Dietary transitions in African cities: leveraging evidence for interventions and policy to prevent diet-related non-communicable diseases (NCDs)

Africa is currently experiencing rapid change partly driven by increasing migration of individuals to cities. Dietary habits are also changing with increasing consumption of unhealthy foods that are high in calories and low in nutrients. Such changes have resulted in increasing levels of obesity in cities, with rates higher for women. Policy responses have been limited in success so far, and are mostly influenced by experiences in higher income countries which are less relevant to African cities. There is also less understanding of the factors that drive food consumption in Africa, particularly the role that people's social networks play (e.g. family or peer groups) and the neighbourhoods that individuals live in (e.g. access to fast food outlets). There is a need for stronger evidence that accounts for the environments that people live in to inform strategies to promote healthier food consumption in African cities.

Our project will explore the factors that are associated with food consumption patterns (what people eat) and practices (how, where, when and with whom they eat) within two African cities (Nairobi and Accra). We will undertake novel approaches for collecting data on food consumption and practices, and the factors associated with them. The different approaches will use both existing scientific evidence as well as including the views of local people and stakeholders in identifying solutions to the problem of eating poor quality high calorie diets. These will include: reviewing the state of knowledge throughout published research and analysing existing information on dietary behaviours; interviewing people about what kinds of food they eat and how they eat it (e.g. in a hurry, alone or with others) and using photography with local people to explore the factors that influence these decisions. We will also be mapping the food environment in people's neighbourhoods (e.g. location and type of food outlets available) to explore how characteristics/features in the environment might influence people's food consumption and practices. Based upon the results of this, we will be able to identify the range of factors that are associated with dietary patterns and practices. We will then compare these factors to current policy approaches in these settings to assess which gaps may require addressing and identify interventions with local experts and policy makers that may be useful to do so.

The proposed research will strengthen existing partnerships and build new ones, enhancing capacity in research, thereby paving the way for development of new interventions that are more likely to be effective. Our results will then be shared more widely with experts and policy makers from similar African cities via webinars, social media and regular updates on our project website. This will help them design effective strategies to improve dietary patterns and practices to tackle obesity.

Our project investigates the changing food and nutrition environment in the context of rapid urbanisation in Africa. The overall aim is to explore food consumption patterns and practices and the factors associated with them in two African cities (Nairobi and Accra). The project is divided into three interrelated work packages. Workpackage 1 will synthesise evidence on current food consumption patterns and practices and explore their social and physical determinants. It will gather all known secondary data on food consumption patterns and practices for the two countries and undertake a meta-analysis of demographic and social correlates of these. A systematic review will be undertaken to explore the current state of knowledge regarding the factors influencing food consumption patterns and practices in urban Africa.
Mixed methods data collection will be undertaken including a 24-hour recall to collect information on food consumption and practices. This will be combined with a Photovoice exercise to examine which social and physical factors influence participants' food consumption. This will be supplemented with spatial data on the features of participants' neighbourhoods that may influence food consumption. Findings will be synthesised into a framework map of the factors that influence food consumption in these two African cities.
Workpackage 2 will develop context-appropriate policy. It will examine the current range of policies in each country, and explore how they relate to our framework map. We will produce guidelines for encouraging healthy diets and review what interventions could be implemented using a realist literature review to identify what could works in these contexts, resulting in a policy brief detailing potential interventions.
Workpackage 3 will focus on knowledge translation and disseminating findings to key policy makers and the public. It will involve a photography exhibition based on workpackage 1, as well as national stakeholder meetings.

ODA justification:
This study involves a multidisciplinary team comprising UK and LMIC investigators from 2 partner countries. Kenya is listed under 'other low income countries' on the DAC list of ODA recipients, and Ghana is a lower middle income country. Both countries are experiencing rapid urbanisation, leading to changes in food consumption patterns. Such changes are associated with an increased prevalence of diet-related non-communicable diseases (NCDs). Health policies, including dietary guidelines, have not kept up with this rapid pace of change. Mortality from NCDs is increasing in both countries and is likely to hinder future economic development through increasing costs of healthcare. Both partner countries, in consultation with their Ministries of Health, have identified the need for national food-based dietary guidelines and the development of context-specific interventions to prevent diet-related NCDs. This research is important to the welfare and future health of the populations in these two countries; particularly among socio-economically disadvantaged groups which are experiencing the greatest increase in overweight/obesity. The research is also relevant for other African countries that are following similar trajectories of rapid urbanisation and dietary change. The major impact of this study will be to identify interventions to promote healthy diets to prevent diet-related NCDs, adapted to these contexts and to the lives of adolescents and adults. By focusing on environments that drive unhealthy food consumption, emerging interventions will benefit the whole community, thereby positively impacting on development. Well-nourished populations have better capacity for cognitive development and participation in the labour market, which also positively impact on development.

Beneficiaries of the research include:
1) The adolescent and adult participants in Accra and Nairobi who take part in the photovoice activities and the opportunity to express a voice through the exhibition portraying their personal food environments. We will thereby empower the local community with the capacity of using photography to influence change in the nutrition environment in their communities. 2) Community leaders (e.g. community health workers, village elders, community group leaders, local NGOs) who engage in the dissemination workshops of the overall findings of this exercise. 3) Local, national and regional stakeholders (eg nutrition units in the ministries of health and agriculture, WFP, WHO, FAO regional office, Federation of African Nutrition Societies, IFPRI, Scaling Up Nutrition knowledge networks/academic platforms) who will be engaged in the project from inception through consultative meetings at critical points of the study, including before and after policy mapping; in preparation for evidence synthesis, and throughout knowledge translation. Findings from the study will also be disseminated to policy and decision makers (internationally, nationally and locally) through factsheets, policy briefs, blogs, and through various institutional websites. 4) Academic researchers in LMICs and globally will benefit from the research through the dissemination of project findings at international conferences, scientific publications and capacity building activities. At the heart of our team's vision is capacity building, particularly for early career researchers. We will include young researchers in the project team, including postdoctoral researchers. We will facilitate a workshops to allow sharing of academic knowledge and learning from the different institutions involved in the research team including early career and senior researchers. 5. Advocacy groups including human rights activists and the media are likely to use the evidence generated from this study to advocate for review of policies and guidelines in the relevant ministries and county governments, and practices among nutrition and health stakeholders.