weeshhoouulldd bbe ablle tto decide OObbeessooggenic facttorrss inifnlufleuenncciningg ddiiettarry behhaavvioiouursr s oof fa addoolelesscceennttss iinn EEtthhiiooppiaia Ursula Trübswasser Ursula Trübswasser “We should be able to decide” - Obesogenic factors influencing dietary behaviours of women and adolescents in Ethiopia Ursula Trübswasser Propositions 1. Supported by evidence-based information, a healthy environment and trusting parents, adolescents can make their own dietary choices. (this thesis) 2. Assessing the food environment without the perspective of people living in it, only tells part of a story. (this thesis) 3. Researchers from high-income countries can add value to research in low- and middle-income countries only when they are aware of their limitations and privileges. 4. The lower the funding for research, the more focused, creative, and hands-on researchers have to be. 5. Eating and sharing diverse foods in different cultures not only feeds but nourishes. 6. Women cannot have it all, neither can men, but if men had less, everyone would have more. Propositions belonging to the thesis, entitled “We should be able to decide” - Obesogenic factors influencing dietary behaviours of adolescents in Ethiopia Ursula Trübswasser Wageningen, 8 July, 2022 “We should be able to decide” Obesogenic factors influencing dietary behaviours of adolescents in Ethiopia Ursula Trübswasser “We should be able to decide” Obesogenic factors influencing dietary behaviours of adolescents in Ethiopia Ursula Trübswasser Promotor Prof. Dr E.J.M. Feskens Professor of Global Nutrition Wageningen University & Research Co-promotors Thesis Dr E.F. Talsma Assistant Professor, Division of Human Nutrition and Health submitted in fulfilment of the requirements for the degree of doctor at Wageningen University & Research Wageningen University by the authority of the Rector Magnificus, Other members Prof. Dr A.P.J. Mol, Dr L. Vaandrager, Wageningen University & Research in the presence of the Dr Y. Berhane, Addis Continental Institute of Public Health, Addis Ababa, Ethiopia Thesis Committee appointed by the Academic Board Dr S. Wertheim-Heck, Wageningen University & Research to be defended in public Dr C. Béné, Alliance of Bioversity and the International Center for Tropical on Friday 8 July 2022 Agriculture, Cali, Colombia at 11 a.m. in the Omnia Auditorium. This research was conducted under the auspices of the Graduate School VLAG (Advanced Studies in Food Technology, Agrobiotechnology, Nutrition and Health Sciences) “We should be able to decide” Obesogenic factors influencing dietary behaviours of adolescents in Ethiopia Ursula Trübswasser Promotor Prof. Dr E.J.M. Feskens Professor of Global Nutrition Wageningen University & Research Co-promotors Thesis Dr E.F. Talsma Assistant Professor, Division of Human Nutrition and Health submitted in fulfilment of the requirements for the degree of doctor at Wageningen University & Research Wageningen University by the authority of the Rector Magnificus, Other members Prof. Dr A.P.J. Mol, Dr L. Vaandrager, Wageningen University & Research in the presence of the Dr Y. Berhane, Addis Continental Institute of Public Health, Addis Ababa, Ethiopia Thesis Committee appointed by the Academic Board Dr S. Wertheim-Heck, Wageningen University & Research to be defended in public Dr C. Béné, Alliance of Bioversity and the International Center for Tropical on Friday 8 July 2022 Agriculture, Cali, Colombia at 11 a.m. in the Omnia Auditorium. This research was conducted under the auspices of the Graduate School VLAG (Advanced Studies in Food Technology, Agrobiotechnology, Nutrition and Health Sciences) To Mathilde and Felix Ursula Trübswasser “We should be able to decide” - Obesogenic factors influencing dietary behaviours of women and adolescents in Ethiopia 204 pages PhD thesis, Wageningen University, Wageningen, the Netherlands (2022) With references, with summary in English ISBN: 978-94-6447-214-1 DOI: https://doi.org/10.18174/568896 To Mathilde and Felix Ursula Trübswasser “We should be able to decide” - Obesogenic factors influencing dietary behaviours of women and adolescents in Ethiopia 204 pages PhD thesis, Wageningen University, Wageningen, the Netherlands (2022) With references, with summary in English ISBN: 978-94-6447-214-1 DOI: https://doi.org/10.18174/568896 CONTENTS Chapter 1 General Introduction 5 Chapter 2 Factors influencing obesogenic behaviours of adolescent girls 29 and women in low- and middle-income countries: A qualitative evidence synthesis Chapter 3 Assessing factors influencing adolescents’ dietary behaviours in 79 urban Ethiopia using participatory photography Chapter 4 Influencing factors of the school and home environment on 99 adolescents’ dietary behaviours in Addis Ababa, Ethiopia Chapter 5 How is the food environment addressed in Ethiopian polices 121 compared with global good practice benchmarks? A policy review Chapter 6 General discussion 157 Summary 183 Summary in Amharic 189 Acknowledgements 195 About the author 201 CONTENTS Chapter 1 General Introduction 5 Chapter 2 Factors influencing obesogenic behaviours of adolescent girls 29 and women in low- and middle-income countries: A qualitative evidence synthesis Chapter 3 Assessing factors influencing adolescents’ dietary behaviours in 79 urban Ethiopia using participatory photography Chapter 4 Influencing factors of the school and home environment on 99 adolescents’ dietary behaviours in Addis Ababa, Ethiopia Chapter 5 How is the food environment addressed in Ethiopian polices 121 compared with global good practice benchmarks? A policy review Chapter 6 General discussion 157 Summary 183 Summary in Amharic 189 Acknowledgements 195 About the author 201 ABBREVIATIONS AND ACRONYMS AGP Agricultural Growth Programme AMICYN Adolescent, Maternal, Infant and Young Child Nutrition BMI Body Mass Index CASP Critical Appraisals Skills Programme DDS-W Dietary Diversity Score for Women EFDA Ethiopian Food and Drug Administration ENTREQ Enhancing Transparency in Reporting the Synthesis of Qualitative Research Food-Epi Healthy Food Environment Policy Index FV Fruits and vegetables FNP Food and Nutrition Policy GDR Global Dietary Recommendations GIS Geographic Information System GPS Global Positioning System GS Government school(s) GTP Growth and Transformation Plan INFORMAS International Network for Food and Obesity/Non-Communicable Diseases Research, Monitoring and Action Support IFPRI International Food Policy Research Institute LMIC Low- and Middle-Income Country/ies MDD-W Minimum Dietary Diversity for Women NCD Noncommunicable Diseases NNP National Nutrition Program NSA Nutrition Sensitive Agriculture NSAP National Strategy Action Plan PS Private school(s) PSNP Productive Safety Net Programme QES Qualitative Evidence Synthesis S.E. Standard Error SES Socio-economic status SD Standard Deviation SSB Sugar-Sweetened Beverages UNICEF United Nations Children’s Fund WHO World Health Organization WRA Women of Reproductive Age ABBREVIATIONS AND ACRONYMS AGP Agricultural Growth Programme AMICYN Adolescent, Maternal, Infant and Young Child Nutrition BMI Body Mass Index CASP Critical Appraisals Skills Programme DDS-W Dietary Diversity Score for Women EFDA Ethiopian Food and Drug Administration ENTREQ Enhancing Transparency in Reporting the Synthesis of Qualitative Research Food-Epi Healthy Food Environment Policy Index FV Fruits and vegetables FNP Food and Nutrition Policy GDR Global Dietary Recommendations GIS Geographic Information System GPS Global Positioning System GS Government school(s) GTP Growth and Transformation Plan INFORMAS International Network for Food and Obesity/Non-Communicable Diseases Research, Monitoring and Action Support IFPRI International Food Policy Research Institute LMIC Low- and Middle-Income Country/ies MDD-W Minimum Dietary Diversity for Women NCD Noncommunicable Diseases NNP National Nutrition Program NSA Nutrition Sensitive Agriculture NSAP National Strategy Action Plan PS Private school(s) PSNP Productive Safety Net Programme QES Qualitative Evidence Synthesis S.E. Standard Error SES Socio-economic status SD Standard Deviation SSB Sugar-Sweetened Beverages UNICEF United Nations Children’s Fund WHO World Health Organization WRA Women of Reproductive Age CHAPTER 1 General introduction Chapter 1 BACKGROUND to lower energy expenditure, higher susceptibility to the effects of a high-fat diet and impaired regulation of food intake or food assistance programmes, especially in Problem of malnutrition urban LMIC settings where energy-dense food becomes increasingly available.14-16 Malnutrition affects many people around the world. Globally, in 2020 around 149.2 Overweight and obesity are also associated with socio-economic status and, million children under 5 years of age were stunted and 45.4 million were wasted. In depending on the income level of the country, these associations are shifting.17In the same year, 38.9 million children were overweight and 570.8 million girls and LMIC, the more affluent and/or those with higher educational attainment are more women of reproductive age were anaemic. Overweight and obesity affects 2.2 likely to be obese, but with increasing income level of a country the burden of billion adults and rates are rising in every part of the world, with no country obesity shifts to the poor.18 Urbanization and the physical environment have also successfully reversing this trend.1 been associated with overweight and obesity, the highest prevalence being in LMIC but also in urban areas of sub-Saharan Africa.4,19,20 Most children with malnutrition live in sub-Saharan Africa and Asia.2 Also, the burden of overweight and obesity is not equally distributed, as more than 70% of all Although the causes of malnutrition are complex, an unhealthy diet remains one of adults with overweight and obesity live in low- and middle-income countries the key contributors, with data from the last 10 years showing that diets have only 1 (LMIC).3 Furthermore, women in LMIC have a higher overweight and obesity improved marginally. Globally, the intake of some healthy foods (whole grains, fruit prevalence than men in LMIC.4,5 and vegetables) has increased slightly but fish and legume intake remains sub- optimal. Furthermore, sugary drink intake and red and processed meat Adolescents (age 10–19 years) are also affected by different types of malnutrition. consumption increased between 2010 and 2018.1 The prevalence of overweight in adolescent boys increased from 14.4% in 2010 to 20.2% in 2019 and in girls from 13.8% to 18.4% in the same period. One study The diets of adolescents in LMIC are also reported to be inadequate, seeming to be estimated that in 2016 a total of 324 million adolescents between 10 and 24 years predominantly cereal-based and limited in terms of animal-sourced foods, fruit, and of age were overweight.6 Simultaneously, anaemia affected 430 million adolescents vegetables. Particularly in urban areas, an increased consumption of processed globally in 2016, which is an increase of 20% from the 357 million in 1990.6 Although energy-dense and nutrient-poor foods and drinks has been reported.21,22 A literature 21 thinness in 2010 declined from 12.3% to 7.9% in girls and from 13.4% to 8.1% in review by Keats et al. found that 4% of adolescent girls consume sugar-sweetened boys, it remains high.1 Similar to the adult population, adolescents in Asia and Africa beverages (SSB) daily and 49% weekly. In LMIC, street foods high in unhealthy fats, are most affected by malnutrition, with more girls affected by overweight and sugar and salt contribute 12–40% of children’s energy intake.19 Among adolescent obesity.5,7-10 girls from LMIC, 20% consume fast food daily and 32% consume these foods two or three times a week.21 Consumption of fast foods and other processed foods has This co-existence of over- and underweight in the same population, also termed the increased particularly among school-age children and adolescents in urban areas of 23 double burden of malnutrition, affects most LMIC. The focus of this thesis is on LMIC. overweight and obesity, which has been associated with multiple causes. Adolescence: An important period for dietary behaviours Causes of overweight and obesity Adolescence encompasses a period defined by rapid physical growth, psychological and behavioural changes and major social role transitions, and is most commonly Overall, the factors leading to overweight or obesity include: unhealthy eating defined as covering the age range of 10–19 years.24 This period is very important in patterns; lack of physical activity; increased sedentary behaviours and short sleep terms of nutrition because the nutritional requirements are increased.25 It is also a duration; stress; environmental pollutants; genetic, pre-natal, parenting and family time when dietary preferences and habits are formed26 that can impact adolescents’ factors; social norms; and physical activity and food environments.4,11,12 future health and nutrition, as well that of future generations.26-28 Pre-natal factors are related to the nutritional status of mothers, with children of Certain behaviours of adolescents could be detrimental to their health, such as a overweight or obese women tending to have higher birth weights and more body preference for processed, fast and snack food, a low vegetable and fruit intake and fat, leading to increased risk of developing obesity later in life.13 Furthermore, the skipping of meals.29 Snacking in children and adolescents aged 5–19 years has stunted or underweight children are also more likely to be overweight as adults due 6 General Introduction BACKGROUND to lower energy expenditure, higher susceptibility to the effects of a high-fat diet and impaired regulation of food intake or food assistance programmes, especially in 1 Problem of malnutrition urban LMIC settings where energy-dense food becomes increasingly available.14-16 Malnutrition affects many people around the world. Globally, in 2020 around 149.2 Overweight and obesity are also associated with socio-economic status and, million children under 5 years of age were stunted and 45.4 million were wasted. In depending on the income level of the country, these associations are shifting.17In the same year, 38.9 million children were overweight and 570.8 million girls and LMIC, the more affluent and/or those with higher educational attainment are more women of reproductive age were anaemic. Overweight and obesity affects 2.2 likely to be obese, but with increasing income level of a country the burden of 18 billion adults and rates are rising in every part of the world, with no country obesity shifts to the poor. Urbanization and the physical environment have also successfully reversing this trend.1 been associated with overweight and obesity, the highest prevalence being in LMIC but also in urban areas of sub-Saharan Africa.4,19,20 Most children with malnutrition live in sub-Saharan Africa and Asia.2 Also, the burden of overweight and obesity is not equally distributed, as more than 70% of all Although the causes of malnutrition are complex, an unhealthy diet remains one of adults with overweight and obesity live in low- and middle-income countries the key contributors, with data from the last 10 years showing that diets have only 1 (LMIC).3 Furthermore, women in LMIC have a higher overweight and obesity improved marginally. Globally, the intake of some healthy foods (whole grains, fruit prevalence than men in LMIC.4,5 and vegetables) has increased slightly but fish and legume intake remains sub- optimal. Furthermore, sugary drink intake and red and processed meat Adolescents (age 10–19 years) are also affected by different types of malnutrition. consumption increased between 2010 and 2018.1 The prevalence of overweight in adolescent boys increased from 14.4% in 2010 to 20.2% in 2019 and in girls from 13.8% to 18.4% in the same period. One study The diets of adolescents in LMIC are also reported to be inadequate, seeming to be estimated that in 2016 a total of 324 million adolescents between 10 and 24 years predominantly cereal-based and limited in terms of animal-sourced foods, fruit, and of age were overweight.6 Simultaneously, anaemia affected 430 million adolescents vegetables. Particularly in urban areas, an increased consumption of processed globally in 2016, which is an increase of 20% from the 357 million in 1990.6 Although energy-dense and nutrient-poor foods and drinks has been reported.21,22 A literature thinness in 2010 declined from 12.3% to 7.9% in girls and from 13.4% to 8.1% in review by Keats et al.21 found that 4% of adolescent girls consume sugar-sweetened boys, it remains high.1 Similar to the adult population, adolescents in Asia and Africa beverages (SSB) daily and 49% weekly. In LMIC, street foods high in unhealthy fats, sugar and salt contribute 12–40% of children’s energy intake.19are most affected by malnutrition, with more girls affected by overweight and Among adolescent obesity.5,7-10 girls from LMIC, 20% consume fast food daily and 32% consume these foods two or three times a week.21 Consumption of fast foods and other processed foods has This co-existence of over- and underweight in the same population, also termed the increased particularly among school-age children and adolescents in urban areas of double burden of malnutrition, affects most LMIC. The focus of this thesis is on LMIC.23 overweight and obesity, which has been associated with multiple causes. Adolescence: An important period for dietary behaviours Causes of overweight and obesity Adolescence encompasses a period defined by rapid physical growth, psychological and behavioural changes and major social role transitions, and is most commonly Overall, the factors leading to overweight or obesity include: unhealthy eating defined as covering the age range of 10–19 years.24 This period is very important in patterns; lack of physical activity; increased sedentary behaviours and short sleep terms of nutrition because the nutritional requirements are increased.25 It is also a duration; stress; environmental pollutants; genetic, pre-natal, parenting and family 4,11,12 time when dietary preferences and habits are formed26 that can impact adolescents’ factors; social norms; and physical activity and food environments. future health and nutrition, as well that of future generations.26-28 Pre-natal factors are related to the nutritional status of mothers, with children of Certain behaviours of adolescents could be detrimental to their health, such as a overweight or obese women tending to have higher birth weights and more body preference for processed, fast and snack food, a low vegetable and fruit intake and fat, leading to increased risk of developing obesity later in life.13 Furthermore, the skipping of meals.29 Snacking in children and adolescents aged 5–19 years has stunted or underweight children are also more likely to be overweight as adults due 7 Chapter 1 been associated with poor dietary patterns and increasing obesity trends.23 who purchased and consumed non-traditional foods were perceived to have better Adolescents’ preference for unhealthy foods and beverages,30 their desire for social standing whereas those consuming traditional foods faced ridicule;37 autonomy, motivation to gain social status,31 risk aversion or lack of motivation for therefore, adolescents might choose to spend the small amount of money they have long-term health consequences32 and exposure to advertising of unhealthy foods on snacks.31 and beverages33,34 can all negatively influence their diets. The socio-economic status and income of an individual or household also determine Causes of unhealthy diets which foods are affordable. A review on the dietary behaviours of African women found that higher status was associated with higher fruit and vegetable Causes of unhealthy diets can best be described using the socio-ecological consumption and dietary diversity.36 In contrast, lower socio-economic status and framework (Fig. 1.1), categorizing factors into individual-, social-, physical- and limited affordability of foods were associated with lower diversity. A study on macro-level factors.35 women in Kenya found that food affordability was the most important factor for women living in urban informal settlements.38 In addition, healthy foods are often more expensive than unhealthy foods and the cost of a healthy diet is beyond most Macro-level environment people’s purchasing power. Globally, the cost of a healthy diet was estimated to be (policy) 3.27–4.57 USD per day, which is above the international poverty line of 1.90 USD. Three billion people globally are not able to afford the cheapest version of a healthy Physical environment diet, of which most live in Southern Asia (1.3 billion) and sub-Saharan Africa (829 (settings: school, community, work, home) million).39 For adolescents, access to food depends on food-purchasing decisions taken by caregivers and guardians, but also on the level of autonomy they can exercise with potential pocket money.30 Social environment (family, community, peers) Social-level factors Individual factors At the social level, the influences of family, peers, friends and the broader (personal) community are crucial because the gender roles and norms that girls and women Convenience have to fit into could influence their food choices or body image.36 Parents can play Dietary behaviours the role of gatekeepers for adolescents, but this changes as the children get older and gain increasing autonomy and agency to make and act on decisions and also as their peers become more influential.29-31 While parental influence is associated with Figure 1.1. Socio-ecological framework healthier options, peer influence has been linked to unhealthy foods and beverages such as SSB and energy-dense foods.40,41 Studies suggest that the availability and Individual-level factors accessibility of healthy or unhealthy foods within the home promotes the consumption of these foods in adolescents.42,43 Furthermore, more permissive At the individual level, biological factors, preferences, habits, and socio-economic parenting styles predicted a higher intake of sugary drinks.41 Social pressure linked status are important factors for dietary behaviours. Specific to the African setting to certain foods and beverages could also influence parents of adolescents to and adolescent girls and women, one review identified 17 determinants of diet and purchase unhealthy food items for their children, despite their knowledge and related behaviours, mostly related to individual and household food environments; preference for healthy diets.37 determinants included perceptions of body image and diet, nutrition-related knowledge, dietary behaviours and preferences, such as meal skipping or snacking, Physical-level factors and socio-economic factors such as education and food expenditure.36 With regard The physical environment in which people live is an important determinant of to adolescents, preferences, habits, social norms and biological factors play an dietary choices. Food environments are central components of food systems, where important role. Especially in LMIC, a preference for ‘modern food’ was associated people interact with the food system by purchasing, preparing, and consuming food. with higher perceived social status. A South African study found that adolescents 8 General Introduction been associated with poor dietary patterns and increasing obesity trends.23 who purchased and consumed non-traditional foods were perceived to have better Adolescents’ preference for unhealthy foods and beverages,30 their desire for social standing whereas those consuming traditional foods faced ridicule;37 1 autonomy, motivation to gain social status,31 risk aversion or lack of motivation for therefore, adolescents might choose to spend the small amount of money they have long-term health consequences32 and exposure to advertising of unhealthy foods on snacks.31 and beverages33,34 can all negatively influence their diets. The socio-economic status and income of an individual or household also determine Causes of unhealthy diets which foods are affordable. A review on the dietary behaviours of African women found that higher status was associated with higher fruit and vegetable Causes of unhealthy diets can best be described using the socio-ecological consumption and dietary diversity.36 In contrast, lower socio-economic status and framework (Fig. 1.1), categorizing factors into individual-, social-, physical- and limited affordability of foods were associated with lower diversity. A study on macro-level factors.35 women in Kenya found that food affordability was the most important factor for women living in urban informal settlements.38 In addition, healthy foods are often more expensive than unhealthy foods and the cost of a healthy diet is beyond most Macro-level environment people’s purchasing power. Globally, the cost of a healthy diet was estimated to be (policy) 3.27–4.57 USD per day, which is above the international poverty line of 1.90 USD. Three billion people globally are not able to afford the cheapest version of a healthy Physical environment diet, of which most live in Southern Asia (1.3 billion) and sub-Saharan Africa (829 (settings: school, community, work, home) million).39 For adolescents, access to food depends on food-purchasing decisions taken by caregivers and guardians, but also on the level of autonomy they can exercise with potential pocket money.30 Social environment (family, community, peers) Social-level factors Individual factors At the social level, the influences of family, peers, friends and the broader (personal) community are crucial because the gender roles and norms that girls and women Convenience have to fit into could influence their food choices or body image.36 Parents can play Dietary behaviours the role of gatekeepers for adolescents, but this changes as the children get older and gain increasing autonomy and agency to make and act on decisions and also as their peers become more influential.29-31 While parental influence is associated with Figure 1.1. Socio-ecological framework healthier options, peer influence has been linked to unhealthy foods and beverages such as SSB and energy-dense foods.40,41 Studies suggest that the availability and Individual-level factors accessibility of healthy or unhealthy foods within the home promotes the consumption of these foods in adolescents.42,43 Furthermore, more permissive 41 At the individual level, biological factors, preferences, habits, and socio-economic parenting styles predicted a higher intake of sugary drinks. Social pressure linked status are important factors for dietary behaviours. Specific to the African setting to certain foods and beverages could also influence parents of adolescents to and adolescent girls and women, one review identified 17 determinants of diet and purchase unhealthy food items for their children, despite their knowledge and related behaviours, mostly related to individual and household food environments; preference for healthy diets.37 determinants included perceptions of body image and diet, nutrition-related knowledge, dietary behaviours and preferences, such as meal skipping or snacking, Physical-level factors and socio-economic factors such as education and food expenditure.36 With regard The physical environment in which people live is an important determinant of to adolescents, preferences, habits, social norms and biological factors play an dietary choices. Food environments are central components of food systems, where important role. Especially in LMIC, a preference for ‘modern food’ was associated people interact with the food system by purchasing, preparing, and consuming food. with higher perceived social status. A South African study found that adolescents 9 Chapter 1 The main elements of the food environment are availability, physical and economic transnational industries to expand their markets in these settings.62 For adolescents, access, promotion, advertising and food quality and safety.44 social media is also important; it allows direct marketing and influences community attitudes beyond the physical borders of a neighbourhood or a country.26,63 Food Food environments in urban areas of LMIC have been changing with the expansion marketing was found to be directly linked to children’s preferences, nutrition of modern retail,45 the growing availability of ultra-processed, energy-dense, knowledge and consumption patterns,62 increasing unhealthy eating behaviours.64 nutrient-poor foods46 due to expansion of transnational food and beverage cooperations into emerging markets and the globalization of food trade.47 In South Maco-level factors Africa, for instance, the supermarket sector was estimated to account for 75% of all grocery sales.48 While supermarkets provide lower prices and potentially better Macro-level factors such as urbanization, food supply and national policies also hygiene for many products, they also provide ultra-processed foods. However, determine food availability. Urban centres are expanding, accompanied by especially in LMIC, traditional outlets and open markets offer fresh produce at lower prices than supermarkets.49-51 improved access to electricity, which can increase the shelf life of perishable food, reduce food hazards, and simplify food preparation, leading to changes in consumption patterns. Furthermore, urbanization in Africa is associated with fewer The different elements of the food environment (availability, accessibility, people working in the agricultural sector,65 thus individual energy requirements are affordability, convenience and safety) have been associated with dietary 52,53 reduced but, at the same time, the demand for convenience food by working people outcomes. A review on qualitative studies from high-income countries found with limited time to spend on food preparation is increased.66,67 Urban diets that availability, accessibility and affordability determined store choice, purchasing therefore include more fast food, street food and ultra-processed food and behaviour and food choice.53 Studies in high-income countries also defined and beverages that contain high levels of salt, sugar and undesirable fats,68 which categorised different retail outlets. For instance, corner stores and convenience replace traditional diets.46 A review of food environments in LMIC identified positive stores were described as having less variety and fewer or no healthy items 53 associations between levels of urbanization and the availability of market-based compared to supermarkets. Challenges to the access of stores due to lack of food vendors, such as fast-food restaurants, full-service restaurants and transport puts lower socio-economic groups in particular into so-called ‘food supermarkets.69 deserts’, where residents cannot access affordable, healthy food.54 However, in LMIC, small shops, informal vendors or open markets are important outlets to access 55,56 In addition, the current food supply does not meet the dietary needs. Fruit and affordable food. In Brazil, for instance, the availability of fruit and vegetables in vegetable availability, for instance, cannot meet the population needs to achieve the retail food environment was associated with higher fruit and vegetable 57 the dietary recommendations in most countries. Based on current World Health consumption. Similarly, a higher availability of SSB was associated with increased 57 Organization (WHO) recommendations of 400g per day, the production of fruit and SSB consumption. Eating outside the home was associated with lower vegetable vegetables is 22% below global population requirements and 58% below consumption but also more diverse diets.36 Furthermore, in LMIC, street food is a consumption needs in low-income countries.3,66 In contrast, staple cereal, oil and major contributor to the total intake of fat, trans-fatty acids and sugar58 and has also animal-source food availability has increased worldwide.66 been associated with food safety concerns because it is often prepared and sold in precarious conditions that lack sanitary surveillance and legal control.59 Available tools to identify factors influencing obesogenic diets As adolescents get older, their environment expands from their home environment to schools and the retail environment surrounding their schools and homes. The food environment can be assessed in objective or perceived terms. Objective Adolescents therefore increasingly consume food out of the home.32 The availability measures can assess proximity or density of different outlets (availability), distance of unhealthy food options at school in LMIC has been associated with the to different outlets, convenience, and available transport (accessibility), prices of consumption of these foods, such as soft drinks and deep-fried snack food.60 On the different food items and beverages at different outlets or neighbourhoods, store other hand, private schools in LMIC with cafeterias selling fruit were associated with audits of food prices (affordability) and type, proximity and density of advertising. lower consumption of salty snacks.42,61 However, different methods might be necessary for different food environments. Downs et al.70 defined natural food environments as wild or cultivated and built The food environment is also characterised by food marketing. In low- and middle- environments as either informal or formal market environments. Most food income settings, children and adolescents are often targeted by fast-food chains and environment assessments have been developed, conducted and validated in high- income countries, where food environments are mostly formal and not as diverse 10 General Introduction The main elements of the food environment are availability, physical and economic transnational industries to expand their markets in these settings.62 For adolescents, access, promotion, advertising and food quality and safety.44 social media is also important; it allows direct marketing and influences community 1 attitudes beyond the physical borders of a neighbourhood or a country.26,63 Food Food environments in urban areas of LMIC have been changing with the expansion marketing was found to be directly linked to children’s preferences, nutrition of modern retail,45 the growing availability of ultra-processed, energy-dense, knowledge and consumption patterns,62 increasing unhealthy eating behaviours.64 nutrient-poor foods46 due to expansion of transnational food and beverage cooperations into emerging markets and the globalization of food trade.47 In South Maco-level factors Africa, for instance, the supermarket sector was estimated to account for 75% of all grocery sales.48 While supermarkets provide lower prices and potentially better Macro-level factors such as urbanization, food supply and national policies also hygiene for many products, they also provide ultra-processed foods. However, determine food availability. Urban centres are expanding, accompanied by especially in LMIC, traditional outlets and open markets offer fresh produce at lower 49-51 improved access to electricity, which can increase the shelf life of perishable food, prices than supermarkets. reduce food hazards, and simplify food preparation, leading to changes in consumption patterns. Furthermore, urbanization in Africa is associated with fewer The different elements of the food environment (availability, accessibility, people working in the agricultural sector,65 thus individual energy requirements are affordability, convenience and safety) have been associated with dietary 52,53 reduced but, at the same time, the demand for convenience food by working people outcomes. A review on qualitative studies from high-income countries found with limited time to spend on food preparation is increased.66,67 Urban diets that availability, accessibility and affordability determined store choice, purchasing 53 therefore include more fast food, street food and ultra-processed food and behaviour and food choice. Studies in high-income countries also defined and beverages that contain high levels of salt, sugar and undesirable fats,68 which categorised different retail outlets. For instance, corner stores and convenience replace traditional diets.46 A review of food environments in LMIC identified positive stores were described as having less variety and fewer or no healthy items 53 associations between levels of urbanization and the availability of market-based compared to supermarkets. Challenges to the access of stores due to lack of food vendors, such as fast-food restaurants, full-service restaurants and transport puts lower socio-economic groups in particular into so-called ‘food supermarkets.69 deserts’, where residents cannot access affordable, healthy food.54 However, in LMIC, small shops, informal vendors or open markets are important outlets to access 55,56 In addition, the current food supply does not meet the dietary needs. Fruit and affordable food. In Brazil, for instance, the availability of fruit and vegetables in vegetable availability, for instance, cannot meet the population needs to achieve the retail food environment was associated with higher fruit and vegetable 57 the dietary recommendations in most countries. Based on current World Health consumption. Similarly, a higher availability of SSB was associated with increased 57 Organization (WHO) recommendations of 400g per day, the production of fruit and SSB consumption. Eating outside the home was associated with lower vegetable vegetables is 22% below global population requirements and 58% below consumption but also more diverse diets.36 Furthermore, in LMIC, street food is a consumption needs in low-income countries.3,66 In contrast, staple cereal, oil and major contributor to the total intake of fat, trans-fatty acids and sugar58 and has also animal-source food availability has increased worldwide.66 been associated with food safety concerns because it is often prepared and sold in precarious conditions that lack sanitary surveillance and legal control.59 Available tools to identify factors influencing obesogenic diets As adolescents get older, their environment expands from their home environment to schools and the retail environment surrounding their schools and homes. The food environment can be assessed in objective or perceived terms. Objective Adolescents therefore increasingly consume food out of the home.32 The availability measures can assess proximity or density of different outlets (availability), distance of unhealthy food options at school in LMIC has been associated with the to different outlets, convenience, and available transport (accessibility), prices of consumption of these foods, such as soft drinks and deep-fried snack food.60 On the different food items and beverages at different outlets or neighbourhoods, store other hand, private schools in LMIC with cafeterias selling fruit were associated with audits of food prices (affordability) and type, proximity and density of advertising. lower consumption of salty snacks.42,61 However, different methods might be necessary for different food environments. Downs et al.70 defined natural food environments as wild or cultivated and built The food environment is also characterised by food marketing. In low- and middle- environments as either informal or formal market environments. Most food income settings, children and adolescents are often targeted by fast-food chains and environment assessments have been developed, conducted and validated in high- income countries, where food environments are mostly formal and not as diverse 11 Chapter 1 as in LMIC71,72 There is therefore little knowledge of the influence of food environments on diets or nutritional outcomes in LMIC, even though food Policy action to prevent obesogenic behaviours environment research is increasingly taking place in LMIC.69,73 Several policy actions have been identified to promote healthy diets that are high in The food environment can be mapped with geographic information system (GIS)- quality, safety and nutrients but limited in nutrient-poor refined foods high in based methods to assess the density or proximity of different categories of outlets.69 sugars, fats and/or salt, including ultra-processed foods.80-82 Policy actions can One of the first methods to assess specific elements within the food environment address the different levels of influence described in the socio-ecological framework was developed by Glanz et al.74 as part of the Nutrition Environment Measure Survey above (Fig 1.1). For instance, at the individual level, approaches such as education (NEMS). The NEMS tools assess the availability of specific foods within a store, using and raising public awareness using counselling or behaviour change communication store inventories to categorise vendors according to food items based on American can be promoted to increase the appeal of nutritious foods. Such actions targeting diets. In 2013, the International Network for Food and Obesity/Non-Communicable the individual as opposed to physical- or macro-level factors are prioritised in most Diseases Research, Monitoring and Action Support (INFORMAS) developed a countries.83,84 comprehensive set of tools to measure different dimensions of the food environment, such as food composition, labelling, promotion, provision, retail, prices, trade, and investment.75 Policymakers can also reshape food environments using a variety of policy actions, Since then, several tools to assess prices and such as taxes on unhealthy foods and beverages to decrease the affordability of SSB, affordability have been developed, such as the Cost of a Healthy Diet tool,71 which for example.80 Food provision in schools and public institutions can contribute to collects prices for least-cost items available in local markets to meet the national improved access to nutritious food and reduced access to unhealthy food. food-based dietary guidelines in order to calculate the cost of a healthy diet.39 Furthermore, regulations related to the marketing of unhealthy foods and beverages or food labelling could reduce the appeal of unhealthy food.81,82,84 Although there is a range of measures and tools available, no standardised measure for food environment assessments exists. In LMIC especially, methods for the Price interventions, taxation and subsidies, food provision in school settings, evaluation of different dimensions of informal market food environments are 71 product reformulation to reduce sugar, fats and salt and reducing package sizes scarce. A review of food environment studies in LMIC concluded that most studies were all found to be effective at changing consumer behaviour and dietary used quantitative GIS-based methods to describe or analyse the food environment intake:84,85 For instance, the Mexican soda tax implemented in 2014 showed a 12% in terms of availability (vendor counts or densities), and only half of them tested reduction in the consumption of taxed beverages over a one-year period; and the associations with diet, nutrition or health outcomes.69 junk food tax in Mexico showed a 5% reduction in consumption of the taxed foods.85 Despite the evidence for policy action addressing the food environment, action on Perceptions of consumers can be assessed using questionnaires containing different availability, processing and marketing have been limited in LMIC.73,83 At the macro items related to accessibility of outlets and availability, affordability or desirability level, actions could promote the agricultural production of certain crops through of healthy foods that respondents rank on a scale.72,76,77 Qualitative methods to subsidies or by improving the supply of nutritious foods through international trade. capture perceptions and people’s lived experience of food environments include in- Also, technology and research could be geared towards breeding, storage, depth interviews, group discussions, visual or geospacial methods, observations of transport, and the processing of healthy foods. routines and practices, and participatory action research methods such as Photovoice.78 Studies using perceived measures of the food environment are limited A study assessing policy actions to promote healthier diets in 144 countries compared to those that use GIS-based methods and are mostly focused on high- identified 36 countries with explicit actions in their policies to increase fruit and income countries. In LMIC, only two studies were identified that assessed perceived 69 vegetable intake,86 20 countries with actions aimed at addressing dietary fat availability. Furthermore, mixed-method studies in food environment research 69 consumption and 23 countries with actions to limit salt intake.86 The Healthy Food have been underutilised and quantitative methods are often not linked with Environment Policy Index (Food-EPI) assesses the extent of implementation of consumer surveys or interviews,71 risking to homogenise neighbourhoods while 79 recommended food environment policies compared with international best ignoring the lived realities of residents. Our study therefore aimed to use a mixed- practices; by 2018 it had been implemented in 11 countries, of which most method approach to assess the food environment in terms of perceived and implement one or two key policies rather than a comprehensive policy package objective measures that includes GIS-based methods as well as people’s lived across all areas of the food environment to promote healthy diets.87 In Ghana, for experiences. instance, three-quarters of all good practice indicators were assigned a ‘low’ rating 12 General Introduction as in LMIC71,72 There is therefore little knowledge of the influence of food environments on diets or nutritional outcomes in LMIC, even though food 1 Policy action to prevent obesogenic behaviours environment research is increasingly taking place in LMIC.69,73 Several policy actions have been identified to promote healthy diets that are high in The food environment can be mapped with geographic information system (GIS)- quality, safety and nutrients but limited in nutrient-poor refined foods high in based methods to assess the density or proximity of different categories of outlets.69 sugars, fats and/or salt, including ultra-processed foods.80-82 Policy actions can One of the first methods to assess specific elements within the food environment address the different levels of influence described in the socio-ecological framework was developed by Glanz et al.74 as part of the Nutrition Environment Measure Survey above (Fig 1.1). For instance, at the individual level, approaches such as education (NEMS). The NEMS tools assess the availability of specific foods within a store, using and raising public awareness using counselling or behaviour change communication store inventories to categorise vendors according to food items based on American can be promoted to increase the appeal of nutritious foods. Such actions targeting diets. In 2013, the International Network for Food and Obesity/Non-Communicable the individual as opposed to physical- or macro-level factors are prioritised in most Diseases Research, Monitoring and Action Support (INFORMAS) developed a countries.83,84 comprehensive set of tools to measure different dimensions of the food environment, such as food composition, labelling, promotion, provision, retail, Policymakers can also reshape food environments using a variety of policy actions, prices, trade, and investment.75 Since then, several tools to assess prices and such as taxes on unhealthy foods and beverages to decrease the affordability of SSB, affordability have been developed, such as the Cost of a Healthy Diet tool,71 which for example.80 Food provision in schools and public institutions can contribute to collects prices for least-cost items available in local markets to meet the national improved access to nutritious food and reduced access to unhealthy food. food-based dietary guidelines in order to calculate the cost of a healthy diet.39 Furthermore, regulations related to the marketing of unhealthy foods and beverages or food labelling could reduce the appeal of unhealthy food.81,82,84 Although there is a range of measures and tools available, no standardised measure for food environment assessments exists. In LMIC especially, methods for the Price interventions, taxation and subsidies, food provision in school settings, evaluation of different dimensions of informal market food environments are 71 product reformulation to reduce sugar, fats and salt and reducing package sizes scarce. A review of food environment studies in LMIC concluded that most studies were all found to be effective at changing consumer behaviour and dietary used quantitative GIS-based methods to describe or analyse the food environment intake:84,85 For instance, the Mexican soda tax implemented in 2014 showed a 12% in terms of availability (vendor counts or densities), and only half of them tested reduction in the consumption of taxed beverages over a one-year period; and the associations with diet, nutrition or health outcomes.69 junk food tax in Mexico showed a 5% reduction in consumption of the taxed foods.85 Despite the evidence for policy action addressing the food environment, action on Perceptions of consumers can be assessed using questionnaires containing different availability, processing and marketing have been limited in LMIC.73,83 At the macro items related to accessibility of outlets and availability, affordability or desirability 72,76,77 level, actions could promote the agricultural production of certain crops through of healthy foods that respondents rank on a scale. Qualitative methods to subsidies or by improving the supply of nutritious foods through international trade. capture perceptions and people’s lived experience of food environments include in- Also, technology and research could be geared towards breeding, storage, depth interviews, group discussions, visual or geospacial methods, observations of transport, and the processing of healthy foods. routines and practices, and participatory action research methods such as Photovoice.78 Studies using perceived measures of the food environment are limited A study assessing policy actions to promote healthier diets in 144 countries compared to those that use GIS-based methods and are mostly focused on high- identified 36 countries with explicit actions in their policies to increase fruit and income countries. In LMIC, only two studies were identified that assessed perceived vegetable intake,86 20 countries with actions aimed at addressing dietary fat availability.69 Furthermore, mixed-method studies in food environment research 69 consumption and 23 countries with actions to limit salt intake.86 The Healthy Food have been underutilised and quantitative methods are often not linked with Environment Policy Index (Food-EPI) assesses the extent of implementation of consumer surveys or interviews,71 risking to homogenise neighbourhoods while 79 recommended food environment policies compared with international best ignoring the lived realities of residents. Our study therefore aimed to use a mixed- practices; by 2018 it had been implemented in 11 countries, of which most method approach to assess the food environment in terms of perceived and implement one or two key policies rather than a comprehensive policy package objective measures that includes GIS-based methods as well as people’s lived across all areas of the food environment to promote healthy diets.87 In Ghana, for experiences. instance, three-quarters of all good practice indicators were assigned a ‘low’ rating 13 Chapter 1 in relation to international best practice.88 In Kenya, where nutrition-related non- A recent study on adolescents aged 10–18 years in Addis Ababa found an communicable diseases were recognised as a growing problem, one-third of all overweight/obesity rate of 21.2%.102 areas were in the implementation phase.89 Furthermore, most food-related policy actions were identified as biased towards undernutrition and food security, and as In Ethiopia, women’s age, wealth status, educational attainment and urban curative rather than preventative.90 residence have been associated with being overweight.98,101,103 These findings suggest changing nutritional and lifestyle trends, the consumption of energy-dense, For adolescents, policy action traditionally focused on micronutrient nutrient-poor foods and less physical activity in urban populations of higher socio- supplementation but increasingly actions are directed more broadly at healthy economic status.103 For adolescents in Ethiopia, studies found associations between diets; however, this is mostly in high-income countries. For instance, European overweight and private school attendance, wealth, frequency of meat and fast food countries have taken action to tackle the digital marketing of unhealthy products to consumption and time watching TV or using a computer.101,104-106 adolescents.91 Many of the successful and large-scale adolescent nutrition programmes in LMIC focus on micronutrient deficiencies, especially anaemia Diets in Ethiopia reduction through weekly iron and folate distributions, but also on diets overall and undernutrition. Fewer policies and interventions address overweight and obesity in Urban populations in Ethiopia spend more of their income on non-food items and a adolescents in LMIC.92 higher share of their budget on animal products, oils and fats, as well as fruit and vegetables.107 Although this implies dietary diversity in urban areas is better,108 the Situation in Ethiopia household fruit and vegetable consumption is still below the recommended amount.109 Setting: Urban Ethiopia Studies with Ethiopian adolescents indicated sub-optimal intakes of micronutrient- Ethiopia has one of the fastest growing economies in East Africa, with rapidly rich fruit and vegetables and protein-source foods but substantial intakes of salted growing urbanization.93 In 2014, 19% of Ethiopians were living in urban areas and it snacks, cookies, sweets and fizzy drinks, especially in urban and affluent settings.110 is estimated that the urban population will triple by 2034.94 In 2015, more than 80% A 35% increase in the sugar consumption of adolescents over the past 15 years has 111 of the urban population lived in secondary cities and towns of less than 0.5 million been observed and another study reported that 22.7% of adolescents consumed people.68 Almost one-quarter of all people in Ethiopia who live in urban areas reside SSB at least once in a week during the previous three months.112 The latter study in Addis Ababa, the capital city. Addis Ababa is home to about 5 million people and was conducted in a small town, so this percentage could be even higher in bigger this figure is estimated to reach 9 million in 2035.95 cities. However, the causes of unhealthy dietary behaviours have not yet been studied in adolescents. Malnutrition in Ethiopia Food environment in Ethiopia Malnutrition is a major public health problem in Ethiopia. Until recently, undernutrition and micronutrient deficiencies were dominating, but overweight and Food environments in Ethiopia have changed in recent years in terms of food obesity rates, especially in adult women in urban areas, are increasing.96-99 While availability, prices, and retail outlets. The availability of foods is determined by the the national average of overweight and obesity remains low (3% in men and 8% in agricultural production, which significantly increased between 2011 and 2015.113 women), a review of studies, mostly on urban adults in Ethiopia, found prevalences However, this increased production stems primarily from the cereal sector at the ranging from 4.7% to 40.1%. The estimated pooled prevalence rate was 19%.98 A expense of other food groups, leading to lower production diversity.113 This lack of study in Addis Ababa found the rates of overweight and obesity in adults to be 21.5% diversity can in turn affect what foods are available or affordable at market level. and 2.9%, respectively.100 Prices of nutrient-dense foods such as fruit, vegetables and unprocessed meat Together with the persistent prevalence of underweight, Ethiopia is affected by a increased by 21–74% in the period 2005–2018, whereas prices of sugar, oils and fats double burden of malnutrition. In Addis Ababa, overall, more than one-third (34.7%) declined by 41–49%.114 This higher cost of nutrient-dense foods such as fruit and of women were estimated to be either under- or overweight in 2014.101 vegetables makes them unaffordable, especially to the poorest households in Ethiopia.115 14 General Introduction in relation to international best practice.88 In Kenya, where nutrition-related non- A recent study on adolescents aged 10–18 years in Addis Ababa found an communicable diseases were recognised as a growing problem, one-third of all overweight/obesity rate of 21.2%.102 1 areas were in the implementation phase.89 Furthermore, most food-related policy actions were identified as biased towards undernutrition and food security, and as In Ethiopia, women’s age, wealth status, educational attainment and urban curative rather than preventative.90 residence have been associated with being overweight.98,101,103 These findings suggest changing nutritional and lifestyle trends, the consumption of energy-dense, For adolescents, policy action traditionally focused on micronutrient nutrient-poor foods and less physical activity in urban populations of higher socio- supplementation but increasingly actions are directed more broadly at healthy economic status.103 For adolescents in Ethiopia, studies found associations between diets; however, this is mostly in high-income countries. For instance, European overweight and private school attendance, wealth, frequency of meat and fast food countries have taken action to tackle the digital marketing of unhealthy products to consumption and time watching TV or using a computer.101,104-106 adolescents.91 Many of the successful and large-scale adolescent nutrition programmes in LMIC focus on micronutrient deficiencies, especially anaemia Diets in Ethiopia reduction through weekly iron and folate distributions, but also on diets overall and undernutrition. Fewer policies and interventions address overweight and obesity in Urban populations in Ethiopia spend more of their income on non-food items and a adolescents in LMIC.92 higher share of their budget on animal products, oils and fats, as well as fruit and vegetables.107 Although this implies dietary diversity in urban areas is better,108 the Situation in Ethiopia household fruit and vegetable consumption is still below the recommended amount.109 Setting: Urban Ethiopia Studies with Ethiopian adolescents indicated sub-optimal intakes of micronutrient- Ethiopia has one of the fastest growing economies in East Africa, with rapidly rich fruit and vegetables and protein-source foods but substantial intakes of salted growing urbanization.93 In 2014, 19% of Ethiopians were living in urban areas and it snacks, cookies, sweets and fizzy drinks, especially in urban and affluent settings.110 is estimated that the urban population will triple by 2034.94 In 2015, more than 80% A 35% increase in the sugar consumption of adolescents over the past 15 years has 111 of the urban population lived in secondary cities and towns of less than 0.5 million been observed and another study reported that 22.7% of adolescents consumed people.68 Almost one-quarter of all people in Ethiopia who live in urban areas reside SSB at least once in a week during the previous three months.112 The latter study in Addis Ababa, the capital city. Addis Ababa is home to about 5 million people and was conducted in a small town, so this percentage could be even higher in bigger this figure is estimated to reach 9 million in 2035.95 cities. However, the causes of unhealthy dietary behaviours have not yet been studied in adolescents. Malnutrition in Ethiopia Food environment in Ethiopia Malnutrition is a major public health problem in Ethiopia. Until recently, undernutrition and micronutrient deficiencies were dominating, but overweight and Food environments in Ethiopia have changed in recent years in terms of food obesity rates, especially in adult women in urban areas, are increasing.96-99 While availability, prices, and retail outlets. The availability of foods is determined by the the national average of overweight and obesity remains low (3% in men and 8% in agricultural production, which significantly increased between 2011 and 2015.113 women), a review of studies, mostly on urban adults in Ethiopia, found prevalences However, this increased production stems primarily from the cereal sector at the ranging from 4.7% to 40.1%. The estimated pooled prevalence rate was 19%.98 A expense of other food groups, leading to lower production diversity.113 This lack of study in Addis Ababa found the rates of overweight and obesity in adults to be 21.5% diversity can in turn affect what foods are available or affordable at market level. and 2.9%, respectively.100 Prices of nutrient-dense foods such as fruit, vegetables and unprocessed meat Together with the persistent prevalence of underweight, Ethiopia is affected by a increased by 21–74% in the period 2005–2018, whereas prices of sugar, oils and fats double burden of malnutrition. In Addis Ababa, overall, more than one-third (34.7%) declined by 41–49%.114 This higher cost of nutrient-dense foods such as fruit and of women were estimated to be either under- or overweight in 2014.101 vegetables makes them unaffordable, especially to the poorest households in Ethiopia.115 15 Chapter 1 Objectives With regard to retail development, Ethiopia has a unique situation because direct foreign investments are not allowed, which has kept multinational retail chains from The overall objective of this thesis is to understand the factors influencing dietary entering the country.116 Food retail outlets in Addis Ababa include a mix of private behaviours of women and adolescents in LMIC, and specifically of adolescents in modern retail, public cooperatives and small informal vendors. The importance of Ethiopia. Additionally, it aims to explore how these adolescents perceive their food these outlets differs depending on the food products, as many of them are environment and how policies address the different factors of the food specialised, such as millers and butchers. Higher-end retail entails increasing private environment. modern retail selling high-quality products, whereas the lower end includes cooperatives that sell subsidised and price-controlled products such as sugar, flour, In this thesis the following objectives will be addressed: and oil. The prices and quality of food in the different outlets vary: for instance, 1. To synthesise the qualitative evidence on factors influencing obesogenic white wheat flour costs almost twice as much in modern retail compared to local behaviours among women and adolescent girls in LMIC (Chapter 2). flour mills; and fruit and vegetables sold at modern retail outlets are commonly 2. To assess factors influencing the dietary behaviours of adolescents in Addis more expensive and of better quality.116 Ababa, Ethiopia (Chapter 3). 3. To assess whether food environments in and around schools in urban RELEVANCE AND OBJECTIVES OF THE THESIS Ethiopia influence the dietary diversity, purchasing behaviour and body mass index (BMI) status of adolescents (Chapter 4). Relevance 4. To assess how different food environment domains have been addressed in Ethiopian policy goals and actions over time and how they compare with It is expected that adolescents’ dietary behaviours will be influenced by the income, global good practice benchmarks (Chapter 5). practices, and nutrition knowledge of their family, as adolescents have limited decision-making power in Ethiopia. To a certain extent, their choices should also be Framework used in the research influenced by what is available, affordable, or advertised in the food environment. The different spheres that are expected to influence the adolescents’ diets can be The main underlying framework used for this study was the socio-ecological seen in the socio-ecological framework mentioned above (Fig. 1.1). However, the framework defined by Bronfenbrenner117 and a framework developed by Story et impact of all these factors on adolescents’ diets has not yet been studied in Ethiopia. al.,43 which has also been adapted to the African context.118 These frameworks are all based on a similar structure, with the individual at the centre, influenced by Adolescents have been mostly neglected in the global priority setting,26 which could factors from the individual-, social-, physical- and macro-level environments.119 be due to the limited data available on adolescents’ diets and nutritional status.31 Even less research is available on the causes and consequences of dietary With regard to the food environment, there are different ways of framing it: Glanz behaviours and malnutrition at individual, household, community and national et al.74 defined the different influencing environments, such as consumer, level, especially related to overweight and obesity.21,26,92 Overweight and obesity in community and organizational, whereas Turner et al.69 divided the food adolescents has therefore been identified as a key area for further research environment into external and personal. While most public health nutrition considerations, especially in the African and Asian contexts.92 disciplines take a socio-ecological approach,35,119,120 agricultural and food system disciplines tend to focus more on the physical food environment located in the food Increases in overweight and obesity are part of the global nutrition transition, which system, which could affect the dietary outcomes of individuals.44,52,119 While all is starting slowly in Ethiopia, making it an important time to look at influencing these frameworks represent mostly the same factors, food system frameworks tend factors in the environment and identify potential entry points for interventions to exclude the influence of social factors.119 before the situation worsens. Given that no country in the world has been able to reverse the upward trend in obesity rates, it is even more important to address The different chapters of this thesis address different levels of the socio-ecological overweight and obesity before it becomes a societal problem in Ethiopia. This framework (Fig. 1.1): the evidence synthesis described in Chapter 2 uses the socio- research is therefore aimed at assessing the different influencing factors and how ecological framework as a starting point but deconstructs it, together with they are addressed in current policies. frameworks designed to understand the influencing factors of physical activity behaviours, and then develops a data-driven framework based on the findings; the 16 General Introduction Objectives With regard to retail development, Ethiopia has a unique situation because direct 1 foreign investments are not allowed, which has kept multinational retail chains from The overall objective of this thesis is to understand the factors influencing dietary entering the country.116 Food retail outlets in Addis Ababa include a mix of private behaviours of women and adolescents in LMIC, and specifically of adolescents in modern retail, public cooperatives and small informal vendors. The importance of Ethiopia. Additionally, it aims to explore how these adolescents perceive their food these outlets differs depending on the food products, as many of them are environment and how policies address the different factors of the food specialised, such as millers and butchers. Higher-end retail entails increasing private environment. modern retail selling high-quality products, whereas the lower end includes cooperatives that sell subsidised and price-controlled products such as sugar, flour, In this thesis the following objectives will be addressed: and oil. The prices and quality of food in the different outlets vary: for instance, 1. To synthesise the qualitative evidence on factors influencing obesogenic white wheat flour costs almost twice as much in modern retail compared to local behaviours among women and adolescent girls in LMIC (Chapter 2). flour mills; and fruit and vegetables sold at modern retail outlets are commonly 2. To assess factors influencing the dietary behaviours of adolescents in Addis more expensive and of better quality.116 Ababa, Ethiopia (Chapter 3). 