UNIVERSITY OF GHANA COLLEGE OF BASIC AND APPLIED SCIENCES DEPARTMENT OF NUTRITION AND FOOD SCIENCES NUTRITIONAL STATUS, SOURCES OF NUTRITION INFORMATION, WEIGHT PERCEPTIONS AND WEIGHT MANAGEMENT PRACTICES AMONG YOUNG ADULTS IN THE ACCRA METROPOLIS BY ESI YAABAH QUAIDOO (10552340) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MPHIL NUTRITION DEGREE JULY 2017 DECLARATION I, Esi Yaabah Quaidoo, author of this thesis do hereby declare that this work was done in whole by me in the Department of Nutrition and Food Science of the University of Ghana, under the supervision of Dr. Agartha Ohemeng and Dr. Margaret Amankwah-Poku. All references cited in this work have been fully acknowledged. ……………………………………. ………………………………… Esi Y. Quaidoo Date (Student) ……………………………………... ………………………………… Dr. Agartha Ohemeng Date (Principal Supervisor) ……………………………………… .………………………………... Dr. Margaret Amankwah-Poku Date (Co-supervisor) i DEDICATION I dedicate this work to my mother, Margaret Obeng-Quaidoo, and my brothers, Nana Kwamina Quaidoo and Kobina Obeng Quaidoo for their endless love, support and encouragement. Also, to Mr. and Mrs. Obed Obeng-Addae, Mr. Daniel Boateng Kusi, Mr. Emmanuel Osa, Mr. and Mrs. Michael Akuamah-Boateng, Edwina Abbey and Abena Twumasi, thank you for supporting and believing in me. ii ACKNOWLEDGEMENT My greatest acknowledgement goes to God Almighty, for His Strength, Guidance, Grace and Wisdom throughout the period of this study. A special thank you goes to my supervisory committee. I am greatly indebted to Dr. Agartha Ohemeng and Dr. Margaret Amankwah-Poku for their consistent guidance, input, encouragement and support to make this thesis possible. To the management of the Accra shopping mall, I say a big thank you for opening your doors to me. I am also grateful to all the young adults I met at the Accra shopping mall and Makola market, who agreed to participate in this study. To my dependable field assistants, thank you for your reliability and devotion throughout the period of data collection. I also wish to thank my family and friends for their prayers and support. Thank you to all the lecturers, support staff and my colleagues of the Nutrition and Food Science Department of the University of Ghana, Legon who assisted me in diverse ways towards the completion of this thesis. Thank you all so much for taking time and energy to assist me. iii ABSTRACT Background: Young adults experience significant life changes which often give them prime control over their nutritional choices; there is however limited information from developing countries on the factors that influence nutritional habits in this life stage. This study sought to provide data on the nutrition information acquisition behaviours, how weight was perceived and managed by a sample of young adults living in the Accra metropolis. Methods: This study was cross-sectional involving young adults (N=192) between 18-25 years recruited at the Accra shopping mall (n=93) and the Makola market (n=99) in the Accra metropolis of Ghana. A pretested questionnaire was used to collect information on demographic characteristics, sources of nutrition information, weight perceptions, weight management strategies, lifestyle and dietary habits. Anthropometric measurements of all study participants were taken using standard procedures. Pearson chi-square test and logistic regression were conducted in order to identify possible associations between sources of nutrition information and the nutritional status; and the possible relationship between weight perception and the nutritional status of young adults. Results: Online resources were the most used source of nutrition information; healthcare professionals were the least used source, although they were perceived as the most reliable. Half of the study’s participants thought that they were slimmer than they actually were in reality. Majority of study participants perceived normal weight status as the ideal body for themselves and for members of the opposite sex; majority also felt Ghanaian society wanted them to be normal weight. For participants who were actively managing their weight, three major strategies were identified: engaging in physical activity (39.0%), dieting (35.6%) and making lifestyle modifications (25.4%). There was no significant relationship between sources of participants’ iv nutrition information and their nutritional status {(95% CI: 0.46 – 1.64) and (95% CI: 0.58 – 2.20)}. However, a significant relationship was observed between weight perception and nutritional status of participants (95% CI: 0.15 – 0.61): young adults who had an inaccurate body image perception were 70% less likely to have a healthy nutritional status than young adults who had an accurate body image perception. Conclusion: There is a need to enlighten the Ghanaian youth on scouting and identifying quality online nutrition and health information. It would also be helpful for healthcare professionals to use online resources as a mode to offer credible information to young adults on nutrition and nutrition-related topics from a Ghanaian point of view so as to provide guidance to members of the young adulthood population. v TABLE OF CONTENTS Contents…………..……………………..……………………………………………………Page DECLARATION ............................................................................................................................ i DEDICATION ............................................................................................................................... ii ACKNOWLEDGEMENT ............................................................................................................ iii ABSTRACT .................................................................................................................................. iv TABLE OF CONTENTS ..................................................................................................................... vi LIST OF FIGURES ....................................................................................................................... ix LIST OF TABLES .......................................................................................................................... x ACRONYMS AND ABBREVIATIONS ...................................................................................... xi CHAPTER ONE ............................................................................................................................ 1 1.0 INTRODUCTION ................................................................................................................. 1 1.1 Rationale.............................................................................................................................. 3 1.2 Study objectives .................................................................................................................. 5 CHAPTER TWO ........................................................................................................................... 6 2.0 LITERATURE REVIEW ...................................................................................................... 6 2.1 Conceptual framework .......................................................................................................... 6 2.2 Nutritional habits of young adults ......................................................................................... 8 2.2.1 Dietary guidelines for young adults .............................................................................. 11 2.3 Young adults’ nutrition information acquisition behaviours ............................................ 13 2.3.1 Sources of nutrition information ................................................................................. 14 2.4 Weight perceptions ............................................................................................................ 17 2.4.1 Sociocultural influences on body image cultivation ................................................... 20 2.5 Weight management practices .......................................................................................... 21 2.5.1 Physical activity ............................................................................................................. 23 2.5.2 Dieting ............................................................................................................................ 25 2.5.3 Pharmacotherapy ............................................................................................................ 27 2.5.4 Surgery ........................................................................................................................... 27 2.5.5 Lifestyle modifications ................................................................................................... 28 vi CHAPTER THREE...................................................................................................................... 30 3.0 METHODOLOGY ............................................................................................................... 30 3.1 Research design ................................................................................................................. 30 3.2 Research setting................................................................................................................. 30 3.3 Study population ............................................................................................................... 31 3.4 Inclusion criteria and exclusion criteria ............................................................................ 32 3.5 Sample size determination .............................................................................................. 32 3.6 Data collection.................................................................................................................. 33 3.7 Measures and instruments ................................................................................................. 34 3.7.1 Demographic information .......................................................................................... 34 3.7.2 Assessment of sources of nutrition information ........................................................ 34 3.7.3 Assessment of weight management practices and lifestyle ....................................... 35 3.7.4 Assessment of weight perceptions ............................................................................. 36 3.7.5 Anthropometric measurements ................................................................................... 37 3.8 Statistical analyses ........................................................................................................... 37 3.9 Ethical consideration ......................................................................................................... 39 CHAPTER FOUR.....................................................................................................................................40 4.0 RESULTS ............................................................................................................................ 40 4.1 Demographic characteristics of participants ..................................................................... 40 4.2 Participants’ reported sources of nutrition information ................................................... 41 4.2.1 Participants’ perceived reliability of sources of nutrition information ...................... 43 4.3 Weight perceptions of participants ................................................................................... 44 4.4 Anthropometric measurements of study participants ....................................................... 