University of Ghana http://ugspace.ug.edu.gh SCHOOL Of PUBLIC HEALTH, COLLEGE m' m:Al.m SCIENCES.l~\'ERSITY m' GIIANA LEGON SUGAK,SWf:nENED BEVERAGE CONSt:MPTION AMIlNG UNIVERSITY OF GHANA STl1Ut:N'fS MODI iP.:" MANU:V WILSON (lNDFX NlMBER-10359295) nus DlSS[.RT ATION IS SUBMITED TO THE UNIVERSITY OF GHANA. LEGON IN PARTlAI_ FULFlLLMF.NT OF TIlE REQUIREMENT FOR THE AWARD OF THE MASTER OF PVBLIC HEAL m DEGREE. JULY 2012 DECLARATION ~ MOIlUPUEHn MivAeNrsLiEtYy WofI LGSOhNa •n ..a.. .h."t,t dpec::/1/aureg !shapt awciteh .tuheg e.xecdeputi.ognh of ",f_ __p oapIo'l ____d ulyoclaJowlcdsed,tbisworlcisthe .....t ofmyOWll _______ mil it .... oeithcr ill pan oor whole _ pac:nted -.ror-cIaJroe. ~ ............ . ~ .. DR RICHMOND ~YEJm!Y (PRIMARy SUPERVISOR) University oDf EGDhICaAnTaI OhNtt p://ugspace.ug.edu.gh I dediC:lI1.e this work 10 m~ ""Ih:. ( , I.ITla, ;l11d I.:h.ldren. Annemaude and Beresford, whose love and 5upporttr.vebroughtTnCthis rar. rhankyou University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT I first of all want lO thank God for his g.uidance and sustenance throughout lhis program. Many thanks to my supervisor, Or Richmond Aryeetey. for his patience. encouragement, continuous ~upport and knowledge instilled in me. God bless you. My sincere grallhidc g~ to Professor Fred Sinka. Dr S.O. Sackey, professor Adanu, Dr Norgbe. Dr Amos laar. Dr Christine Clerk and all other lecturers of the MPH program whose impartalionofknowledge is springboard for more advenrures. [ al~ wan! 10 thank my research assistants for their relentless efforts in ensuring that work was successfully completed To Profcuor AMI LartC) \11' !hl." Food and Nutrition Department, University of Ghana. the managen of Jubilee and InlCmal1llrW Students Hostels. Mrs. Pearl Mensah, Volta Hall, Evandy Hostel for their support and tremendous help during the preliminaries of my research work. I thank you all . To the students and numerous participants. your Jove for my research title 'Sugar-Sweetened Beveragcs' which you aJways re-echo when you drink a bonle or can of the beverage. has been a motivation wbic:h has aJso sustained me throughout this work. Thank you and God bleS! you. T AJlLE OF COI'ITENTS. University of Ghana http://ugspace.ug.edu.gh PAGE .•. 1 DECLARATION ..... . ...... 11 IlWICATION. III ACKNOWI.EDGfMENl r ABLE OF CONTENTS ... LIST OF TABLES .... . IX LIST OF FIGURES ... . .... IX LIST OF ABREVIATIONS . ....... . X ABSTRACT ... . ..... XI CHAm~R()NF 1.0 INTRODUCTION ..... . 1.1 BACKGROUND .. . . ..... 1 1.2 PROBLEM STATi' MENT. I.) JUSTIFICATION 1.4 OBJECTIVES. . .. .............. ..... 3 1.4.1 GENERAL OBJECTIVE .. . 1.4.2 SPECIfUC OBJECTIVES ... .. .. ....... ..... ) CHAPTER TWO University of Ghana http://ugspace.ug.edu.gh LITERA n JRE R£VIEW 2 J ()HISITIOS OF SUGAR-SWEETENED-BEVERAGES . .. .. 4 , .2 CONSUMPTION PATTERNS OF SUGAR-SWEETENED REVERAGES ..... ~ 2.3 DETERMINANTS OF SSB CONSLIMPTlON ... .. .. .... 7 2.3.1 ADVERTISEMENT AND PROMOTION... .. ........ .. .. .. .. 7 2.3.2 TELEVISION WATCHlNG. . . .............9 2.3.3 ACCESSIBILITY... .. .. 9 2.3.4 ECONOMIC STATUS AND PRICE .... .... .... .. _II 2.3.~ TASTE AND PREFERENCES ........ .. .. ... 12 2.4 ROLE OF SSBs IN I>ON-COMMUN ICABLE DISEASES. . .Il 2 4 I SSB, AND WEIGHT GAIN 2.4.2 SSBs. OBESITY AND CANCER ... . ................ IS 2.4.3 SSBs AND DIABETES ... . .16 2.4.4 SSB, AND CARDIVASCULAR DISEASES ... 2.4.S SSIb AND NON·ALCOHOLIC FATTY LIVER DISEASES ............... 16 24.6 SSBs AND DENTAL CARIES .... .......... 17 2.'_7 SSBs AND GOUT .. .. ............ 17 .17 2.4 .&S SB, AND NCO, IN GlIANA .... . University of Ghana http://ugspace.ug.edu.gh ..18 2.5 PUBLIC IlEAL TH IMPORTANCE Of SSB, CHAl'TER THREF .... .. 21 3.0 METHODS. ... 3.1 sruOy .. ..2 1 DF.SI(j~ 3.2 PROFILE OF snJDY AREA ... ...... 21 3.2.1 RESIDENTIAL FACiLITIES ........ .. ....... 21 3.2.2 CATERING FACILITIES ... .. .. .... 22 33 VARIABLES. .. ..... 22 3.3.1 DEPENDENT VARIABLES . . .. .. ..... 22 3.3.2 INDEPENDENT VA RIABI.ES .... .... 26 3.4 STUDY POPI'LATION .. . .....2 9 3.5 SAMPLING ... 3.S.1 SAMPLE SIZE DETERMINATION 3.5.2 SAMPLING METHOD ... 3.6 DATA COLI.ECTION TECHNIQUES AND TOOLS. .. .. .................... )) 3.6.1 TRAINING AND RECRUITMENT OF INTERVIEWERS University of Ghana http://ugspace.ug.edu.gh ..... 33 AND ASSISTANTS ...... .. ..34 3.6.2 QUALITY CONTROL 3.6.3 DATA PROCESSING AND ANAL YSIS ... 34 3.6.4 ELIGIBILITY CRITERIA .. ..........3 5 3.6.5 ETHICAL CONSJI)ERA TIONS . .... 35 3.6.6 PREThSTI:-IG ... .... .3 5 HAPTERFOUR 4.0 RESULTS .. .. ........ 36 4.1 BACKGROUND CHARACTERISTICS .. . . ... ..... .. ... 36 4.2 FREQUENCY Of SSB CONSUMPTION .. . .. ............ ... . .... 37 4.3 QUANTITY OF SSB, CONSUMED .. . . .. .. .. .. .. ..40 4.4 SOURCES OF SSB CALORIES ... .. .. .... ...........4 3 4.5 DETI' RMINANTS OF SSB CONSUMPTION. . ...... . ... 44 CHAPTER FIVE University of Ghana http://ugspace.ug.edu.gh .... 46 5.0 DISCUSSION . CHAPTER SIX 6.0 CONCLUSION AND RECOMMENDATION.... . ...... 51 6.1 CONCLUSIONS ... ..... 51 6.2 RECO"-l"-lENDA nONS . .. . .. .52 REFI'RENCES ... 53 APPENDICES PAGE APPENDIX I: ETIilCM. CLEARANCE-GHANA HEAL TIl SERVICE REVIEW COMMnTIE ... 67 APPENDIX 2: CONSENT FORM .. ... 68 APPENDIX 3: QUESTIONNAIRE ON SI!GAR-SWEETENED BEVERAGE CONSUMPTION AMO);G UNIVERSITY OF GHANA STI jlJl-.NTS ..........7 1 APPENDIX 4: QUESTIONNAIRE ON DETI' RMINANTS OF SUGAR-SWEETENED BEVERAGE CONSliMPTION. . ............. .. 72 APPENDIX 5: QUESTIONNAIRE ON BEVERAGE CONSlIMPTION FREQlIENCY IN TIlE LASTJO DAYS (I MONnl). . ........ 73 APPENDIX.: QUESTIONNAIRE ON THE CONTEXT IN WHICH SUGAR-SWEETENED BEVERAGE WAS COt-:S'·MEIl ..... 74 I.IST OF TABLES University of Ghana http://ugspace.ug.edu.gh PAUE TABLE I ABtl 1.1 SAMPLE RECODED DATA SHOWING HOW STUDENTS WHO HAD CONSU\1ED AN SSB WERE DETERMINED.... . .. ......... 24 TABLE 3.2 SAMPl.E DATA SIIOWINU HOW "DAILY CAl.ORlC INTAKE OF SSB WAS OBTAINED .... ...... 25 TABLE ) .) !)JSTRIBUTIO!'< OF THE STlJUENTS' PUPULA TION ACROSS THE NINE HALLS .. . ...........3 1 4.1 BACKGROUND CHARACTERISTICS OF UNIVERSITY STUDENTS, LEGON .. .........3 6 FIG 4.1 PERCENTAGE OF STUDENTS RI,PORTING SSB CONSU\1PTION IN THE PAST MONTH .. ........... .37 TABLE 4.2 PERCENTAGE OF STUDENTS RlPORTING CONSUMPTION OF SPECIFIC SSBs IN' THE PAST MONTH .... TABLE 4.3 PERCENTAGE OF STUDENTS REPORTING CONSlIMPTION OF SSB IN THE PAST MONTH BY BACKGROUND CHARACTERISTICS. .. ........ .. 39 FlU 4.2 THE TYPICAl. AMOUNT OF CALORIES TflAT A STLDE'NT COt\SUMES FROM SSJlIN A DAY (KCAlJD) ... . .......... .40 TABLE4.4 AVERAGE DAlLY CAlORIC INTAKJ'S OF SSBS BY STUDENTS' BACKGROUND CHARACTERISTICS (KCAUD) ... .. .......... 42 TABII- • ~ PERC .... "-(iE:" 01 SnVE~TS WilD CO'SL \-II: ) SSBS J.-R()~I D1HERE "I SOL'Ul{CnEiSv ersity of Ghana http://ugspace.ug.edu.gh ABL t6 DET R\{I~ASlS Of Hit y C \LORI( JNI AKI· or SSR (KCAliD). 45 LIST 01 AHBR~V- '\ T1U'S S8 SUG,\R-SWI'I' TENI-!) ar\'l',RAGl • (,iIlANA.lUAI III SI·RV!CI DIIS. DL~toGRi\Pllil A~I) IIiALfll sl 'I{VI:::Y WORI 0 IirAl fli ORGA:-JI/ATION SOCJ()·fTU!\'()\!IC STAn:s FOOl) IREQl T~(Y QU S TIO:-INAIRl B\t1 BODY \1ASSI);DIX ABSTRACT University of Ghana http://ugspace.ug.edu.gh c.xccssive consumption of sugar-sweetened beverJ.!!cs (SSBs) is a major nsk factor for obesity and other non- commmicable diseases. more so for a COWllJ'y Wldergoing nutrition transition such as Ghana. This study look a multistaae cluster sample of 329 students of the University of Ghana to determine the frequency, quantity and context of 5SB consumption among the students. The sample included 94% undergraduates, 4 J% females, and 54% young adults (21-25 yean). Anthropomcuic measurements indtcatcd that 25% of the students were overweiahl. A Food Frequency QuestioMam~ was used to deteribe all beverages consumed by the SlUdents over a period of one month. The results indicate that the majority (96%) of the students had consumed some amount of SSB in the put month. v.