3. To assess whether food environments in and around schools in urban RELEVANCE AND OBJECTIVES OF THE THESIS Ethiopia influence the dietary diversity, purchasing behaviour and body mass index (BMI) status of adolescents (Chapter 4). Relevance 4. To assess how different food environment domains have been addressed in Ethiopian policy goals and actions over time and how they compare with It is expected that adolescents’ dietary behaviours will be influenced by the income, global good practice benchmarks (Chapter 5). practices, and nutrition knowledge of their family, as adolescents have limited decision-making power in Ethiopia. To a certain extent, their choices should also be Framework used in the research influenced by what is available, affordable, or advertised in the food environment. The different spheres that are expected to influence the adolescents’ diets can be The main underlying framework used for this study was the socio-ecological seen in the socio-ecological framework mentioned above (Fig. 1.1). However, the framework defined by Bronfenbrenner117 and a framework developed by Story et impact of all these factors on adolescents’ diets has not yet been studied in Ethiopia. al.,43 which has also been adapted to the African context.118 These frameworks are all based on a similar structure, with the individual at the centre, influenced by Adolescents have been mostly neglected in the global priority setting,26 which could factors from the individual-, social-, physical- and macro-level environments.119 be due to the limited data available on adolescents’ diets and nutritional status.31 Even less research is available on the causes and consequences of dietary With regard to the food environment, there are different ways of framing it: Glanz behaviours and malnutrition at individual, household, community and national et al.74 defined the different influencing environments, such as consumer, level, especially related to overweight and obesity.21,26,92 Overweight and obesity in community and organizational, whereas Turner et al.69 divided the food adolescents has therefore been identified as a key area for further research environment into external and personal. While most public health nutrition considerations, especially in the African and Asian contexts.92 disciplines take a socio-ecological approach,35,119,120 agricultural and food system disciplines tend to focus more on the physical food environment located in the food Increases in overweight and obesity are part of the global nutrition transition, which system, which could affect the dietary outcomes of individuals.44,52,119 While all is starting slowly in Ethiopia, making it an important time to look at influencing these frameworks represent mostly the same factors, food system frameworks tend factors in the environment and identify potential entry points for interventions to exclude the influence of social factors.119 before the situation worsens. Given that no country in the world has been able to reverse the upward trend in obesity rates, it is even more important to address The different chapters of this thesis address different levels of the socio-ecological overweight and obesity before it becomes a societal problem in Ethiopia. This framework (Fig. 1.1): the evidence synthesis described in Chapter 2 uses the socio- research is therefore aimed at assessing the different influencing factors and how ecological framework as a starting point but deconstructs it, together with they are addressed in current policies. frameworks designed to understand the influencing factors of physical activity behaviours, and then develops a data-driven framework based on the findings; the 17 Chapter 1 study in Chapter 3 uses the socio-ecological frameworks developed by Story et al.35 Chapter 6 provides a general discussion of the main chapters (Chapters 2–5), and Ossei-Kwasi et al.118 in the design and analysis; Chapter 4 mostly focuses on synthesizing the key findings and reflecting on the methodologies used and future mapping the physical environment and understanding its influence on individual research and policy actions. factors and dietary behaviours; and Chapter 5 focuses on the physical environment, applying frameworks specific to food environment policies.44,121 OUTLINE OF THIS TEHSIS RESEARCH METHODOLOGIES Table 1.1 provides an overview of the main chapters, summarizing the objectives and methods used in this thesis. This thesis applied a mixed-method research approach, employing both quantitative Table 1.1. Overview of thesis chapters and methodologies and qualitative methods. For Chapter 2, a qualitative evidence synthesis (QES) was Chapter Objective Setting and Methodology used to bring together the different types of qualitative evidence; QES is an umbrella population/ term for the methodologies associated with the systematic review of qualitative study material research evidence.122 This systematic review followed a framework synthesis 2. Factors influencing To synthesise the LMIC; Qualitative methodology to extract, analyse and synthesise the qualitative data from primary obesogenic behaviours qualitative evidence on qualitative evidence research studies.123 of adolescent girls factors influencing research studies synthesis and women in LMIC: a obesogenic behaviours For Chapter 3, we applied participatory action research using the Photovoice qualitative among women and method, in which participants take photographs of their local environment to evidence synthesis adolescent girls in LMIC document and represent their community in relation to a specific topic. The three- 3. Assessing factors To assess factors Two schools in Participatory influencing adolescents’ influencing the dietary Addis Ababa, action research: staged approach includes individual and/or group discussions to select (i.e. choose dietary behaviours behaviours of Ethiopia; 26 Photovoice the photographs that best reflect the topic), contextualise (i.e. explain the context in urban Ethiopia using adolescents in Addis adolescents, of the photographs) and analyse (i.e. identify the issues, themes and emerging participatory Ababa, Ethiopia 14–19 years old theories) the photographs.78,124 photography 4. Adolescents face To assess whether food Twelve schools Cross-sectional: A cross-sectional approach was used for Chapter 4. Using interview-administered pervasive advertising environments in and in Addis Ababa, mapping of questionnaires, participants were interviewed on socio-demographic characteristics and availability of ultra- around schools in urban Ethiopia; school food and food consumption. Height and weight were also measured to assess the BMI processed foods and Ethiopia influence 217 environment status. In addition, the food environment in and around selected schools was beverages in and around dietary diversity, adolescents, (advertising and assessed using protocols from INFORMAS to measure food environments that schools in Addis Ababa, purchasing behaviour 15–19 years old food outlets), Ethiopia and the BMI status of dietary diversity contain elements on food advertising and types of food outlets.125 adolescents and BMI of adolescents For Chapter 5, a policy analysis was conducted using the on the INFORMAS Food- 5. Benchmarking policy To assess how different Ethiopia; Thematic EPI framework as a basis.121 This study analysed Ethiopian policy documents with goals and action for food environment national policy analysis of regard to policy actions addressing food environments and the respective dietary healthy food domains have been papers policy and nutritional goals. The documents were outputs of decision-making126 and environments in Ethiopia addressed in Ethiopian documents included legal outputs (from the highest to lowest hierarchy: proclamations, to prevent malnutrition policy goals and actions regulations, directives), documents stating overarching government plans (policies in all its forms over time and how they and strategies) and sectoral documents proposing policy actions to implement compare with global good practice policy goals (sectoral strategies, action plans, programme documents or benchmarks guidelines).127 18 General Introduction study in Chapter 3 uses the socio-ecological frameworks developed by Story et al.35 Chapter 6 provides a general discussion of the main chapters (Chapters 2–5), and Ossei-Kwasi et al.118 in the design and analysis; Chapter 4 mostly focuses on synthesizing the key findings and reflecting on the methodologies used and future 1 mapping the physical environment and understanding its influence on individual research and policy actions. factors and dietary behaviours; and Chapter 5 focuses on the physical environment, applying frameworks specific to food environment policies.44,121 OUTLINE OF THIS TEHSIS RESEARCH METHODOLOGIES Table 1.1 provides an overview of the main chapters, summarizing the objectives and methods used in this thesis. This thesis applied a mixed-method research approach, employing both quantitative Table 1.1. Overview of thesis chapters and methodologies and qualitative methods. For Chapter 2, a qualitative evidence synthesis (QES) was Chapter Objective Setting and Methodology used to bring together the different types of qualitative evidence; QES is an umbrella population/ term for the methodologies associated with the systematic review of qualitative study material research evidence.122 This systematic review followed a framework synthesis 2. Factors influencing To synthesise the LMIC; Qualitative methodology to extract, analyse and synthesise the qualitative data from primary obesogenic behaviours qualitative evidence on qualitative evidence research studies.123 of adolescent girls factors influencing research studies synthesis and women in LMIC: a obesogenic behaviours For Chapter 3, we applied participatory action research using the Photovoice qualitative among women and method, in which participants take photographs of their local environment to evidence synthesis adolescent girls in LMIC document and represent their community in relation to a specific topic. The three- 3. Assessing factors To assess factors Two schools in Participatory influencing adolescents’ influencing the dietary Addis Ababa, action research: staged approach includes individual and/or group discussions to select (i.e. choose dietary behaviours behaviours of Ethiopia; 26 Photovoice the photographs that best reflect the topic), contextualise (i.e. explain the context in urban Ethiopia using adolescents in Addis adolescents, of the photographs) and analyse (i.e. identify the issues, themes and emerging participatory Ababa, Ethiopia 14–19 years old theories) the photographs.78,124 photography 4. Adolescents face To assess whether food Twelve schools Cross-sectional: A cross-sectional approach was used for Chapter 4. Using interview-administered pervasive advertising environments in and in Addis Ababa, mapping of questionnaires, participants were interviewed on socio-demographic characteristics and availability of ultra- around schools in urban Ethiopia; school food and food consumption. Height and weight were also measured to assess the BMI processed foods and Ethiopia influence 217 environment status. In addition, the food environment in and around selected schools was beverages in and around dietary diversity, adolescents, (advertising and assessed using protocols from INFORMAS to measure food environments that schools in Addis Ababa, purchasing behaviour 15–19 years old food outlets), Ethiopia and the BMI status of dietary diversity contain elements on food advertising and types of food outlets.125 adolescents and BMI of adolescents For Chapter 5, a policy analysis was conducted using the on the INFORMAS Food- 5. Benchmarking policy To assess how different Ethiopia; Thematic EPI framework as a basis.121 This study analysed Ethiopian policy documents with goals and action for food environment national policy analysis of regard to policy actions addressing food environments and the respective dietary healthy food domains have been papers policy and nutritional goals. The documents were outputs of decision-making126 and environments in Ethiopia addressed in Ethiopian documents included legal outputs (from the highest to lowest hierarchy: proclamations, to prevent malnutrition policy goals and actions regulations, directives), documents stating overarching government plans (policies in all its forms over time and how they and strategies) and sectoral documents proposing policy actions to implement compare with global good practice policy goals (sectoral strategies, action plans, programme documents or benchmarks guidelines).127 19 Chapter 1 References 16. Keino S, Plasqui G, Ettyang G, et al. Determinants of Stunting and Overweight among Young Children and Adolescents in Sub-Saharan Africa. Food Nutr Bull. 2014; 1. Global Nutrition Report: The state of global nutrition. Bristol, UK; 2021, Development 35(2):167-178. doi:10.1177/156482651403500203 Initiatives 17. Monteiro CA, Conde WL, Lu B, et al. Obesity and inequities in health in the developing 2. FAO, IFAD, UNICEF, WFP, WHO. The State of Food Security and Nutrition in the World world. Int J Obes Relat Metab Disord. 2004; 28(9):1181-1186. 2021. Transforming Food Systems for Food Security, Improved Nutrition and doi:10.1038/sj.ijo.0802716 Affordable Healthy Diets for All. Rome; 2021. https://doi.org/10.4060/cb4474en. 18. Dinsa GD, Goryakin Y, Fumagalli E, et al. Obesity and socioeconomic status in 3. Shekar M, Popkin B. Obesity: Health and Economic Consequences of an Impending developing countries: a systematic review. Obes Rev. 2012; 13(11):1067-1079. Global Challenge. Washington D.C.; 2020. doi:10.1111/j.1467-789X.2012.01017.x 4. Ford ND, Patel SA, Narayan KM. Obesity in Low- and Middle-Income Countries: 19. Steyn NP, McHiza ZJ. Obesity and the nutrition transition in Sub-Saharan Africa. Ann Burden, Drivers, and Emerging Challenges. Annu Rev Public Health. 2017; 38:145-164. N Y Acad Sci. 2014; 1311:88-101. doi:10.1111/nyas.12433 doi:10.1146/annurev-publhealth-031816-044604 20. Muthuri SK, Francis CE, Wachira L-JM, et al. Evidence of an overweight/obesity 5. Darling AM, Sunguya B, Ismail A, et al. Gender differences in nutritional status, diet transition among school-aged children and youth in Sub-Saharan Africa: a systematic and physical activity among adolescents in eight countries in sub-Saharan Africa. Trop review. PLoS One. 2014; 9(3):e92846. doi:10.1371/journal.pone.0092846 Med Int Heal. 2020; 25(1):33-43. doi:10.1111/tmi.13330 21. Keats EC, Rappaport AI, Shah S, et al. The Dietary Intake and Practices of Adolescent 6. Azzopardi PS, Hearps SJC, Francis KL, et al. Progress in adolescent health and Girls in Low- and Middle-Income Countries: A Systematic Review. Nutrients. wellbeing: tracking 12 headline indicators for 195 countries and territories, 2018;10(12). doi:10.3390/nu10121978 1990–2016. Lancet. 2019; 393(10176):1101-1118. doi:10.1016/S0140- 22. Ochola S, Masibo PK. Childhood and adolescence are critical stages offering a window 6736(18)32427-9 of opportunity for interventions to inculcate healthy eating habits to mitigate the 7. Manyanga T, El-Sayed H, Doku DT, et al. The prevalence of underweight, overweight, occurrence of diet-related chronic diseases in later life associated with poor eating obesity and associated risk factors among school-going adolescents in seven African habits in earlier, Ann Nutr Metab; 2014;64(suppl 2):24–40 countries. BMC Public Health. 2014; 28;14:887; doi:10.1186/1471-2458-14-887 23. Kupka R, Siekmans K, Beal T. The diets of children: Overview of available data for 8. Abarca-Gómez L, Abdeen ZA, Hamid ZA, et al. Worldwide trends in body-mass index, children and adolescents. Glob Food Sec. 2020; 27:100442. doi:10.1016/j.gfs.2020. underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 100442 population-based measurement studies in 128,9 million children, adolescents, and 24. WHO. The Global Strategy for Women’s, Children’s, and Adolescents’ Health (2016– adults. Lancet. 2017; 390(10113):2627-2642. doi:10.1016/S0140-6736(17)32129-3 30).; 2015. https://www.who.int/life-course/partners/global-strategy/globalstrategy 9. Rodriguez-Martinez A, Zhou B, Sophiea MK, et al. Height and body-mass index report2016-2030-lowres.pdf. trajectories of school-aged children and adolescents from 1985 to 2019 in 200 25. Hollis JL, Collins CE, DeClerck F, et al. Defining healthy and sustainable diets for countries and territories: a pooled analysis of 2181 population-based studies with 65 infants, children and adolescents. Glob Food Sec. 2020;27:100401. doi: million participants. Lancet. 2020; 396(10261):1511-1524. doi:10.1016/S0140- https://doi.org/10.1016/j.gfs.2020.100401 6736(20)31859-6 26. Patton GC, Neufeld LM, Dogra S, et al. Nourishing our future: the Lancet Series on 10. Danquah FI, Ansu-Mensah M, Bawontuo V, et al. Prevalence, incidence, and trends of adolescent nutrition. Lancet. 2022; 399(10320):123-125. doi:10.1016/S0140- childhood overweight/obesity in Sub-Saharan Africa: a systematic scoping review. 6736(21)02140-1 Arch Public Heal. 2020; 78(1):109. doi:10.1186/s13690-020-00491-2 27. Viner RM. Adolescents’ health needs: the same the world over. Arch Dis Child. 2013; 11. Butland B, Jebb S, Koppelman P. Foresight. Tackling Obesities: Future Choices -Project 98(1):2. doi:10.1136/archdischild-2012-302523 Report.; 2007. 28. Stok FM, de Vet E, de Ridder DT, et al. The potential of peer social norms to shape 12. Agurs-Collins T, Bouchard C. Gene-nutrition and gene-physical activity interactions in food intake in adolescents and young adults: a systematic review of effects and the etiology of obesity. Introduction. Obesity (Silver Spring). 2008; 16 Suppl 3: S2-S4. moderators. Heal Psychol Rev. 2016; 10(3):326-340. doi:10.1080/17437199.2016. doi:10.1038/oby.2008.510 1155161 13. Symonds ME, Mendez MA, Meltzer HM, et al. Early Life Nutritional Programming of 29. Leandro CG, Fonseca EV da S da, de Lim CR, et al. Barriers and Enablers That Influence Obesity: Mother-Child Cohort Studies. Ann Nutr Metab. 2013; 62(2):137-145. Overweight/Obesity/Obesogenic Behavior in Adolescents From Lower-Middle doi:10.1159/000345598 Income Countries: A Systematic Review. Food Nutr Bull. 2019. doi:10.1177/ 14. Hawkes C, Ruel MT, Salm L, et al. Double-duty actions: seizing programme and policy 0379572119853926 opportunities to address malnutrition in all its forms. Lancet. 2020; 395(10218):142- 30. Raza A, Fox EL, Morris SS, et al. Conceptual framework of food systems for children 155. doi:10.1016/S0140-6736(19)32506-1 and adolescents. Glob Food Sec. 2020. doi:10.1016/j.gfs.2020.100436 15. Wells JC, Sawaya AL, Wibaek R, et al. The double burden of malnutrition: aetiological 31. Neufeld LM, Andrade EB, Ballonoff Suleiman A, et al. Food choice in transition: pathways and consequences for health. . 2020; 395(10217):75-88. adolescent autonomy, agency, and the food environment. Lancet. 2022; Lancet doi:10.1016/S0140-6736(19)32472-9 399(10320):185-197. doi:10.1016/S0140-6736(21)01687-1 20 General Introduction References 16. Keino S, Plasqui G, Ettyang G, et al. Determinants of Stunting and Overweight among Young Children and Adolescents in Sub-Saharan Africa. Food Nutr Bull. 2014; 1 1. Global Nutrition Report: The state of global nutrition. Bristol, UK; 2021, Development 35(2):167-178. doi:10.1177/156482651403500203 Initiatives 17. Monteiro CA, Conde WL, Lu B, et al. Obesity and inequities in health in the developing 2. FAO, IFAD, UNICEF, WFP, WHO. The State of Food Security and Nutrition in the World world. Int J Obes Relat Metab Disord. 2004; 28(9):1181-1186. 2021. Transforming Food Systems for Food Security, Improved Nutrition and doi:10.1038/sj.ijo.0802716 Affordable Healthy Diets for All. Rome; 2021. https://doi.org/10.4060/cb4474en. 18. Dinsa GD, Goryakin Y, Fumagalli E, et al. Obesity and socioeconomic status in 3. Shekar M, Popkin B. Obesity: Health and Economic Consequences of an Impending developing countries: a systematic review. Obes Rev. 2012; 13(11):1067-1079. Global Challenge. Washington D.C.; 2020. doi:10.1111/j.1467-789X.2012.01017.x 4. Ford ND, Patel SA, Narayan KM. Obesity in Low- and Middle-Income Countries: 19. Steyn NP, McHiza ZJ. Obesity and the nutrition transition in Sub-Saharan Africa. Ann Burden, Drivers, and Emerging Challenges. Annu Rev Public Health. 2017; 38:145-164. N Y Acad Sci. 2014; 1311:88-101. doi:10.1111/nyas.12433 doi:10.1146/annurev-publhealth-031816-044604 20. Muthuri SK, Francis CE, Wachira L-JM, et al. Evidence of an overweight/obesity 5. Darling AM, Sunguya B, Ismail A, et al. Gender differences in nutritional status, diet transition among school-aged children and youth in Sub-Saharan Africa: a systematic and physical activity among adolescents in eight countries in sub-Saharan Africa. Trop review. PLoS One. 2014; 9(3):e92846. doi:10.1371/journal.pone.0092846 Med Int Heal. 2020; 25(1):33-43. doi:10.1111/tmi.13330 21. Keats EC, Rappaport AI, Shah S, et al. The Dietary Intake and Practices of Adolescent 6. Azzopardi PS, Hearps SJC, Francis KL, et al. Progress in adolescent health and Girls in Low- and Middle-Income Countries: A Systematic Review. Nutrients. wellbeing: tracking 12 headline indicators for 195 countries and territories, 2018;10(12). doi:10.3390/nu10121978 1990–2016. Lancet. 2019; 393(10176):1101-1118. doi:10.1016/S0140- 22. Ochola S, Masibo PK. Childhood and adolescence are critical stages offering a window 6736(18)32427-9 of opportunity for interventions to inculcate healthy eating habits to mitigate the 7. Manyanga T, El-Sayed H, Doku DT, et al. The prevalence of underweight, overweight, occurrence of diet-related chronic diseases in later life associated with poor eating obesity and associated risk factors among school-going adolescents in seven African habits in earlier, Ann Nutr Metab; 2014;64(suppl 2):24–40 countries. BMC Public Health. 2014; 28;14:887; doi:10.1186/1471-2458-14-887 23. Kupka R, Siekmans K, Beal T. The diets of children: Overview of available data for 8. Abarca-Gómez L, Abdeen ZA, Hamid ZA, et al. Worldwide trends in body-mass index, children and adolescents. Glob Food Sec. 2020; 27:100442. doi:10.1016/j.gfs.2020. underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 100442 population-based measurement studies in 128,9 million children, adolescents, and 24. WHO. The Global Strategy for Women’s, Children’s, and Adolescents’ Health (2016– adults. Lancet. 2017; 390(10113):2627-2642. doi:10.1016/S0140-6736(17)32129-3 30).; 2015. https://www.who.int/life-course/partners/global-strategy/globalstrategy 9. Rodriguez-Martinez A, Zhou B, Sophiea MK, et al. Height and body-mass index report2016-2030-lowres.pdf. trajectories of school-aged children and adolescents from 1985 to 2019 in 200 25. Hollis JL, Collins CE, DeClerck F, et al. Defining healthy and sustainable diets for countries and territories: a pooled analysis of 2181 population-based studies with 65 infants, children and adolescents. Glob Food Sec. 2020;27:100401. doi: million participants. Lancet. 2020; 396(10261):1511-1524. doi:10.1016/S0140- https://doi.org/10.1016/j.gfs.2020.100401 6736(20)31859-6 26. Patton GC, Neufeld LM, Dogra S, et al. Nourishing our future: the Lancet Series on 10. Danquah FI, Ansu-Mensah M, Bawontuo V, et al. Prevalence, incidence, and trends of adolescent nutrition. Lancet. 2022; 399(10320):123-125. doi:10.1016/S0140- childhood overweight/obesity in Sub-Saharan Africa: a systematic scoping review. 6736(21)02140-1 Arch Public Heal. 2020; 78(1):109. doi:10.1186/s13690-020-00491-2 27. Viner RM. Adolescents’ health needs: the same the world over. Arch Dis Child. 2013; 11. Butland B, Jebb S, Koppelman P. Foresight. Tackling Obesities: Future Choices -Project 98(1):2. doi:10.1136/archdischild-2012-302523 Report.; 2007. 28. Stok FM, de Vet E, de Ridder DT, et al. The potential of peer social norms to shape 12. Agurs-Collins T, Bouchard C. Gene-nutrition and gene-physical activity interactions in food intake in adolescents and young adults: a systematic review of effects and the etiology of obesity. Introduction. Obesity (Silver Spring). 2008; 16 Suppl 3: S2-S4. moderators. Heal Psychol Rev. 2016; 10(3):326-340. doi:10.1080/17437199.2016. doi:10.1038/oby.2008.510 1155161 13. Symonds ME, Mendez MA, Meltzer HM, et al. Early Life Nutritional Programming of 29. Leandro CG, Fonseca EV da S da, de Lim CR, et al. Barriers and Enablers That Influence Obesity: Mother-Child Cohort Studies. Ann Nutr Metab. 2013; 62(2):137-145. Overweight/Obesity/Obesogenic Behavior in Adolescents From Lower-Middle doi:10.1159/000345598 Income Countries: A Systematic Review. Food Nutr Bull. 2019. doi:10.1177/ 14. Hawkes C, Ruel MT, Salm L, et al. Double-duty actions: seizing programme and policy 0379572119853926 opportunities to address malnutrition in all its forms. Lancet. 2020; 395(10218):142- 30. Raza A, Fox EL, Morris SS, et al. Conceptual framework of food systems for children 155. doi:10.1016/S0140-6736(19)32506-1 and adolescents. Glob Food Sec. 2020. doi:10.1016/j.gfs.2020.100436 15. Wells JC, Sawaya AL, Wibaek R, et al. The double burden of malnutrition: aetiological 31. Neufeld LM, Andrade EB, Ballonoff Suleiman A, et al. Food choice in transition: pathways and consequences for health. . 2020; 395(10217):75-88. adolescent autonomy, agency, and the food environment. Lancet. 2022; Lancet doi:10.1016/S0140-6736(19)32472-9 399(10320):185-197. doi:10.1016/S0140-6736(21)01687-1 21 Chapter 1 32. Fox EL, Timmer A. Children’s and adolescents’ characteristics and interactions with 48. Battersby J. Food System transformation in the Absence of Food System Planning: The the food system. Glob Food Sec. 2020. doi:10.1016/j.gfs.2020.100419 Case of Supermarket and Shopping Mall Retail Expansion in Cape Town, South Africa. 33. Smith R, Kelly B, Yeatman H, et al. Food marketing influences children’s attitudes, Built Environ. 2017; 43:417-430. doi:10.2148/benv.43.3.417 preferences and consumption: A systematic critical review. Nutrients. 2019; 11(4). 49. Reardon T, Tschirley D, Liverpool-Tasie LSO, et al. The processed food revolution in doi:10.3390/nu11040875 African food systems and the double burden of malnutrition. Glob Food Sec. 2021; 34. Kelly B, Boyland E, King L, et al. Children’s exposure to television food advertising 28:100466. doi:https://doi.org/10.1016/j.gfs.2020.100466 contributes to strong brand attachments. Int J Environ Res Public Health. 2019; 16(13). 50. Minten B, Reardon T. Food Prices, Quality, and Quality’s Pricing in Supermarkets doi:10.3390/ijerph16132358 versus Traditional Markets in Developing Countries. Rev Agric Econ. 2008; 30(3):480- 35. Story M, Kaphingst KM, Robinson-O’Brien R, et al. Creating healthy food and eating 490. http://www.jstor.org/stable/30225891. environments: policy and environmental approaches. Annu Rev Public Health. 2008; 51. Nordhagen S. Food supply chains and child and adolescent diets: A review. Glob Food 29:253-272. doi:10.1146/annurev.publhealth.29.020907.090926 Sec. 2020; 27:100443. doi:https://doi.org/10.1016/j.gfs.2020.100443 36. Gissing SC, Pradeilles R, Osei-Kwasi HA, et al. Drivers of dietary behaviours in women 52. Turner C, Aggarwal A, Walls H, et al. Concepts and critical perspectives for food living in urban Africa: a systematic mapping review. Public Heal Nutr. 2017; environment research: A global framework with implications for action in low- and 20(12):2104-2113. doi:10.1017/S1368980017000970 middle-income countries. Glob Food Sec. 2018; 18:93-101. doi:https://doi.org 37. Brown C, Shaibu S, Maruapula S, et al. Perceptions and attitudes towards food choice /10.1016/j.gfs.2018.08.003 in adolescents in Gaborone, Botswana. Appetite. 2015; 95:29-35. doi:10.1016/ 53. Pitt E, Gallegos D, Comans T, et al. Exploring the influence of local food environments j.appet.2015.06.018 on food behaviours: A systematic review of qualitative literature. Public Health Nutr. 38. Downs SM, Fox EL, Zivkovic A, et al. Drivers of food choice among women living in 2017. doi:10.1017/S1368980017001069 informal settlements in Nairobi, Kenya. Appetite. 2022; 168:105748. doi: 54. Cummins S, Macintyre S. “Food deserts”--evidence and assumption in health policy https://doi.org/10.1016/j.appet.2021.105748 making. BMJ. 2002; 325(7361):436-438. doi:10.1136/bmj.325.7361.436 39. Herforth A, Bai Y, Venkat A, et al. Cost and Affordability of Healthy Diets across and 55. Anggraini R, Februhartanty J, Bardosono S, et al. Food Store Choice Among Urban within Countries. Background Paper for The State of Food Security and Nutrition in the Slum Women Is Associated With Consumption of Energy-Dense Food. Asia-Pacific J World 2020. Rome; 2020. https://doi.org/10.4060/cb2431en. public Heal. 2016; 28(5):458-468. doi:10.1177/1010539516646849 40. Banna JC, Buchthal OV, Delormier T, et al. Influences on eating: a qualitative study of 56. Wertheim-Heck SCO, Vellema S, Spaargaren G. Constrained consumer practices and adolescents in a periurban area in Lima, Peru. BMC Public Health. 2015; 16(1):40. food safety concerns in Hanoi. Int J Consum Stud. 2014. doi:10.1111/ijcs.12093 doi:10.1186/s12889-016-2724-7 57. Duran AC, de Almeida SL, Latorre M do RDO, et al. The role of the local retail food 41. Verstraeten R, Leroy JL, Pieniak Z, et al. Individual and Environmental Factors environment in fruit, vegetable and sugar-sweetened beverage consumption in Brazil. Influencing Adolescents’ Dietary Behavior in Low- and Middle-Income Settings. PLoS Public Health Nutr. 2016; 19(6):1093-1102. doi:10.1017/S1368980015001524 One. 2016; 11(7):e0157744. https://doi.org/10.1371/journal.pone.0157744. 58. Steyn NP, McHiza Z, Hill J, et al. Nutritional contribution of street foods to the diet of 42. Pacific R, Martin HD, Kulwa K, et al. Contribution of Home and School Environment in people in developing countries: a systematic review. Public Health Nutr. 2014; Children’s Food Choice and Overweight/Obesity Prevalence in African Context: 17(6):1363-1374. doi:10.1017/S1368980013001158 Evidence for Creating Enabling Healthful Food Environment. Pediatr Heal Med Ther. 59. Abrahale K, Sousa S, Albuquerque G, et al. Street food research worldwide: a scoping 2020; 11:283-295. doi:10.2147/PHMT.S257549 review. J Hum Nutr Diet. 2018; 32. doi:10.1111/jhn.12604 43. Story M, Neumark-Sztainer D, French S. Individual and Environmental Influences on 60. Gonçalves VSS, Figueiredo ACMG, Silva SA, et al. The food environment in schools and Adolescent Eating Behaviors. J Am Diet Assoc. 2002;102(3, Supplement): S40-S51. their immediate vicinities associated with excess weight in adolescence: A systematic doi:https://doi.org/10.1016/S0002-8223(02)90421-9 review and meta-analysis. Health Place. 2021; 71:102664. doi:10.1016/j.healthplace. 44. HLPE. Nutrition and Food Systems. A Report by the High Level Panel of Experts on Food 2021.102664 Security and Nutrition of the Committee on World Food Security. Rome; 2017. 61. Azeredo CM, de Rezende LFM, Canella DS, et al. Food environments in schools and in 45. Reardon T, Timmer CP, Barrett CB, et al. The Rise of Supermarkets in Africa, Asia, and the immediate vicinity are associated with unhealthy food consumption among Latin America. Am J Agric Econ. 2003; 85(5):1140-1146. http://www.jstor.org Brazilian adolescents. Prev Med. 2016. doi:10.1016/j.ypmed.2016.03.026 /stable/1244885. 62. Cairns G, Angus K, Hastings G, et al. Systematic reviews of the evidence on the nature, 46. Monteiro CA, Moubarac JC, Cannon G, et al. Ultra-processed products are becoming extent and effects of food marketing to children. A retrospective summary. Appetite. dominant in the global food system. Obes Rev. 2013;14 Suppl 2:21-28. 2013; 62:209-215. doi:10.1016/j.appet.2012.04.017 doi:10.1111/obr.12107 63. Murphy G, Corcoran C, Tatlow-Golden M, et al. See, like, share, remember: 47. Popkin BM, Corvalan C, Grummer-Strawn LM. Dynamics of the double burden of Adolescents’ responses to unhealthy-, healthy- and non-food advertising in social malnutrition and the changing nutrition reality. Lancet. 2020; 395(10217):65-74. media. Int J Environ Res Public Health. 2020; 17(7). doi:10.3390/ijerph17072181 doi:10.1016/S0140-6736(19)32497-3 22 General Introduction 32. Fox EL, Timmer A. Children’s and adolescents’ characteristics and interactions with 48. Battersby J. Food System transformation in the Absence of Food System Planning: The the food system. Glob Food Sec. 2020. doi:10.1016/j.gfs.2020.100419 Case of Supermarket and Shopping Mall Retail Expansion in Cape Town, South Africa. 1 33. Smith R, Kelly B, Yeatman H, et al. Food marketing influences children’s attitudes, Built Environ. 2017; 43:417-430. doi:10.2148/benv.43.3.417 preferences and consumption: A systematic critical review. Nutrients. 2019; 11(4). 49. Reardon T, Tschirley D, Liverpool-Tasie LSO, et al. The processed food revolution in doi:10.3390/nu11040875 African food systems and the double burden of malnutrition. Glob Food Sec. 2021; 34. Kelly B, Boyland E, King L, et al. Children’s exposure to television food advertising 28:100466. doi:https://doi.org/10.1016/j.gfs.2020.100466 contributes to strong brand attachments. Int J Environ Res Public Health. 2019; 16(13). 50. Minten B, Reardon T. Food Prices, Quality, and Quality’s Pricing in Supermarkets doi:10.3390/ijerph16132358 versus Traditional Markets in Developing Countries. Rev Agric Econ. 2008; 30(3):480- 35. Story M, Kaphingst KM, Robinson-O’Brien R, et al. Creating healthy food and eating 490. http://www.jstor.org/stable/30225891. environments: policy and environmental approaches. Annu Rev Public Health. 2008; 51. Nordhagen S. Food supply chains and child and adolescent diets: A review. Glob Food 29:253-272. doi:10.1146/annurev.publhealth.29.020907.090926 Sec. 2020; 27:100443. doi:https://doi.org/10.1016/j.gfs.2020.100443 36. Gissing SC, Pradeilles R, Osei-Kwasi HA, et al. Drivers of dietary behaviours in women 52. Turner C, Aggarwal A, Walls H, et al. Concepts and critical perspectives for food living in urban Africa: a systematic mapping review. Public Heal Nutr. 2017; environment research: A global framework with implications for action in low- and 20(12):2104-2113. doi:10.1017/S1368980017000970 middle-income countries. Glob Food Sec. 2018; 18:93-101. doi:https://doi.org 37. Brown C, Shaibu S, Maruapula S, et al. Perceptions and attitudes towards food choice /10.1016/j.gfs.2018.08.003 in adolescents in Gaborone, Botswana. Appetite. 2015; 95:29-35. doi:10.1016/ 53. Pitt E, Gallegos D, Comans T, et al. Exploring the influence of local food environments j.appet.2015.06.018 on food behaviours: A systematic review of qualitative literature. Public Health Nutr. 38. Downs SM, Fox EL, Zivkovic A, et al. Drivers of food choice among women living in 2017. doi:10.1017/S1368980017001069 informal settlements in Nairobi, Kenya. Appetite. 2022; 168:105748. doi: 54. Cummins S, Macintyre S. “Food deserts”--evidence and assumption in health policy https://doi.org/10.1016/j.appet.2021.105748 making. BMJ. 2002; 325(7361):436-438. doi:10.1136/bmj.325.7361.436 39. Herforth A, Bai Y, Venkat A, et al. Cost and Affordability of Healthy Diets across and 55. Anggraini R, Februhartanty J, Bardosono S, et al. Food Store Choice Among Urban within Countries. Background Paper for The State of Food Security and Nutrition in the Slum Women Is Associated With Consumption of Energy-Dense Food. Asia-Pacific J World 2020. Rome; 2020. https://doi.org/10.4060/cb2431en. public Heal. 2016; 28(5):458-468. doi:10.1177/1010539516646849 40. Banna JC, Buchthal OV, Delormier T, et al. Influences on eating: a qualitative study of 56. Wertheim-Heck SCO, Vellema S, Spaargaren G. Constrained consumer practices and adolescents in a periurban area in Lima, Peru. BMC Public Health. 2015; 16(1):40. food safety concerns in Hanoi. Int J Consum Stud. 2014. doi:10.1111/ijcs.12093 doi:10.1186/s12889-016-2724-7 57. Duran AC, de Almeida SL, Latorre M do RDO, et al. The role of the local retail food 41. Verstraeten R, Leroy JL, Pieniak Z, et al. Individual and Environmental Factors environment in fruit, vegetable and sugar-sweetened beverage consumption in Brazil. Influencing Adolescents’ Dietary Behavior in Low- and Middle-Income Settings. 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Public Heal Nutr Among Second Cycle Primary School Children in Kirkos Sub-City, Addis Ababa, 2020; 23(14):2584-2601. doi: 10.1017/S1368980019005305. Ethiopia. Glob Adv Heal Med. 2021; 10:21649561211017884. doi:10.1177/ 119. Holdsworth M, Landais E. Urban food environments in Africa: implications for policy 21649561211017883 and research. Proc Nutr Soc. 2019; 78(4):513-525. doi:10.1017/S0029665118002938 103. Yeshaw Y, Kebede SA, Liyew AM, et al. Determinants of overweight/obesity among 120. Swinburn B, Egger G, Raza F. Dissecting Obesogenic Environments: The Development reproductive age group women in Ethiopia: Multilevel analysis of Ethiopian and Application of a Framework for Identifying and Prioritizing Environmental demographic and health survey. BMJ Open. 2020; 10(3). doi:10.1136/bmjopen-2019- Interventions for Obesity. Prev Med. 1999;29(6):563-570. doi:https://doi.org/ 034963 10.1006/pmed.1999.0585 104. Gali N, Tamiru D, Tamrat M. The Emerging Nutritional Problems of School 121. Swinburn B, Vandevijvere S, Kraak V, et al. Monitoring and benchmarking government Adolescents: Overweight/Obesity and Associated Factors in Jimma Town, Ethiopia. J policies and actions to improve the healthiness of food environments: A proposed Pediatr Nurs. 2017; 35:98-104. doi:10.1016/j.pedn.2017.03.002 government healthy food environment policy index. Obes Rev. 2013. doi:10.1111/ 105. Hassen K, Gizaw G, Belachew T. Dual Burden of Malnutrition Among Adolescents of obr.12073 Smallholder Coffee Farming Households of Jimma Zone, Southwest Ethiopia. Food 122. Flemming K, Booth A, Garside R, et al. Qualitative evidence synthesis for complex Nutr Bull. 2017; 38(2):196-208. doi:10.1177/0379572117701660 interventions and guideline development: clarification of the purpose, designs and 106. Teshome T, Singh P, Moges D. Prevalence and associated factors of overweight and relevant methods. BMJ Glob Heal. 2019. doi:10.1136/bmjgh-2018-000882 obesity among high school adolescents in urban communities of Hawassa, southern 123. Booth A, Carroll C. How to build up the actionable knowledge base: the role of ‘best Ethiopia. Curr Res Nutr Food Sci. 2013; 1(1):23-36. doi:10.12944/CRNFSJ.1.1.03 fit’ framework synthesis for studies of improvement in healthcare. BMJ Qual Saf. 107. Worku IH, Dereje M, Minten B, et al. Diet transformation in Africa: the case of 2015; 24:bmjqs-2014. doi:10.1136/bmjqs-2014-003642 Ethiopia. Agric Econ. 2017; 48:73-86. doi:10.1111/agec.12387 124. Wang CC, Yi WK, Tao ZW, et al. Photovoice as a Participatory Health Promotion 108. Hirvonen K. Rural–urban differences in children’s dietary diversity in Ethiopia: A Strategy. Health Promot Int. 1998; 13(1):75-86. doi:10.1093/heapro/13.1.75 Poisson decomposition analysis. Econ Lett. 2016; 147:12-15. doi:10.1016/ 125. Kelly B, King L, Baur L, et al. Monitoring food and non-alcoholic beverage promotions j.econlet.2016.08.003 to children. Obes Rev. 2013. doi:10.1111/obr.12076 109. Ruel M, Minot N, Smith L. Patterns and Determinants of Fruit and Vegetable 126. Knill C, Schulze K, Tosun J. Regulatory Policy Outputs and Impacts: Exploring a Consumption in Sub-Saharan Africa.; 2005. Complex Relationship. Regul Gov. 2012; 6. doi:10.1111/j.1748-5991.2012.01150.x 110. Fall CHD, Abera M, Chopra H, et al. Anthropometric nutritional status, and social and 127. Law Ethiopia - Ethiopian Law Information Portal. https://www.lawethiopia.com/ dietary characteristics of African and Indian adolescents taking part in the TALENT index.php. Accessed April 5, 2021. (Transforming Adolescent Lives through Nutrition) qualitative study. Public Health Nutr. 2021; 24(16):5249-5260. doi:DOI:10.1017/S1368980020001901 111. Aurino E, Fernandes M, Penny ME. The nutrition transition and adolescents’ diets in low- and middle-income countries: a cross-cohort comparison. Public Health Nutr. 2017; 20(1):72-81. doi:10.1017/S1368980016001865 27 CHAPTER 2 Factors influencing obesogenic behaviours of adolescent girls and women in low- and middle-income countries: a qualitative evidence synthesis Ursula Trübswasser Roos Verstraeten Leah Salm Michelle Holdsworth Kaleab Baye Andrew Booth Edith J. M. Feskens Stuart Gillespie Elise F. Talsma Obesity Reviews https://doi.org/10.1111/obr.13163 Chapter 2 INTRODUCTION overweight and obesity in LMIC, most research on obesogenic behaviours has been conducted in high-income countries. Furthermore, previous systematic reviews Adolescent girls and women of reproductive age are particularly vulnerable to focused only on Africa,26–28 on diets of adolescents in LMIC,1 on young children,29,30 ⁠ malnutrition (including undernutrition, micronutrient deficiency, overweight and and on adolescents31,32 or on considerations for interventions to prevent obesity) due to poor dietary intakes,1 inequitable distribution of food within overweight and obesity.21,33 Little of this evidence stems from qualitative households,2 dietary taboos,3 and gender inequality.4 Growth spurts, pregnancy and research26–28 as primarily this prior research was aimed at quantifying the influence lactation during adolescence substantially increase nutrient requirements, making of different drivers. This limits the understanding of the specific factors influencing adolescents even more at risk.5 Furthermore, malnutrition can span generations obesogenic behaviours in LMIC settings,34 which are experiencing rapidly and affect all stages of the lifecycle. For example, women classified as underweight transitioning obesogenic environments and changing behaviours. To address these are more likely to give birth to infants with a low-birth weight.4 Obesity among changing behaviours effectively with interventions throughout the lifecycle, a better mothers can also have adverse health effects on new-borns and increase the risk understanding of how and why adolescent girls and women of reproductive age for childhood obesity.6 (WRA) make their dietary choices is urgently needed. A synthesis of primary qualitative research studies would elicit multiple perspectives, views, beliefs, and Overweight and obesity are rising in every part of the world, with women and priorities in relation to such influencing factors, and would go beyond the existing adolescent girls particularly affected, and no country has successfully reversed this evidence. This review aims to serve this purpose and address these knowledge gaps, trend.7 Globally, the prevalence of adult women with overweight and obesity by synthesizing the qualitative evidence on factors influencing obesogenic increased significantly over a short period of time (from 32% in 2010 to 40% by behaviours among adolescent girls and WRA, specifically in LMIC. 2016).7 This burden is not equally distributed, as more than 70% of all adults with overweight and obesity live in low- and middle-income countries (LMIC).8 For METHODS adolescent girls (aged 15-19 years) in LMIC, more than 10% are classified as having obesity or overweight, with rates either being stagnant or on the rise between 2000 To identify factors influencing obesogenic behaviours in adolescent girls and WRA and 2017.9 This increase in obesity has also been faster compared to adults.10 As (aged 10-49 years old) in LMIC we applied a qualitative evidence synthesis (QES). major risk factors for noncommunicable diseases (NCD), overweight and obesity not QES is an “umbrella term for the methodologies associated with the systematic only affect morbidity and mortality of individuals, but also drive a growing economic review of qualitative research evidence”.35 It refers to all methods that bring burden on health care systems and societies.11,12 together different types of qualitative evidence. In this QES we perform a systematic review following a framework synthesis36 methodology to extract, analyse and Recognised drivers of overweight and obesity in LMIC include increasing synthesise the qualitative data from primary research studies. This method helps urbanization, changing food environments with the expansion of modern retail,13 connect and integrate findings from included primary research studies with existing and growing availability of ultra-processed, energy-dense, nutrient-poor foods.14 theory.36 For our review, it involved two complementary tasks of i) identifying Additionally, rising numbers of women in the workforce increase the demand for existing frameworks and theories and ii) identifying eligible studies.37 The protocol convenience foods and out-of-home consumption.15 Together with reduced was documented according to PRISMA-P guidelines38 and registered a priori to physical activity due to more sedentary lifestyles and less conducive built describe detailed inclusion criteria and analytic methods (PROSPERO environments,16 these factors represent important contributors to overweight and CRD42019134044; available from: https://www.crd.york.ac.uk/prospero/display obesity.17,18 Other contributing factors relate to socio-economic status,19 genetics,20 _record.php?ID=CRD42019134044). The Enhancing Transparency in Reporting the ⁠stress, early-life undernutrition4 and cultural beliefs about body size,21 among Synthesis of Qualitative Research (ENTREQ) statement was followed to report this others.22 There is also evidence that food assistance programs, which aim to reduce qualitative evidence synthesis.39 undernutrition, actually contribute to adult overweight and obesity.23 For adolescents in particular, exposure to food and drink advertising, and the role of the Theoretical framework family/home environment, as well as the school environment, are important influences on overweight and obesity.24,25 We aimed to identify existing frameworks and theories that conceptualised how factors influence the following obesogenic behaviours: unhealthy diets and physical Obesogenic behaviours are promoting or contributing to obesity through unhealthy inactivity. We searched for existing frameworks using a within-topic search40 on diets, physical inactivity, or high sedentary behaviours. Despite the apparent rise of MEDLINE using the below described search strategy (supporting material 1) 30 Qualitative evidence synthesis INTRODUCTION overweight and obesity in LMIC, most research on obesogenic behaviours has been conducted in high-income countries. Furthermore, previous systematic reviews Adolescent girls and women of reproductive age are particularly vulnerable to focused only on Africa,26–28 on diets of adolescents in LMIC,1 on young children,29,30 ⁠ malnutrition (including undernutrition, micronutrient deficiency, overweight and and on adolescents31,32 or on considerations for interventions to prevent obesity) due to poor dietary intakes,1 inequitable distribution of food within overweight and obesity.21,33 Little of this evidence stems from qualitative households,2 dietary taboos,3 and gender inequality.4 Growth spurts, pregnancy and research26–28 as primarily this prior research was aimed at quantifying the influence 2 lactation during adolescence substantially increase nutrient requirements, making of different drivers. This limits the understanding of the specific factors influencing adolescents even more at risk.5 Furthermore, malnutrition can span generations obesogenic behaviours in LMIC settings,34 which are experiencing rapidly and affect all stages of the lifecycle. For example, women classified as underweight transitioning obesogenic environments and changing behaviours. To address these are more likely to give birth to infants with a low-birth weight.4 Obesity among changing behaviours effectively with interventions throughout the lifecycle, a better mothers can also have adverse health effects on new-borns and increase the risk understanding of how and why adolescent girls and women of reproductive age for childhood obesity.6 (WRA) make their dietary choices is urgently needed. A synthesis of primary qualitative research studies would elicit multiple perspectives, views, beliefs, and Overweight and obesity are rising in every part of the world, with women and priorities in relation to such influencing factors, and would go beyond the existing adolescent girls particularly affected, and no country has successfully reversed this evidence. This review aims to serve this purpose and address these knowledge gaps, trend.7 Globally, the prevalence of adult women with overweight and obesity by synthesizing the qualitative evidence on factors influencing obesogenic increased significantly over a short period of time (from 32% in 2010 to 40% by behaviours among adolescent girls and WRA, specifically in LMIC. 2016).7 This burden is not equally distributed, as more than 70% of all adults with overweight and obesity live in low- and middle-income countries (LMIC).8 For METHODS adolescent girls (aged 15-19 years) in LMIC, more than 10% are classified as having obesity or overweight, with rates either being stagnant or on the rise between 2000 To identify factors influencing obesogenic behaviours in adolescent girls and WRA and 2017.9 This increase in obesity has also been faster compared to adults.10 As (aged 10-49 years old) in LMIC we applied a qualitative evidence synthesis (QES). major risk factors for noncommunicable diseases (NCD), overweight and obesity not QES is an “umbrella term for the methodologies associated with the systematic only affect morbidity and mortality of individuals, but also drive a growing economic review of qualitative research evidence”.35 It refers to all methods that bring burden on health care systems and societies.11,12 together different types of qualitative evidence. In this QES we perform a systematic review following a framework synthesis36 methodology to extract, analyse and Recognised drivers of overweight and obesity in LMIC include increasing synthesise the qualitative data from primary research studies. This method helps urbanization, changing food environments with the expansion of modern retail,13 connect and integrate findings from included primary research studies with existing and growing availability of ultra-processed, energy-dense, nutrient-poor foods.14 theory.36 For our review, it involved two complementary tasks of i) identifying Additionally, rising numbers of women in the workforce increase the demand for existing frameworks and theories and ii) identifying eligible studies.37 The protocol convenience foods and out-of-home consumption.15 Together with reduced was documented according to PRISMA-P guidelines38 and registered a priori to physical activity due to more sedentary lifestyles and less conducive built describe detailed inclusion criteria and analytic methods (PROSPERO environments,16 these factors represent important contributors to overweight and CRD42019134044; available from: https://www.crd.york.ac.uk/prospero/display obesity.17,18 Other contributing factors relate to socio-economic status,19 genetics,20 _record.php?ID=CRD42019134044). The Enhancing Transparency in Reporting the s⁠ tress, early-life undernutrition4 and cultural beliefs about body size,21 among Synthesis of Qualitative Research (ENTREQ) statement was followed to report this others.22 There is also evidence that food assistance programs, which aim to reduce qualitative evidence synthesis.39 undernutrition, actually contribute to adult overweight and obesity.23 For adolescents in particular, exposure to food and drink advertising, and the role of the Theoretical framework family/home environment, as well as the school environment, are important influences on overweight and obesity.24,25 We aimed to identify existing frameworks and theories that conceptualised how factors influence the following obesogenic behaviours: unhealthy diets and physical Obesogenic behaviours are promoting or contributing to obesity through unhealthy inactivity. We searched for existing frameworks using a within-topic search40 on diets, physical inactivity, or high sedentary behaviours. Despite the apparent rise of MEDLINE using the below described search strategy (supporting material 1) 31 Chapter 2 together with the following search syntax: framework* OR theor* or model* or Eligibility criteria concept*. We did not limit ourselves to the “Low- and Middle-Income Countries” concept to allow for inclusion of frameworks developed for various contexts.41 This Studies were eligible if they were conducted in a LMIC (using the World Bank scoping search identified six frameworks. Four of them were adaptations of the definition of LMIC as of 201952), were of qualitative nature, and included female socio-ecological framework;42–47 two of the frameworks on physical activity and adolescents or women of reproductive age (10-49 years). The selection of the age sedentary behaviours were structured differently.48,49 None of the individual group was based on the World Health Organization (WHO) definition of adolescents frameworks were sufficiently comprehensive to capture factors influencing (10-19 years) and WRA (15-49 years) and the importance of following a lifecycle obesogenic behaviours.36 We therefore deconstructed the six identified approach. If studies included a broader age range and/or male participants, frameworks44,46–50 into individual constructs and fitted them within the levels of verbatim quotations and/or authors’ interpretation had to be clearly attributable to influence (individual, social, physical, macro) of the socio-ecological framework,45 girls or women aged 10-49 years to be included. Studies with clinical populations which has also been previously adapted for dietary factors in the African context.50 were not included. Phenomena of interest were perceptions related to obesogenic Subsequently, by merging or renaming these constructs, an a priori meta- behaviours and/or potential influencing factors of these behaviours of adolescent framework was developed including a total of 78 constructs across the four levels girls or WRA. Studies had to apply qualitative methods but were only included if of influence (appendix 2.2). Constructs were omitted when they were not applicable qualitative findings were explicitly reported and distinguishable from quantitative to our research question, such as those relating to different age groups (geriatric data, in the case of mixed methods studies. The review was limited to studies syndromes/sarcopenia48). published in English without any restrictions in terms of year of publication. Correspondence, commentaries, and editorials were excluded. Identification of eligible studies Screening process Search strategy All retrieved references were imported into Endnote and, after de-duplication, data To identify eligible studies, searches were conducted in five electronic databases: on references were imported into Microsoft Excel. One reviewer (UT) conducted Web of Science (http://www.webofknowledge.com), SCOPUS (https://www. title and abstract screening following the eligibility criteria and retrieved and scopus.com), CABI abstracts (https://www.ovid.com/product-details.31.html), reviewed full texts of selected references for inclusion. To ensure the quality of MEDLINE (Pubmed; http://www/ncbi.nlm.nih.gob/pubmed), and Psyc-INFO inclusion, independent reviews at title and abstract screening (28% by KB) and full (https://www.ebsco.com/products/research-databases/apa-psycinfo). Google text screening (22% by KB and LS) were performed by co-authors. In case of Scholar was searched for grey literature. Subsequently, citation searches were disagreement, discrepancies in selection of references were discussed between conducted for all included references on Google Scholar. Additional eligible studies reviewers. In case of doubt at any stage, the record was carried forward to the were identified from the reference lists of included studies. The initial search subsequent stage. Reasons for exclusion were recorded at every stage of the strategy was developed in MEDLINE using the Setting, Perspective, Interest, screening (Figure 2.1). phenomenon of, Comparison and Evaluation (SPICE) model51 combining search terms for setting (LMIC), perspective (adolescent girls and women of reproductive age, 10-49 years of age), phenomenon of interest (perceptions and/or potential influencing factors of obesogenic behaviours) and evaluation (themes identified from original qualitative research). Scoping searches were conducted in MEDLINE to refine the search strategy, using database-specific indexing terms. The search syntax was further adapted to the specific requirements of each database. A social science librarian provided input into the search strategy. The final search syntax included text words and MeSH terms (appendix 2.1). The search was conducted in May 2019, citation alerts were set up in all the databases and the search was updated in January 2020 to ensure inclusion of relevant publications since the first search. 32 Qualitative evidence synthesis together with the following search syntax: framework* OR theor* or model* or Eligibility criteria concept*. We did not limit ourselves to the “Low- and Middle-Income Countries” concept to allow for inclusion of frameworks developed for various contexts.41 This Studies were eligible if they were conducted in a LMIC (using the World Bank scoping search identified six frameworks. Four of them were adaptations of the definition of LMIC as of 201952), were of qualitative nature, and included female socio-ecological framework;42–47 two of the frameworks on physical activity and adolescents or women of reproductive age (10-49 years). The selection of the age sedentary behaviours were structured differently.48,49 None of the individual group was based on the World Health Organization (WHO) definition of adolescents 2 frameworks were sufficiently comprehensive to capture factors influencing (10-19 years) and WRA (15-49 years) and the importance of following a lifecycle obesogenic behaviours.36 We therefore deconstructed the six identified approach. If studies included a broader age range and/or male participants, frameworks44,46–50 into individual constructs and fitted them within the levels of verbatim quotations and/or authors’ interpretation had to be clearly attributable to influence (individual, social, physical, macro) of the socio-ecological framework,45 girls or women aged 10-49 years to be included. Studies with clinical populations which has also been previously adapted for dietary factors in the African context.50 were not included. Phenomena of interest were perceptions related to obesogenic Subsequently, by merging or renaming these constructs, an a priori meta- behaviours and/or potential influencing factors of these behaviours of adolescent framework was developed including a total of 78 constructs across the four levels girls or WRA. Studies had to apply qualitative methods but were only included if of influence (appendix 2.2). Constructs were omitted when they were not applicable qualitative findings were explicitly reported and distinguishable from quantitative to our research question, such as those relating to different age groups (geriatric data, in the case of mixed methods studies. The review was limited to studies syndromes/sarcopenia48). published in English without any restrictions in terms of year of publication. Correspondence, commentaries, and editorials were excluded. Identification of eligible studies Screening process Search strategy All retrieved references were imported into Endnote and, after de-duplication, data To identify eligible studies, searches were conducted in five electronic databases: on references were imported into Microsoft Excel. One reviewer (UT) conducted Web of Science (http://www.webofknowledge.com), SCOPUS (https://www. title and abstract screening following the eligibility criteria and retrieved and scopus.com), CABI abstracts (https://www.ovid.com/product-details.31.html), reviewed full texts of selected references for inclusion. To ensure the quality of MEDLINE (Pubmed; http://www/ncbi.nlm.nih.gob/pubmed), and Psyc-INFO inclusion, independent reviews at title and abstract screening (28% by KB) and full (https://www.ebsco.com/products/research-databases/apa-psycinfo). Google text screening (22% by KB and LS) were performed by co-authors. In case of Scholar was searched for grey literature. Subsequently, citation searches were disagreement, discrepancies in selection of references were discussed between conducted for all included references on Google Scholar. Additional eligible studies reviewers. In case of doubt at any stage, the record was carried forward to the were identified from the reference lists of included studies. The initial search subsequent stage. Reasons for exclusion were recorded at every stage of the strategy was developed in MEDLINE using the Setting, Perspective, Interest, screening (Figure 2.1). phenomenon of, Comparison and Evaluation (SPICE) model51 combining search terms for setting (LMIC), perspective (adolescent girls and women of reproductive age, 10-49 years of age), phenomenon of interest (perceptions and/or potential influencing factors of obesogenic behaviours) and evaluation (themes identified from original qualitative research). Scoping searches were conducted in MEDLINE to refine the search strategy, using database-specific indexing terms. The search syntax was further adapted to the specific requirements of each database. A social science librarian provided input into the search strategy. The final search syntax included text words and MeSH terms (appendix 2.1). The search was conducted in May 2019, citation alerts were set up in all the databases and the search was updated in January 2020 to ensure inclusion of relevant publications since the first search. 33 Chapter 2 Data extraction and coding References identified through Additional references identified Data extraction of the following descriptive characteristics was performed by UT: database search (n=8670) through other sources (n= 232) country/countries in which the study was conducted, income level of the country, setting of the study, characteristics of the participants (including number, age, Duplicates (n=3555) gender in case of inclusion of a male population), and type of obesogenic behaviour. Excluded (n=3854) The a priori defined meta-framework (appendix 2.2) was used to code data, Not attributable to or not WRA n=902 including verbatim quotations from participants as well as author interpretations, References after removal of Not LMIC n=353 on influencing factors. Coding was performed independently by UT and the review duplicates Not obesogenic behaviour n= 2024 (n=5115) Not primary research n=34 team (KB, LS, MH and RV) in NVivo (12.5.0), and followed a stepwise approach. First, Not in English n=26 the coding framework was piloted by coding data from two papers (UT, RV, MH, LS, Duplicates n=515 KB) which was further refined based on discussions. Subsequently data of all included references were coded against the constructs of the meta-framework Excluded (n=819) Not attributable to or not WRA n=62 Finally, 11 of these coded references were checked by co-reviewers to ensure Not LMIC n=164 quality control and harmonization of coding. Discrepancies were discussed and Abstracts of references screened Not obesogenic behaviour n= 368 (n=1261) addressed in coding the remaining references. Not qualitative research n=165 Not in English n=1 Not primary study n=57 Quality assessment Duplicates n=2 Methodological quality of included references was assessed using the Critical Appraisals Skills Programme (CASP) checklist for qualitative research assessing validity of the results, the analysis and reporting of the data and the value of the Excluded (n=608) research.53 One reviewer (UT) assessed all references and to ensure a consistent Full text of references reviewed Not attributable to or not AWRA n=173 application of the CASP criteria, two reviewers (AB and RV) independently assessed for eligibility Not LMIC n=82 (n=671) Not obesogenic behaviour n= 183 10% of the verdicts. Studies were not excluded based on their quality, but a Not qualitative research n=121 sensitivity analysis was conducted to evaluate the relative contribution of quality on Not in English or no access n=49 the review findings.54 Eligible references for data Data analysis and synthesis extraction (n=63) Additional references from search Jan 2020 The analysis used a deductive approach by systematically coding data with the a (n=9) priori constructs included in the meta-framework (appendix 2.2) and was complemented by an inductive approach when data did not fit the meta- References included in the review framework. All coded quotations, including memos written throughout the coding (n=72) reporting on a total of 71 studies process, were then analysed to identify themes inductively. Themes were then iteratively rearranged by refining and merging overlapping themes. Based on themes, a summary of findings was prepared for review by all authors. Identified themes were visualised in the data-driven socio-ecological framework (Figure 2.2). Figure 2.1. PRIMSA chart Appendix 2.3 provides an overview of all identified themes and studies supporting them. Sensitivity analyses were conducted for a number of sub-categories, such as study quality (high or low), population (adolescent girls or adult women), continent 34 Qualitative evidence synthesis Data extraction and coding References identified through Additional references identified Data extraction of the following descriptive characteristics was performed by UT: database search (n=8670) through other sources (n= 232) country/countries in which the study was conducted, income level of the country, setting of the study, characteristics of the participants (including number, age, Duplicates (n=3555) gender in case of inclusion of a male population), and type of obesogenic behaviour. 2 Excluded (n=3854) The a priori defined meta-framework (appendix 2.2) was used to code data, Not attributable to or not WRA n=902 including verbatim quotations from participants as well as author interpretations, References after removal of Not LMIC n=353 on influencing factors. Coding was performed independently by UT and the review duplicates Not obesogenic behaviour n= 2024 (n=5115) Not primary research n=34 team (KB, LS, MH and RV) in NVivo (12.5.0), and followed a stepwise approach. First, Not in English n=26 the coding framework was piloted by coding data from two papers (UT, RV, MH, LS, Duplicates n=515 KB) which was further refined based on discussions. Subsequently data of all included references were coded against the constructs of the meta-framework Excluded (n=819) Not attributable to or not WRA n=62 Finally, 11 of these coded references were checked by co-reviewers to ensure Not LMIC n=164 quality control and harmonization of coding. Discrepancies were discussed and Abstracts of references screened Not obesogenic behaviour n= 368 (n=1261) addressed in coding the remaining references. Not qualitative research n=165 Not in English n=1 Not primary study n=57 Quality assessment Duplicates n=2 Methodological quality of included references was assessed using the Critical Appraisals Skills Programme (CASP) checklist for qualitative research assessing validity of the results, the analysis and reporting of the data and the value of the Excluded (n=608) research.53 One reviewer (UT) assessed all references and to ensure a consistent Full text of references reviewed Not attributable to or not AWRA n=173 application of the CASP criteria, two reviewers (AB and RV) independently assessed for eligibility Not LMIC n=82 (n=671) Not obesogenic behaviour n= 183 10% of the verdicts. Studies were not excluded based on their quality, but a Not qualitative research n=121 sensitivity analysis was conducted to evaluate the relative contribution of quality on Not in English or no access n=49 the review findings.54 Eligible references for data Data analysis and synthesis extraction (n=63) Additional references from search Jan 2020 The analysis used a deductive approach by systematically coding data with the a (n=9) priori constructs included in the meta-framework (appendix 2.2) and was complemented by an inductive approach when data did not fit the meta- References included in the review framework. All coded quotations, including memos written throughout the coding (n=72) reporting on a total of 71 studies process, were then analysed to identify themes inductively. Themes were then iteratively rearranged by refining and merging overlapping themes. Based on themes, a summary of findings was prepared for review by all authors. Identified themes were visualised in the data-driven socio-ecological framework (Figure 2.2). Figure 2.1. PRIMSA chart Appendix 2.3 provides an overview of all identified themes and studies supporting them. Sensitivity analyses were conducted for a number of sub-categories, such as study quality (high or low), population (adolescent girls or adult women), continent 35 Chapter 2 (Africa, Asia, or South America) and setting (rural or urban) in order to identify Table 2.1. General characteristics – Number of studies themes specific to those categories. This was conducted by bringing together and analysing data within these subgroups; quotes were rearranged by subgroup Characteristics Africa (n) Asia (n) South America (n) highlighting more granular findings. The additional eligible references identified through the search update were added to the synthesis in January 2020; they were Phenomenon coded and analysed for new emerging themes or for strengthening existing ones Diet 6 18 8 and underwent quality assessment.55 Physical activity 6 10 1 Diet and physical activity 11 6 5 RESULTS Population Adolescents 13 21 8 Results of the data synthesis are presented by level of the socio-ecologic model, i.e. Women 6 9 5 individual, social, physical, and macro level and supported with quotations of Adolescents and women 4 4 1 participants (in quotation marks) as well as author interpretations from included Setting references (reference, country, and population). Findings of the sensitivity analyses Urban 17 25 8 are mentioned whenever we found a difference. Additional quotations are provided Rural 4 2 2 in appendix 2.4. Urban and rural 2 5 4 Not specified 0 2 0 Income level of the country General characteristics Low income 1 1 0 Lower-middle income 8 14 4 The full text review resulted in a total of 72 included references reporting on a total Upper-middle income 14 19 10 of 71 studies from 27 different countries, with 23 studies conducted in Africa, 34 in Asia, and 14 in South America. Figure 2.1 shows details of references screened, Countries South Africa Iran (11) Mexico (5) included, and excluded and Table 2.1 the general characteristics of the included (12) India (7) Costa Rica (3) Cameroon (2) Indonesia (4) Brazil (2) studies. Ghana (2) China (2) Guatemala (2) Kenya (2) Turkey (2) El Salvador (1) Forty-one studies were conducted with adolescent girls only, 24 with WRA and six Botswana (1) Malaysia (2) Bolivia (1) with both. Thirty-two studies focused on factors influencing dietary behaviours, 17 Cape Verde (1) Nepal (1) on factors influencing physical activity and 22 on factors influencing both Libya (1) Pakistan (1) behaviours. Most studies were conducted in urban areas (n=50), 26 studies were Morocco (1) Samoa (1) conducted in low and lower-middle and 45 in upper-middle income countries. Uganda (1) Sri Lanka (1) Tonga (1) Bangladesh (1) TOTAL 23 34 14 Factors influencing obesogenic behaviours at the individual level Attribution A common perception among participants was considering one’s health or body weight as a destiny114, 137 or “God’s will”103, or blaming their current weight on their own mothers’ concerns about their low childhood weight. Obesity and individual body weight were also perceived as beyond an individual’s control due to genetic predisposition.104, 114, 145, 171 36 Qualitative evidence synthesis (Africa, Asia, or South America) and setting (rural or urban) in order to identify Table 2.1. General characteristics – Number of studies themes specific to those categories. This was conducted by bringing together and analysing data within these subgroups; quotes were rearranged by subgroup Characteristics Africa (n) Asia (n) South America (n) highlighting more granular findings. The additional eligible references identified through the search update were added to the synthesis in January 2020; they were Phenomenon coded and analysed for new emerging themes or for strengthening existing ones Diet 6 18 8 2 and underwent quality assessment.55 Physical activity 6 10 1 Diet and physical activity 11 6 5 RESULTS Population Adolescents 13 21 8 Results of the data synthesis are presented by level of the socio-ecologic model, i.e. Women 6 9 5 individual, social, physical, and macro level and supported with quotations of Adolescents and women 4 4 1 participants (in quotation marks) as well as author interpretations from included Setting references (reference, country, and population). Findings of the sensitivity analyses Urban 17 25 8 are mentioned whenever we found a difference. Additional quotations are provided Rural 4 2 2 in appendix 2.4. Urban and rural 2 5 4 Not specified 0 2 0 Income level of the country General characteristics Low income 1 1 0 Lower-middle income 8 14 4 The full text review resulted in a total of 72 included references reporting on a total Upper-middle income 14 19 10 of 71 studies from 27 different countries, with 23 studies conducted in Africa, 34 in Asia, and 14 in South America. Figure 2.1 shows details of references screened, Countries South Africa Iran (11) Mexico (5) included, and excluded and Table 2.1 the general characteristics of the included (12) India (7) Costa Rica (3) Cameroon (2) Indonesia (4) Brazil (2) studies. Ghana (2) China (2) Guatemala (2) Kenya (2) Turkey (2) El Salvador (1) Forty-one studies were conducted with adolescent girls only, 24 with WRA and six Botswana (1) Malaysia (2) Bolivia (1) with both. Thirty-two studies focused on factors influencing dietary behaviours, 17 Cape Verde (1) Nepal (1) on factors influencing physical activity and 22 on factors influencing both Libya (1) Pakistan (1) behaviours. Most studies were conducted in urban areas (n=50), 26 studies were Morocco (1) Samoa (1) conducted in low and lower-middle and 45 in upper-middle income countries. Uganda (1) Sri Lanka (1) Tonga (1) Bangladesh (1) TOTAL 23 34 14 Factors influencing obesogenic behaviours at the individual level Attribution A common perception among participants was considering one’s health or body weight as a destiny114, 137 or “God’s will”103, or blaming their current weight on their own mothers’ concerns about their low childhood weight. Obesity and individual body weight were also perceived as beyond an individual’s control due to genetic predisposition.104, 114, 145, 171 37 Chapter 2 Some even believed that “nothing can be done about it” when overweight is Subjective norms inherited. (Ghana, WRA)104 Adolescents did not perceive obesity as an immediate threat, but something older Perceived body weight. Overweight was perceived as a sign of a healthy, wealthy people struggle with, only to be faced in the future or when confronted with health and happy life,114, 119, 122, 130, 138, 151, 159 and as a symbol of beauty.104, 125, 139, 166 Thinness problems.116, 117, 218, 137, 150, 155. was conversely associated with illness.125, 130, 151, 170 For adolescent girls, thinness was the ideal in two studies,131, 172 while in another study, thin girls were teased for Awareness looking androgynous.147 A higher body weight was also expected for older and married women, reflecting dignity, maturity,104, 130, 138, 166 motherhood or Participants in the included studies were aware of the importance of physical marriage.114, 130, 138, 155 activity 101, 125, 139 149 and mental health,157 as well as the potential negative effects of In Africa, a larger body was associated with health, attractiveness, and wealth, physical inactivity.108 However, the perception that physical activity was only whereas in Asia and South America thinner and “feminine” looking bodies were relevant for weight loss was also revealed.124, 170 more socially desirable. “I don’t remember anybody who I’ve come across talking about exercising. Only when they want to lose weight, then they want to exercise.” (South Africa, Gender. Women and girls were expected to look beautiful and feminine.131,139, 146, WRA)170 148, 156, 166 Participants were also concerned about which types of physical activity Awareness of the importance of healthy diets included the importance of dietary were gender-appropriate, making vigorous or outdoor activities less accessible for diversity,132, 135 eating fresh or natural foods,116, 117, 151 while avoiding fatty, salty, girls.147, 149, 101, 128, 161 sugary or fast foods.114, 116, 150 Healthy diet misconceptions were related to “Soccer is for men, ballet is for women, this is like saying strength and delicacy...” consuming snacks and skipping meals, which were perceived as positive due to (Costa Rica, adolescents) 147 eating less.111 Some perceived