through TACLED, UGSPH partnered with the Ministry of Food and Agriculture (MoFA) and co-convened selected key stakeholders from government and non-government partner institutions to initiate the FBDGs development process. During this process, a concept note for the FBDGs was prepared, a national multisectoral technical task team (MTTT) established and MTTT commenced meetings to start the process of FBDGs development. Between 2017 and 2018, the MTTT convened four meetings during which the scope and objectives, evidence review, and guiding principles for the FBDGs were established. Also, during these two years, the TACLED project generated primary evidence that contributed to the evidence review process for FBDGs development in Ghana, particularly evidence on dietary intake and food environments [38-41]. The work of the MTTT was, however, stalled by the expiration of the TACLED project in 2018. https://doi.org/10.18697/ajfand.107.21830 19706 In 2018, the MTTT reached out to the FAO for technical and financial support to continue the FBDGs development. In response to this request, the FAO organized a capacity building workshop for Ghana’s MTTT members, and other selected stakeholders, in 2019. This workshop focused on the preparations for implementing a FBDGs, particularly, the process of evidence review. Following the capacity building workshop, the FAO provided funding and technical support to the Ghana MTTT through the UGSPH. Establishment of Task team: Ghana’s FBDGs MTTT was established under the joint leadership of MoFA and UGSPH. Because the FBDGs need to be anchored in a government entity (a ministry, an agency or an institute), the Ministry of Food and Agriculture (MoFA) led the process of inviting stakeholder institutions to participate in the MTTT. Following the capacity building workshop and funding received from the FAO, additional stakeholders were invited to participate in the MTTT, increasing its membership from seven to 21. In addition to these, other institutions invited themselves to participate in the MTTT. The expanded MTTT had experts representing a broader range of partner institutions (Table 2). The expanded MTTT was given its terms of reference in August 2020 and commenced work immediately. However, it was not until December 2020 when it was formally inaugurated by the Ministry of Food and Agriculture. The MTTT has since completed the process of confirming the objectives and scope for the FBDGs, agreed on guiding principles for the FBDGs, validated the evidence review, and prioritized the key issues that will inform the FBDGs based on the validated evidence. FBDGs objectives and targets: Based on the validated and prioritized evidence, the MTTT discussed and identified the key dietary challenges in Ghana. Based on this, the prioritized issues for the FBDGs were identified as child undernutrition, adolescent and adult overweight and obesity, and micronutrient deficiencies across the general population. In addition, malnutrition among the elderly was also identified, by consensus as a key problem, although there is limited published evidence on this issue. It was suggested that experts on health issues of the aged should be invited to support the work of the MTTT when discussing recommendations for older persons. The MTTT also discussed and agreed on a list of 12 guiding principles for Ghana’s FBDGs development, as outlined in Box 1. https://doi.org/10.18697/ajfand.107.21830 19707 Box 1: guiding principles for development of the national Food based dietary guidelines for Ghana 1. Be evidence-based 2. Focus not just on nutrition but also health 3. Tackle patterns of food intake 4. Be culturally acceptable and sensitive 5. Focus on practicality 6. Be food-based rather than nutrient based 7. Gender sensitive 8. Sensitive to the needs of vulnerable groups 9. Have lifestyle recommendation 10. Be user friendly 11. Food groups that Ghanaians will understand 12. Guidelines on role of family and friends Figure 1: Proposed pathway for development of Food-based dietary guidelines Review of evidence: The evidence review covered a wide range of questions that were guided by a list compiled by the FAO for this purpose. The FAO list was altered minimally, and often, based on existing evidence. The review topics were divided into 10 main categories (Box 2). Nine of the topics were focused on evidence about diets in the local Ghanaian context. The tenth topic was focused on international evidence on nutrition/diet and disease relationships as well as recommendations from globally applicable evidence reviews. This topic provided evidence for designing the technical messages for the FBDGs. The evidence for each topic was reviewed by a local experts across various research institutions in Ghana, and in some cases, in partnership with external research partners (Table 3). Graduate students from these institutions were involved in carrying out most of the reviews. Each of the topics were reviewed using