-ith 35% reporting daily consumption. fruit drinks, ""oonalcd drinks. lad energy drinks were the most common types of SSB conswned. Consumpcion I~-d was high across all groups of students. The majority of students accessed thcir SSB, from campus, with 57% obtaining them from restaurants and pubs, 33% from supennarkets. and 300/, from table-top vendors. Socicreconomic and attitudinal factors of students significantly predicted lhe amount of SSB calories conswned (p < 0.01). Students who found it man: difficult drinking less SSB, those who spent more hours watching 1V, and those who pcn::eivc SSBs 1.5 good source of energy consumed more SSB calories than other students; while IlUdcnts who depended regularly on handouts consumed less calories of SSBs than those who did not. Given the high consumption of SSBs among stUdents, a more concerted etTon is needed to sensitizc SlUdcnts on the risk factorsofnon-communicablediseases CHAPTER ONE University of Ghana http://ugspace.ug.edu.gh INTRODUcnON 1.1 BACKGROUND SSBs are defined as beverages containing caloric !'>v.\.'Clcnccs and include soft drinks (soda or pop). fruit drinks. sport drinks, lea and colIce drinks, energy drinks, sweetened milk or milk altcmatives. and any other beverage to which sugar, typically high tructosc com syrup or sucrose (table sugar),hasbeen added (Wang etal .• 2008) Non-Communicable Disea.'iCS continue 10 be a big problem as the consumption of SSB! risegiobaJly due to added su8ariotbesc beverages, contributingexccss calories as a risk factor which lcads CO o\·crwtigh1. Tbe increased use ofsugar.sweetened bevcrages is among the subgroups of the young. adolescents and aged whose negative behavior. envirorunenl, its large market and powerful promotion channels of advertisement may promote all enabling condition for the development of non-communicable diseases In • study done in the US by Malik etaJ. (2006), it was shown that if a can of soda which is equivalent to 14()..150 calories is added to a typical US diet whh calories from other sources not reduced, one SSB per day could lead to::l weight gain of7kg O'"er I year, substantiating the evidence that higher consumpt:ion of 8SB intake is associated with high risk of weight gain and obesity in children and adults. In the US, the most recent da1a. show that Children and Adults consume about 172 and 17SkeaJ of SSBs per day. respectively (Brownell et aI., 2(09). In similar studies done in the US, youths consuming ssns were shown to have increased their intake of calories, which contribute to obesity amona youth worldwide (KmlY.& Krebs-Smith. 2010); and the highest cOOSUl1lC'n of SSBs wereU andiovleescresnittsy aogefd G 1h2 atno a1 9h tytepa:r/s/. ungosn-pHaiscpaen.iuc gb.leacdkus .agnhd Me-xican- Americans of low income (Wang et al . :OOR) In Ghana, epidemiologic, demographic. and nulntion transition (de Oraft Aikins et aI., 2005) continues to affect the dietary hahia and rate of consumption of SSBs of the Ghanaian peo", creating conditions for the development of non- communicable diseases. According to WilD (2003), over 1 billion adults throughout the world are overweight; and in Ghana, !hIdies done by Amoah et al. (2003). in urban and rural areas showed an oVCTall crude prevalence of o\'erwc:iBht of 23.4% among adults aged 2Syears and above. In 21:M}.1 at least four conditions- stroke. hypertension, diabetes and cancer- had become one of the top ten causes of death in at least each regional health facility (Agyei MenW\. 2004). and in 2005 out-pllic:nl hypertension cases towed 250,000 (805u, 2005). 1.2 PROBLEM STATEMLNf University of Ghana http://ugspace.ug.edu.gh There is an increase in the conswnptH1Q of SSBs ,Iobally and according to (Malik el aJ.. 2006: Brownell eI al .. 2009: Reedy et aI .. 2010) this is contributing excess calorics from its added sugar and is • potential risk factor for the development of Non-Communicable Diseases. In Ghana no evidence exi5ls on SSB consumption behavior. 1.3 JUSTIFlCA TlON As we don't know [he conswnption rale of SSBs among University of Ghana students and the context in which SSB consumption occurs, this 5tudy seeks to find out and provide, data to fill the knowledge gap of the category of people concerned, ~ risk groups, and design appropriate intervention targeting the University in the prevention and controJofaocess 10 SSBs and the promollonofheallhy adverts 1.4 OBJECTlVF.S To describe SSB Consumption among students of the University of Ghana and the deten:ninantso(conswnption U.2Speci&cObjtctiY. .: (I) To describe the quantity and frequcnl:Y ofSSB consumption (2) To describe the contexi in which SSB consumption occun (3) To identify de1emllnanl:i of SSB consumption CHAPTER TWO University of Ghana http://ugspace.ug.edu.gh LITERATURE REVIEW 2.1 DEnNmON OF SUGAR-SWEEn:NED O.:VERAGES Then: are several definitions of SSBs and their definitions vary according to different raearcbc:rs (Bleich c:t aJ., 2009), with respect to source of added sugar (Guthrie & Monon, 2000) and contributor to caloric (Block. 2004). SSBs are defined as soft drinks (Soda or Pop): Nonalcoholic. flavored, carbonated or non-carbonated beverages prepared and sold in bonJes or cans; Fruit drinks, punches, orades: sweetened beverages 0 fdiluted fruit juice; SportS drinks: beverages designed to help athletes rehyjrate, as well as replenish electrolytes sugar. and other nutrients; Tea and coffee drinks : to which caloric s\o\.'Cctcncrshavebeenadded; Energy drinks: carbonated drinks containing large amounts of caffeine. sugar. vitamins. amino acids and herbal stimulants; and Sweetened milk or milk ahernatives: blending sweetened powder (SucruSI!, table sugar) or syrup (High f'nxcosc com syrup) and milk. Adding sugar in milk does not increase the overall protein and nutncal: but calories per serving. which makes it different from other SSBs. High fructose com syrup is almost used in all beverages as added caloric ~" ..-. etcn ..-. rs by manufacturers of soft and fruit drinks (Popkin et aJ., 2006). For example HFCS-42 and HFCS-SS have different calories in different be\"erages, and HFCS is inexpensive compared to other sWtttenen. In acx:ordance with the Beverage Guideline Panel, SSBs ~ furthr:r c.alegorized as combined (i.e., No sugar, Low sugar and High sugar) (ibid). In a survey. a cut-off point for sugar contents in milks was estimated as 6%, therefore more thin 6% of total sugar was considered as High sugar and lower • Low sup 4 (Lasater el 81 .. 2011). In some studies SSBs are categorized as follo""5: High encrgy (soft drinks. swUeenteinvede rtseai tyan do fc oGffehe,a nswae ehtetntepd :/j/uuicge sapnda cfreui.t udgri.nekds. ua.lgolhe · a typical Mexican beverage made with sugar. com meal usua!ly, or other substitutes such as rice floor or starch); Higb enerb'}' with some benefit (whole milk, milk flavored, fruit juice), and Lowencrg) (SWCClcneddiet beverages) (Barqueraetal .. 2010). 