that exercise could replace a healthy diet,172 while Girls were also not expected to show muscles,139 look sweaty, messy, or tanned,139, others preferred to diet instead of engaging in physical activity.148 147, 157, 162 since these were signs of poverty or masculinity. Menstruation,157 school Findings from the sensitivity analysis revealed that only participants from rural uniforms and religious dress codes also kept women and girls from being active.143, settings associated risks of underweight, food borne diseases and the importance 145, 152 Furthermore, women and girls were less likely to engage in physical activity of food and micronutrients for growth with healthy diets.120, 122, 160 163, 167 due to prohibition in some countries on them being unaccompanied in public.101, 103, 111, 123 136, 143, 152, 157 In addition, women and girls were faced with sexual harassment Food safety concerns and objectification for wearing exercise clothes.136, 147, 171 Food safety concerns were related to food adulteration, expiry dates, hormones and Age. Physical activity was perceived as more appropriate for schoolgirls and not for pesticides or other chemicals contained in foods.102, 109, 117, 135, 144 Overall, adult women.125, 151, 155, 170, 171 This perception that any sport or physical activity was (un)healthiness of food was perceived more in relation to food safety and hygiene only appropriate for young people was most dominant in Africa. than nutritional quality per se.163 Participants perceived packaged foods as the safer Exercise was seen to be associated with what children and young people did, and option,110, 111 which could limit fruit and vegetable consumption.134, 153 it was not acceptable for women (particularly married women) to be seen “A snack which is produced by dirty hands contains microbes and can cause exercising. (South Africa, WRA and adolescents)170 illness. […] Therefore, I prefer packed puffs and chips to traditional bread and cheese because they are safer”. (Iran, adolescents) 110 Social status. Sedentary lifestyle and car ownership were associated with higher Food prepared outside the home was generally considered unhealthy while home- socio-economic status,123, 125, 139 while active transport was stigmatised as being for cooked food was considered safer.109, 111, 120, 135, 153, 164 Food seen as unsafe was also poor people.123 Certain types of foods were also associated with higher social status. perceived as tasty, so that participants ate food they considered unhealthy,135 Traditional foods, homegrown vegetables or packed meals taken from home to notwithstanding food safety concerns.168 The sensitivity analysis revealed that in school were considered less socially favourable.113, 135, 137, 140, 166 However, an South America, food safety concerns were only expressed in relation to additives abundance of food,131 eating out, eating packed food, modern snacks were seen as and processing level, whereas in Africa and Asia, hygiene concerns around street a sign of wealth.111, 113, 114, 140, 146, 163, 166, 167 Particularly for adolescents, unhealthy food were often raised. foods were perceived as more popular, while eating healthily made them feel like an outcast.113 38 Qualitative evidence synthesis Some even believed that “nothing can be done about it” when overweight is Subjective norms inherited. (Ghana, WRA)104 Adolescents did not perceive obesity as an immediate threat, but something older Perceived body weight. Overweight was perceived as a sign of a healthy, wealthy people struggle with, only to be faced in the future or when confronted with health and happy life,114, 119, 122, 130, 138, 151, 159 and as a symbol of beauty.104, 125, 139, 166 Thinness problems.116, 117, 218, 137, 150, 155. was conversely associated with illness.125, 130, 151, 170 For adolescent girls, thinness was the ideal in two studies,131, 172 while in another study, thin girls were teased for 2 Awareness looking androgynous.147 A higher body weight was also expected for older and married women, reflecting dignity, maturity,104, 130, 138, 166 motherhood or Participants in the included studies were aware of the importance of physical marriage.114, 130, 138, 155 activity 101, 125, 139 149 and mental health,157 as well as the potential negative effects of In Africa, a larger body was associated with health, attractiveness, and wealth, physical inactivity.108 However, the perception that physical activity was only whereas in Asia and South America thinner and “feminine” looking bodies were relevant for weight loss was also revealed.124, 170 more socially desirable. “I don’t remember anybody who I’ve come across talking about exercising. Only when they want to lose weight, then they want to exercise.” (South Africa, Gender. Women and girls were expected to look beautiful and feminine.131,139, 146, WRA)170 148, 156, 166 Participants were also concerned about which types of physical activity Awareness of the importance of healthy diets included the importance of dietary were gender-appropriate, making vigorous or outdoor activities less accessible for diversity,132, 135 eating fresh or natural foods,116, 117, 151 while avoiding fatty, salty, girls.147, 149, 101, 128, 161 sugary or fast foods.114, 116, 150 Healthy diet misconceptions were related to “Soccer is for men, ballet is for women, this is like saying strength and delicacy...” consuming snacks and skipping meals, which were perceived as positive due to (Costa Rica, adolescents) 147 eating less.111 Some perceived that exercise could replace a healthy diet,172 while Girls were also not expected to show muscles,139 look sweaty, messy, or tanned,139, others preferred to diet instead of engaging in physical activity.148 147, 157, 162 since these were signs of poverty or masculinity. Menstruation,157 school Findings from the sensitivity analysis revealed that only participants from rural uniforms and religious dress codes also kept women and girls from being active.143, settings associated risks of underweight, food borne diseases and the importance 145, 152 Furthermore, women and girls were less likely to engage in physical activity of food and micronutrients for growth with healthy diets.120, 122, 160 163, 167 due to prohibition in some countries on them being unaccompanied in public.101, 103, 111, 123 136, 143, 152, 157 In addition, women and girls were faced with sexual harassment Food safety concerns and objectification for wearing exercise clothes.136, 147, 171 Food safety concerns were related to food adulteration, expiry dates, hormones and Age. Physical activity was perceived as more appropriate for schoolgirls and not for pesticides or other chemicals contained in foods.102, 109, 117, 135, 144 Overall, adult women.125, 151, 155, 170, 171 This perception that any sport or physical activity was (un)healthiness of food was perceived more in relation to food safety and hygiene only appropriate for young people was most dominant in Africa. than nutritional quality per se.163 Participants perceived packaged foods as the safer Exercise was seen to be associated with what children and young people did, and option,110, 111 which could limit fruit and vegetable consumption.134, 153 it was not acceptable for women (particularly married women) to be seen “A snack which is produced by dirty hands contains microbes and can cause exercising. (South Africa, WRA and adolescents)170 illness. […] Therefore, I prefer packed puffs and chips to traditional bread and cheese because they are safer”. (Iran, adolescents) 110 Social status. Sedentary lifestyle and car ownership were associated with higher Food prepared outside the home was generally considered unhealthy while home- socio-economic status,123, 125, 139 while active transport was stigmatised as being for cooked food was considered safer.109, 111, 120, 135, 153, 164 Food seen as unsafe was also poor people.123 Certain types of foods were also associated with higher social status. perceived as tasty, so that participants ate food they considered unhealthy,135 Traditional foods, homegrown vegetables or packed meals taken from home to notwithstanding food safety concerns.168 The sensitivity analysis revealed that in school were considered less socially favourable.113, 135, 137, 140, 166 However, an South America, food safety concerns were only expressed in relation to additives abundance of food,131 eating out, eating packed food, modern snacks were seen as and processing level, whereas in Africa and Asia, hygiene concerns around street a sign of wealth.111, 113, 114, 140, 146, 163, 166, 167 Particularly for adolescents, unhealthy food were often raised. foods were perceived as more popular, while eating healthily made them feel like an outcast.113 39 Chapter 2 Motivation and habit strength current habits, such as skipping breakfast and the tendency to overeat once people attained higher socio-economic status in adulthood.114, 138 For adolescents, financial Participants emphasised the importance of making physical activity and healthy autonomy was associated with the amount of pocket money they received from dietary practices a habit from childhood onwards.109, 114, 116, 124, 136, 137, 138, 149 At the their parents. Adolescents from poorer families did not tend to receive pocket same time, unhealthy habits engrained from childhood were difficult to change for money,105 while most parents who gave their adolescent children pocket money adults.114, 138 Adolescent girls’ reported a preference for indoor, sedentary activities were not concerned with how it was used106, 120, 158. involving screen time on different media devices, and a tendency to laziness, which kept them from engaging in physical activity,101, 111, 129, 152, 154, 157, 162, 165, 166 while adult Factors influencing obesogenic behaviours at the social level women struggled to establish good habits due to lack of time.136 Motivations to lose weight, eat healthily or engage in physical activity were mostly related to an Family environment experience of poor health, a disease diagnosis114, 128, 155 or the desire to look beautiful.137, 167, 169 Traditional gender roles in the household, such as cooking for the family, tempted “I am a fast food lover but the dream of being skinny forces me to have self- adult women to eat more,138 and taking care of children kept women from engaging control. In my age, appearance is the most important concern for a girl.” in physical activity.128 Prioritizing and adapting to the husband and children’s dietary (Pakistan, adolescents)167 preferences has also been reported.109, 126, 144 While women would prefer home- cooked meals, they agreed to eat at restaurants at children’s request126 or Taste, satisfaction, and pleasure previously vegetarian women would start eating meat if their husband was not vegetarian.109 Taste was an important factor in adolescents and women’s dietary choices. Fast “…We do not eat green vegetables now. My husband does not like to eat.” (India, foods were perceived as tasty110, 114, 132 due to their combination of salty, sweet and, WRA)109 sometimes, artificial flavours,111, 117, 146, 164, 165 which made unprocessed foods such For adult women, time constraints were also a major factor given their traditional as fruit and vegetables less tasty or appealing to participants.117 roles in the family and household.128, 136, 141 “Nowadays people don’t like taking the traditional foods, they despise the ‘mboga’ (green vegetables), they say it’s not sweet. So they prefer taking the For adolescents, parental support and parenting style had major impacts on junk food like pizzas.” (165, Kenya, adolescents) obesogenic behaviours. For physical activity, parents were either supportive133, 141, In addition to taste, attractive and colourful packaging of snack food was a 162 or dissuasive,135, 136, 147, 149, 152, 156, 170 financially or emotionally. Overall, temptation.137, 146 While adolescents mostly referred to experimenting with new adolescents reported that they had limited control over their own schedules and tastes of fast and snack foods,111, 140, 164, 166, 168 women associated tastiness with diets. Adolescents’ diets were mostly perceived to be positively influenced by meat, fried foods, traditional or spicy dishes.102, 116, 118, 132, 151 In urban settings, parental habits, through the information they provided about healthy diets,101, 113, participants put a stronger emphasis on taste, while for rural participants foods 172 the foods provided or prepared at home117, 120, 158, 165, 167, 168 or meals the primarily had to satisfy their appetite. adolescents shared together with their families.146 Mothers prepared most of the Pleasure and fun were important factors, particularly for physical activity. Lower food consumed at home120, 131, 132, 155, 158, 167 and therefore exerted the strongest intensity physical activity was associated with more fun.125 Having fun with friends influence. Overall, mothers cared about their children’s diets and prepared food for or making new friends while being physically active was also an important them for school.132, 167 motivating factor.101, 139 “When we are with parents, we eat healthy foods, they don’t allow us to eat junk foods when we are at home.” (India, adolescents)120 Socio-economic status However, parents were also seen as negative role models with regard to diets102, 103, 124, 137, 166, 171 or being too busy to prepare food at home.146, 158, 165 Affordability of physical activity was influenced by the cost of classes and membership fees for recreation facilities.147, 152 Healthy diets were seen as Academic pressure unaffordable; as fruit, vegetables, meat and wholegrain cereal were perceived as more expensive than staples,125, 159, 163, 171, 172 snacks or fast foods.111, 117, 164, 165, 167 Adolescents in all studies seemed to struggle with lack of time due to academic Food insecurity during childhood was perceived as having a lasting impact on pressure from the school or parents, which affected time available for engaging in 40 Qualitative evidence synthesis Motivation and habit strength current habits, such as skipping breakfast and the tendency to overeat once people attained higher socio-economic status in adulthood.114, 138 For adolescents, financial Participants emphasised the importance of making physical activity and healthy autonomy was associated with the amount of pocket money they received from dietary practices a habit from childhood onwards.109, 114, 116, 124, 136, 137, 138, 149 At the their parents. Adolescents from poorer families did not tend to receive pocket same time, unhealthy habits engrained from childhood were difficult to change for money,105 while most parents who gave their adolescent children pocket money adults.114, 138 Adolescent girls’ reported a preference for indoor, sedentary activities were not concerned with how it was used106, 120, 158. 2 involving screen time on different media devices, and a tendency to laziness, which kept them from engaging in physical activity,101, 111, 129, 152, 154, 157, 162, 165, 166 while adult Factors influencing obesogenic behaviours at the social level women struggled to establish good habits due to lack of time.136 Motivations to lose weight, eat healthily or engage in physical activity were mostly related to an Family environment experience of poor health, a disease diagnosis114, 128, 155 or the desire to look beautiful.137, 167, 169 Traditional gender roles in the household, such as cooking for the family, tempted “I am a fast food lover but the dream of being skinny forces me to have self- adult women to eat more,138 and taking care of children kept women from engaging control. In my age, appearance is the most important concern for a girl.” in physical activity.128 Prioritizing and adapting to the husband and children’s dietary (Pakistan, adolescents)167 preferences has also been reported.109, 126, 144 While women would prefer home- cooked meals, they agreed to eat at restaurants at children’s request126 or Taste, satisfaction, and pleasure previously vegetarian women would start eating meat if their husband was not vegetarian.109 Taste was an important factor in adolescents and women’s dietary choices. Fast “…We do not eat green vegetables now. My husband does not like to eat.” (India, foods were perceived as tasty110, 114, 132 due to their combination of salty, sweet and, WRA)109 sometimes, artificial flavours,111, 117, 146, 164, 165 which made unprocessed foods such For adult women, time constraints were also a major factor given their traditional as fruit and vegetables less tasty or appealing to participants.117 roles in the family and household.128, 136, 141 “Nowadays people don’t like taking the traditional foods, they despise the ‘mboga’ (green vegetables), they say it’s not sweet. So they prefer taking the For adolescents, parental support and parenting style had major impacts on junk food like pizzas.” (165, Kenya, adolescents) obesogenic behaviours. For physical activity, parents were either supportive133, 141, In addition to taste, attractive and colourful packaging of snack food was a 162 or dissuasive,135, 136, 147, 149, 152, 156, 170 financially or emotionally. Overall, temptation.137, 146 While adolescents mostly referred to experimenting with new adolescents reported that they had limited control over their own schedules and tastes of fast and snack foods,111, 140, 164, 166, 168 women associated tastiness with diets. Adolescents’ diets were mostly perceived to be positively influenced by meat, fried foods, traditional or spicy dishes.102, 116, 118, 132, 151 In urban settings, parental habits, through the information they provided about healthy diets,101, 113, participants put a stronger emphasis on taste, while for rural participants foods 172 the foods provided or prepared at home117, 120, 158, 165, 167, 168 or meals the primarily had to satisfy their appetite. adolescents shared together with their families.146 Mothers prepared most of the Pleasure and fun were important factors, particularly for physical activity. Lower food consumed at home120, 131, 132, 155, 158, 167 and therefore exerted the strongest intensity physical activity was associated with more fun.125 Having fun with friends influence. Overall, mothers cared about their children’s diets and prepared food for or making new friends while being physically active was also an important them for school.132, 167 motivating factor.101, 139 “When we are with parents, we eat healthy foods, they don’t allow us to eat junk foods when we are at home.” (India, adolescents)120 Socio-economic status However, parents were also seen as negative role models with regard to diets102, 103, 124, 137, 166, 171 or being too busy to prepare food at home.146, 158, 165 Affordability of physical activity was influenced by the cost of classes and membership fees for recreation facilities.147, 152 Healthy diets were seen as Academic pressure unaffordable; as fruit, vegetables, meat and wholegrain cereal were perceived as more expensive than staples,125, 159, 163, 171, 172 snacks or fast foods.111, 117, 164, 165, 167 Adolescents in all studies seemed to struggle with lack of time due to academic Food insecurity during childhood was perceived as having a lasting impact on pressure from the school or parents, which affected time available for engaging in 41 Chapter 2 physical activity.101, 103, 107, 124, 129, 145, 152, 154, 156, 161, 162, 165, 172 They also reported a lack 138, 145, 149, 152, 154, 162, 171 were lacking equipment,101,125, 128 were perceived dirty136 or of time to prepare or pack food for school,141 forcing them to skip meals107, 120, 164, inappropriate for women in terms of open hours or equipment.136, 154 Access to 166, 168 or displace them with snacks.111 In addition to the school, parents put sport facilities was also limited due to lack of transport,166 distance 101 or pressure on their children to get good grades, prioritizing education over physical membership fees.101, 125, 128, 152, 154, 166 activity as a means to help their children escape poverty.136, 139 “My family that always encouraged me to do exercise from childhood to high Safety. Getting to sport facilities or freely moving in public spaces were generally school, at the first year of high school told me: now the time for exercise is over. perceived as unsafe. Free spaces, such as parks, beaches were not seen as safe due It is the time to study!” (Iran, WRA)136 to crime, dogs, traffic, or human trafficking.101, 123, 128, 129, 136, 145, 149, 154, 159, 161, 162, 166, While lack of time, both generally and related to school, was an issue for 171 adolescents in all three continents, pressure from parents and the education system The built environment was a major factor as most of the facilities like parks and featured only in Asia. playgrounds are not accessible or are not well managed. There is hardly any space for footpaths in Kerala, much of which is encroached by vehicle parking. Peer influence Rain, traffic, and stray dogs are leading people to walk early in the morning and with a companion. (India, WRA)128 In most cases, peer pressure to join in with eating and sharing food did not For women, girls, and parents there was also a fear of sexual violence, assault101, 139, encourage healthy eating.113, 150, 169 One study found that peer influence was 161 or of getting kidnapped.172 positive when adolescent girls exchanged knowledge about foods that could Two studies reported changes over time, when playing on the street was safe and contribute to weight gain.141 The amount of time spent with peers affected the accessible, compared to the densely built environment of the present.152, 170 The increasing influence peers exerted in comparison to parents. Particularly, spending sensitivity analysis revealed that while rural areas offered more opportunities for leisure time with friends or studying together was often associated with eating out, active transport, they lacked facilities and opportunities for different types of eating snacks, street, or fast food,104, 110, 111, 117, 130, 135, 158 which was often the only physical activity. thing adolescent girls felt they could control in their otherwise busy, overscheduled lives.168 Availability of and access to food. From most studies, it was apparent that Being in the social network of friends was expressed as one of the main factors availability of healthy options was perceived as limited while fast and snack foods causing unhealthy eating habits. In some cases, students declared that when were widely available.106, 111, 112, 120, 121, 132, 142, 145, 160, 164, 165, 171, 172 they go out with their friends, they eat lot of junk foods as a routine way of social Fruit and vegetables were perceived as less available in peri-urban and urban areas interaction. (Iran, adolescents)106 than in rural areas.109, 134 Unhealthy foods were also perceived as cheaper,165, 172 and For physical activity, peers also played an important role in encouraging adolescents available in small shops that were easily accessible in most neighbourhoods.109, 112, to be more active101, 163 or more sedentary.165 Meeting friends or making new 138 Supermarkets and open markets, which had cheaper and healthier options friends as part of physical activity motivated girls.101, 139, 162 For adult women, having available such as fruit and vegetables were often distant.112, 138, 160, 166 a social network and friends with whom to engage in physical activity was With large supermarkets located farther away from home, families regularly motivating.123 Not having a supportive network or friends, could be detrimental to depend on neighbourhood tienditas and other local vendors for goods. (El weight loss attempts.125, 126 Salvador, adolescents)160 Distance to supermarkets was only mentioned in South America and Africa, while in Factors influencing obesogenic behaviours at the physical level Asia small neighbourhood stores were used to purchase fresh fruit and vegetables.109 Availability of unhealthy snack food was mentioned mostly in urban Built environment studies. Availability of opportunities for physical activity. Physical activity in public spaces, School environment particularly in urban areas, was limited due to vehicular traffic and a lack of open spaces and sidewalks.128, 161 Publicly accessible spaces were considered unusable as Availability and accessibility of physical activity. Schools were considered settings they were dirty,152, 156, 161 vandalised,171, 172 or unsafe due to dangerous waste.156, 161 with safe and affordable facilities for physical activity.141, 145, 163, 165 However, sport Poor infrastructure influenced access to sport facilities, which, when available103, 125, facilities and equipment were not always available or appropriate.101 42 Qualitative evidence synthesis physical activity.101, 103, 107, 124, 129, 145, 152, 154, 156, 161, 162, 165, 172 They also reported a lack 138, 145, 149, 152, 154, 162, 171 were lacking equipment,101,125, 128 were perceived dirty136 or of time to prepare or pack food for school,141 forcing them to skip meals107, 120, 164, inappropriate for women in terms of open hours or equipment.136, 154 Access to 166, 168 or displace them with snacks.111 In addition to the school, parents put sport facilities was also limited due to lack of transport,166 distance 101 or pressure on their children to get good grades, prioritizing education over physical membership fees.101, 125, 128, 152, 154, 166 activity as a means to help their children escape poverty.136, 139 “My family that always encouraged me to do exercise from childhood to high Safety. Getting to sport facilities or freely moving in public spaces were generally 2 school, at the first year of high school told me: now the time for exercise is over. perceived as unsafe. Free spaces, such as parks, beaches were not seen as safe due It is the time to study!” (Iran, WRA)136 to crime, dogs, traffic, or human trafficking.101, 123, 128, 129, 136, 145, 149, 154, 159, 161, 162, 166, While lack of time, both generally and related to school, was an issue for 171 adolescents in all three continents, pressure from parents and the education system The built environment was a major factor as most of the facilities like parks and featured only in Asia. playgrounds are not accessible or are not well managed. There is hardly any space for footpaths in Kerala, much of which is encroached by vehicle parking. Peer influence Rain, traffic, and stray dogs are leading people to walk early in the morning and with a companion. (India, WRA)128 In most cases, peer pressure to join in with eating and sharing food did not For women, girls, and parents there was also a fear of sexual violence, assault101, 139, encourage healthy eating.113, 150, 169 One study found that peer influence was 161 or of getting kidnapped.172 positive when adolescent girls exchanged knowledge about foods that could Two studies reported changes over time, when playing on the street was safe and contribute to weight gain.141 The amount of time spent with peers affected the accessible, compared to the densely built environment of the present.152, 170 The increasing influence peers exerted in comparison to parents. Particularly, spending sensitivity analysis revealed that while rural areas offered more opportunities for leisure time with friends or studying together was often associated with eating out, active transport, they lacked facilities and opportunities for different types of eating snacks, street, or fast food,104, 110, 111, 117, 130, 135, 158 which was often the only physical activity. thing adolescent girls felt they could control in their otherwise busy, overscheduled lives.168 Availability of and access to food. From most studies, it was apparent that Being in the social network of friends was expressed as one of the main factors availability of healthy options was perceived as limited while fast and snack foods causing unhealthy eating habits. In some cases, students declared that when were widely available.106, 111, 112, 120, 121, 132, 142, 145, 160, 164, 165, 171, 172 they go out with their friends, they eat lot of junk foods as a routine way of social Fruit and vegetables were perceived as less available in peri-urban and urban areas interaction. (Iran, adolescents)106 than in rural areas.109, 134 Unhealthy foods were also perceived as cheaper,165, 172 and For physical activity, peers also played an important role in encouraging adolescents available in small shops that were easily accessible in most neighbourhoods.109, 112, to be more active101, 163 or more sedentary.165 Meeting friends or making new 138 Supermarkets and open markets, which had cheaper and healthier options friends as part of physical activity motivated girls.101, 139, 162 For adult women, having available such as fruit and vegetables were often distant.112, 138, 160, 166 a social network and friends with whom to engage in physical activity was With large supermarkets located farther away from home, families regularly motivating.123 Not having a supportive network or friends, could be detrimental to depend on neighbourhood tienditas and other local vendors for goods. (El weight loss attempts.125, 126 Salvador, adolescents)160 Distance to supermarkets was only mentioned in South America and Africa, while in Factors influencing obesogenic behaviours at the physical level Asia small neighbourhood stores were used to purchase fresh fruit and vegetables.109 Availability of unhealthy snack food was mentioned mostly in urban Built environment studies. Availability of opportunities for physical activity. Physical activity in public spaces, School environment particularly in urban areas, was limited due to vehicular traffic and a lack of open spaces and sidewalks.128, 161 Publicly accessible spaces were considered unusable as Availability and accessibility of physical activity. Schools were considered settings they were dirty,152, 156, 161 vandalised,171, 172 or unsafe due to dangerous waste.156, 161 with safe and affordable facilities for physical activity.141, 145, 163, 165 However, sport Poor infrastructure influenced access to sport facilities, which, when available103, 125, facilities and equipment were not always available or appropriate.101 43 Chapter 2 Availability and accessibility of food. Schools with cafeterias offered healthy changes in diets between grandparents and the adolescents.127, 144, 163 However, choices,113, 140, 166 but due to long queues, poor food safety, inferior taste, and high particularly in South American studies, participants framed this transition in terms prices,115, 150 158, 167, 168, 169 students felt compelled to buy cheaper snack food from of the loss of indigenous, not just traditional foods. small vendors. A private school girl explained, “I think the fact that we have kiosks inside [the Advertising school] does not help, because it induces us to buy and eat junk food.” (Guatemala, adolescents)145 Food and beverage advertising was ubiquitous and mostly targeted unhealthy Healthy foods, such as fruit and vegetables were either unavailable or unaffordable foods111, 137, 143, 150, 158, 167 across many platforms including TV, newspapers, social at schools.150, 104, 130, 159, 164 While in some countries, students were not allowed to media, street flyers, free deliveries or displays within the store.109, 111, 112, 129, 137, 168 leave the school compound, they had multiple opportunities to buy cheap fast or Participants appeared to be subconsciously influenced, stating trustworthiness of snack food from small vendors on the way to or from school.110, 111, 113, 115, 122, 140, 141, certain brands or claiming to use TV advertisements as a source of information.105, 145, 164, 166, 168 129, 140 Curriculum and teachers support. While curricula contained nutrition and physical "There are many TV commercials for puffed cheese and crisps but not for healthy education topics, they were often substituted for other subjects,101, 136, 162 or relied snacks such as raisins and fruits.” (Iran, adolescents)137 on teachers’ motivation.128, 145 Girls also stated that physical education in schools Social media and pop culture seem to exert an increasing influence, pushing primarily focused on competitive sports, in which girls were less interested, and that adolescents towards more sedentary behaviours. Engaging in social media can also teachers prioritised boys in sports.129, 145, 147, 149, 152, 162 influence their dietary choices.111, 140, 167 “Boys are told to play soccer, jog, or do some kind of sport, but we’re just told to Extensive networks and use of social media infiltrated with information about sit in any place or do whatever you want.” (Costa Rica, adolescents)147 eateries and snacks are likely contributing to the already strong yearning for From the sensitivity analysis it was apparent that the above-mentioned gender snack foods. (Indonesia, adolescents)111 issues in school were more prevalent in Asia and South America. Urbanization Factors influencing obesogenic behaviours at the macro level Food availability in urban areas was usually perceived as better than in rural Cultural norms and traditions areas.109, 114, 134 This was more nuanced, as fruit and vegetables in rural areas were perceived as more accessible, available and of better quality,109, 134, 144, 167 while in Several studies reported shifts in food culture. Overall, traditional and home-cooked urban areas the availability of unhealthy foods was increasing.144 Urban life was also foods were perceived as healthier than food prepared outside the home,109, 110, 113, associated with sedentary lifestyles due to increasing mechanisation and 120 121, 135, 153, 164, 166 and imported food was perceived as unhealthy.121, 127, 151 technology.109, 126, 128, 165, 170 As mentioned above, increasingly built environments “Our own local food is better for health and even for Samoan people to be were perceived as limiting opportunities for physical activity in urban spaces.152 stronger. If we eat overseas food, we will get fat – it’s not good for the body.” “One impact of current technology is that we are not required to move physically. (Samoa, WRA)127 As a result, people become fatter because they are becoming lazier to move.” However, as described above, the taste of non-traditional food,111,166 as well as the (Indonesia, WRA)126 popularity of eating out at international food chains,146, 166, 167 led to a perceived shift Economic development, particularly in cities, including increasing consumerism was of non-traditional food increasingly replacing traditional or local foods.113, 127, 168 This perceived as a barrier to healthy lifestyles.103 Furthermore, the busy urban lifestyles shift was also recognised in terms of older generations eating healthier and with more women in the workforce and reduced appreciation of food preparation117 consuming more unprocessed, local foods,127, 144 which led to adolescents feeling impacted on cooking and eating habits. Studies highlighted the increasing need for torn between traditional and modern culture.168 Cultural norms were associated quick, simple, and convenient meals.109, 117, 121, 146, 158, 172 with certain foods and behaviours. Particularly in South Africa, physical activity and consumption of raw vegetables was associated with white or rich people and not part of “black culture”.166, 170 On all continents, participants observed a transition from traditional and local to modern and imported foods. This was also apparent in terms of generational 44 Qualitative evidence synthesis Availability and accessibility of food. Schools with cafeterias offered healthy changes in diets between grandparents and the adolescents.127, 144, 163 However, choices,113, 140, 166 but due to long queues, poor food safety, inferior taste, and high particularly in South American studies, participants framed this transition in terms prices,115, 150 158, 167, 168, 169 students felt compelled to buy cheaper snack food from of the loss of indigenous, not just traditional foods. small vendors. A private school girl explained, “I think the fact that we have kiosks inside [the Advertising school] does not help, because it induces us to buy and eat junk food.” 2 (Guatemala, adolescents)145 Food and beverage advertising was ubiquitous and mostly targeted unhealthy Healthy foods, such as fruit and vegetables were either unavailable or unaffordable foods111, 137, 143, 150, 158, 167 across many platforms including TV, newspapers, social at schools.150, 104, 130, 159, 164 While in some countries, students were not allowed to media, street flyers, free deliveries or displays within the store.109, 111, 112, 129, 137, 168 leave the school compound, they had multiple opportunities to buy cheap fast or Participants appeared to be subconsciously influenced, stating trustworthiness of snack food from small vendors on the way to or from school.110, 111, 113, 115, 122, 140, 141, certain brands or claiming to use TV advertisements as a source of information.105, 145, 164, 166, 168 129, 140 Curriculum and teachers support. While curricula contained nutrition and physical "There are many TV commercials for puffed cheese and crisps but not for healthy education topics, they were often substituted for other subjects,101, 136, 162 or relied snacks such as raisins and fruits.” (Iran, adolescents)137 on teachers’ motivation.128, 145 Girls also stated that physical education in schools Social media and pop culture seem to exert an increasing influence, pushing primarily focused on competitive sports, in which girls were less interested, and that adolescents towards more sedentary behaviours. Engaging in social media can also teachers prioritised boys in sports.129, 145, 147, 149, 152, 162 influence their dietary choices.111, 140, 167 “Boys are told to play soccer, jog, or do some kind of sport, but we’re just told to Extensive networks and use of social media infiltrated with information about sit in any place or do whatever you want.” (Costa Rica, adolescents)147 eateries and snacks are likely contributing to the already strong yearning for From the sensitivity analysis it was apparent that the above-mentioned gender snack foods. (Indonesia, adolescents)111 issues in school were more prevalent in Asia and South America. Urbanization Factors influencing obesogenic behaviours at the macro level Food availability in urban areas was usually perceived as better than in rural Cultural norms and traditions areas.109, 114, 134 This was more nuanced, as fruit and vegetables in rural areas were perceived as more accessible, available and of better quality,109, 134, 144, 167 while in Several studies reported shifts in food culture. Overall, traditional and home-cooked urban areas the availability of unhealthy foods was increasing.144 Urban life was also foods were perceived as healthier than food prepared outside the home,109, 110, 113, associated with sedentary lifestyles due to increasing mechanisation and 120 121, 135, 153, 164, 166 and imported food was perceived as unhealthy.121, 127, 151 technology.109, 126, 128, 165, 170 As mentioned above, increasingly built environments “Our own local food is better for health and even for Samoan people to be were perceived as limiting opportunities for physical activity in urban spaces.152 stronger. If we eat overseas food, we will get fat – it’s not good for the body.” “One impact of current technology is that we are not required to move physically. (Samoa, WRA)127 As a result, people become fatter because they are becoming lazier to move.” However, as described above, the taste of non-traditional food,111,166 as well as the (Indonesia, WRA)126 popularity of eating out at international food chains,146, 166, 167 led to a perceived shift Economic development, particularly in cities, including increasing consumerism was of non-traditional food increasingly replacing traditional or local foods.113, 127, 168 This perceived as a barrier to healthy lifestyles.103 Furthermore, the busy urban lifestyles shift was also recognised in terms of older generations eating healthier and with more women in the workforce and reduced appreciation of food preparation117 consuming more unprocessed, local foods,127, 144 which led to adolescents feeling impacted on cooking and eating habits. Studies highlighted the increasing need for torn between traditional and modern culture.168 Cultural norms were associated quick, simple, and convenient meals.109, 117, 121, 146, 158, 172 with certain foods and behaviours. Particularly in South Africa, physical activity and consumption of raw vegetables was associated with white or rich people and not part of “black culture”.166, 170 On all continents, participants observed a transition from traditional and local to modern and imported foods. This was also apparent in terms of generational 45 Chapter 2 Data-driven framework DISCUSSION Using the a priori meta-framework allowed us to conceptualise the factors that are This review sought to synthesise qualitative evidence on factors influencing perceived to directly or indirectly influence obesogenic behaviours by adolescent obesogenic (eating and physical activity) behaviours in adolescent girls and WRA in girls and WRA. After synthesis, the identified themes through both the deductive LMIC. Influencing factors were examined across multiple contexts and within and and inductive approach resulted in the data-driven framework as presented in across social, physical, and macro-levels using an a priori defined meta-framework. Figure 2.2 Individual-level factors were prominent in our framework, identifying The data synthesis revealed a data-driven framework that included influencing food safety concerns and attribution in addition to the constructs of the a priori factors on adolescent girls and WRA, as well as their obesogenic behaviours. These meta-framework. Data on physical and macro level factors were limited and are factors are interrelated and reflect their individual, social, physical, and macro-level therefore represented to a limited extent in our framework. Gender was identified influences. The findings of this synthesis provide a greater insight into the as cutting across all four levels in our framework. obesogenic behaviours of adolescent girls and women in LMIC, which will help to inform design interventions for obesity prevention tailored to different stages of the lifecycle. Macro Level Urbanization Cultural norms and traditions Physical level Awareness of the value of a healthy diet and physical activity for good health was Built environment - good overall, but it was overshadowed by a failure to recognise the importance of School environment availability and accesss to (adolescents) food and PA a healthy behaviours for everyone across the lifecycle. This attribution error Social level appeared relevant for both dietary and physical activity behaviours. Adolescents Family Peer School pressure G perceived healthy lifestyles as only relevant for older people and, therefore, not of environment influence (adolescents) E N immediate concern to them, which has also been found in high-income Individual level D E countries.56,57 Women, on the other hand, often perceived their body weight or Taste Awareness R preference and Subjective health as predestined. Physical activity was considered more appropriate for either pleasure norms Food safety perceptions children, older people with poor health and/or overweight, professional athletes or Motivation/ Socio-economic men. Reduced engagement with physical activity with increasing age could also be habit strength status Attribution due to life transition periods, competing priorities such as schoolwork,58 social Convenience activities and/or increased workload.59 Obesogenic behaviours Fear of poor food hygiene and stronger trust in packaged, labelled and/or processed Figure 2.2. Conceptual framework food were most dominant in studies from Africa and Asia. This immediate fear of food safety can overshadow concerns for more long-term concerns related to nutrition.60 Improving food hygiene of healthier foods and beverages, or even the perception of improved food hygiene, therefore, has a role to play in preventing obesity and related NCD, while taking into account the role that informal vendors and markets play in providing fruit and vegetables.61 Changes in diets and physical activity were apparent due to migration from rural to urban areas, and this held true across generations. At the same time, women across studies observed that increasing urbanization increased availability and affordability of unhealthy ultra-processed and snack foods, and reduced access to safe and affordable spaces for physical activity and limited time for healthy behaviours due to busy lives. The shift from traditional to ultra-processed food, limited time to prepare fresh food and the omnipresence and promotion of cheap, unhealthy ultra-processed foods and drinks in school or neighbourhood 46 Qualitative evidence synthesis Data-driven framework DISCUSSION Using the a priori meta-framework allowed us to conceptualise the factors that are This review sought to synthesise qualitative evidence on factors influencing perceived to directly or indirectly influence obesogenic behaviours by adolescent obesogenic (eating and physical activity) behaviours in adolescent girls and WRA in girls and WRA. After synthesis, the identified themes through both the deductive LMIC. Influencing factors were examined across multiple contexts and within and and inductive approach resulted in the data-driven framework as presented in across social, physical, and macro-levels using an a priori defined meta-framework. 2 Figure 2.2 Individual-level factors were prominent in our framework, identifying The data synthesis revealed a data-driven framework that included influencing food safety concerns and attribution in addition to the constructs of the a priori factors on adolescent girls and WRA, as well as their obesogenic behaviours. These meta-framework. Data on physical and macro level factors were limited and are factors are interrelated and reflect their individual, social, physical, and macro-level therefore represented to a limited extent in our framework. Gender was identified influences. The findings of this synthesis provide a greater insight into the as cutting across all four levels in our framework. obesogenic behaviours of adolescent girls and women in LMIC, which will help to inform design interventions for obesity prevention tailored to different stages of the lifecycle. Macro Level Urbanization Cultural norms and traditions Physical level Awareness of the value of a healthy diet and physical activity for good health was Built environment - good overall, but it was overshadowed by a failure to recognise the importance of School environment availability and accesss to (adolescents) food and PA a healthy behaviours for everyone across the lifecycle. This attribution error Social level appeared relevant for both dietary and physical activity behaviours. Adolescents Family Peer School pressure G perceived healthy lifestyles as only relevant for older people and, therefore, not of environment influence (adolescents) E N immediate concern to them, which has also been found in high-income Individual level D E countries.56,57 Women, on the other hand, often perceived their body weight or Taste Awareness R preference and Subjective health as predestined. Physical activity was considered more appropriate for either pleasure norms Food safety perceptions children, older people with poor health and/or overweight, professional athletes or Motivation/ Socio-economic men. Reduced engagement with physical activity with increasing age could also be habit strength status Attribution due to life transition periods, competing priorities such as schoolwork,58 social Convenience activities and/or increased workload.59 Obesogenic behaviours Fear of poor food hygiene and stronger trust in packaged, labelled and/or processed Figure 2.2. Conceptual framework food were most dominant in studies from Africa and Asia. This immediate fear of food safety can overshadow concerns for more long-term concerns related to nutrition.60 Improving food hygiene of healthier foods and beverages, or even the perception of improved food hygiene, therefore, has a role to play in preventing obesity and related NCD, while taking into account the role that informal vendors and markets play in providing fruit and vegetables.61 Changes in diets and physical activity were apparent due to migration from rural to urban areas, and this held true across generations. At the same time, women across studies observed that increasing urbanization increased availability and affordability of unhealthy ultra-processed and snack foods, and reduced access to safe and affordable spaces for physical activity and limited time for healthy behaviours due to busy lives. The shift from traditional to ultra-processed food, limited time to prepare fresh food and the omnipresence and promotion of cheap, unhealthy ultra-processed foods and drinks in school or neighbourhood 47 Chapter 2 environments tempted girls and women to buy them. These dietary shifts, alongside dignity, wealth, good health, and beauty, which has been acknowledged previously increasing availability and promotion of unhealthy foods, have been well defined as as relevant in poor, rural communities across Africa.26,27 the ‘nutrition transition’14,15 in prior literature on LMIC and in low-income communities of high income countries.62 Dietary shifts from traditional food As revealed by our sensitivity analysis, the identified factors might differ between towards more eating away from home and consuming convenience food high in urban and rural settings and adolescents and WRA. In rural settings, awareness of sugar has been observed in other LMIC following migration to urban centres.27,63,64 underweight and micronutrient deficiencies, as well as the importance of eating Participants have also observed changes in urban planning, which caused limited food that is filling rather than tasty, were more widespread. Accessing healthy, safe access to aesthetic, safe and secure recreation spaces or facilities. The latter has fruit and vegetables was a challenge, particularly in studies from South America and been associated with crime and fear of sexual harassment27 as well as lower levels Africa, which could be due to a reduction in urban neighbourhood markets of physical activity.16 accompanied by a rise in remote supermarkets.13,70 The perception that healthy foods are expensive is also supported by studies assessing price data in LMIC,71 Pronounced across most identified themes of our framework is the influence of making healthy diets difficult to afford for lower socio-economic populations.72 gender norms. Culturally-, socially- and religiously-driven gender roles appear to For adolescent girls, choosing unhealthy, “modern” foods gave them a feeling of hinder girls and women from being physically active and from consuming healthy empowerment. Even with the little pocket money they had, as their parents food. Girls and women experienced physical activity and/or clothing restrictions controlled most of their other choices, they were able to buy snacks at and around based on familial, societal, or religious norms. Additionally, girls and women have school based on taste, appearance, and social desirability of their peers. Peer to fulfil roles in the household and family, which further limits their time available influence towards ‘modern’ food has also been described in high-income countries, for physical activity, especially when added to employment and childcare but with more pressure towards expensive and branded products.56 The increasing responsibilities. Busier lives were also described, particularly by employed adult availability of mass/social media could make sedentary lifestyles more tempting for women. However, few studies focused on workplaces, which could have offered adolescent girls. Besides being poor role models for physical activity, parents valuable insights into possible interventions for adult women given their increasing pressured their adolescent children into studying over being physically active, which presence in the workforce. These types of time limitations have been associated was also found in families of low-income settings in high-income countries.58 For with more women classified as having obesity.65 Furthermore, girls and women adult women, lack of peer influence, lack of a social network and/or sufficient time might prefer different types of physical activity than men,66 but school curricula, besides family and household responsibilities could be limiting factors for physical urban environments and/or gym facilities do not cater for their interests.58,59,67 activity and were also shown to affect women’s overall autonomy.73 Globally, girls and women tend to be less physically active than men/boys,68 with highest rates of insufficient physical activity in south/central Asia and the Middle Limitations and implications for future research/programming East and north Africa.68 These regions were also identified by our review as most culturally restrictive of public movement of girls and women. Similar to our findings, Although this review followed a rigorous methodology and we have moderate to quantitative studies have identified limited opportunities for safe and accessible high confidence that the review findings are a reasonable representation of the leisure time activity.66,68 Also, the fact that physical education programmes in phenomenon of interest,74 it was not without limitations. Considering solely the schools are not tailored to girls’ needs, by focusing more on athletic abilities rather perspectives of women and adolescent girls limited findings of this review to the than encouragement, was confirmed by other studies in low-income settings of female perspective. Gender norms were identified as a strong cross-cutting issue high-income countries.58,59 The tendency of women in the reviewed studies to for almost all the influencing factors. Thus, male perceptions would enrich insights conform with their husbands’ and children’s dietary choices could also affect their into these societal issues.28 Only two of the included studies were conducted in low- own dietary behaviours.2,26 Poor decision-making power and gender inequality in income countries, which poses an important gap for future research. Furthermore, general appears to expose women more strongly to multiple burdens of this review solely included factors influencing obesogenic behaviours, and did not malnutrition.69 Furthermore, women and girls in the reviewed studies, particularly consider factors that influence underweight or micronutrient deficiencies. from South America and Asia, also felt pressure to conform to their society’s However, this review does acknowledge the role of early life food shortage as an feminine ideals, which for girls mostly meant being thin. This could push them important influencing factor to later life weight status. In light of the increasing towards dieting rather than eating a balanced diet, while avoiding looking double burden of malnutrition, this may be particularly relevant, as more than half sweaty/dirty from engaging in physical activity to maintain a ‘feminine’ of the included studies (n=48) were conducted in countries with medium, high, or appearance.67 For adult women, larger body sizes were associated with maturity, very high double burden of malnutrition.15 48 Qualitative evidence synthesis environments tempted girls and women to buy them. These dietary shifts, alongside dignity, wealth, good health, and beauty, which has been acknowledged previously increasing availability and promotion of unhealthy foods, have been well defined as as relevant in poor, rural communities across Africa.26,27 the ‘nutrition transition’14,15 in prior literature on LMIC and in low-income communities of high income countries.62 Dietary shifts from traditional food As revealed by our sensitivity analysis, the identified factors might differ between towards more eating away from home and consuming convenience food high in urban and rural settings and adolescents and WRA. In rural settings, awareness of sugar has been observed in other LMIC following migration to urban centres.27,63,64 underweight and micronutrient deficiencies, as well as the importance of eating 2 Participants have also observed changes in urban planning, which caused limited food that is filling rather than tasty, were more widespread. Accessing healthy, safe access to aesthetic, safe and secure recreation spaces or facilities. The latter has fruit and vegetables was a challenge, particularly in studies from South America and been associated with crime and fear of sexual harassment27 as well as lower levels Africa, which could be due to a reduction in urban neighbourhood markets of physical activity.16 accompanied by a rise in remote supermarkets.13,70 The perception that healthy foods are expensive is also supported by studies assessing price data in LMIC,71 Pronounced across most identified themes of our framework is the influence of making healthy diets difficult to afford for lower socio-economic populations.72 gender norms. Culturally-, socially- and religiously-driven gender roles appear to For adolescent girls, choosing unhealthy, “modern” foods gave them a feeling of hinder girls and women from being physically active and from consuming healthy empowerment. Even with the little pocket money they had, as their parents food. Girls and women experienced physical activity and/or clothing restrictions controlled most of their other choices, they were able to buy snacks at and around based on familial, societal, or religious norms. Additionally, girls and women have school based on taste, appearance, and social desirability of their peers. Peer to fulfil roles in the household and family, which further limits their time available influence towards ‘modern’ food has also been described in high-income countries, for physical activity, especially when added to employment and childcare but with more pressure towards expensive and branded products.56 The increasing responsibilities. Busier lives were also described, particularly by employed adult availability of mass/social media could make sedentary lifestyles more tempting for women. However, few studies focused on workplaces, which could have offered adolescent girls. Besides being poor role models for physical activity, parents valuable insights into possible interventions for adult women given their increasing pressured their adolescent children into studying over being physically active, which presence in the workforce. These types of time limitations have been associated was also found in families of low-income settings in high-income countries.58 For with more women classified as having obesity.65 Furthermore, girls and women adult women, lack of peer influence, lack of a social network and/or sufficient time might prefer different types of physical activity than men,66 but school curricula, besides family and household responsibilities could be limiting factors for physical urban environments and/or gym facilities do not cater for their interests.58,59,67 activity and were also shown to affect women’s overall autonomy.73 Globally, girls and women tend to be less physically active than men/boys,68 with highest rates of insufficient physical activity in south/central Asia and the Middle Limitations and implications for future research/programming East and north Africa.68 These regions were also identified by our review as most culturally restrictive of public movement of girls and women. Similar to our findings, Although this review followed a rigorous methodology and we have moderate to quantitative studies have identified limited opportunities for safe and accessible high confidence that the review findings are a reasonable representation of the leisure time activity.66,68 Also, the fact that physical education programmes in phenomenon of interest,74 it was not without limitations. Considering solely the schools are not tailored to girls’ needs, by focusing more on athletic abilities rather perspectives of women and adolescent girls limited findings of this review to the than encouragement, was confirmed by other studies in low-income settings of female perspective. Gender norms were identified as a strong cross-cutting issue high-income countries.58,59 The tendency of women in the reviewed studies to for almost all the influencing factors. Thus, male perceptions would enrich insights conform with their husbands’ and children’s dietary choices could also affect their into these societal issues.28 Only two of the included studies were conducted in low- own dietary behaviours.2,26 Poor decision-making power and gender inequality in income countries, which poses an important gap for future research. Furthermore, general appears to expose women more strongly to multiple burdens of this review solely included factors influencing obesogenic behaviours, and did not malnutrition.69 Furthermore, women and girls in the reviewed studies, particularly consider factors that influence underweight or micronutrient deficiencies. from South America and Asia, also felt pressure to conform to their society’s However, this review does acknowledge the role of early life food shortage as an feminine ideals, which for girls mostly meant being thin. This could push them important influencing factor to later life weight status. In light of the increasing towards dieting rather than eating a balanced diet, while avoiding looking double burden of malnutrition, this may be particularly relevant, as more than half sweaty/dirty from engaging in physical activity to maintain a ‘feminine’ of the included studies (n=48) were conducted in countries with medium, high, or appearance.67 For adult women, larger body sizes were associated with maturity, very high double burden of malnutrition.15 49 Chapter 2 facilities for the community, which would encourage physical activity of out-of- This qualitative evidence synthesis revealed several implications for future research. school adolescents and women. Similar to the conclusions of a review on Africa-only studies that included mainly quantitative research, we found that factors related to the physical and macro level In conclusion, some of the identified factors are similar to those identified in high- are insufficiently studied and require further investigation.26,27 income countries such as increasing availability, affordability and promotion of This could be due to the fact that participants in qualitative studies are more likely unhealthy food; peer pressure; social desirability and time constraints related to to focus on barriers or facilitators at individual and social levels, and that qualitative food and physical activity, particularly in adolescents of lower income communities. studies are less likely to be used to capture the physical food environment and the Specific to LMIC is the concern for the food safety of perishable foods that macro environment.50 More than 100 studies had to be excluded given a lack of data increasingly drives consumption of unhealthy foods. Busier lives influenced by attributable to participant sex or age; data on the socio-economic status of gender norms and limited safe and secure exercise spaces keep girls and women participants were also inconsistent. Clearer and attributable information on from being physically active. Diverse and flexible solutions, at different levels and participants’ demographic and socio-economic situation would help put research for rural and urban settings, are urgently needed to address these obesogenic findings into more specific contexts and has significant potential to strengthen the factors in low- and middle-income countries, where most people with overweight evidence-base and inform future interventions. In most studies, data on individual and obesity live. level factors were predominant. Finding programme and policy solutions to overcome the growing obesity pandemic is a significant challenge. As has been demonstrated in our framework, the drivers are complex and span multiple individual and environmental levels. Historically, obesity programmes have focused on education interventions targeting individual behaviours and responsibility. Our findings showed that improving education remains relevant, but that education interventions should put a stronger focus on the misconceived association between food safety and nutrient content of food. Furthermore, the importance of promoting healthy diets and physical activity for everyone across the whole lifecycle should be addressed through interventions tailored specifically to adolescent girls and WRA. However, addressing determinants of the broader environment beyond the individual level through novel solutions is also called for. Gender norms need to be addressed with both men and women regarding traditional roles of women and girls in society that negatively impact on nutrition and by supporting employed women through workplace interventions. Food system innovations75,76 offer potential solutions to making healthy food more available, affordable, safe, and appealing, while making unhealthy foods less available and affordable. This could be achieved by combining education, regulatory (advertising) and/or fiscal interventions (taxation) while improving implementation of hygiene and food safety standards in all settings, but particularly in schools.8,77 Transport and urban planning policies could further improve access to healthy food and safe recreation spaces.78 Education policies should focus more on curricula for nutrition and physical education33 with the latter aiming to more strongly promote girls’ participation. Guidelines for school food supply should not only target potential cafeterias but vendors in and around schools.79 Given the poor security in many LMIC urban areas, schools could also provide access to safe recreation 50 Qualitative evidence synthesis facilities for the community, which would encourage physical activity of out-of- This qualitative evidence synthesis revealed several implications for future research. school adolescents and women. Similar to the conclusions of a review on Africa-only studies that included mainly quantitative research, we found that factors related to the physical and macro level In conclusion, some of the identified factors are similar to those identified in high- are insufficiently studied and require further investigation.26,27 income countries such as increasing availability, affordability and promotion of This could be due to the fact that participants in qualitative studies are more likely unhealthy food; peer pressure; social desirability and time constraints related to 2 to focus on barriers or facilitators at individual and social levels, and that qualitative food and physical activity, particularly in adolescents of lower income communities. studies are less likely to be used to capture the physical food environment and the Specific to LMIC is the concern for the food safety of perishable foods that macro environment.50 More than 100 studies had to be excluded given a lack of data increasingly drives consumption of unhealthy foods. Busier lives influenced by attributable to participant sex or age; data on the socio-economic status of gender norms and limited safe and secure exercise spaces keep girls and women participants were also inconsistent. Clearer and attributable information on from being physically active. Diverse and flexible solutions, at different levels and participants’ demographic and socio-economic situation would help put research for rural and urban settings, are urgently needed to address these obesogenic findings into more specific contexts and has significant potential to strengthen the factors in low- and middle-income countries, where most people with overweight evidence-base and inform future interventions. In most studies, data on individual and obesity live. level factors were predominant. Finding programme and policy solutions to overcome the growing obesity pandemic is a significant challenge. As has been demonstrated in our framework, the drivers are complex and span multiple individual and environmental levels. Historically, obesity programmes have focused on education interventions targeting individual behaviours and responsibility. Our findings showed that improving education remains relevant, but that education interventions should put a stronger focus on the misconceived association between food safety and nutrient content of food. Furthermore, the importance of promoting healthy diets and physical activity for everyone across the whole lifecycle should be addressed through interventions tailored specifically to adolescent girls and WRA. However, addressing determinants of the broader environment beyond the individual level through novel solutions is also called for. Gender norms need to be addressed with both men and women regarding traditional roles of women and girls in society that negatively impact on nutrition and by supporting employed women through workplace interventions. Food system innovations75,76 offer potential solutions to making healthy food more available, affordable, safe, and appealing, while making unhealthy foods less available and affordable. This could be achieved by combining education, regulatory (advertising) and/or fiscal interventions (taxation) while improving implementation of hygiene and food safety standards in all settings, but particularly in schools.8,77 Transport and urban planning policies could further improve access to healthy food and safe recreation spaces.78 Education policies should focus more on curricula for nutrition and physical education33 with the latter aiming to more strongly promote girls’ participation. Guidelines for school food supply should not only target potential cafeterias but vendors in and around schools.79 Given the poor security in many LMIC urban areas, schools could also provide access to safe recreation 51 Chapter 2 References 18. Popkin BM. The shift in stages of the nutrition transition in the developing world differs from past experiences! Public Heal Nutr. 2002; 5(1A):205-214. 1. Keats C, Rappaport A, Jain R, et al. Diet and Eating Practices among Adolescent Girls doi:10.1079/PHN2001295 . Arlington, VA: 19. Monteiro CA, Moura EC, Conde WL, et al. Socioeconomic status and obesity in adult in Low- and Middle-Income Countries: A Systemic Review Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) populations of developing countries: a review. Bull World Heal Organ. 2004; project; 2018. 82(12):940-946. doi:/S0042-96862004001200011 2. Harris-Fry H, Shrestha N, Costello A, et al. Determinants of intra-household food 20. Agurs-Collins T, Bouchard C. Gene-nutrition and gene-physical activity interactions in allocation between adults in South Asia - a systematic review. . 2017; the etiology of obesity. Introduction. Obesity (Silver Spring). 2008; 16 Suppl 3(Suppl Int J Equity Heal 16(1):107. doi:10.1186/s12939-017-0603-1 3):S2-S4. doi:10.1038/oby.2008.510 3. Zerfu TA, Umeta M, Baye K. Dietary habits, food taboos, and perceptions towards 21. Jaacks LM, Kavle J, Perry A, et al. Programming maternal and child overweight and weight gain during pregnancy in Arsi, rural central Ethiopia: a qualitative cross- obesity in the context of undernutrition: current evidence and key considerations for sectional study. . 2016; 35(1):22. doi:10.1186/s41043-016-0059-8 low- and middle-income countries. Public Health Nutr. 2017; 20(7):1286-1296. J Health Popul Nutr 4. Wells JC, Sawaya AL, Wibaek R, et al. The double burden of malnutrition: aetiological doi:10.1017/S1368980016003323 pathways and consequences for health. . 2020; 395(10217):75-88. 22. Butland B, Jebb S, Koppelman P. Foresight. Tackling Obesities: Future Choices -Project Lancet doi:10.1016/S0140-6736(19)32472-9 Report.; 2007. 5. Webster-Gandy J, Madden A, Holdsworth M. 23. Leroy JL, Olney DK, Ruel MT. PROCOMIDA, a Food-Assisted Maternal and Child Health Oxford Handbook of Nutrition and . Oxford Han. Oxford University Press and Nutrition Program, Contributes to Postpartum Weight Retention in Guatemala: Dietetics 6. Black RE, Victora CG, Walker SP, et al. Maternal and child undernutrition and A Cluster-Randomized Controlled Intervention Trial. J Nutr. 2019; 149(12):2219-2227. overweight in low-income and middle-income countries. . 2013; doi:10.1093/jn/nxz175 Lancet 382(9890):427-451. doi:10.1016/S0140-6736(13)60937-X 24. Lobstein T, Jackson-Leach R, Moodie ML, et al. Child and adolescent obesity: part of 7. . Bristol, UK; 2018. a bigger picture. Lancet (London, England). 