47 4.5 Weight management strategies.......................................................................................... 48 4.5.1 Assessment of study participants who were actively managing their weight ........... 48 4.5.2 Strategies employed by participants to alter or maintain weight status ..................... 51 4.6 Lifestyle habits of study participants ................................................................................ 52 4.6.1 Physical activity levels of study participants in a typical week ................................ 52 4.6.2 Reported dietary habits of study participants ............................................................. 53 4.7 Association between sources of nutrition information and nutritional status .................. 56 4.8 Relationship between weight perceptions and nutritional status of young adults........... 58 vii CHAPTER FIVE .......................................................................................................................... 60 5.0 DISCUSSION ................................................................................................................... 60 5.1 Background characteristics of participants ................................................................... 60 5.2 Participants’ sources of nutrition information and perceived reliability of sources ...... 60 5.3 Participants’ weight perceptions ...................................................................................... 65 5.3.1 Participants’ self-assessment of weight status ........................................................... 65 5.3.2 Participants’ perceptions on ideal body of the opposite sex ...................................... 66 5.3.3 Participants’ perceptions on Ghanaian society body ideals ....................................... 67 5.4 Lifestyle habits of participants ........................................................................................ 68 5.4.1 Participants’ physical activity levels ......................................................................... 69 5.4.2 Dietary habits of participants ..................................................................................... 70 5.5 Anthropometry of study participants............................................................................... 73 5.6 Weight management strategies of participants ............................................................... 74 5.8 Limitations to the study ................................................................................................... 78 CHAPTER SIX ............................................................................................................................. 79 6.0 CONCLUSION AND RECCOMMENDATIONS .............................................................. 79 6.1 Conclusion ....................................................................................................................... 79 6.2 Recommendations ........................................................................................................... 80 REFERENCES ............................................................................................................................. 81 APPENDICES .............................................................................................................................. 88 Appendix I: Individual consent form ........................................................................................ 88 Appendix II: Research Questionnaire ....................................................................................... 91 Appendix III: Score Sheet for research questionnaire .............................................................. 97 viii LIST OF FIGURES Figure……….……………………………………………………………………..………….Page Figure 2.1: Conceptual map showing the factors that influence young adults’ nutrition choices and nutrition-related behaviours………....………………..…….…..............7 Figure 4.1: Sources of participants’ nutrition information………………..……………………..42 Figure 4.2: Perceived reliability of sources of nutrition information……………….…...……....43 Figure 4.3: Participants’ perception on source of pressure to be a certain weight.........…….......44 Figure 4.4: Feel-weight-status-minus-Actual-weight-status index of participants...…….…........45 Figure 4.5: Nutritional status of study participants……………….…....…………………..….....47 Figure 4.6: Participants’ personal concerns on their current body weight……………................48 Figure 4.7: What female participants were doing about their weight at the time of the interview…..…..………………...……………………………....………..…….…...49 Figure 4.8: What male participants were doing about their weight at the time of the interview…………………………………………………………………...……......50 Figure 4.9: Weight management strategies employed by participants………….…….…............51 Figure 4.10: Participants’ time spent in moderate-intensity physical activity in a typical week……………………………………………...….…...…...53 Figure 4.11: Meals consumed by participants’ on a typical day and the sources of meals…………………………………...………………………………..…..….….54 Figure 4.12: Participants consumption of certain foods in a typical week………..……….….…55 ix LIST OF TABLES Table…………………………………………………………………………………………..Page Table 4.1: Demographic classification of participants……………………………….……….....41 Table 4.2: Participants’ perceptions on body ideals………………………………….….……....46 Table 4.3: Mean (SD) of anthropometric measurements grouped according to sex....…….........47 Table 4.4: Sources of nutrition information versus nutritional status of participants.…….….....56 Table 4.5: Logistic regression showing relationship between family members as a source of nutrition information and nutritional status of participants……………..……...........57 Table 4.6: Logistic regression showing relationship between friends/peers as a source of nutrition information and nutritional status of participants……………..…….….......58 Table 4.7: Predictors of healthy nutritional status in young adults ….………...…..……...….....59 x ACRONYMS AND ABBREVIATIONS BMI Body Mass Index CDC Centers for Disease Control and Prevention ECBAS Ethics Committee for Basic and Applied Science FAI Feel-weight-status-minus-Actual-weight-status Index GSS Ghana Statistical Services ILO International Labour Organization ISCO International Standard Classification of Occupations LAGB Laparoscopic adjustable gastric band LRGBY Laparoscopic Roux-en-Y gastric-by-pass NHANES National Health & Nutrition Examination Survey SPSS Statistical Package for Social Scientists WHO World Health Organization WHR Waist-to-hip ratio xi CHAPTER ONE 1.0 INTRODUCTION The unique life stage that typically occurs between the ages of 18 to 25 can be termed emerging adulthood or young adulthood. This is where a young person moves from the tussles of adolescence and prepares to take on the responsibilities of adulthood (Majors, 2015; Maruf, Akinpelu, & Nwankwo, 2012; Poobalan & Aucott, 2016). Young adulthood is a life-stage set apart from any other. One cannot be referred to as an adolescent since adolescence is characterized by dependency on caretakers and neither can one be referred to as a full-fledged adult since adulthood is characterized by enduring social responsibilities and self-sufficiency which has not usually been fully attained at young adulthood (Arnett, 2000). Relative independence from caretakers during young adulthood, changes in finance, living arrangements, and time availability are factors that influence young adults’ food choices (Papadaki, Hondros, Scott, & Kapsokefalou, 2007). Young adults who previously had little to no control over their food choices shift to having prime control over what, when and how they want to eat (Chimeli, 2015). Many individuals develop habits that are harmful to their health such as drinking excessive amounts of alcohol and eating unhealthily during young adulthood (Abel, Hofmann, Ackermann, Bucher, & Sakarya, 2015). Apart from dietary patterns changing, young adults tend to be concerned about their physical appearance and how to change or maintain it for various reasons including to appeal to romantic partners, fit into certain peer groups or simply gain confidence in themselves (El Ansari, Vodder Clausen, Mabhala, & Stock, 2010). The way young adults perceive weight influences their weight management behaviours (Sirang et al., 2013). In Ghana, the traditionally appreciated body type tends to equate what is referred to as the 1 overweight body type in developed countries (Adusei, 2014). West African social desirability for overweight states has been observed through some African ethnic groups’ cultural practices that encourage obesity, for example, the pre-marital “fattening rooms” practiced in Nigeria (Benkeser, Biritwum, & Hill, 2012). Young adults seeking to conform to their society’s beauty ideals may seek counsel from inappropriate sources on how to achieve their body goals (Ali, Rizzo, & Heiland, 2013). The desire a young person may have to meet beauty ideals set by their society may result in looking up information on certain weight management strategies which may be questionable. Practicing some of these weight management practices could lead to adverse health outcomes later on in life (Malinauskas, Raedeke, Aeby, Smith, & Dallas, 2006). Young people in general have a heavy online presence and are exposed to different online resources which offer a myriad of information to a young person (Perloff, 2014; Zhang, 2012). The world has become a global village; the speed at which information spreads in society is overwhelming making the acquisition of information on nutrition-related matters such as managing one’s weight relatively easy. Yet, sources of information vary in their degree of credibility and accessibility; the problem is that information can be fabricated or can bring about contradictory theories (Hillis, 2015; Obasola & Agunbiade, 2016).There is an overwhelming amount of information and perspectives available on nutrition, fitness and strategies to manage weight causing nutrition and public health scientists to endeavor to pinpoint the exact information that brings about health and well-being throughout life (Hillis, 2015). Positive health and dietary habits formed during adolescence, and taken into the young adulthood period, form the basis for continued healthy nutritional habits in future stages of development (Poobalan & Aucott, 2016). The race-specific link between body size and beauty (Ali et al., 2013) indicates the need to understand the nutritional behaviours and nutrition-related topics 2 such as weight perceptions of individuals within specific age demographics in order to create public health interventions that are innovative, population specific and culturally acceptable for healthy weight promotion within communities. In Ghana, to my knowledge, no accessible study has reported on nutrition information acquisition methods of young adults and linked this to weight management practices within the young adult population. This research adds to the body of scientific literature regarding the means through which young adults in an urban African capital gain information concerning their nutrition, their weight perceptions and their weight management practices, given the unique life circumstances they face. 1.1 Rationale There has been high interest in body image and how weight is perceived around the world, with several studies documenting a prevalence of different body weights as ideal in different parts of the world (Maruf et. al., 2012). However, majority of these studies come from outside of Africa. Studies investigating weight perceptions in adolescents abound but studies describing the nutritional