2.2. CONSUMPTION PATTERNS OF SUGAR-SWETEENED BEVERAGES Nalional sut\·c)"s conducted in the US between 2005 and 2008 indicate that approximately one·half of the U.S. population reponed consuming at least one SSB on any given day. Males were found to consume an average of 175 calories per day, while Fcma1cs. 94 calories (Ogden ct w.. 2011). Between 2005 ~ 2006, black Americans of both sexes. across a wide age range, were found to consume more calories from SSB per day compattd with whites of the same ages. In black females aged 31·50 years, average daily consumption of calories from SSBs is double that in white females in this age group (USDA, 2010). SSB! accounted for 13 percentoftota1 daily caloric intake in adolescents in2004(Wangetal.2008) In. Los Angeles County Health Swvey (LACHS, 2007), children aged 17yrs or younger wne found to consume at least one SSB a day, whi le more than 38% of adults consumed at least one SSB a day. High risks groups identified in the Comty were high school students: more lhanone-third drank at least 4 sodas in a week. Fifty percent of males. c:om,.re to 28% of females. consumed at least one SSB • day. The Americ:an Heart Auociation's recommended .....' CC.k.ly ceiling of SSB consumption is 450 calories (or equivalently, 3 cansofsoda)(Lloyd-Jonesdal., 2010). 5 In 2006. a study was earried out at ArbnsIs University. in Little Rcx:k. to evaluate SSB cOMUDlptioUn naimvoengrs ciotlyle goef sGtudhenatsn. aA htotttapl :o/f/u 26g5s upnadcereJ.ruldgU.lelad wue.rge hsurveyed. of which 66% wen: ...." meP.. 3()O/. sophomores, 46% from minorit)' poups. and 51% below the aF of 21. In thIl study. West and colleagues (2006) found that 95"'0 of undergraduates MIt reportal consumption of It least one SSB in the put month and 65% reported daily con.. . umption of some form of SSB. 1be a\'cI1lge daily caloric intake in the overall SElpiC from all SSBs was 543:1: 671 kcalid. Men were mon: likely than women 10 10 eonswnc!OlDle form ofSSS daily (740/. vs. 610/.). Soda was the only SSB thai most maJes ~ consurrtina. with 480/. reportin, daily consumption and 86% conswnption at some time in the month. However, Fruit drinks were the SSBs that contributed the arealest proportion of calories on the averaae (267k1caJ), with Sodas contributing 187kcalld. Soda was also reported by most undeTgnduate Females, with 32% rqklrtin~ daily consumption and 74% consumption al some time in the past month. Among Women. Fruit drinks contributed the greatest proportion ofcaIoric intake (241kcal per day) dw! Soda (I 50 kcal per day) (Weste, 81., 20(6) A study by Shields, CorraJes. and Mettallinos-Katsaras (2004) examined the frequency of consumption uf gourmet coffee beverages among college women. by adminiscering • bnerage questionnain= to a total of 165 wtdcrgraduate and graduale women. A tompu;SOfl of gourmet coffee CODIUmers versus non-consumen showed thai gounnel coffee consumer.; consumed an additional 206 calories and 32 grams of sugar per day more than Ihe non-c:onsumcn. 1be study concluded a signiftcant pen;:entap of collqc: women consumed pumeI Q)ttC:c beverages. which contributes 10 addilional rat and energy intakUe • n..idvleor osvietnyI lo dfi cGwhy ainntaake .h ttp://ugspace.ug.edu.gh A mela. analysis by Vartanian. Schwartz, and Brownell (2001) on the effects of SSB consumplion showcd tILIt individuals do not reduce their calorie intake from other foods for the extra calories in tbc:te beverages and lh.:rcfore arc !.:unsuming man: calories overall. Those who consume these beverages drink less milk and have less overall calcium conswnption. and consumption of these beverages is related to higher inlake of carbohydrates.1ower inlakcs offnaits and dietary fiber. and a variety ofmacronutrients. 2.3 DETERMINANTS OF SSB CONSUMPTION: and cnvironmantal facton. which include: 1.3.1 Adnrtisc.ent and Promotion: The marketing of SSlh i ... an Important environmcntal factor that influences SSB conswnplion. While only few causal studies link marketing directly 10 consumption. "perts ha\'C concluded thai heavier marketing of highooCalorie. low·nutricnt foods and beverages encourages people 10 conswne (Harris. Barah. & Brownell. 2009; McGinnis. Goocman, .t Knuk, 2006) Beverage and food products an: commonly marketed throuah television, magazine and outdoor advertising. The advertisements are always strategic. For the U.S population. Tirodbr ond JaiD (2003) compoml 8SB odvatiscm. ... on prime time 1V pn>poms primary watched by blacks 10 those y,3h:hed by whiles: for the year 1999. and found that blacks werUe mnoivree erxspict»ye do thf aGn whhaitnesa t oh TtVtp-b:a//5utdg SsSpBa acdvee.nuisgem.eednlus.. gA hsimilar study by Henderson and Kelly (2005) found that SSB advertisements., in 2003, were 10.6". more on black prime time TV shows than those watched most often by the general public. An examination of 500 food ad\'crtiscmcnh in three well-established, black-orienced magazines from issues published in 1984-2003 found that SSBs were the mOS1 frequent category of food-related advertisements in the magazines: Ebony (13% of adS). Essence (14%ofadds) and Jet {18% of adds) (Maslin and Campo, 2009) In across-sectional prevaJence study of outdoor obesity·related advertising, Yancey and colleagues (2009) contcn; analyzed outdoor advertisements in low- and high-income bl.ac.k. Latino, and white neighborhoods io Austin. Los Angeles, New Yor~ and Philadelphia. and found that higher-income neighborhoods generally had lower number of ads. while black and Latino neighborhoods had lhe most ads higher caJorie/low- nutrient foods,which included SSBs Adven.ising is just one component of a more complex and multifaceted marketing system tlw SSB companies use to target potential consumers. Other marketing tools U3'ed include. promotions, public relations. sponsonhips and the pt'ovision of employment opportunities. A 2010 report from the Coca·Cola company of U.S. describes their strong focUi on multicultural marketing. including a comprehensive focu.tr.unt to the Ghanaian public health. The WHO (2005) recommended the ' mullifacclcd multi-institutional' responses to the 110'-1 chronic disease burden using the three proflg approach, which involved the epidemlOlogK:aJ surveillance. primary and 5CCondary prevention with a goal of prcvenlina chronic dio:ea.~ in lay healthy communities through health promotion and prcvenling rof11pl":.1llons. and improving the quality of life of people with chronic diseases lhroua,h medical. psychological and/or eoonomic interventions. In 2005, Ministry of Health Ghana announced .. paradigm shift from curative to pre\'enlive scrYICes spearheaded by the Regenerative Health and Nutrition program that aims at empoweriJli lay communities to adopt healthy lifestyles (MOll Ghana.. 2007), as Ghana disease burden conlinues to undermine its developmentaJ goab. Eighl) petcenl of the rep,nal htaith budgets - usually 10 'I. or less of the national budget (WHO, 200 I) - has been aJlOQIed to commWlicable disease for the last decade (WHO-Afro, 2006). Human resources in Africa for betJtb penonnel per 100,000 populations iochade physicians (21). nUNeS (981. public health professionals (1), 19 cardlolo~ists (0.41. and oncologists (0.1) (Alwan. Maclean. & Mandil. 