2015; 385(9986):2510-2520. Global Nutrition Report: Shining a Light to Spur Action on Nutrition Development Initiatives. doi:10.1016/S0140-6736(14)61746-3 8. Shekar M, Popkin B. 25. Lobstein T, Dibb S. Evidence of a possible link between obesogenic food advertising Obesity: Health and Economic Consequences of an Impending . Washington D.C.; 2020. and child overweight. Obes Rev. 2005; 6(3):203-208. doi:10.1111/j.1467- Global Challenge 9. Benedict R, Schmale A, Namaste S. 789X.2005.00191.x Adolescent Nutrition 2000-2017: DHS Data on . Rockville, Maryland, USA; 26. Gissing SC, Pradeilles R, Osei-Kwasi HA, et al. Drivers of dietary behaviours in women Adolescents Age 15-19. DHS Comparative Report No. 47 2018. living in urban Africa: a systematic mapping review. Public Heal Nutr. 2017; 10. Afshin A, Forouzanfar MH, Reitsma MB, et al. Health effects of overweight and 20(12):2104-2113. doi:10.1017/S1368980017000970 obesity in 195 countries over 25 years. . 2017. 27. Ozodiegwu ID, Littleton MA, Nwabueze C, et al. A qualitative research synthesis of N Engl J Med doi:10.1056/NEJMoa1614362 contextual factors contributing to female overweight and obesity over the life course 11. WHO. in sub-Saharan Africa. PLoS One. 2019; 14(11):e0224612. Global Status Report on Noncommunicable Diseases 2010. Geneva; 2011. 12. Rtveladze K, Marsh T, Webber L, et al. Health and Economic Burden of Obesity in doi:10.1371/journal.pone.0224612 Brazil. . 2013; 8(7). 28. Osei-Kwasi HA, Mohindra A, Booth A, et al. Factors influencing dietary behaviours in PLoS One 13. Reardon T, Timmer CP, Barrett CB, et al. The Rise of Supermarkets in Africa, Asia, and urban food environments in Africa: a systematic mapping review. Public Heal Nutr (In Latin America. Am J Agric Econ. 2003; 85(5):1140-1146. Press. 2020). http://www.jstor.org/stable/1244885. 29. Osei-Assibey G, Dick S, Macdiarmid J, et al. The influence of the food environment on 14. Monteiro CA, Moubarac JC, Cannon G, et al. Ultra-processed products are becoming overweight and obesity in young children: a systematic review. BMJ Open. 2012; 2(6). dominant in the global food system. . 2013; 14 Suppl 2:21-28. doi:10.1136/bmjopen-2012-001538 Obes Rev doi:10.1111/obr.12107 30. Mazarello Paes V, Ong KK, Lakshman R. Factors influencing obesogenic dietary intake 15. Popkin BM, Corvalan C, Grummer-Strawn LM. Dynamics of the double burden of in young children (0–6 years): systematic review of qualitative evidence. BMJ Open. malnutrition and the changing nutrition reality. . 2020; 395(10217):65-74. 2015; 5(9):e007396. doi:10.1136/bmjopen-2014-007396 Lancet doi:10.1016/S0140-6736(19)32497-3 31. Leandro CG, Fonseca EV da S da, de Lim CR, et al. Barriers and Enablers That Influence 16. Bauman AE, Reis RS, Sallis JF, et al. Correlates of physical activity: why are some Overweight/Obesity/Obesogenic Behavior in Adolescents From Lower-Middle people physically active and others not? . 2012; 380(9838):258-271. Income Countries: A Systematic Review. Food Nutr Bull. 2019. Lancet doi:10.1016/S0140-6736(12)60735-1 doi:10.1177/0379572119853926 17. Ford ND, Patel SA, Narayan KM. Obesity in Low- and Middle-Income Countries: 32. Madjdian DS, Azupogo F, Osendarp SJM, et al. Socio-cultural and economic Burden, Drivers, and Emerging Challenges. . 2017; 38:145-164. determinants and consequences of adolescent undernutrition and micronutrient Annu Rev Public Health doi:10.1146/annurev-publhealth-031816-044604 52 Qualitative evidence synthesis References 18. Popkin BM. The shift in stages of the nutrition transition in the developing world differs from past experiences! Public Heal Nutr. 2002; 5(1A):205-214. 1. Keats C, Rappaport A, Jain R, et al. Diet and Eating Practices among Adolescent Girls doi:10.1079/PHN2001295 . Arlington, VA: 19. Monteiro CA, Moura EC, Conde WL, et al. Socioeconomic status and obesity in adult in Low- and Middle-Income Countries: A Systemic Review Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) populations of developing countries: a review. Bull World Heal Organ. 2004; project; 2018. 82(12):940-946. doi:/S0042-96862004001200011 2. Harris-Fry H, Shrestha N, Costello A, et al. Determinants of intra-household food 20. Agurs-Collins T, Bouchard C. Gene-nutrition and gene-physical activity interactions in 2 allocation between adults in South Asia - a systematic review. . 2017; the etiology of obesity. Introduction. Obesity (Silver Spring). 2008; 16 Suppl 3(Suppl Int J Equity Heal 16(1):107. doi:10.1186/s12939-017-0603-1 3):S2-S4. doi:10.1038/oby.2008.510 3. Zerfu TA, Umeta M, Baye K. Dietary habits, food taboos, and perceptions towards 21. Jaacks LM, Kavle J, Perry A, et al. Programming maternal and child overweight and weight gain during pregnancy in Arsi, rural central Ethiopia: a qualitative cross- obesity in the context of undernutrition: current evidence and key considerations for sectional study. . 2016; 35(1):22. doi:10.1186/s41043-016-0059-8 low- and middle-income countries. Public Health Nutr. 2017; 20(7):1286-1296. J Health Popul Nutr 4. Wells JC, Sawaya AL, Wibaek R, et al. The double burden of malnutrition: aetiological doi:10.1017/S1368980016003323 pathways and consequences for health. . 2020; 395(10217):75-88. 22. Butland B, Jebb S, Koppelman P. Foresight. Tackling Obesities: Future Choices -Project Lancet doi:10.1016/S0140-6736(19)32472-9 Report.; 2007. 5. Webster-Gandy J, Madden A, Holdsworth M. 23. Leroy JL, Olney DK, Ruel MT. PROCOMIDA, a Food-Assisted Maternal and Child Health Oxford Handbook of Nutrition and . Oxford Han. Oxford University Press and Nutrition Program, Contributes to Postpartum Weight Retention in Guatemala: Dietetics 6. Black RE, Victora CG, Walker SP, et al. Maternal and child undernutrition and A Cluster-Randomized Controlled Intervention Trial. J Nutr. 2019; 149(12):2219-2227. overweight in low-income and middle-income countries. doi:10.1093/jn/nxz175 Lancet. 2013; 382(9890):427-451. doi:10.1016/S0140-6736(13)60937-X 24. Lobstein T, Jackson-Leach R, Moodie ML, et al. Child and adolescent obesity: part of 7. . Bristol, UK; 2018. a bigger picture. Lancet (London, England). 2015; 385(9986):2510-2520. Global Nutrition Report: Shining a Light to Spur Action on Nutrition Development Initiatives. doi:10.1016/S0140-6736(14)61746-3 8. Shekar M, Popkin B. 25. Lobstein T, Dibb S. Evidence of a possible link between obesogenic food advertising Obesity: Health and Economic Consequences of an Impending . Washington D.C.; 2020. and child overweight. Obes Rev. 2005; 6(3):203-208. doi:10.1111/j.1467- Global Challenge 9. Benedict R, Schmale A, Namaste S. 789X.2005.00191.x Adolescent Nutrition 2000-2017: DHS Data on . Rockville, Maryland, USA; 26. Gissing SC, Pradeilles R, Osei-Kwasi HA, et al. Drivers of dietary behaviours in women Adolescents Age 15-19. DHS Comparative Report No. 47 2018. living in urban Africa: a systematic mapping review. Public Heal Nutr. 2017; 10. Afshin A, Forouzanfar MH, Reitsma MB, et al. Health effects of overweight and 20(12):2104-2113. doi:10.1017/S1368980017000970 obesity in 195 countries over 25 years. . 2017. 27. Ozodiegwu ID, Littleton MA, Nwabueze C, et al. A qualitative research synthesis of N Engl J Med doi:10.1056/NEJMoa1614362 contextual factors contributing to female overweight and obesity over the life course 11. WHO. . Geneva; 2011. in sub-Saharan Africa. PLoS One. 2019; 14(11):e0224612. Global Status Report on Noncommunicable Diseases 2010 12. Rtveladze K, Marsh T, Webber L, et al. Health and Economic Burden of Obesity in doi:10.1371/journal.pone.0224612 Brazil. . 2013; 8(7). 28. Osei-Kwasi HA, Mohindra A, Booth A, et al. Factors influencing dietary behaviours in PLoS One 13. Reardon T, Timmer CP, Barrett CB, et al. The Rise of Supermarkets in Africa, Asia, and urban food environments in Africa: a systematic mapping review. Public Heal Nutr (In Latin America. Am J Agric Econ. 2003; 85(5):1140-1146. Press. 2020). http://www.jstor.org/stable/1244885. 29. Osei-Assibey G, Dick S, Macdiarmid J, et al. The influence of the food environment on 14. Monteiro CA, Moubarac JC, Cannon G, et al. Ultra-processed products are becoming overweight and obesity in young children: a systematic review. BMJ Open. 2012; 2(6). dominant in the global food system. . 2013; 14 Suppl 2:21-28. doi:10.1136/bmjopen-2012-001538 Obes Rev doi:10.1111/obr.12107 30. Mazarello Paes V, Ong KK, Lakshman R. Factors influencing obesogenic dietary intake 15. Popkin BM, Corvalan C, Grummer-Strawn LM. Dynamics of the double burden of in young children (0–6 years): systematic review of qualitative evidence. BMJ Open. malnutrition and the changing nutrition reality. . 2020; 395(10217):65-74. 2015; 5(9):e007396. doi:10.1136/bmjopen-2014-007396 Lancet doi:10.1016/S0140-6736(19)32497-3 31. Leandro CG, Fonseca EV da S da, de Lim CR, et al. Barriers and Enablers That Influence 16. Bauman AE, Reis RS, Sallis JF, et al. Correlates of physical activity: why are some Overweight/Obesity/Obesogenic Behavior in Adolescents From Lower-Middle people physically active and others not? . 2012; 380(9838):258-271. Income Countries: A Systematic Review. Food Nutr Bull. 2019. Lancet doi:10.1016/S0140-6736(12)60735-1 doi:10.1177/0379572119853926 17. Ford ND, Patel SA, Narayan KM. Obesity in Low- and Middle-Income Countries: 32. Madjdian DS, Azupogo F, Osendarp SJM, et al. Socio-cultural and economic Burden, Drivers, and Emerging Challenges. . 2017; 38:145-164. determinants and consequences of adolescent undernutrition and micronutrient Annu Rev Public Health doi:10.1146/annurev-publhealth-031816-044604 53 Chapter 2 deficiencies in LLMICs: a systematic narrative review. Ann N Y Acad Sci. 2018; 48. Chastin SF, De Craemer M, Lien N, et al. The SOS-framework (Systems of Sedentary 1416(1):117-139. behaviours): an international transdisciplinary consensus framework for the study of 33. Verstraeten R, Roberfroid D, Lachat C, et al. Effectiveness of preventive school-based determinants, research priorities and policy on sedentary behaviour across the life obesity interventions in low- and middle-income countries: A systematic review. Am course: a DEDIPAC-study. Int J Behav Nutr Phys Act. 2016; 13:83. doi:10.1186/s12966- J Clin Nutr. 2012. doi:10.3945/ajcn.112.035378 016-0409-3 34. Romieu I, Dossus L, Barquera S, et al. Energy balance and obesity: what are the main 49. Condello G, Ling FC, Bianco A, et al. Using concept mapping in the development of drivers? Cancer Causes Control. 2017; 28(3):247-258. doi:10.1007/s10552-017-0869- the EU-PAD framework (EUropean-Physical Activity Determinants across the life z course): a DEDIPAC-study. BMC Public Health. 2016; 16(1):1145. doi:10.1186/s12889- 35. Flemming K, Booth A, Garside R, et al. Qualitative evidence synthesis for complex 016-3800-8 interventions and guideline development: clarification of the purpose, designs and 50. Holdsworth M, Landais E. Urban food environments in Africa: implications for policy relevant methods. BMJ Glob Heal. 2019. doi:10.1136/bmjgh-2018-000882 and research. Proc Nutr Soc. 2019; 78(4):513-525. doi:10.1017/S0029665118002938 36. Booth A, Carroll C. How to build up the actionable knowledge base: the role of ‘best 51. Booth A. Clear and present questions: Formulating questions for evidence based fit’ framework synthesis for studies of improvement in healthcare. BMJ Qual Saf. practice. Libr HI TECH. 2006; 24. doi:10.1108/07378830610692127 2015; 24:bmjqs-2014. doi:10.1136/bmjqs-2014-003642 52. World Bank Country and Lending Groups. 37. Ziemann A, Brown L, Sadler E, et al. Influence of external contextual factors on the https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank- implementation of health and social care interventions into practice within or across country-and-lending-groups2019. Accessed March 1, 2019. countries—a protocol for a ‘best fit’ framework synthesis. Syst Rev. 2019; 8(1):258. 53. CASP. Critical Appraisal Skills Programme. CASP (Sytematic Review) Checklist. doi:10.1186/s13643-019-1180-8 www.casp-uk.net. Published 2018. Accessed September 1, 2019. 38. Shamseer L, Moher D, Clarke M, et al. Preferred reporting items for systematic review 54. Carroll C, Booth A, Lloyd-Jones M. Should We Exclude Inadequately Reported Studies and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ. From Qualitative Systematic Reviews? An Evaluation of Sensitivity Analyses in Two 2015; 349. doi:10.1136/bmj.g7647 Case Study Reviews. Qual Health Res. 2012; 22(10):1425-1434. 39. Tong A, Flemming K, McInnes E, et al. Enhancing transparency in reporting the doi:10.1177/1049732312452937 synthesis of qualitative research: ENTREQ. BMC Med Res Methodol. 2012; 12(1):181. 55. France EF, Wells M, Lang H, et al. Why, when and how to update a meta-ethnography doi:10.1186/1471-2288-12-181 qualitative synthesis. Syst Rev. 2016; 5(1):44. doi:10.1186/s13643-016-0218-4 40. Booth A, Carroll C. Systematic searching for theory to inform systematic reviews: is it 56. Scott S, Reilly J, Giles EL, et al. Socio-ecological influences on adolescent (aged 10-17) feasible? Is it desirable? Heal Inf Libr J. 2015; 32(3):220-235. doi:10.1111/hir.12108 alcohol use and linked unhealthy eating behaviours: Protocol for a systematic review 41. Booth A. Unpacking your literature search toolbox: on search styles and tactics. Heal and synthesis of qualitative studies. Syst Rev. 2017. doi:10.1186/s13643-017-0574-8 Inf Libr J. 2008; 25(4):313-317. doi:10.1111/j.1471-1842.2008.00825.x 57. Neumark-Sztainer D, Story M, Perry C, et al. Factors influencing food choices of 42. Simmons A, Mavoa HM, Bell AC, et al. Creating community action plans for obesity adolescents: Findings from focus- group discussions with adolescents. J Am Diet prevention using the ANGELO (Analysis Grid for Elements Linked to Obesity) Assoc. 1999. doi:10.1016/S0002-8223(99)00222-9 Framework. Health Promot Int. 2009; 24(4):311-324. doi:10.1093/heapro/dap029 58. Corr M, McSharry J, Murtagh EM. Adolescent Girls’ Perceptions of Physical Activity: A 43. Swinburn BA, Sacks G, Hall KD, et al. The global obesity pandemic: shaped by global Systematic Review of Qualitative Studies. Am J Heal Promot. 2019. drivers and local environments. Lancet. 2011; 378(9793):804-814. doi:10.1177/0890117118818747 doi:10.1016/S0140-6736(11)60813-1 59. Martins J, Marques A, Sarmento H, et al. Adolescents’ perspectives on the barriers 44. Stok FM, Hoffmann S, Volkert D, et al. The DONE framework: Creation, evaluation, and facilitators of physical activity: A systematic review of qualitative studies. Health and updating of an interdisciplinary, dynamic framework 2.0 of determinants of Educ Res. 2014. doi:10.1093/her/cyv042 nutrition and eating. PLoS One. 2017; 12(2):e0171077. 60. Walls H, Baker P, Chirwa E, et al. Food security, food safety & healthy nutrition: are doi:10.1371/journal.pone.0171077 they compatible? Glob Food Sec. 2019; 21. doi:10.1016/j.gfs.2019.05.005 45. Story M, Kaphingst KM, Robinson-O’Brien R, et al. Creating healthy food and eating 61. Wertheim-Heck SCO, Raneri JE. A cross-disciplinary mixed-method approach to environments: policy and environmental approaches. Annu Rev Public Health. 2008; understand how food retail environment transformations influence food choice and 29:253-272. doi:10.1146/annurev.publhealth.29.020907.090926 intake among the urban poor: Experiences from Vietnam. Appetite. 2019; 46. Booth SL, Sallis JF, Ritenbaugh C, et al. Environmental and societal factors affect food 142:104370. doi:https://doi.org/10.1016/j.appet.2019.104370 choice and physical activity: rationale, influences, and leverage points. Nutr Rev. 62. Pitt E, Gallegos D, Comans T, et al. Exploring the influence of local food environments 2001; 59(3 Pt 2):S21-39; discussion S57-65. doi:10.1111/j.1753-4887.2001.tb06983.x on food behaviours: A systematic review of qualitative literature. Public Health Nutr. 47. Sallis JF, Cervero RB, Ascher W, et al. An ecological approach to creating active living 2017. doi:10.1017/S1368980017001069 communities. Annu Rev Public Health. 2006; 27:297-322. 63. Cockx L, Colen L, De Weerdt J. From corn to popcorn? Urbanization and dietary doi:10.1146/annurev.publhealth.27.021405.102100 change: Evidence from rural-urban migrants in Tanzania. World Dev. 2018; 110:140- 159. doi:https://doi.org/10.1016/j.worlddev.2018.04.018 54 Qualitative evidence synthesis deficiencies in LLMICs: a systematic narrative review. Ann N Y Acad Sci. 2018; 48. Chastin SF, De Craemer M, Lien N, et al. The SOS-framework (Systems of Sedentary 1416(1):117-139. behaviours): an international transdisciplinary consensus framework for the study of 33. Verstraeten R, Roberfroid D, Lachat C, et al. Effectiveness of preventive school-based determinants, research priorities and policy on sedentary behaviour across the life obesity interventions in low- and middle-income countries: A systematic review. Am course: a DEDIPAC-study. Int J Behav Nutr Phys Act. 2016; 13:83. doi:10.1186/s12966- J Clin Nutr. 2012. doi:10.3945/ajcn.112.035378 016-0409-3 34. Romieu I, Dossus L, Barquera S, et al. Energy balance and obesity: what are the main 49. Condello G, Ling FC, Bianco A, et al. Using concept mapping in the development of drivers? Cancer Causes Control. 2017; 28(3):247-258. doi:10.1007/s10552-017-0869- the EU-PAD framework (EUropean-Physical Activity Determinants across the life 2 z course): a DEDIPAC-study. BMC Public Health. 2016; 16(1):1145. doi:10.1186/s12889- 35. Flemming K, Booth A, Garside R, et al. Qualitative evidence synthesis for complex 016-3800-8 interventions and guideline development: clarification of the purpose, designs and 50. Holdsworth M, Landais E. Urban food environments in Africa: implications for policy relevant methods. BMJ Glob Heal. 2019. doi:10.1136/bmjgh-2018-000882 and research. Proc Nutr Soc. 2019; 78(4):513-525. doi:10.1017/S0029665118002938 36. Booth A, Carroll C. How to build up the actionable knowledge base: the role of ‘best 51. Booth A. Clear and present questions: Formulating questions for evidence based fit’ framework synthesis for studies of improvement in healthcare. BMJ Qual Saf. practice. Libr HI TECH. 2006; 24. doi:10.1108/07378830610692127 2015; 24:bmjqs-2014. doi:10.1136/bmjqs-2014-003642 52. World Bank Country and Lending Groups. 37. Ziemann A, Brown L, Sadler E, et al. Influence of external contextual factors on the https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank- implementation of health and social care interventions into practice within or across country-and-lending-groups2019. Accessed March 1, 2019. countries—a protocol for a ‘best fit’ framework synthesis. Syst Rev. 2019; 8(1):258. 53. CASP. Critical Appraisal Skills Programme. CASP (Sytematic Review) Checklist. doi:10.1186/s13643-019-1180-8 www.casp-uk.net. Published 2018. Accessed September 1, 2019. 38. Shamseer L, Moher D, Clarke M, et al. Preferred reporting items for systematic review 54. Carroll C, Booth A, Lloyd-Jones M. Should We Exclude Inadequately Reported Studies and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ. From Qualitative Systematic Reviews? An Evaluation of Sensitivity Analyses in Two 2015; 349. doi:10.1136/bmj.g7647 Case Study Reviews. Qual Health Res. 2012; 22(10):1425-1434. 39. Tong A, Flemming K, McInnes E, et al. Enhancing transparency in reporting the doi:10.1177/1049732312452937 synthesis of qualitative research: ENTREQ. BMC Med Res Methodol. 2012; 12(1):181. 55. France EF, Wells M, Lang H, et al. Why, when and how to update a meta-ethnography doi:10.1186/1471-2288-12-181 qualitative synthesis. Syst Rev. 2016; 5(1):44. doi:10.1186/s13643-016-0218-4 40. Booth A, Carroll C. Systematic searching for theory to inform systematic reviews: is it 56. Scott S, Reilly J, Giles EL, et al. Socio-ecological influences on adolescent (aged 10-17) feasible? Is it desirable? Heal Inf Libr J. 2015; 32(3):220-235. doi:10.1111/hir.12108 alcohol use and linked unhealthy eating behaviours: Protocol for a systematic review 41. Booth A. Unpacking your literature search toolbox: on search styles and tactics. Heal and synthesis of qualitative studies. Syst Rev. 2017. doi:10.1186/s13643-017-0574-8 Inf Libr J. 2008; 25(4):313-317. doi:10.1111/j.1471-1842.2008.00825.x 57. Neumark-Sztainer D, Story M, Perry C, et al. Factors influencing food choices of 42. Simmons A, Mavoa HM, Bell AC, et al. Creating community action plans for obesity adolescents: Findings from focus- group discussions with adolescents. J Am Diet prevention using the ANGELO (Analysis Grid for Elements Linked to Obesity) Assoc. 1999. doi:10.1016/S0002-8223(99)00222-9 Framework. Health Promot Int. 2009; 24(4):311-324. doi:10.1093/heapro/dap029 58. Corr M, McSharry J, Murtagh EM. Adolescent Girls’ Perceptions of Physical Activity: A 43. Swinburn BA, Sacks G, Hall KD, et al. The global obesity pandemic: shaped by global Systematic Review of Qualitative Studies. Am J Heal Promot. 2019. drivers and local environments. Lancet. 2011; 378(9793):804-814. doi:10.1177/0890117118818747 doi:10.1016/S0140-6736(11)60813-1 59. Martins J, Marques A, Sarmento H, et al. Adolescents’ perspectives on the barriers 44. Stok FM, Hoffmann S, Volkert D, et al. The DONE framework: Creation, evaluation, and facilitators of physical activity: A systematic review of qualitative studies. Health and updating of an interdisciplinary, dynamic framework 2.0 of determinants of Educ Res. 2014. doi:10.1093/her/cyv042 nutrition and eating. PLoS One. 2017; 12(2):e0171077. 60. Walls H, Baker P, Chirwa E, et al. Food security, food safety & healthy nutrition: are doi:10.1371/journal.pone.0171077 they compatible? Glob Food Sec. 2019; 21. doi:10.1016/j.gfs.2019.05.005 45. Story M, Kaphingst KM, Robinson-O’Brien R, et al. Creating healthy food and eating 61. Wertheim-Heck SCO, Raneri JE. A cross-disciplinary mixed-method approach to environments: policy and environmental approaches. Annu Rev Public Health. 2008; understand how food retail environment transformations influence food choice and 29:253-272. doi:10.1146/annurev.publhealth.29.020907.090926 intake among the urban poor: Experiences from Vietnam. Appetite. 2019; 46. Booth SL, Sallis JF, Ritenbaugh C, et al. Environmental and societal factors affect food 142:104370. doi:https://doi.org/10.1016/j.appet.2019.104370 choice and physical activity: rationale, influences, and leverage points. Nutr Rev. 62. Pitt E, Gallegos D, Comans T, et al. Exploring the influence of local food environments 2001; 59(3 Pt 2):S21-39; discussion S57-65. doi:10.1111/j.1753-4887.2001.tb06983.x on food behaviours: A systematic review of qualitative literature. Public Health Nutr. 47. Sallis JF, Cervero RB, Ascher W, et al. An ecological approach to creating active living 2017. doi:10.1017/S1368980017001069 communities. Annu Rev Public Health. 2006; 27:297-322. 63. Cockx L, Colen L, De Weerdt J. From corn to popcorn? Urbanization and dietary doi:10.1146/annurev.publhealth.27.021405.102100 change: Evidence from rural-urban migrants in Tanzania. World Dev. 2018; 110:140- 159. doi:https://doi.org/10.1016/j.worlddev.2018.04.018 55 Chapter 2 64. Bren d’Amour C, Pandey B, Reba M, et al. Urbanization, processed foods, and eating List of references includeed in the qualitative evidence synthesis out in India. Glob Food Sec. 2020. doi:10.1016/j.gfs.2020.100361 101. Abdelghaffar E-A, Hicham EK, Siham B, et al. Perspectives of adolescents, parents, and 65. Pinto KA, Griep RH, Rotenberg L, et al. Gender, time use and overweight and obesity teachers on barriers and facilitators of physical activity among school-age in adults: Results of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). adolescents: a qualitative analysis. Environ Health Prev Med. 2019; 24(1):21. PLoS One. 2018; 13(3):e0194190. https://doi.org/10.1371/journal.pone.0194190. 102. Abdi N, Sadeghi R, Zamani-Alavijeh F, et al. Explaining nutritional habits and behaviors 66. Azevedo MR, Araújo CLP, Reichert FF, et al. Gender differences in leisure-time of low socioeconomic status women in Sanandaj: a qualitative content analysis. physical activity. Int J Public Health. 2007; 52(1):8-15. doi:10.1007/s00038-006-5062- Electron Physician. 2016; 8(1):1733-1739. 1 103. Amiri P, Ghofranipour F, Ahmadi F, et al, Barriers to a healthy lifestyle among obese 67. Spencer RA, Rehman L, Kirk SFL. Understanding gender norms, nutrition, and physical adolescents: a qualitative study from Iran. Int J Public Heal. 2011; 56(2):181-189. activity in adolescent girls: a scoping review. Int J Behav Nutr Phys Act. 2015; 12:6. 104. Aryeetey RNO. Perceptions and Experiences of Overweight among Women in the Ga doi:10.1186/s12966-015-0166-8 East District, Ghana. Front Nutr. 2016;3. 68. Guthold R, Stevens GA, Riley LM, et al. Worldwide trends in insufficient physical 105. Atik D, Ertekin ZO. Children’s perception of food and healthy eating: Dynamics behind activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with their food preferences. Int J Consum Stud. 2013; 37(1):59-65. 1.9 million participants. Lancet Glob Heal. 2018; 6(10):e1077-e1086. 106. Bagherniya M, Darani FM, Keshavarz SA, et al. The Impact of Adolescent Friendships doi:10.1016/S2214-109X(18)30357-7 on Unhealthy Eating Behaviors of Overweight and Obese Adolescents: A Qualitative 69. Wells JCK, Marphatia AA, Cole TJ, et al. Associations of economic and gender Study. Int J Pediatr. 2018. inequality with global obesity prevalence: Understanding the female excess. Soc Sci 107. Bagherniya M, Darani FM, Sharma M, et al. Qualitative study to determine stressors Med. 2012; 75(3):482-490. doi:https://doi.org/10.1016/j.socscimed.2012.03.029 influencing dietary and physical activity behaviors of overweight and obese 70. Popkin BM, Reardon T. Obesity and the food system transformation in Latin America. adolescents in Iran. Int J Prev Med. 2019; 10(1). Obes Rev. 2018; 19(8):1028-1064. doi:10.1111/obr.12694 108. Baheiraei A, Hamzehgardeshi Z, Mohammadi MR, et al. Iranian adolescents’ 71. Headey DD, Alderman HH. The Relative Caloric Prices of Healthy and Unhealthy Foods insufficient physical activity: a mixed methods explanatory sequential study. Int J Differ Systematically across Income Levels and Continents. J Nutr. 2019; Adolesc Med Heal. 2016; 28(1):79-89. 149(11):2020-2033. doi:10.1093/jn/nxz158 109. Bailey C, Garg V, Deksha K, et al. Food choice drivers in the context of the nutrition 72. Hirvonen K, Bai Y, Headey D, et al. Affordability of the EAT-Lancet reference diet: a transition in Delhi, India. J Nutr Educ Behav. 2018; 50(7):675-686. global analysis. Lancet Glob Heal. 2020; 8(1):e59-e66. doi:10.1016/S2214- 110. Bastami F, Zamani-Alavijeh F, et al. Factors behind healthy snack consumption at 109X(19)30447-4 school among high-school students: a qualitative study. BMC Public Health. 2019; 73. Kandpal E, Baylis K. The Social Lives of Married Women : Peer Effects in Female 19(1):1342. Autonomy and Investments in Children (English). Policy Research Working Paper; No. 111. Blum L, Mellisa A, Sari EK, et al. Snacking behavior in adolescent girls living in urban WPS 8831. Washington D.C.; 2019. cities in Java, Indonesia. Ann Nutr Metab. 2017; 71:568. 74. Lewin S, Booth A, Glenton C, et al. Applying GRADE-CERQual to qualitative evidence 112. Bridle-Fitzpatrick S. Food deserts or food swamps?: A mixed-methods study of local synthesis findings: Introduction to the series. Implement Sci. 2018. food environments in a Mexican city. Soc Sci Med. 2015; 142:202-213. doi:10.1186/s13012-017-0688-3 113. Brown C, Shaibu S, Maruapula S, et al. Perceptions and attitudes towards food choice 75. De Brauw A, Van den Berg M, Brouwer ID, et al. Food System Innovations for Healthier in adolescents in Gaborone, Botswana. Appetite. 2015; 95:29-35. Diets in Low and Middle-Income Countries. Washington, DC: International Food Policy 114. Caamano MC, Ronquillo D, Kimoto R, et al. Beliefs and motives related to eating and Research Institute (IFPRI); 2019. body size: a comparison of high-BMI and normal-weight young adult women from 76. Hawkes C, Ruel MT, Salm L, et al. Double-duty actions: seizing programme and policy rural and urban areas in Mexico. BMC Public Health. 2016; 16(1):1014. opportunities to address malnutrition in all its forms. Lancet. 2020; 395(10218):142- 115. Cacavas K, Mavoa H, Kremer P, et al. Tongan adolescents’ eating patterns: 155. doi:10.1016/S0140-6736(19)32506-1 opportunities for intervention. Asia Pac J Public Heal. 2011; 23(1):24-33. 77. Micha R, Karageorgou D, Bakogianni I, et al. Effectiveness of school food environment 116. Carrete L, Arroyo P. Social marketing to improve healthy dietary decisions: Insights policies on children’s dietary behaviors: A systematic review and meta-analysis. PLoS from a qualitative study in Mexico. Qual Mark Res An Int J. 2014;17(3):239-263. One. 2018; 13(3):e0194555. doi:10.1371/journal.pone.0194555 117. Chan K, Tse T, Tam D, et al. Perception of healthy and unhealthy food among Chinese 78. Heath GW, Parra DC, Sarmiento OL, et al. Evidence-based intervention in physical adolescents. Young Consum. 2016; 17(1):32-45. activity: lessons from around the world. Lancet (London, England). 2012; 118. Chang CT, Chang KH, Cheah WL. Adults’ perceptions of being overweight or obese: a 380(9838):272-281. doi:10.1016/S0140-6736(12)60816-2 focus group study. Asia Pac J Clin Nutr. 2009; 18(2):257-264. 79. L’Abbe M, Schermel A, Minaker L, et al. Monitoring foods and beverages provided 119. Cohen E, Amougou N, Ponty A, et al. Nutrition Transition and Biocultural and sold in public sector settings. Obes Rev. 2013; 14 Suppl 1:96-107. Determinants of Obesity among Cameroonian Migrants in Urban Cameroon and doi:10.1111/obr.12079 France. Int J Env Res Public Heal. 2017; 14(7). 56 Qualitative evidence synthesis 64. Bren d’Amour C, Pandey B, Reba M, et al. Urbanization, processed foods, and eating List of references includeed in the qualitative evidence synthesis out in India. Glob Food Sec. 2020. doi:10.1016/j.gfs.2020.100361 101. Abdelghaffar E-A, Hicham EK, Siham B, et al. Perspectives of adolescents, parents, and 65. Pinto KA, Griep RH, Rotenberg L, et al. Gender, time use and overweight and obesity teachers on barriers and facilitators of physical activity among school-age in adults: Results of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). adolescents: a qualitative analysis. Environ Health Prev Med. 2019; 24(1):21. PLoS One. 2018; 13(3):e0194190. https://doi.org/10.1371/journal.pone.0194190. 102. Abdi N, Sadeghi R, Zamani-Alavijeh F, et al. Explaining nutritional habits and behaviors 66. Azevedo MR, Araújo CLP, Reichert FF, et al. Gender differences in leisure-time of low socioeconomic status women in Sanandaj: a qualitative content analysis. physical activity. Int J Public Health. 2007; 52(1):8-15. doi:10.1007/s00038-006-5062- 2 Electron Physician. 2016; 8(1):1733-1739. 1 103. Amiri P, Ghofranipour F, Ahmadi F, et al, Barriers to a healthy lifestyle among obese 67. Spencer RA, Rehman L, Kirk SFL. Understanding gender norms, nutrition, and physical adolescents: a qualitative study from Iran. Int J Public Heal. 2011; 56(2):181-189. activity in adolescent girls: a scoping review. Int J Behav Nutr Phys Act. 2015; 12:6. 104. Aryeetey RNO. Perceptions and Experiences of Overweight among Women in the Ga doi:10.1186/s12966-015-0166-8 East District, Ghana. Front Nutr. 2016;3. 68. Guthold R, Stevens GA, Riley LM, et al. Worldwide trends in insufficient physical 105. Atik D, Ertekin ZO. Children’s perception of food and healthy eating: Dynamics behind activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with their food preferences. Int J Consum Stud. 2013; 37(1):59-65. 1.9 million participants. Lancet Glob Heal. 2018; 6(10):e1077-e1086. 106. Bagherniya M, Darani FM, Keshavarz SA, et al. The Impact of Adolescent Friendships doi:10.1016/S2214-109X(18)30357-7 on Unhealthy Eating Behaviors of Overweight and Obese Adolescents: A Qualitative 69. Wells JCK, Marphatia AA, Cole TJ, et al. Associations of economic and gender Study. Int J Pediatr. 2018. inequality with global obesity prevalence: Understanding the female excess. Soc Sci 107. Bagherniya M, Darani FM, Sharma M, et al. Qualitative study to determine stressors Med. 2012; 75(3):482-490. doi:https://doi.org/10.1016/j.socscimed.2012.03.029 influencing dietary and physical activity behaviors of overweight and obese 70. Popkin BM, Reardon T. Obesity and the food system transformation in Latin America. adolescents in Iran. Int J Prev Med. 2019; 10(1). Obes Rev. 2018; 19(8):1028-1064. doi:10.1111/obr.12694 108. Baheiraei A, Hamzehgardeshi Z, Mohammadi MR, et al. Iranian adolescents’ 71. Headey DD, Alderman HH. The Relative Caloric Prices of Healthy and Unhealthy Foods insufficient physical activity: a mixed methods explanatory sequential study. Int J Differ Systematically across Income Levels and Continents. J Nutr. 2019; Adolesc Med Heal. 2016; 28(1):79-89. 149(11):2020-2033. doi:10.1093/jn/nxz158 109. Bailey C, Garg V, Deksha K, et al. Food choice drivers in the context of the nutrition 72. Hirvonen K, Bai Y, Headey D, et al. Affordability of the EAT-Lancet reference diet: a transition in Delhi, India. J Nutr Educ Behav. 2018; 50(7):675-686. global analysis. Lancet Glob Heal. 2020; 8(1):e59-e66. doi:10.1016/S2214- 110. Bastami F, Zamani-Alavijeh F, et al. Factors behind healthy snack consumption at 109X(19)30447-4 school among high-school students: a qualitative study. BMC Public Health. 2019; 73. Kandpal E, Baylis K. The Social Lives of Married Women : Peer Effects in Female 19(1):1342. Autonomy and Investments in Children (English). Policy Research Working Paper; No. 111. Blum L, Mellisa A, Sari EK, et al. Snacking behavior in adolescent girls living in urban WPS 8831. Washington D.C.; 2019. cities in Java, Indonesia. Ann Nutr Metab. 2017; 71:568. 74. Lewin S, Booth A, Glenton C, et al. Applying GRADE-CERQual to qualitative evidence 112. Bridle-Fitzpatrick S. Food deserts or food swamps?: A mixed-methods study of local synthesis findings: Introduction to the series. Implement Sci. 2018. food environments in a Mexican city. Soc Sci Med. 2015; 142:202-213. doi:10.1186/s13012-017-0688-3 113. Brown C, Shaibu S, Maruapula S, et al. Perceptions and attitudes towards food choice 75. De Brauw A, Van den Berg M, Brouwer ID, et al. Food System Innovations for Healthier in adolescents in Gaborone, Botswana. Appetite. 2015; 95:29-35. Diets in Low and Middle-Income Countries. Washington, DC: International Food Policy 114. Caamano MC, Ronquillo D, Kimoto R, et al. Beliefs and motives related to eating and Research Institute (IFPRI); 2019. body size: a comparison of high-BMI and normal-weight young adult women from 76. Hawkes C, Ruel MT, Salm L, et al. Double-duty actions: seizing programme and policy rural and urban areas in Mexico. BMC Public Health. 2016; 16(1):1014. opportunities to address malnutrition in all its forms. Lancet. 2020; 395(10218):142- 115. Cacavas K, Mavoa H, Kremer P, et al. Tongan adolescents’ eating patterns: 155. doi:10.1016/S0140-6736(19)32506-1 opportunities for intervention. Asia Pac J Public Heal. 2011; 23(1):24-33. 77. Micha R, Karageorgou D, Bakogianni I, et al. Effectiveness of school food environment 116. Carrete L, Arroyo P. Social marketing to improve healthy dietary decisions: Insights policies on children’s dietary behaviors: A systematic review and meta-analysis. PLoS from a qualitative study in Mexico. Qual Mark Res An Int J. 2014;17(3):239-263. One. 2018; 13(3):e0194555. doi:10.1371/journal.pone.0194555 117. Chan K, Tse T, Tam D, et al. Perception of healthy and unhealthy food among Chinese 78. Heath GW, Parra DC, Sarmiento OL, et al. Evidence-based intervention in physical adolescents. Young Consum. 2016; 17(1):32-45. activity: lessons from around the world. Lancet (London, England). 2012; 118. Chang CT, Chang KH, Cheah WL. Adults’ perceptions of being overweight or obese: a 380(9838):272-281. doi:10.1016/S0140-6736(12)60816-2 focus group study. Asia Pac J Clin Nutr. 2009; 18(2):257-264. 79. L’Abbe M, Schermel A, Minaker L, et al. Monitoring foods and beverages provided 119. Cohen E, Amougou N, Ponty A, et al. Nutrition Transition and Biocultural and sold in public sector settings. Obes Rev. 2013; 14 Suppl 1:96-107. Determinants of Obesity among Cameroonian Migrants in Urban Cameroon and doi:10.1111/obr.12079 France. Int J Env Res Public Heal. 2017; 14(7). 57 Chapter 2 120. Correa N, Rajaraman D, Swaminathan S, et al. Perceptions of healthy eating amongst 138. Kimoto R, Ronquillo D, Caamaño MC, et al. Food, eating and body image in the lives Indian adolescents in India and Canada. Appetite. 2017; 116:471-479. of low socioeconomic status rural Mexican women living in Queretaro State, Mexico. 121. Craveiro I, Alves D, Amado M, et al. Determinants, Health Problems, and Food Heal Place. 2014. Insecurity in Urban Areas of the Largest City in Cape Verde. Int J Env Res Public Heal. 139. Kinsman J, Norris SA, Kahn K, et al. A model for promoting physical activity among 2016; 13(11). rural South African adolescent girls. Glob Health Action. 2015. 122. Dapi LN, Omoloko C, Janlert U, et al. I Eat to be Happy, to be Strong, and to Live." - 140. Kroone D, Alant B. Understanding influences on teenage food choices in a Durban Perceptions of rural and urban adolescents in Cameroon, Africa. J Nutr Educ Behav. high school with a view to improving praxis. Int J Consum Stud. 2012; 36(4):472-479. 2007; 39(6):320-326. 141. Kurschner S, Madrigal L, Chacon V, et al. Impact of school and work status on diet and 123. De Silva Weliange S, Fernando D, Gunatilake J. Neighbourhood social environment on physical activity in rural Guatemalan adolescent girls: a qualitative study. Ann N Y physical activity among adults in Sri Lanka: a qualitative inquiry. J Coll Community Acad Sci. July 2019. Physicians Sri Lanka. 2018; 24:28. 142. Lacroix E, Oliveira E, Castro JS de, et al. “There is no way to avoid the first bite”: a 124. Doegah P, Amoateng A. Misconceptions about Physical Activity among Ghanaian qualitative investigation of addictive-like eating in treatment-seeking Brazilian Youth. In: 2017 International Population Conference. IUSSP; 2017. women and men. Appetite. 2019; 137:35-46. 125. Draper CE, Davidowitz KJ, Goedecke JH. Perceptions relating to body size, weight loss 143. Lemamsha H, Papadopoulos C, Randhawa G. Understanding the risk and protective and weight-loss interventions in black South African women: a qualitative study. factors associated with obesity amongst Libyan adults - a qualitative study. BMC Public Heal Nutr. 2016; 19(3):548-556. Public Health. 2018; 18(1):493. 126. Fachruddin II, Februhartanty J, Bardosono S, et al. Perceptions of the causes of 144. Lipus AC, Leon JS, Calle SC, et al. “It is not natural anymore”: nutrition, urbanization, obesity among normal weight, overweight and obese Indonesian women: A mixed and indigenous identity on Bolivia’s Andean plateau. (Special Issue: Connundrums of methods approach. Malays J Nutr. 2019; 25:S97-S110. care.). Qual Health Res. 2018; 28(11):1802-1812. 127. Farrell P, Thow AM, Schuster S, et al. Access to a Nutritious Diet in Samoa: Local 145. Madrigal L, Adams I, Chacon V, et al. Perceived barriers to achieving a healthy weight: Insights. Ecol Food Nutr. 2019; 58(3):189-206. a qualitative study using focus groups at public and private schools in Guatemala City. 128. Garg S, Raman Kutty V. “Do I need exercise?” A Qualitative Study on Factors Affecting BMC Public Health. 2017; 17(1):16. Leisure-Time Physical Activity in India. Qual Rep. 2019; 24(5):1065-1082. 146. Majabadi HA, Solhi M, Montazeri A, et al. Factors Influencing Fast-Food Consumption 129. Gavaravarapu SM, Rao KM, Nagalla B, et al. Assessing differences in risk perceptions Among Adolescents in Tehran: A Qualitative Study. Iran Red Crescent Med J. 2016; about obesity among “normal-weight” and “overweight” adolescents—A qualitative 18(3). study. J Nutr Educ Behav. 2015; 47(6):488-497. 147. Monge-Rojas R, Fuster-Baraona T, Garita-Arce C, et al. How Self-Objectification 130. Georgina S. Body size perceptions of women and obesity in urban Uganda. Afr Study Impacts Physical Activity Among Adolescent Girls in Costa Rica. J Phys Act Heal. 2017; Monogr. 2019; 40(1):1-21. 14(2):123-129. 131. Gonçalves H, González DA, Araújo CP, et al. Adolescents’ perception of causes of 148. Monge-Rojas R, Fuster-Baraona T, Garita C, et al. The influence of gender stereotypes obesity: Unhealthy lifestyles or heritage? J Adolesc Heal. 2012. on eating habits among Costa Rican adolescents. Am J Heal Promot. 2015; 29(5):303- 132. Habibie IY, Brouwer I, Februhartanty J. Eating behaviour of young female workers 310. with low socioeconomic status in Malang City, East Java: A qualitative study. Malays 149. Monge-Rojas R, Garita-Arce C, Sánchez-López M, et al. Barriers to and Suggestions for J Nutr. 2019; 25:S75-S86. a Healthful, Active Lifestyle as Perceived by Rural and Urban Costa Rican Adolescents. 133. Hosseini S V, Anoosheh M, Abbaszadeh A, et al. Qualitative Iranian study of parents’ J Nutr Educ Behav. 2009; 41(3):152-160. roles in adolescent girls’ physical activity habit development. Nurs Heal Sci. 2013; 150. Monge-Rojas R, Garita C, Sánchez M, et al. Barriers to and motivators for healthful 15(2):207-212. eating as perceived by rural and urban Costa Rican adolescents. J Nutr Educ Behav. 134. Hunter-Adams J, Battersby J, Oni T. Food insecurity in relation to obesity in peri-urban 2005; 37(1):33-40. Cape Town, South Africa: Implications for diet-related non-communicable disease. 151. Mugo A. Obesity Among Women in Rural Kenya: Knowledge, Beliefs, and Perceptions. Appetite. 2019; 137:244-249. ProQuest Diss Theses. 2016. 135. Islam MR, Trenholm J, Rahman A, et al. Sociocultural influences on dietary practices 152. Öztürk P, Koca C. Generational analysis of leisure time physical activity participation and physical activity behaviors of rural adolescents—A qualitative exploration. of women in Turkey. Leis Stud. 2019; 38(2):232-244. Nutrients. 2019; 11(12). 153. Pahlm J, Svensson J, Joshi SK, et al. Physical activity and diet among adolescents of 136. Kalani ZM, Pourmovahed ZM, Farajkhoda TP, et al Qualitative Approach to Women’s Kathmandu, Nepal: Knowledge and attitudes. J Kathmandu Med Coll. 2014. Perspectives on Exercise in Iran. Int J Community Based Nurs Midwifery. 2018; 154. Peykari N, Eftekhari MB, Tehrani FR, et al. Promoting Physical Activity Participation 6(2):156-166. among Adolescents: The Barriers and the Suggestions. Int J Prev Med. 2015; 6. 137. Karimi-Shahanjarini A, Omidvar N, Bazargan M, et al. Iranian female adolescent’s 155. Phillips EA, Comeau DL, Pisa PT, et al. Perceptions of diet, physical activity, and views on unhealthy snacks consumption: A qualitative study. Iran J Public Health. obesity-related health among black daughter-mother pairs in Soweto, South Africa: a 2010. qualitative study. BMC Public Health. 2016; 16:750. 58 Qualitative evidence synthesis 120. Correa N, Rajaraman D, Swaminathan S, et al. Perceptions of healthy eating amongst 138. Kimoto R, Ronquillo D, Caamaño MC, et al. Food, eating and body image in the lives Indian adolescents in India and Canada. Appetite. 2017; 116:471-479. of low socioeconomic status rural Mexican women living in Queretaro State, Mexico. 121. Craveiro I, Alves D, Amado M, et al. Determinants, Health Problems, and Food Heal Place. 2014. Insecurity in Urban Areas of the Largest City in Cape Verde. Int J Env Res Public Heal. 139. Kinsman J, Norris SA, Kahn K, et al. A model for promoting physical activity among 2016; 13(11). rural South African adolescent girls. Glob Health Action. 2015. 122. Dapi LN, Omoloko C, Janlert U, et al. I Eat to be Happy, to be Strong, and to Live." - 140. Kroone D, Alant B. Understanding influences on teenage food choices in a Durban Perceptions of rural and urban adolescents in Cameroon, Africa. J Nutr Educ Behav. high school with a view to improving praxis. 2 Int J Consum Stud. 2012; 36(4):472-479. 2007; 39(6):320-326. 141. Kurschner S, Madrigal L, Chacon V, et al. Impact of school and work status on diet and 123. De Silva Weliange S, Fernando D, Gunatilake J. Neighbourhood social environment on physical activity in rural Guatemalan adolescent girls: a qualitative study. Ann N Y physical activity among adults in Sri Lanka: a qualitative inquiry. J Coll Community Acad Sci. July 2019. Physicians Sri Lanka. 2018; 24:28. 142. Lacroix E, Oliveira E, Castro JS de, et al. “There is no way to avoid the first bite”: a 124. Doegah P, Amoateng A. Misconceptions about Physical Activity among Ghanaian qualitative investigation of addictive-like eating in treatment-seeking Brazilian Youth. In: 2017 International Population Conference. IUSSP; 2017. women and men. Appetite. 2019; 137:35-46. 125. Draper CE, Davidowitz KJ, Goedecke JH. Perceptions relating to body size, weight loss 143. Lemamsha H, Papadopoulos C, Randhawa G. Understanding the risk and protective and weight-loss interventions in black South African women: a qualitative study. factors associated with obesity amongst Libyan adults - a qualitative study. BMC Public Heal Nutr. 2016; 19(3):548-556. Public Health. 2018; 18(1):493. 126. Fachruddin II, Februhartanty J, Bardosono S, et al. Perceptions of the causes of 144. Lipus AC, Leon JS, Calle SC, et al. “It is not natural anymore”: nutrition, urbanization, obesity among normal weight, overweight and obese Indonesian women: A mixed and indigenous identity on Bolivia’s Andean plateau. (Special Issue: Connundrums of methods approach. Malays J Nutr. 2019; 25:S97-S110. care.). Qual Health Res. 2018; 28(11):1802-1812. 127. Farrell P, Thow AM, Schuster S, et al. Access to a Nutritious Diet in Samoa: Local 145. Madrigal L, Adams I, Chacon V, et al. Perceived barriers to achieving a healthy weight: Insights. Ecol Food Nutr. 2019; 58(3):189-206. a qualitative study using focus groups at public and private schools in Guatemala City. 128. Garg S, Raman Kutty V. “Do I need exercise?” A Qualitative Study on Factors Affecting BMC Public Health. 2017; 17(1):16. Leisure-Time Physical Activity in India. Qual Rep. 2019; 24(5):1065-1082. 146. Majabadi HA, Solhi M, Montazeri A, et al. Factors Influencing Fast-Food Consumption 129. Gavaravarapu SM, Rao KM, Nagalla B, et al. Assessing differences in risk perceptions Among Adolescents in Tehran: A Qualitative Study. Iran Red Crescent Med J. 2016; about obesity among “normal-weight” and “overweight” adolescents—A qualitative 18(3). study. J Nutr Educ Behav. 2015; 47(6):488-497. 147. Monge-Rojas R, Fuster-Baraona T, Garita-Arce C, et al. How Self-Objectification 130. Georgina S. Body size perceptions of women and obesity in urban Uganda. Afr Study Impacts Physical Activity Among Adolescent Girls in Costa Rica. J Phys Act Heal. 2017; Monogr. 2019; 40(1):1-21. 14(2):123-129. 131. Gonçalves H, González DA, Araújo CP, et al. Adolescents’ perception of causes of 148. Monge-Rojas R, Fuster-Baraona T, Garita C, et al. The influence of gender stereotypes obesity: Unhealthy lifestyles or heritage? J Adolesc Heal. 2012. on eating habits among Costa Rican adolescents. Am J Heal Promot. 2015; 29(5):303- 132. Habibie IY, Brouwer I, Februhartanty J. Eating behaviour of young female workers 310. with low socioeconomic status in Malang City, East Java: A qualitative study. Malays 149. Monge-Rojas R, Garita-Arce C, Sánchez-López M, et al. Barriers to and Suggestions for J Nutr. 2019; 25:S75-S86. a Healthful, Active Lifestyle as Perceived by Rural and Urban Costa Rican Adolescents. 133. Hosseini S V, Anoosheh M, Abbaszadeh A, et al. Qualitative Iranian study of parents’ J Nutr Educ Behav. 2009; 41(3):152-160. roles in adolescent girls’ physical activity habit development. Nurs Heal Sci. 2013; 150. Monge-Rojas R, Garita C, Sánchez M, et al. Barriers to and motivators for healthful 15(2):207-212. eating as perceived by rural and urban Costa Rican adolescents. J Nutr Educ Behav. 134. Hunter-Adams J, Battersby J, Oni T. Food insecurity in relation to obesity in peri-urban 2005; 37(1):33-40. Cape Town, South Africa: Implications for diet-related non-communicable disease. 151. Mugo A. Obesity Among Women in Rural Kenya: Knowledge, Beliefs, and Perceptions. Appetite. 2019; 137:244-249. ProQuest Diss Theses. 2016. 135. Islam MR, Trenholm J, Rahman A, et al. Sociocultural influences on dietary practices 152. Öztürk P, Koca C. Generational analysis of leisure time physical activity participation and physical activity behaviors of rural adolescents—A qualitative exploration. of women in Turkey. Leis Stud. 2019; 38(2):232-244. Nutrients. 2019; 11(12). 153. Pahlm J, Svensson J, Joshi SK, et al. Physical activity and diet among adolescents of 136. Kalani ZM, Pourmovahed ZM, Farajkhoda TP, et al Qualitative Approach to Women’s Kathmandu, Nepal: Knowledge and attitudes. J Kathmandu Med Coll. 2014. Perspectives on Exercise in Iran. Int J Community Based Nurs Midwifery. 2018; 154. Peykari N, Eftekhari MB, Tehrani FR, et al. Promoting Physical Activity Participation 6(2):156-166. among Adolescents: The Barriers and the Suggestions. Int J Prev Med. 2015; 6. 137. Karimi-Shahanjarini A, Omidvar N, Bazargan M, et al. Iranian female adolescent’s 155. Phillips EA, Comeau DL, Pisa PT, et al. Perceptions of diet, physical activity, and views on unhealthy snacks consumption: A qualitative study. Iran J Public Health. obesity-related health among black daughter-mother pairs in Soweto, South Africa: a 2010. qualitative study. BMC Public Health. 2016; 16:750. 59 Chapter 2 156. Phillips JS, Awotidebe AW. The influence of the social environment on youth physical Appendix 2.1. Search syntax for Medline activity: sport education and community development. (Special Issue: Current issues in sport, physical activity, recreation and health.). African J Phys Heal Educ Recreat Danc. 2015; 21(Suppl. 1):263-271. SPICE No Pub med Syntax Search 157. Rajaraman D, Correa N, Punthakee Z, et al. Perceived Benefits, Facilitators, 5/29/2019 Disadvantages, and Barriers for Physical Activity Amongst South Asian Adolescents in Perspective #1 ((Adolescent OR Adult) AND (girl OR woman OR female)) OR 864580 India and Canada. J Phys Act Heal. 2015; 12(7):931-941 (woman OR female) 158. Rathi N, Riddell L, Worsley A. What influences urban Indian secondary school Phenomenon #2 Diet, food, and nutrition [MeSH Terms] OR diet OR dietary 1872517 students’ food consumption?—A qualitative study. Appetite. 2016; 105:790-797. of interest OR nutrition OR overweight OR obesity OR obesogenic OR 159. Rodriguez-Ventura AL, Pelaez-Ballestas I, Samano-Samano R, et al. Barriers to lose obese OR physical activity [MeSH Terms] OR “physical weight from the perspective of children with overweight/obesity and their parents: a activity" OR sedentary lifestyle sociocultural approach. J Obes. 2014; 2014:575184. LMIC #3 Afghanistan OR Angola OR Bangladesh OR Benin OR Bhutan 4454035 160. Romero MYM, Jeitner EC, Francis LA. Visualizing Perceived Enablers of and Barriers OR Bolivia OR “Burkina Faso” OR Burkina OR Burundi OR to Healthy Eating by Youth in Rural El Salvador. J Nutr Educ Behav. 2019; 51:348-356. “Cabo Verde” OR “Cape verde” OR Cambodia OR Cameroon 161. Saimon R, Choo WY, Bulgiba A. “Feeling unsafe”: A photovoice analysis of factors OR Cameron OR “Central African Republic” OR Chad OR influencing physical activity behavior among malaysian adolescents. Asia-Pacific J Comoros OR Comoro OR Comores OR “Democratic Republic Public Heal. 2015. of Congo” OR “Republic of Congo” OR Congo OR “Côte 162. Satija A, Khandpur N, Satija S, et al. Physical Activity Among Adolescents in India: A d’Ivoire” OR “Ivory Coast” OR Djibouti OR Egypt OR “El Qualitative Study of Barriers and Enablers. Heal Educ Behav. 2018; 45(6):926-934. Salvador” OR Eritrea OR Ethiopia OR Gambia OR Georgia OR 163. Sedibe HM, Kahn K, Edin K, et al. Qualitative study exploring healthy eating practices Ghana OR Guinea OR “Guinea-Bissau” Or Haiti OR Honduras and physical activity among adolescent girls in rural South Africa. BMC Pediatr. 2014; OR India OR Indonesia OR Kenya OR Kiribati OR Korea OR 14(1):211. Kosovo OR “Kyrgyz Republic” OR Kyrgyzstan OR Kirghizia OR 164. Sondari M, Brouwer I, Februhartanty J. Eating behaviour of adolescent schoolgirls in Lao OR Laos OR Lesotho OR Liberia Or Madagascar Or Malang, East Java: A qualitative study. Malays J Nutr. 2019; 25:S87-S96. Malawi OR Mali OR Mauritania Or Micronesia OR Moldova 165. Ssewanyana D, van Baar A, Newton CR, Abubakar A. A contextually relevant approach OR Mongolia OR Morocco OR Mozambique OR Myanmar to assessing health risk behavior in a rural sub-Saharan Africa setting: the Kilifi health OR Burma OR Nauru OR Nepal Or Nicaragua OR Niger OR risk behavior questionnaire. BMC Public Health. 2018; 18(1):774. Nigeria OR Pakistan OR “Papua New Guinea” OR Peru OR 166. Stupar D, Eide WB, Bourne L, et al. The nutrition transition and the human right to Philippines OR Rwanda OR Ruanda OR “Sao Tome and adequate food for adolescents in the Cape Town metropolitan area: Implications for Principe” OR Senegal OR “Sierra Leone” OR “Solomon nutrition policy. Food Policy. 2012; 37(3):199-206. Islands” OR Somalia OR “South Sudan” OR “Sri Lanka” OR 167. Usman A, Javed M, Amjad A, et al. Food, City and Young Globavores: perceptions of Sudan OR Swaziland OR Syria OR Tajikistan OR Tadzhikistan Pakistani urban youth about food choices and healthy eating. Anthropol. 2017; 27(1- OR Tadjikistan OR Tanzania OR “Timor-Leste” OR “East 3):143-151. Timor” OR Togo OR “Togolese Republic” OR Tunisia OR 168. Veeck A, Grace Yu F, Yu H, et al. Influences on food choices of urban Chinese Uganda OR Ukraine OR Uzbekistan OR Vanuatu OR Vietnam teenagers. Young Consum. 2014; 15(4):296-311. OR “West Bank and Gaza” OR Gaza OR Yemen OR Zambia 169. Voorend CGN, Norris SA, Griffiths PL, et al. “We eat together; today she buys, OR Zimbabwe OR Albania OR Algeria OR “American Samoa” tomorrow I will buy the food”: adolescent best friends’ food choices and dietary OR Armenia OR Azerbaijan OR Belarus OR Belize OR “Bosnia practices in Soweto, South Africa. Public Health Nutr. 2013; 16(3):559-567. and Herzegovina” OR Botswana OR Brazil OR Bulgaria OR 170. Walter CM, Du Randt R. Socio-cultural barriers to physical activity among black China OR Colombia OR “Costa Rica” OR Cuba OR Dominica Isixhosa speaking professional women in the Nelson Mandela Metropolitan OR “Dominican Republic” OR Ecuador OR “Equatorial municipality. South African J Res Sport Phys Educ Recreat. 2011; 33(2):143-155. Guinea” OR Fiji OR Gabon OR Grenada OR Guatemala OR 171. Ware LJ, Prioreschi A, Bosire E, et al. Environmental, Social, and Structural Constraints Guyana OR Iran OR Iraq OR Jamaica OR Jordan OR Kazakh* for Health Behavior: Perceptions of Young Urban Black Women During the OR Lebanon OR Libya OR Macedonia OR Malaysia OR Preconception Period-A Healthy Life Trajectories Initiative. J Nutr Educ Behav. 2019. Maldives OR “Marshall Islands” OR Mauritius OR Mexico OR 172. Wrottesley S V, Bosire EN, Mukoma G, et al. Age and gender influence healthy eating Montenegro OR Namibia OR Paraguay OR Peru OR Romania and physical activity behaviours in South African adolescents and their caregivers: OR “Russian Federation” OR Samoa OR Serbia OR “South Transforming Adolescent Lives through Nutrition Initiative (TALENT). Public Health Africa” OR “South African” OR “Saint Lucia” OR “Saint Nutr. 2019. 60 Qualitative evidence synthesis 156. Phillips JS, Awotidebe AW. The influence of the social environment on youth physical Appendix 2.1. Search syntax for Medline activity: sport education and community development. (Special Issue: Current issues in sport, physical activity, recreation and health.). African J Phys Heal Educ Recreat . 2015; 21(Suppl. 1):263-271. SPICE No Pub med Syntax Search Danc 157. Rajaraman D, Correa N, Punthakee Z, et al. Perceived Benefits, Facilitators, 5/29/2019 Disadvantages, and Barriers for Physical Activity Amongst South Asian Adolescents in Perspective #1 ((Adolescent OR Adult) AND (girl OR woman OR female)) OR 864580 India and Canada. 2 J Phys Act Heal. 2015; 12(7):931-941 (woman OR female) 158. Rathi N, Riddell L, Worsley A. What influences urban Indian secondary school Phenomenon #2 Diet, food, and nutrition [MeSH Terms] OR diet OR dietary 1872517 students’ food consumption?—A qualitative study. Appetite. 2016; 105:790-797. of interest OR nutrition OR overweight OR obesity OR obesogenic OR 159. Rodriguez-Ventura AL, Pelaez-Ballestas I, Samano-Samano R, et al. Barriers to lose obese OR physical activity [MeSH Terms] OR “physical weight from the perspective of children with overweight/obesity and their parents: a activity" OR sedentary lifestyle sociocultural approach. J Obes. 2014; 2014:575184. LMIC #3 Afghanistan OR Angola OR Bangladesh OR Benin OR Bhutan 4454035 160. Romero MYM, Jeitner EC, Francis LA. Visualizing Perceived Enablers of and Barriers OR Bolivia OR “Burkina Faso” OR Burkina OR Burundi OR to Healthy Eating by Youth in Rural El Salvador. J Nutr Educ Behav. 2019; 51:348-356. “Cabo Verde” OR “Cape verde” OR Cambodia OR Cameroon 161. Saimon R, Choo WY, Bulgiba A. “Feeling unsafe”: A photovoice analysis of factors OR Cameron OR “Central African Republic” OR Chad OR influencing physical activity behavior among malaysian adolescents. Asia-Pacific J Comoros OR Comoro OR Comores OR “Democratic Republic Public Heal. 2015. of Congo” OR “Republic of Congo” OR Congo OR “Côte 162. Satija A, Khandpur N, Satija S, et al. Physical Activity Among Adolescents in India: A d’Ivoire” OR “Ivory Coast” OR Djibouti OR Egypt OR “El Qualitative Study of Barriers and Enablers. Heal Educ Behav. 2018; 45(6):926-934. Salvador” OR Eritrea OR Ethiopia OR Gambia OR Georgia OR 163. Sedibe HM, Kahn K, Edin K, et al. Qualitative study exploring healthy eating practices Ghana OR Guinea OR “Guinea-Bissau” Or Haiti OR Honduras and physical activity among adolescent girls in rural South Africa. BMC Pediatr. 2014; OR India OR Indonesia OR Kenya OR Kiribati OR Korea OR 14(1):211. Kosovo OR “Kyrgyz Republic” OR Kyrgyzstan OR Kirghizia OR 164. Sondari M, Brouwer I, Februhartanty J. Eating behaviour of adolescent schoolgirls in Lao OR Laos OR Lesotho OR Liberia Or Madagascar Or Malang, East Java: A qualitative study. Malays J Nutr. 2019; 25:S87-S96. Malawi OR Mali OR Mauritania Or Micronesia OR Moldova 165. Ssewanyana D, van Baar A, Newton CR, Abubakar A. A contextually relevant approach OR Mongolia OR Morocco OR Mozambique OR Myanmar to assessing health risk behavior in a rural sub-Saharan Africa setting: the Kilifi health OR Burma OR Nauru OR Nepal Or Nicaragua OR Niger OR risk behavior questionnaire. BMC Public Health. 2018; 18(1):774. Nigeria OR Pakistan OR “Papua New Guinea” OR Peru OR 166. Stupar D, Eide WB, Bourne L, et al. The nutrition transition and the human right to Philippines OR Rwanda OR Ruanda OR “Sao Tome and adequate food for adolescents in the Cape Town metropolitan area: Implications for Principe” OR Senegal OR “Sierra Leone” OR “Solomon nutrition policy. Food Policy. 2012; 37(3):199-206. Islands” OR Somalia OR “South Sudan” OR “Sri Lanka” OR 167. Usman A, Javed M, Amjad A, et al. Food, City and Young Globavores: perceptions of Sudan OR Swaziland OR Syria OR Tajikistan OR Tadzhikistan Pakistani urban youth about food choices and healthy eating. Anthropol. 2017; 27(1- OR Tadjikistan OR Tanzania OR “Timor-Leste” OR “East 3):143-151. Timor” OR Togo OR “Togolese Republic” OR Tunisia OR 168. Veeck A, Grace Yu F, Yu H, et al. Influences on food choices of urban Chinese Uganda OR Ukraine OR Uzbekistan OR Vanuatu OR Vietnam teenagers. Young Consum. 2014; 15(4):296-311. OR “West Bank and Gaza” OR Gaza OR Yemen OR Zambia 169. Voorend CGN, Norris SA, Griffiths PL, et al. “We eat together; today she buys, OR Zimbabwe OR Albania OR Algeria OR “American Samoa” tomorrow I will buy the food”: adolescent best friends’ food choices and dietary OR Armenia OR Azerbaijan OR Belarus OR Belize OR “Bosnia practices in Soweto, South Africa. Public Health Nutr. 2013; 16(3):559-567. and Herzegovina” OR Botswana OR Brazil OR Bulgaria OR 170. Walter CM, Du Randt R. Socio-cultural barriers to physical activity among black China OR Colombia OR “Costa Rica” OR Cuba OR Dominica Isixhosa speaking professional women in the Nelson Mandela Metropolitan OR “Dominican Republic” OR Ecuador OR “Equatorial municipality. South African J Res Sport Phys Educ Recreat. 2011; 33(2):143-155. Guinea” OR Fiji OR Gabon OR Grenada OR Guatemala OR 171. Ware LJ, Prioreschi A, Bosire E, et al. Environmental, Social, and Structural Constraints Guyana OR Iran OR Iraq OR Jamaica OR Jordan OR Kazakh* for Health Behavior: Perceptions of Young Urban Black Women During the OR Lebanon OR Libya OR Macedonia OR Malaysia OR Preconception Period-A Healthy Life Trajectories Initiative. J Nutr Educ Behav. 2019. Maldives OR “Marshall Islands” OR Mauritius OR Mexico OR 172. Wrottesley S V, Bosire EN, Mukoma G, et al. Age and gender influence healthy eating Montenegro OR Namibia OR Paraguay OR Peru OR Romania and physical activity behaviours in South African adolescents and their caregivers: OR “Russian Federation” OR Samoa OR Serbia OR “South Transforming Adolescent Lives through Nutrition Initiative (TALENT). Public Health Africa” OR “South African” OR “Saint Lucia” OR “Saint Nutr. 2019. 61 Chapter 2 Vincent and the Grenadines” OR Suriname Or Thailand OR Appendix 2.2. Framework for coding Tonga OR Turkey OR Turkmenistan OR Tuvalu OR Venezuela #4 "developing country" OR “developing countries” OR 139654 "developing world" OR "middle income country" OR Framework Codes Definition and/or examples reference "middle income countries" OR "low income country" OR "low income countries" OR “low and middle income Individual - demographics country” OR “low and middle income countries” OR lmic OR Socio-economic aspects of the individual (Wealth, Income, SES of the lmics OR "third world" 1 1, 2, 3, 4, 5 quality of life, food expenditure, food insecurity of the individual Setting #5 #3 OR #4 4503091 individual, pocket money) Evaluation #6 qualitative research OR “focus group” OR “focus groups” 267277 Educational attainment of the individual, not family/HH Educational 2 1, 5 members, plans for education, studying pressure, health OR narrative* OR narration OR “semi-structured level literacy, private/public school, obligatory uniform interview*” OR ethnograph* OR “lived experience” OR “key 3 Employment 1, 2, 3 Employment status of individual, shift work, out-of school, informant” OR “key informants” OR “grounded theory” OR 4 Family situation 1, 2, 3, 4, 6 Marital status, dependency on others, single, having children “thematic analysis” OR “content analysis” OR “action Cultural Culturally-defined demography (nationality, ethnicity, migration research” OR “participatory research” OR “mixed method” 5 1, 2, 3 characteristics history) OR "mixed methods" OR “mixed approaches” OR “mixed Individual - biological study” OR “process evaluation” OR "in-depth interview" OR “in-depth interviews” Age of individual and/or pubertal stage, life experience, life 6 Age 1, 2, 3, 4, 5 #7 #1 AND #2 AND #5AND #6 2993 stage Physical health status, oral system and oral functionality #8 #7 AND English 2886 (problems with chewing, wearing dentures, leg power, health 7 Physical health 1, 2, 3, 4, 5, 6 status, burden of disease, vision, sleep characteristics), Pathological conditions affecting physical capacity, such as injuries, pain or disabilities, healthy lifestyle Weight status/body composition/overweight, obesity in the 8 Anthropometry 1, 2, 3, 4 past/actual BMI, physical size and shape (BMI, birth weight) Physiological characteristics especially relevant for diet and Food related 9 1, 4, 5 nutrition that are not covered by other categories (e.g food physiology allergies, obesity-associated genes) Brain function/functionality, psychological disorders 10 Mental health 1, 2, 3, 4 (depression, eating disorder, …), sub-consciousness, compensating for loneliness/boredom Physical function, training response, physical fitness, skills Physical 11 2, 3 (strength, endurance, coordination, agility, flexibility, energy capacity level, dose/response-training/response) Genetic predisposition for nutrient intolerances or weight gain, 12 Genetics 2, 3, 5 or talent for certain sports, individual metabolism, individual physiology Pregnancy/lact 13 1, 2 Past or current pregnancies, family planning, contraceptive use ation Individual - cognitive Psychological strategies for regulation of consumption, situational occurrence of feeling hungry, food deprivation and Appetite and 14 1, 4, 5 satiety/eating regulation, sensory system and sensory hunger perception (fat liking, taste preferences) related to taste/aroma of food/food appearance Affective states and stable moods (depressive symptomatology, Mood and 15 1, 2, 3, 4 positive emotions), feeling of inadequacy, teasing, pleasure, emotions frustration) Perception of diet quality/health/food safety/time spent 16 Perception 1, 2, 3, 6 sitting/PA barriers, Perceptions of risks related to physical 62 Qualitative evidence synthesis Vincent and the Grenadines” OR Suriname Or Thailand OR Appendix 2.2. Framework for coding Tonga OR Turkey OR Turkmenistan OR Tuvalu OR Venezuela #4 "developing country" OR “developing countries” OR 139654 "developing world" OR "middle income country" OR Framework Codes Definition and/or examples reference "middle income countries" OR "low income country" OR "low income countries" OR “low and middle income Individual - demographics country” OR “low and middle income countries” OR lmic OR Socio-economic aspects of the individual (Wealth, Income, 2 SES of the lmics OR "third world" 1 1, 2, 3, 4, 5 quality of life, food expenditure, food insecurity of the individual Setting #5 #3 OR #4 4503091 individual, pocket money) Evaluation #6 qualitative research OR “focus group” OR “focus groups” 267277 Educational attainment of the individual, not family/HH Educational 2 1, 5 members, plans for education, studying pressure, health OR narrative* OR narration OR “semi-structured level literacy, private/public school, obligatory uniform interview*” OR ethnograph* OR “lived experience” OR “key 3 Employment 1, 2, 3 Employment status of individual, shift work, out-of school, informant” OR “key informants” OR “grounded theory” OR 4 Family situation 1, 2, 3, 4, 6 Marital status, dependency on others, single, having children “thematic analysis” OR “content analysis” OR “action Cultural Culturally-defined demography (nationality, ethnicity, migration research” OR “participatory research” OR “mixed method” 5 1, 2, 3 characteristics history) OR "mixed methods" OR “mixed approaches” OR “mixed Individual - biological study” OR “process evaluation” OR "in-depth interview" OR “in-depth interviews” Age of individual and/or pubertal stage, life experience, life 6 Age 1, 2, 3, 4, 5 #7 #1 AND #2 AND #5AND #6 2993 stage Physical health status, oral system and oral functionality #8 #7 AND English 2886 (problems with chewing, wearing dentures, leg power, health 7 Physical health 1, 2, 3, 4, 5, 6 status, burden of disease, vision, sleep characteristics), Pathological conditions affecting physical capacity, such as injuries, pain or disabilities, healthy lifestyle Weight status/body composition/overweight, obesity in the 8 Anthropometry 1, 2, 3, 4 past/actual BMI, physical size and shape (BMI, birth weight) Physiological characteristics especially relevant for diet and Food related 9 1, 4, 5 nutrition that are not covered by other categories (e.g food physiology allergies, obesity-associated genes) Brain function/functionality, psychological disorders 10 Mental health 1, 2, 3, 4 (depression, eating disorder, …), sub-consciousness, compensating for loneliness/boredom Physical function, training response, physical fitness, skills Physical 11 2, 3 (strength, endurance, coordination, agility, flexibility, energy capacity level, dose/response-training/response) Genetic predisposition for nutrient intolerances or weight gain, 12 Genetics 2, 3, 5 or talent for certain sports, individual metabolism, individual physiology Pregnancy/lact 13 1, 2 Past or current pregnancies, family planning, contraceptive use ation Individual - cognitive Psychological strategies for regulation of consumption, situational occurrence of feeling hungry, food deprivation and Appetite and 14 1, 4, 5 satiety/eating regulation, sensory system and sensory hunger perception (fat liking, taste preferences) related to taste/aroma of food/food appearance Affective states and stable moods (depressive symptomatology, Mood and 15 1, 2, 3, 4 positive emotions), feeling of inadequacy, teasing, pleasure, emotions frustration) Perception of diet quality/health/food safety/time spent 16 Perception 1, 2, 3, 6 sitting/PA barriers, Perceptions of risks related to physical 63 Chapter 2 Framework Framework Codes Definition and/or examples Codes Definition and/or examples reference reference activity in the environment or in general (fear of falling, safety) Food culture existing in the family / household, family PA or risks related to consumption of unhealthy foods or lack of Family habits behaviours, TV watching, parental food- and eating-related 36 1, 2, 3, 4, 5 physical activity, fear of disease and practices behaviours, parental thoughts and beliefs about food and Knowledge, skills and abilities related to health, nutrition, diet- eating, parental feeding styles (restrictions, pressure-to-eat) 17 Knowledge 1, 3, 4 disease relationship, PA, cooking Socio-economic aspects of the family / household (HH food 37 Family/HH SES 1, 2, 4, 5 Body weight perception, body satisfaction, (dis)satisfaction with security, HH budget constraints) 18 Body image 1, 2 one's weight or body image, physical appearance Family/parent Personality traits and styles, temperament, motivation, self- 38 nutritional 3, 4, 5 Body weight, BMI, (present or past) of family members 19 Personality 2, 3, 4, 5 identity, social competence, self-esteem, self-worth, self- status confidence, selflessness, laziness, interest in PA/diet Family/parent Individual-difference traits concerned with controlling the self 39 3, 5 Level of education of parent, career, relative education level (impulsivity, self-control), locus of control, life satisfaction, 20 Self-regulation 2, 3, 4 karma, fatalism, decision making power), self-efficacy, Community Community habits related to diet, PA and health, communal temptation, disempowerment 40 habits or 1, 2, 3, 4 eating, community activities, and programs (also programs from Attitudinal Beliefs, values, personal thoughts and beliefs and attitudes behaviours NGO, non-profit) 21 1, 2, 3, 4, 5 beliefs about food, eating, physical activity, dieting to lose weight 41 Role modelling 2, 6 Modelling diet or physical activity behaviour of or for others Individual - practices and patterns The direct influence on people by peers, or the effect on an Preferences, and/or habits and routines and habitual behaviour Diet habits and Peer/friend individual who gets encouraged to follow their peers by 22 1, 2, 4, 5 around food consumption (Snacking, habitual eating, speed of 42 1, 2, 4, preferences influence changing their attitudes, values or behaviours to conform to the eating, skipping meals) peer/friend Time Time constraints, stress, life stressor, perceived fatigue, 23 1, 2, 3, 4 Trends in pop culture, champions promoting healthy diets or management convenience, pressure, busy lifestyle 43 Popular culture 1, 2, 3, physical activity, social media use and influences on diet or Physically active work in the house, cleaning, doing sports at 24 HH activities 2, 6 physical activity home Religious Religious practices that restrict certain foods or drinks, or Occupational Capability to combine sport, cooking with education/work, job 25 2, 3, 6 44 beliefs and 1, 2, 5, require certain ways of dressing that could impact physical activities related energy expenditure practices activity 26 PA level 1, 2, 3 Level of activity, type of activity, strength of activity Support/reward/encouragement from community family, Regular habits, routines, habitual behaviour related to physical 27 PA habit 2, 3, 6 Support of peers, partner to be physically active, to eat healthy, to lose activity and/or sports 45 family/peers/p 1, 3, 6 weight, parents’ expectations, parents’ rules and information, Addictions and/or risk behaviours related to alcohol, drugs, self- artner parental style, information and advice from 28 Addictions 1, 2, 3, 4 medication, e.g. diet pills or overweight gain pills; parents/peers/partner gambling)/related health behaviours, bulimia, anorexia Capacity of a teacher to have a positive or negative effect on Hobbies, spare time activities that could be active or sedentary Teacher 29 Leisure activity 2 46 From data the habit, behaviour or knowledge of the student related to diet (seated, TV watching), holiday activity influence or physical activity An activity done regularly in one's leisure time for pleasure, only Gender divide in society, societal roles for women/men (e.g. Eating out vs. use when “eating at home” is mentioned in comparison with 30 1 47 Gender norms 1, 2, 3, women discouraged to leave house or do PA), norms related to at home “eating out”, also refers to homecooked