behaviours of 18 to 25 year olds in developing countries are rare to come across even though this is a critical stage of development. The few studies that address young adults from developing countries report on the relationship between nutritional status of study participants as the key outcome of interest and variables such as obese parents and family socioeconomic status (Baalwa, Byarugaba, Kabagambe, & Otim, 2010; Olusanya & Omotayo, 2011; Poobalan & Aucott, 2016). Yet, variables such as the nutrition information acquisition behaviours and how this information translates into practiced weight management strategies has not been reported even though the factors that contribute to a person’s nutritional status is multifaceted. Sirang et al., (2013), indicated that weight perceptions have the ability to influence weight management 3 practices which in turn affects the nutritional status of the individual. Further questions can be asked as to where exactly information on selected weight management techniques comes from. Obasola and Agunbiade, (2016) investigated where young adults from a Nigerian university accessed information on nutrition and fitness; online resources was the major source. This study however did not address perceptions on health-related matters such as weight and usage of acquired information. Also, the studies that have sought to describe some nutritional habits of study participants within the 18 to 25 age bracket have been done using institutionalized young adults, with the primary outcomes to assess weight, body mass index and fat composition. Institutionalized young adults (i.e. young adults in post-secondary institutions of learning) are convenient to study due to their ease in locating at institutions, but can limit the generalization of results since not all young adults pursue a post-secondary education. This study therefore sought to examine young adults visiting shopping centres, thus having a high likelihood of including both institutionalized and non-institutionalized participants. There is lack of information on young adults’ sources of nutrition information. For reasons which include relatively easier accessibility to the internet and the fact that young adults are more experienced than ever with digital media, there may be dynamics in nutrition information seeking behaviours among young adults which may be different from older adults especially in light of global technological advancements. Additionally, information on nutritional behaviours such as weight management strategies concerning the emerging adult population, especially at this critical life-stage of their development, is limited. Studies related to perceptions and influences regarding body ideals of young Ghanaians is lacking. Such information is needed to develop interventions that can promote a lifespan of good nutrition and good health. 4 1.2 Study objectives 1.2.1 Main Objective This study sought to assess the sources of nutrition information, weight perceptions and the weight management strategies of young adults in the Accra Metropolis. 1.2.2 Specific Objectives The specific aims of the study were: 1. To investigate sources from which nutrition information is acquired and current weight perceptions among the young adults living in the Accra Metropolis 2. To assess the lifestyle and physical activity level of participants 3. To identify weight management strategies employed by young adults in the study area 4. To examine the relationship between source of nutrition information and the nutritional status of young adults 5. To ascertain the relationship between weight perceptions and the nutritional status of participants. 5 CHAPTER TWO 2.0 LITERATURE REVIEW Young adults are required to make big adjustments while learning to cope with new life situations, such as leaving the home they were brought up in, in order to pursue activities and to an extent fend for their own needs (Poobalan & Aucott, 2016). Individuals going through young adulthood are demographically diverse and exposed to different life circumstances: some pursue post-secondary educations as soon as they complete their secondary school education while others engage in activities outside of academia such as working yet all the same relevant to progressing in life (Larson, Neumark-Sztainer, Laska, & Story, 2011). Literature on young adults has been examined extensively and certain trains of thought are presented in this chapter to identify the factors that directly or indirectly impact on the nutritional behaviours and inevitably the nutritional status of young adults. 2.1 Conceptual framework The conceptual framework was constructed based broadly on the theoretical model of ‘Attitude, Social influences and Self-efficacy’ (i.e. the ASE model) from de Vries, Dijkstra, & Kuhlman, (1988), who described an individual’s approach towards their health using these three variables. Inferentially, the ASE model suggests that nutritional behaviours are a result of one’s attitude, social influences and self-efficacy; which are all personal factors. However, according to Brown et al., (2011), personal factors interrelate with environmental factors and these range of factors influence the lifestyle of a young person leading to the nutrition behaviours observed. In an attempt to explain young adults’ nutrition behaviours which inevitably lead to their nutritional 6 status, two major interrelated stages are portrayed in Figure 2.1, environmental and personal factors. ENVIRONMENTAL FACTORS PERSONAL FACTORS  Socioeconomic systems  Individual health status  Food security  Attitudes and personal  Disseminators of information principles  Cultural identity and ideals  Self-efficacy  Food trends and fads  Body image perceptions  Living arrangement  Physiological needs  Peer influences  Genetic makeup  Food preferences  Food making abilities  Eating habits Lifestyle Nutrition choices and nutrition-related behaviours Nutritional Status Figure 2.1. Conceptual map showing the factors that influence young adults nutrition choices and nutrition-related behaviours (author’s own construct) Per the literature reviewed, the environmental factors that could influence a young person’s nutrition behaviours involve the socioeconomic systems of the society he or she belongs to; this refers to how the said society is advancing, or remaining the same, or regressing as a result of local, regional or the international economy (Renzaho, McCabe, & Swinburn, 2012). Other environmental factors include matters related to the food security of a young adult such as the production of food, availability of food and the distribution of food. Disseminators of 7 information in the society include old media (traditional media) and new media (online resources) which may play a role in determining nutrition behaviours as they market ideas and products that have the ability to influence behaviours (Perloff, 2014). Also, the cultural unit one belongs to and the ideals of said unit, the food trends (e.g. fast food or fads), a young adult’s living arrangements and the peer group one belongs to can all influence a young person’s approach to nutrition as discussed in the literature that follows. Personal factors identified were the belief a young adult has in their capability to perform behaviours vital to attain specific health goals in response to a need to change or remain the same out of an awareness of certain health statuses. Also, the perceptions one has about body ideals can influence a young adult’s lifestyle and in turn have an impact on the nutrition choices made. Physiological needs (Corleone, 2014) and genetic dispositions (Brown et al., 2011) contribute in affecting a young adult’s nutrition choices as well. Personal preferences towards food, skills related to preparing one’s own meals and eating habits formed from childhood and adolescence as a result of family unit socialization and parental modelling all influence a young adult’s nutrition behaviours (Brown et al., 2011). 2.2 Nutritional habits of young adults Young adulthood is a new period in life where young individuals have significantly more freedom to choose when it comes to food than previous life stages (Chimeli, 2015). A cross- sectional study conducted by Papadaki et al., (2007), assessed how living arrangements affect the nutritional habits of a sample of young adults aged 20 to 24 years attending a Greek university. A total of eighty-four participants filled a food habits questionnaire on their present food habits and their food habits before they started university. Study participants who still lived with their 8 family did not show much changes in their eating behaviours since starting university while participants who had moved away from their family reduced their weekly intake of fruits, olive oil, pulses, vegetables and fish, but increased their sugar, fast food and alcohol consumption (Papadaki et al., 2007). This study suggested that young adults who were away from caretaker/parental observation and had taken on the duties of putting together their own meals had taken on unhealthy dietary habits. Greiner, Holmes, & Hollenbeck, (2005), reported of a similar finding in their study conducted in the United States of America on 352 students who had just started university and were living away from their families for the first time in their lives. Information on their nutrition-related behaviours was collected using a questionnaire. Majority of participants gained weight after a year of living away from home. Alcohol consumption increased significantly, while physical activity dropped and the intake of vegetables and fruits decreased significantly. The study concluded that there were significant negative changes in the young adults’ nutrition related behaviour after they left home (Greiner et al., 2005). Many parents do try to restrict their children from consuming excessive amounts of certain foods but young people tend to show different eating behaviours when away from home or parental scrutiny (de Castro, King, Duarte-Gardea, Gonzalez-Ayala, & Kooshian 2012; Song, 2016). Self-prepared food tends to be healthier than food made away from home yet young adults consume a chunk of their total daily energy away from home (Eisenberg & Burgess, 2015; Larson et al., 2011). Larson, Perry, Story, & Neumark-Sztainer, (2006), investigated meal preparation behaviours, culinary skills, resources for meal preparation and the links with nutrition quality among a sample of 1,710 young adults aged 18 to 23 years. The authors reported personal meal preparation in general was low and even though both sexes had basic 9 culinary skills it was particularly low among young adult males. Males, who were African American and living away from home were significantly related to less frequent meal preparation. Most participants ate out at fast food joints and the common reason given for not preparing their own meals was time constraints (Larson et al., 2006). Driskell, Meckna, & Scales, (2006), arrived at a similar conclusion that males spent less time preparing their own meals. In their study that investigated the eating habits of a group of young adults, it was observed that significantly more young male adults (i.e. 84%) reported typically eating fast foods for lunch while only 58% of female participants reported doing this (Driskell et al., 2006). Larson et al., (2011), conducted a cross-sectional study that examined 2,287 young adults eating meals not prepared at home and the associations with dietary intake and weight status. As observed by Larson et al., (2006), there was frequent patronage of fast food eateries that mainly served sugar-sweetened beverages and energy-dense meals with low key nutrients. Fast food consumption was associated with poorer diet quality and a higher risk of developing an overweight status (Larson et al., 2011). The studies discussed above are researches that were conducted in developed countries. The situation with young adults who live in developing countries, especially those residing in countries making socioeconomic shifts, is that they experience a greater amount of financial freedom than their predecessors (Popkin, Adair, & Ng, 2012). There is an availability of convenience foods and fast foods from numerous shopping malls, convenience shops and food outlets which have sprouted up remarkably in recent years and have changed the means through which food is acquired as compared to previous years when it was deemed a luxury to an average young person in a developing country to eat out (de Castro et al., 2012; Poobalan & Aucott, 2016). Developing countries are experiencing an increase in more educated and 10 wealthier young individuals who engage in less physical activity but consume greater amounts of energy dense foods; hence the rises in the prevalence of obesity being recorded especially in the urban areas of sub-Saharan Africa and South Asia (Ettarh, Van de Vijver, Oti, & Kyobutungi, 2013). Health professionals now not only have to tackle the high prevalence of life-long nutrition-related diseases, but the fact that these diseases are showing up at younger ages than before (Hillis, 2015). 