2001). Number of Doctors anUd nciovrreerspsointydi nogf pGophulaatnioan hraTttiops :/i/nu fgivse poafc thee. uregg.ioends uin. g2h007 were as folloW5: Greater Accra - TSS 10 1:5202, Ashanti - 428 101:10.667. Eastern region - I~H 10 I: J841.Brong-Ahafo -96 tol:22419.and Western -71 to I: 33794. with NationaJ- 1.676 Doctors (MOH Ghana, 2007). Somc advocacy groups in Ghana wcre formed. clinic set up partnerships and collaborative projects established. in the drive towards the fight against chronic diseases; naming a few are the Ghana Diabetes Association, Sicklc cell Association, Ghana Heart Foundation. Korle-Bu Breast (Canccr) Clinic. The UK· Africa Academic Partnership on Chronic Disease(a model for the future? ), and the Ghana and c.meroun collaborative proj~ct. So much has been invested in chronic diseases and progress bas been slow, therefore the demand for early intervcnlioo to investigate the causes of these diseases which are the potentiaJ risk rae tors such as SSBs is indecd ne«ssary. 20 CHAPTER THREE University of Ghana http://ugspace.ug.edu.gh METHODS 3.1 STUDY J)[SIGN A cross-sectional survey design was employed to study the consumption paUc:ms of SSBs and their determinants among students of the University of Ghana 3.2 PROFILE OF STUDY AREA The Univasity of Ghana lies about 13 kilomctCTS noM-east of Accra. the capital of Ghana,. at an a1titudc of bct"'~ 90 and 100 meterS. It is the oldest and largest of six public Universities in Ghana. The University currently has a student porulati~m of about 28.SOO, with anundcrgraduate popuJation of 18.96S and amalelfemaJe ralio ofaboul 2:1, Forcipt students constitute about 38Q/" of the student population (Planning and informatIOn Services Directoratc. 2008) 3.2.1 RaideDtial FadUties The Univmity pro\'ides accommodation in halls of residence for both post-graduate and UDdcrgnl.dua\.c students. IradllionaJiy. there are five halls of residence a\'ailablc to all students, namdy, Leaon. Akuafo, Commonwealth. Volta and Mensah Sart.h, in order of seniority. Howe\cr. there are other residential facilities on campus thaI have been co- opted by the l :mvcrsit)'. lbcsc include the Pu:.tgmduatc Hostel. Valco Trust Hostel. InternatIOnal SrudcDts' Hostel, SNNIT Hostels (or Ghana Hostels) and the Jubilee 21 Hoile!. More recently I'C'cognized residential facilities include the Bani Hostel, Evandy Hostel. LimUannni vHeorssteilt ayn do AfJ Gex.hanadenr aK whatptopn:g/ /Huogstselp. ace.ug.edu.gh 3.2.2 CateriagFacilities There are a nwnber of catering facilities across the University campus. Each traditional haJl has a cattting facility and couple of ouclets for consuming sut;ar-sweetened beverages. These SSB outlets are also common in the hostels.. departments and lecture theaters. In addition, there arc designated catering facilities at some research centers and lecture theaters. These include Tasty Treats Catenng Services at the Noguchi Memorial Institute of Medical Research, and the many catering outlets within the Central Cafeteria and Jones Quartey B~lding . There is also a supenno.rkct on campus located close to the ln1emational Students' Hostels. There is a small market in the same area and another close to the L>epartmcnl afFine Arts where slUdenls can purchase sugar-sweetened beverages. 3.3 VARIABLES 3.3.1 DepeDdeotVariablei Two main deperxlcnl variables \Io"tTC constru<:ted to gauge the level of SSB consumption among student.!: oae on frequency of consumption and the other on quantity coru:umed. The variable on frequt..-ney tracked whether a respondent had consumed any SSB in the past month. This was labeled as "Any SSB". The variable on quantity sought to estimate the 8\'crage amOWlt of SSB consumed by each respondent in a day. nus was measured in 22 kilocalones (Kcai) and was labeled -daily caloric intake" ' . 'I'hnc t¥l'O main dependent variables wUenn: ifvurethresr ibtryo koenf dGowhna bnya ty hpet topf: S/S/uBg csonpsawcneed. u(cgar.beodnaute.dg dhrink, energy drink. fruiljuice, tea.'colTecand sweetened milk). resulting in 12 dependent variables in all CompuJation f'J/ Any consumption ofS SB: To determine whether OJ student had consumed any SSB within the past month, an indicator variable was 5(:tto check the student' s response: to the question of ~frequency of consumption" asked on each of the 28 be\'erage items. to dclcmune whether the student Iwd consumed at least one of the items in the past month. To simplify the process, the fiequency' quesaion was fi~ changed into a count question: the "Daily", "4-6 time~ per week", ""2.3 times a week", ""On occasion", .,d "Never" response categories on each of the 28 items were re-classified to simply read as "Consumed" and "Never conswncd", with code 1 assigned to "Conswned" and 0 to "Never consumed" . Next, the 28 items were added 10 create a composite indc-~ The IIldex was then transfonncd into an indicator variable of Os .ad Is by maintaining all Os and Is in the index and rc-coding al1 higher numben into I Oust as illustrated in Table 3.1 below}. In the resulting indicator variable, code I sianifies a student who has consumed at least one beverage item in the past month and eode 0 ODe who never consumed any beverage item in the period ' Tk~wriable~measun:don.dai)yscakrOl'easy~witbsimilar5tudin , Ontht: ocha'hIDd.,~~\'InIbIcW1lSDleasuredonamonthlyratbcrthanadailybaWbecatdCooIy.few n:spondmb~lbaItbeY~.~OIICSSBrvay"'ialheputmODlb.anumbcrdw -*esprofiliaaof~b)lbelfbackvo-lcblncterilbcs~difBeu.b 23 University of Ghana http://ugspace.ug.edu.gh --comum tKwl in the ~C~O"c.~l ... n ... dmjlk) . Complll4liDn Dj Daily cfllDric u.liIu ojS SB: For each of the beverace items, each student's reported "frequency of consumption" of the bevcn.ge \Aoa5 combined with the '"typical serving size" (i.e. the typic&! amount of the beverage consumed on each occasion of consumption) 10 estimate the amuunt of the beverage consumod in the past month. For this purpose, the response categories of the questions on "&equenc)' of consumption" were appropriately weighted: The response Cltf'gOf)' labeled "Dai ly" was assigned a score of 30. the category "4·6 lime per y,.-eek" wasassisncd·tolal score of 20 ba.sed on the midpoinl of the scale (5) and noting that then: are 4 week in a month, the '"2·3 times per week" category was assiiJlCd a score of 10 based on the argument of the later, "Occasionally" a score of I and "Never" O. 'The data on '"typical !CrYing size" for each beveraae item Wl3 standardized to a common scale by con\crtiaa the number and size olbottle!, cans. pecks and mugs of the item consumed lDlo amoum of energy conswncd, measured in kilocalories. An estimate of the "momhJy 24 calon\: intake" of each beverage item was then detennined for each student by multipl}ingU tnhiev fererqsuietnyc yo fo fG chonasunmap thiotnt pan:/d/ uthges ptyapiccael .suegrv.iengd usiz.ge hof the items together. 1be resulting 28 multiplicative indices were then added together to obtain a grand index for the total amount of calories of SSB consumed by each student in a month. This grand index was then divided by the figure 30 to obtain an estimate of the average amount or calories ofSSBs consumed by each student in a day (as illustrated in rahle 'l2 below). Tabk 3.2: Sa_pac dlita YOW-illl IMnt' "daily caloric intake" or SSB was obtained .~ Irc~damountofbever eitemsconsumedinthepastmonth MOnth_I Daily I Cokc_Fre Coke_Ca Coke_lnd I "'ITIC_Fre T/C_Ca TIC_lnd)' CaJori q I x q 1 "x Calone c I ro-- 0.00 0.00 ... I 236.00 236.00 ~~~OO Inf~ 2 I 330.00 330.00. I 354.00 354.0015249.9508.33 310 3300.0033000.00 ... 10 236.00 2360.0013575.0452.50 6600.00 132000.g ... 120 472.00 9440.0020120.1 670.67 5 fro--l-'9900.00 297000.~ 'Iiil 14160.