meal vs restaurant food preparation and purchase, Women empowerment cooked/prepared meal Thoughts and beliefs related to one’s cultural background 31 SB levels 2 Level of sedentary behaviour 48 Culture 1, 2, 3, 4 (background, norms, view on leisure time, health believes, Active Taking the bike, walking, running etc to work/school, car 32 2, 3, 6 cultural requirements), national traditions and identity transport ownership Social networks, social ties, community recommendations, Sleep and sleeping patterns (chronotype, sleep duration), also 33 Sleep pattern 1, 2, 3, 4 49 Social networks 1, 2, 4, 5, 6 social isolation, social inclusion, participating/member in social includes sleeping quality/time clubs, social climate, social pressure, social judgment Intentions to e.g. lose weight, do physical activity, self-PA 34 Intentions 1, 3 Diet- and eating-related influences from others in the monitoring, dieting environment, norms and taboos restricting certain foods e.g. Social level from pregnant or lactating women, traditional taboos, Social 50 Social norms 1, 2, 3, 5 Composition, cohesion and structure of the family/household comparison; Social norms to conform, subjective norms, social HH (number of children, family size, structure/having a/living with a roles, stigma, Social class, does not includes gender norms (see 35 1, 2, 4 composition parent or children, house help)/Food allocation in HH), female- code 47) headed household Physical/Built environment 64 Qualitative evidence synthesis Framework Framework Codes Definition and/or examples Codes Definition and/or examples reference reference activity in the environment or in general (fear of falling, safety) Food culture existing in the family / household, family PA or risks related to consumption of unhealthy foods or lack of Family habits behaviours, TV watching, parental food- and eating-related 36 1, 2, 3, 4, 5 physical activity, fear of disease and practices behaviours, parental thoughts and beliefs about food and Knowledge, skills and abilities related to health, nutrition, diet- eating, parental feeding styles (restrictions, pressure-to-eat) 17 Knowledge 1, 3, 4 disease relationship, PA, cooking Socio-economic aspects of the family / household (HH food 37 Family/HH SES 1, 2, 4, 5 2 Body weight perception, body satisfaction, (dis)satisfaction with security, HH budget constraints) 18 Body image 1, 2 one's weight or body image, physical appearance Family/parent Personality traits and styles, temperament, motivation, self- 38 nutritional 3, 4, 5 Body weight, BMI, (present or past) of family members 19 Personality 2, 3, 4, 5 identity, social competence, self-esteem, self-worth, self- status confidence, selflessness, laziness, interest in PA/diet Family/parent Individual-difference traits concerned with controlling the self 39 3, 5 Level of education of parent, career, relative education level (impulsivity, self-control), locus of control, life satisfaction, 20 Self-regulation 2, 3, 4 karma, fatalism, decision making power), self-efficacy, Community Community habits related to diet, PA and health, communal temptation, disempowerment 40 habits or 1, 2, 3, 4 eating, community activities, and programs (also programs from Attitudinal Beliefs, values, personal thoughts and beliefs and attitudes behaviours NGO, non-profit) 21 1, 2, 3, 4, 5 beliefs about food, eating, physical activity, dieting to lose weight 41 Role modelling 2, 6 Modelling diet or physical activity behaviour of or for others Individual - practices and patterns The direct influence on people by peers, or the effect on an Preferences, and/or habits and routines and habitual behaviour Diet habits and Peer/friend individual who gets encouraged to follow their peers by 22 1, 2, 4, 5 around food consumption (Snacking, habitual eating, speed of 42 1, 2, 4, preferences influence changing their attitudes, values or behaviours to conform to the eating, skipping meals) peer/friend Time Time constraints, stress, life stressor, perceived fatigue, 23 1, 2, 3, 4 Trends in pop culture, champions promoting healthy diets or management convenience, pressure, busy lifestyle 43 Popular culture 1, 2, 3, physical activity, social media use and influences on diet or Physically active work in the house, cleaning, doing sports at 24 HH activities 2, 6 physical activity home Religious Religious practices that restrict certain foods or drinks, or Occupational Capability to combine sport, cooking with education/work, job 25 2, 3, 6 44 beliefs and 1, 2, 5, require certain ways of dressing that could impact physical activities related energy expenditure practices activity 26 PA level 1, 2, 3 Level of activity, type of activity, strength of activity Support/reward/encouragement from community family, Regular habits, routines, habitual behaviour related to physical 27 PA habit 2, 3, 6 Support of peers, partner to be physically active, to eat healthy, to lose activity and/or sports 45 family/peers/p 1, 3, 6 weight, parents’ expectations, parents’ rules and information, Addictions and/or risk behaviours related to alcohol, drugs, self- artner parental style, information and advice from 28 Addictions 1, 2, 3, 4 medication, e.g. diet pills or overweight gain pills; parents/peers/partner gambling)/related health behaviours, bulimia, anorexia Capacity of a teacher to have a positive or negative effect on Hobbies, spare time activities that could be active or sedentary Teacher 29 Leisure activity 2 46 From data the habit, behaviour or knowledge of the student related to diet (seated, TV watching), holiday activity influence or physical activity An activity done regularly in one's leisure time for pleasure, only Gender divide in society, societal roles for women/men (e.g. Eating out vs. use when “eating at home” is mentioned in comparison with 30 1 47 Gender norms 1, 2, 3, women discouraged to leave house or do PA), norms related to at home “eating out”, also refers to homecooked meal vs restaurant food preparation and purchase, Women empowerment cooked/prepared meal Thoughts and beliefs related to one’s cultural background 31 SB levels 2 Level of sedentary behaviour 48 Culture 1, 2, 3, 4 (background, norms, view on leisure time, health believes, Active Taking the bike, walking, running etc to work/school, car 32 2, 3, 6 cultural requirements), national traditions and identity transport ownership Social networks, social ties, community recommendations, Sleep and sleeping patterns (chronotype, sleep duration), also 33 Sleep pattern 1, 2, 3, 4 49 Social networks 1, 2, 4, 5, 6 social isolation, social inclusion, participating/member in social includes sleeping quality/time clubs, social climate, social pressure, social judgment Intentions to e.g. lose weight, do physical activity, self-PA 34 Intentions 1, 3 Diet- and eating-related influences from others in the monitoring, dieting environment, norms and taboos restricting certain foods e.g. Social level from pregnant or lactating women, traditional taboos, Social 50 Social norms 1, 2, 3, 5 Composition, cohesion and structure of the family/household comparison; Social norms to conform, subjective norms, social HH (number of children, family size, structure/having a/living with a roles, stigma, Social class, does not includes gender norms (see 35 1, 2, 4 composition parent or children, house help)/Food allocation in HH), female- code 47) headed household Physical/Built environment 65 Chapter 2 Framework Framework Codes Definition and/or examples Codes Definition and/or examples reference reference Cooking facilitates, condition, sanitation and hygiene/food Any guidelines (FBDG), policies or programs, campaigns availability/type of housing, backyard space, food storage promoting healthy diets or aiming to reduce malnutrition for Home Govt 51 1, 2, 3, 4, 5, 6 facilities, home gardening, access to garden, land use, number the general population or specific population group (unless they environment 66 Diet/nutrition 1, 2, 3, 4 of screens in dwelling, TV in bedroom, facilities/space to do are school related that it would be code 67), would also include policies physical activity promotion of healthy diets through info materials (posters, Walkability, cycle-ability, public open spaces, green/blue leaflets etc) Built areas/parks, deprivation, hygiene and sanitation, food School and 52 1, 2, 4, 5, 6 Educational institutions (school, university): health/diet/PA environment availability in neighbourhood, safety/crime in neighbourhood, 67 education 3, 5, 6 guidelines/policies/Nutrition/PE curricula/sitting policies traffic policies Cafes, restaurants, canteens, shops, markets: availability, Economic regulations, General taxation of property, investment hygiene and sanitation, distance, density, diversity, types of regulations, food outlets (not foods or drinks that would be 53 Food outlets 1, 4, 5 food available at the outlet (if related to neighbourhood in 68 Macroeconomy 1, 2, 3, 6 under label 65), investments for farmers, shop owners, sport general, use code 52) centres/facilities etc, mortgage costs, fiscal advantages for sport Food clubs Exposure to posters/banners etc on street, in outlets, ads on TV 54 promotion/adv 1, 2, 4 Transport Policies related to mobility, road safety, parking regulations, related to un/healthy foods, drinks or physical activity/sports 69 1,2, 3, 5, 6 ertising policies bike paths etc Recreation Health clubs, community activity providers: affordability, Policies and programs designed to reduce poverty and 55 2, 3, 5, 6 facilities availability, sport competitions vulnerability by promoting efficient labour markets, diminishing Public, safety, convenience, infrastructure, access, availability, people's exposure to risks, and enhancing their capacity 56 Transport 1, 2, 3, 5, 6 70 Social policies 1, 2, 4 distance to work/school to protect themselves against hazards, programs to strengthen Extrinsic or intrinsic attributes of food items or meals: food social networks, pension, welfare/social protection policies, Product 57 1, 4 adulteration, contamination, texture, shelf life, labelling, health insurance attributes packing, portion sizes, preparation method, perishability Density of outlets/public spaces, architecture and building Healthiness of meals, foods available near school, meal codes, land use policies, design of public spaces, park policies, School 58 1, 2, 3, 5, 6 standards, PA guidelines, time spent outdoor, playing spaces, urbanization, planning public spaces, use when rural-urban environment 71 Urban planning 1, 2, 3, 5, 6 also includes settings such as college and university comparison is made and migration from rural to urban areas or Availability/accessibility of services, advise from health care when difference between “modern” and “traditional” are 59 Health care 2, 3, 5 staff, food supply at health care facilities, parking, green spaces discussed at health facilities Human Nutritionists, dieticians, Nutrition HR at workplace, school, Workplace 72 resources for 1, 2, 3 health services, govt plans/curricula to train 60 2, 3, 5, 6 Workplace canteens, sports facilities, parking, transport options environment nutrition nutritionists/dieticians, academic training Prices for food, transport, energy, gas, recreation activities, gym 73 Prices 1, 2, 4 Macro environment membership, consumerism, luxury Broader government policies that are not covered in the other 74 Government 1, 2, 4, 5 Production, processing of food, food and agriculture policies, categories 61 Food supply 1, 3, 4, 5, 6 food regulations (labelling, packaging, safety, quality), food and Human rights that could affect diets or physical activity: The drink advertising right to food, a human right protecting the right for people to 75 Human rights 3 Provides goods and services to treat patients with curative, feed themselves or the Freedom of movement, mobility rights, Health care 62 2, 5, 6 preventive, rehabilitative, and palliative care, also includes right to travel system health care industry, pharma industry etc., health care policies Climate, weather, nature, Seasonality, climate change, extreme Exercise, physical activity industry, including recreation weather conditions affecting food production, possibilities to be 63 Sport industry 3, 5 76 Environment 1, 2, 3, 4 industry, sports organizations active outside, weather conducive with physical activity, TV, media, internet, regulations restricting media, availability of environmental policies Information 64 1, 2, 3, 5, 6 networks, social media policies etc, including entertainment Political Wars or conflicts in countries or regions, political systems and industry 77 1, 2, 6 industry in/stability their (in)stability, crime, safety, also economic stability Any guidelines, policies, programs or campaigns, promoting Shifts in dietary intake (from “traditional” to “western”/ Nutrition physical activity or reduction in sedentary behaviour for the 78 From data “modern” diets) due to demographic, economic or transition Govt PA general population or specific population group (unless they are epidemiological changes 65 2, 3, 4, 6 policies school related that it would be code 67), would also include promotion of PA through info materials (posters, leaflets etc), public recreation and campaigns 66 Qualitative evidence synthesis Framework Framework Codes Definition and/or examples Codes Definition and/or examples reference reference Cooking facilitates, condition, sanitation and hygiene/food Any guidelines (FBDG), policies or programs, campaigns availability/type of housing, backyard space, food storage promoting healthy diets or aiming to reduce malnutrition for Home Govt 51 1, 2, 3, 4, 5, 6 facilities, home gardening, access to garden, land use, number the general population or specific population group (unless they environment 66 Diet/nutrition 1, 2, 3, 4 of screens in dwelling, TV in bedroom, facilities/space to do are school related that it would be code 67), would also include policies physical activity promotion of healthy diets through info materials (posters, 2 Walkability, cycle-ability, public open spaces, green/blue leaflets etc) Built areas/parks, deprivation, hygiene and sanitation, food School and 52 1, 2, 4, 5, 6 Educational institutions (school, university): health/diet/PA environment availability in neighbourhood, safety/crime in neighbourhood, 67 education 3, 5, 6 guidelines/policies/Nutrition/PE curricula/sitting policies traffic policies Cafes, restaurants, canteens, shops, markets: availability, Economic regulations, General taxation of property, investment hygiene and sanitation, distance, density, diversity, types of regulations, food outlets (not foods or drinks that would be 53 Food outlets 1, 4, 5 food available at the outlet (if related to neighbourhood in 68 Macroeconomy 1, 2, 3, 6 under label 65), investments for farmers, shop owners, sport general, use code 52) centres/facilities etc, mortgage costs, fiscal advantages for sport Food clubs Exposure to posters/banners etc on street, in outlets, ads on TV 54 promotion/adv 1, 2, 4 Transport Policies related to mobility, road safety, parking regulations, related to un/healthy foods, drinks or physical activity/sports 69 1,2, 3, 5, 6 ertising policies bike paths etc Recreation Health clubs, community activity providers: affordability, Policies and programs designed to reduce poverty and 55 2, 3, 5, 6 facilities availability, sport competitions vulnerability by promoting efficient labour markets, diminishing Public, safety, convenience, infrastructure, access, availability, people's exposure to risks, and enhancing their capacity 56 Transport 1, 2, 3, 5, 6 70 Social policies 1, 2, 4 distance to work/school to protect themselves against hazards, programs to strengthen Extrinsic or intrinsic attributes of food items or meals: food social networks, pension, welfare/social protection policies, Product 57 1, 4 adulteration, contamination, texture, shelf life, labelling, health insurance attributes packing, portion sizes, preparation method, perishability Density of outlets/public spaces, architecture and building Healthiness of meals, foods available near school, meal codes, land use policies, design of public spaces, park policies, School 58 1, 2, 3, 5, 6 standards, PA guidelines, time spent outdoor, playing spaces, urbanization, planning public spaces, use when rural-urban environment 71 Urban planning 1, 2, 3, 5, 6 also includes settings such as college and university comparison is made and migration from rural to urban areas or Availability/accessibility of services, advise from health care when difference between “modern” and “traditional” are 59 Health care 2, 3, 5 staff, food supply at health care facilities, parking, green spaces discussed at health facilities Human Nutritionists, dieticians, Nutrition HR at workplace, school, Workplace 72 resources for 1, 2, 3 health services, govt plans/curricula to train 60 2, 3, 5, 6 Workplace canteens, sports facilities, parking, transport options environment nutrition nutritionists/dieticians, academic training Prices for food, transport, energy, gas, recreation activities, gym 73 Prices 1, 2, 4 Macro environment membership, consumerism, luxury Broader government policies that are not covered in the other 74 Government 1, 2, 4, 5 Production, processing of food, food and agriculture policies, categories 61 Food supply 1, 3, 4, 5, 6 food regulations (labelling, packaging, safety, quality), food and Human rights that could affect diets or physical activity: The drink advertising right to food, a human right protecting the right for people to 75 Human rights 3 Provides goods and services to treat patients with curative, feed themselves or the Freedom of movement, mobility rights, Health care 62 2, 5, 6 preventive, rehabilitative, and palliative care, also includes right to travel system health care industry, pharma industry etc., health care policies Climate, weather, nature, Seasonality, climate change, extreme Exercise, physical activity industry, including recreation weather conditions affecting food production, possibilities to be 63 Sport industry 3, 5 76 Environment 1, 2, 3, 4 industry, sports organizations active outside, weather conducive with physical activity, TV, media, internet, regulations restricting media, availability of environmental policies Information 64 1, 2, 3, 5, 6 networks, social media policies etc, including entertainment Political Wars or conflicts in countries or regions, political systems and industry 77 1, 2, 6 industry in/stability their (in)stability, crime, safety, also economic stability Any guidelines, policies, programs or campaigns, promoting Shifts in dietary intake (from “traditional” to “western”/ Nutrition physical activity or reduction in sedentary behaviour for the 78 From data “modern” diets) due to demographic, economic or transition Govt PA general population or specific population group (unless they are epidemiological changes 65 2, 3, 4, 6 policies school related that it would be code 67), would also include promotion of PA through info materials (posters, leaflets etc), public recreation and campaigns 67 Chapter 2 Framework references Appendix 2.3. Themes and supporting studies 1. Holdsworth M, Landais E. Urban food environments in Africa: implications for policy and research. Proc Nutr Soc. 2019;78(4):513-525. Theme (Number Studies supporting the theme 2. Chastin SF, de Craemer M, Lien N, et al. The SOS-framework (Systems of Sedentary behaviours): of studies) an international transdisciplinary consensus framework for the study of determinants, research Individual level priorities and policy on sedentary behaviour across the life course: a DEDIPAC-study. Int J Behav Attribution (16) Amiri 2011, Aryeetey 2016, Blum 2019, Caamano 2016, Carrete 2012, Garg 2019, Nutr Phys Act. 2016;13:83. Gavaravarapu 2015, Goncalves 2012, Karimi-Shahanja 2010, Lemamsha 2018, Lipus 3. Condello G, Ling FC, Bianco A, et al. Using concept mapping in the development of the EU-PAD 2019, Madrigal-2017, Monge-Rojas 2005, Phillips-2016, Walter 2011, Ware 2019 framework (EUropean-Physical Activity Determinants across the life course): a DEDIPAC-study. BMC public health Awareness (56) Abdelghaffar 2019, Abdi 2016, Atik 2013, Amiri 2011, Aryeetey2016, Bagherniya . 2016;16(1):1145. 2018, Bailey 2018, Bastami 2019, Brown 2015, Blum 2019, Caamano 2016, Carrete 4. Stok FM, Hoffmann S, Volkert D, et al. The DONE framework: Creation, evaluation, and updating 2012, Chan 2015, Chang 2009, Correa 2017, Craveiro 2016, Dapi 2007, De Silva of an interdisciplinary, dynamic framework 2.0 of determinants of nutrition and eating. PLoS One. Weliange 2018, Doegah, Draper-2016, Fachruddin 2019, Farell 2019, Garg 2019, 2017;12(2):e0171077. Gavaravarapu 2015, Goncalves-2012, Habibie 2019, Islam 2019, Kalani 2017, Kimoto 5. Booth SL, Sallis JF, Ritenbaugh C, et al. Environmental and societal factors affect food choice and physical activity: rationale, influences, and leverage points. Nutr Rev 2014, Kinsman 2015, Kroone 2012, Kurschner 2019, Karimi-Shahanja-2010, . 2001;59(3 Pt 2):S21-39; Lemamsha-2018, Lipus 2019, Madrigal-2017, Monge-Rojas 2005/2009, Majabadi discussion S57-65. 2016, Monge-Rojas 2015, Mugo 2016, Pahlm 2013, Peykari 2015, Phillips-2016, 6. Sallis JF, Cervero RB, Ascher W, Henderson KA, Kraft MK, Kerr J. An ecological approach to creating active living communities. Annu Rev Public Health Rajaraman 2015, Rodriguez-Ventu-2014, Romero 2019, Saimon 2015, Satija 2018, . 2006;27:297-322. Sedibe-2014, Sondari 2019, Stupar 2007, Usman 2017, Veeck 2014, Wrottesley 2019, Walter 2011, Ware 2019 Food safety Abdi 2016, Bailey 2018, Bastami 2019, Blum 2019, Carrete 2012, Chan 2015, Correa concerns (20) 2017, Garg 2019, Hunter-Adams 2019, Islam 2019, Lipus 2019, Atik 2013, Mugo 2016, Pahlm 2013, Sedibe 2014, Sondari 2019, Stupar 2007, Usman 2017, Veeck 2014, Voorend 2013 Subjective norms Brown 2015, Caamano-2016, Carrete 2012, Chan 2015, Cohen 2017, Dapi-2007, De (43) Silva Weliange 2018, Doegah, Draper-2016, Farell 2019, Garg 2019, Amiri2011, Georgina 2019, Goncalves-2012, Hunter-Adams 2019, Islam 2019, Kalani 2017, Karimi-Shahanja-2010, Kimoto 2014, Kinsman-2015, Aryeetey 2016, Kroone 2012, Kurschner 2019, Lacroix 2019, Lemamsha-2018, Majabadi 2016, Monge Rojas 2017, Monge-Rojas 2015, Monge-Rojas-2009, Mugo 2016, Phillips-2016, Rajaraman 2015, Rodriguez-Ventu-2014, Bagherniya 2018, Saimon 2015, Satija 2018 Sedibe-2014, Stupar 2007, Usman 2017, Voorend-2013, Walter 2011, Ware 2019, Wrottesley 2019 Motivation – Abdelghaffar 2019, Amiri 2011, Aryeetey 2016, Baheiraei 2016, Bailey 2018, Bastami habit strength 2019, Blum 2019, Caamano-2016, Carrete 2012, Chang 2009, Craveiro 2016, Dapi- (47) 2007, Doegah, Draper-2016, Fachruddin 2019, Garg 2019, Gavaravarapu 2015, Goncalves-2012, Hosseini-2013, Islam 2019, Kalani 2017, Karimi-Shahanja-2010, Kimoto 2014, Kroone 2012, Kurschner 2019, Lacroix 2019, Lemamsha-2018, Madrigal-2017, Monge-Rojas 2005/2009, Monge-Rojas 2015, Mugo 2016, Ozturk 2019, Peykari 2015, Phillips-2016, Rajaraman 2015, Rodriguez-Ventu-2014, Saimon 2015, Satija 2018, Sedibe-2014, Ssewanyana 2018, Sondari 2019, Stupar 2007, Usman 2017, Veeck 2014, Voorend-2013, Walter 2011, Ware 2019, Wrottesley 2019 Taste (29) Abdi 2016, Atik 2013, Bastami 2019, Blum 2019, Bridle-Fitzpatrick 2015, Brown 2015, Caamano-2016, Carrete 2012, Chan 2015, Chang 2009, Craveiro 2016, Dapi 2007, Gavaravarapu 2015, Goncalves-2012, Habibie 2019, Islam 2019, Karimi-Shahanja- 2010, Kimoto 2014, Kroone 2012, Majabadi 2016, Monge-Rojas 2005, Mugo 2016, Sedibe-2014, Sondari 2019, Ssewanyana 2018, Stupar 2007, Usman 2017, Veeck 2014, Voorend 2013, Wrottesley 2019 SES (44) Abdi 2016, Amiri2011, Atik 2013, Bagherniya 2018, Baheiraei 2016, Bailey 2018, Blum 2019, Bridle-Fitzpatrick 2015, Brown 2015, Caamano-2016 Cacavas 2011, Carrete 2012, Chan 2015, Correa 2017, Craveiro 2016, Dapi-2007, De Silva Weliange 2018, Draper-2016, Farell 2019, Garg 2019, Georgina 2019, Goncalves- 2012, Hunter-Adams 2019, Islam 2019, Karimi-Shahanja-2010, Kimoto 2014, Kinsman- 2015, Lemamsha-2018, Lipus 2019 68 Qualitative evidence synthesis Framework references Appendix 2.3. Themes and supporting studies 1. Holdsworth M, Landais E. Urban food environments in Africa: implications for policy and research. Proc Nutr Soc. 2019;78(4):513-525. Theme (Number Studies supporting the theme 2. Chastin SF, de Craemer M, Lien N, et al. The SOS-framework (Systems of Sedentary behaviours): of studies) an international transdisciplinary consensus framework for the study of determinants, research Individual level priorities and policy on sedentary behaviour across the life course: a DEDIPAC-study. Int J Behav Attribution (16) Amiri 2011, Aryeetey 2016, Blum 2019, Caamano 2016, Carrete 2012, Garg 2019, Nutr Phys Act 2 . 2016;13:83. Gavaravarapu 2015, Goncalves 2012, Karimi-Shahanja 2010, Lemamsha 2018, Lipus 3. Condello G, Ling FC, Bianco A, et al. Using concept mapping in the development of the EU-PAD 2019, Madrigal-2017, Monge-Rojas 2005, Phillips-2016, Walter 2011, Ware 2019 framework (EUropean-Physical Activity Determinants across the life course): a DEDIPAC-study. BMC public health Awareness (56) Abdelghaffar 2019, Abdi 2016, Atik 2013, Amiri 2011, Aryeetey2016, Bagherniya . 2016;16(1):1145. 2018, Bailey 2018, Bastami 2019, Brown 2015, Blum 2019, Caamano 2016, Carrete 4. Stok FM, Hoffmann S, Volkert D, et al. The DONE framework: Creation, evaluation, and updating of an interdisciplinary, dynamic framework 2.0 of determinants of nutrition and eating. PLoS One 2012, Chan 2015, Chang 2009, Correa 2017, Craveiro 2016, Dapi 2007, De Silva . Weliange 2018, Doegah, Draper-2016, Fachruddin 2019, Farell 2019, Garg 2019, 2017;12(2):e0171077. Gavaravarapu 2015, Goncalves-2012, Habibie 2019, Islam 2019, Kalani 2017, Kimoto 5. Booth SL, Sallis JF, Ritenbaugh C, et al. Environmental and societal factors affect food choice and 2014, Kinsman 2015, Kroone 2012, Kurschner 2019, Karimi-Shahanja-2010, physical activity: rationale, influences, and leverage points. Nutr Rev. 2001;59(3 Pt 2):S21-39; Lemamsha-2018, Lipus 2019, Madrigal-2017, Monge-Rojas 2005/2009, Majabadi discussion S57-65. 6. 2016, Monge-Rojas 2015, Mugo 2016, Pahlm 2013, Peykari 2015, Phillips-2016, Sallis JF, Cervero RB, Ascher W, Henderson KA, Kraft MK, Kerr J. An ecological approach to Rajaraman 2015, Rodriguez-Ventu-2014, Romero 2019, Saimon 2015, Satija 2018, creating active living communities. Annu Rev Public Health. 2006;27:297-322. Sedibe-2014, Sondari 2019, Stupar 2007, Usman 2017, Veeck 2014, Wrottesley 2019, Walter 2011, Ware 2019 Food safety Abdi 2016, Bailey 2018, Bastami 2019, Blum 2019, Carrete 2012, Chan 2015, Correa concerns (20) 2017, Garg 2019, Hunter-Adams 2019, Islam 2019, Lipus 2019, Atik 2013, Mugo 2016, Pahlm 2013, Sedibe 2014, Sondari 2019, Stupar 2007, Usman 2017, Veeck 2014, Voorend 2013 Subjective norms Brown 2015, Caamano-2016, Carrete 2012, Chan 2015, Cohen 2017, Dapi-2007, De (43) Silva Weliange 2018, Doegah, Draper-2016, Farell 2019, Garg 2019, Amiri2011, Georgina 2019, Goncalves-2012, Hunter-Adams 2019, Islam 2019, Kalani 2017, Karimi-Shahanja-2010, Kimoto 2014, Kinsman-2015, Aryeetey 2016, Kroone 2012, Kurschner 2019, Lacroix 2019, Lemamsha-2018, Majabadi 2016, Monge Rojas 2017, Monge-Rojas 2015, Monge-Rojas-2009, Mugo 2016, Phillips-2016, Rajaraman 2015, Rodriguez-Ventu-2014, Bagherniya 2018, Saimon 2015, Satija 2018 Sedibe-2014, Stupar 2007, Usman 2017, Voorend-2013, Walter 2011, Ware 2019, Wrottesley 2019 Motivation – Abdelghaffar 2019, Amiri 2011, Aryeetey 2016, Baheiraei 2016, Bailey 2018, Bastami habit strength 2019, Blum 2019, Caamano-2016, Carrete 2012, Chang 2009, Craveiro 2016, Dapi- (47) 2007, Doegah, Draper-2016, Fachruddin 2019, Garg 2019, Gavaravarapu 2015, Goncalves-2012, Hosseini-2013, Islam 2019, Kalani 2017, Karimi-Shahanja-2010, Kimoto 2014, Kroone 2012, Kurschner 2019, Lacroix 2019, Lemamsha-2018, Madrigal-2017, Monge-Rojas 2005/2009, Monge-Rojas 2015, Mugo 2016, Ozturk 2019, Peykari 2015, Phillips-2016, Rajaraman 2015, Rodriguez-Ventu-2014, Saimon 2015, Satija 2018, Sedibe-2014, Ssewanyana 2018, Sondari 2019, Stupar 2007, Usman 2017, Veeck 2014, Voorend-2013, Walter 2011, Ware 2019, Wrottesley 2019 Taste (29) Abdi 2016, Atik 2013, Bastami 2019, Blum 2019, Bridle-Fitzpatrick 2015, Brown 2015, Caamano-2016, Carrete 2012, Chan 2015, Chang 2009, Craveiro 2016, Dapi 2007, Gavaravarapu 2015, Goncalves-2012, Habibie 2019, Islam 2019, Karimi-Shahanja- 2010, Kimoto 2014, Kroone 2012, Majabadi 2016, Monge-Rojas 2005, Mugo 2016, Sedibe-2014, Sondari 2019, Ssewanyana 2018, Stupar 2007, Usman 2017, Veeck 2014, Voorend 2013, Wrottesley 2019 SES (44) Abdi 2016, Amiri2011, Atik 2013, Bagherniya 2018, Baheiraei 2016, Bailey 2018, Blum 2019, Bridle-Fitzpatrick 2015, Brown 2015, Caamano-2016 Cacavas 2011, Carrete 2012, Chan 2015, Correa 2017, Craveiro 2016, Dapi-2007, De Silva Weliange 2018, Draper-2016, Farell 2019, Garg 2019, Georgina 2019, Goncalves- 2012, Hunter-Adams 2019, Islam 2019, Karimi-Shahanja-2010, Kimoto 2014, Kinsman- 2015, Lemamsha-2018, Lipus 2019 69 Chapter 2 Theme (Number Studies supporting the theme Theme (Number Studies supporting the theme of studies) of studies) Monge-Rojas 2005/2009, Mugo 2016, Ozturk 2019, Pahlm 2013, Phillips 2015, Culture (30) Abdelghaffar 2019, Abdi 2016, Amiri2011, Atik 2013, Bailey 2018, Bastami 2019, Blum Phillips-2016, Rodriguez-Ventu-2014, Sedibe 2014, Sondari 2019, Ssewanyana 2018, 2019, Brown 2015, Carrete 2012, Chan 2015, Correa 2017, Craveiro 2016, Farell 2019, Stupar 2007, Usman 2017, Veeck 2014, Voorend-2013, Ware 2019, Wrottesley 2019 Hunter-Adams 2019, Islam 2019, Karimi-Shahanja-2010, Kroone 2012, Lemamsha- Social level 2018, Lipus 2019, Majabadi 2016, Mugo 2016, Ozturk 2019, Phillips-2016, Rathi 2016, Family Abdi 2016, Aryeetey-2016, Bailey 2018, Caamano-2016, Carrete 2012, Cohen 2017, Sedibe-2014, Ssewanyana 2018, Stupar 2007, Usman 2017, Veeck 2014, Walter 2011, environment – Fachruddin 2019, Garg 2019, Kalani 2017, Kimoto 2014, Kurschner 2019, Lipus 2019, Ware 2019 women (14) Mugo 2016, Phillips-2016 Urbanization (16) Bailey 2018, Correa 2017, Chan 2015, Craveiro 2016, Dapi-2007, Fachruddin 2019, Family Abdelghaffar 2019, Abdi 2016, Amiri2011, Atik 2013, Bagherniya 2018, Baheiraei Garg 2019, Hunter-Adams 2019, Kalani 2017, Lipus 2019, Majabadi 2016, Monge- environment - 2016, Bastami 2019, Blum 2019, Brown 2015, Carrete 2012, Chan 2015, Correa 2017, Rojas-2009, Ozturk 2019, Rajaraman 2015, Walter 2011, Wrottesley 2019 adolescents (46) Craveiro 2016, Doegah, Gavaravarapu 2015, Goncalves-2012, Habibie 2019, Hosseini- 2013, Islam 2019, Kalani 2017, Karimi-Shahanja-2010, Kinsman-2015, Kroone 2012, Kurschner 2019, Madrigal-2017, Majabadi 2016, Monge Rojas 2017, Monge-Rojas 2005/2009, Monge-Rojas 2015, Ozturk 2019, Peykari 2015, Phillips 2015, Phillips- 2016, Rajaraman 2015, Rathi 2016, Rodriguez-Ventu-2014, Saimon 2015, Satija 2018, Sondari 2019, Ssewanyana 2018, Stupar 2007, Usman 2017, Veeck 2014, Voorend- 2013, Walter 2011, Ware 2019, Wrottesley 2019 Academic Abdelghaffar 2019, Amiri2011, Bagherniya 2019, Baheiraei 2016, Blum 2019, Correa pressure (26) 2017, Doegah, Gavaravarapu 2015, Kalani 2017, Kurschner 2019, Madrigal-2017, Monge-Rojas-2009, Ozturk 2019, Pahlm 2013, Peykari 2015, Phillips 2015, Rajaraman 2015, Rodriguez-Ventu-2014, Saimon 2015, Satija 2018, Sedibe-2014, Sondari 2019, Ssewanyana 2018, Stupar 2007, Veeck 2014, Ware 2019, Wrottesley 2019 Peer influence Abdelghaffar 2019, Bagherniya 2018, Baheiraei 2016, Bastami 2019, Blum 2019, (34) Brown 2015, Cacavas 2011, Chan 2015, De Silva Weliange 2018, Draper-2016, Fachruddin 2019, Habibie 2019, Islam 2019, Kalani 2017, Karimi-Shahanja-2010, Kimoto 2014, Kroone 2012, Kurschner 2019, Lemamsha-2018, Lipus 2019, Monge Rojas 2017, Monge-Rojas 2005, Rajaraman 2015, Rathi 2016, Saimon 2015, Satija 2018, Sedibe-2014, Ssewanyana 2018, Stupar 2007, Usman 2017, Veeck 2014, Voorend-2013, Walter 2011, Ware 2019, Wrottesley 2019 Physical level Built environment Abdelghaffar 2019, Amiri2011, Baheiraei 2016, Craveiro 2016, De Silva Weliange – PA (27) 2018, Draper-2016, Garg 2019, Gavaravarapu 2015, Kalani 2017, Kimoto 2014, Kinsman-2015, Lemamsha-2018, Madrigal-2017, Monge Rojas 2017, Monge-Rojas- 2009, Ozturk 2019, Peykari 2015, Phillips 2015, Rajaraman 2015, Rodriguez-Ventu- 2014, Saimon 2015, Satija 2018, Sedibe-2014, Stupar 2007, Walter 2011, Ware 2019, Wrottesley 2019 Built environment Amiri2011, Atik 2013, Bagherniya 2018, Bailey 2018, Blum 2019, Bridle-Fitzpatrick – food (34) 2015, Carrete 2012, Chan 2015, Correa 2017, Craveiro 2016, Dapi-2007, Fachruddin 2019, Habibie 2019, Hunter-Adams 2019, Islam 2019, Karimi-Shahanja-2010, Kimoto 2014, Kroone 2012, Lacroix 2019, Lemamsha-2018, Madrigal-2017, Mugo 2016, Pahlm 2013, Rathi 2016, Rodriguez-Ventu-2014, Romero 2019, Sedibe-2014, Sondari 2019, Ssewanyana 2018, Stupar 2007, Usman 2017, Veeck 2014, Voorend-2013, Ware 2019, Wrottesley 2019 School Abdelghaffar 2019, Atik 2013, Bagherniya 2018, Baheiraei 2016, Bastami 2019, Blum environment (33) 2019, Brown 2015, Cacavas 2011, Correa 2017, Garg 2019, Gavaravarapu 2015, Hosseini-2013, Islam 2019, Kalani 2017, Karimi-Shahanja-2010, Kroone 2012, Kurschner 2019, Madrigal-2017, Monge Rojas 2017, Monge-Rojas 2005/2009, Ozturk 2019, Phillips 2015, Rajaraman 2015, Rathi 2016, Rodriguez-Ventu-2014, Satija 2018, Sedibe-2014, Sondari 2019, Ssewanyana 2018, Stupar 2007, Veeck 2014, Voorend- 2013, Walter 2011, Wrottesley 2019 Work Kalani, Fachruddin, Habibie, Lacroix environment (4) Macro level 70 Qualitative evidence synthesis Theme (Number Studies supporting the theme Theme (Number Studies supporting the theme of studies) of studies) Monge-Rojas 2005/2009, Mugo 2016, Ozturk 2019, Pahlm 2013, Phillips 2015, Culture (30) Abdelghaffar 2019, Abdi 2016, Amiri2011, Atik 2013, Bailey 2018, Bastami 2019, Blum Phillips-2016, Rodriguez-Ventu-2014, Sedibe 2014, Sondari 2019, Ssewanyana 2018, 2019, Brown 2015, Carrete 2012, Chan 2015, Correa 2017, Craveiro 2016, Farell 2019, Stupar 2007, Usman 2017, Veeck 2014, Voorend-2013, Ware 2019, Wrottesley 2019 Hunter-Adams 2019, Islam 2019, Karimi-Shahanja-2010, Kroone 2012, Lemamsha- Social level 2018, Lipus 2019, Majabadi 2016, Mugo 2016, Ozturk 2019, Phillips-2016, Rathi 2016, Family Abdi 2016, Aryeetey-2016, Bailey 2018, Caamano-2016, Carrete 2012, Cohen 2017, Sedibe-2014, Ssewanyana 2018, Stupar 2007, Usman 2017, Veeck 2014, Walter 2011, 2 environment – Fachruddin 2019, Garg 2019, Kalani 2017, Kimoto 2014, Kurschner 2019, Lipus 2019, Ware 2019 women (14) Mugo 2016, Phillips-2016 Urbanization (16) Bailey 2018, Correa 2017, Chan 2015, Craveiro 2016, Dapi-2007, Fachruddin 2019, Family Abdelghaffar 2019, Abdi 2016, Amiri2011, Atik 2013, Bagherniya 2018, Baheiraei Garg 2019, Hunter-Adams 2019, Kalani 2017, Lipus 2019, Majabadi 2016, Monge- environment - 2016, Bastami 2019, Blum 2019, Brown 2015, Carrete 2012, Chan 2015, Correa 2017, Rojas-2009, Ozturk 2019, Rajaraman 2015, Walter 2011, Wrottesley 2019 adolescents (46) Craveiro 2016, Doegah, Gavaravarapu 2015, Goncalves-2012, Habibie 2019, Hosseini- 2013, Islam 2019, Kalani 2017, Karimi-Shahanja-2010, Kinsman-2015, Kroone 2012, Kurschner 2019, Madrigal-2017, Majabadi 2016, Monge Rojas 2017, Monge-Rojas 2005/2009, Monge-Rojas 2015, Ozturk 2019, Peykari 2015, Phillips 2015, Phillips- 2016, Rajaraman 2015, Rathi 2016, Rodriguez-Ventu-2014, Saimon 2015, Satija 2018, Sondari 2019, Ssewanyana 2018, Stupar 2007, Usman 2017, Veeck 2014, Voorend- 2013, Walter 2011, Ware 2019, Wrottesley 2019 Academic Abdelghaffar 2019, Amiri2011, Bagherniya 2019, Baheiraei 2016, Blum 2019, Correa pressure (26) 2017, Doegah, Gavaravarapu 2015, Kalani 2017, Kurschner 2019, Madrigal-2017, Monge-Rojas-2009, Ozturk 2019, Pahlm 2013, Peykari 2015, Phillips 2015, Rajaraman 2015, Rodriguez-Ventu-2014, Saimon 2015, Satija 2018, Sedibe-2014, Sondari 2019, Ssewanyana 2018, Stupar 2007, Veeck 2014, Ware 2019, Wrottesley 2019 Peer influence Abdelghaffar 2019, Bagherniya 2018, Baheiraei 2016, Bastami 2019, Blum 2019, (34) Brown 2015, Cacavas 2011, Chan 2015, De Silva Weliange 2018, Draper-2016, Fachruddin 2019, Habibie 2019, Islam 2019, Kalani 2017, Karimi-Shahanja-2010, Kimoto 2014, Kroone 2012, Kurschner 2019, Lemamsha-2018, Lipus 2019, Monge Rojas 2017, Monge-Rojas 2005, Rajaraman 2015, Rathi 2016, Saimon 2015, Satija 2018, Sedibe-2014, Ssewanyana 2018, Stupar 2007, Usman 2017, Veeck 2014, Voorend-2013, Walter 2011, Ware 2019, Wrottesley 2019 Physical level Built environment Abdelghaffar 2019, Amiri2011, Baheiraei 2016, Craveiro 2016, De Silva Weliange – PA (27) 2018, Draper-2016, Garg 2019, Gavaravarapu 2015, Kalani 2017, Kimoto 2014, Kinsman-2015, Lemamsha-2018, Madrigal-2017, Monge Rojas 2017, Monge-Rojas- 2009, Ozturk 2019, Peykari 2015, Phillips 2015, Rajaraman 2015, Rodriguez-Ventu- 2014, Saimon 2015, Satija 2018, Sedibe-2014, Stupar 2007, Walter 2011, Ware 2019, Wrottesley 2019 Built environment Amiri2011, Atik 2013, Bagherniya 2018, Bailey 2018, Blum 2019, Bridle-Fitzpatrick – food (34) 2015, Carrete 2012, Chan 2015, Correa 2017, Craveiro 2016, Dapi-2007, Fachruddin 2019, Habibie 2019, Hunter-Adams 2019, Islam 2019, Karimi-Shahanja-2010, Kimoto 2014, Kroone 2012, Lacroix 2019, Lemamsha-2018, Madrigal-2017, Mugo 2016, Pahlm 2013, Rathi 2016, Rodriguez-Ventu-2014, Romero 2019, Sedibe-2014, Sondari 2019, Ssewanyana 2018, Stupar 2007, Usman 2017, Veeck 2014, Voorend-2013, Ware 2019, Wrottesley 2019 School Abdelghaffar 2019, Atik 2013, Bagherniya 2018, Baheiraei 2016, Bastami 2019, Blum environment (33) 2019, Brown 2015, Cacavas 2011, Correa 2017, Garg 2019, Gavaravarapu 2015, Hosseini-2013, Islam 2019, Kalani 2017, Karimi-Shahanja-2010, Kroone 2012, Kurschner 2019, Madrigal-2017, Monge Rojas 2017, Monge-Rojas 2005/2009, Ozturk 2019, Phillips 2015, Rajaraman 2015, Rathi 2016, Rodriguez-Ventu-2014, Satija 2018, Sedibe-2014, Sondari 2019, Ssewanyana 2018, Stupar 2007, Veeck 2014, Voorend- 2013, Walter 2011, Wrottesley 2019 Work Kalani, Fachruddin, Habibie, Lacroix environment (4) Macro level 71 Chapter 2 Appendix 2.4. Table of all identified themes with relevant Theme Illustrative quotations quotations Body image related to Marriage and pregnancy were two major explanations they provided for age, marriage and this increase of weight. There was a strong belief of weight differences motherhood between señoras (Mrs.) and señoritas (Miss); Señoritas should be slim, and señoras could be fat (Kimoto 2014) Theme Illustrative quotations Movement of girls and Do you know what people would call us if I go out for a walk in the late INDIVIDUAL LEVEL women in public evening with our daughters? We would be considered a bad lot of Attribution women. We have to safeguard ourselves and our children from getting Obesity/body weight participants who believed that factors such as genetics or even God’s will bad labels. So, we do not go to the park or the beach unless my husband is destiny were more influential toward their obesity, than their lifestyle (Amiri is able to accompany us.” (De Silva 2018) 2011) Gender-appropriate Soccer is for men, ballet is for women, this is like saying strength and Obesity/body weight In making a case for heredity, it was argued by the discussion groups that physical activity delicacy . . . .” (Monge-Rojas 2017) is hereditary some women were overweight because being overweight is a part of Exercise was seen to be associated with what children and young people their families. Based on this belief, the weight gained by such women is Age-appropriate did, and it was not acceptable for women (particularly married women) considered “natural.” Some even believed that “nothing can be done physical activity to be seen exercising. Women were discouraged by the ―destructive talk about it” when overweight is inherited" (Aryeetey 2016) of community members (Walter 2011) Obesity is a problem Right now, it’s not something important that could create a problem for Physical activity Another important factor was on attitudes that people have towards of the future/older my health. Maybe in the future I need to be more careful about my associated with status being ‘active for transportation for day to day activities’. People of a age weight. (16-yearold girl) (Amiri 2011) certain social strata are expected to use motor vehicles for Awareness transportation. Use of personal motorised vehicle was seen as a symbol Awareness physical participants believed “appropriate regular physical activity is very of social status. (De Silva 2018) activity benefits effective for health” and “inactivity habits result in reversed health Food associated with “… because you feel like an outcast because you are the only one that outcomes.” (Peykari 2015) status goes to the cafeteria, so you have to get money and go to the tuck shop.” Awareness of physical Most of the time we join or want to exercise because of weight. I don’t (Brown 2015) activity for weight loss remember anybody who I’ve come across talking about exercising. Only Body image related to My family, everybody goes, “Wow, you're so fat. Only poor people get when they want to lose weight then they want to exercise. (Walter 2011) income that fat. Why are you like this? Middle class people don't gain weight.” Awareness of “Avoid eating a lot of junk food, like hamburgers and pizzas; it’s not bad You know? It's horrible. You already feel bad about yourself, right? And (un)healthy foods to eat them, but not very often.” (Madrigal 2017) then a bunch of people go and say those things. You don't need to hear it Awareness related to We know we should eat fruits, vegetables, protein from meat and eggs, because you already know. Every day you look at the mirror, you know it. the amount but the exact amount we do not know (woman, married, merchant, 40-50 So it's always a slap in the face, right? (Lacroix 2019) years old).(Carrete 116) Motivation/habit strength Awareness related to some older adolescent girls did not see the independent benefits of being Physical activity habits “I have it [PA] all planned. I cook the meal for the next day every night, so diet versus physical physically active and believed that it was not necessary if they were I am free in the morning. My husband wakes me up early and we go activity following a healthy diet: ‘I think I would rather eat healthy and not together to the park to do exercise.” (Kalani 2018) exercise,’ (Adolescent girl, 15–17 years) (Wrottesley 2019) Dietary habits It was clear that soft drink consumption was a deep-seated habit that Perceived food safety sometimes was perceived by participants as an addiction. The habit of Unhealthy related to “A snack which is produced by dirty hands contains microbes and can drinking soft drinks was clearly associated with certain occasions in their unsafe cause illness. For instance, I have seen hairs in bread and cheese snacks social life, such as casual encounters, celebrations, or certain meals with a sold at school café. Therefore, I prefer packed puffs and chips to high-energy content, where soft drinks seemed necessary to enjoy the traditional bread and cheese because they are safer”. (Bastami 2019) moment. (Caamano 2016) Eating out versus at “We will have the road side vendors food, it’s not safe having because it’s Motivations to lose “I am a fast food lover but the dream of being skinny forces me to have home open food and we don’t know how they made it but it just tempts us” weight self-control. In my age, appearance is the most important concern for a [Indian urban high SES normal weight girls]. (Correa 2017) girl.” (Usman 2017) Food safety being part “Actually, I think food safety is not a big deal. As long as you do not Taste and pleasure of life immediately die after eating it, everything is ok. Nothing is safe. What Taste and Nowadays people don’t like taking the traditional foods, they despise the food is safe? Even the vegetables you buy in the market are not safe. attractiveness of food ‘mboga’ (green vegetables), they say it’s not sweet. So they prefer taking They have pesticide on them. Even things cooked at home are not that the junk food like pizzas. They take junk food over the traditional food safe, because the ingredients bought from the market are not necessarily (Ssewanyana 2018). safe. A restaurant may cook with used oil. So what can you do?” (Female Pleasure related to “I’m enjoying by doing sport,” and “I exercise to entertain myself.” Having 16) (Veeck 2014) physical activity fun was a strong facilitator of adolescent PA. (Abdelghaffer 2019) Subjective norms SOCIAL LEVEL Body image related to “For a woman, being overweight suggests that her husband takes good Family environment – adult women status care of her, that he is comfortable, he has money.” (Cohen 2017) 72 Qualitative evidence synthesis Appendix 2.4. Table of all identified themes with relevant Theme Illustrative quotations quotations Body image related to Marriage and pregnancy were two major explanations they provided for age, marriage and this increase of weight. There was a strong belief of weight differences motherhood between señoras (Mrs.) and señoritas (Miss); Señoritas should be slim, and señoras could be fat (Kimoto 2014) Theme Illustrative quotations Movement of girls and Do you know what people would call us if I go out for a walk in the late INDIVIDUAL LEVEL women in public evening with our daughters? We would be considered a bad lot of Attribution 2 women. We have to safeguard ourselves and our children from getting Obesity/body weight participants who believed that factors such as genetics or even God’s will bad labels. So, we do not go to the park or the beach unless my husband is destiny were more influential toward their obesity, than their lifestyle (Amiri is able to accompany us.” (De Silva 2018) 2011) Gender-appropriate Soccer is for men, ballet is for women, this is like saying strength and Obesity/body weight In making a case for heredity, it was argued by the discussion groups that physical activity delicacy . . . .” (Monge-Rojas 2017) is hereditary some women were overweight because being overweight is a part of Exercise was seen to be associated with what children and young people their families. Based on this belief, the weight gained by such women is Age-appropriate did, and it was not acceptable for women (particularly married women) considered “natural.” Some even believed that “nothing can be done physical activity to be seen exercising. Women were discouraged by the ―destructive talk about it” when overweight is inherited" (Aryeetey 2016) of community members (Walter 2011) Obesity is a problem Right now, it’s not something important that could create a problem for Physical activity Another important factor was on attitudes that people have towards of the future/older my health. Maybe in the future I need to be more careful about my associated with status being ‘active for transportation for day to day activities’. People of a age weight. (16-yearold girl) (Amiri 2011) certain social strata are expected to use motor vehicles for Awareness transportation. Use of personal motorised vehicle was seen as a symbol Awareness physical participants believed “appropriate regular physical activity is very of social status. (De Silva 2018) activity benefits effective for health” and “inactivity habits result in reversed health Food associated with “… because you feel like an outcast because you are the only one that outcomes.” (Peykari 2015) status goes to the cafeteria, so you have to get money and go to the tuck shop.” Awareness of physical Most of the time we join or want to exercise because of weight. I don’t (Brown 2015) activity for weight loss remember anybody who I’ve come across talking about exercising. Only Body image related to My family, everybody goes, “Wow, you're so fat. Only poor people get when they want to lose weight then they want to exercise. (Walter 2011) income that fat. Why are you like this? Middle class people don't gain weight.” Awareness of “Avoid eating a lot of junk food, like hamburgers and pizzas; it’s not bad You know? It's horrible. You already feel bad about yourself, right? And (un)healthy foods to eat them, but not very often.” (Madrigal 2017) then a bunch of people go and say those things. You don't need to hear it Awareness related to We know we should eat fruits, vegetables, protein from meat and eggs, because you already know. Every day you look at the mirror, you know it. the amount but the exact amount we do not know (woman, married, merchant, 40-50 So it's always a slap in the face, right? (Lacroix 2019) years old).(Carrete 116) Motivation/habit strength Awareness related to some older adolescent girls did not see the independent benefits of being Physical activity habits “I have it [PA] all planned. I cook the meal for the next day every night, so diet versus physical physically active and believed that it was not necessary if they were I am free in the morning. My husband wakes me up early and we go activity following a healthy diet: ‘I think I would rather eat healthy and not together to the park to do exercise.” (Kalani 2018) exercise,’ (Adolescent girl, 15–17 years) (Wrottesley 2019) Dietary habits It was clear that soft drink consumption was a deep-seated habit that Perceived food safety sometimes was perceived by participants as an addiction. The habit of Unhealthy related to “A snack which is produced by dirty hands contains microbes and can drinking soft drinks was clearly associated with certain occasions in their unsafe cause illness. For instance, I have seen hairs in bread and cheese snacks social life, such as casual encounters, celebrations, or certain meals with a sold at school café. Therefore, I prefer packed puffs and chips to high-energy content, where soft drinks seemed necessary to enjoy the traditional bread and cheese because they are safer”. (Bastami 2019) moment. (Caamano 2016) Eating out versus at “We will have the road side vendors food, it’s not safe having because it’s Motivations to lose “I am a fast food lover but the dream of being skinny forces me to have home open food and we don’t know how they made it but it just tempts us” weight self-control. In my age, appearance is the most important concern for a [Indian urban high SES normal weight girls]. (Correa 2017) girl.” (Usman 2017) Food safety being part “Actually, I think food safety is not a big deal. As long as you do not Taste and pleasure of life immediately die after eating it, everything is ok. Nothing is safe. What Taste and Nowadays people don’t like taking the traditional foods, they despise the food is safe? Even the vegetables you buy in the market are not safe. attractiveness of food ‘mboga’ (green vegetables), they say it’s not sweet. So they prefer taking They have pesticide on them. Even things cooked at home are not that the junk food like pizzas. They take junk food over the traditional food safe, because the ingredients bought from the market are not necessarily (Ssewanyana 2018). safe. A restaurant may cook with used oil. So what can you do?” (Female Pleasure related to “I’m enjoying by doing sport,” and “I exercise to entertain myself.” Having 16) (Veeck 2014) physical activity fun was a strong facilitator of adolescent PA. (Abdelghaffer 2019) Subjective norms SOCIAL LEVEL Body image related to “For a woman, being overweight suggests that her husband takes good Family environment – adult women status care of her, that he is comfortable, he has money.” (Cohen 2017) 73 Chapter 2 Theme Illustrative quotations Theme Illustrative quotations Impact of marriage or For women, established gender roles as primary care givers (packing Accessibility of public Built environment was a major factor as most of the facilities like parks motherhood lunch for kids and family in the morning and evening, prioritising family’s spaces and playgrounds are not accessible or are not well managed. There is health over their own) deprived them of the opportunity of walking hardly any space for footpaths in Kerala, much of which is encroached by (while men could very well take their health walk or sleep during that vehicle parking. Rain, traffic, and stray dogs are leading people to walk time). (Garg 2016) early in the morning and with a companion (Garg 2019) Family food …We do not eat green vegetables now. My husband does not like to eat. Safety in built “It is not safe to go out around my house because there are many preferences (Bailey 2018) environment criminals.” Girls added that there are not enough green spaces or Time constraints for I used to play basketball. But to be honest, I hardly can go anywhere “natural environments” where they can enjoy physical activities. physical activity anymore. I have to care for my two babies now and so it is difficult. The (Madrigal 2017) only time I leave the house is for errands. (Kurschner 2019) Availability and access to food Family environment – Availability of food When asked what she thought, for her, was the biggest obstacle to adolescent girls healthy eating habits, she said, “sweets because they are everywhere.” Parental style or “When we are with parents we eat healthy foods, they don’t allow us to (Bridle-Fitzpatrick 2015) support eat junk foods when we are at home” [Indian low SES girls]. (Correa 2017) Accessibility to food With large supermarkets located farther away from home, families Parents as role models "If we had more healthy snacks than junk foods at home, this would make outlets regularly depend on neighborhood tienditas and other local vendors for us choose healthier snacks." (Karimi-Shahanjarini 2010) goods. These stores serve as both opportunities and barriers in the Influence of mothers “My mother does not allow me to go to work if I do not have my context of healthy eating. The juxtaposition of fruits and vegetables, breakfast. She also does not want me to eat spicy food” (Habibie 2019) which are often overly ripe and vulnerable to pests such as fruit flies and Academic pressure other insects and animals, and which are placed next to protected, shelf- Time constraints to Due to fierce competition for entrance to a prestigious university, most stable prepackaged chips, cookies, noodles, and similar products, eat urban school-age children, such as the student quoted above, are illustrates a dietary health battle in action found within such an important expected to spend almost all of their waking hours engaged in study, place for youth and their families. (Romero 2019) whether in school, at special “after school cram schools” operated by School environment teachers or private companies or at home. (Veeck 2014) Availability of facilities Within the school environment, limited sports facilities, lack of qualified Parental rules about “My family that always encouraged me to do exercise from childhood to for physical activity coaches, lack of opportunity for unstructured play coupled with an studying high school, at the first year of high school told me: now the time for emphasis on elite sports and sport camps, demotivating teachers, and exercise is over. It is the time to study!” (21 Y/O university student) lack of role models were other impediments to activity. Girls additionally (Kalani 2017) felt that they had fewer PA options available at school compared with Exhaustion from School hours limited the time available to engage in physical activities. boys. (Satja 2018) studying Adolescents mentioned little leisure time and lack of energy after school Availability of food at A private school girl explained, “I think the fact that we have kiosks inside were barriers to physical activity. (Monge-Rojas 2009) school [the school] does not help, because it induces us to buy and eat junk Peer influence food.” (Madrigal 2017) Eating together with Being in the social network of friends was expressed as one of the main Availability of food Some schools will not allow students to leave their campus during the friends factors causing unhealthy eating habits. In some cases, students declared around school day. To meet the needs of students restricted to campuses, many that when they go out with their friends, they eat lot of junk foods as a restaurants offer delivery services to school-age students. As explained by routine way of social interaction. (Bagherniya 2018) our informants, these restaurants will deliver food directly to students at Spending time Similarly, another female adolescent stated that even the social influence their schools. Students can order food by telephone, by text message or together of peers at school influence her to make unhealthy dietary choices. She through mobile applications during breaks between classes, and then the stated that “I think just being around school at all like even if you pack restaurant will deliver the food via motorbike or bicycle to the school your own healthy lunch you still you see people walking around with pies gates for the students to pick up at lunch time. Some of these restaurants and sweets and Rolly Pops (lollipop); (Brown 2015) are “delivery only,” underscoring how the busy lives of students have Social network for having strong social networks in the community was thought to have a transformed the retail landscape. (Veeck 2014) adults positive effect on PA. (De Silva 2018) Curriculum and ‘‘In schools we have two periods every week for games and physical PHYSICAL LEVEL support from teachers education, but all games are played only by boys. Nothing is given to girls. Built environment If we play, boys tease or make fun of us.’’ (Gavaravarapu 2015) Availability and access to physical activity Workplace environment Availability of facilities Limitations in the of community’s environment—specifically, lack of Food availability at “When I go to work, I have breakfast again, because everyone’s eating for physical activity facilities for physical activity and the lack of a supportive environment— work right? There’s no way you can go in without grabbing a cookie, a coffee..” impeded the adoption of a healthful, active life- style. ‘‘. it depends on (Lacroix 2019) where you live you can’t go out because there’s too much traffic and it’s MACRO LEVEL very dangerous.’’ (Monge-Rojas 2009) Cultural norms and traditions 74 Qualitative evidence synthesis Theme Illustrative quotations Theme Illustrative quotations Impact of marriage or For women, established gender roles as primary care givers (packing Accessibility of public Built environment was a major factor as most of the facilities like parks motherhood lunch for kids and family in the morning and evening, prioritising family’s spaces and playgrounds are not accessible or are not well managed. There is health over their own) deprived them of the opportunity of walking hardly any space for footpaths in Kerala, much of which is encroached by (while men could very well take their health walk or sleep during that vehicle parking. Rain, traffic, and stray dogs are leading people to walk time). (Garg 2016) early in the morning and with a companion (Garg 2019) Family food …We do not eat green vegetables now. My husband does not like to eat. Safety in built “It is not safe to go out around my house because there are many 2 preferences (Bailey 2018) environment criminals.” Girls added that there are not enough green spaces or Time constraints for I used to play basketball. But to be honest, I hardly can go anywhere “natural environments” where they can enjoy physical activities. physical activity anymore. I have to care for my two babies now and so it is difficult. The (Madrigal 2017) only time I leave the house is for errands. (Kurschner 2019) Availability and access to food Family environment – Availability of food When asked what she thought, for her, was the biggest obstacle to adolescent girls healthy eating habits, she said, “sweets because they are everywhere.” Parental style or “When we are with parents we eat healthy foods, they don’t allow us to (Bridle-Fitzpatrick 2015) support eat junk foods when we are at home” [Indian low SES girls]. (Correa 2017) Accessibility to food With large supermarkets located farther away from home, families Parents as role models "If we had more healthy snacks than junk foods at home, this would make outlets regularly depend on neighborhood tienditas and other local vendors for us choose healthier snacks." (Karimi-Shahanjarini 2010) goods. These stores serve as both opportunities and barriers in the Influence of mothers “My mother does not allow me to go to work if I do not have my context of healthy eating. The juxtaposition of fruits and vegetables, breakfast. She also does not want me to eat spicy food” (Habibie 2019) which are often overly ripe and vulnerable to pests such as fruit flies and Academic pressure other insects and animals, and which are placed next to protected, shelf- Time constraints to Due to fierce competition for entrance to a prestigious university, most stable prepackaged chips, cookies, noodles, and similar products, eat urban school-age children, such as the student quoted above, are illustrates a dietary health battle in action found within such an important expected to spend almost all of their waking hours engaged in study, place for youth and their families. (Romero 2019) whether in school, at special “after school cram schools” operated by School environment teachers or private companies or at home. (Veeck 2014) Availability of facilities Within the school environment, limited sports facilities, lack of qualified Parental rules about “My family that always encouraged me to do exercise from childhood to for physical activity coaches, lack of opportunity for unstructured play coupled with an studying high school, at the first year of high school told me: now the time for emphasis on elite sports and sport camps, demotivating teachers, and exercise is over. It is the time to study!” (21 Y/O university student) lack of role models were other impediments to activity. Girls additionally (Kalani 2017) felt that they had fewer PA options available at school compared with Exhaustion from School hours limited the time available to engage in physical activities. boys. (Satja 2018) studying Adolescents mentioned little leisure time and lack of energy after school Availability of food at A private school girl explained, “I think the fact that we have kiosks inside were barriers to physical activity. (Monge-Rojas 2009) school [the school] does not help, because it induces us to buy and eat junk Peer influence food.” (Madrigal 2017) Eating together with Being in the social network of friends was expressed as one of the main Availability of food Some schools will not allow students to leave their campus during the friends factors causing unhealthy eating habits. In some cases, students declared around school day. To meet the needs of students restricted to campuses, many that when they go out with their friends, they eat lot of junk foods as a restaurants offer delivery services to school-age students. As explained by routine way of social interaction. (Bagherniya 2018) our informants, these restaurants will deliver food directly to students at Spending time Similarly, another female adolescent stated that even the social influence their schools. Students can order food by telephone, by text message or together of peers at school influence her to make unhealthy dietary choices. She through mobile applications during breaks between classes, and then the stated that “I think just being around school at all like even if you pack restaurant will deliver the food via motorbike or bicycle to the school your own healthy lunch you still you see people walking around with pies gates for the students to pick up at lunch time. Some of these restaurants and sweets and Rolly Pops (lollipop); (Brown 2015) are “delivery only,” underscoring how the busy lives of students have Social network for having strong social networks in the community was thought to have a transformed the retail landscape. (Veeck 2014) adults positive effect on PA. (De Silva 2018) Curriculum and ‘‘In schools we have two periods every week for games and physical PHYSICAL LEVEL support from teachers education, but all games are played only by boys. Nothing is given to girls. Built environment If we play, boys tease or make fun of us.’’ (Gavaravarapu 2015) Availability and access to physical activity Workplace environment Availability of facilities Limitations in the of community’s environment—specifically, lack of Food availability at “When I go to work, I have breakfast again, because everyone’s eating for physical activity facilities for physical activity and the lack of a supportive environment— work right? There’s no way you can go in without grabbing a cookie, a coffee..” impeded the adoption of a healthful, active life- style. ‘‘. it depends on (Lacroix 2019) where you live you can’t go out because there’s too much traffic and it’s MACRO LEVEL very dangerous.’’ (Monge-Rojas 2009) Cultural norms and traditions 75 Chapter 2 Theme Illustrative quotations Eating out versus at Healthy foods were described as home-made due to safety and home cleanliness, whereas unhealthy foods contain monosodium glutamate and preservatives or have extreme colours or flavours, are high in oil and fats, and may be unhygienic, with fast, junk, and fried street foods mentioned as examples. (Blum 2017) Traditional versus Our own local food is better for health and even for Samoan people to be modern stronger. If we eat overseas food we will get fat – it’s not good for the body.” (41-year-old participant); (Farrel 2019) It’s not in our culture … I’ve been living without it for such a long time so why should I start now? They’ll tell you, hey, in the olden days we were healthy without exercising. If you do your duties at home then you’re fit, they’ll tell you. Black women aren’t meant to exercise, it’s for White people. Normally jogging and eating healthy diet or doing sports, it’s not in our culture. (Walter 2011) Sharing meals a few number of participants preferred eating home-cooked foods because of the emotional atmosphere of eating with family members: “Eating traditional foods with families is better because the family members are together; eating fast food creates a distance between the adolescents and their family” (Majabadi 2016) Social media and Extensive networks and use of social media infiltrated with information advertising about eateries and snacks are likely contributing to the already strong yearning for snack foods (Blum 2017) "There are many TV commercials for puffed cheese and crisps but not for healthy snacks such as raisins and fruits.” (Karimi-Shahanjarini 2010) Urbanization Food availability “From my village to Delhi, it’s a drastic change. Here we have less milk and other items, here everyone is keen to eat outside food. I was healthier when I was in my village as compared to Delhi.” (Bailey 2018) Sedentary lifestyle One overweight woman stated that the increasing prevalence of obesity was the result of modern technology. “One impact of current technology is that we are not required to move physically. As a result, people become fatter because they are becoming lazier to move” (OW/OB, 21 years old, unmarried, working) (Fachruddin 2019) Economic “nowadays, both the father and the mother are employed and they do development not have much time to cook, so they just buy fast food” (Majabadi 2016) 76 Qualitative evidence synthesis 2 77 CHAPTER 3 Assessing factors influencing adolescents’ dietary behaviours in urban Ethiopia using participatory photography Ursula Trübswasser Kaleab Baye Michelle Holdsworth Megan Loeffen Edith JM Feskens Elise F Talsma Public Health Nutrition DOI: 10.1017/S1368980020002487 Chapter 3 INTRODUCTION METHODS Globally, more children and adolescents are moderately or severely underweight Participants and Setting than are obese, but obesity is expected to overtake underweight rates by 2022.1 Rates of overweight and obesity in 12–15-year-olds in low- and middle-income This study was conducted in two schools in Addis Ababa, Ethiopia. Schools are a countries (LMIC) have been reported at 21.4%.2 convenient setting to access adolescents in urban settings for studies that require participants to be gathered on multiple occasions. One private and one government Most research in recent years in LMIC has targeted maternal and child nutrition, school were selected based on recommendations from the Bureau of Education of aiming to interrupt the intergenerational cycle of malnutrition.3 More recently, the City of Addis Ababa, based on the commitment of the school principals and adolescence has been identified as a second window of opportunity for catch-up proximity to each other. The schools are 1.29 km apart and share a similar growth,4 but also as a period in which nutritional needs increase and lifelong dietary neighbourhood in the busy, central part of town, called Sidist Kilo. The selection of habits and preferences are formed. These habits can influence adolescents’ school types was used as a proxy for socio-economic status (SES).22 Physical nutritional status as well as that of future generations.5 proximity to each other was important to explore how school populations of different SES experience the same neighbourhood environment. The link between poor quality diets low in diversity with malnutrition has been well established.6 However little research in LMIC has been conducted on the factors Based on sample sizes of previous Photovoice studies,23 15 adolescents were influencing dietary choices.7-9 Some of these factors are related to increasing recruited for each school using purposive sampling with the assistance of one urbanization and changes in urban food environments, encompassing food teacher in each school. To be eligible, participants had to be between 14 and 20 availability, physical and economic access; advertising; and food quality and safety.10 years old, own a smartphone, and be committed to participate in one meeting each Increased availability of energy-dense, nutrient-poor, ultra-processed foods is week for the four weeks of the study. The age group of 14 to 20 years was selected potentially detrimental to adolescent diets and nutritional status, as research from as the study methodology required a high level of participation, communication and LMIC has shown.8,11 conceptualization skills, which older adolescents are more likely to provide.24 In this age group, school attendance in Addis Ababa is higher than 60%.25 Since the rules of Ethiopia has a rapidly growing urban population12 that is increasingly spending more the private school prohibited students from carrying mobile phones on the school on animal products, oils and fats, as well as fruit and vegetables, while prices for premises, digital cameras (Sony DSCW800) were given to the private school students sugar and oil have been decreasing.13 However, overweight currently affects <5% of for the period of the study. adolescents and is mostly a concern for adult women in urban populations of higher wealth quintiles in Ethiopia.14 As research from other LMIC has shown, these trends Design and Data Collection are likely to shift to other age and socio-economic groups.11 For adolescents in particular, unhealthy school food environments, as well as This study used the Photovoice method to assess adolescents’ perceptions of factors parents and peers, can influence their food choices.15,16 Assessing adolescents’ influencing their dietary behaviours, following the three-staged approach of views of their food environment could provide a better understanding of potential selecting (choosing the photographs that best reflect the topic); contextualizing factors influencing their food choices.17 This could further contribute to knowledge (explaining the context of the photographs); and codifying (identifying the issues, 26 related to factors of the personal food environment, such as desirability, themes and theories emerging from the photographs). affordability and accessibility, which remain understudied.10 In addition, the use of qualitative research in LMIC has been identified as a gap in adolescent research.15,18 Data collection in the government school was conducted during October to Photovoice is a participatory action research methodology that has been used November 2018 and in the private school during May to June 2019. At the beginning previously in food environment studies with adolescents in resource-poor settings of the study, one-on-one interviews were conducted with all participants to collect of high-income countries or in LMIC.17,19-21 This Photovoice study will therefore fill a information on their demographic profile including age, gender, and residence. significant gap in understanding the factors influencing dietary behaviours of After receiving training on the objectives of the study, basic photography, ethics and adolescents in the urban LMIC setting of Addis Ababa, Ethiopia. safety, participants were asked to take photographs during a two-week period on the following two topics: (1) “Challenges in your environment to eat healthy”; and (2) “Opportunities in your environment to eat healthy”. Participants were asked to 80 Photovoice study INTRODUCTION METHODS Globally, more children and adolescents are moderately or severely underweight Participants and Setting than are obese, but obesity is expected to overtake underweight rates by 2022.1 Rates of overweight and obesity in 12–15-year-olds in low- and middle-income This study was conducted in two schools in Addis Ababa, Ethiopia. Schools are a countries (LMIC) have been reported at 21.4%.2 convenient setting to access adolescents in urban settings for studies that require participants to be gathered on multiple occasions. One private and one government Most research in recent years in LMIC has targeted maternal and child nutrition, school were selected based on recommendations from the Bureau of Education of aiming to interrupt the intergenerational cycle of malnutrition.3 More recently, the City of Addis Ababa, based on the commitment of the school principals and adolescence has been identified as a second window of opportunity for catch-up proximity to each other. The schools are 1.29 km apart and share a similar 3 growth,4 but also as a period in which nutritional needs increase and lifelong dietary neighbourhood in the busy, central part of town, called Sidist Kilo. The selection of habits and preferences are formed. These habits can influence adolescents’ school types was used as a proxy for socio-economic status (SES).22 Physical nutritional status as well as that of future generations.5 proximity to each other was important to explore how school populations of different SES experience the same neighbourhood environment. The link between poor quality diets low in diversity with malnutrition has been well established.6 However little research in LMIC has been conducted on the factors Based on sample sizes of previous Photovoice studies,23 15 adolescents were influencing dietary choices.7-9 Some of these factors are related to increasing recruited for each school using purposive sampling with the assistance of one urbanization and changes in urban food environments, encompassing food teacher in each school. To be eligible, participants had to be between 14 and 20 availability, physical and economic access; advertising; and food quality and safety.10 years old, own a smartphone, and be committed to participate in one meeting each Increased availability of energy-dense, nutrient-poor, ultra-processed foods is week for the four weeks of the study. The age group of 14 to 20 years was selected potentially detrimental to adolescent diets and nutritional status, as research from as the study methodology required a high level of participation, communication and LMIC has shown.8,11 conceptualization skills, which older adolescents are more likely to provide.24 In this age group, school attendance in Addis Ababa is higher than 60%.25 Since the rules of Ethiopia has a rapidly growing urban population12 that is increasingly spending more the private school prohibited students from carrying mobile phones on the school on animal products, oils and fats, as well as fruit and vegetables, while prices for premises, digital cameras (Sony DSCW800) were given to the private school students sugar and oil have been decreasing.13 However, overweight currently affects <5% of for the period of the study. adolescents and is mostly a concern for adult women in urban populations of higher wealth quintiles in Ethiopia.14 As research from other LMIC has shown, these trends Design and Data Collection are likely to shift to other age and socio-economic groups.11 For adolescents in particular, unhealthy school food environments, as well as This study used the Photovoice method to assess adolescents’ perceptions of factors parents and peers, can influence their food choices.15,16 Assessing adolescents’ influencing their dietary behaviours, following the three-staged approach of views of their food environment could provide a better understanding of potential selecting (choosing the photographs that best reflect the topic); contextualizing factors influencing their food choices.17 This could further contribute to knowledge (explaining the context of the photographs); and codifying (identifying the issues, 26 related to factors of the personal food environment, such as desirability, themes and theories emerging from the photographs). affordability and accessibility, which remain understudied.10 In addition, the use of qualitative research in LMIC has been identified as a gap in adolescent research.15,18 Data collection in the government school was conducted during October to Photovoice is a participatory action research methodology that has been used November 2018 and in the private school during May to June 2019. At the beginning previously in food environment studies with adolescents in resource-poor settings of the study, one-on-one interviews were conducted with all participants to collect of high-income countries or in LMIC.17,19-21 This Photovoice study will therefore fill a information on their demographic profile including age, gender, and residence. significant gap in understanding the factors influencing dietary behaviours of After receiving training on the objectives of the study, basic photography, ethics and adolescents in the urban LMIC setting of Addis Ababa, Ethiopia. safety, participants were asked to take photographs during a two-week period on the following two topics: (1) “Challenges in your environment to eat healthy”; and (2) “Opportunities in your environment to eat healthy”. Participants were asked to 81 Chapter 3 take a minimum of three photographs per topic but were instructed not to interviews and discussions were digitally recorded and simultaneously translated undertake any selection of photographs prior to their interview. The training did not and transcribed from Amharic into English. An a priori codebook was developed include any information on nutrition or definitions of “healthy diet” to avoid based on existing literature and structured by four influencing spheres (individual, influencing the knowledge and perceptions of participants related to “healthy diet”. social, physical, and macro level environment) of a socio-ecological framework,15 The four facilitators (three females, one male) had prior experience in qualitative which has also been adapted to the African context.28 research and/or in working with adolescents and were fluent in the local language, Amharic. They were trained by two researchers on the study protocol and All participants were partially involved in data analysis as they selected photographs, facilitation techniques to guide participants during the study period. All identified common themes in the photographs and categorised photographs questionnaires and materials for participants were translated into Amharic and then according to themes. After finalization of the data collection, two researchers back translated into English to ensure accuracy. independently conducted first cycle open deductive and inductive coding27 using ATLAS.ti version 8.3.1 for Mac. The researchers then compared findings, merged When participants returned with their photographs, individual photo-elicit codes, and examined discrepancies in coding to establish a standardised method.29 interviews were conducted, during which participants provided captions for every Thematic areas were identified by collating data relevant to each code, code group photograph and selected a maximum of three photographs per topic, for a total of and the four influencing spheres.30 no more than six photographs. Facilitators gently guided participants in the selection process by reminding them of the topics. Interviews lasted on average 50 minutes. Furthermore, the 130 photographs selected by participants were categorised The interviews followed a set of interview questions, abbreviated as “SHOWeD” in inductively based on the different environments (school, neighbourhood, home, the Photovoice methodology,26 which were adapted with supporting questions, to social) and different types of foods (fruit and vegetables, fried street food, sugar- make them more understandable for adolescents:24 (supporting questions are sweetened beverages and candy, and home cooked meals) visible in the provided in parentheses) 1. What do you See here?; 2. What's really Happening photographs. This analysis of photographs further contributed to identifying here? (What might have happened before the photo was taken?; Why did it themes. happen?); 3. How does this relate to Our lives? (Why did you take the photo and what might others see in the photo?; What did you feel about the subject of the RESULTS photo?); 4. Why does this problem or this strength exist? 5. Why is the situation like this?; and 6. What can we Do about this?. Out of the 30 recruited adolescents, 26 completed the study (female=17; male=9). After one week, the photographs selected during individual interviews were printed The participants completing the study were aged 14-20 years old and 15 attended and then used in focus group discussions (FGDs). For each school, two FGDs were the government school (GS) and 11 attended the private school (PS) (Table 3.1). conducted with 5-8 participants and two facilitators in each. In the government Reasons for loss to follow-up were: dropping out of the study (n=2) or losing the school, these FGDs were separated by gender; however, in the private school, FGDs camera (n=2). Participants took a total of 722 photographs (mean=28), of which they were conducted in one female-only and one mixed gender group, since there were selected 130 photographs (mean=5; Table 3.2). Most of the selected photographs only two male participants in that school. In the FGDs, one photograph was selected (n=68) were taken on the streets around the school or the neighbourhoods where for each topic, which was then discussed, following the same “SHOWeD” question the participants lived, which was in the same or neighbouring sub-cities of Addis guide mentioned above. Combining individual interviews with group discussion Ababa to the two schools. The foods pictured in these photographs were primarily enhanced data richness by providing additional insights from individuals on some of of fruit and vegetables sold on the street (n=35) or foods prepared on the street, the issues raised in the FGDs. Individual interviews also provided an opportunity for such as fried potatoes, samosas, or donuts (n=22). The home environment was the participants to share more personal reflections, which adolescents may be more second most common environment represented in the photographs (n=34), which self-conscious of doing in a group setting. in some photographs (n=22) depicted the home setting, including home-cooked food, family members or food preparations in their kitchens. Data Analysis Descriptive data from questionnaires were double-entered and checked by a second researcher in Windows Excel and analysed with SPSS Statistics V25.0 for Mac. All 82 Photovoice study take a minimum of three photographs per topic but were instructed not to interviews and discussions were digitally recorded and simultaneously translated undertake any selection of photographs prior to their interview. The training did not and transcribed from Amharic into English. An a priori codebook was developed include any information on nutrition or definitions of “healthy diet” to avoid based on existing literature and structured by four influencing spheres (individual, influencing the knowledge and perceptions of participants related to “healthy diet”. social, physical, and macro level environment) of a socio-ecological framework,15 The four facilitators (three females, one male) had prior experience in qualitative which has also been adapted to the African context.28 research and/or in working with adolescents and were fluent in the local language, Amharic. They were trained by two researchers on the study protocol and All participants were partially involved in data analysis as they selected photographs, facilitation techniques to guide participants during the study period. All identified common themes in the photographs and categorised photographs questionnaires and materials for participants were translated into Amharic and then according to themes. After finalization of the data collection, two researchers back translated into English to ensure accuracy. independently conducted first cycle open deductive and inductive coding27 using ATLAS.ti version 8.3.1 for Mac. The researchers then compared findings, merged 3 When participants returned with their photographs, individual photo-elicit codes, and examined discrepancies in coding to establish a standardised method.29 interviews were conducted, during which participants provided captions for every Thematic areas were identified by collating data relevant to each code, code group photograph and selected a maximum of three photographs per topic, for a total of and the four influencing spheres.30 no more than six photographs. Facilitators gently guided participants in the selection process by reminding them of the topics. Interviews lasted on average 50 minutes. Furthermore, the 130 photographs selected by participants were categorised The interviews followed a set of interview questions, abbreviated as “SHOWeD” in inductively based on the different environments (school, neighbourhood, home, the Photovoice methodology,26 which were adapted with supporting questions, to social) and different types of foods (fruit and vegetables, fried street food, sugar- make them more understandable for adolescents:24 (supporting questions are sweetened beverages and candy, and home cooked meals) visible in the provided in parentheses) 1. What do you See here?; 2. What's really Happening photographs. This analysis of photographs further contributed to identifying here? (What might have happened before the photo was taken?; Why did it themes. happen?); 3. How does this relate to Our lives? (Why did you take the photo and what might others see in the photo?; What did you feel about the subject of the RESULTS photo?); 4. Why does this problem or this strength exist? 5. Why is the situation like this?; and 6. What can we Do about this?. Out of the 30 recruited adolescents, 26 completed the study (female=17; male=9). After one week, the photographs selected during individual interviews were printed The participants completing the study were aged 14-20 years old and 15 attended and then used in focus group discussions (FGDs). For each school, two FGDs were the government school (GS) and 11 attended the private school (PS) (Table 3.1). conducted with 5-8 participants and two facilitators in each. In the government Reasons for loss to follow-up were: dropping out of the study (n=2) or losing the school, these FGDs were separated by gender; however, in the private school, FGDs camera (n=2). Participants took a total of 722 photographs (mean=28), of which they were conducted in one female-only and one mixed gender group, since there were selected 130 photographs (mean=5; Table 3.2). Most of the selected photographs only two male participants in that school. In the FGDs, one photograph was selected (n=68) were taken on the streets around the school or the neighbourhoods where for each topic, which was then discussed, following the same “SHOWeD” question the participants lived, which was in the same or neighbouring sub-cities of Addis guide mentioned above. Combining individual interviews with group discussion Ababa to the two schools. The foods pictured in these photographs were primarily enhanced data richness by providing additional insights from individuals on some of of fruit and vegetables sold on the street (n=35) or foods prepared on the street, the issues raised in the FGDs. Individual interviews also provided an opportunity for such as fried potatoes, samosas, or donuts (n=22). The home environment was the participants to share more personal reflections, which adolescents may be more second most common environment represented in the photographs (n=34), which self-conscious of doing in a group setting. in some photographs (n=22) depicted the home setting, including home-cooked food, family members or food preparations in their kitchens. Data Analysis Descriptive data from questionnaires were double-entered and checked by a second researcher in Windows Excel and analysed with SPSS Statistics V25.0 for Mac. All 83 Chapter 3 Table 3.1. Demographic information of participants in the Photovoice study as meat and sweet foods, should be consumed in moderation. Participants also had good knowledge related to food safety and hygiene and the resulting effects on Characteristics n Mean ± SD or % health and expressed their concerns about cleanliness. Taking photographs of specific outlets that participants frequented made them further aware of how their Participants’ age (years) 26 17.0 ± 1.8 food is actually prepared (Figure 3.1). “...after I do my house chores and my hands get dirty, I wash my hands using tap School water. Cleanliness is important. Moreover, clean water is important for cooking Private school 11 42% healthy food.” (Girl, 16 years, GS) Public school 15 58% “I like potatoes and I would eat it even if you prepare it in any way. And the situation on the picture influences me; it got me thinking is this how our food is Gender prepared?” (Girl, 15 years PS) (Figure 3.1) Male 9 35% Female 17 65% School year 9 10 39% 11 4 15% 12 12 46% Table 3.2. Number of photographs taken by participants, by category Photo Category n Mean ± SD or % Total 722 27.8 ± 21.7 Selected photographs 130 5 ± 1.3 Types of food visible Street foods 22 17% Fruits or vegetables 35 27% Sugar-sweetened beverages or candy 9 7% Home cooked food 22 17% Type of environment Home setting 34 26% School compound, internal 9 7% Figure 3.1. “Erteb” [Amharic for fried potato sandwich] (Girl, 15 years PS) Street setting 68 52% Social setting 18 14% The activity where participants assigned photographs to different themes revealed what they perceived as healthy or unhealthy. Photographs assigned to the “unhealthy food” theme included mostly fried foods prepared on the roadside, but Individual Level also included three photographs of fruit and vegetables sold in carts on the road, which were therefore perceived unclean. However, fruit and vegetables presented Knowledge. Knowledge of nutrition and food safety appeared to be an important in a clean manner as well as packaged foods sold in shops, were associated with factor at the individual level. Participants knew about the health benefits of fruit and “healthy foods”. vegetables, the importance of consuming diverse diets, and that certain foods, such 84 Photovoice study Table 3.1. Demographic information of participants in the Photovoice study as meat and sweet foods, should be consumed in moderation. Participants also had good knowledge related to food safety and hygiene and the resulting effects on Characteristics n Mean ± SD or % health and expressed their concerns about cleanliness. Taking photographs of specific outlets that participants frequented made them further aware of how their Participants’ age (years) 26 17.0 ± 1.8 food is actually prepared (Figure 3.1). “...after I do my house chores and my hands get dirty, I wash my hands using tap School water. Cleanliness is important. Moreover, clean water is important for cooking Private school 11 42% healthy food.” (Girl, 16 years, GS) Public school 15 58% “I like potatoes and I would eat it even if you prepare it in any way. And the situation on the picture influences me; it got me thinking is this how our food is Gender prepared?” (Girl, 15 years PS) (Figure 3.1) 3 Male 9 35% Female 17 65% School year 9 10 39% 11 4 15% 12 12 46% Table 3.2. Number of photographs taken by participants, by category Photo Category n Mean ± SD or % Total 722 27.8 ± 21.7 Selected photographs 130 5 ± 1.3 Types of food visible Street foods 22 17% Fruits or vegetables 35 27% Sugar-sweetened beverages or candy 9 7% Home cooked food 22 17% Type of environment Home setting 34 26% School compound, internal 9 7% Figure 3.1. “Erteb” [Amharic for fried potato sandwich] (Girl, 15 years PS) Street setting 68 52% Social setting 18 14% The activity where participants assigned photographs to different themes revealed what they perceived as healthy or unhealthy. Photographs assigned to the “unhealthy food” theme included mostly fried foods prepared on the roadside, but Individual Level also included three photographs of fruit and vegetables sold in carts on the road, which were therefore perceived unclean. However, fruit and vegetables presented Knowledge. Knowledge of nutrition and food safety appeared to be an important in a clean manner as well as packaged foods sold in shops, were associated with factor at the individual level. Participants knew about the health benefits of fruit and “healthy foods”. vegetables, the importance of consuming diverse diets, and that certain foods, such 85 Chapter 3 Food preferences. Despite their knowledge, participants liked the taste of fried and “Since I am an Ethiopian, I enjoy sharing meals and eating together.” (Boy, 18 sweet foods. years, GS) –Figure 3.2 “I took this picture because most people I know including me consume such sweets and it has become kind of like an addiction.” (Girl, 17 years, PS) Socio-economic status. Not having the financial means to buy what participants considered healthy food, was summarised well by one boy from the government school: “It doesn’t matter how knowledgeable we are if that knowledge is not translated into money, then it is useless.” (Boy, 17 years, GS) Talking about their own and their families’ financial struggles, participants from the government school expressed how important affordability was in influencing their food choices, and how hard it was for them and their families to make a living. “It is the most important factor that influences my food choice, I wish that I could have more money and be able to eat what I want.” (Girl, 17 years, GS) Due to these financial limitations, certain foods were considered as outside the participants’ reach, such as meat and fish, while others, such as “Shiro”, a legume- based powder that is used for stews or vegetables sold by “Gulits”, informal sellers on the side of the road, were considered more available and affordable. “Most of us have love for meat and want to eat meat but we can’t afford it.” (Girl, 18 years, GS) Figure 3.2. “Eating together” (Boy, 18 years, GS) Social Level Peer influence. Peer influence was particularly strong in and around school, where the adolescents often ate fried street food. Family influence. Families play an important role in adolescents’ food choices, “My friends like chips and when I’m with them I eat chips too. (…) There is peer particularly mothers, who do most of the cooking. Mostly in the government school, pressure around school and peer pressure has the power to change your life and this influence was perceived as negative, limiting the choices of the adolescents. eating at places like this one because friends’ influence might have some impact “My mom is the one who cooks everything for us. We have no say in what we eat on my health.” (Girl, 16 years, PS) or want to eat. We have to have what she gives us.” (FGD, Boys, GS) Participants from the private school described their mothers’ influence as more positive given their concern for their children’s health. Physical Level “Because mothers usually want the best for their children and want to feed them good food which helps them grow… My mom …doesn’t let me eat raw meat Food availability and affordability. All participants were influenced by what is because it would make me sick.” (Girl, 14 years, PS) available and affordable in the physical environment around their schools and their Fathers in the government school were described solely as “breadwinners”, while in homes. The adolescents and their families purchased most of their foods from the private school, fathers appeared to be the ones buying unhealthy foods. outlets that were available in their neighbourhoods. There were no supermarkets in ”…my father usually buys me cakes and soft drinks but my mother doesn’t let me the neighbourhoods where they live, and instead of travelling long distances to have that.” (FGD mixed, PS) supermarkets, the participants and their families bought their food at small kiosks, open markets, and informal vendors. Participants, therefore, faced limited options Food culture. Participants perceived the Ethiopian tradition of sharing food and due to lack of affordable outlets forcing them to buy street foods of inadequate eating together as positive and motivating to eat healthy. quality. “I grew up eating like this, social events such as this give me the chance to eat “Even my friends and I get out of school we sometimes buy and eat this because healthy.” (Boy, 18 years, GS) we don’t have other options.” (Girl, 15 years, PS) 86 Photovoice study Food preferences. Despite their knowledge, participants liked the taste of fried and “Since I am an Ethiopian, I enjoy sharing meals and eating together.” (Boy, 18 sweet foods. years, GS) –Figure 3.2 “I took this picture because most people I know including me consume such sweets and it has become kind of like an addiction.” (Girl, 17 years, PS) Socio-economic status. Not having the financial means to buy what participants considered healthy food, was summarised well by one boy from the government school: “It doesn’t matter how knowledgeable we are if that knowledge is not translated into money, then it is useless.” (Boy, 17 years, GS) Talking about their own and their families’ financial struggles, participants from the 3 government school expressed how important affordability was in influencing their food choices, and how hard it was for them and their families to make a living. “It is the most important factor that influences my food choice, I wish that I could have more money and be able to eat what I want.” (Girl, 17 years, GS) Due to these financial limitations, certain foods were considered as outside the participants’ reach, such as meat and fish, while others, such as “Shiro”, a legume- based powder that is used for stews or vegetables sold by “Gulits”, informal sellers on the side of the road, were considered more available and affordable. “Most of us have love for meat and want to eat meat but we can’t afford it.” (Girl, 18 years, GS) Figure 3.2. “Eating together” (Boy, 18 years, GS) Social Level Peer influence. Peer influence was particularly strong in and around school, where the adolescents often ate fried street food. Family influence. Families play an important role in adolescents’ food choices, “My friends like chips and when I’m with them I eat chips too. (…) There is peer particularly mothers, who do most of the cooking. Mostly in the government school, pressure around school and peer pressure has the power to change your life and this influence was perceived as negative, limiting the choices of the adolescents. eating at places like this one because friends’ influence might have some impact “My mom is the one who cooks everything for us. We have no say in what we eat on my health.” (Girl, 16 years, PS) or want to eat. We have to have what she gives us.” (FGD, Boys, GS) Participants from the private school described their mothers’ influence as more positive given their concern for their children’s health. Physical Level “Because mothers usually want the best for their children and want to feed them good food which helps them grow… My mom …doesn’t let me eat raw meat Food availability and affordability. All participants were influenced by what is because it would make me sick.” (Girl, 14 years, PS) available and affordable in the physical environment around their schools and their Fathers in the government school were described solely as “breadwinners”, while in homes. The adolescents and their families purchased most of their foods from the private school, fathers appeared to be the ones buying unhealthy foods. outlets that were available in their neighbourhoods. There were no supermarkets in ”…my father usually buys me cakes and soft drinks but my mother doesn’t let me the neighbourhoods where they live, and instead of travelling long distances to have that.” (FGD mixed, PS) supermarkets, the participants and their families bought their food at small kiosks, open markets, and informal vendors. Participants, therefore, faced limited options Food culture. Participants perceived the Ethiopian tradition of sharing food and due to lack of affordable outlets forcing them to buy street foods of inadequate eating together as positive and motivating to eat healthy. quality. “I grew up eating like this, social events such as this give me the chance to eat “Even my friends and I get out of school we sometimes buy and eat this because healthy.” (Boy, 18 years, GS) we don’t have other options.” (Girl, 15 years, PS) 87 Chapter 3 “In our neighbourhood this place is our marketplace. This is because we can only afford to buy from here.” (Boy, 17 years, GS) Hygiene and sanitation. Participants largely categorised outlets into “good” and “bad” based on cleanliness and the way food items were displayed within the shop. When fruit and vegetables were presented in a clean and neat manner, the adolescents were motivated to buy them. Also, if they or their families trusted that the vendor was “being careful with the products”, they would prefer doing their food purchases there. “Most of us eat fruits and vegetables and the cleanliness of the area and the attractive arrangement is appealing and motivating us to eat healthy food” (FGD, girls, GS) Informal food outlets, such as marketplaces on the sidewalk, were all considered unsafe and unhealthy by the participants. The poor hygiene in these places due to pollution or public urination was a major concern for the participants. ‘No peeing allowed’ so it means people pee over here and the vendors when they come here to set up their items, they don’t even clean the area and before they set up people would have peed right there.” (Boy, 17 years, GS) When outlets were not clean or the environment around the outlet was dirty, even the sight of such uncleanliness could affect adolescents’ appetites and they reported refraining from buying foods that would actually be beneficial for their health. “This is a marketplace and it is not clean at all. The food sold here might be attractive but because the surroundings are not clean it doesn’t entice you to buy and consume it.” (Girl, 15 years, PS) Lack of water in their neighbourhoods as well as their houses could also affect what the adolescents were eating. A participant was concerned about not having water available to wash garlic, which is usually used for stews that are thoroughly cooked. “We use garlic in our day-to-day diet. If there’s no water available when we prepare Figure 3.3. “The shops supply” (Boy, 17 years, GS) food, we might just peel the garlic and use it without washing it” (Boy, 17 years, GS) Eating out. Eating food that was prepared at home was considered the healthiest, Packaged food. Given the poor hygiene of the environment, the outlets, and the safest, and cheapest option for the participants. food itself, the participants considered packaged foods as a healthier option. The “Home is always better in terms of healthy food instead of eating at restaurants adolescents also appreciated the information related to ingredients and expiry dates cafes or from street food. It is well prepared clean and healthy.” (FGD Boys, GS) on packaged foods. “You can see the packed food here and you can read their contents and Macro Level understand what you want to eat.” (Boy 17 years, GS) – Figure 3.3 Food safety regulations. There were two main areas where participants expressed the need for the government to intervene. The first was related to food safety and poor hygiene of food outlets. The second referred to banning certain food outlets. Since the participants considered the lack of space and financial means of vendors 88 Photovoice study “In our neighbourhood this place is our marketplace. This is because we can only afford to buy from here.” (Boy, 17 years, GS) Hygiene and sanitation. Participants largely categorised outlets into “good” and “bad” based on cleanliness and the way food items were displayed within the shop. When fruit and vegetables were presented in a clean and neat manner, the adolescents were motivated to buy them. Also, if they or their families trusted that the vendor was “being careful with the products”, they would prefer doing their food purchases there. “Most of us eat fruits and vegetables and the cleanliness of the area and the 3 attractive arrangement is appealing and motivating us to eat healthy food” (FGD, girls, GS) Informal food outlets, such as marketplaces on the sidewalk, were all considered unsafe and unhealthy by the participants. The poor hygiene in these places due to pollution or public urination was a major concern for the participants. ‘No peeing allowed’ so it means people pee over here and the vendors when they come here to set up their items, they don’t even clean the area and before they set up people would have peed right there.” (Boy, 17 years, GS) When outlets were not clean or the environment around the outlet was dirty, even the sight of such uncleanliness could affect adolescents’ appetites and they reported refraining from buying foods that would actually be beneficial for their health. “This is a marketplace and it is not clean at all. The food sold here might be attractive but because the surroundings are not clean it doesn’t entice you to buy and consume it.” (Girl, 15 years, PS) Lack of water in their neighbourhoods as well as their houses could also affect what the adolescents were eating. A participant was concerned about not having water available to wash garlic, which is usually used for stews that are thoroughly cooked. “We use garlic in our day-to-day diet. If there’s no water available when we prepare Figure 3.3. “The shops supply” (Boy, 17 years, GS) food, we might just peel the garlic and use it without washing it” (Boy, 17 years, GS) Eating out. Eating food that was prepared at home was considered the healthiest, Packaged food. Given the poor hygiene of the environment, the outlets, and the safest, and cheapest option for the participants. food itself, the participants considered packaged foods as a healthier option. The “Home is always better in terms of healthy food instead of eating at restaurants adolescents also appreciated the information related to ingredients and expiry dates cafes or from street food. It is well prepared clean and healthy.” (FGD Boys, GS) on packaged foods. “You can see the packed food here and you can read their contents and Macro Level understand what you want to eat.” (Boy 17 years, GS) – Figure 3.3 Food safety regulations. There were two main areas where participants expressed the need for the government to intervene. The first was related to food safety and poor hygiene of food outlets. The second referred to banning certain food outlets. Since the participants considered the lack of space and financial means of vendors 89 Chapter 3 as the main reason for poor hygiene, they believed that the government should DISCUSSION enforce food safety guidelines as well as provide appropriate, clean, and large spaces for vendors. This study used participatory photography (Photovoice) to explore the factors “Hopefully these kinds of places would be improved and blossom into big shops influencing dietary behaviours of adolescents in Addis Ababa, Ethiopia. Findings so that they can accommodate more customers and a variety of fresh from the photographs, interviews and group discussions undertaken shed light on vegetables.” (Girl, 14 years, PS) several key factors in adolescents’ environments, particularly in their social and For some food outlets, particularly the informal vendors selling fruit or vegetables physical environments. While mothers and peers played an important role in in carts or fried foods outside the school, as well as school canteens, participants adolescents’ food choices, they were mostly influenced by poor hygiene and called to have them shut down and banned by the government for their lack of sanitation of food outlets or their proximal environments. Food prices also appeared cleanliness. to be a key factor for the adolescents attending the government school. However, “I hope to see that street vending and street food become banned in the city.” – dietary behaviours of all participants were affected by what is affordable and (Girl, 16 years, GS) available in the direct vicinity of their home and school environments. Food prices. The second macro-level issue discussed by participants is related to While participants showed good knowledge related to nutrition, hygiene and food food prices, which they considered high due to the poor economic situation in the safety, this knowledge did not necessarily translate into their food choices, which country. Participants also remarked that unhealthy foods like sweets and frying oil could be due to their preference for fried food, possibly related to the taste and were cheap, while foods like meat or fish were rarely affordable. appearance of food. Participants further discussed how their choices are limited to “Healthy foods should be cheaper and unhealthy foods should become more what is available and affordable in their neighbourhoods and how they perceived expensive so people would stop consuming them…. Healthy foods are expensive unhealthy foods as cheaper than healthy foods. These observations are supported mostly and we go for cheap stuff sold on the streets. Had both healthy and by previous research from Ethiopia that showed that the price of fruit, vegetables unhealthy food been the same price we wouldn’t buy cheap food we would have and animal source foods is increasing, while the cost of sugar, oils and fats is options.” (Boy, 17 years, GS) – Figure 3.4 decreasing.13 Since the participants’ knowledge of what is healthy was also skewed towards food safety, their choices were strongly affected by food safety factors in the physical environment. Concerns about the conditions in which foods were prepared or sold and about pollution in general, have been reported from other LMIC. 31-33 Similarly to the participants in this study, mothers in a qualitative study in Addis Ababa expressed their fears related to unhygienic street food, while recognizing that these foods were also inexpensive.34 Informal sellers and small shops are important in countries like Ethiopia as they often make fruit and vegetables more accessible than supermarkets.35 The participants of this study suggested banning informal vendors, which could have an impact on the availability of fruit and vegetables.36,37 Unclean food outlets or environments could therefore keep adolescents from eating healthy foods such as fruit and vegetables. Their concerns could push them to consume more packaged food which may include ultra-processed. Lack of water in the households could aggravate this even further due to the fear of not being able to wash fruit and vegetables properly. Participants in this study indicated that they had limited decision-making power on Figure 3.4. “Sweet food that we can easily buy” (Boy, 17 years, GS) the food choices made in their families, particularly by their mother, which is something adolescents also struggle with in other countries.38 However, even when participants were on their way to or from school, where they were free to decide 90 Photovoice study as the main reason for poor hygiene, they believed that the government should DISCUSSION enforce food safety guidelines as well as provide appropriate, clean, and large spaces for vendors. This study used participatory photography (Photovoice) to explore the factors “Hopefully these kinds of places would be improved and blossom into big shops influencing dietary behaviours of adolescents in Addis Ababa, Ethiopia. Findings so that they can accommodate more customers and a variety of fresh from the photographs, interviews and group discussions undertaken shed light on vegetables.” (Girl, 14 years, PS) several key factors in adolescents’ environments, particularly in their social and For some food outlets, particularly the informal vendors selling fruit or vegetables physical environments. While mothers and peers played an important role in in carts or fried foods outside the school, as well as school canteens, participants adolescents’ food choices, they were mostly influenced by poor hygiene and called to have them shut down and banned by the government for their lack of sanitation of food outlets or their proximal environments. Food prices also appeared cleanliness. to be a key factor for the adolescents attending the government school. However, “I hope to see that street vending and street food become banned in the city.” – 3 dietary behaviours of all participants were affected by what is affordable and (Girl, 16 years, GS) available in the direct vicinity of their home and school environments. Food prices. The second macro-level issue discussed by participants is related to While participants showed good knowledge related to nutrition, hygiene and food food prices, which they considered high due to the poor economic situation in the safety, this knowledge did not necessarily translate into their food choices, which country. Participants also remarked that unhealthy foods like sweets and frying oil could be due to their preference for fried food, possibly related to the taste and were cheap, while foods like meat or fish were rarely affordable. appearance of food. Participants further discussed how their choices are limited to “Healthy foods should be cheaper and unhealthy foods should become more what is available and affordable in their neighbourhoods and how they perceived expensive so people would stop consuming them…. Healthy foods are expensive unhealthy foods as cheaper than healthy foods. These observations are supported mostly and we go for cheap stuff sold on the streets. Had both healthy and by previous research from Ethiopia that showed that the price of fruit, vegetables unhealthy food been the same price we wouldn’t buy cheap food we would have and animal source foods is increasing, while the cost of sugar, oils and fats is options.” (Boy, 17 years, GS) – Figure 3.4 decreasing.13 Since the participants’ knowledge of what is healthy was also skewed towards food safety, their choices were strongly affected by food safety factors in the physical environment. Concerns about the conditions in which foods were prepared or sold and about pollution in general, have been reported from other LMIC. 31-33 Similarly to the participants in this study, mothers in a qualitative study in Addis Ababa expressed their fears related to unhygienic street food, while recognizing that these foods were also inexpensive.34 Informal sellers and small shops are important in countries like Ethiopia as they often make fruit and vegetables more accessible than supermarkets.35 The participants of this study suggested banning informal vendors, which could have an impact on the availability of fruit and vegetables.36,37 Unclean food outlets or environments could therefore keep adolescents from eating healthy foods such as fruit and vegetables. Their concerns could push them to consume more packaged food which may include ultra-processed. Lack of water in the households could aggravate this even further due to the fear of not being able to wash fruit and vegetables properly. Participants in this study indicated that they had limited decision-making power on Figure 3.4. “Sweet food that we can easily buy” (Boy, 17 years, GS) the food choices made in their families, particularly by their mother, which is something adolescents also struggle with in other countries.38 However, even when participants were on their way to or from school, where they were free to decide 91 Chapter 3 what to eat, they still seemed to choose foods that they themselves consider potential problems in their neighbourhood, and are able to identify solutions and unhealthy (in nutritional terms). This could be due to a preference for fried or snack should therefore be consulted and involved in future research and food15 but also due to peer pressure.39 While participants perceived the Ethiopian programming.44,45 Capitalizing on the existing knowledge of adolescents should be culture of sharing as positive, sharing food with peers could influence them also key, not only for themselves, but also to educate their peers, families, or street negatively if group pressure pushes adolescents into consuming unhealthy foods in vendors. Nutrition is currently only integrated into the biology curriculum in and around the school. 38,40,41 Ethiopian schools. Addressing nutrition as part of practical projects across the curriculum, with outreach to parents, vendors and the wider community would The application of Photovoice in this study was useful, not only to identify factors in provide an entry point to establish healthy dietary patterns not only for the adolescents’ environments influencing their dietary behaviours, but also because it adolescent, but also for other members of the community. Parents should also be helped adolescents to record and reflect about their community, and to promote closely involved in any nutrition interventions for adolescents, while mothers, as the critical dialogue about important issues.26 Participants of this study reported that ones who habitually prepare foods at home, have been targeted traditionally, they appreciated expressing their “feelings using photographs rather than talking”, fathers should also be involved due to their role in food purchasing. and that the study helped “create awareness” and made them “look deeply inside the environment”. Photovoice could be a useful method to give adolescents an Our findings also identified the need to increase access to healthy, affordable, and opportunity to have their voices heard and to critically look at their environments.43 safe foods in and around schools, which could be achieved through enforcing food safety guidelines for informal sellers37 and for school canteens,46 taxing unhealthy While the sample size is appropriate compared to other Photovoice studies23 and foods such as sugar-sweetened beverages,47 and/or directly providing or subsidizing provides important insights into influences of adolescents’ dietary behaviours in healthy foods such as fruit and vegetables.48,49 Restricting energy-dense nutrient- LMIC, the findings cannot be generalised to all adolescents in urban Ethiopia. poor snack foods from school compounds could help reduce consumption of such Sampling in the private school was biased towards girls, who were more committed foods.48 In addition, the national food-based dietary guidelines that are currently to the study in general, but did not express themselves as much despite the gender- under development could be another opportunity to improve adolescent diets.50 separated focus group discussions. In the government school, the selection criteria Offering individual pieces of fruit or vegetables around schools has been shown to of owning a mobile phone could have biased the sample to higher socio-economic increase fruit consumption as well as sales of fruit for the vendors51 and should be groups, even though mobile phone ownership in urban Ethiopia is at 70%.14 considered more widely with free or subsidised schemes within schools. Application of some SHOWeD questions proved initially to be challenging when Future studies should investigate the role that these different interventions could photos were taken of issues or food items that did not show an obvious problem. have on the safety, availability and affordability of foods and drinks in urban Ethiopia This required the facilitators to follow up with questions to understand the story and how adolescents and their families would respond to them. behind the photograph. Following the first round of individual interviews, the supporting questions were therefore added to the FGDs if participants struggled to respond. The findings of this study contribute to a better understanding of the factors influencing food choices of adolescents in urban Ethiopia. Adolescents’ knowledge related to nutrition and food safety, their concerns about affordability and hygiene in the physical food environment and food outlets, as well as their families and peers all contribute to their choices. These choices in the long-term could also contribute to the disease burden of overweight, obesity and nutrition related-non communicable diseases in Ethiopia. Our study identified different ways in which researchers and practitioners could apply the findings in future work. Adolescents in this study confirmed that they are competent citizens and knowledgeable about their lives, their environment, and 92 Photovoice study what to eat, they still seemed to choose foods that they themselves consider potential problems in their neighbourhood, and are able to identify solutions and unhealthy (in nutritional terms). This could be due to a preference for fried or snack should therefore be consulted and involved in future research and food15 but also due to peer pressure.39 While participants perceived the Ethiopian programming.44,45 Capitalizing on the existing knowledge of adolescents should be culture of sharing as positive, sharing food with peers could influence them also key, not only for themselves, but also to educate their peers, families, or street negatively if group pressure pushes adolescents into consuming unhealthy foods in vendors. Nutrition is currently only integrated into the biology curriculum in and around the school. 38,40,41 Ethiopian schools. Addressing nutrition as part of practical projects across the curriculum, with outreach to parents, vendors and the wider community would The application of Photovoice in this study was useful, not only to identify factors in provide an entry point to establish healthy dietary patterns not only for the adolescents’ environments influencing their dietary behaviours, but also because it adolescent, but also for other members of the community. Parents should also be helped adolescents to record and reflect about their community, and to promote closely involved in any nutrition interventions for adolescents, while mothers, as the critical dialogue about important issues.26 Participants of this study reported that ones who habitually prepare foods at home, have been targeted traditionally, 3 they appreciated expressing their “feelings using photographs rather than talking”, fathers should also be involved due to their role in food purchasing. and that the study helped “create awareness” and made them “look deeply inside the environment”. Photovoice could be a useful method to give adolescents an Our findings also identified the need to increase access to healthy, affordable, and opportunity to have their voices heard and to critically look at their environments.43 safe foods in and around schools, which could be achieved through enforcing food safety guidelines for informal sellers37 and for school canteens,46 taxing unhealthy While the sample size is appropriate compared to other Photovoice studies23 and foods such as sugar-sweetened beverages,47 and/or directly providing or subsidizing provides important insights into influences of adolescents’ dietary behaviours in healthy foods such as fruit and vegetables.48,49 Restricting energy-dense nutrient- LMIC, the findings cannot be generalised to all adolescents in urban Ethiopia. poor snack foods from school compounds could help reduce consumption of such Sampling in the private school was biased towards girls, who were more committed foods.48 In addition, the national food-based dietary guidelines that are currently to the study in general, but did not express themselves as much despite the gender- under development could be another opportunity to improve adolescent diets.50 separated focus group discussions. In the government school, the selection criteria Offering individual pieces of fruit or vegetables around schools has been shown to of owning a mobile phone could have biased the sample to higher socio-economic increase fruit consumption as well as sales of fruit for the vendors51 and should be groups, even though mobile phone ownership in urban Ethiopia is at 70%.14 considered more widely with free or subsidised schemes within schools. Application of some SHOWeD questions proved initially to be challenging when Future studies should investigate the role that these different interventions could photos were taken of issues or food items that did not show an obvious problem. have on the safety, availability and affordability of foods and drinks in urban Ethiopia This required the facilitators to follow up with questions to understand the story and how adolescents and their families would respond to them. behind the photograph. Following the first round of individual interviews, the supporting questions were therefore added to the FGDs if participants struggled to respond. The findings of this study contribute to a better understanding of the factors influencing food choices of adolescents in urban Ethiopia. Adolescents’ knowledge related to nutrition and food safety, their concerns about affordability and hygiene in the physical food environment and food outlets, as well as their families and peers all contribute to their choices. These choices in the long-term could also contribute to the disease burden of overweight, obesity and nutrition related-non communicable diseases in Ethiopia. Our study identified different ways in which researchers and practitioners could apply the findings in future work. Adolescents in this study confirmed that they are competent citizens and knowledgeable about their lives, their environment, and 93 Chapter 3 References 16. Madjdian DS, Azupogo F, Osendarp SJM, et al. 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Findholt NE, Michael YL, Davis MM. Photovoice engages rural youth in childhood 5. Viner RM. Adolescence and the social determinants of health. Lancet. 2013; 379: 1641– obesity prevention. Public Heal Nurs. 2011; 28, 186-192. doi: 10.1111/j.1525- 52. Doi: 10.4314/eajph.v7i3.64738 6. Arimond M, Ruel MT. Dietary Diversity Is Associated with Child Nutritional Status: 1446.2010.00895.x. Evidence from 11 Demographic and Health Surveys. .; 2004 134, 2579-2585. Doi: 22. Begna TN. Public Schools and Private Schools in Ethiopia: Partners in National J Nutr 10.1093/jn/134.10.2579 Development? Int J Humanit Soc Sci Educ. 2017; 4, 100-111. http://dx.doi.org/10.20431/2349-0381.0402010 7. Monteiro CA, Moura EC, Conde WL, et al. Socioeconomic status and obesity in adult 23. Catalani C, Minkler M. Photovoice: a review of the literature in health and public health. populations of developing countries: a review. Bull World Heal Organ. 2004; 82, 940- 946. Doi: /S0042-96862004001200011 Heal Educ Behav. 2010; 37, 424-451. doi: 10.1177/1090198109342084. 8. Popkin BM, Adair LS, Ng SW. Global nutrition transition and the pandemic of obesity in 24. Wilson N, Dasho S, Martin A, et al. Engaging Young Adolescents in Social Action Through PhotovoiceThe Youth Empowerment Strategies (YES!) Project. J Early Adolesc. 2007; 27, developing countries. Nutr Rev. 2012; 70, 3-21. Doi. 10.1111/j.1753-4887.2011.00456.x 241-261. doi: 10.1177/0272431606294834 9. Gissing SC, Pradeilles R, Osei-Kwasi HA, et al. Drivers of dietary behaviours in women living in urban Africa: a systematic mapping review. 2017; 20, 2104- 25. UNFPA. Adolescents and Youth Dashboard - Ethiopia. Public Heal Nutr. 2113. Doi.10.1017/S1368980017000970 https://www.unfpa.org/data/adolescent-youth/ET. Accessed May 1, 2020. 10. Turner C, Aggarwal A, Walls H, et al. Concepts and critical perspectives for food 26. Wang CC, Yi WK, Tao ZW, et al. Photovoice as a Participatory Health Promotion Strategy. Health Promot Int. 1998; 13, 75-86. https://doi.org/10.1093/heapro/13.1.75 environment research: A global framework with implications for action in low- and middle-income countries. . 2018; 18, 93-101. 27. Story M, Kaphingst KM, Robinson-O’Brien R, et al. Creating healthy food and eating Glob Food Sec https://doi.org/10.1016/j.gfs.2018.08.003 environments: policy and environmental approaches. Annu Rev Public Health. 2008; 29, 11. Monteiro CA, D’A Benicio MH, Conde WL, et al. Shifting obesity trends in Brazil. 253-272. doi: 10.1146/annurev.publhealth.29.020907.090926. Eur J 28. Holdsworth M, Landais E. Urban food environments in Africa: implications for policy Clin Nutr. 2000; 54, 342-346. Doi.10.1038/sj.ejcn.1600960 and research. Proc Nutr Soc. 2019; 78, 513-525. doi:10.1017/S0029665118002938 12. World Urbanization Prospects 2018. United Nations DESA/Population Division; 2018. 13. Bachewe FN, Minten B. The Rising Costs of Nutritious Foods: The Case of Ethiopia. 29. Saldana J. The Coding Manual for Qualitative Research. Third Edition Ed. . London: SAGE Washington, DC and Addis Ababa, Ethiopia: International Food Policy Research Institute Publications. 2009. (IFPRI) and Federal Democratic Republic of Ethiopia Policy Studies Institute. Strategy 30. Ryan GW, Bernard HR. Techniques to Identify Themes. Field methods. 2003; 15, 85-109. https://doi.org/10.1177/1525822X02239569 Support Program, Working paper 134, 2019. 14. CSA (Central Statistical Agency) and ICF International, Ethiopia Demographic and Health 31. Omari R, Frempong G. Food safety concerns of fast food consumers in urban Ghana. Survey 2016. Addis Ababa, Ethiopia and Calverton, MD, USA: CSA and ICF International. Appetite. 2016; 98, 49-54. https://doi.org/10.1016/j.appet.2015.12.007 2016. 32. Gavaravarapu SRM, Vemula SR, Rao P, et al. Focus group studies on food safety knowledge, perceptions, and practices of school-going adolescent girls in South India. J 15. Story M, Neumark-Sztainer D, French S. Individual and Environmental Influences on Nutr Educ Behav. 2009; 41, 340-346. doi: 10.1016/j.jneb.2008.12.003. Adolescent Eating Behaviors. J Am Diet Assoc. 2002; 102 (3, Supplement): 40- 51. https://doi.org/10.1016/S0002-8223(02)90421-9 33. Mmari K, Lantos H, Brahmbhatt H, How adolescents perceive their communities: a qualitative study that explores the relationship between health and the physical environment. BMC Public Health. 2014; 14, 349. doi: 10.1186/1471-2458-14-349. 94 Photovoice study References 16. Madjdian DS, Azupogo F, Osendarp SJM, et al. Socio-cultural and economic determinants and consequences of adolescent undernutrition and micronutrient deficiencies in LLMICs: a systematic narrative review. Ann N Y Acad Sci. 2018; 1416, 117- 1. Abarca-Gómez L, Abdeen ZA, Hamid ZA, et al. Worldwide trends in body-mass index, 139. https://doi.org/10.1111/nyas.13670 underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128,9 million children, adolescents, and 17. Heidelberger L, Smith C. The Food Environment Through the Camera Lenses of 9- to 13- adults. . 2017; 390, 2627–2642. doi.org/10.1016/S0140-6736(17)32129-3 Year-Olds Living in Urban, Low-Income, Midwestern Households: A Photovoice Project. Lancet J Nutr Educ Behav. 2015; 47, 437-445. doi: 10.1016/j.jneb.2015.05.005. 2. World Health Organization. https://www.who.int/news-room/fact- 18. Keats, EC, Rappaport AI, Jain R, et al. Diet and Eating Practices among Adolescent Girls sheets/detail/obesityand-overweight. Accessed November 15, 2019. 3. Bhutta ZA, Lassi ZS, Bergeron G, et al. Delivering an action agenda for nutrition in Low- and Middle-Income Countries: A Systemic Review. Arlington, VA: Strengthening interventions addressing adolescent girls and young women: priorities for Partnerships, Results, and Innovations in Nutrition Globally (SPRING) project; 2018. implementation and research. . 2017; 1393, 61-71. 19. Romero MYM, Jeitner EC, Francis LA. Visualizing Perceived Enablers of and Barriers to Ann N Y Acad Sci Healthy Eating by Youth in Rural El Salvador. 3 J Nutr Educ Behav. 2019; 51, 348-356. doi: 10.1111/nyas.13352 https://doi.org/10.1016/j.jneb.2018.09.012 4. Prentice AAM, Ward KA, Goldberg GR, et al. Critical windows for nutritional interventions against stunting. . 2013; 97: 911-918. Doi: 20. Strack RW, Magill C, McDonagh K. Engaging youth through photovoice. Heal Promot Pr. Am J Clin Nutr 10.3945/ajcn.112.052332 2004; 5, 49-58. https://doi.org/10.1016/j.jneb.2018.09.012 21. Findholt NE, Michael YL, Davis MM. Photovoice engages rural youth in childhood 5. Viner RM. Adolescence and the social determinants of health. Lancet. 2013; 379: 1641– obesity prevention. Public Heal Nurs. 2011; 28, 186-192. doi: 10.1111/j.1525- 52. Doi: 10.4314/eajph.v7i3.64738 6. Arimond M, Ruel MT. Dietary Diversity Is Associated with Child Nutritional Status: 1446.2010.00895.x. Evidence from 11 Demographic and Health Surveys. .; 2004 134, 2579-2585. Doi: 22. Begna TN. Public Schools and Private Schools in Ethiopia: Partners in National J Nutr 10.1093/jn/134.10.2579 Development? Int J Humanit Soc Sci Educ. 2017; 4, 100-111. http://dx.doi.org/10.20431/2349-0381.0402010 7. Monteiro CA, Moura EC, Conde WL, et al. Socioeconomic status and obesity in adult 23. Catalani C, Minkler M. Photovoice: a review of the literature in health and public health. populations of developing countries: a review. Bull World Heal Organ. 2004; 82, 940- 946. Doi: /S0042-96862004001200011 Heal Educ Behav. 2010; 37, 424-451. doi: 10.1177/1090198109342084. 8. Popkin BM, Adair LS, Ng SW. Global nutrition transition and the pandemic of obesity in 24. Wilson N, Dasho S, Martin A, et al. Engaging Young Adolescents in Social Action Through PhotovoiceThe Youth Empowerment Strategies (YES!) Project. J Early Adolesc. 2007; 27, developing countries. Nutr Rev. 2012; 70, 3-21. Doi. 10.1111/j.1753-4887.2011.00456.x 241-261. doi: 10.1177/0272431606294834 9. Gissing SC, Pradeilles R, Osei-Kwasi HA, et al. Drivers of dietary behaviours in women living in urban Africa: a systematic mapping review. 2017; 20, 2104- 25. UNFPA. Adolescents and Youth Dashboard - Ethiopia. Public Heal Nutr. 2113. Doi.10.1017/S1368980017000970 https://www.unfpa.org/data/adolescent-youth/ET. Accessed May 1, 2020. 10. Turner C, Aggarwal A, Walls H, et al. Concepts and critical perspectives for food 26. Wang CC, Yi WK, Tao ZW, et al. Photovoice as a Participatory Health Promotion Strategy. Health Promot Int. 1998; 13, 75-86. https://doi.org/10.1093/heapro/13.1.75 environment research: A global framework with implications for action in low- and middle-income countries. . 2018; 18, 93-101. 27. Story M, Kaphingst KM, Robinson-O’Brien R, et al. Creating healthy food and eating Glob Food Sec https://doi.org/10.1016/j.gfs.2018.08.003 environments: policy and environmental approaches. Annu Rev Public Health. 2008; 29, 11. Monteiro CA, D’A Benicio MH, Conde WL, et al. Shifting obesity trends in Brazil. 253-272. doi: 10.1146/annurev.publhealth.29.020907.090926. Eur J 28. Holdsworth M, Landais E. Urban food environments in Africa: implications for policy Clin Nutr. 2000; 54, 342-346. Doi.10.1038/sj.ejcn.1600960 and research. Proc Nutr Soc. 2019; 78, 513-525. doi:10.1017/S0029665118002938 12. World Urbanization Prospects 2018. United Nations DESA/Population Division; 2018. 13. Bachewe FN, Minten B. The Rising Costs of Nutritious Foods: The Case of Ethiopia. 29. Saldana J. The Coding Manual for Qualitative Research. Third Edition Ed. . London: SAGE Washington, DC and Addis Ababa, Ethiopia: International Food Policy Research Institute Publications. 2009. (IFPRI) and Federal Democratic Republic of Ethiopia Policy Studies Institute. Strategy 30. Ryan GW, Bernard HR. Techniques to Identify Themes. Field methods. 2003; 15, 85-109. https://doi.org/10.1177/1525822X02239569 Support Program, Working paper 134, 2019. 14. CSA (Central Statistical Agency) and ICF International, Ethiopia Demographic and Health 31. Omari R, Frempong G. Food safety concerns of fast food consumers in urban Ghana. Survey 2016. Addis Ababa, Ethiopia and Calverton, MD, USA: CSA and ICF International. Appetite. 2016; 98, 49-54. https://doi.org/10.1016/j.appet.2015.12.007 2016. 32. Gavaravarapu SRM, Vemula SR, Rao P, et al. Focus group studies on food safety knowledge, perceptions, and practices of school-going adolescent girls in South India. J 15. Story M, Neumark-Sztainer D, French S. Individual and Environmental Influences on Nutr Educ Behav. 2009; 41, 340-346. doi: 10.1016/j.jneb.2008.12.003. Adolescent Eating Behaviors. J Am Diet Assoc. 2002; 102 (3, Supplement): 40- 51. https://doi.org/10.1016/S0002-8223(02)90421-9 33. Mmari K, Lantos H, Brahmbhatt H, How adolescents perceive their communities: a qualitative study that explores the relationship between health and the physical environment. BMC Public Health. 2014; 14, 349. doi: 10.1186/1471-2458-14-349. 95 Chapter 3 34. Berhane HY, Ekstrom EC, Jirstrom M, et al. What Influences Urban Mothers’ Decisions on What to Feed Their Children Aged Under Five: The Case of Addis Ababa, Ethiopia. 50. Bekele TH, de Vries JJ, Trijsburg L, et al. Methodology for developing and evaluating Nutrients. 2018; 10, 1142. doi: 10.3390/nu10091142 food-based dietary guidelines and a Healthy Eating Index for Ethiopia: a study protocol. 35. Assefa T, Abebe G, Lamoot I, et al. Urban food retailing and food prices in Africa: the BMJ Open. 2019; 9, e027846. doi: 10.1136/bmjopen-2018-027846. case of Addis Ababa, Ethiopia. 51. Gebremichael B. Effectiveness of selling fruits in pieces or in bulk in improving fruit J Agribus Dev Emerg Econ. 2016; 6, 2. http://www.emeraldinsight.com/doi/abs/10.1108/JADEE-02-2015-0009 consumption of high-school students: A cluster randomized controlled trial in urban 36. Wertheim-Heck SCO, Raneri JE. A cross-disciplinary mixed-method approach to setting of Ethiopia. MSc Thesis, 2019. Addis Ababa University. understand how food retail environment transformations influence food choice and intake among the urban poor: Experiences from Vietnam. Appetite. 2019; 142, 104370. https://doi.org/10.1016/j.appet.2019.104370 37. Grace D. Food Safety in Low and Middle Income Countries. Int J Env Res Public Heal. 2015; 12,10490-10507. doi: 10.3390/ijerph120910490 38. Blum LS, Khan R, Sultana M, et al. Using a gender lens to understand eating behaviours of adolescent females living in low-income households in Bangladesh. Matern Child Nutr. 2019; 15, e12841. doi: 10.1111/mcn.12841 39. Stok FM, de Vet E, de Ridder DT, et al. The potential of peer social norms to shape food intake in adolescents and young adults: a systematic review of effects and moderators. Heal Psychol Rev. 2016; 10, 326-340. doi: 10.1080/17437199.2016.1155161. 40. Rathi N, Riddell L, Worsley A. What influences urban Indian secondary school students’ food consumption? - A qualitative study. Appetite. 2016; 105, 790-797. doi: 10.1016/j.appet.2016.07.018. 41. Brown C, Shaibu S, Maruapula S, et al. Perceptions and attitudes towards food choice in adolescents in Gaborone, Botswana. Appetite. 2015; 95, 29-35. doi: 10.1016/j.appet.2015.06.018 42. Wang C, Burris MA. Photovoice: Concept, Methodology, and Use for Participatory Needs Assessment. Heal Educ Behav. 1997; 24, 369-387. doi: 10.1177/109019819702400309. 43. Foster-Fishman P, Nowell B, Deacon Z, et al. Using methods that matter: the impact of reflection, dialogue, and voice. Am J Community Psychol. 2005; 36, 275-291. doi: 10.1007/s10464-005-8626-y. 44. Necheles JW, Chung EQ, Hawes-Dawson J, et al. The Teen Photovoice Project: a pilot study to promote health through advocacy. Prog Community Heal Partnersh. 2007; 1, 221-229. Doi:10.1353/cpr.2007.0027 45. Wang CC. Youth Participation in Photovoice as a Strategy for Community Change. J Community Pract. 2006; 14, 147-161. doi: 10.1300/J125v14n01_09 46. L’Abbe M, Schermel A, Minaker L, et al. Monitoring foods and beverages provided and sold in public sector settings. Obes Rev. 2013; 14, Suppl 1, 96-107. doi: 10.1111/obr.12079. 47. Barquera S, Campos I, Rivera JA. Mexico attempts to tackle obesity: the process, results, push backs and future challenges. Obes Rev. 2013; 14, Suppl 2:69-78. doi: 10.1111/obr.12096. 48. Micha R, Karageorgou D, Bakogianni I, et al. Effectiveness of school food environment policies on children’s dietary behaviors: A systematic review and metaanalysis. PLoS One. 2018; 13, e0194555. doi: 10.1371/journal.pone.0194555. 49. de Brauw A, Van den Berg M, Brouwer ID, et al. Food System Innovations for Healthier Diets in Low and Middle-Income Countries. Washington, DC: International Food Policy Research Institute (IFPRI), 2019. https://doi.org/10.2499/p15738coll2.133156 96 Photovoice study 50. Bekele TH, de Vries JJ, Trijsburg L, et al. Methodology for developing and evaluating food-based dietary guidelines and a Healthy Eating Index for Ethiopia: a study protocol. BMJ Open. 2019; 9, e027846. doi: 10.1136/bmjopen-2018-027846. 51. Gebremichael B. Effectiveness of selling fruits in pieces or in bulk in improving fruit consumption of high-school students: A cluster randomized controlled trial in urban setting of Ethiopia. MSc Thesis, 2019. Addis Ababa University. 