2.2.1 Dietary guidelines for young adults Constituents of a healthy and diversified diet differs depending on a person’s food preferences, food environment, beliefs regarding food, physiological and psychological traits but the basic guidelines for a healthy diet remain the same (Larson et al., 2006; Papadaki et al., 2007; World Health Organization, 2015). Dietary guidelines for early adulthood generally encourage the daily intake of fruits, vegetables as well as fibre while limiting intake of saturated fats as well as sodium and avoiding trans-fats altogether (Brown et al., 2011). Fruits, vegetables, legumes, nuts and whole grains should be eaten on a daily basis to ensure the body is receiving adequate amounts of vitamins and minerals and that the daily dietary fibre recommendation has been met. According to the World Health Organization, young adults who consume a minimum of 400 grams (i.e. 5 portions: filling one-third of a flat plate) of vegetables and fruits a day, lessen the chances of developing nutrition-related diseases (World Health Organization, 2015). To ensure meeting the 400 gram mark, a wide array of vegetables should always be added to meals; one can simply fill their plate with clean raw vegetables and make fruits a first choice snack (Brown et al., 2011). According to registered dietitian and health coach Jill Corleone, a young adult only needs 142 to 200 grams of protein foods a day; plant- 11 based protein such as protein from seeds, nuts and beans diversify diet and provide essential vitamins and minerals that promote optimal bodily function (Corleone, 2014). Young male adults’ calorie needs is approximately 2,400 to 3000 calories a day while young female adults need about 1,800 to 2400 calories a day to carry out normal metabolic function and maintain a healthy weight status (Corleone, 2014). Free sugars in the diet should be less than 50 grams (i.e. approximately 12 leveled teaspoons) for a person of normal weight status and a reduction in consumption to less than 25 grams provides additional health benefits (World Health Organization, 2015). Free sugars refers to sugars naturally found in honey, syrups, fruit juices and fruit concentrates and also the sugars added to food products and drinks (Brown et al., 2011; Larson et al., 2011). Intake of free sugars can be reduced by reducing the intake of sugar- sweetened beverages, pastries, sweetened snacks and confectionaries; instead a young adult is encouraged to snack on fruits and raw vegetables (World Health Organization, 2015). A total energy consumption of less than 30% should come from fats. Trans-fats, which are present in processed foods, fast foods, fried foods, pastries and spreads, do not constitute a healthy diet (World Health Organization, 2015). Unsaturated fats (sources include nuts, avocadoes, fish, canola and olive oil) have been found to be healthier than saturated fats (sources include fatty meat, butter, cheese, palm oil and coconut oil) (Yeung & Laquatra, 2003). Consumption of fats can be reduced by eating less processed foods containing trans fats (checking the nutritional facts panel can help identify this) and limiting the intake of foods containing large quantities of saturated fats such as fast food (World Health Organization, 2015). Dietary guidelines exist to guide young adults to achieve diversified and balanced diets in order to promote overall good health, yet, the reviewed literature found that young adults make unhealthy food choices. In an attempt to reduce unhealthy dietary practices among young adults, 12 questions are raised on where nutrition information is acquired to influence their food choices and nutrition behaviours. 2.3 Young adults’ nutrition information acquisition behaviours Acquisition of information occurs intentionally or per chance. The deliberate attempt to acquire information refers to a conscious determination to obtain information in response to a need or a lack of know-how in one’s mind, whereas opportunistic gaining of information refers to a situation where a person without warning comes across fascinating or beneficial information (Basic & Erdelez, 2014). Nutrition information forms a component of health information (Obasola & Agunbiade, 2016). Miller & Cassady, (2015), defined nutrition knowledge as having an awareness of practices and concepts related to nutrition including adequate food intake and wellbeing, food intake and disease, foods signifying key sources of nutrients and dietary guidelines and references. Acquiring nutrition information is important because it could inform nutrition choices positively and promote the maintenance of a healthy weight status (Hillis, 2015). A study in 2007 investigated whether increased knowledge in nutrition really translated into positive dietary behaviours. Two hundred college students, majority of who were between18 and 20 years old, self-reported their eating habits in a survey. It was observed that an increase in the understanding of nutrition was directly proportional to the increased probability of meeting dietary guidelines for fruit, dairy, protein and whole grains (Kolodinsky, Harveyberino, Berlin, Johnson & Reynolds, 2007). Borgmeier & Westenhoefer, (2009), found that highly educated people were more aware of the relationship between diet and health, and as a result were more inclined to use nutrition labels and make better food choices. 13 Both studies reported above by Kolodinsky et al., (2007), and Borgmeier & Westenhoefer, (2009), describe overall better eaters as having a higher understanding of nutrition. Yet, a study conducted by Misra, (2007), brings about an interesting alternate point of view. A total of 537 young adults’ nutrition knowledge was assessed. One would have expected the graduate student participants would have higher nutrition knowledge than the undergraduate student participants because of presumed better understanding yet it was the undergraduate participants who had more of a positive attitude towards their nutrition as well as having higher nutrition knowledge than the graduate participants (Misra, 2007). Where participants in these studies gathered their information on nutrition on was however not highlighted. 2.3.1 Sources of nutrition information According to Percheski & Hargittai, (2011), sources of health information can broadly be categorized as: family and friends, healthcare professionals, online resources and traditional media. Family members and friends make up our physical social networks (Perloff, 2014). Healthcare professionals consist of individuals with certification and expertise in the healthcare service that provides curative, preventive, rehabilitative or promotional health services (Percheski & Hargittai, 2011). Online resources consist of the internet, websites, blogs, vlogs, search engines, apps and a wide variety of social media sites such as Facebook (Zhang, 2012). Traditional media includes radio shows, television shows, newspapers, magazines, newsletters, tax press and other printed publications made to disseminate information (Perloff, 2014). Where a young person looks for information depends on their social context. According to Majors, (2015), more young American females than males access nutrition information from family members and magazines. An Iranian study found television programmes to be the first 14 go-to for health information, followed by family members and/or close friends, books and public libraries whereas a British study reported of the internet being the first go-to for health information, followed by books and asking friends or family (Percheski & Hargittai, 2011). Percheski & Hargittai, (2011), listed web sites, healthcare professionals and traditional media as common sources of health information in their study that tested 1,060 young adults. Using a self- administered questionnaire, they found that the internet served purely as a complementary source of information and not as a substitute for other sources such as healthcare professionals, family members and peers among their sample. Interestingly, family members and friends was the most popular source of health information with 89.5% of participants reporting that they frequently used this source more than all the others (Percheski & Hargittai, 2011). Perloff, (2014), backs this finding with the observation that young adults who still live with their family are less likely to use any other source of information apart from family members and friends. Apparently, young adults go to the internet when looking up topics that they feel is sensitive or embarrassing talking to family members or friends about. The internet provides anonymity to access information on sex, diet, nutrition, medications, exercise and mental health information (Basic & Erdelez, 2014; Obasola & Agunbiade, 2016). Basic & Erdelez, (2014), conducted a study on 2,193 undergraduate university students’ health information acquisition behaviours using a softcopy survey. The study sample of young adults reported using the internet, to a greater extent, for information on everyday life matters. The most common topics looked up was diet/nutrition and fitness/exercise (Basic & Erdelez, 2014). Another study by Head & Eisenberg, (2010), using a sample size of 8,353 undergraduate students attending different American universities, investigated the sources of information for participants’ personal use as well as course work. Study participants reported in the survey that 15 they took little at face value regardless of where the information came from although they used the internet the most and the campus library to a lesser extent (Head & Eisenberg, 2010). Participants in this study did not wholly trust information that came from the internet. Zhang, (2012), had a similar observation as Head & Eisenberg, (2010). Zhang, (2012), conducted interviews on 38 college students in order to investigate their usage and opinions of social networking sites for health and fitness information. Information on health was intentionally sought by young adults using search engines but unintentionally encountered when they used social networking sites. Interestingly social networks, for example, Facebook were not an effectual venue for interacting on health-related issues because young adults felt maintaining a positive image of themselves as a fit person in their online network was important even though they might have been struggling with a health issue (Zhang, 2012). On the other hand a Nigerian study conducted by Obasola & Agunbiade, (2016), found that majority of their study participants (72.7%) perceived health information from the internet as accurate and dependable. The study examined online health seeking behaviours of 400 university undergraduates in Nigeria using a cross-sectional study design. Through the use of surveys they found that daily internet use was on the average and use was constrained by poor electricity supply, the high cost of internet access and poor delivery of services (Obasola & Agunbiade, 2016). These were three different studies, two conducted in a developed country and one conducted in a developing country. Even though online resources were the most popular source of health information in the studies, there was a stark difference in its perceived reliability. Young adulthood is a time also characterized by a concern with physical appearance management (Ali et al., 2013; Perloff, 2014) and with literature indicating that young adults 16 actively seek information on nutrition-related topics such as fitness and weight management, the views young adults have on weight is of interest. 