~ 27399.9 913.33 TIC-Tea/Coffee __ ~ To obWn estimates on daily caloric intake for each of the five types of 5SBs. similar procedures were used. The only difference was in the number or multiplicative indices added. For each SSB type. only the multiplicative indices of beverage items falling directJ)' under the 8SB type were added. On carbonated drinks for example. only the multiplicative iDdices of Coca-Cola. Alvaro, Fanta, Sprite. 7-Up and Muscatella \\--ere .tded 10 obu.in a grand index for the monthly caloric intake of this type of SSB by each student 25 3.3.2 lAdepeadentvariables University of Ghana http://ugspace.ug.edu.gh The independent variabh:s included variables summari/ing the background characteristics of each student. These comprised variables OIl the student's Sex, Age, Educational level. Ethnic Origin and Han of Rcsidence. Sex was recorded as a binary variable (Female "" l, Male-O). In line with the literature, females arc expccted to frequently consume SSBs, and to consumc more calories than Males Age was measured originally on a continuous scale. For ease of description however, four categorics of age groups were defined (18-20. 21-25, 26·30 and 31+). The continuous version of the variable was howc\-er used in the analytic section to obtain a reliable estimate of the effect of age on the quanti~y of SSB consumed. It wa.o; c:xpected that younger Sludc:nls will consume SSBs more frequently and in larger quantities than oJderstudenlS Similar cxpt:(:tations were held of graduate and undergraduate students: Undergraduates, who are relatively younger, were expected to consume more calories of SSBs than graduates. Thus. educational level was recorded on an ordinal scale with two o.:atcgorico; (Graduate--l,Undergraduate:O). Ethnic origin and baH of rcsidencel , which originally were nominal variables with several eategories. 'A"Cre re-clas.sified as dichotomous nominal variables (Expalriate-i. 2Inlh~study.hallsofreSidencerefertobotbthehaditionalhallsOfmidmceandtheOfficially recogmZ£UitlO).! variables were treated as if they .... ere eonunullu$ ..... hcn used in the analytic scction, a practice that is common in social science, Three indicator "ariablcs were define to gauge the usefulness of SSBs as aphrodisiac, appetizer,and energi7..er(Yes""l, N~, in eoctl case), and five defined on the socio- economic status of students, which originally was a variable with six categories (Have no source of regular income-O, Gets handout from friends and family-I, Receives reminances-2, Receives money from parents""J. Hove income from lx:casional jol>-=4. Have regu.lat income from employmcnp5). The last category - students having no source ofrqular income - served 85 the refer~e group. A NOl4bk OlllCofM Vtlrltrb/~ It is expected that students who consume high amount of SSBs would be more obese than tOOK students woo consume low amount. To get a sense of how SSB consumption could iDCre8Se the risk of weight gain, the Body Mass Index (BMI) of each student was determined. Each stUdent's BMI "',as calculated by taking the ratio of the student 's weight to the square ofhislher height (kglm'). 8MI = WeIght (Height)' Whilethis ....- asmeasurcd initially on a continuous scale, for purposes of description, the BMI wascatqorized into Underweight« 18.S kg! m'l, Nonna! (18.5 _ 24.9 k&lm2) and (h·crwcight(>25Jlkgfml). 1.4 STUDY POPULAT lO~ University of Ghana http://ugspace.ug.edu.gh The study IX'pulalioll ... ,Impriscd Male and Female Graduate and Undergraduate students. rcgistem.l in one of the faculties and residing on me Legon university campus in March 2011 1.S SAMPLING 3.5.1 Sample Sift Dtterminatio. Iu there were no Ivailable da&a nationally to employ as a baseline for reported daily or moothly inWce ofSSB.1 assumed that exlttly 50 percent of the students consume at least one bcvcn&c in I month. U5in& a 95% confide-nce level and a 5% margin of error. I obtainedthesamplesizc' n:. 22 .p~: - p) = 1.962;~~~. O.S = 385 When: it .. the z, •• wre a.uociated with the auumed confidence level p the asswned proponion of students who consume at least one 5SB in a month c ~ the tolerable marain of error in estimate! about the frequency of SSB consumption While my sample was actually based on a multi·stase duster sampllng design. I could noc fKtOr in the design effC'C1 into the eah:u1ation of the sample size. There were no available srudies ftom which t could get estimates of the intra·duster comlation coefficients between halls {tlwt i~ measures of how simnar students 1ft: in the different 29 halls). These estimates are required to cumpute the variance of 8 statistic like mean monthly SSUBn ciovnesurmspittiyo no ffr oGm ha amunhai~ shtatatpe :c/l/uustgers spamapclee. .wuhgic.he dinu tu.gmh is needed to estimate the design effect. Given thi! limil81.ion, I estimated the sample size as if I was going to use a simple random sampling procedure, a sampling design that is itself difficult to implement with student population because a complete and well-defined sampling frame is not always available or accessible. Thus, the actual margin of error of eSlimatc~ from the overall sample is somewhat more that the assumed SYo. 3.5.2 Sampliag Method A multi·stage cluster sampling design was used in selecting the 385 students. First. a rando"; procedure was used to select 9 halls of residence from a list of 141. This ~ then followed by a systematic .selection of rooms from the selected haHs of residence; and then by a random selection of on person from each of the selected rooms for interview. With the limited time and fund available for the study, only 9 of the 14 halls of residence were surveyed. First, the 14 halls were numbered, and a simple random technique used to selm Q number.>. Halls with numbers corresponding to the ones selected were then included in the study. While the balls were not stratified further by their graduate or undergraduate statu... , the selected hall~ 3f'e fairly representative of the graduate and the undergraduate student population on 4:ampus ~. indicatcs haJlsofresidencli: dropped from the study In this sfudy: Halls (Legon·, Akuafo. Commonwealth. Volta, Mensah Sarbah); Hostels (Postgraduate. Valco Trust •• lntemational Studena', ~.Jubilec, Bani. F.vandy, Limmann·, Alexander Kwarpong.). The decisioa. CO G'op S, halls was ~ased on the limited time and funds available for the survey, and tbeneedtobaveadesJrablemarglOofenor. 30 For each of the halls selccted. the swdenI population and number of rooms occupied by students ",-Ueren dievteerrmsiniteyd forofm G thhea mnanaa ghert topr :s/e/nuiogr stuptoar.c Teh.eu ngu.mebderus .tghehn fonned the basis for the allocation of the sample 10 and determination of the sampling interval for the hall(mlable4.1betow). Having determined the number of students to be interviewed from each hall. a systematic random samplina technique was used \0 sek!ct a number of rooms in each hall. The number of rooms selected corresponded to the total nwnber of interviews allocated to the hall. Fi.rst., a sampling interval was determined for each hall. This involves detennininB the ratio of rooms occupied by students in the haJl to the sample size allocated to the hall. For example, Mensah Sarbah haJi had 268 occupied rooms and an allucated sample size of 46. Di~·iding 268 by 46 gives an approximate value of 6, which is taken as the sampling interval for this hall. r.ble3.J DistribudoDorthestudeDb POPU"UOD Bcro15tbe9b• • 10.4 40 6 __- '::.10,,--.1_ 39 7 ~~ ____- +_ ___~ 9.