existing evidence from published peer reviewed literature as well as from grey literature, including reports of nationally representative surveys, policy/program documents, as well as program/institutional reports relevant to https://doi.org/10.18697/ajfand.107.21830 19708 the topic. A systematic repeatable process was adopted in the review of each topic. The evidence review was restricted to documents that were published in the last 10 years; government policies that were older than 10 years, but which were still applicable beyond 10 years were included. The review methodology and findings of all the topic reviews have been published (reference supplement editorial). The reviews were initiated and completed between March and September 2020. Validation of evidence: Although an initial evidence review was carried out in 2018, it was not as comprehensive and systematic as the one that was carried out in 2020, following the FAO-led capacity building workshop in 2019. The second evidence review was initiated at the peak of the initial outbreak of the novel SARS-COV-2 pandemic. Thus, the validation process, which was intended to be completed within a 4-day in-person meeting, was delayed significantly. This was because the pandemic containment regulations in Ghana did not allow face-to-face meetings. Also, some of the evidence reviews were delayed and thus were not all ready at the time the evidence validation began. The process of validation was in two stages. The first part was a series of online presentations of the evidence review findings to the MTTT in virtual seminars via the Zoom virtual meeting platform. During these virtual meetings, reviewers of the various topics presented the findings and opportunity was provided for the MTTT members to interact with the reviewers, ask clarification questions and to suggest additional evidence sources, as well as make other input to improve the review reports. The ‘breakout room’ function of Zoom was useful for creating smaller groups of MTTT members to enable more in-depth discussion of the review findings. Prior to each topic’s presentation, the report was shared with MTTT members to enable them read the report prior to presentation of the summary. In addition, all PowerPoint presentations and evidence review reports were shared with MTTT members using google drive virtual folder. Following each presentation, reviewers had opportunity to revise and finalize and submit an updated report. An average of 17 participants (range:14-29) attended the online validation meetings. In October 2020, a one-day face-to-face meeting was held to allow the MTTT to have a final validation discussion of all the key evidence across all the nine local evidence topics. To facilitate this process, a printed copy of the summary evidence for each topic was provided to participants. Following a PowerPoint presentation of all the evidence, the committee validated the evidence for that topic through a secret poll. This process was continued until all the evidence was validated. The validation process in this meeting also identified further evidence that needed to be addressed; these evidence gaps were filled, subsequently, by the reviewers. Prioritization of FBDGs issues: prioritization of the validated evidence was carried out in a two-step process. The first step involved an online google forms survey of key issues from the validated evidence. The survey was open only to MTTT members. Following the survey, the summarized responses from the survey were discussed via an online zoom meeting to confirm and finalize the priority issues for Ghana’s FBDGs. As part of the prioritization meeting, the MTTT also discussed and finalized decisions on https://doi.org/10.18697/ajfand.107.21830 19709 the scope of Ghana’s FBDGs. It was agreed that Ghana’s FBDGs will be designed to meet the needs of the entire population of Ghana, across all age groups. In addition, the FBDGs will make specific recommendations to cover the dietary guidance needs of pregnant and lactating women. The MTTT also decided that the recommendations will not only focus on behaviour change messages targeting individuals and groups, but will also recommend changes that will influence how diet-related policies and programs are formulated and implemented across government and non-government agencies, including recommendations for food systems, and food environments. Formulation of Key messages: In November 2020, the MTTT commenced discussions on technical messages for the FBDGs. The FBDGs recommendations developed messages in response to the findings of the prioritized nutrition problems. The technical message development focused an overall message of promoting diet diversity across six main food groups as well as a discretionary food group. The six main food groups were 1. fruits; 2. vegetables; 3. fat and oils; 4. cereals, grains, roots, and tubers; 5. Animal Source foods; and 6. Legumes and nuts. The six food groups were based