2.4 Weight perceptions Perceived body image consists of: 1) the body an individual identifies as the way they look, 2) the body an individual actually desires for them self, 3) the body an individual considers ideal for the opposite sex and 4) the body an individual feels the society he or she belongs to dictates as ideal (Maruf et al., 2012). When a person has a realistic and positive attitude about their body, they tend to show appreciation, respect and acceptance for themselves and as such these individuals are more likely to have control over their dietary behaviours (Andrew, Tiggemann, & Clark, 2016; Maruf et al., 2012; Quick & Byrd-Bredbenner, 2014). El Ansari et al., (2010), studied differences in body image perception between participants from two European countries. Eight hundred and sixteen (816) British and 548 Danish young adults were given self-administered questionnaires in a cross-sectional survey that assessed their body image perceptions. Participants who thought of themselves as “too thin” were 8.6%, “just right” were 37.7% and “too fat” were 53.7% although these were not their actual weight statuses using anthropometric measurements. Andrew et al., (2016) stated that individuals with a precise awareness of their own weight status have more control over their eating behaviours and are more likely to be happier and confident with themselves. Participants in the study by El Ansari et al., (2010), study who perceived themselves as “too fat” (although they were not necessarily ‘fat’) were more likely to be females and reported feeling stressed and unhappy with their lives. The observation made by El Ansari et al., (2010) that participant who perceived themselves as too fat had a desire to be slimmer corresponds to Grogan, Gill, Brownbridge, Kilgariff, & 17 Whalley’s, (2013), study on 20 women’s experiences of dress fit and body image in the United Kingdom. Study participants’ spontaneous reaction to clothes they tried on was audio-recorded. Participants were also body-scanned and photographed in their favourite dress and told to discuss both the scan and the photograph in semi-structured interviews. A slender hourglass physique with full breasts and full hips along with a small well-defined waist was the body idealized by all the women examined regardless of their actual physique. All these women wanted to be “in proportion” and not to be “fat” or masculine-looking (Grogan et al., 2013). Other studies have examined body image discrepancies using indices which indicated how realistic or unrealistic individuals’ opinions of their bodies are. Body image discrepancies can be calculated using the body mass index (BMI) of a person and the person’s self-perceived body image. Anthropometry, the study of the measurements of bone, muscle and adipose tissue of the human body provides a commonly applicable, convenient and non-intrusive technique for measuring parts and composition of the human body (Ogunlade & Adalumo, 2015). Body mass index (BMI) is an anthropometric parameter calculated as the weight in kilograms divided by the 2 2 square of the height in meters (kg/m ); a BMI of less than 18.5 kg/m is recorded as underweight 2 and greater than 25 kg/m is recorded overweight, falling between these ranges is considered normal weight status (World Health Organization, 2004). An interesting study from Italy conducted by Zaccagni, Masotti, Donati, Mazzoni, & Gualdi-Russo, (2014), used 354 young female adults with a mean age of 21.5 ± 2.9 years and 380 young male adults with a mean age of 22.1 ± 3.6 years. The body image discrepancy results were positive in most female participants and negative in most males, indicating an inclination for the females to overestimate their weight status and of the males to underestimate it. Interestingly, both female and male participants in this study felt that the opposite sex would prefer a thinner ideal than they actually did; in fact, 18 male participants wanted curvier females and the females wanted a more muscular male (Zaccagni et al., 2014). The results of the study showed a high dissatisfaction with weight status in females, with most preferring thinner bodies than in males examined. A similar study by Maruf et al., (2012), examined the perceived body image and weight of 121 Nigerian university undergraduates with a mean age of 22.34±1.88 years. Sixty percent (60%) of male study participants perceived themselves to have normal weight when they were actually overweight while 50% of females perceived themselves to be normal weight when they were actually overweight. Interestingly, normal weight participants thought that they were fatter than they actually were. The overweight female participants estimated their personal ideal and desired body images bigger (fatter) than their self-perceived body image (showing a desire to be fatter). Male participants perceived smaller body images for the female than the female perceived for the male. Most study participants in Zaccagni et al’s., (2014), study indicated that they would have liked to be thin (slender) whereas study participants in Maruf et al’s., (2012) study, had desires that run through being normal weight and overweight. The fact that there was a desire to be thinner among the Italian sample than the Nigerian sample may be explained by socio-cultural influencers of weight perception. One of the barriers to reducing the rise in obesity in developing countries could be its cultural acceptability. Black people tend to receive positive feedback about their bodies from friends and family even though they are clearly overweight (Quick & Byrd- Bredbenner, 2014; Maruf et al., 2012). 19 2.4.1 Sociocultural influences on body image cultivation Weight patterns and body image perceptions are greatly influenced by social settings. Physical attractiveness is a valuable tool in many situations of human interaction and as such, many are keen to live up to the standards set by the society they belong to; stigmatization of certain weight statuses (overweight or underweight) may lead to a search for the perfect body (Ali et al., 2013; Coetzee et al., 2012). Many societies in sub-Saharan Africa attribute large body sizes to good living and high social status, hence consider it desirable (Coetzee et al., 2012; Ettarh et al., 2013). Thus, ideal body weight perceptions of a society can influence the development of certain nutritional statuses. Quick & Byrd-Bredbenner, (2014), found in their study that among Black and Hispanic communities, big full-bodies (curves, big breasts and round buttocks) are considered signs of wellness and high status. Studies show Black people as less likely than other racial groups to perceive themselves as overweight and this may be due to many Blacks belonging to collectivist cultures (Ali et al., 2013; Renzaho et al., 2012). Collectivist cultures are characterized by a deeply vested interest in promoting social relationships and this is often shown through nurture and food exchange. Bodies are seen as indicators of success or failure in family members being able to cater for others in the same family (Renzaho et al., 2012). Many western cultures are quite opposite and promote individualist lifestyles. Typical characteristics of individualist cultures are that individuals are loosely associated with others and they are primarily motivated by their own preferences (Renzaho et al., 2012). Individualist cultural values are more likely to be prejudiced against ‘fat’ people because thinness in such societies is associated with having self-control, being attractive, youthful and elegant (Maruf et al., 2012; Zaccagni et al., 2014). In fact, young obese Caucasian females are more likely to be socially marginalized compared to their non-obese white 20 counterparts but this is not the case with obese Black females (Ali et al., 2013). The westernized ideal body for males, though more flexible than the stereotypical ‘thin’ female physique, holds several typical features: thinness, strength (vigor) and height (Perloff, 2014). Young adults from developing countries who are acculturated to the individualist culture are more likely to want to attain the ‘ideal’ buff or thin image (Coetzee et al., 2012; Quick & Byrd-Bredbenner, 2014). Current political and economic progress in Africa may have altered body size favourites among young Africans. According to Coetzee et al., (2012), modern Black African female fashion models in South Africa are much thinner than their Caucasian European-descended colleagues. Also, African female university students have reported more eating disorders than their White female counterparts. A young person’s body image is important to them, and as a result some seek physical forms using a wide range of behaviours and activities. Weight perception has been found to be an excellent predictor of weight management behaviour than a person’s actual weight status (Sirang et al., 2013). Thus, improving the way one view’s their body, plays a role in increasing appropriate weight management behaviours in young people (Zaccagni et al., 2014). 