~1__ 35 6 10.1 )9 6 10.1 )9 6 100.0 38S lJ Next. a simple random sampling technique wa<; used to delennine a room for the first inlcniew. afteUr nwihviceh rsthiet ys aomfp lGingh ainntearv ahl twtpas: /a/uppglisedp. aInc eth.eu egx.aemdpule. gonh Mensah Sarbah.the first 6 rooms on the right-sideofthe entrance to !he haU were listed and one randomly selected _ the 3~ room. I then went to the 9111 room, the ISIh room, and so on, visiting every sixth room thereafter until the required nwnber of rooms was visited. On visiting a selected room. a simple random sampling technique was used to select llUdeots for the actua1lnterview. This involved listing the names of all official members of the room. present or absent, and then randomly selecting one person for interview using a lottery method, for students that were absent. a maximwn of two call backs was made after which failure to respond led to a replacement.· There were occasions where some respondents \o\tte not substituted, a situatil)8 that resulted in a reduction in the actual sample SiLC. This mostly happened at the later stage of fieldwork . when most of the students had started writing their ex.aminationsand were not available. Some had even completed their examinations and left campus. Thus. it would have been difficult obseving the Mct scientific procedures for su~iluting non-respondents, as I would hive to sc:k"(;t from only students who were available and were willing to spare some time doing the SUf\'cy. a situation that would have introduced more bias into the sample. 3.6 DATA COLLF.CTlON TECBNlQUESrrOOLS University of Ghana http://ugspace.ug.edu.gh An mlen'it'" of studeots was conducted by trained interviewers at the halls and hostels. A Food Frequency Questionnaire was employed with respondents to report on beverages conswned over a period of one month. Anthwrometric measurement of weight was taken with an electronic digital scale seca 170 Floor 10 the nearest 0. 1 kg, in the morning. Height was measured with a microtoise seca stadiometer to the DeBlTSI 0.1 em. During these procedures. an upright position was maintained with arms freely hanging and head plate rested on the crown. Heavy clothing and shoes WeTt' removed. 3.6.1. TraiDiDg and R«raitmeDtoflnteniewenl Assistants Two field assistants. with university degrees, were ['e(:ruited to a..o;sisl with the interviews The two were given detailed briefmg on the Food Frequency Questionnaire. They wcre trained on how 10 estimate beverage serving sizc:s with the help of teaching aids such as measuring cups, cans and boules ofhc\crages and familiar packs. Knowledge about the kx:aI, regional or ethnic beverages available in the market was important and the intervie"'-ers were provided with standardized neutral probing questions so as to avoid leading. They were also given some general guidelines on interviewing and research ethics, and had the opportunity CO test their knowledge prior CO the actual survey- specifically in mock inten.'iews and the pre-test 33 3.6.2. QuaiityCoDtrol University of Ghana http://ugspace.ug.edu.gh Recruitmenl ofpeNmncl who were very motivalcdand with the requisite background constituted the intct\'lewers; and COC" an improved \\'orkmg relationship, both material and financial motiutioo was ensured. To ensure thIt the questionnaires were complete and consislent, regular control checks were: maintained. Research Assistants weR COflilnuous)y supervised to ensure standardized procedures were used in the data coliectlOn.The weighting scales were checked each day for error and calibrated before use. Data was entered t"lCe by different qualified personnel. and the resulting entries validated by matching basic frequencies. Sorting ledmiques were used to COfT'ect erroncoU! and mismatcheci entries 0" individual and linked variables in the tina) dataset before subjecting it 10 analysis. ha\ing crosschecked the values from the appropriate questioMairc:s 3.6.3. Data ProceulDg alld ADaIy.u Questionnaires were coded and entered into SPSS software version 16.0. The resultiag dala was then cleaned, analyzed and presented using bar charts, frequency distributions and cross tables. 1be results were tested for statistical significance u.o;ing Chi-square, independent-ample I-test and one·way ANOVA where appropriate, and reported at three levels of significance • 10010, 5% and I %. A Mu11i\'ariate OLS linear Regression was abo used to identify the detenninanlS ofSSB consumption. 3.6.4. EligibUityCriteria University of Ghana http://ugspace.ug.edu.gh Graduate and Undergraduate students who belonged to one of the faculties registered with the University ofUhana and were officially residing in one of the halls or hostels on campus were eligible for the srudy. Moreover, participanls who showed their willingness 10 participate in the study by submitting a completed consent fonn were included in the srudy. 3.6.5. EtbicalcoDsideratioDs Permission was obWned and study approved by the Ghana Health Service Ethics Review Committee and Ethical I~ues in Research Design and Procedures such as voluntary panicipation, refusal right, benefits. safety of procedure and confidentiality were addressed. Informed writtenconsenl v.ClSobtained from participants before the sl udy. 3.6.6. PmestiDK Qucslionnain:s were administered and interviewers pretested at the Hila Limann Hostel. This enabled the investigator to analyze the strengths, weaknc:~ and validity of research and necessarycorrection!l were made prior to the actua1 process. 3S CHAPTER FOUR University of Ghana http://ugspace.ug.edu.gh RESULTS BACKGROUND CHARACTERISTICS Oul of the targctl-d wnple of 385 students, a total of 329 actually participated in the survey. This represented a response rate of 85.5%. Of the 329 students that panicipaled. 59.1% were males and 41.00/, ","'etc females. Thr majority were W1dergraduates (94.4%) in Level 100 (38.6%). were aged between 18 and 25 years (92.7%).1Dd had norma1 Body Ma.u Indices (i.e. a BMI between 18.5 and 24.9 kg/mt) (67.8%). About aquarler (24SV.) wm=o\le1"Weigbt. Table 4.1: Backcro. .. Characteristics oflbe tDtve~ity Stude.1s, Legoa. I BacqrouadCharacteristics Frequency Percentage ~- -If T_I"_T .. ~9.0 135 41.0 11·20 126 -,,-,- Age Group 21.25 179 ;4.4 26' Under .d~t' Goad ..., 19 S.' 50.5 49.5 7.9 67.S 24.6 56.S 16.7 36 A little over half(SO.S%) of the students were living in traditional halls afthe University. while the resUt (n49i.v50e/.r) switeyre orefs iGdinhga inn hao shtetltsp o:n/ /cuagmspups.a Tchee .sutugd.eentds uaJ.sgo hcame from ethnically diverse backgrounds. Akan. Ewe. Ga-Adangbe, Northern tribe. and other ethnic groups outside Cihana (Table 4.1). 4.2 FREQUENCY OF SSB COSSUMPTION 'The vast majority of the students (96%) indicated thlll they havt: con~umed at least one Sugar-Sweetened Beverage (SSS) in the past month. Many reported consumption of carbonated drinks (88.8%). fruit drinks (67.2%) and energy drinks (60.8%). Reported daiiy consumption ofSSS was however very low: only 35% of the students indicated that they consumed some: type of SSB every day in the past month, 'Nith consumers of tea,. coffee and energy drinks in the majority (Figure 4.1) . • Atleaslonceinthepastmontb .o.ily 96. • llLI,~. L AaySSB C~nated truitDrink LlcqyDnnk TCIlfCofTee Type ofSSB 37 In terms of speciftc beverage Items. Coca~Cola. Muw. Tea/Coffee. Fanta and Don Simons weUre nthiev meorsst irteyp oortef dG beh\'aernagae sh thtatip w:/e/rue g(osnpsuamceed .aut gso.meed tuim.eg ihn the month. Six (58.4~). 