on evidence of food groups commonly consumed in Ghana as well as stakeholder technical understanding of the food consumption behaviour of persons living in Ghana[40]. Diet Modelling: Two experts have worked together, with support from FAO, to conduct diet modelling aimed at estimating the quantities of each food group that will contribute to an optimal diet for persons living in Ghana. The outcome of the modelling is an information on portion sizes that will be used to inform the development of a food guide communication tool along with the FBDGs. Summary of evidence review findings Key Nutrition and Health Problems and Risk factors: Ghana is currently in an advanced stage of nutrition transition with simultaneous occurrence of undernutrition and caloric overnutrition[11, 42]. An estimated 10% of Ghanaian infants are born with a low birth weight. One-fifth of young children under 5 years are chronically undernourished while 7% are acutely undernourished[11]. There are, however, wide disparities of undernutrition among this age group. There is also unacceptably high rates of anemia (>65%), iron, and vitamin A deficiency among children below age five[43]. Among adolescents (ages 10-18), overweight rate is increasing, especially among those living in urban settings[44]. Although there is limited evidence, it is suggestive of high rates of underweight and stunting among adolescents [11, 45]. Adult overweight among women is high and increasing[11, 16]. There is also high and increasing rates of diet-related non-communicable diseases (NCDs) including diabetes mellitus type II, hypertension, and some cancers (particularly breast and cervical)[11, 46, 47]. There is limited evidence on health and nutrition of older persons which suggests high overweight and NCD rates[48]. Diets and food consumption: Based on national food balance sheet data, only 7% of Ghanaians are considered undernourished[17, 18]. However, food security prevalence is much higher from a household perspective[19, 20]. Households typically spend > 40% of annual expenditure on food[6, 49]; in Northern Ghana, an average of 16% of https://doi.org/10.18697/ajfand.107.21830 19710 households are moderately or severely food insecure[19]. There is high variability in food insecurity rate across districts, reaching 40% in some districts, while others reported less than 5%. Young children’s diets are mainly cereal-based[11]. School-age children and adolescents have preference for energy-dense and high-fat foods; their consumption of dark-green leafy vegetables is low[50, 51]. Street food is frequently reported, and especially for rice-based meals[40, 52]. Among young children, breastfeeding practices are suboptimal[11, 12]. For example, exclusive breastfeeding rate is currently estimated at 43%, considerably lower than the national target of 80%. Prevalence of complementary feeding frequency and diversity are both low and declining over time[11]. Early introduction of pre-lacteal feeds, water and other foods limit achievement of breastfeeding standards while misperception and limited maternal support adversely affect complementary feeding of young children. There is infrequent consumption of nutrient-rich fruits, vegetables, and animal source foods. Adult and adolescent dietary consumption is suboptimal and increasingly including nutrient-rich energy-dense foods[52, 53]. Food availability, safety and trade: Net per capita food production was higher than consumption in all food categories, except for vegetables, fish and fishery products[54]. Overall, food imports exceeded food exports in all food categories, except cocoa beans and products, root crops and tubers, oil-bearing crops and nuts, and fruits and fruit products. By weight, the major staple foods produced in Ghana are cassava, yam and maize. However, consumption of foods was driven by location of consumers[6, 55, 56]. Cassava, maize, rice, and yams were the main staple crops consumed in Ghana. Underutilized foods such as palm weevil larvae and turkey berry identified[57]. At the household level, farm production diversification was identified as an important driver of consumption[55, 58, 59]. Fruit and vegetable consumption in Ghana have been declining since 2013[54]. There was also a rise in the importation and consumption of processed foods. Food safety issues identified included contamination with microbes, aflatoxin, polycyclic aromatic hydrocarbons (in smoked fish), heavy metals (particularly mercury in fish), pesticide residues (vegetables and fruits), and food adulteration[54, 60-64]. Food and nutrition policy and programs: there is a wide range of government policies and programs spanning nutrition-specific and nutrition-sensitive sectors[65]. Within the health sector, multiple policies exist including those related to child feeding, rehabilitation of malnourished children and adults, micronutrient nutrition, infection- prevention/management, and family planning[66]. These policies exist