3 97 CHAPTER 4 Influencing factors of the school and home environment on adolescents’ dietary behaviours in Addis Ababa, Ethiopia Ursula Trübswasser Elise F. Talsma Selamawit Ekubay Maartje P. Poelman Michelle Holdsworth Edith J.M. Feskens Kaleab Baye Frontiers in Public Health doi.org/10.3389/fpubh.2022.861463 Chapter 4 INTRODUCTION assessed whether food environments in and around schools in urban Ethiopia influence dietary diversity, quality, body mass index (BMI) status or adolescents’ Dietary behaviours within populations are highly dependent on which food and perceptions of their school and home food environment. beverages are available, affordable, safe or convenient in their surroundings (food environment).1 Food environments can be defined as the spaces where individuals METHODS interact with the food system and encompass availability, promotion, quality, convenience and physical and economic access.2 Availability and cost influence Study design and context adolescents’ dietary behaviours, as well as their appeal and aspirational association.3 Food environments are changing globally due to expanding A cross-sectional study was conducted, including school food environment audits as urbanization, technology, trade and labour markets. These changes are leading to well as interviews with students of private and government schools. The selection increased availability of energy-dense, nutrient-poor, ultra-processed foods and of private and government schools was used as a proxy for socio-economic status, beverages associated with the ‘nutrition transition’.4 This in turn can negatively based on the rationale that private schools charge tuition fees.23 The schools were affect dietary quality, with high consumption of ultra-processed foods and selected in collaboration with Addis Ababa Bureau of Education and the Addis Ababa beverages, such as sugar-sweetened beverages (SSB). SSB are associated with poor sub-city administration using a list of all middle and high schools in the city. Our aim nutrition and health outcomes, including overweight and obesity and diet-related 5 was to identify a pair of one private and one government school that had less than non-communicable diseases. a 0.5 km distance between them to ensure that participants from both schools shared the same food environment. Twelve schools fulfilled this criterion and were The nutrition transition has taken place in high-income countries over the last few located in six different sub-cities of Addis Ababa, Ethiopia (Arada, Bole, Kality, Kirkos, decades and is well underway in low- and middle-income countries (LMIC),5,6 7 Kolfe-Keranio and Laphto). including in Africa. Changing food environments can influence the dietary habits of adolescents,8 who spend a lot of their time at school and are at a critical time of habit formation and Participant recruitment increasing autonomy.9-11 The promotion of ultra-processed foods and beverages often targets children and adolescents to generate brand awareness, preference Given the scarcity of data on adolescents in schools, and the multiple outcomes of and loyalty, securing a future consumer base.12 Hence, food environments around interest, the sample size was calculated to detect a medium effect size (Cohen’s d; schools can play a critical role in adolescents’ diets.9;13,14 As studies from mostly high- 0.5 SD) difference between two means, assuming α = 0.05 and power = 0.95. Lists income countries but also LMIC have shown, the availability of unhealthy food or of all enrolled students and their ages were obtained for all the sampled schools. beverages inside or around schools, in the absence of parental supervision, From these lists, containing a total of 1500 students/school on average, 20 negatively affects dietary choices.9;15-18 In LMIC, parental education and occupation adolescents (aged 15–19 years) were randomly selected. In every school, a teacher were also found to be associated with better nutritional status and dietary assisted with identifying adolescents and informing them and their parents about behaviours.19,20 the study. This resulted in a total target sample of 240 adolescents who were invited for interview. Adolescents’ diets in LMIC seem to be inadequate: predominantly cereal-based and limited in terms of animal-source foods, fruit and vegetables.21 Particularly in urban Data collection procedure areas, increased consumption of processed energy-dense and nutrient-poor foods and drinks has been reported.8 In Ethiopia, up to a third of adolescents consume SSB Enumerators with experience in data collection and with an excellent command of on a daily basis.22 Whether these dietary behaviours are related to the food the local language, Amharic, were recruited and trained for three days on environment surrounding schools in Ethiopia remains unknown. Pupils in many interviewing skills, dietary intake assessments and anthropometric measurements. countries, including Ethiopia, have limited pocket money to spend and their The training was followed by a pre-test of the adolescents’ questionnaire and the caregivers act as ‘gatekeepers’ of their choices.10 However, how Ethiopian food environment audit tools, which permitted adaptations when necessary. Using adolescents from different socio-economic backgrounds are exposed to food outlets interview-administered questionnaires, information on socio-demographic on the way to and from school and how this can affect their dietary and purchasing characteristics and food consumption was assessed for the recruited adolescent behaviours and nutritional status requires exploration. Therefore, this study participants in all schools. Moreover, height and weight were measured to assess 100 School food environment study INTRODUCTION assessed whether food environments in and around schools in urban Ethiopia influence dietary diversity, quality, body mass index (BMI) status or adolescents’ Dietary behaviours within populations are highly dependent on which food and perceptions of their school and home food environment. beverages are available, affordable, safe or convenient in their surroundings (food environment).1 Food environments can be defined as the spaces where individuals METHODS interact with the food system and encompass availability, promotion, quality, convenience and physical and economic access.2 Availability and cost influence Study design and context adolescents’ dietary behaviours, as well as their appeal and aspirational association.3 Food environments are changing globally due to expanding A cross-sectional study was conducted, including school food environment audits as urbanization, technology, trade and labour markets. These changes are leading to well as interviews with students of private and government schools. The selection increased availability of energy-dense, nutrient-poor, ultra-processed foods and of private and government schools was used as a proxy for socio-economic status, beverages associated with the ‘nutrition transition’.4 This in turn can negatively based on the rationale that private schools charge tuition fees.23 The schools were affect dietary quality, with high consumption of ultra-processed foods and selected in collaboration with Addis Ababa Bureau of Education and the Addis Ababa beverages, such as sugar-sweetened beverages (SSB). SSB are associated with poor sub-city administration using a list of all middle and high schools in the city. Our aim nutrition and health outcomes, including overweight and obesity and diet-related 4 was to identify a pair of one private and one government school that had less than non-communicable diseases.5 a 0.5 km distance between them to ensure that participants from both schools shared the same food environment. Twelve schools fulfilled this criterion and were The nutrition transition has taken place in high-income countries over the last few located in six different sub-cities of Addis Ababa, Ethiopia (Arada, Bole, Kality, Kirkos, decades and is well underway in low- and middle-income countries (LMIC),5,6 Kolfe-Keranio and Laphto). including in Africa.7 Changing food environments can influence the dietary habits of adolescents,8 who spend a lot of their time at school and are at a critical time of habit formation and Participant recruitment increasing autonomy.9-11 The promotion of ultra-processed foods and beverages often targets children and adolescents to generate brand awareness, preference Given the scarcity of data on adolescents in schools, and the multiple outcomes of and loyalty, securing a future consumer base.12 Hence, food environments around interest, the sample size was calculated to detect a medium effect size (Cohen’s d; schools can play a critical role in adolescents’ diets.9;13,14 As studies from mostly high- 0.5 SD) difference between two means, assuming α = 0.05 and power = 0.95. Lists income countries but also LMIC have shown, the availability of unhealthy food or of all enrolled students and their ages were obtained for all the sampled schools. beverages inside or around schools, in the absence of parental supervision, From these lists, containing a total of 1500 students/school on average, 20 negatively affects dietary choices.9;15-18 In LMIC, parental education and occupation adolescents (aged 15–19 years) were randomly selected. In every school, a teacher were also found to be associated with better nutritional status and dietary assisted with identifying adolescents and informing them and their parents about behaviours.19,20 the study. This resulted in a total target sample of 240 adolescents who were invited for interview. Adolescents’ diets in LMIC seem to be inadequate: predominantly cereal-based and limited in terms of animal-source foods, fruit and vegetables.21 Particularly in urban Data collection procedure areas, increased consumption of processed energy-dense and nutrient-poor foods and drinks has been reported.8 In Ethiopia, up to a third of adolescents consume SSB Enumerators with experience in data collection and with an excellent command of on a daily basis.22 Whether these dietary behaviours are related to the food the local language, Amharic, were recruited and trained for three days on environment surrounding schools in Ethiopia remains unknown. Pupils in many interviewing skills, dietary intake assessments and anthropometric measurements. countries, including Ethiopia, have limited pocket money to spend and their The training was followed by a pre-test of the adolescents’ questionnaire and the caregivers act as ‘gatekeepers’ of their choices.10 However, how Ethiopian food environment audit tools, which permitted adaptations when necessary. Using adolescents from different socio-economic backgrounds are exposed to food outlets interview-administered questionnaires, information on socio-demographic on the way to and from school and how this can affect their dietary and purchasing characteristics and food consumption was assessed for the recruited adolescent behaviours and nutritional status requires exploration. Therefore, this study participants in all schools. Moreover, height and weight were measured to assess 101 Chapter 4 the BMI status. As a next step, the external and internal food environment in and Food environment assessment around all 12 schools was assessed using protocols from the International Network for Food and Obesity/Non-Communicable Diseases Research, Monitoring and For each school, the external food environment around the school within a radius Action Support (INFORMAS) network to measure food environments that contain of 0.5 km was assessed for visibility and advertising of foods and beverages using elements on food promotion (advertising) and types of food outlets.24 Data were the INFORMAS protocol for ‘Promotion – Outdoor Advertising’, which has been used collected between March and June 2019. in other LMIC.24 Food advertisements were categorized as advertisements promoting food or beverage brands on stationary objects, such as posters, banners, Socio-economic variables and purchasing behaviour bus-stop advertisements, flags, furniture, umbrellas, tables, fridges or free-standing signs in public spaces. For every advertisement, the category, location (GPS code), Since adolescents were not able to provide information on family income, they were size (small, medium or large) and type of food or beverage advertised were asked about 13 different assets that their family owned, based on the family recorded. Food outlets were assessed in terms of outlet categories, location (GIS affluence scale25 and the asset list included in the Ethiopian Demographic Health code), presence of advertising and display of fruit, vegetables or SSB. Enumerators Survey (yes = 1, no = 0).26 From the responses, we calculated the sum of all scores did not enter any stores but walked up and down every single street in the defined by assigning one point to each asset (min–max score = 0–13). Additionally, we asked radius. if adolescents had their own bedroom, received pocket money and how they commuted to school. If they received pocket money, we asked for the amount they The data collection tool for the food environment assessment was pre-tested in received per week and if they spent it on SSB, sweets, fruit or fried foods. October 2018, in central Addis Ababa (Arat Kilo), in an area close to two of the schools. During the pre-test 12 categories of food outlets were identified, as any Adolescents’ perceptions of their school and home food environment shop, café or restaurant selling food or beverages, and categorized as ‘informal’ if the shop’s structure (if any) was movable and not permanent (see appendix 4.1 for the 12 categories). The tool was tested on each food outlet type and the findings We assessed adolescents’ perceptions in terms of the availability of fruit and were used to amend the tool. The food environment of the first two schools was vegetables or snacks at their homes, as well as their perception of availability and assessed by two independent teams of enumerators to align the data collection advertising of (un)healthy foods in the school food environment. We used tested 20 procedure and assess inter-rater reliability. Within the school compound, we statements previously used in studies with adolescents or in studies assessing 27,28 assessed any presence of food or beverage advertising and whether SSB were sold perceptions of the food environment. The statements were read to the at the school cafeteria. participants and they reported their agreement with each statement using a five- point Likert scale (1 = strongly disagree to 5 = strongly agree). Data quality control Dietary intake assessment All tools were translated into Amharic, a local language. The quality of the translation was checked by back-translating the questionnaires into English. All data Interviewers used an open-ended qualitative 24-hour recall, starting with an from the individual interviews and the food environment were entered on tablets unstructured listing of all foods and beverages consumed, followed by memory cues (Lenovo TAB 7 essentials) and questionnaires were programmed with Skip Logic to assess consumption over the previous 24 hours. using the Open Data Kit, which is an electronic data collection program. Data were uploaded daily on a secure, centrally managed server, allowing daily quality checks Anthropometric measures from the first author. Daily debriefs with enumerators were conducted by the first and third authors to discuss and resolve any potential challenges. Height and weight were measured with standardized measurements in triplicate. Height was measured with stadiometers (SECA 213) in a standing position without Data analysis shoes and was recorded to the nearest 0.1 cm.29 Electronic weighing scales (SECA 872) with a weighing capacity of 10–140 kg were used to assess the weight of all All consumed food items and beverages from the previous 24 hours were participants to the nearest 0.1 kg. categorized into 10 food groups following the Minimum Dietary Diversity for 102 School food environment study the BMI status. As a next step, the external and internal food environment in and Food environment assessment around all 12 schools was assessed using protocols from the International Network for Food and Obesity/Non-Communicable Diseases Research, Monitoring and For each school, the external food environment around the school within a radius Action Support (INFORMAS) network to measure food environments that contain of 0.5 km was assessed for visibility and advertising of foods and beverages using elements on food promotion (advertising) and types of food outlets.24 Data were the INFORMAS protocol for ‘Promotion – Outdoor Advertising’, which has been used collected between March and June 2019. in other LMIC.24 Food advertisements were categorized as advertisements promoting food or beverage brands on stationary objects, such as posters, banners, Socio-economic variables and purchasing behaviour bus-stop advertisements, flags, furniture, umbrellas, tables, fridges or free-standing signs in public spaces. For every advertisement, the category, location (GPS code), Since adolescents were not able to provide information on family income, they were size (small, medium or large) and type of food or beverage advertised were asked about 13 different assets that their family owned, based on the family recorded. Food outlets were assessed in terms of outlet categories, location (GIS affluence scale25 and the asset list included in the Ethiopian Demographic Health code), presence of advertising and display of fruit, vegetables or SSB. Enumerators Survey (yes = 1, no = 0).26 From the responses, we calculated the sum of all scores did not enter any stores but walked up and down every single street in the defined by assigning one point to each asset (min–max score = 0–13). Additionally, we asked radius. if adolescents had their own bedroom, received pocket money and how they 4 commuted to school. If they received pocket money, we asked for the amount they The data collection tool for the food environment assessment was pre-tested in received per week and if they spent it on SSB, sweets, fruit or fried foods. October 2018, in central Addis Ababa (Arat Kilo), in an area close to two of the schools. During the pre-test 12 categories of food outlets were identified, as any Adolescents’ perceptions of their school and home food environment shop, café or restaurant selling food or beverages, and categorized as ‘informal’ if the shop’s structure (if any) was movable and not permanent (see appendix 4.1 for the 12 categories). The tool was tested on each food outlet type and the findings We assessed adolescents’ perceptions in terms of the availability of fruit and were used to amend the tool. The food environment of the first two schools was vegetables or snacks at their homes, as well as their perception of availability and assessed by two independent teams of enumerators to align the data collection advertising of (un)healthy foods in the school food environment. We used tested 20 procedure and assess inter-rater reliability. Within the school compound, we statements previously used in studies with adolescents or in studies assessing 27,28 assessed any presence of food or beverage advertising and whether SSB were sold perceptions of the food environment. The statements were read to the at the school cafeteria. participants and they reported their agreement with each statement using a five- point Likert scale (1 = strongly disagree to 5 = strongly agree). Data quality control Dietary intake assessment All tools were translated into Amharic, a local language. The quality of the translation was checked by back-translating the questionnaires into English. All data Interviewers used an open-ended qualitative 24-hour recall, starting with an from the individual interviews and the food environment were entered on tablets unstructured listing of all foods and beverages consumed, followed by memory cues (Lenovo TAB 7 essentials) and questionnaires were programmed with Skip Logic to assess consumption over the previous 24 hours. using the Open Data Kit, which is an electronic data collection program. Data were uploaded daily on a secure, centrally managed server, allowing daily quality checks Anthropometric measures from the first author. Daily debriefs with enumerators were conducted by the first and third authors to discuss and resolve any potential challenges. Height and weight were measured with standardized measurements in triplicate. Height was measured with stadiometers (SECA 213) in a standing position without Data analysis shoes and was recorded to the nearest 0.1 cm.29 Electronic weighing scales (SECA 872) with a weighing capacity of 10–140 kg were used to assess the weight of all All consumed food items and beverages from the previous 24 hours were participants to the nearest 0.1 kg. categorized into 10 food groups following the Minimum Dietary Diversity for 103 Chapter 4 Women (MDD-W) approach, which is useful to reflect the micronutrient adequacy RESULTS of diets and is recommended for use in LMIC.30 In addition, foods and beverages were assigned to one of four categories of the NOVA classification based on their Description of sample level of processing.31 However, our study only focused on whether the foods and beverages consumed fell into the fourth NOVA category of ultra-processed foods. Dietary data were also categorized into Global Dietary Recommendations (GDR) From a total of 240 eligible adolescents, 217 completed the study; the average age scores, which in addition to the MDD-W add value as indicators of dietary quality.32 of participants was 17.2 (SD 1.0) years and slightly more than half (59%) were female Diet patterns were assessed in terms of their adherence to global dietary (Table 4.1). More adolescents from private schools received pocket money and the recommendations for fruit and vegetables, dietary fibre, free sugars, saturated fat, amounts were also higher for private school students. Over three-quarters of total fat, legumes, nuts and seeds, whole grains and processed meats. adolescents (79%) walked less than 10 minutes from a car or bus to the school gate. Only private school children reported travelling to school in their parent’s car (data The GDR score is composed of two subcomponents: GDR-Healthy, which is an not shown). indicator of the recommendations on nine groups of ‘healthy’ foods; and GDR-Limit, which is an indicator of the recommendations on eight dietary components to limit, Table 4.1. Socio-demographic and anthropometric characteristics of study such as snacks, ultra-processed foods/beverages and deep-fried foods.32 Dietary participants (total and separated by school type) data are presented in terms of mean dietary diversity scores based on the number Total Private Government P value of food groups (min–max score = 0–10), the mean GDR-Healthy, GDR-Limit and GDR (n = 217) schools schools total (calculated by subtracting GDR-Limit from GDR-Healthy and adding 9 to (n = 107) (n = 110) transform the indicator to a range of 0–18), the percentage of adolescents Mean ± SD or n (%) consuming different food groups and ultra-processed foods (based on the NOVA Age (years) 17.2 ± 1.0 17.1 ± 1.1 17.2 ± 0.9 0.25 classification). The BMI-for-age z-scores were calculated using WHO AnthroPlus v Gender 1.0.4 to assess the nutritional status of the participants. Female 128 (59) 59 (55.1) 69 (62.7) 0.27 Socio-economic indicators IBM SPSS Statistics v25.0 was used for data analysis. Continuous variables are Number of assets2 10.1 ± 1.6 10.8 ± 1.4 9.5 ± 1.5 <0.001 presented as mean ± SD and counts as frequency (percentage). To estimate the Own bedroom 88 (40.6) 63 (58.9) 25 (22.7) <0.001 relationship of food environment and socio-economic indicators with dietary and Receives pocket money 161 (74.2) 93 (43.3) 68 (31.6) <0.001 nutritional outcomes, we performed a multiple linear regression analysis with Weekly pocket money 94.8 ± 87.2 110.9 ± 101.0 72.9 ± 57.4 <0.001 dietary diversity scores, diet quality (GDR-Healthy, GDR-Limit) scores or BMI z- amount (Ethiopian Birr)1 scores as the dependent variable and number of outlets around the school, SSB Nutritional status advertising or sale within the school compound, number of assets in the household BMI-for-age z-score -0.7 ± 1.2 -0.6 ± 1.3 -0.8 ± 1.1 0.15 and pocket money of the student as independent variables. Education level of the (mean) parents was included in the model as a potential confounding factor. We Underweight3 28 (12.9) 16 (14.9) 12 (10.9) 0.21 dichotomized the food environment variables (number of outlets) into low density Overweight3 16 (7.4) 11(10.3) 5 (4.6) 0.21 (defined as equal or below the median) or high density (values above the median) Obesity3 4 (1.8) 2 (1.9) 2 (1.8) 0.21 so that the estimated coefficient was not influenced by outliers. Normal weight 168 (77.8) 78 (72.9) 90 (82.6) 0.21 1 Ethiopian currency. 2Min-max score = 0-13.3Underweight, z-score < -2; overweight, z-score Perceptions of the school and home food environment were also dichotomized by > +1 and < +2; obese, z-score > +2. collapsing ‘strongly agree and agree’ together and ‘strongly disagree and disagree’ together. We then performed a binary logistic regression of the perception variables BMI, dietary diversity and quality of adolescents with the same food environment and socio-economic variables as independent variables. Statistical significance was set at α = 0.05 and all tests were two-sided. Over three-quarters of adolescents (77%) had a normal weight, whereas 13% were classified as underweight and 9% as overweight or obese (Table 4.1); the mean BMI z-score was -0.7 (SD 1.2). The mean dietary diversity (DD) score of adolescents was 3.6 (SD 0.9) out of 10 food groups (Table 4.2). Adolescents from private schools had 104 School food environment study Women (MDD-W) approach, which is useful to reflect the micronutrient adequacy RESULTS of diets and is recommended for use in LMIC.30 In addition, foods and beverages were assigned to one of four categories of the NOVA classification based on their Description of sample level of processing.31 However, our study only focused on whether the foods and beverages consumed fell into the fourth NOVA category of ultra-processed foods. Dietary data were also categorized into Global Dietary Recommendations (GDR) From a total of 240 eligible adolescents, 217 completed the study; the average age scores, which in addition to the MDD-W add value as indicators of dietary quality.32 of participants was 17.2 (SD 1.0) years and slightly more than half (59%) were female Diet patterns were assessed in terms of their adherence to global dietary (Table 4.1). More adolescents from private schools received pocket money and the recommendations for fruit and vegetables, dietary fibre, free sugars, saturated fat, amounts were also higher for private school students. Over three-quarters of total fat, legumes, nuts and seeds, whole grains and processed meats. adolescents (79%) walked less than 10 minutes from a car or bus to the school gate. Only private school children reported travelling to school in their parent’s car (data The GDR score is composed of two subcomponents: GDR-Healthy, which is an not shown). indicator of the recommendations on nine groups of ‘healthy’ foods; and GDR-Limit, which is an indicator of the recommendations on eight dietary components to limit, Table 4.1. Socio-demographic and anthropometric characteristics of study such as snacks, ultra-processed foods/beverages and deep-fried foods.32 Dietary participants (total and separated by school type) 4 data are presented in terms of mean dietary diversity scores based on the number Total Private Government P value of food groups (min–max score = 0–10), the mean GDR-Healthy, GDR-Limit and GDR (n = 217) schools schools total (calculated by subtracting GDR-Limit from GDR-Healthy and adding 9 to (n = 107) (n = 110) transform the indicator to a range of 0–18), the percentage of adolescents Mean ± SD or n (%) consuming different food groups and ultra-processed foods (based on the NOVA Age (years) 17.2 ± 1.0 17.1 ± 1.1 17.2 ± 0.9 0.25 classification). The BMI-for-age z-scores were calculated using WHO AnthroPlus v Gender 1.0.4 to assess the nutritional status of the participants. Female 128 (59) 59 (55.1) 69 (62.7) 0.27 Socio-economic indicators IBM SPSS Statistics v25.0 was used for data analysis. Continuous variables are Number of assets2 10.1 ± 1.6 10.8 ± 1.4 9.5 ± 1.5 <0.001 presented as mean ± SD and counts as frequency (percentage). To estimate the Own bedroom 88 (40.6) 63 (58.9) 25 (22.7) <0.001 relationship of food environment and socio-economic indicators with dietary and Receives pocket money 161 (74.2) 93 (43.3) 68 (31.6) <0.001 nutritional outcomes, we performed a multiple linear regression analysis with Weekly pocket money 94.8 ± 87.2 110.9 ± 101.0 72.9 ± 57.4 <0.001 dietary diversity scores, diet quality (GDR-Healthy, GDR-Limit) scores or BMI z- amount (Ethiopian Birr)1 scores as the dependent variable and number of outlets around the school, SSB Nutritional status advertising or sale within the school compound, number of assets in the household BMI-for-age z-score -0.7 ± 1.2 -0.6 ± 1.3 -0.8 ± 1.1 0.15 and pocket money of the student as independent variables. Education level of the (mean) parents was included in the model as a potential confounding factor. We Underweight3 28 (12.9) 16 (14.9) 12 (10.9) 0.21 dichotomized the food environment variables (number of outlets) into low density Overweight3 16 (7.4) 11(10.3) 5 (4.6) 0.21 (defined as equal or below the median) or high density (values above the median) Obesity3 4 (1.8) 2 (1.9) 2 (1.8) 0.21 so that the estimated coefficient was not influenced by outliers. Normal weight 168 (77.8) 78 (72.9) 90 (82.6) 0.21 1 Ethiopian currency. 2Min-max score = 0-13.3Underweight, z-score < -2; overweight, z-score Perceptions of the school and home food environment were also dichotomized by > +1 and < +2; obese, z-score > +2. collapsing ‘strongly agree and agree’ together and ‘strongly disagree and disagree’ together. We then performed a binary logistic regression of the perception variables BMI, dietary diversity and quality of adolescents with the same food environment and socio-economic variables as independent variables. Statistical significance was set at α = 0.05 and all tests were two-sided. Over three-quarters of adolescents (77%) had a normal weight, whereas 13% were classified as underweight and 9% as overweight or obese (Table 4.1); the mean BMI z-score was -0.7 (SD 1.2). The mean dietary diversity (DD) score of adolescents was 3.6 (SD 0.9) out of 10 food groups (Table 4.2). Adolescents from private schools had 105 Chapter 4 significantly higher mean DD than their peers from government schools (P < 0.05). Table 4.2. Dietary and purchasing behaviour of study participants: consumption With regard to the GDR, on average, adolescents consumed 3.4 out of the 9 health- and purchase by food group and level of processing (total and separated by school promoting food groups (GDR-Healthy) and less than 1 food or drink of the 8 groups type) that should be limited or avoided (GDR-Limit). Private school adolescents had higher GDR-Limit scores. In the 24-hour period before the interview, most adolescents All schools Private Government P value consumed grains (99%), vegetables (mostly onions: 98%) and pulses (77%), but eggs (n = 217) (n = 107) (n = 110) (3%), dairy foods (5%) or nuts (6%) were rarely consumed. Dark-green leafy Mean ± SD or n (%) vegetables and other vitamin A-rich fruit or vegetables were consumed by less than Dietary diversity one-third of adolescents. In contrast, ultra-processed foods and beverages, basically Mean dietary diversity 3.6 ± 0.9 3.7 ± 1.0 3.4 ± 0.8 <0.001 sweets and SSB, were consumed by almost a quarter (23.5%) of adolescents. Meat score consumption was higher in private school adolescents (24.3% vs. 6.4% in GDR GDR Total 11.72 ± 1.26 11.64 ± 1.36 11.80 ± 1.16 0.34 government schools). GDR-Healthy 3.35 ± 1.03 3.34 ± 1.14 3.28 ± 0.90 0.29 GDR-Limit 0.64 ± 0.75 0.79 ± 0.79 0.48 ± 0.67 <0.001 Three-quarters of adolescents (74%) received pocket money, which they spent on Consumption of different food groups fried food (55%), sweets (25%) or SSB (19%). While this was the case for all Grain 216 (99.5) 107 (100) 109 (99.1) 1.00 adolescents receiving pocket money, private school attendance was associated with Pulses 168 (77.4) 82 (76.6) 86 (78.2) 0.87 purchasing more SSB. Nuts 14 (6.5) 10 (9.3) 4 (3.6) 0.10 Dairy 11 (5.1) 6 (5/6) 5 (4.5) 0.77 Adolescents’ perceptions of their home and school food environment Meat 33 (15.2) 26 (24.3) 7 (6.4) <0.001 Egg 6 (2.8) 5 (4.7) 1 (0.9) 0.12 Dark-green leafy 44 (20.3) 27 (25.2) 17 (15.5) 0.09 Adolescents from both schools agreed that food outlets around the school sell snack vegetables foods, although they also perceived healthy food to be available. While most of Vitamin A-rich fruit or 56 (25.8) 27 (25.2) 29 (26.4) 0.88 them perceived the advertising to be of unhealthy foods or beverages, most also vegetables disagreed that there was a lot of advertising in the neighbourhood (Table 4.3). Other vegetables 213 (98.2) 105 (98.1) 108 (98.2) 1.00 Having fruit and vegetables available in their homes, in addition to unhealthy snacks, Other fruit 11 (5.1) 5 (4.7) 6 (5.5) 1.00 was more likely to be reported by private school adolescents. Ultra-processed foods 51 (23.5) 29 (27.1) 22 (20) 0.26 or beverages Use of pocket money for1 SSB 31 (19.3) 25 (26.9) 6 (8.8) 0.01 Sweets 40 (24.8) 25 (26.9) 15 (22.1) 0.84 Fruit 9 (5.6) 6 (6.5) 3 (4.4) 1.00 Fried food 89 (55.3) 57 (61.3) 32 (47.0) 0.20 1n = 161: n = 93 for private schools; n = 68 for government schools. GDR = Global Dietary Recommendations; SSB = sugar-sweetened beverages. 106 School food environment study significantly higher mean DD than their peers from government schools (P < 0.05). Table 4.2. Dietary and purchasing behaviour of study participants: consumption With regard to the GDR, on average, adolescents consumed 3.4 out of the 9 health- and purchase by food group and level of processing (total and separated by school promoting food groups (GDR-Healthy) and less than 1 food or drink of the 8 groups type) that should be limited or avoided (GDR-Limit). Private school adolescents had higher GDR-Limit scores. In the 24-hour period before the interview, most adolescents All schools Private Government P value consumed grains (99%), vegetables (mostly onions: 98%) and pulses (77%), but eggs (n = 217) (n = 107) (n = 110) (3%), dairy foods (5%) or nuts (6%) were rarely consumed. Dark-green leafy Mean ± SD or n (%) vegetables and other vitamin A-rich fruit or vegetables were consumed by less than Dietary diversity one-third of adolescents. In contrast, ultra-processed foods and beverages, basically Mean dietary diversity 3.6 ± 0.9 3.7 ± 1.0 3.4 ± 0.8 <0.001 sweets and SSB, were consumed by almost a quarter (23.5%) of adolescents. Meat score consumption was higher in private school adolescents (24.3% vs. 6.4% in GDR GDR Total 11.72 ± 1.26 11.64 ± 1.36 11.80 ± 1.16 0.34 government schools). GDR-Healthy 3.35 ± 1.03 3.34 ± 1.14 3.28 ± 0.90 0.29 GDR-Limit 0.64 ± 0.75 0.79 ± 0.79 0.48 ± 0.67 <0.001 Three-quarters of adolescents (74%) received pocket money, which they spent on Consumption of different food groups fried food (55%), sweets (25%) or SSB (19%). While this was the case for all Grain 216 (99.5) 107 (100) 109 (99.1) 1.00 4 adolescents receiving pocket money, private school attendance was associated with Pulses 168 (77.4) 82 (76.6) 86 (78.2) 0.87 purchasing more SSB. Nuts 14 (6.5) 10 (9.3) 4 (3.6) 0.10 Dairy 11 (5.1) 6 (5/6) 5 (4.5) 0.77 Adolescents’ perceptions of their home and school food environment Meat 33 (15.2) 26 (24.3) 7 (6.4) <0.001 Egg 6 (2.8) 5 (4.7) 1 (0.9) 0.12 Dark-green leafy 44 (20.3) 27 (25.2) 17 (15.5) 0.09 Adolescents from both schools agreed that food outlets around the school sell snack vegetables foods, although they also perceived healthy food to be available. While most of Vitamin A-rich fruit or 56 (25.8) 27 (25.2) 29 (26.4) 0.88 them perceived the advertising to be of unhealthy foods or beverages, most also vegetables disagreed that there was a lot of advertising in the neighbourhood (Table 4.3). Other vegetables 213 (98.2) 105 (98.1) 108 (98.2) 1.00 Having fruit and vegetables available in their homes, in addition to unhealthy snacks, Other fruit 11 (5.1) 5 (4.7) 6 (5.5) 1.00 was more likely to be reported by private school adolescents. Ultra-processed foods 51 (23.5) 29 (27.1) 22 (20) 0.26 or beverages Use of pocket money for1 SSB 31 (19.3) 25 (26.9) 6 (8.8) 0.01 Sweets 40 (24.8) 25 (26.9) 15 (22.1) 0.84 Fruit 9 (5.6) 6 (6.5) 3 (4.4) 1.00 Fried food 89 (55.3) 57 (61.3) 32 (47.0) 0.20 1n = 161: n = 93 for private schools; n = 68 for government schools. GDR = Global Dietary Recommendations; SSB = sugar-sweetened beverages. 107 Chapter 4 Table 4.3. Adolescents’ perception of the school and home food environment Description of the internal and external food environment Statement All schools Private Government P value Within the school compound, we found that all but two private schools sold SSB at (n = 217) (n = 107) (n = 110) their cafeteria and three government schools had advertising for SSB on the school n (%) compound. In the 0.5 km radius around a private or a public school, we found an In my house we always have fruit and vegetables average of 436 (SD 366) food outlets, but with large differences between sub-cities, (Strongly) disagree 105 (48.4) 35 (32.7) 68 (64.8) <0.001 ranging from 113 to 924 food outlets. The schools in the Kality and Arada sub-cities (Strongly) agree 105 (48.4) 63 (58.9) 33 (31.4) Neither agree nor 7 (3.2) 9 (8.4) 9 (8.2) had the highest numbers of food outlets surrounding them (Table 4.4), which is due disagree to the dense inner-city location of Arada and the large market area in Kality. In my house we always have fast food, sodas and snacks Consequently, the absolute exposure to outlets selling fruit and vegetables was (Strongly) disagree 174 (80.2) 76 (71.0) 98 (89.1) <0.001 highest in Kality. Display of SSB was highest in food outlets in Arada. Kiosks were the (Strongly) agree 30 (13.8) 23 (21.5) 7 (6.4) most common food outlets, representing 21.9% of all outlets in all clusters, and they Neither agree nor 13 (6.0) 8 (7.5) 5 (4.5) had the largest proportion of advertisement and displays of SSB (46.9% and 60.0%, disagree respectively). The absolute number of advertisements was also highest in Arada (n There are lots of shops selling snack food in the school neighbourhood = 720) and Kality (n = 405). However, in all sub-cities most of these advertisements (Strongly) disagree 29 (13.4) 16 (15.0) 13 (11.8) 0.79 promoted SSB (89.9%). Most advertisements were positioned on food outlets (Strongly) agree 184 (84.8) 89 (83.2) 95 (86.4) (89.1%) and presented as posters, boards or banners. The second most common Neither agree nor 4 (1.8) 2 (1.9) 2 (1.8) form of advertising was as part of the food outlet’s equipment, such as umbrellas, disagree Healthy foods are available in the school neighbourhood tablecloths or fridges (20.0%). The least common forms of advertisements were (Strongly) disagree 27 (12.4) 12 (11.2) 15 (13.6) 0.47 large billboards (0.9%). (Strongly) agree 176 (81.1) 90 (84.1) 86 (78.2) Neither agree nor 14 (6.5) 5 (4.7) 9 (8.2) Factors influencing adolescents’ diets and BMI status disagree There is a lot of food advertising in the school neighbourhood Dietary diversity was higher in adolescents with assets in the household when (Strongly) disagree 127 (58.5) 63 (58.9) 64 (58.2) 0.99 considering both food environment and socio-economic variables; this was also the (Strongly) agree 84 (38.7) 41 (38.3) 43 (39.1) Neither agree nor 6 (2.8) 3 (2.8) 3 (2.7) case for the GDR-Healthy score (Table 4.5). This association remained when disagree including parents’ education into the model. No other associations were found with The advertising is mostly promoting unhealthy food and drink consumption of unhealthy food groups (GDR-Limit) or BMI-for-age and socio- (Strongly) disagree 77 (35.5) 36 (33.6) 41 (37.3) 0.81 economic indicators. Factors in the food environment were neither associated with (Strongly) agree 127 (58.5) 65 (60.7) 63 (56.4) dietary scores nor BMI-for age z-scores. Neither agree nor 13 (6.0) 6 (5.6) 7 (6.4) disagree Adolescents’ perceptions of the home environment were also associated with assets and pocket money (data not shown). Adolescents from households with more assets or pocket money were more likely to perceive that, at their homes, they always had fruit and vegetables as well as snacks, which could be an explanation for the positive association of assets with dietary outcomes. 108 School food environment study Description of the internal and external food environment Within the school compound, we found that all but two private schools sold SSB at their cafeteria and three government schools had advertising for SSB on the school compound. In the 0.5 km radius around a private or a public school, we found an average of 436 (SD 366) food outlets, but with large differences between sub-cities, ranging from 113 to 924 food outlets. The schools in the Kality and Arada sub-cities had the highest numbers of food outlets surrounding them (Table 4.4), which is due to the dense inner-city location of Arada and the large market area in Kality. Consequently, the absolute exposure to outlets selling fruit and vegetables was highest in Kality. Display of SSB was highest in food outlets in Arada. Kiosks were the most common food outlets, representing 21.9% of all outlets in all clusters, and they had the largest proportion of advertisement and displays of SSB (46.9% and 60.0%, respectively). The absolute number of advertisements was also highest in Arada (n = 720) and Kality (n = 405). However, in all sub-cities most of these advertisements 4 promoted SSB (89.9%). Most advertisements were positioned on food outlets (89.1%) and presented as posters, boards or banners. The second most common form of advertising was as part of the food outlet’s equipment, such as umbrellas, tablecloths or fridges (20.0%). The least common forms of advertisements were large billboards (0.9%). Factors influencing adolescents’ diets and BMI status Dietary diversity was higher in adolescents with assets in the household when considering both food environment and socio-economic variables; this was also the case for the GDR-Healthy score (Table 4.5). This association remained when including parents’ education into the model. No other associations were found with consumption of unhealthy food groups (GDR-Limit) or BMI-for-age and socio- economic indicators. Factors in the food environment were neither associated with dietary scores nor BMI-for age z-scores. Adolescents’ perceptions of the home environment were also associated with assets and pocket money (data not shown). Adolescents from households with more assets or pocket money were more likely to perceive that, at their homes, they always had fruit and vegetables as well as snacks, which could be an explanation for the positive association of assets with dietary outcomes. 109 Chapter 4 110 Table 4.4 Food outlets (type, characteristics) and advertising in and around (0.5 km radius) schools (private and government) in the respective sub-city of Addis Ababa, Ethiopia, n (%) Mean, all Arada Bole Kality Kirkos Kolfe- Laphto sub-cities Keranio School1 PS GS PS GS PS GS PS GS PS GS PS GS SSB sold at school y y n y y y y y y y n y SSB advertised at school n y n n n n n n n y n y Type of outlet Outlets, total 436 832 134 924 155 460 113 Kiosks 93 121 (14.5) 26 (19.4) 193 (20.9) 46 (29.7) 136 (29.6) 38 (33.6) Supermarkets 5 9 (1.1) 3 (2.2) 4 (0.5) 0 4 (0.9) 9 (7.9) Sweet seller, informal 35 100 (12.0) 7 (5.2) 39 (4.2) 0 63 (13.7) 0 Fruit and vegetable stall 39 34 (4.1) 7 (5.2) 156 (17.2) 8 (5.2) 23 (5.0) 4 (3.5) Local café 101 313 (37.6) 38 (28.4) 116 (12.5) 51 (32.9) 70 (15.2) 18 (15.9) Other 163 255 (30.6) 53 (39.6) 416 (45.0) 50 (32.3) 164 (35.7) 44 (38.9) Outlets with food or beverage visibility/advertising FV visibly displayed in outlet 78 28 (3.4) 21 (15.7) 295 (31.9) 19 (12.3) 85 (18.5) 21 (18.6) SSB visibly displayed in outlet 115 353 (42.4) 82 (61.2) 145 (15.7) 41 (26.5) 48 (10.4) 20 (17.7) Food and beverage advertising on outlet 103 234 (28.1) 41 (30.6) 195 (21.1) 48 (30.9) 74 (16.1) 25 (22.1) Food and beverage advertising Advertising, total 246 720 87 405 99 126 44 Advertising of ultra-processed food or beverages 222 628 (87.2) 77 (88.5) 388 (95.8) 92 (92.9) 113 (89.7) 34 (77.3) Position of advertising on food outlet 220 648 (90.0) 80 (92.0) 359 (88.6) 90 (90.9) 105 (83.3) 40 (90.9) Advertising type 176 401 (55.7) 74 (85.0) 359 (88.6) 91 (91.9) 89 (70.7) 33 (88.6) (poster, board or banner) 1PS = private school, GS = government school. y = yes; n = no; FV = fruits or vegetables ; SSB = sugar-sweetened beverages. Table 4.5. Potential influencing factors on dietary diversity, quality or nutritional status by applying multiple linear regression Dietary diversity GDR-Healthy GDR-Limit BMI-for-age Predictors Beta S.E. P Beta S.E. P Beta S.E. P Beta S.E. P Food environment High number of -0.18 0.16 0.25 -0.11 0.17 0.52 0.04 0.12 0.73 0.14 0.19 0.48 food outlets (> 460) SSB sold at school 0.09 0.21 0.67 0.21 0.23 0.36 0.25 0.16 0.14 0.43 0.26 0.09 SSB advertised at 0.07 0.17 0.67 -0.98 0.18 0.59 0.04 0.13 0.76 0.16 0.21 0.45 school Socio-economic Asset score 0.11 0.05 0.04 0.12 0.06 0.03 0.02 0.04 0.65 0.09 0.06 0.15 Receiving pocket -0.83 0.18 0.64 0.23 0.19 0.23 0.13 0.14 0.37 0.22 0.22 0.31 money Education of -0.04 0.08 0.63 0.01 0.09 0.94 0.12 0.06 0.06 0.01 0.10 0.96 parents S.E. = standard error; GDR = Global Dietary Recommendations; BMI = body mass index; SSB = sugar-sweetened beverages. School food environment study 4 111 Table 4.4 Food outlets (type, characteristics) and advertising in and around (0.5 km radius) schools (private and government) in the respective sub-city of Addis Ababa, Ethiopia, n (%) Mean, all Arada Bole Kality Kirkos Kolfe- Laphto sub-cities Keranio School1 PS GS PS GS PS GS PS GS PS GS PS GS SSB sold at school y y n y y y y y y y n y SSB advertised at school n y n n n n n n n y n y Type of outlet Outlets, total 436 832 134 924 155 460 113 Kiosks 93 121 (14.5) 26 (19.4) 193 (20.9) 46 (29.7) 136 (29.6) 38 (33.6) Supermarkets 5 9 (1.1) 3 (2.2) 4 (0.5) 0 4 (0.9) 9 (7.9) Sweet seller, informal 35 100 (12.0) 7 (5.2) 39 (4.2) 0 63 (13.7) 0 Fruit and vegetable stall 39 34 (4.1) 7 (5.2) 156 (17.2) 8 (5.2) 23 (5.0) 4 (3.5) Local café 101 313 (37.6) 38 (28.4) 116 (12.5) 51 (32.9) 70 (15.2) 18 (15.9) Other 163 255 (30.6) 53 (39.6) 416 (45.0) 50 (32.3) 164 (35.7) 44 (38.9) Outlets with food or beverage visibility/advertising FV visibly displayed in outlet 78 28 (3.4) 21 (15.7) 295 (31.9) 19 (12.3) 85 (18.5) 21 (18.6) SSB visibly displayed in outlet 115 353 (42.4) 82 (61.2) 145 (15.7) 41 (26.5) 48 (10.4) 20 (17.7) Food and beverage advertising on outlet 103 234 (28.1) 41 (30.6) 195 (21.1) 48 (30.9) 74 (16.1) 25 (22.1) Food and beverage advertising Advertising, total 246 720 87 405 99 126 44 Advertising of ultra-processed food or beverages 222 628 (87.2) 77 (88.5) 388 (95.8) 92 (92.9) 113 (89.7) 34 (77.3) Position of advertising on food outlet 220 648 (90.0) 80 (92.0) 359 (88.6) 90 (90.9) 105 (83.3) 40 (90.9) Advertising type 176 401 (55.7) 74 (85.0) 359 (88.6) 91 (91.9) 89 (70.7) 33 (88.6) (poster, board or banner) 1PS = private school, GS = government school. y = yes; n = no; FV = fruits or vegetables ; SSB = sugar-sweetened beverages. Table 4.5. Potential influencing factors on dietary diversity, quality or nutritional status by applying multiple linear regression Dietary diversity GDR-Healthy GDR-Limit BMI-for-age Predictors Beta S.E. P Beta S.E. P Beta S.E. P Beta S.E. P Food environment High number of -0.18 0.16 0.25 -0.11 0.17 0.52 0.04 0.12 0.73 0.14 0.19 0.48 food outlets (> 460) SSB sold at school 0.09 0.21 0.67 0.21 0.23 0.36 0.25 0.16 0.14 0.43 0.26 0.09 SSB advertised at 0.07 0.17 0.67 -0.98 0.18 0.59 0.04 0.13 0.76 0.16 0.21 0.45 school Socio-economic Asset score 0.11 0.05 0.04 0.12 0.06 0.03 0.02 0.04 0.65 0.09 0.06 0.15 Receiving pocket -0.83 0.18 0.64 0.23 0.19 0.23 0.13 0.14 0.37 0.22 0.22 0.31 money Education of -0.04 0.08 0.63 0.01 0.09 0.94 0.12 0.06 0.06 0.01 0.10 0.96 parents S.E. = standard error; GDR = Global Dietary Recommendations; BMI = body mass index; SSB = sugar-sweetened beverages. Chapter 4 DISCUSSION establishments are increasing and tend to cluster around schools.16 Furthermore, in LMIC, food companies are developing extensive distribution networks, providing 5 The aim of our study was to examine food environments in and around schools in point-of-sale advertising materials or free distributions, and using spaces with the urban Ethiopia and to explore how they might influence dietary diversity, quality, highest consumer traffic to tempt consumers into buying ultra-processed foods or 37 BMI status or adolescents’ perceptions of their school and home food environment. beverages. Unlike other studies from LMIC, we did not find that unhealthy food We observed that high dietary diversity as well as higher consumption of healthy environments around schools were directly linked with poorer dietary quality9 or 38,39 foods was associated with adolescents from households with more assets. For both higher BMI. This could largely be due to the fact that students take their own groups of students, our study found a high density of food outlets within the 0.5 km lunch to school, with their parents acting as ‘gatekeepers’ of their choices.10 radius around the schools, as well as widespread promotion and display of ultra- Therefore, parental and social norms could have a stronger influence on processed foods and beverages in and around the schools. While such an adolescents’ diets than the physical food environment. However, adolescents are at environment is not conducive to promoting healthy dietary behaviours, we cannot a critical stage in life, learning to make their own dietary choices, and with conclude that these environmental factors directly explain adolescents’ diet or decreasing influence of parents and increasing financial autonomy their dietary weight status. behaviours could be more strongly influenced by the food environment.10 The differences between private and government-school adolescents in terms of Schools provide a well-defined and preferred setting for prevention strategies to their dietary diversity and purchasing of SSB could be explained by the socio- improve the diets of children and adolescents.14 The external and internal school economic status of their families, which we assessed using the number of assets or environment assessed by our study was not conducive to healthy food choices. the amount of pocket money the adolescents receive. Parents who give pocket Current Ethiopian school policies are limited to school feeding and food safety and money without spending stipulations could create financial autonomy, but the lack lack actions on the availability or advertising of food in and around schools,40 which of supervision could also potentially worsen the unhealthy dietary behaviours of are needed to extend policy action to focus on addressing all forms of malnutrition. adolescents.33 Studies have shown the different roles that parents play in food consumption. Mothers preparing food at home have been described as a positive Strengths and limitations influence, whereas high-income parents who are too busy to prepare food may become negative role models.33-35 In our sample, adolescents from households with To our knowledge, this is the first study to map food environments in and around more assets also perceived that both healthy and unhealthy foods were available in schools in urban Ethiopia and explore how this is associated with the dietary their households. Globally, consuming SSB is socially stratified, with high-income behaviours and weight status of adolescents. Due to its cross-sectional nature, the groups consuming them in LMIC and shifting to lower income groups as a country’s study only provides a snapshot of the prevailing food environment and diet diversity income level increases.5 Our data support this, as purchases of SSB in Ethiopia were at the time of the survey and therefore does not allow causal inferences to be made. greater among participants with more household assets. Assessing only the school environment might have been a limitation because the home environment can also play an important role. Considering the limited amount We observed that adolescents who spent their pocket money on food/beverages of pocket money that students reported receiving and also the ‘gatekeeping’ role of were more likely to spend it on fried foods, sweets or SSB rather than on fruit. parents, adolescents’ interaction with the food environment in and around the Purchasing little or no fruit on the way to or from school, even though it is widely school was limited. Given this limited interaction with the food environment, available, could also be due to food safety concerns related to fruit sold in adolescents’ perceptions of the food environment could be a better proxy for their unhygienic conditions or lack of clean water to wash it.36 Furthermore, adolescents’ potential behaviour. Furthermore, reducing our food environment measures to the purchasing choices provided an insight into their preference for fried food, sweets number of food outlets might have simplified the complexity of the study. or SSB over fruit. As opposed to fresh fruit, adolescents could consider packaged Measuring specific elements of the food environment that we identified as relevant ultra-processed foods or beverages to be a safer and socially more acceptable and for adolescents’ purchasing behaviour, such as availability, price and vicinity of fried desirable option.33,36 food, could have been a better indicator. However, such a detailed assessment of the food environment was not feasible with the resources available. Despite this Ultra-processed food and beverages, such as sweets and SSB, were found to be limitation, our detailed description of the food environment in and around the widely advertised and displayed visibly in the food outlets surrounding schools. A schools, the auditing of advertising by food group and by processing level, along with recent review found that in high-income countries, unhealthy retail food the diet characterization and perceptions of the adolescents, make this study 112 School food environment study DISCUSSION establishments are increasing and tend to cluster around schools.16 Furthermore, in LMIC, food companies are developing extensive distribution networks, providing 5 The aim of our study was to examine food environments in and around schools in point-of-sale advertising materials or free distributions, and using spaces with the urban Ethiopia and to explore how they might influence dietary diversity, quality, highest consumer traffic to tempt consumers into buying ultra-processed foods or 37 BMI status or adolescents’ perceptions of their school and home food environment. beverages. Unlike other studies from LMIC, we did not find that unhealthy food We observed that high dietary diversity as well as higher consumption of healthy environments around schools were directly linked with poorer dietary quality9 or foods was associated with adolescents from households with more assets. For both higher BMI.38,39 This could largely be due to the fact that students take their own groups of students, our study found a high density of food outlets within the 0.5 km lunch to school, with their parents acting as ‘gatekeepers’ of their choices.10 radius around the schools, as well as widespread promotion and display of ultra- Therefore, parental and social norms could have a stronger influence on processed foods and beverages in and around the schools. While such an adolescents’ diets than the physical food environment. However, adolescents are at environment is not conducive to promoting healthy dietary behaviours, we cannot a critical stage in life, learning to make their own dietary choices, and with conclude that these environmental factors directly explain adolescents’ diet or decreasing influence of parents and increasing financial autonomy their dietary weight status. behaviours could be more strongly influenced by the food environment.10 The differences between private and government-school adolescents in terms of Schools provide a well-defined and preferred setting for prevention strategies to 4 their dietary diversity and purchasing of SSB could be explained by the socio- improve the diets of children and adolescents.14 The external and internal school economic status of their families, which we assessed using the number of assets or environment assessed by our study was not conducive to healthy food choices. the amount of pocket money the adolescents receive. Parents who give pocket Current Ethiopian school policies are limited to school feeding and food safety and money without spending stipulations could create financial autonomy, but the lack lack actions on the availability or advertising of food in and around schools,40 which of supervision could also potentially worsen the unhealthy dietary behaviours of are needed to extend policy action to focus on addressing all forms of malnutrition. adolescents.33 Studies have shown the different roles that parents play in food consumption. Mothers preparing food at home have been described as a positive Strengths and limitations influence, whereas high-income parents who are too busy to prepare food may become negative role models.33-35 In our sample, adolescents from households with To our knowledge, this is the first study to map food environments in and around more assets also perceived that both healthy and unhealthy foods were available in schools in urban Ethiopia and explore how this is associated with the dietary their households. Globally, consuming SSB is socially stratified, with high-income behaviours and weight status of adolescents. Due to its cross-sectional nature, the groups consuming them in LMIC and shifting to lower income groups as a country’s study only provides a snapshot of the prevailing food environment and diet diversity income level increases.5 Our data support this, as purchases of SSB in Ethiopia were at the time of the survey and therefore does not allow causal inferences to be made. greater among participants with more household assets. Assessing only the school environment might have been a limitation because the home environment can also play an important role. Considering the limited amount We observed that adolescents who spent their pocket money on food/beverages of pocket money that students reported receiving and also the ‘gatekeeping’ role of were more likely to spend it on fried foods, sweets or SSB rather than on fruit. parents, adolescents’ interaction with the food environment in and around the Purchasing little or no fruit on the way to or from school, even though it is widely school was limited. Given this limited interaction with the food environment, available, could also be due to food safety concerns related to fruit sold in adolescents’ perceptions of the food environment could be a better proxy for their unhygienic conditions or lack of clean water to wash it.36 Furthermore, adolescents’ potential behaviour. Furthermore, reducing our food environment measures to the purchasing choices provided an insight into their preference for fried food, sweets number of food outlets might have simplified the complexity of the study. or SSB over fruit. As opposed to fresh fruit, adolescents could consider packaged Measuring specific elements of the food environment that we identified as relevant ultra-processed foods or beverages to be a safer and socially more acceptable and for adolescents’ purchasing behaviour, such as availability, price and vicinity of fried desirable option.33,36 food, could have been a better indicator. However, such a detailed assessment of the food environment was not feasible with the resources available. Despite this Ultra-processed food and beverages, such as sweets and SSB, were found to be limitation, our detailed description of the food environment in and around the widely advertised and displayed visibly in the food outlets surrounding schools. 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Socio-cultural and economic based obesity interventions in low- and middle-income countries: A systematic review. determinants and consequences of adolescent undernutrition and micronutrient Am J Clin Nutr, 2012; 96(2), 415–438. https://doi.org/10.3945/ajcn.112.035378 deficiencies in LLMICs: A systematic narrative review. Ann N Y Acad Sci, 2018; 1416(1), 36. Trübswasser, U., Baye, K., Holdsworth, M., et al. Assessing factors influencing 117–139. adolescents’ dietary behaviours in urban Ethiopia using participatory photography. 20. Verstraeten, R., Leroy, J. L., Pieniak, Z., et al. Individual and environmental factors Public Heal Nutr, 2020; 24(12), 3615–3623. influencing adolescents’ dietary behavior in low- and middle-income settings. PLOS https://doi.org/10.1017/s1368980020002487 ONE, 2016; 11(7), e0157744. https://doi.org/10.1371/journal.pone.0157744 37. Bridle-Fitzpatrick, S. Food deserts or food swamps?: A mixed-methods study of local 21. Keats, E C, Rappaport, A I, Shah, S, et al. The dietary intake and practices of adolescent food environments in a Mexican city. Soc Sci Med, 2015; 142, 202–213. girls in low- and middle-income countries: A systematic review. Nutrients, 2018; 10(12), https://doi.org/10.1016/j.socscimed.2015.08.010 1978. doi:10.3390/nu10121978 38. Chiang, P. H., Wahlqvist, M. L., Lee, M. S., et al. Fast-food outlets and walkability in 22. Berhane, Y., Canavan, C. R., Darling, A. M., et al. The age of opportunity: Prevalence of school neighbourhoods predict fatness in boys and height in girls: A Taiwanese key risk factors among adolescents 10–19 years of age in nine communities in sub- population study. Public Heal Nutr, 2011; 14(9), 1601–1609. Saharan Africa. Trop Med Int Health, 2020; 25(1), 15–32. https://doi.org/10.1017/S1368980011001042 https://doi.org/10.1111/tmi.13339 39. Mendez, N., Barrera-Pérez, M., Palma-Solís, M., et al. “You are not fat, you are 23. Begna, T. N. Public schools and private schools in Ethiopia: Partners in national hermosa”: Mexican caregivers share their perceptions about their role supporting their development? Int J Humanit Soc Sci, 2017; 4(2), 100–111. morbidly obese children. Hisp Health Care Int, 2014; 12(4), 174–182. 24. Kelly, B., King, L., Baur, L., et al. Monitoring food and non-alcoholic beverage promotions https://doi.org/10.1891/1540-4153.12.4.174 to children. Obes Rev, 2013; 14(Suppl 1), 59–69. https://doi.org/10.1111/obr.12076 40. Trübswasser, U., Genye, T., Bossuyt, A. Review of the Nutrition Policy Landscape in 25. Doku, D., Koivusilta, L., Rimpelä, A. Indicators for measuring material affluence of Ethiopia 2010–2020. 2020. Retrieved from adolescents in health inequality research in developing countries. Child Indic Res, 2010; http://www.nipn.ephi.gov.et/sites/default/files/inlinefiles/ 3, 243–260. https://doi.org/10.1007/s12187- 009-9045-7 Nutrition_Policy_Landscape_FINAL_Report.pdf 26. CSA. Ethiopia Demographic and Health Survey 2019. Addis Ababa, Ethiopia and 41. Mahesh, R., Vandevijvere, S., Dominick, C., et al. Relative contributions of Rockville, MA, USA: Central Statistical Agency and ICF. 2019. recommended food environment policies to improve population nutrition: Results from 27. Green, S. H., Glanz, K. Development of the Perceived Nutrition Environment Measures a Delphi study with international food policy experts. Public Heal Nutr, 2018; 21(11), Survey. Am J Prev Med, 2015; 49(1), 50–61. 2142–2148. https://doi.org/DOI: 10.1017/S1368980018001076 https://doi.org/10.1016/j.amepre.2015.02.004 42. Bekele, T. H., De Vries, J. J. H. M., Trijsburg, L., et al. Methodology for developing and 28. Vedovato, G. M., Trude, A. C. B., Kharmats, A. Y., et al. Degree of food processing of evaluating food-based dietary guidelines and a Healthy Eating Index for Ethiopia: A household acquisition patterns in a Brazilian urban area is related to food buying study protocol. BMJ Open, 2019; 9(7), e027846. https://doi.org/10.1136/bmjopen- preferences and perceived food environment. Appetite, 2015; 87, 296–302. 2018-027846 https://doi.org/https://doi.org/10.1016/j.appet.2014.12.229 29. Lohman, T. G., Roche, A. F., Martorell, R. Anthropometric Standardization Reference Manual. Champaign, IL: Human Kinetics Books. 1988. 116 School food environment study 14. Turner, K., Foster, C., Allender, S., et al. A systematic review of how researchers 30. FAO, FHI 360; Minimum Dietary Diversity for Women – A Guide to Measurement. Rome: characterize the school environment in determining its effect on student obesity. BMC Food and Agriculture Organization, 2016. Obesity, 2015; 2, 13. https://doi.org/10.1186/s40608-015-0045-5 31. Monteiro, C. A., Moubarac, J. C., Cannon, G., et al. Ultra-processed products are 15. Brown, C., Shaibu, S., Maruapula, S., et al. Perceptions and attitudes towards food becoming dominant in the global food system. Obes Rev, 2013; 14(Suppl 2), 21–28. choice in adolescents in Gaborone, Botswana. Appetite, 2015; 95, 29–35. https://doi.org/10.1111/obr.12107 https://doi.org/10.1016/j.appet.2015.06.018 32. Herforth, A. W., Wiesmann, D., Martínez-Steele, E., et al. Introducing a suite of low- 16. Peres, C., Gardone, D., Mendes, L., et al. Retail food environment around schools and burden diet quality indicators that reflect healthy diet patterns at population level. Curr overweight: A systematic review. Nut Rev, 2020; 78(10), 841–856. Dev in Nut, 2020; 4(12), 168–168. https://doi.org/10.1093/cdn/nzaa168 https://doi.org/10.1093/nutrit/nuz110 33. Trübswasser, U., Verstraeten, R., Salm, L., et al. Factors influencing obesogenic 17. Turner, C., Kalamatianou, S., Drewnowski, A., et al. Food environment research in low- behaviours of adolescent girls and women in low- and middle-income countries: A and middle-income countries: A systematic scoping review. Adv Nutr, 2020; 11(2), 387– qualitative evidence synthesis. Obes Rev, 2020; 22(4), e13163. 397. https://doi.org/10.1093/advances/nmz031 https://doi.org/https://doi.org/10.1111/obr.13163 18. Williams, J., Scarborough, P., Matthews, A., et al. A systematic review of the influence 34. Gray, H., Buro, A. W., Ikan, J. B., et al. School-level factors associated with obesity: A of the retail food environment around schools on obesity-related outcomes. Obes Rev, systematic review of longitudinal studies. Obes Rev, 2019; 20, 1–17. 2014; 15(5), 359–374. https://doi.org/10.1111/obr.12142 35. Verstraeten, R., Roberfroid, D., Lachat, C., et al. Effectiveness of preventive school- 19. Madjdian, D. S., Azupogo, F., Osendarp, S. J. M., et al. Socio-cultural and economic based obesity interventions in low- and middle-income countries: A systematic review. determinants and consequences of adolescent undernutrition and micronutrient Am J Clin Nutr, 2012; 96(2), 415–438. https://doi.org/10.3945/ajcn.112.035378 4 deficiencies in LLMICs: A systematic narrative review. Ann N Y Acad Sci, 2018; 1416(1), 36. Trübswasser, U., Baye, K., Holdsworth, M., et al. Assessing factors influencing 117–139. adolescents’ dietary behaviours in urban Ethiopia using participatory photography. 20. Verstraeten, R., Leroy, J. L., Pieniak, Z., et al. Individual and environmental factors Public Heal Nutr, 2020; 24(12), 3615–3623. influencing adolescents’ dietary behavior in low- and middle-income settings. PLOS https://doi.org/10.1017/s1368980020002487 ONE, 2016; 11(7), e0157744. https://doi.org/10.1371/journal.pone.0157744 37. Bridle-Fitzpatrick, S. Food deserts or food swamps?: A mixed-methods study of local 21. Keats, E C, Rappaport, A I, Shah, S, et al. The dietary intake and practices of adolescent food environments in a Mexican city. Soc Sci Med, 2015; 142, 202–213. girls in low- and middle-income countries: A systematic review. Nutrients, 2018; 10(12), https://doi.org/10.1016/j.socscimed.2015.08.010 1978. doi:10.3390/nu10121978 38. Chiang, P. H., Wahlqvist, M. L., Lee, M. S., et al. Fast-food outlets and walkability in 22. Berhane, Y., Canavan, C. R., Darling, A. M., et al. The age of opportunity: Prevalence of school neighbourhoods predict fatness in boys and height in girls: A Taiwanese key risk factors among adolescents 10–19 years of age in nine communities in sub- population study. Public Heal Nutr, 2011; 14(9), 1601–1609. Saharan Africa. Trop Med Int Health, 2020; 25(1), 15–32. https://doi.org/10.1017/S1368980011001042 https://doi.org/10.1111/tmi.13339 39. Mendez, N., Barrera-Pérez, M., Palma-Solís, M., et al. “You are not fat, you are 23. Begna, T. N. Public schools and private schools in Ethiopia: Partners in national hermosa”: Mexican caregivers share their perceptions about their role supporting their development? Int J Humanit Soc Sci, 2017; 4(2), 100–111. morbidly obese children. Hisp Health Care Int, 2014; 12(4), 174–182. 24. Kelly, B., King, L., Baur, L., et al. Monitoring food and non-alcoholic beverage promotions https://doi.org/10.1891/1540-4153.12.4.174 to children. Obes Rev, 2013; 14(Suppl 1), 59–69. https://doi.org/10.1111/obr.12076 40. Trübswasser, U., Genye, T., Bossuyt, A. Review of the Nutrition Policy Landscape in 25. Doku, D., Koivusilta, L., Rimpelä, A. Indicators for measuring material affluence of Ethiopia 2010–2020. 2020. Retrieved from adolescents in health inequality research in developing countries. Child Indic Res, 2010; http://www.nipn.ephi.gov.et/sites/default/files/inlinefiles/ 3, 243–260. https://doi.org/10.1007/s12187- 009-9045-7 Nutrition_Policy_Landscape_FINAL_Report.pdf 26. CSA. Ethiopia Demographic and Health Survey 2019. Addis Ababa, Ethiopia and 41. Mahesh, R., Vandevijvere, S., Dominick, C., et al. Relative contributions of Rockville, MA, USA: Central Statistical Agency and ICF. 2019. recommended food environment policies to improve population nutrition: Results from 27. Green, S. H., Glanz, K. Development of the Perceived Nutrition Environment Measures a Delphi study with international food policy experts. Public Heal Nutr, 2018; 21(11), Survey. Am J Prev Med, 2015; 49(1), 50–61. 2142–2148. https://doi.org/DOI: 10.1017/S1368980018001076 https://doi.org/10.1016/j.amepre.2015.02.004 42. Bekele, T. H., De Vries, J. J. H. M., Trijsburg, L., et al. Methodology for developing and 28. Vedovato, G. M., Trude, A. C. B., Kharmats, A. Y., et al. Degree of food processing of evaluating food-based dietary guidelines and a Healthy Eating Index for Ethiopia: A household acquisition patterns in a Brazilian urban area is related to food buying study protocol. BMJ Open, 2019; 9(7), e027846. https://doi.org/10.1136/bmjopen- preferences and perceived food environment. Appetite, 2015; 87, 296–302. 2018-027846 https://doi.org/https://doi.org/10.1016/j.appet.2014.12.229 29. Lohman, T. G., Roche, A. F., Martorell, R. Anthropometric Standardization Reference Manual. Champaign, IL: Human Kinetics Books. 1988. 117 Chapter 4 Appendix 4.1 Food outlet categories 1. Supermarket/small shop: Modern retail outlet with checkout counters, big selection of food items. Examples include supermarket chains called Bambis, Hirut or Fresh corner 2. Kiosk: usually tiny house/hut on the road, usually only one or two sellers. Not possible to enter. Selling sodas, snacks, sometimes eggs, matches, phone credit etc 3. Fruit and vegetable stall: mostly selling fruits and vegetables, sometimes also other small food items. 4. Open market: open space, with multiple stalls for different food items, such as Shola or Merkato. 5. Informal street seller mobile: has a cart with one or two different fruit or vegetable items. Not at the same place at regular times. 