5 (49.2 and 47.6%) and 4 (41.3% each) in every 10 students have consumed Coca-cola, Alvaro, Tea. Fanta or Don Simons, respectively, at least once in the month. Five of the cari'Kmaled drinks were among the top 8 most reportedly consumed beverages in me pasl month (Table 4.2). Table 4.2: Peruataa;e of studeals repordag cOllSumptioD of speciftc SSUs in tbe pasl aoot. E .." ", -f""%TFnii' -,---.;;-' C.,. ... Fo' MIlk l%'TOaI~1{, . Dria" D.~II~, ~l, -· ' Driak .- . S~~e~,.;,,-;;-~ Milo rn:-IIDonSlmonl~ 58.4 Choc-mllk [8.2 Tea 47.4 lucozade 24.0 Ceres ' 24.9 Alvaro 49.2~k; I 11.3 Coffee 19.8 1 jB1ueJeans 11 .6 PureJoy 1 228 Fanta 41.3 ~~~try 16.1 Red Bull 10.9 BlueSkies 21.6 Sprite 38.9 Condensed rs.m- Milk 8.2 10.3 Fruilelli IS.2 Muscarella 0.6 Mall I-*Sbor""""k" ,,-t.;<"'0H---+- f---f- P_ 0.3 '-- ~ 1be percentage of srudents who reported con~uming one or more; SSBs in the past month (i.e. 96%) was virtually unchanged for the different categories of sex, ethnicity. educational level and hall of residence. For lhe different types of SSB however, the results show significant variationsac:ross the differmtcltegories of age. The 261- year age· group was more likely 10 have consumed tea/coffee in the past month than the18-20 and 21- 25 year age-groups (79.2". VS. SO.8 and 55.3%, P < 0.05). On the contrary, the younger age groups were more likely than the oldest to have consumed energ.y drink or milk in the past month (61.9 and 63.1% VI. 31.5% ~ energy drink, p < 0.01; and Uni49.2 avned r3s9i.7ty"0 ovsf. 1G6.7h%a n- a htptpmilk, <: //ugspace.ug.edu.gh0.10) Moreover, all the Ewes. GalAdangbes and International students reported consuming some form of SSB in the past month. with 3& 2, 41.2 and 39.3,",0. respectively, reporting daily consumption of SSBs. me vast majority of the ethnie groups conswned carbonated drinks A substantial proportion of Ewes also conswned energy drinks and fruit drinks. and Ga/Adangbes and international srudents also eooswne tea and fruit drinks (Table 4 .3) Table 4.3: PercC'Dtage or studeab Rportbt& cOD,umpdoD oISSB fa .lIe pu. moatb by bllldq:rouodcblllrlllclerlstics ~ ~~-sweetetledim~~ -~ r- . "acqrouDd Cltarlllcte. rtsll.cs Any L.noa. forni' T"f.n.efKY· fOaJ Miik N ~ SSB Drink Dnn!. Duo:'OkC -j-"iC.:.c:ff.; =. -t-.....,--l-;;;:;-l Sex - ~~lc~' :::~ ~:: ~:~ I !:::; ~ ~j!:~ ~ ~ 111·20 95.290.5 66.7 . 61.9· 50.8··49.2·"126 .__ . ~!:25 :~:; ~::~ L ~b:~ ~~:~: ~!:~:: ~::~::: I;: I RC'\Idcncc Hall 97.0 90.4 72.4 59.6 62.7 45.8 166 ~IimKM ~::I -~ 88.2 :i:: :i:~ ~:; ~!:~ ~ ::! .. E,,"~ 100.0 94.5 69.1 69.1 40.0 ]4.5-- '5"5" ~ I~~t ~~:; ~:~ ~~:: ~~:~ !!:; i: bn. student 100.0 96.4 57.1 57.1 60.3 39.3 28 l Undcrwciaht 92.3 84.6 57.7 57.7 34.6 46.2 26 8MI Norm.l 96.4 88.3 67.6 60.8 58.1 46.4 222 Overweid1t 96.3 91.4 69.1 61.7 54.3 27.2 81 !~;';=~~~':OD::'.~~~:;n~dence~:! ~!.~ Ji~ 4.3 Qi'ANTITY OF SSB. CO!'/SLMED University of Ghana http://ugspace.ug.edu.gh The I\'crage daily caloric intake from SSBs is 571 kilocalories per day (kcal/d), with fruit drinks and carbonated drinks contributing the largest amount of calories from SSBs (42.5 and 26.r!., respectively). The remaining SSB calories caJne from sugared tea/coffee (13.4-10). energy drinks (IO.9%) and sweetened milk (7.0%). (kcal/d) !KUlI/d) 3Q.89 :--l FruitOrink CarbonldDnnk TeafCoffcc Ettcl'J,) L>nnk Type of SSB Average daily calories consumed from aU SSBs combined did not show any marked variation across the categories of education. age, ethnicity, sex, hall of residence and BMI. Ilowner. the amount of calories consumed from the different ~ragc types showed some notable patterns, Graduates' calorie intake of supred tealcoffce was substantiaUy higher than undergraduates' (163 vs.71 kcaUd. p < 0.01). This is equivalent 40 10 a 130.0% higher intake. On the other hand. undergraduates "ere more likely to ~lIn .. umccnUerngiyvderirnskisttyh aongf rGadhuaalens(ap h< t0tp.1:0/)/.u gspace.ug.edu.gh Older studenlS were more likely to conswne higher amount of caJories from tea/coffee than younger students (175, 65 and 74 kcaUd for the 26+, 21·25 and 18-20 year age- groups. respectively: p < 0.01). Younger students were more likely than older students 10 consume greater amount of calories from energy drinks (87,51 and II kcaVd for the 18.20,21-25 and 26+ year age-groups. respectively) and milk (61, 30 and 7 kcalJd) ( p 550.42 223.87 139.89' 68.98" 55.74 51.94 lP"oup Ewe 754.12 384.55 221.60' 51.06-- 73.10 23.82 GaiA be 515.91 159.64 146.67' 108.51" ANOVA 1 Northern S21.72 213.46 100.69' 107.41" ~~::~- :OMJ-_= ~459'JKI51.1'iI 122.96' 108.73" SI.lI ~ Underwei 1 T 188.96 '82.69 163.31 52.65' 59.43 30.88' ANOVA Normal T 51(9(3'-2]9.86 160.73 70.91' 68.81 49.01' Ovcrwei&ht 579.33 301.9'iI 115.33 99.45' 44.78 17.79- "CurraII Undergraduate Ontdttate . ~~~.~ ;::~ 153.44 71.21'" 65.15' 41.88 t_ I 89.16 162.72'" 1.3.17' 7.36 ·P at departments and markets on campus (30.1%). Some 7.9Y. of the students also said they got their SSBs from vending machines (Table 4.4). A total 0(83 students (2S.2"o) indicated two or more soW"ces from which they obtained their SSBs. Only 5.2% said they sourced their SSBs from homes and social events outside campus. Teble ".5: Pen:eatll/,e! or students who consumed SSBJ rrom difJereot sourCH 43 4.5 DETERMINANTS OF SSB CONSUMPTION University of Ghana http://ugspace.ug.edu.gh To identify the key determinants of SSB consumption, a multivariate OLS regression model was coostrucled. Prior lO constructing this model. a bh,ariatc: correlation analysis was carried out between the main dependent \'ariable (daily ca10ric intake of 8SB) and all the independent variabh:s (background characteristics and the various attitudinal factors) to identify variables to include in the model: only independent variables that showed 4 sllong association with the main dependent variable were included in the modcJ . Fortunately,noncofthe independent variables was excessively correlatcd withanother . Table 4.6 sho""S that. overall, the regression model is statistical ly significant in ~plaining SSB consumption (p < 0.01). The model reveals thai soci~~nomic status and attitudinal factors jointly c)o;plaincd 5.6% of the total variance in daily SSB caloric intake, The resuJts a1so indicate that addiction 10 SSB and hours spent watching TV were Significant predictors of the calories of SSB consumed (p < 0.01 in bolh cases), MOfCO\'er. students" ho perceive SSBs as good source of energy tended to consume them more than those who see them otherwise, Again, students who depended mainly on handouts from parenls. family members and friends were more likely to conswne lower amount ofSSBs than their other counterparts (p < 0,05 in boIhcases) T.ble 4.6: Dele,..i• ••t lI or Daily Caloric I.take orSSB (kcalld) University of Ghana http://ugspace.ug.edu.gh Slandordiiiid coefficien15 CS of SSB consumed. Consumption level was high across all groups of student. . 3 The majority of SlUdenls access their SSB! from campus. with 51% obtaining them from restaurants and pubs, 330/. from supermarkets, 30% from table·top vendors at departments and mini-markets. 4 Socio-~onomic am.I altitudinal factors significantly influenced the amount of SSB calorie! conswned: Students who find it mon: difficult drinking less SSB. those ",ho spent ~ hours v,3h.:hing TV, and those who percch"c SSBs as good sow-ce of energy conswncd mote SSB calories than other students; while students who depended on handouts consumed less calorics of SSl:h (han those who did not. 6.2 RECOMMENDAn ONS, University of Ghana http://ugspace.ug.edu.gh Given the high consumption of SSBs among students of the University. a more concerted effort is needed t05ensitize Slooentson Ihc risk factors of NCDs. I. 1be Student Representative Council shou1d engage with the Regenerative Health and Nutrition Program. the Ghana Oiabetes Association. the University Hospital. Food and Nutrition Deranml!nl and School of Public Health to design and implement programs aimed at reducing SSB conswnplion on campus. 