in separate documents and are also integrated in the national nutrition policy which is the flagship nutrition policy in Ghana[9]. Outside of the health sector, nutrition-relevant policies and programs exist across ministries, departments and agencies implementing programs in agriculture, local government, trade and industry. A recent stakeholder engagement indicated that there are important gaps government nutrition initiatives and recommended actions to fill the policy and program gaps[27, 67]. Recommended actions include development of food-based dietary guidelines for Ghana. https://doi.org/10.18697/ajfand.107.21830 19711 Sustainable food system: Although subsistence farming remains a major livelihood for Ghanaians, limited evidence shows that there is declining arable land in both urban and rural settings[68, 69]. Most household production is a combination of crops and animals. Animal farming, typically, employs non-intensive methods. Production of poultry (an important animal source food) has been declining over time in Ghana[70]. Fish capture in Ghana has also drastically declined due to overexploitation[71, 72]. Many rural farmers engage in cash crop farming. There is evidence that cash cropping families consume less diverse/quality diets. Further, the revenue from cash crops does not provide such families with a living or adequate income to purchase food for household consumption. There is high amount of food waste and loss along the value chain[73]. For example, 92 metric tons of fish were lost to inadequate storage facilities over a six year period in Western region alone[74]; in the Ashanti region, 8% of cultivated rice is lost at the harvesting stage, and a further 9% is lost during drying and storage[75]. Packaging along the food results in increased use of plastics; about 90% of urban residents in the Eastern region use single-use plastics for food packaging. However, there are also reports of using renewable packaging (leaves) in the Ashanti region[76, 77]. An estimated 28,000 tons of plastic waste is generated from bagged water consumption, nationally[78]. Other impacts of food system on the ecosystem include excessive hunting, and uncontrolled use of agro-chemicals[79, 80]. Food environment: Although there is increasing growth of supermarkets and other food vending outlets, traditional open markets are the main source of food for Ghanaian households, in both urban and rural areas[81]. Ready-to-eat traditional foods is a major source of foods purchased for consumption by majority of Ghanaian children, adolescents and adults[82, 83]. In urban Accra, availability of traditional markets within a neighbourhood was linked with lower consumption of ultra-processed food. In the same study, increasing number of convenience stores was linked with 90% more likelihood or consuming street food[84]. In urban and rural settings, consumption of energy-dense nutrient-poor foods such as fried yam and sugar-sweetened beverages is common. Key drivers of healthy eating identified include media information, lack of appropriate storage facilities in food value change, cultural perceptions and practices, seasonality of fruit availability, limited awareness of nutrient value of nutrient-rich foods, food safety and low productivity of nutrient-rich foods. The feeding of young children is affected by inadequate resources including lack of breastfeeding rooms at work places [85]. Behaviours and food-related habits: there are not many studies focusing on dietary habits. Generally, location, price, gender roles, and social relationships are the key drivers of eating behavior. In particular, women and children’s diets are influenced by food prohibitions, myths, and prescriptions. A wide range of food preparation methods are employed although frying with oil has been identified to dominate across different food groups. Adolescents and young persons were identified as having a higher likelihood to skip meals. Street foods are commonly purchased for meals, especially for breakfast and lunch. However, majority of households eat at home-prepared meals in dinner. https://doi.org/10.18697/ajfand.107.21830 19712 Non-dietary behaviours: nationally-representative studies and large-subnational studies have reported that almost one-third of adult males and more than half of adult females do not have an active lifestyle. Higher inactivity among females has also been reported among adolescents and young persons. Physical inactivity was more likely among urban dwellers. Subnational studies reported that alcoholic beverage consumption was common among adolescents, adults, and older persons. However, only a small percent of survey respondents was categorized as heavy drinkers (3%- 10%). Participation in festivals and the desire to demonstrate belongingness were identified as drivers of alcohol consumption among adolescents. Only one study reported type of alcoholic beverages consumed: drink beer (60%), local beer, pito (15%), spirits (11%) palm wine (7.5%) and akpeteshie (7%). In observational studies among adults and older persons, alcohol consumption was associated with elevated blood pressure, overweight, underweight among elderly women, female sexual dysfunction, and depression. Food and nutrition communication: Television and radio remain the main electronic means of accessing information in Ghana[11, 16, 86]. However, internet and social media has grown rapidly in the past decade and are quickly becoming important sources of information, especially among younger, urban-dwelling, educated Ghanaians[86]. Food and nutrition reporting is uncommon and unstructured through mainstream media sources. Health workers remain the main source of nutrition and health information. The media (TV, radio, outdoor banners, and billboards) is, however, important for advertising of food and nutrition messages; especially advertising of sugar sweetened beverages, noodles, energy-dense nutrient-poor snack foods, and alcoholic beverages[39, 87-90]. Young children are usually exposed to these advertisements and are often featured in advertising and promotions[29, 88]. Most children who are exposed to such advertisement are influenced by, and change their preferences based on the advertisements[29]. There is rapidly growing ownership and access to electronic devices (computers, tablets, mobile phones)[6, 11, 16, 49]. Next steps Following the completion of the technical messages, the next steps in the process will be translation of the technical messages into a format that is easily understood. Thereafter, the messages will be pre-tested in selected communities across the country among key target groups. Upon successful testing, the feedback will be used to finalize the messages and validated by the MTTT and key stakeholders. Thereafter, the recommendations will be ready for publication, and dissemination. The MTTT anticipates that the final publication and launch of the FBDGs for Ghana will be completed in 2021. Lessons Learned Over the past four years, Ghana has made significant progress towards completing its FBDGs. Implementation of a food based dietary guidelines is not a simple task. Some of the key lessons from the FBDGs development process has been outlined here. These lessons can serve as guideposts for future FBDGs development in Ghana, as well as for other countries. https://doi.org/10.18697/ajfand.107.21830 19713 Lesson 1 Political will: Broad consultation and sustained effort to involve key stakeholders has been important for ensuring cross-sectoral participation. When institutions were consulted at a high level (usually at the level of the institutional director), technical officers were able to justify the long hours and frequency of MTTT meetings. In addition, the MTTT co-chairs had to build and manage relationships with the technical officers participating in the MTTT. These cordial relationships were a necessary motivation and complementary to the official directives given by directors for their technical staff to participate in the MTTT. During the process, a mini launch of the FBDGs development as well as official inauguration of the MTTT helped to give visibility for the participating institutions and thereby increased their commitment to the FBDGs development process. Lesson 2 Planning and time management: Long-term planning was important and enabled key activities related to evidence review and validation to be implemented, successfully. To achieve this, the MTTT meeting agendas were prepared ahead and shared with participants usually two weeks ahead, so that they can include it in their plans. Despite efforts to plan ahead, the processes of evidence review, and validation were delayed significantly by the COVID-19 pandemic. Since this pandemic was not anticipated, alternative planning using online meetings were used to mitigate the effect of the pandemic (that is, not being able to meet in person), until it was safe to do so, later in the process. A period of less than 12 months was planned for the evidence review. However, it has become clear that without enough dedicated skilled staff, it is difficult to achieve needed outcomes for FBDGs development within a short period. Lesson 3 Capacity building: The process in Ghana has been possible because some of the MTTT had participated in the FAO workshop on evidence review and FBDGs development. Without this training, the process of FBDGs development in Ghana will have taken longer. The training also equipped the team with clear guidance on how to carry out important tasks. In addition to the workshop in Accra, FAO staff from Rome participated in some of the MTTT meetings via virtual meeting platforms and through this means, provided useful guidance to the work of the MTTT. Lesson 4 Multisectoral Action: The MTTT discussions benefitted immensely from the unique capacities and knowledge of members from different government and non- government agencies. This diversity of