2.5 Weight management practices Weight management strategies aim to help individuals gain weight, lose weight or maintain a healthy body weight. Altering weight in the first place can be an odious task to complete but the real challenge comes when one is to maintain weight change once it has been achieved. Whether a person is trying to gain, maintain or lose weight it all starts with motivation (Ceccarini, Borrello, Pietrabissa, Manzoni, & Castelnuovo, 2015). In other words, the issue is not starting a weight management regimen but how to stay committed to a goal, pursue it and avoid slipping 21 back into previous habits (Strychar, 2007). It can be tempting to take ‘short-cuts’ even though some weight management strategies are clearly unhealthy. For example, the lucrative diet industry promotes assortments of products which advertise quick results with minimal fuss (Andrew et al., 2016). Fad diets (i.e. popular diets that generally promise quick results) which restrict consumption of key nutrients altogether (e.g. no carbohydrates), severe energy restriction of 800 calories or lower, strict food limitations (e.g. never eat red meat) and gimmicks (e.g. eat peppers to speed up metabolic activity) can be unhealthy as well (Brown et al., 2011). Some of the most maladaptive weight loss behaviours include smoking cigarettes to reduce appetite in order to lose weight and skipping meals intentionally with the aim of losing weight (Malinauskas et al., 2006). Several studies have investigated interventions for young adults to achieve their set out weight goals. Stice, Orjada, & Tristan, (2006), for example, focused on educational interventions through courses on a university campus to improve nutrition knowledge. The outcome of a 15- week course on obesity and eating disorders among 25 women compared with 70 control participants (females as well) from another eating disorder symptomatology course were assessed. The mean participant age was 21.3 years and it was carried out in order to address weight gain issues, eating habits and body dissatisfaction. Intervention participants maintained their self-reported BMI at post-test and 6-month follow-up, whereas control participants experienced an increase in BMI (p=0.025). Intervention participants also exhibited significant decreases in body dissatisfaction, dieting, and eating disorder symptoms at 6-month follow-up; showing that nutrition education as an intervention played a role in meeting set out weight management targets (Stice et al., 2006). A similarly designed study by Gow, Trace, & Mazzeo, (2010), assessed the outcome of a 6-week internet-based intervention course on a sample of 22 American freshmen; the authours assessed BMI and weight-related behaviours. The study subjects had a lower mean BMI at post-intervention assessment, after controlling for baseline BMI (p =0.05) indicating that course-based interventions can result in positive weight management outcomes (Gow et al., 2010). Another study focused on intervening on multiple weight related behaviours i.e. physical activity, diet, sleep, stress control, alcohol and drug usage (Werch et al., 2007). The study showed encouraging results with an underlining theme of adherence to long-term healthful eating habits and consistent physical activity in achieving and maintaining healthy weight among young adults. Brown et al., (2011), recommended that a certified health professional should be consulted when one seeks to alter their weight in order for a comprehensive anthropometric assessment, biochemical assessment, clinical assessment, food environment assessment and diet history to be conducted to understand the patient’s personal experience in order to formulate an effective individualized weight management plan. Weight management strategies can be categorized into five broad groups: physical activity, dieting, pharmacotherapy, surgery and lifestyle modifications (Ayisi-Addo, Ayisi-Addo, & Ohemeng, 2016; Grief & Miranda, 2010; Joo & Lee, 2014). 2.5.1 Physical activity Studies in physical activity have revealed that persons with normal body mass index engage in more exercise than their underweight or overweight counterparts (Sirang et al., 2013), and, active individuals regardless of their body weight, tend to be more satisfied with their body than less active individuals (Zaccagni et al., 2014). Young adulthood is a period where weight easily fluctuates; in fact, a moderate decrease in physical activity than previously participated in 23 contributes to weight gain (Majors, 2015). An interesting longitudinal observational study in the United States conducted by Wengreen & Moncur, (2009), gives credence to Majors’, (2015) statement. Wengreen & Moncur, (2009), investigated 159 young adults’ changes in eating behaviours, physical activity, and body weight during their move from high school to university. Baseline weight was measured at the beginning of their first semester and the new weight taken at the end of the same semester. Participants also filled surveys on their eating behaviours, physical activity and a few other health-related behaviours during their final six months at high school in August, 2005 and throughout their first semester at university in December, 2005. The 2 mean BMI at baseline assessment was 23.0±3.8 kg/m . Almost one quarter of the young adults in this study gained a significant amount of weight during their first semester at university. Even though the mean amount of weight gained during the study was modest (i.e. 1.5 kg), 23% of participants gained ≥ 5% of their baseline body weight. The average weight gain among those who gained ≥ 5% of baseline body weight was 4.5 kg. Study participants who gained ≥ 5% of body weight reported less physical activity during their first semester at the university than at high school as compared to the participants who did not gain ≥ 5% of body weight. The World Health Organization recommends that healthy adults aged 18 to 64 years participate in at least 150 minutes per week of moderate intensity aerobic physical activity and for additional benefits 300 minutes per week is sufficient (World Health Organization, 2010). Moderate-intensity aerobic physical activity refers to movements of the body that require a person to exert themselves in a manner that makes one breathe hard or sweat due to an elevated heart rate (Centers for Disease Control and Prevention, 2015). Even without a diet change, aerobic physical activity equal to walking at 4 miles per hour for a total of 150 minutes a week or jogging at 6 miles per hour for 75 minutes a week results in reductions in body fat and significant losses in 24 intra-abdominal fat which are consistent with improved metabolic function (Brown et al., 2011). Individuals who are active are very likely to achieve weight maintenance, have a healthy body mass and body composition (World Health Organization, 2010). 2.5.2 Dieting Dieting strategies are advertised everywhere (Brown et al., 2011) to the extent that one may not be aware that they are actually dieting, unless specifically explained to that eating behaviours used to consciously alter weight is dieting. Dieting refers to any method of food limitation, use of food supplements or changes in normal food consumed with the intention of altering weight (Malinauskas et al., 2006). Majors, (2015) reported in his study that women are more likely to diet than men. According to Brown et al., (2011), it is estimated that 71% of females and 42% of males are dieting at any given time. Malinauskas et al., (2006), studied the dieting practices, weight perceptions, and body composition of 185 females aged 18 to 24 years attending a university. Anthropometric measurements were taken to assess body composition and a questionnaire was filled on dieting practices as well as a 30-day physical activity recall. Findings in this study showed majority of participants (83%) used dieting for weight loss and believed that they would be fatter had they not dieted. Many participants in this study reported using physical activity to control their weight, but only 19% exercised at a level that would promote significant weight loss. Despite it being common knowledge that dieting alone is quite ineffective, it still remains a popular weight management tool of choice. Ayisi-Addo et al., (2016), researched on weight management practices among clients on a commercial weight loss programme in Ghana. It was a cross-sectional study with 50 participants. A survey was used to gather information on previous weight loss regimen and the reasons for 25 dropping out of stated programmes. Over half of the study participants had tried a weight loss regimen before the current one they were on and 88.5% left the regimen before their desired weight alteration had been achieved. The common strategies that had been tried were internet sourced diets (67.9%), commercial weight loss shakes (42.9%) and exercise (28.6%). According to the attrition rates, it is inferential to say that the previous programmes lacked the qualities to be an effective weight loss strategy (it was not sustainable). The observation made in this study that majority of participants had tried an online diet or commercial shakes correlates with the statement made by Malinauskas et al., (2006), that dieting alone is one of the most common weight management strategies employed by people, irrespective of weight status. Not all diets are unhealthy or ineffective. Dieting strategies that allow modest weight loss and its maintenance emphasize eating food which is low in energy density, for example vegetables and whole grains. This permits individuals to eat more food but less energy is consumed, which increases satisfaction and prevents energy overconsumption. Energy overconsumption would lead to excess calories in the body which would accumulate and result in weight gain (Raynor et al., 2011).Some popular diets such as the Mediterranean diet are very healthy (Brown et al., 2011). Other popular diets include the Atkins diet (which advocates high-fat ‘good fat’ and a low-carbohydrate diet) and the South Beach Diet has a similar regimen that promotes the increased consumption of ‘good carbohydrate’ (complex carbohydrates) (Grief & Miranda, 2010). Several studies however emphasize that considerable weight change would require a combination of a healthy dieting routine that encourages physical activity and behavioural change. 26 2.5.3 Pharmacotherapy The use of medication as a weight management strategy has shown modest success, with weight regain usually reported after therapy was stopped (Grief & Miranda, 2010). Hence, healthcare professionals usually combine medication with lifestyle modification interventions (Joo & Lee, 2014). Pharmacotherapy agents are grouped by the duration of treatment i.e. short term usage or long term usage: drugs such as benzphetamine, phendimetrazine and phentermine are for short term treatment (Joo & Lee, 2014). Sibutramine (Meridia) and orlistat (Xenical) are the only drugs permitted by the United States’ Food and Drugs Board as acceptable to use for long-term weight loss regimens in treating obesity (Grief & Miranda, 2010). 2.5.4 Surgery This is an effective tool that can be used to lose weight, although the surgery alone will not help a person who has lost weight to maintain it (Richardson et al., 2009). Surgery is not the first point of call in treating overweight or obesity statuses; these strategies are only applied in critical morbidly obese cases (Joo & Lee, 2014). Bariatric surgery is one medical means for achieving successful long-term weight loss in individuals with morbid or complicated obesity (Grief & Miranda, 2010). Common surgeries done for weight reduction are laparoscopic adjustable gastric band (LAGB) and laparoscopic Roux-en-Y gastric-by-pass (LRGBY), with the latter making up majority of all bariatric procedures (Richardson et al., 2009). Vomiting is often reported after weight-loss surgeries and chronic issues with malnutrition occur because of nutrient malabsorption making it vital to monitor patients for some time after the procedure (Richardson et al., 2009). Studies demonstrate that the bulk of obese people, who reduced weight through hospital-originated interventions, returned to their original weight in three to five years after they 27 were treated (Ceccarini et al., 2015). Weight loss will only remain if a long-term change in physiology occurs, otherwise a person will revert to their original or worsened state (de Castro et al., 2012). The main influences to successful weight loss maintenance after bariatric surgery are the patient’s ability to make lifestyle modifications with nutrition and exercise being the most important aspects (Grief & Miranda, 2010; Richardson et al., 2009). 