2 Management of Radio Universe (the University Radio) is hereby encouraged to make health education and awareness more regular on the station. They should have a specific program and air-time for discussing various' risk. factors of NCDs - especially. SSBs. TIte program could Ix a panel discussion or interview of experts, but should have a phone· in segment for students. 3. The University Hospital should make basic screening of NCDs more available to students. Clinicians could prm'idc ~reenjng scn·jces to student durinB spor1ing events, hall or SRC anniversary celebrations, and during school registrations 4. 1De University athourity should develop a school wellness policy that encourages sale of healthier beveraa:es on campus and restrict unhealthy ones. 1be authority could collaborate with retailers on campY! to raise prices ofunheaJtby beverages. to ecouragc mo~ healthy behaviour from students, and dedicate the returns towards NCD prevention programs on campus. 5 Future research is needed to examine daily SSB consumption along with daily food iDIake to detennine the contribution of SSBs to total daily caloric intake. 52 REFERENCES University of Ghana http://ugspace.ug.edu.gh Agyti_ Mensah. S. (2004). Epidemiological change at the tum of the: 21" century; Accra (Ghana) in Transition: Paper presenled at the seminar on Health in African cities, Harvard Centre for Population studies. Harvard University; Cambridge. 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T., N ..b . C., Mays. G . & [-.ddinp. KU. n(2i0v0e6)r.s Siteylf -oRef pGortheda nSuag ahr-tStwpe:e//teungeds pBaevceera.gue gI.netadkeu .agmhong College Students. Obesity 14, 1825-1831. doi: 10.10381oby.2006.210 Wiecha., J. L .• Peterson. K. L . Ludwig. D. S .• Kim. J.. Sobol. A.. & Gortmaker, S. L. (2006a). When children e.n what they watch: impact of lelevision \'iewing on dietry intake in youth. Archives ofP ediotrics & AdoltJcttU Medicine. 160{4 ):436-442 Wiecha. J. l.. Finkelstein. D . Troped. P. J• • Fragala, M., & Peterson, K. E. (2006b) School Vending Machine Usc and fasl-Food Restaurant Use Are Associated with Sugar- Sweetened Be\-crage Intake in Youth. Journal O/IM Americun Dieldu: ciWl;Onlion, 106: 1624-1 6)0. World Cancer Research fund, .tAmeucan Inslirule for Cancer Re$earch. (2001). Food. Nlltrrtwn. Phyllcui A.tII'It)'. 0Itd 1M fH"l'wntIOft of conct r a Global p.'rSpecrllIl! Retrived from AICR. World Health Organization (200S). Prr~nlj"g Chronic Dluase A I'ital inl'e;s/tffenl. ucncva: WHO Yen, S. T .. Lin, 8., Smallwood, OM, &: Andrew, M. (2004). Demand ror NonaJcoholic Beveragc5: the case of low-income households. AgrIbusiness, 20(3):309-21. Yancey. A. K. . Cole, B. L.oB rown, R.o et.1. (2009). A cross-sectional pre"atence study oretbnica1lytargetedandgeneral audienceoutdoorobesity-rclatedadvemsing.MilbanJc Quarterly. 87: 155-84. 65 Zoellner. J. Estabrooks. P. A., Da\'}'. B M. . Chen. Y-C. Y. • You. W. • (2012). Exploring University of Ghana http://ugspace.ug.edu.gh the Theory of Planned Behavior to I::xplain Sugar·sweetened Beverage ConsUtnpcioo. Journal o/l\'Ulrllmn FUllcClI;nnond BeItovIOY. 44:172.177. 66 University of Ghana http://ugspace.ug.edu.gh CIIANA II£ALTH St:RVK£ [TllleAL REVIEW CO\I;\1ITTEE IlIrauofrllplyth~ -«r_rM"cff~ 1.!t!~.JoD.Jt!~lfd ISpellpp!VVi!dpr1*KOI. You are abo 10 mfon!l tht ERC and your mOilltforpniullOft ~fOft.lly ~o(lIlcrrMMdlrmdinp_ PIe&sc.IOO1IYS~lhcpnllO(oIMkntlrlC.honnumbtriaaJlfIItIn~'1,e""t'~~'OIIlolt'" -' q£,~~ O~ CYNTHIA OANNI:RMAN (GHHl.C VICE CHAIRMAN) APP.:NDlX 2 ('ONSENT FORM University of Ghana http://ugspace.ug.edu.gh Title: Suga. ... sweete.ed 8r¥erage ceDJ8IIlptioa ....D I Uaivenity or Gbaaa studeDU PriDcipaJ Ilivestigator: Dr Modupeh Manley Wilson QualifiatioD:~ Etbkal Clearance -10 NO- GHS-EBC: HflOII Address: Box LG 13. OepctmeOt of Population. Family and Reproductive Health. School of Public Health. College of Hea1th Sciences, University of Ghana. Legon. Tel. 0545500018 E-mail rednW"Singtraininginstitule .~)"ahoo.com. You are invited to par1icipate in "the survey of Sugar-sweetened Beverage Crm:>urnption amone University of Ghana students. Legon campus is our study site. involving nine (baIlslhOSlelsl where lhe rnearch will be conducted. Prior to Ihc conduct of this study, it will be required of you 10 furnish us with infonnalion about thc quantity and frequenc)" of Sugat-s,,"-ectc:ned bC\'erage consumption, context in which Sugar-sweetened ~erage occurs and identify detenninants of Sugar-sweetened beverage consumption to cfi"etlivelydesignintcn·cntions. Our study population will be both Graduate and Underpaduate students belonging to one faculty, residing on Legon campus and registered with the University of Ghana. Study participants will be contacted to partlcipatc in an interview, which will take about 40 mmutcstoeomplete.Detailsaboullhevarinu,proccduresareindicatedinlhesections lhatfollow 68 YourparticipalioninlheSludyisvolunl8I) and there will be no ncptiveconsequence for University of Ghana http://ugspace.ug.edu.gh n:fusalalan)'stageofthcSlUdy. The procedure involved in this study is safe and simple and will involve onJy weight and height measurements Vthich will done with ~rcal care and with no physical, mental or emotional harm. Interviews will be audio. recorded and stored for two weeks. Confidentiality will be maintained by ensuring that questionnaires. infonned consent fonns are stomt in locked fik: cablnels under !.he custody of the principaJ investigator, data entered in SPSS software by research assistants and interviewers given study ID nwnber for each participant, responsible person for data was the PI which will be aceesscd onJy by members of the study team. No compensation in monetary or non-monetary terms will be given to the eligible person who consented topanicipate in the study. If you have any question about the study do nol hesitate to contact the Principal In\·estiptor Dr Modupeh Manley Wilson and if you have any question about your right as a research panicipant you may also contact to Rev. Dr Ayctc-Nyampong, chairperson, NMlMR-IRB Noguchi Mcmmiai Institute for Medical Research, I body through wlUch thestudyhlsbeenre\-ie. ...' edandapproved.MOBILE0208IS236 .. afterwxierslandinsthc: pwpose University of Ghana http://ugspace.ug.edu.gh of the study. apu:d to participate SilloJlat\ft I \humbpi,nl of respondent o..tt:ofinterview ... Signature oJ interviewer 10 APPENDIX 3 OUESTIOUNnNiAvIeRrFs. itOyN o fS GUGhAaRn-aSW hEttIpTE:/N/uEgDs pBaEcJ!eE!.!uj\g.G.eE dCuO.gNhSloMPTION AMONG UNIVERSITY OF GHANA STUDENTS PLEASE provide answers to the fntIU"lnl::qUl!"'lons, TICK I I where apprOprllte /"N.m;:- i/Ho'''''-- I Sub~(tIO IS.bl ·1(1) ofSupr-swectentd beverBllt>;nlheISSI (2) ..... .... . I !;:~amr!~: party, (3) .. . scoreltable top etc and t~ ~ rank for high to low ~~~_-:-,....----=-;::;-,- ~ Q24 . Sugar-sweetened Strongly agree ( ) Agrec( ) :;::gCS are easy 10 ~~ opinion ~ ~ Strongly disaSKR ) .... Q25 ~ Sugat-swectcMd- Stroaaly agree i ) Ajree ( ) I be\"cragcsat\: expcnm"f! ~~:pinion (l._ I Q26 I conswne supr- Strong.ly &&ret ( ) J :~et~~~;~ ~fopi~ion (] ·Q27 Usundtankthetlu