participation from carefully selected stakeholders enriched the discussions, enabled access to information that will otherwise not be publicly available, and increased awareness of policies and programs there were still in advanced stages of preparation but not yet publicized or were ongoing but were missed in the evidence review. The varied institutional backgrounds also enabled better understanding of the existing institutional coordination and relationships that could be leveraged for development and implementation of the FBDGs in Ghana. Lesson 5 Resources: Diverse resources were necessary for implementation of Ghana’s FBDG including skilled personnel, and funding for procured services. Having adequate resources was critical and allowed the MTTT to focus its attention on the FBDGs development process. Funds provided by FAO was most helpful, especially for the evidence reviews, as well as all the meetings of the MTTT, both virtual and in-person. https://doi.org/10.18697/ajfand.107.21830 19714 The current process has provided a useful guide to estimate the resources needed for future FBDGs development in Ghana. CONCLUSION A diverse multi-stakeholder technical task team, with the support of FAO has made significant progress in the development of FBDGs in Ghana. Limited funding, lack of capacity and slow response by key agencies were responsible for the slow process. Although this process has taken almost four years since its inception in 2016, the process is currently close to completion. It is anticipated that by the end of 2021, the national FBDGs for Ghana will be completed. The lessons learned will make the process more efficient for future FBDGs development. https://doi.org/10.18697/ajfand.107.21830 19715 Table 1: Existing documents that outline dietary guidance for persons living in Ghana Year of Document title Institution which Target group Key dietary guidance Status of publication published document document 2007 Infant and young child Ghana Health Service Infants and young Breastfeeding, complementary foods, Due for feeding strategy children (0-5 years) feeding behavior, food safety revision 2009 Nutrition facts for Ghana Health Families in Ghana Breastfeeding, complementary feeding, In use or Ghanaian families Service/UNICEF family diets, eating during pregnancy usable and lactation 2010 Dietary and physical Ministry of health Families in Ghana In use or activity guidelines for usable Ghana 2012 National Policy for the Ministry of Health General Population of Regulation of food advertising, Expired; new Prevention and Ghana guidance on fats, salt, alcohol, non- version Control of Chronic alcoholic beverages, fruits and drafted Non-Communicable vegetables Diseases in Ghana 2013 National Food Safety Ministry of Health Implementing Agencies Food safety and quality for the general In use or Policy and nutrition population usable stakeholder institutions 2016 National Nutrition Ghana Health Service Implementing Agencies Nutrition needs of infants, young In use or Policy and nutrition children, school-age children, usable stakeholder institutions adolescents, women, men and, micronutrient supplementation https://doi.org/10.18697/ajfand.107.21830 19716 Table 2: List of institutions and number of representatives on the Multi-sectoral Technical Task Team Institution Number of Roles participants Ministry of Food and Agriculture 1 Co-Chairperson 1 Member University of Ghana School of Public Health 1 Co-chairperson 1 Member 1 Secretary World Health Organization 1 Member Food and Agriculture Organization 2 Members Council for Scientific and Industrial Research 2 Members University of Ghana Nutrition Department 1 member Kwame Nkrumah University of Science and Technology 1 member The Ministry of Health 1 member The Ghana health Service 1 Member University of Health and Allied Sciences 2 members Ghana Academy of Nutrition and Dietetics 2 Members Ghana School Feeding program (GSFP) 1 Member The World Food Programme (WFP) 1 Member United Nations Children’s Fund (UNICEF) 1 Member Food and Drugs Authority 1 Member Ghana Standards Authority 1 Member National Development Planning Commission (NDPC) 1 Member Ghana Statistical Service (GSS) 1 Member Ministry of Finance (MoF) 1 Member International Food Policy Research Institute (IFPRI) 1 Member Ghana School Feeding Program (GSFP) 1 member School Health Education Program (SHEP) 1 member University for Development Studies (UDS 1 member https://doi.org/10.18697/ajfand.107.21830 19717 Table 3: Topics included in evidence review for Ghana’s food based dietary guidelines Topic Key questions in the topic Institution leading topic 1 Nutrition and health outcomes and drivers in Ghana University of Ghana School of Public Health 2 Dietary intake across diverse population groups in Ghana University of Ghana School of Public Health 3 Nutrition-relevant policies and programs in Ghana University of Ghana School of Public Health 4. 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