2.5.5 Lifestyle modifications The best way to alter weight is to have a long term lifestyle change that emphasizes consumption of nutrient-dense foods to meet nutrient requirements coupled with physical activity to shape and firm the body and a strong psychological support system in order to maintain the weight change when it occurs (Brown et al., 2011; Ceccarini et al., 2015). Decreasing the amount of sedentary activities and consuming a balanced diet of 2 to 3 healthy diversified meals, contribute to managing one’s weight especially within the young adult population (Hillis, 2015; Majors, 2015). According to Grief & Miranda, 2010, the National Weight Control Registry in the United States of America, is a comprehensive and extensive compilation of information from individuals who have successfully lost weight and maintained said weight loss. Nighty-eight percent (98%) of study participants improved their food intake in some way to lose weight, 94% increased their exercising (brisk walking being the most commonly reported type of exercise), 90% exercised about one hour every day, 78% consumed breakfast every day, 75% measured their weight at least once a week and 62% of the participants watched less than 10 hours of television per week (Grief & Miranda, 2010). Strategies that can help young adults achieve and maintain a healthy weight include nutrition education for individuals entering this life stage since 28 an increase in overall nutrition awareness is said to result in better nutrition behaviours (Laska et al., 2012; Majors, 2015). Food choices, as well as lifestyle factors, genetic make-up, and the environment one resides in, determine an individual’s ability to maintain good health and abate the development of chronic nutrition-related diseases. Young adults need access to a range of healthful foods, knowledge to guide appropriate food choices, and positive attitudes towards food and eating, balanced with discipline in order to achieve healthy nutritional statuses (Brown et al., 2011). Good nutrition choices come from accurate sources of nutrition information (Chimeli, 2015). Nutrition choices in early adulthood years affect health and nutritional status in future years. Weight perceptions that young individuals have pushes them to seek certain body types through certain weight management behaviours which also affect nutritional status. Individuals with a positive body image accord their body with care and respect and are comfortable even with those body parts which are contrary to a society’s ideals (Andrew et al., 2016). Promoting lifestyle modifications through nutrition education and counselling from healthcare experts and the use of a theoretical perspective (i.e. the health belief model, the theory of planned behaviour, the social cognitive theory or the trans-theoretical model) can go a long way in improving the well-being of a person who would like to alter their weight (Ceccarini et al., 2015; Strychar, 2007). 29 CHAPTER THREE 3.0 METHODOLOGY 3.1 Research design This was a cross-sectional study conducted at two key shopping areas in Accra. Participants of different ages but similar characteristics were studied at one point in time. 3.2 Research setting The study took place in the Accra metropolis in the Greater Accra Region of Ghana. Accra is the capital city of Ghana; an urban and vibrant setting that comprises of people of diverse ethnicities, occupations, and backgrounds. Accra has many shopping areas which are heavily populated with young individuals. Shopping areas are a central point of convergence for people from different localities, especially the youth (Matthews, Taylor, Percy-Smith, & Limb, 2000). Participants in a study conducted by Ahmed, Ghingold, & Dahari, (2007), described shopping areas as a welcoming place for the youth especially, to socialize with friends. This indicates that shopping areas can be used as an alternative convenient research setting for collecting data on young adults due to the fact that shopping areas have evolved from mere venues for purchasing items and into convergent points for young adults to socialize and participate in other recreational activities. Also, shopping areas are open to a diverse range of people, including young adults who are not in post-secondary educational institutes as well as those who are in post-secondary educational institutes. Thus, this setting provides researchers with a wide range of participants to select from and thus bring variability to a study’s results. According to google map data 2016, the shopping malls and major markets located in the Accra metropolis were as follows: 30 Shopping malls: Marina mall, A&C shopping centre, Makola shopping mall, Achimota retail centre, Accra mall, Oxford street mall, Junction mall-Nungua, Palace Hypermarket interchange, Melcom plus, Melcom shopping mall-Accra central, Shaaba shopping mall, and the Legon mall. Markets: Agbosbloshie market, Nima market, Makola market, Kaneshie market, Osu market, Salaga market and Kantamanto market. The names of the shopping malls and markets were written on pieces of papers and mixed up in two different bowls for each. A volunteer, who had nothing to do with this study, was asked to pick a paper from each bowl; the Accra mall and Makola market were randomly selected using this technique i.e. the fishbowl technique The Accra Mall is a retail and shopping center located in the Accra metropolis of Accra, Ghana, on the Tetteh Quarshie Interchange adjacent to the Tema Motorway. It is one of the modern and most patronized shopping areas in Ghana. The mall is enclosed, has 20,322 square metres of retail space and accommodates 65 line-shops and 9 restaurants, all of which are highly patronized by the youth (www.accramall.com). Makola market is located in the Accra metropolitan area and is an extensive open-space shopping area. It consists of rows upon rows of stalls, people selling openly on pavements; one can purchase several food products, African textiles, clothes, shoes and cosmetics. The market’s central location ensures that it enjoys a lot of patronage from residents of Accra and tourists alike (Oteng‐Ababio & Sarpong, 2015). 3.3 Study population The target population was young adults between the ages of 18 to 25. 31 3.4 Inclusion criteria and exclusion criteria Young adults were included if they: a) had completed at least their junior high school education, b) were residing in the Accra metropolis at the commencement of the study and c) were willing to participate in the study. Individuals with symptomatic diseases, pedal oedema, physically disabled or who were pregnant were excluded from the study as this would have affected the accuracy of anthropometric measurements. 3.5 Sample size determination According to the Ghana Statistical Services (GSS), 2010 Population and Housing Census, 15 to 19 year olds in the Greater Accra Region make up a sum total of 388, 403 (9.7%); 20 to 24 year olds are 458,075 in number (11.4%) and 25 to 29 year olds are 443, 383 in number (11.1%). The age demographic of Ghanaians has been stratified such that getting an exact figure for the population of 18 to 25 year olds from the 2010 population and housing census would not be possible; hence estimates had to be made from data provided. th In view of this, the first assumption was that, 18 to 19 year olds made up 2/5 of the 15 to 19 year old population i.e. 2/5 x 388,403 = 155,361 people th The second assumption was that 25 year olds made 1/5 of the 25 to 29 year old population i.e. 1/5 x 443,383 = 88,677 people 32 The 20 to 24 year old population, which was 458,075, was not mathematically manipulated since this age group fell within the study’s target group. Therefore, the estimated population of 18 to 25 year olds in the Greater Accra Region was 702,113 people (i.e. 155,361 people + 88,677 people + 458,075 = 702,113). The sample size was calculated based on Yamane’s Formula: 2 n = N/1+Ne Where: n = sample size N= approximated population size e= margin of error Thus, using a confidence level of 92%: N = 702,113 e= 8% = 0.08 n= 702,113 = 156.22 2 1+ (702,113 x 0.08 ) This was approximately 157 young adults Using a contingency rate of 10%, 173 subjects were calculated to be the minimum number of study participants to be recruited for this study. 3.6 Data collection Participants were recruited using convenience sampling method at both the Accra mall and Makola market. The researcher and her field assistants briefly engaged young adults encountered at the research settings to establish if they resided in the Accra metropolis, their date of birth to confirm their age and whether they met every aspect of this study’s inclusion criteria. The 33 objectives of the study were thoroughly explained to prospective participants, after which, written consent to participate in the study was obtained from all interested participants once they verbally agreed to participate. A pretested questionnaire was used to obtain demographic information, as well as data for the three major sections of the study i.e. sources of nutrition information, weight perceptions and weight management practices. The structured questionnaire was interviewer administered and hence interviews and anthropometric measurements were conducted in-person by the researcher and field assistants. Study participants spent approximately 20 minutes on the questionnaire. A total of 192 study participants completed the questionnaire and had their anthropometric measurements taken. 3.7 Measures and instruments A structured questionnaire was used to obtain data from the participants (see Appendix II). This assessed several variables as described below. 3.7.1 Demographic information This included gender, ethnicity, age, marital status, occupation and highest education qualification. 3.7.2 Assessment of sources of nutrition information The questions posed in this section were adapted from Percheski & Hargittai (2011), in their study on health information-seeking behaviours in a college-aged population. According to Percheski & Hargittai, (2011), sources of health information could be categorized into four major groups i.e. family and friends, healthcare professionals, online resources and traditional media. 34 Alternatively, family and friends could be treated as separate entities. In this study, five sources of information were provided in a table: Family members, online resources, friends and peers, healthcare professionals and traditional media. A Likert scale with options: ‘always’, ‘sometimes’, ‘rarely’ and ‘never’, was provided for participants to identify how often they turn to these sources when they seek information regarding their nutrition. The researcher made room for any other likely option that a participant may mention. Perceived trustworthiness of these sources was also assessed, using a Likert scale with options: ‘unreliable’, ‘fairly reliable’, ‘very reliable’, and ‘accurate’. 3.7.3 Assessment of weight management practices and lifestyle In this section, questions addressed whether a participant was trying to do something about their weight. Participants were asked whether they were currently trying to lose weight, gain weight, maintain their current weight or were not trying to do anything about their weight. In assessing the perceived sources of pressure to be a certain weight, an open-ended question was posed to identify who talked the most about the participant’s weight. Further questions were posed to identify any approaches or treatments actively being used by a participant to alter or manage their weight. Questions were adapted from Majors, (2015) and pilot tested before use. Lifestyle behaviours were examined using a series of questions that assessed alcohol consumption, whether participants were smokers or not and their physical activity levels in a typical week. Questions were adapted from Majors, (2015) and Zaccagni et al., (2014). Information was gathered on the number of complete meals a participant ate on a typical day, whether these meals were home-cooked or bought, how often one ate out and how many sachets of water a participant drank on a typical day. A food frequency questionnaire was adapted from 35 Majors, (2015) and the United States’ National Health & Nutrition Examination Survey (NHANES); it was slightly modified to fit into the Ghanaian context. Statements questioning how often food options were consumed in a typical week were presented and a Likert scale was attached to these questions with the options: 1-2 times a week, 3-4 times a week, 5-6 times a week, 7 times a week or never. This was to identify dietary patterns of the participants. 3.7.4 Assessment of weight perceptions Pulvers’ figure rating scale (Pulvers et al., 2004) was shown to participants in this section of the questionnaire. This particular standardized figure rating scale was used because of its cultural relevance as a body image rating instrument for people of African descent (Pulvers et al., 2004). Participants were presented a series of nine male and nine female silhouette pictures that depicted body sizes starting from very thin (assigned ‘1’) and ending at morbidly obese (assigned ‘9’). The assignment of body weight status on the figure rating scale was as follows: underweight (silhouettes 1 and 2), Normal Weight (silhouettes 3, 4 and 5), Overweight (silhouettes 6 and 7) and Obese (silhouettes 8 and 9).The pictures were arranged in two rows. The top row depicted male body sizes while the one below represented body sizes for females. Participants were required to circle one of the nine silhouettes that fit the participant’s idea of what their current body looks like, the body type the participant wants for them self, the body type the participant thinks Ghanaian society wants for their sex and the ideal body for the opposite sex. This section of the questionnaire was adapted from Pulvers et al., (2004); Maruf et al., (2012); Zaccagni et al., (2014). 36 3.7.5 Anthropometric measurements All anthropometric measurements were taken as per standard procedures (CDC, 2007). The height of study participants was taken using a portable wall-mounted stadiometer (Seca GmBh & Co. 2171821009 Stadiometer). Participants stood upright with their back against a wall and their head in the Frankfurt horizontal plane while the researcher and field assistant took the height measurement. Weight was measured using a digital weighing scale (Ohaus SD 200 Digital Scale); participants wore light clothing and were barefoot or wearing light socks whilst their weight and height were being measured. The waist and hips was measured using a flexible tape measure, in order to calculate the waist-to-hip ratio of participants. 3.8 Statistical analyses Demographic data, sources of nutrition information, perceived reliability, weight perceptions, anthropometric measurements, weight management strategies, lifestyle habits and dietary habits of participants underwent descriptive analysis. The analysis of participants’ Feel-weight-status-minus-Actual-weight-status Index (FAI), i.e. a section of weight perceptions, was as follows: the BMI of a participant was referred to as their ‘Actual-weight-status’. Actual-weight-status was categorized based on WHO’s cut-points for 2 2 adults: underweight i.e. a BMI below 18.5 kg/m , normal weight i.e. BMI from 18.5kg/m to 2 2 2 2 24.9 kg/m , overweight i.e. BMI from 25 kg/m to 29.9 kg/m , and obese i.e. above 29.9 kg/m . As described by Zaccagni et al., (2014), in their study, FAI is an index used to assess if there is or not a realistic weight status perception in a participant on the basis of body size assessment (i.e. Actual-weight-status) and the feel figure (i.e. the silhouette a participant picked as their opinion of what their current body looks like). Scores were calculated by subtracting the actual- weight-status score from perceived current body weight score (i.e. feel-weight-status). An 37 underweight actual-weight-status got a score of 1, normal weight actual-weight-status got a score of 2 and overweight actual-weight-status got a score of 3, and an obese actual-weight-status got a score of 4. This conventional code was subtracted from the perceived current body weight (i.e., very thin/thin silhouette, average silhouette, slightly heavy/overweight silhouette and obese silhouette scored 1, 2, 3 and 4 respectively). Scores of zero indicated accurate body image perception. Positive scores indicated that participants perceived that they were heavier (fatter) than they actually were, whereas negative scores indicated that individuals perceived that they were thinner than they actually were in reality. Logistic regression was conducted to examine the possible association between sources of nutrition information and the nutritional status of participants. Source of nutrition information was the independent variable (coded as yes, I use this source or no, I do not use this source) and nutritional status was the dependent variable (coded as unhealthy BMI and healthy BMI for one aspect of the test and unhealthy waist-to-hip ratio and healthy waist-to-hip ratio for the other aspect of the test; both aspects of the test were used to explain participants’ nutritional status). Binary logistic regression analysis was used to examine the possible relationship between weight perceptions and the nutritional status of participants in this study. There were seven independent variables which included Feel-weight-status-minus-Actual-weight-status Index (FAI) which was used to represent weight perceptions (coded as inaccurate body image perception and accurate body image perception). Nutritional status was the dependent variable (coded as unhealthy BMI and healthy BMI for one test-run and unhealthy waist-to-hip ratio and healthy waist-to-hip ratio for another test-run both tests were used to explain participants’ nutritional status). Statistical package for social scientists (SPSS) 16.0 software was used to analyze all data at 95% confidence interval. 38 3.9 Ethical consideration Ethical approval to conduct this study was obtained from the Ethics Committee for Basic and Applied Science (ECBAS), University of Ghana (ECBAS 006/16-17). Permission to collect data from the Accra mall was obtained from management of the mall. Makola market is an open market, thus this process was not required. Participants were enrolled into the study only after they had given consent by signing two copies of the consent form, one of which was kept by each participant and the other by the researcher. They were assured of anonymity and confidentiality in the management of the information that they would provide. They were also made to understand that they had the right to withdraw from the study at any point in time if they wished to. 39 CHAPTER FOUR 4.0 RESULTS 4.1 Demographic characteristics of participants One hundred and ninety-two participants took part in this study; 98 were females (51.0%) and 94 were males (49.0%). Ninety-three participants (48.4%) were interviewed at the Accra shopping mall while 99 participants (51.6%) were interviewed at the Makola market. At the time of survey, 76.0% of participants were single and 24.0% were in romantic relationships. None were married (see Table 4.1). The age of study participants ranged from 18 to 25 years and the mean age was 21.8(2.2) years (Table 4.1). Akans were the major ethnic group in the study. Most of the participants were students (66.1%) and had completed a senior high school level education. 40 Table 4.1. Demographic classification of participants (n=192) Variable Mean (SD) n (%) Age (years) 21.8 (2.2) Ethnicity Akan 94(49.0) Ewe 45(23.4) Ga-Adangbe 40(20.8) Northerner 13(6.8) Occupation* Student 127(66.1) Services/Sales workers 23(12.0) Professionals 19(9.9) Crafts and related trades workers 9(4.7) Clerical support workers 3(1.6) Elementary Occupation 1(0.5) Unemployed 5(2.6) 1 Other 5(2.6) Highest Qualification Senior high school 127(66.1) Post-secondary school 44(22.9) Junior high school 21(10.9) *Aside from ‘student’, occupation of participants was categorized based on the International Standard Classification of Occupations (ISCO) by the International Labour Organization (ILO) 1 Other occupations reported were footballer and actor/actress 2 Includes clerical, vocational, polytechnic and university institutes 4.2 Participants’ reported sources of nutrition information Figure 4.1 illustrates the various sources of nutrition information and the extent to which these sources were used by study participants when seeking information on nutrition. Of the several sources mentioned, online resources were the most popular source used to seek information on nutrition among study participants. Only 5 participants (2.6%) indicated that they never used online resources when seeking information on nutrition. Of the total sample, 178 participants (92.7%) reported that they always turned to online resources when they sought 41 nutrition information. Traditional media was the second most used source when young adults in this study sought nutrition information. One hundred and twelve participants (112; 58.3%) always sought nutrition information from traditional media which include television programmes, radio programmes and newspaper articles. Healthcare professionals were the least used source of nutrition information as 168 participants (87.5%) never sought nutrition information from healthcare professionals, including nutritionists and dietitians. 100% 92.7 90% 87.5 Never 80% Rarely 70% Always 60% 58.3 51.0 50% 40% 38.0 32.3 29.7 29.7 30% 29.7 19.3 20% 12.0 10% 7.8 4.7 4.7 2.6 0% Family Friends/Peers Healthcare Online Traditional Members professionals resources media Source of information Figure 4.1. Sources of participants’ nutrition information (N=192) 42 Percent of participants 4.2.1 Participants’ perceived reliability of sources of nutrition information Figure 4.2 illustrates that majority of study participants, i.e. 166 participants (86.5%), perceived nutrition information from healthcare professionals as very reliable, 14 participants (7.3%) felt information from healthcare professionals was fairly reliable while the rest perceived nutrition information from healthcare professionals as unreliable. One hundred and fifty study participants (150; 78.1%) perceived nutrition information from online resources as very reliable. Nutrition information from friends/ peers was perceived by almost half of participants, (46.9%), as the most unreliable source of nutrition information. 100% Unreliable 90% 86.5 Fairly reliable 80% 78.1 Very reliable 70% 60% 49.0 50% 45.8 46.9 46.4 42.7 40% 35.4 30% 20% 18.8 20.3 10.4 10% 7.3 6.2 4.7 1.6 0% Family Friends/Peers Healthcare Online Traditional members professionals resources media Source of information Figure 4.2. Perceived reliability of sources of nutrition information (N=192) 43 Percent of participants 4.3 Weight perceptions of participants Figure 4.3 illustrates the sources of perceived pressure on participants to be an ‘ideal’ weight. One hundred and thirty six (136) participants (70.8%) believed that friends/peers pressured them to be an ‘ideal’ weight. Friends/Peers Family member 136 (70.8%) 56 (29.2%) Figure 4.3. Participants’ perception on source of pressure to be an ‘ideal’ weight (N=192) *Friends/Peers includes significant others and a football coach 44 Figure 4.4 shows participants’ body image discrepancies using Feel-weight-status-minus-Actual- weight-status Index (FAI). Ninety nine of the participants (51.6%) perceived that they were thinner than they actually were in reality. 9 (4.7%) Perceived weight= Actual weight 99 (51.6%) Perceived weight>Actual weight Perceived weight