6. Informal street seller immobile: has a small space on the sidewalk with for instance onions, chili, tomatoes or candy. Not at the same place at regular times. Categorized into: a. Fruit or vegetable b. Candy 7. Bakery: only selling bread, rolls, sometimes cakes or even eggs. 8. Butcher: sells only beef meat 9. Kebele shop/cooperative: sells subsidized food items like oil, sugar, flour 10. Street food: sells different types of fried foods on the side of the road or as part of another shop 11. Café: a. Traditional/shybet: traditional Ethiopian coffee, also some Ethiopian food b. Modern/Kekbet: chains that sell cakes as well as fast food 12. Restaurant: serves hot meals, such as lunch and dinner 118 School food environment study 4 119 CHAPTER 5 Benchmarking policy goals and actions for healthy food environments in Ethiopia to prevent malnutrition in all its forms using document analysis Ursula Trübswasser Jeroen Candel Tirsit Genye Anne Bossuyt Michelle Holdsworth Kaleab Baye Elise F. Talsma Under review Chapter 5 INTRODUCTION food environment. While evidence suggests that multisectoral policymaking is taking place in Ethiopia, effective coordination and collaboration remains a challenge. ⁠29 Furthermore, Until recently, the greatest nutrition challenges in Ethiopia were the high burden of the extent to which different domains of the food environment have been addressed in undernutrition and micronutrient deficiencies.1,2 However, overweight and obesity rates, Ethiopian policies has not yet been assessed. Prior research on food and nutrition policies particularly in adult women in urban areas, are slowly but steadily increasing, leading to a in Ethiopia has either focused on food supply,30 ⁠ multisectorality,31-33 nutrition sensitive double burden of malnutrition.1-3 In Ethiopia, diets poor in iron or vitamin A and/or high in agriculture,34 infant or child nutrition,35,36 nutrition governance and implementation,37,38 or sodium or low in fruit or whole grains are a major risk factor for malnutrition in all its forms the evidence base for nutrition policies in the health sector.39 No study has yet and disability-adjusted life years.4 Previous research has shown that diets are largely shaped systematically analysed all nutrition-relevant policies in Ethiopia to understand how the by the surrounding food environment,5 including the availability and affordability of different domains of the food environment are addressed. healthy/unhealthy foods and beverages6,7 and the food safety and hygiene of food vendors.8 The food environment can be defined as the physical and social space where To close this gap, the objective of this study was to assess how different food environment consumers interact with the wider food system, thereby including what food is available, domains have been addressed in Ethiopian policy goals and actions over time and how they promoted, safe, convenient and accessible.5 compare with global good practice benchmarks. We also explored how the food environment policy actions are linked with setting goals for potential dietary or nutritional Food environments in Ethiopia have changed in recent years:9 prices of nutrient-dense outcomes, and how this has evolved over time. Our study therefore provides an important foods, such as fruit and vegetables and unprocessed meat, have increased over the period overview of the food environment policy context in Ethiopia and a good entry point for 2007–2016, while prices of sugar, oils and fats have declined.10 Food retail outlets in Addis policy prioritization. Ababa, the capital of Ethiopia, include a mix of private modern retail, public cooperatives and informal micro-sellers.11 A study assessing urban food environments in Ethiopia Theoretical framework revealed that most food or drink advertising was on food outlets and promoted ultra- processed beverages, such as sugar-sweetened beverages (SSB).12 In 2010, the upper- We developed a theoretical framework for our study (Fig. 5.1) based on the food middle class in Eastern and Southern Africa reportedly spent up to 80% of their food and environment domains of the INFORMAS Food-EPI framework,26 which we complemented drink expenditure on processed foods, of which 60% were ultra-processed.13 Perceived lack with insights from other food environment frameworks in order to cover all relevant of food safety related to fresh fruit and vegetables could further increase the consumption domains of the food environment in the Ethiopian context.40-45 INFORMAS identifies eight of ultra-processed foods among urban Ethiopian adolescents.14 In addition, food-borne different food environment domains in the Food-EPI tool, encompassing food composition illnesses pose an immediate risk to Ethiopian consumers due to the unhygienic food and processing, labelling, promotion, provision, retail, prices, trade and investment.26 Based preparation practices and poor environmental health conditions of the food outlets.15 on the assumption that these domains are largely shaped by government action regarding the accessibility, availability and affordability of healthy food choices, the Food-EPI tool has Policy actions to improve food systems by increasing the availability, affordability and been used to rate policy actions in countries against global benchmarks, which are based acceptability of safe and nutritious foods in food environments have been proposed,16 on international best practice examples relevant for each of the food environment some of which have been introduced in several countries.17-20 Examples include taxes and domains.19 incentives to reformulate sugary drinks and foods high in fats, sugars and salt in order to discourage their consumption while also promoting healthy foods,21,22 public food Following the development of the Food-EPI tool, the conceptualization of food procurement policies, provision of free meals in schools, introducing nutritional standards environments has further evolved in terms of its scope and place in the wider food system. or menu labelling in school cafeterias23 and incentive-driven training and certification Food safety was identified as an important domain of the food environment, given its initiatives in informal markets.24 The policy component of the Healthy Food Environment influence on consumers’ food consumption.40-42 Frameworks developed for the African and Policy Index (Food-EPI) tool developed by the International Network for Food and LMIC food environment also highlighted food safety and its importance with regard to the Obesity/Non-Communicable Diseases Research, Monitoring and Action Support sanitation and hygiene of vendors, food adulteration and contamination, especially in (INFORMAS) has been used to identify critical gaps in national policy actions by comparing informal retail in African urban food environments.43, 44 Food-EPI studies in Ghana and these with international good practices.19,25,26 The Food-EPI framework has been applied in Kenya integrated food safety as good practice examples of either trade or retail.27, 28 several countries,19,25 including within Africa,27,28 but not previously in Ethiopia. Our However, food safety cuts across the whole food environment, especially the domains of research will therefore contribute novel insights on the application and scope of the Food- food production, composition, provision, trade and retail,40 therefore we included it as an EPI tool and its indicators of good practice in low- and middle-income countries (LMIC). additional, individual domain in our framework (Fig. 1). Policy actions addressing the food environment require attention from different sectors The reviewed frameworks also recognize that the food environment interacts with the (e.g. health, agriculture, trade, education, social protection, finance), which could affect the whole food system and is not a stand-alone box within a system but overlaps with food 122 Policy review INTRODUCTION food environment. While evidence suggests that multisectoral policymaking is taking place in Ethiopia, effective coordination and collaboration remains a challenge. ⁠29 Furthermore, Until recently, the greatest nutrition challenges in Ethiopia were the high burden of the extent to which different domains of the food environment have been addressed in undernutrition and micronutrient deficiencies.1,2 However, overweight and obesity rates, Ethiopian policies has not yet been assessed. Prior research on food and nutrition policies particularly in adult women in urban areas, are slowly but steadily increasing, leading to a in Ethiopia has either focused on food supply,30 ⁠ multisectorality,31-33 nutrition sensitive double burden of malnutrition.1-3 In Ethiopia, diets poor in iron or vitamin A and/or high in agriculture,34 infant or child nutrition,35,36 nutrition governance and implementation,37,38 or sodium or low in fruit or whole grains are a major risk factor for malnutrition in all its forms the evidence base for nutrition policies in the health sector.39 No study has yet and disability-adjusted life years.4 Previous research has shown that diets are largely shaped systematically analysed all nutrition-relevant policies in Ethiopia to understand how the by the surrounding food environment,5 including the availability and affordability of different domains of the food environment are addressed. healthy/unhealthy foods and beverages6,7 and the food safety and hygiene of food vendors.8 The food environment can be defined as the physical and social space where To close this gap, the objective of this study was to assess how different food environment consumers interact with the wider food system, thereby including what food is available, domains have been addressed in Ethiopian policy goals and actions over time and how they promoted, safe, convenient and accessible.5 compare with global good practice benchmarks. We also explored how the food environment policy actions are linked with setting goals for potential dietary or nutritional Food environments in Ethiopia have changed in recent years:9 prices of nutrient-dense outcomes, and how this has evolved over time. Our study therefore provides an important foods, such as fruit and vegetables and unprocessed meat, have increased over the period overview of the food environment policy context in Ethiopia and a good entry point for 2007–2016, while prices of sugar, oils and fats have declined.10 Food retail outlets in Addis policy prioritization. Ababa, the capital of Ethiopia, include a mix of private modern retail, public cooperatives and informal micro-sellers.11 A study assessing urban food environments in Ethiopia Theoretical framework revealed that most food or drink advertising was on food outlets and promoted ultra- 5 processed beverages, such as sugar-sweetened beverages (SSB).12 In 2010, the upper- We developed a theoretical framework for our study (Fig. 5.1) based on the food middle class in Eastern and Southern Africa reportedly spent up to 80% of their food and environment domains of the INFORMAS Food-EPI framework,26 which we complemented drink expenditure on processed foods, of which 60% were ultra-processed.13 Perceived lack with insights from other food environment frameworks in order to cover all relevant of food safety related to fresh fruit and vegetables could further increase the consumption domains of the food environment in the Ethiopian context.40-45 INFORMAS identifies eight of ultra-processed foods among urban Ethiopian adolescents.14 In addition, food-borne different food environment domains in the Food-EPI tool, encompassing food composition illnesses pose an immediate risk to Ethiopian consumers due to the unhygienic food and processing, labelling, promotion, provision, retail, prices, trade and investment.26 Based preparation practices and poor environmental health conditions of the food outlets.15 on the assumption that these domains are largely shaped by government action regarding the accessibility, availability and affordability of healthy food choices, the Food-EPI tool has Policy actions to improve food systems by increasing the availability, affordability and been used to rate policy actions in countries against global benchmarks, which are based acceptability of safe and nutritious foods in food environments have been proposed,16 on international best practice examples relevant for each of the food environment some of which have been introduced in several countries.17-20 Examples include taxes and domains.19 incentives to reformulate sugary drinks and foods high in fats, sugars and salt in order to discourage their consumption while also promoting healthy foods,21,22 public food Following the development of the Food-EPI tool, the conceptualization of food procurement policies, provision of free meals in schools, introducing nutritional standards environments has further evolved in terms of its scope and place in the wider food system. or menu labelling in school cafeterias23 and incentive-driven training and certification Food safety was identified as an important domain of the food environment, given its initiatives in informal markets.24 The policy component of the Healthy Food Environment influence on consumers’ food consumption.40-42 Frameworks developed for the African and Policy Index (Food-EPI) tool developed by the International Network for Food and LMIC food environment also highlighted food safety and its importance with regard to the Obesity/Non-Communicable Diseases Research, Monitoring and Action Support sanitation and hygiene of vendors, food adulteration and contamination, especially in (INFORMAS) has been used to identify critical gaps in national policy actions by comparing informal retail in African urban food environments.43, 44 Food-EPI studies in Ghana and these with international good practices.19,25,26 The Food-EPI framework has been applied in Kenya integrated food safety as good practice examples of either trade or retail.27, 28 several countries,19,25 including within Africa,27,28 but not previously in Ethiopia. Our However, food safety cuts across the whole food environment, especially the domains of research will therefore contribute novel insights on the application and scope of the Food- food production, composition, provision, trade and retail,40 therefore we included it as an EPI tool and its indicators of good practice in low- and middle-income countries (LMIC). additional, individual domain in our framework (Fig. 1). Policy actions addressing the food environment require attention from different sectors The reviewed frameworks also recognize that the food environment interacts with the (e.g. health, agriculture, trade, education, social protection, finance), which could affect the whole food system and is not a stand-alone box within a system but overlaps with food 123 Chapter 5 supply chains, consumer behaviours and dietary and health outcomes.41, 42, 45 Considering the interlinkages of the food environment with food production,41, 42, 46 we have also Policies and regulations from different sectors: health, agriculture, education, social production, trade, urban planning included policy actions in the food supply chain such as agricultural production, which can influence the food environment in terms of availability, safety, processing, composition and Policy actions in food supply and food environment Policy goals addressing different outcomes provision. Positioned as a central component within food systems, food environments have been recognized as the space where people directly interact with the wider food system by Food supply chain Food environment Diets Nutritional status purchasing, preparing and/or consuming food.41, 43, 44, 47 We therefore also wanted to assess if and how food environment policy actions in Ethiopia are coherent with their goal setting • Agricultural • Food availability: Food production: e.g. provision and retail • Quantity • Overweight/obesity for diets and nutritional status (Fig. 5.1). agro-processing, • Food composition and • Quality • Underweight home-grown school processing • Diversity • Wasting, stunting feeding • Food labelling • Safety • Micronutrient The influence of food environments on diets has been recognized since the early • Processing: e.g. • Food promotion deficiencies conceptualizations of food environments in 2005.48 More recently, the potential of policy fortification • Food prices and affordability • Markets and • Food trade and investment actions to shift consumption towards high quality safe, nutritious foods and away from modern retail • Food safety nutrient-poor refined foods high in sugars, fats and/or salt and ultra-processed foods and beverages has been highlighted.16 The different dimensions of the food environment can affect diets in terms of quantity, quality, diversity and safety, which can influence the nutritional status of populations, manifested in different forms of malnutrition (overweight, Figure 5.1. Theoretical framework of food environment policy actions and goals. obesity, underweight, wasting, stunting, micronutrient deficiencies).41 We included these concepts as potential outcomes of unhealthy food environment policy actions in our METHODOLOGY framework and used them to assess goal setting in the included policy documents. In this assessment, we distinguish between policy goals and actions. Policy actions, also This study analysed Ethiopian policy documents with regard to policy goals and actions referred to as policy instruments, are interventions designed to achieve desired outcomes addressing food environments and related goals for diets and nutritional status over the and impacts. Policy goals are defined as the adoption of an objective related to a specific last decade (2008–2020). The documents were outputs of decision-making in the form of 49 51 issue within a policy document and can inform the issues dominating the policy agenda.50 published strategies, plans or policies and included legal outputs (from the highest to Analysis of the goals set in the policy documents can therefore shed light on the food lowest hierarchy: proclamations, regulations, or directives), documents stating overarching environment outcomes that are being recognized as concerns in Ethiopian policymaking. government plans (policies and strategies) and sectoral documents proposing policy actions to implement policy goals (sectoral strategies, action plans, programme documents or guidelines).52 Our study followed a document analysis focused on the policy component of the Food-EPI tool and the first three steps of its process: analyse context; collect relevant documents; and extract the evidence from the policies and actions.53 As part of the document analysis, content was analysed by identification of the themes related to the food environment domains.54 Data collection Delineating policies addressing ‘food environments’ proved to be challenging, given that numerous policies could affect any domain within food environments55 and given the current lack of explicit intentionality of Ethiopian policies to improve food environments.56 We therefore could not conduct searches for policy documents that were explicitly labelled as ‘food environment’ policies but followed an institutional approach instead. We define institutions as: the sectoral entities within which rules and norms for food and nutrition are 124 Policy review supply chains, consumer behaviours and dietary and health outcomes.41, 42, 45 Considering the interlinkages of the food environment with food production,41, 42, 46 we have also Policies and regulations from different sectors: health, agriculture, education, social production, trade, urban planning included policy actions in the food supply chain such as agricultural production, which can influence the food environment in terms of availability, safety, processing, composition and Policy actions in food supply and food environment Policy goals addressing different outcomes provision. Positioned as a central component within food systems, food environments have been recognized as the space where people directly interact with the wider food system by Food supply chain Food environment Diets Nutritional status purchasing, preparing and/or consuming food.41, 43, 44, 47 We therefore also wanted to assess if and how food environment policy actions in Ethiopia are coherent with their goal setting • Agricultural • Food availability: Food production: e.g. provision and retail • Quantity • Overweight/obesity for diets and nutritional status (Fig. 5.1). agro-processing, • Food composition and • Quality • Underweight home-grown school processing • Diversity • Wasting, stunting feeding • Food labelling • Safety • Micronutrient The influence of food environments on diets has been recognized since the early • Processing: e.g. • Food promotion deficiencies conceptualizations of food environments in 2005.48 More recently, the potential of policy fortification • Food prices and affordability • Markets and • Food trade and investment actions to shift consumption towards high quality safe, nutritious foods and away from modern retail • Food safety nutrient-poor refined foods high in sugars, fats and/or salt and ultra-processed foods and beverages has been highlighted.16 The different dimensions of the food environment can affect diets in terms of quantity, quality, diversity and safety, which can influence the nutritional status of populations, manifested in different forms of malnutrition (overweight, Figure 5.1. Theoretical framework of food environment policy actions and goals. obesity, underweight, wasting, stunting, micronutrient deficiencies).41 We included these concepts as potential outcomes of unhealthy food environment policy actions in our 5 METHODOLOGY framework and used them to assess goal setting in the included policy documents. In this assessment, we distinguish between policy goals and actions. Policy actions, also This study analysed Ethiopian policy documents with regard to policy goals and actions referred to as policy instruments, are interventions designed to achieve desired outcomes addressing food environments and related goals for diets and nutritional status over the and impacts. Policy goals are defined as the adoption of an objective related to a specific last decade (2008–2020). The documents were outputs of decision-making in the form of 51 issue within a policy document49 and can inform the issues dominating the policy agenda.50 published strategies, plans or policies and included legal outputs (from the highest to Analysis of the goals set in the policy documents can therefore shed light on the food lowest hierarchy: proclamations, regulations, or directives), documents stating overarching environment outcomes that are being recognized as concerns in Ethiopian policymaking. government plans (policies and strategies) and sectoral documents proposing policy actions to implement policy goals (sectoral strategies, action plans, programme documents or 52 guidelines). Our study followed a document analysis focused on the policy component of the Food-EPI tool and the first three steps of its process: analyse context; collect relevant documents; and extract the evidence from the policies and actions.53 As part of the document analysis, content was analysed by identification of the themes related to the food environment domains.54 Data collection Delineating policies addressing ‘food environments’ proved to be challenging, given that numerous policies could affect any domain within food environments55 and given the current lack of explicit intentionality of Ethiopian policies to improve food environments.56 We therefore could not conduct searches for policy documents that were explicitly labelled as ‘food environment’ policies but followed an institutional approach instead. We define institutions as: the sectoral entities within which rules and norms for food and nutrition are 125 Chapter 5 set in Ethiopia and which have been involved in food and nutrition policymaking since the the policy documents. A code for ‘food availability’, for instance, was added for policy first National Nutrition Strategy in 2008.55, 57-59 This included ministries and related actions that were not specific to food retail or provision but were more generally about institutions that committed themselves to nutrition-specific and nutrition-sensitive availability. For the analysis, coded data were collated by codes and emerging sub-themes policymaking (Ministries of Agriculture; Finance and Economic Development; Labour and that were either linked to the Food-EPI good practice indicators or to additional themes Social Affairs; Transport; Urban Development and Construction; Water, Irrigation and linked to the food environment domain.60 For instance, for data on food composition, Energy; Women’s, Children and Youth Affairs; Youth and Sport; Education; Health; Trade information related to the Food-EPI good practice indicator ‘food composition and Industry; Food Beverage and Pharmaceutical Industry Development Institute; Disaster standards/targets for processed foods’ was collated, as well as data related to food Risk Management Commission; Food and Drug Administration; Standards Agency). fortification. Data were also collated by year of publication to identify potential changes in policy actions and goal setting over time. Data coding and analysis was conducted by the We first searched the websites of these ministries and institutions for policy outputs. first author (UT), who sought advice from co-authors in cases of doubt to align the approach Subsequently, representatives of 16 ministries or governmental institutions were contacted for coding or analysis. in early 2020 and invited to discuss policy action around food environments. Eight (of 16) key stakeholders agreed to meet and share additional policy documents. IFPRI-Ethiopia also We then defined the proposed policy actions in comparison with global indicators of good provided policy documents that were collected as part of one of their projects; additionally, practice, which have been developed for the Food-EPI tool globally but also adapted to the the websites of UN agencies, such as the World Health Organization Global Database on LMIC context.28, 61 With regards to food safety, no global indicator of good practice exists.62 the Implementation of Nutrition Action (GINA) and the Nutrition Policy Landscape We therefore used the one from the Food-EPI study in Ghana, defined under food retail as Information System (NLiS), the Food and Agriculture Organization Food and Agriculture ‘robust food hygiene policies’.28 All data relevant to a domain were coded and analysed for Policy Decision Analysis and the United Nations Children’s Fund (UNICEF), were searched the results section, since the global indicators only address selected policy actions. We also to identify policy documents on food environments (Fig. 5.2). conducted a historical analysis for which we sorted the coded data by year to identify potential changes and patterns in how food environment domains have been addressed Inclusion criteria for policy documents over the period 2008–2020. This search resulted in a total of 127 documents, which were then screened based on RESULTS eligibility criteria. Policy documents were selected based on their goals, which had to be related to any food environment domain, or outcomes on diets or nutritional status, as This section describes how Ethiopian policy outputs addressed the food environment over defined by our framework (Fig. 5.1). Policy outputs had to be published between 2008 and the period 2008–2020, in terms of the individual domains as defined in our framework and 2020, since Ethiopia’s first National Nutrition Strategy was adopted in 2008. Inclusion of how policy goals addressing food environments and potential outcomes were defined in documents was restricted to national-level policies published in English or in Amharic, one the documents. of the official languages and lingua franca in Ethiopia. Documents had to be available as soft (digital) or hard copy. If documents were published only in Amharic, they were Of the 127 policy documents identified, 89 were excluded for the following reasons: they reviewed by an Amharic-speaking team member (T.G.) and partially translated. Evidence were published before 2008 (n = 7); they were neither available as soft (digital) nor hard collected for this study comprised governmental intentions to act; we did not capture copy (n = 7); they had no policy goal or action addressing any domain of the food government funding for actions that were already implemented.53 environment (n = 71); or they did not include a policy output (n = 4) (Fig. 5.2). The screening process described above resulted in 38 included documents (Table 5.1). Most policy outputs Data extraction and analysis were issued by the Ethiopian Food and Drug Administration (EFDA) (n = 11 out of 38), followed by multisectoral outputs issued by the federal government (n = 9 out of 38) and Data extraction included information related to type and title of document, year of the Ministry of Health (n = 6 out of 38). Almost half of the policy documents were published publication, timeline and main institutions. All selected documents were then imported into in 2016 or 2017 (n = 16 out of 38) (Table 5.1). Nvivo (Version 12.6.0) to conduct a content analysis. The framework developed for our study (Fig. 5.1) was operationalized into a codebook (Appendix 5.1), including codes for the food environment domains (food composition and processing, labelling, promotion, provision, retail, prices, trade and investment, food safety) and for the different outcomes influenced by the food environment: dietary quantity, quality, diversity and safety, and different types of malnutrition (overweight or obesity, underweight, wasting, stunting or micronutrient deficiencies). Policy documents were uploaded in Nvivo and coded using the codebook. These a priori codes were complemented with additional codes revealed from 126 Policy review set in Ethiopia and which have been involved in food and nutrition policymaking since the the policy documents. A code for ‘food availability’, for instance, was added for policy first National Nutrition Strategy in 2008.55, 57-59 This included ministries and related actions that were not specific to food retail or provision but were more generally about institutions that committed themselves to nutrition-specific and nutrition-sensitive availability. For the analysis, coded data were collated by codes and emerging sub-themes policymaking (Ministries of Agriculture; Finance and Economic Development; Labour and that were either linked to the Food-EPI good practice indicators or to additional themes Social Affairs; Transport; Urban Development and Construction; Water, Irrigation and linked to the food environment domain.60 For instance, for data on food composition, Energy; Women’s, Children and Youth Affairs; Youth and Sport; Education; Health; Trade information related to the Food-EPI good practice indicator ‘food composition and Industry; Food Beverage and Pharmaceutical Industry Development Institute; Disaster standards/targets for processed foods’ was collated, as well as data related to food Risk Management Commission; Food and Drug Administration; Standards Agency). fortification. Data were also collated by year of publication to identify potential changes in policy actions and goal setting over time. Data coding and analysis was conducted by the We first searched the websites of these ministries and institutions for policy outputs. first author (UT), who sought advice from co-authors in cases of doubt to align the approach Subsequently, representatives of 16 ministries or governmental institutions were contacted for coding or analysis. in early 2020 and invited to discuss policy action around food environments. Eight (of 16) key stakeholders agreed to meet and share additional policy documents. IFPRI-Ethiopia also We then defined the proposed policy actions in comparison with global indicators of good provided policy documents that were collected as part of one of their projects; additionally, practice, which have been developed for the Food-EPI tool globally but also adapted to the the websites of UN agencies, such as the World Health Organization Global Database on LMIC context.28, 61 With regards to food safety, no global indicator of good practice exists.62 the Implementation of Nutrition Action (GINA) and the Nutrition Policy Landscape We therefore used the one from the Food-EPI study in Ghana, defined under food retail as Information System (NLiS), the Food and Agriculture Organization Food and Agriculture ‘robust food hygiene policies’.28 All data relevant to a domain were coded and analysed for Policy Decision Analysis and the United Nations Children’s Fund (UNICEF), were searched the results section, since the global indicators only address selected policy actions. We also to identify policy documents on food environments (Fig. 5.2). conducted a historical analysis for which we sorted the coded data by year to identify potential changes and patterns in how food environment domains have been addressed Inclusion criteria for policy documents over the period 2008–2020. 5 This search resulted in a total of 127 documents, which were then screened based on RESULTS eligibility criteria. Policy documents were selected based on their goals, which had to be related to any food environment domain, or outcomes on diets or nutritional status, as This section describes how Ethiopian policy outputs addressed the food environment over defined by our framework (Fig. 5.1). Policy outputs had to be published between 2008 and the period 2008–2020, in terms of the individual domains as defined in our framework and 2020, since Ethiopia’s first National Nutrition Strategy was adopted in 2008. Inclusion of how policy goals addressing food environments and potential outcomes were defined in documents was restricted to national-level policies published in English or in Amharic, one the documents. of the official languages and lingua franca in Ethiopia. Documents had to be available as soft (digital) or hard copy. If documents were published only in Amharic, they were Of the 127 policy documents identified, 89 were excluded for the following reasons: they reviewed by an Amharic-speaking team member (T.G.) and partially translated. Evidence were published before 2008 (n = 7); they were neither available as soft (digital) nor hard collected for this study comprised governmental intentions to act; we did not capture copy (n = 7); they had no policy goal or action addressing any domain of the food government funding for actions that were already implemented.53 environment (n = 71); or they did not include a policy output (n = 4) (Fig. 5.2). The screening process described above resulted in 38 included documents (Table 5.1). Most policy outputs Data extraction and analysis were issued by the Ethiopian Food and Drug Administration (EFDA) (n = 11 out of 38), followed by multisectoral outputs issued by the federal government (n = 9 out of 38) and Data extraction included information related to type and title of document, year of the Ministry of Health (n = 6 out of 38). Almost half of the policy documents were published publication, timeline and main institutions. All selected documents were then imported into in 2016 or 2017 (n = 16 out of 38) (Table 5.1). Nvivo (Version 12.6.0) to conduct a content analysis. The framework developed for our study (Fig. 5.1) was operationalized into a codebook (Appendix 5.1), including codes for the food environment domains (food composition and processing, labelling, promotion, provision, retail, prices, trade and investment, food safety) and for the different outcomes influenced by the food environment: dietary quantity, quality, diversity and safety, and different types of malnutrition (overweight or obesity, underweight, wasting, stunting or micronutrient deficiencies). Policy documents were uploaded in Nvivo and coded using the codebook. These a priori codes were complemented with additional codes revealed from 127 Chapter 5 Table 5.1. Overview of the 38 policy documents included Category Number of policy documents Type of document Legal documents 14 Strategies 7 Action plans 6 Programme documents 6 Guidelines 4 Policy 1 Institutions leading the policy document Food and Drug Administration 11 Federal Democratic Republic of Ethiopia 9 Ministry of Health 6 Ministry of Education 5 Ministry of Agriculture 3 Ministry of Finance and Economic Development 1 Ministry of Labour and Social Affairs 1 Ministry of Trade and Industry 1 National Planning Commission 1 Year of publication 2008 2 2009 1 2010 1 2012 2 2013 3 2014 4 2015 3 2016 8 2017 8 2018 3 2019 2 2020 1 Historical analysis of policies addressing food environments Figure 5.2. Overview of policy document collection Over the period 2008–2020, policy outputs for food and nutrition have not only increased in number but also in terms of content and explicit intentionality.56 The different domains of the food environment have also been increasingly addressed over the last 12 years (Fig. 5.3). Policy goals have broadened from a focus on undernutrition, mostly in children <5 years old and women of reproductive age, to recognition of the double burden of malnutrition across the lifecycle. Our historical analysis over more than a decade (2008–2020) revealed three major phases (Table 5.2): the ‘starting out phase’, the ‘nutrition-sensitive phase’ and the ‘food systems phase’. During the first phase between 2008 and 2012, nutrition was put on the agenda 128 Policy review Table 5.1. Overview of the 38 policy documents included Category Number of policy documents Type of document Legal documents 14 Strategies 7 Action plans 6 Programme documents 6 Guidelines 4 Policy 1 Institutions leading the policy document Food and Drug Administration 11 Federal Democratic Republic of Ethiopia 9 Ministry of Health 6 Ministry of Education 5 Ministry of Agriculture 3 Ministry of Finance and Economic Development 1 Ministry of Labour and Social Affairs 1 Ministry of Trade and Industry 1 National Planning Commission 1 Year of publication 5 2008 2 2009 1 2010 1 2012 2 2013 3 2014 4 2015 3 2016 8 2017 8 2018 3 2019 2 2020 1 Historical analysis of policies addressing food environments Figure 5.2. Overview of policy document collection Over the period 2008–2020, policy outputs for food and nutrition have not only increased in number but also in terms of content and explicit intentionality.56 The different domains of the food environment have also been increasingly addressed over the last 12 years (Fig. 5.3). Policy goals have broadened from a focus on undernutrition, mostly in children <5 years old and women of reproductive age, to recognition of the double burden of malnutrition across the lifecycle. Our historical analysis over more than a decade (2008–2020) revealed three major phases (Table 5.2): the ‘starting out phase’, the ‘nutrition-sensitive phase’ and the ‘food systems phase’. During the first phase between 2008 and 2012, nutrition was put on the agenda 129 Chapter 5 with the first National Nutrition Programme (NNP I) calling for multisectoral and nutrition- sensitive approaches, which resulted in the School Health and Nutrition Strategy in 2012.63 The focus of food processing in this phase was mostly on agro-processing, for instance of sugar, with the objective to increase economic growth rather than public health nutrition.64 Policy actions related to food labelling and promotion targeted infant formula and breastmilk substitutes. While taxes on soft drinks were already in place then, it was unclear if this was motivated by public health objectives. Food provision policy action solely focused on schools. The efforts of the first phase intensified in the second phase, which we defined as the ‘nutrition-sensitive phase’ between 2015 and 2017, with nutrition-sensitive programmes applying multi-sectoral approaches in agriculture,65, 66 social protection,67 education,68 and water supply69 and a reinforced food fortification initiative to reduce micronutrient deficiencies.59 With the NNP II, this phase was also marked by a broadened focus on the nutrition of different population groups along the lifecycle and a recognition that factors in the physical food environment influence diet. This led to the first calls for regulatory actions in the food environment from the NNP II.59 Figure 5.3. Number of policy documents addressing food environment domains between The ‘food systems phase’ from 2018 is defined by a more systemic approach towards 2008 and 2020. nutrition, consolidating the nutrition-sensitive efforts into a comprehensive food and nutrition policy.70 Furthermore, the proposals to improve the food environment in the NNP II59 had been articulated more clearly in the National Strategic Action Plan (NSAP) for the Prevention and Control of Non-Communicable Diseases (NCDs).71 Reformulating foods high in saturated fats, sugar and salt was identified as a policy action to achieve the consumption of healthy foods and a reduction in overweight and obesity. At the same time, a more comprehensive excise tax on foods high in saturated fats, sugar and salt was introduced. Despite the achievements in food environment policy actions, the proposal for a policy of food sold in or around schools in the School Health and Nutrition Strategy in 201263 has not yet been taken forward in subsequent policy action, and other gaps compared to global indicators of good practice remained. While food safety has been the most constant and dominant component throughout the whole decade, in this third phase both the Food and Nutrition Policy (FNP) and the second Growth and Transformation Plan (GTP II) proposed a system-wide approach to food safety, including all actors along the entire food chain.70, 72 130 Policy review with the first National Nutrition Programme (NNP I) calling for multisectoral and nutrition- sensitive approaches, which resulted in the School Health and Nutrition Strategy in 2012.63 The focus of food processing in this phase was mostly on agro-processing, for instance of sugar, with the objective to increase economic growth rather than public health nutrition.64 Policy actions related to food labelling and promotion targeted infant formula and breastmilk substitutes. While taxes on soft drinks were already in place then, it was unclear if this was motivated by public health objectives. Food provision policy action solely focused on schools. The efforts of the first phase intensified in the second phase, which we defined as the ‘nutrition-sensitive phase’ between 2015 and 2017, with nutrition-sensitive programmes applying multi-sectoral approaches in agriculture,65, 66 social protection,67 education,68 and water supply69 and a reinforced food fortification initiative to reduce micronutrient deficiencies.59 With the NNP II, this phase was also marked by a broadened focus on the nutrition of different population groups along the lifecycle and a recognition that factors in the physical food environment influence diet. This led to the first calls for regulatory actions in the food environment from the NNP II.59 Figure 5.3. Number of policy documents addressing food environment domains between The ‘food systems phase’ from 2018 is defined by a more systemic approach towards 2008 and 2020. nutrition, consolidating the nutrition-sensitive efforts into a comprehensive food and nutrition policy.70 Furthermore, the proposals to improve the food environment in the NNP 5 II59 had been articulated more clearly in the National Strategic Action Plan (NSAP) for the Prevention and Control of Non-Communicable Diseases (NCDs).71 Reformulating foods high in saturated fats, sugar and salt was identified as a policy action to achieve the consumption of healthy foods and a reduction in overweight and obesity. At the same time, a more comprehensive excise tax on foods high in saturated fats, sugar and salt was introduced. Despite the achievements in food environment policy actions, the proposal for a policy of food sold in or around schools in the School Health and Nutrition Strategy in 201263 has not yet been taken forward in subsequent policy action, and other gaps compared to global indicators of good practice remained. While food safety has been the most constant and dominant component throughout the whole decade, in this third phase both the Food and Nutrition Policy (FNP) and the second Growth and Transformation Plan (GTP II) proposed a system-wide approach to food safety, including all actors along the entire food chain.70, 72 131 Chapter 5 132 Table 5.2. Historical overview of food environment-related national policy documents in Ethiopia Phases Year Policy documents Food environment domains and goals related to nutritional and dietary outcomes ‘Starting out 2008 1. Excise Tax (Amendment) Proclamation Overall food environment interventions: phase’: No. 570/2008 Policy outputs include explicit food environment goals and actions. putting 2. National Nutrition Strategy Nutrition-sensitive interventions for food industry and trade only related to nutrition on 2009 1. Food and Medicine Administration fortification and food safety. the policy Proclamation No. 661/2009 Schools are recognized as platforms for healthy eating promotion but focus on hunger agenda 2010 1. Growth and Transformation Plan I and micronutrient deficiencies. 2012 1. National School Health and Nutrition Physical environment mentioned as crucial but only for physical activity promotion Strategy and NCD prevention, not specific to food. 2. Regulation Investment Incentives No. 270/2012 Individual food environment domains: 2013 1. Infant formula, follow-up formula and Food composition and processing: agro-processing focus on sugar production. formulas for special nutritional purpose Food labelling: infant formula labelling should not discourage breastfeeding. directive Food promotion: unsafe promotion and use of breastmilk substitutes is prohibited. 2. National Nutrition Programme I Food provision: interventions for nutrition services, education and food provision, but 3. ONE WASH National Program also mention of regulating food safety in and around schools. Document Food prices: 30% excise tax on soft drinks introduced, 20% on bottled water, but not clear if motivated by public health objective. Food safety: any imported, packaged, processed, fortified food or nutritional supplements should comply with international and national safety standards; ensure equitable access to safe and affordable water for all. Goals related to nutritional and dietary outcomes: related to nutritional status (underweight/wasting/stunting) of children and women of reproductive age, multisectoral and lifecycle approach, stunting and food fortification new objectives. Who is targeted by policy action: children (mainly under-fives, but schoolchildren too) and women of reproductive age. Main paradigm: multisectoral and lifecycle approach; food fortification introduced. Phases Year Policy documents Food environment domains and goals related to nutritional and dietary outcomes ‘Nutrition- 2014 1. Food Exporters, Importers and Overall food environment interventions: sensitive Wholesalers Directive First mention of unhealthy school food environment potentially contributing to phase’: 2. Regulation for Food, Medicine and unhealthy choices. General call for regulatory interventions in the food environment nutrition- Health Care Administration and Control for NCD prevention and in the school environment (for physical activity only) to sensitive No. 299 prevent childhood obesity; involvement of industry and trade sector limited to food approaches 3. Agriculture Growth Program II fortification and food safety measures. reaching out 4. Homegrown School Feeding Program into different 2015 1. Food Advertising Directive Individual food environment domains: sector 2. Health Sector Transformation Plan 3. Productive Safety Net Programme IV Food composition and processing: food fortification initiative reinforced by creating 2016 1. Food Supplement Directive awareness of food industry related to micronutrient deficiencies, promoting fortified 2. National Nutrition Programme II food and ensuring safety of fortified food. Food promoted for agro-processing is 3. Seqota Declaration Implementation expanded to meat, milk and honey, while previously sugar was singled out for agro- Plan processing. 4.National Nutrition-Sensitive Agriculture Food promotion: focus on nutritious infant food, but also on protection of children in Strategy general, and restricting marketing of foods high in sugar, salt or fat to children. 5. National Hygiene and Environmental Food provision: school food provision through school meals introduced to create a Health Strategy ‘conducive environment’; promote healthy school environment and school feeding to 6. National Guideline on Adolescent, ‘provide students with energy to participate in school activities, have protein content’ Maternal Infant and Young Child to prevent undernutrition; safe food preparation and water supply; create market Nutrition linkages/collaborate with local farmers and food industry for fortified food 7. National Social Protection Strategy production. Social protection programmes to improve food security with cash or food 8. Growth and Transformation Plan II transfers for most vulnerable households. 2017 1. Cereal and Cereal Product Food prices: sugar price stabilization introduced. Manufacturers Internal Quality Control Food safety: safety of different food products that are imported, exported and Establishment Directive distributed; also addressing adulteration and vitamin or mineral supplements; 2. Edible Oil Good Manufacturing mention of food system in terms of food safety risks along the food chain; making Practices school environment healthy, safe and sanitary; safe water for consumption and food 3. Food Manufacturing Factories Pre- safety in manufacturing but also for food service providers and vendors. Licensing Directive 4. Emergency School Feeding Program Implementation Guideline Policy review 5 133 Table 5.2. Historical overview of food environment-related national policy documents in Ethiopia Phases Year Policy documents Food environment domains and goals related to nutritional and dietary outcomes ‘Starting out 2008 1. Excise Tax (Amendment) Proclamation Overall food environment interventions: phase’: No. 570/2008 Policy outputs include explicit food environment goals and actions. putting 2. National Nutrition Strategy Nutrition-sensitive interventions for food industry and trade only related to nutrition on 2009 1. Food and Medicine Administration fortification and food safety. the policy Proclamation No. 661/2009 Schools are recognized as platforms for healthy eating promotion but focus on hunger agenda 2010 1. Growth and Transformation Plan I and micronutrient deficiencies. 2012 1. National School Health and Nutrition Physical environment mentioned as crucial but only for physical activity promotion Strategy and NCD prevention, not specific to food. 2. Regulation Investment Incentives No. 270/2012 Individual food environment domains: 2013 1. Infant formula, follow-up formula and Food composition and processing: agro-processing focus on sugar production. formulas for special nutritional purpose Food labelling: infant formula labelling should not discourage breastfeeding. directive Food promotion: unsafe promotion and use of breastmilk substitutes is prohibited. 2. National Nutrition Programme I Food provision: interventions for nutrition services, education and food provision, but 3. ONE WASH National Program also mention of regulating food safety in and around schools. Document Food prices: 30% excise tax on soft drinks introduced, 20% on bottled water, but not clear if motivated by public health objective. Food safety: any imported, packaged, processed, fortified food or nutritional supplements should comply with international and national safety standards; ensure equitable access to safe and affordable water for all. Goals related to nutritional and dietary outcomes: related to nutritional status (underweight/wasting/stunting) of children and women of reproductive age, multisectoral and lifecycle approach, stunting and food fortification new objectives. Who is targeted by policy action: children (mainly under-fives, but schoolchildren too) and women of reproductive age. Main paradigm: multisectoral and lifecycle approach; food fortification introduced. Phases Year Policy documents Food environment domains and goals related to nutritional and dietary outcomes ‘Nutrition- 2014 1. Food Exporters, Importers and Overall food environment interventions: sensitive Wholesalers Directive First mention of unhealthy school food environment potentially contributing to phase’: 2. Regulation for Food, Medicine and unhealthy choices. General call for regulatory interventions in the food environment nutrition- Health Care Administration and Control for NCD prevention and in the school environment (for physical activity only) to sensitive No. 299 prevent childhood obesity; involvement of industry and trade sector limited to food approaches 3. Agriculture Growth Program II fortification and food safety measures. reaching out 4. Homegrown School Feeding Program into different 2015 1. Food Advertising Directive Individual food environment domains: sector 2. Health Sector Transformation Plan 3. Productive Safety Net Programme IV Food composition and processing: food fortification initiative reinforced by creating 2016 1. Food Supplement Directive awareness of food industry related to micronutrient deficiencies, promoting fortified 2. National Nutrition Programme II food and ensuring safety of fortified food. Food promoted for agro-processing is 3. Seqota Declaration Implementation expanded to meat, milk and honey, while previously sugar was singled out for agro- Plan processing. 4.National Nutrition-Sensitive Agriculture Food promotion: focus on nutritious infant food, but also on protection of children in Strategy general, and restricting marketing of foods high in sugar, salt or fat to children. 5. National Hygiene and Environmental Food provision: school food provision through school meals introduced to create a Health Strategy ‘conducive environment’; promote healthy school environment and school feeding to 6. National Guideline on Adolescent, ‘provide students with energy to participate in school activities, have protein content’ Maternal Infant and Young Child to prevent undernutrition; safe food preparation and water supply; create market Nutrition linkages/collaborate with local farmers and food industry for fortified food 7. National Social Protection Strategy production. Social protection programmes to improve food security with cash or food 8. Growth and Transformation Plan II transfers for most vulnerable households. 2017 1. Cereal and Cereal Product Food prices: sugar price stabilization introduced. Manufacturers Internal Quality Control Food safety: safety of different food products that are imported, exported and Establishment Directive distributed; also addressing adulteration and vitamin or mineral supplements; 2. Edible Oil Good Manufacturing mention of food system in terms of food safety risks along the food chain; making Practices school environment healthy, safe and sanitary; safe water for consumption and food 3. Food Manufacturing Factories Pre- safety in manufacturing but also for food service providers and vendors. Licensing Directive 4. Emergency School Feeding Program Implementation Guideline Chapter 5 Proposed policy goals and actions addressing the food environment overall While individual domains were addressed through specific policy actions (Table 5.3), policy documents also referred to the food environment more generally. Market access, availability and accessibility of food were mentioned as important areas of intervention for healthy diets.70, 73 The most recent agriculture policies promoted the production of diverse crops for consumption, while also trying to ensure diversity available at market and household level.65, 66 The National Guideline for Adolescent, Maternal, Infant and Young Child Nutrition (AMIYCN) stated that ‘availability and access in urban and semi urban areas to fast food outlets, school truck-shops, food stores and vendors in the vicinity may play a role in adolescents’ decision-making’.74 Only the NSAP for the Prevention and Control of NCDs formulated specific goals to ‘create a supportive, health-promoting environment’.71 The FNP defined goals of improving multiple domains of the food environment with regard to availability, accessibility and safety of food.70 Increasing year-round availability of nutrient- dense foods was also the aim of agricultural policy outputs.65,66,73 Goals related to the school food environment included improving access and educational achievement through health and nutrition interventions, such as school feeding and child-friendly, safe, hygienic and healthy school environments.59,63,73,75,76 134 Phases Year Policy documents Food environment domains and goals related to nutritional and dietary outcomes 5. National School Feeding Strategy Goals related to nutritional and dietary outcomes: stunting, wasting and 6. School Water, Sanitation and Hygiene underweight; improve household dietary diversity. First reference to all forms of Strategy and Implementation Action Plan malnutrition. 7. School Health Program Who is targeted by policy action: children (infants/schoolchildren) and women of 8. National Food Fortification Program reproductive age; general population in fortification/food safety actions. Plan of Action Main paradigm: First reference to all forms of malnutrition. ‘Food systems 2018 1. Milk Product Factory Internal Quality Overall food environment interventions: phase’: food Management System Guideline Food environment mentioned in terms of safety of food provided through food environment 2. Baby Food Control Directive outlets and vendors. More systems-oriented thinking for food safety along the value and nutrition 3. Food and Nutrition Policy chain. outcomes 2019 1. Food and Medicine Administration The built environment was addressed but only with regard to physical activity. addressed in Proclamation No. 1112/2019 Proposals for food processing, prices and front-of pack labelling. More specific calls wider food 2. National Strategic Action Plan for the for reformulation compared to previous more generic proposals. system Prevention and Control of Non- Communicable Diseases Individual food environment domains: 2020 1. Excise Tax Proclamation No. 1186/2020 Food composition and processing: reformulation of foods containing saturated fats or salt. Food promotion and labelling: advertising and labelling of breastmilk substitutes, other infant food and fortified food; proposals for front-of pack labelling. Food prices: up to 60% excise tax introduced on foods and beverages high in saturated and trans-fats, sugar and sodium. Food safety: safety, availability and affordability of healthy, sustainable food; systematic approach towards food safety along the value chain. Goals related to nutritional and dietary outcomes: in addition to stunting, wasting and underweight goals, first dietary goal related to unhealthy (in nutrition terms) foods and first goal regarding overweight. Who is targeted by policy action: general population at ‘all stages of life’ and, for NCD prevention, adults above 15 years. Main paradigm: food systems approach; more explicit goals addressing the double burden of malnutrition. Policy review Proposed policy goals and actions addressing the food environment overall While individual domains were addressed through specific policy actions (Table 5.3), policy documents also referred to the food environment more generally. Market access, availability and accessibility of food were mentioned as important areas of intervention for healthy diets.70, 73 The most recent agriculture policies promoted the production of diverse crops for consumption, while also trying to ensure diversity available at market and household level.65, 66 The National Guideline for Adolescent, Maternal, Infant and Young Child Nutrition (AMIYCN) stated that ‘availability and access in urban and semi urban areas to fast food outlets, school truck-shops, food stores and vendors in the vicinity may play a role in adolescents’ decision-making’.74 Only the NSAP for the Prevention and Control of NCDs formulated specific goals to ‘create a supportive, health-promoting environment’.71 The FNP defined goals of improving multiple domains of the food environment with regard to availability, accessibility and safety of food.70 Increasing year-round availability of nutrient- dense foods was also the aim of agricultural policy outputs.65,66,73 Goals related to the school food environment included improving access and educational 5 achievement through health and nutrition interventions, such as school feeding and child-friendly, safe, hygienic and healthy school environments.59,63,73,75,76 135 Phases Year Policy documents Food environment domains and goals related to nutritional and dietary outcomes 5. National School Feeding Strategy Goals related to nutritional and dietary outcomes: stunting, wasting and 6. School Water, Sanitation and Hygiene underweight; improve household dietary diversity. First reference to all forms of Strategy and Implementation Action Plan malnutrition. 7. School Health Program Who is targeted by policy action: children (infants/schoolchildren) and women of 8. National Food Fortification Program reproductive age; general population in fortification/food safety actions. Plan of Action Main paradigm: First reference to all forms of malnutrition. ‘Food systems 2018 1. Milk Product Factory Internal Quality Overall food environment interventions: phase’: food Management System Guideline Food environment mentioned in terms of safety of food provided through food environment 2. Baby Food Control Directive outlets and vendors. More systems-oriented thinking for food safety along the value and nutrition 3. Food and Nutrition Policy chain. outcomes 2019 1. Food and Medicine Administration The built environment was addressed but only with regard to physical activity. addressed in Proclamation No. 1112/2019 Proposals for food processing, prices and front-of pack labelling. More specific calls wider food 2. National Strategic Action Plan for the for reformulation compared to previous more generic proposals. system Prevention and Control of Non- Communicable Diseases Individual food environment domains: 2020 1. Excise Tax Proclamation No. 1186/2020 Food composition and processing: reformulation of foods containing saturated fats or salt. Food promotion and labelling: advertising and labelling of breastmilk substitutes, other infant food and fortified food; proposals for front-of pack labelling. Food prices: up to 60% excise tax introduced on foods and beverages high in saturated and trans-fats, sugar and sodium. Food safety: safety, availability and affordability of healthy, sustainable food; systematic approach towards food safety along the value chain. Goals related to nutritional and dietary outcomes: in addition to stunting, wasting and underweight goals, first dietary goal related to unhealthy (in nutrition terms) foods and first goal regarding overweight. Who is targeted by policy action: general population at ‘all stages of life’ and, for NCD prevention, adults above 15 years. Main paradigm: food systems approach; more explicit goals addressing the double burden of malnutrition. Chapter 5 Table 5.3. Food environment domains in Ethiopian policy documents against Food Good practice indicators Status in Ethiopian policies global indicators of good practice* environment domain (no. of Food Good practice indicators Status in Ethiopian policies policies) environment Restrict promotion of Limited evidence on proposed domain (no. of unhealthy food in settings measures to regulate advertising at policies) where children, including schools on food linked with Food Food composition Standards or targets are set for adolescents, gather (e.g. obesity.86 composition standards/targets set for several (mostly unprocessed) food preschools, schools, sport and and processing content of the nutrients of items, not with the aim of cultural events). (n = 21) concern (trans-fats, added minimizing the nutrients of Restrict marketing of Some provisions of the sugars, salt, saturated fat) in concern but to replace trans-fat breastmilk substitutes. International Code of Marketing of industrially processed foods. and saturated fats with mono and Breastmilk Substitutes being polyunsaturated fats and to reduce adopted.80,82,87 salt.71 Food prices Reduce taxes on healthy foods No evidence on policy action Food composition No evidence on policy action (n = 11) (e.g. low or no sales tax, excise, found. standards/targets set for the found. value-added or import duties content of the nutrients of on fruit and vegetables). concern (trans-fats, added Increase taxes on unhealthy In 2009, excise tax on all types of sugars, salt, saturated fat) in foods (e.g. sugar-sweetened soft drinks, water and other out-of-home meals from food beverages, foods high in beverages; in 2020, tax on service outlets. nutrients of concern). beverages and foods high in salt, Food labelling Ingredient list/nutrient Packaged food is required to sugar, trans-fats and saturated (n = 13) declarations of all packaged include an ingredient list.77-81 fats.88 foods. Existing food subsidies favour No evidence for subsidies Regulations in place for health Nutrition and health claims should healthy foods. favouring healthy foods.72 and nutrition claims to protect comply with FAO Codex Nutrition Food related income support is Food-related support through food consumers against and Health Claims.82-84 for healthy foods vouchers or cash transfers to food- unsubstantiated and insecure households.67,89 misleading nutrition and health Food provision Policies in schools/early Only proposed in terms of a claims. (n = 10) education services for food national standard for food Front-of-pack labelling system Front-of-pack labelling of salt and service activities (canteens, procurement and food handlers in (examples are Nutri-score or sugar content of food at events, fundraising, and around school for food safety traffic lights). packaged/processed foods and promotions, vending machines, control.63,68 drinks only proposed.85 etc.) to provide and promote Menu board labelling system. No evidence on policy action healthy food choices. found. Policies in public setting for No evidence on policy action Food Restrict promotion of Not allowed to advertise any food food service activities found. promotion (n = unhealthy food to children, that has high level of sugar, salt (canteens, food at events, 11) including adolescents in and fat on children’s programme fundraising, promotions, broadcast media (TV, radio). using known personalities.82 vending machines, etc.) to Restrict promotion of No evidence on policy action provide and promote healthy unhealthy food to children, found. food choices. including adolescents in non- Support and training systems As part of school feeding, standard broadcast media (online or to help schools and other training for all actors on food social media). public sector organizations and processing, safety, handling and their caterers meet healthy preparation.68 136 Policy review Table 5.3. Food environment domains in Ethiopian policy documents against Food Good practice indicators Status in Ethiopian policies global indicators of good practice* environment domain (no. of Food Good practice indicators Status in Ethiopian policies policies) environment Restrict promotion of Limited evidence on proposed domain (no. of unhealthy food in settings measures to regulate advertising at policies) where children, including schools on food linked with 86 Food Food composition Standards or targets are set for adolescents, gather (e.g. obesity. composition standards/targets set for several (mostly unprocessed) food preschools, schools, sport and and processing content of the nutrients of items, not with the aim of cultural events). (n = 21) concern (trans-fats, added minimizing the nutrients of Restrict marketing of Some provisions of the sugars, salt, saturated fat) in concern but to replace trans-fat breastmilk substitutes. International Code of Marketing of industrially processed foods. and saturated fats with mono and Breastmilk Substitutes being polyunsaturated fats and to reduce adopted.80,82,87 salt.71 Food prices Reduce taxes on healthy foods No evidence on policy action Food composition No evidence on policy action (n = 11) (e.g. low or no sales tax, excise, found. standards/targets set for the found. value-added or import duties content of the nutrients of on fruit and vegetables). concern (trans-fats, added Increase taxes on unhealthy In 2009, excise tax on all types of sugars, salt, saturated fat) in foods (e.g. sugar-sweetened soft drinks, water and other out-of-home meals from food beverages, foods high in beverages; in 2020, tax on 5 service outlets. nutrients of concern). beverages and foods high in salt, Food labelling Ingredient list/nutrient Packaged food is required to sugar, trans-fats and saturated (n = 13) declarations of all packaged include an ingredient list.77-81 fats.88 foods. Existing food subsidies favour No evidence for subsidies Regulations in place for health Nutrition and health claims should healthy foods. favouring healthy foods.72 and nutrition claims to protect comply with FAO Codex Nutrition Food related income support is Food-related support through food consumers against and Health Claims.82-84 for healthy foods vouchers or cash transfers to food- unsubstantiated and insecure households.67,89 misleading nutrition and health Food provision Policies in schools/early Only proposed in terms of a claims. (n = 10) education services for food national standard for food Front-of-pack labelling system Front-of-pack labelling of salt and service activities (canteens, procurement and food handlers in (examples are Nutri-score or sugar content of food at events, fundraising, and around school for food safety traffic lights). packaged/processed foods and promotions, vending machines, control.63,68 drinks only proposed.85 etc.) to provide and promote Menu board labelling system. No evidence on policy action healthy food choices. found. Policies in public setting for No evidence on policy action Food Restrict promotion of Not allowed to advertise any food food service activities found. promotion (n = unhealthy food to children, that has high level of sugar, salt (canteens, food at events, 11) including adolescents in and fat on children’s programme fundraising, promotions, broadcast media (TV, radio). using known personalities.82 vending machines, etc.) to Restrict promotion of No evidence on policy action provide and promote healthy unhealthy food to children, found. food choices. including adolescents in non- Support and training systems As part of school feeding, standard broadcast media (online or to help schools and other training for all actors on food social media). public sector organizations and processing, safety, handling and their caterers meet healthy preparation.68 137 Chapter 5 Food Good practice indicators Status in Ethiopian policies the NSAP for the Prevention and Control of NCDs proposed actions with regard to environment reformulating nutrients of concern.59,71 domain (no. of We identified policy action relating to processing that went beyond the Food-EPI policies) good practice indicators, such as agro-processing and food fortification. While policy food service policies and documents focused on agro-processing of nutrient-dense foods such as meat and guidelines. Food retail Zoning laws on the No evidence on policy action, but milk, they also included honey and sugar, not motivated by objectives related to (n = 7) density/location of mentioned food environment may public health but to economic development, job creation and international 64,72 healthy/unhealthy food service play a role in adolescents’ food trade. The agriculture policy documents that were already sensitive to nutrition outlets. choices.74 tailored the agro-processing actions more towards ‘ensuring consumption of In-store availability of No evidence on policy action nutritious and diverse foods’.65 This was proposed by focusing on nutrient-rich value healthy/unhealthy foods found. chain crops in production and processing, post-harvest handling, value addition and regulated to promote in-store preservation.59,65,65,70 Fortification of edible oil, flour and salt was also an important availability of healthy foods policy action in different policy documents.57-59,70,73 and limit in-store availability of unhealthy foods. Food labelling Food trade and Trade agreement impacts on No evidence on policy action investment population nutrition and health found. (n = 6) assessed. Food labelling is mandatory and regulated by the EFDA. It should include a list of all Protect regulatory capacity No evidence on policy action ingredients for commercially produced or imported foods, ‘declaring in numerical regarding public health found. form the amount of nutrients present in the per portion of the product as nutrition. recommended for daily consumption or amount per unit for single use’.59,81 The food Food safety Food hygiene policies are Food safety policy documents are label should not include any health claims,79 which are particularly regulated for (n = 32) robust enough and are being numerous and robust, but infant formula and ‘may not be described or presented on any label or in any enforced, where needed, by enforcement is limited.77,78,80,87,90 labelling in a manner that is false, misleading or discouraging breastfeeding’.80 For national and local government Regulations on food safety of to protect human health and imported foods are in place78,79 the front-of-pack labelling or menu board labelling system, we found limited consumers’ interests in relation and training in food safety for food evidence in one document proposing front-of pack labelling of salt and sugar to food. vendors in and around schools, content of processed foods and drinks without specifying its proposed format.71 hotels, restaurants, street vendors and catering.63,70 Food promotion *Adapted from Refs 28 and 61. We found evidence for policy actions restricting the promotion of breastmilk substitutes targeted at infants but limited evidence of marketing restrictions of Proposed policy actions addressing specific food environment domains unhealthy food for children on broadcast media, although not for non-broadcast media or specific settings. The Food Advertising Directive does not allow advertising Food composition and processing of ‘any food which has a high level sugar, salt and fat on children’s programmes using known personalities and other similar ways’,82 but no nutrient profiling For the Food-EPI good practice indicators of setting ‘food composition threshold is provided to determine foods with high levels of sugar, salt or fat. The standards/targets for content of the nutrients of concern (trans-fats, added sugars, NNP II further called for regulations to prevent the exploitation of children, young salt, saturated fat) in industrially processed foods’ or ‘out of home meals from food people and families by advertising unhealthy foods and beverages.59 service outlets’, limited evidence was found in the policy documents. The Ethiopian For the indicator regarding ‘promotion of unhealthy food in settings where children, Standards Agency set standards for several food items, most of them related to including adolescents, gather’, we only found proposals to regulate advertising at unprocessed fruit, vegetables or cereals, but only a few are for processed foods and schools, such as prohibiting promotions on soft drinks, sweets, and foods due to beverages (such as soft drinks, palm oil and sweets) and not with the aim to their impact on obesity.86 reformulate these foods by minimizing the nutrients of concern. Both the NNP II and 138 Policy review Food Good practice indicators Status in Ethiopian policies the NSAP for the Prevention and Control of NCDs proposed actions with regard to environment reformulating nutrients of concern.59,71 domain (no. of We identified policy action relating to processing that went beyond the Food-EPI policies) good practice indicators, such as agro-processing and food fortification. While policy food service policies and documents focused on agro-processing of nutrient-dense foods such as meat and guidelines. Food retail Zoning laws on the No evidence on policy action, but milk, they also included honey and sugar, not motivated by objectives related to (n = 7) density/location of mentioned food environment may public health but to economic development, job creation and international 64,72 healthy/unhealthy food service play a role in adolescents’ food trade. The agriculture policy documents that were already sensitive to nutrition outlets. choices.74 tailored the agro-processing actions more towards ‘ensuring consumption of In-store availability of No evidence on policy action nutritious and diverse foods’.65 This was proposed by focusing on nutrient-rich value healthy/unhealthy foods found. chain crops in production and processing, post-harvest handling, value addition and regulated to promote in-store preservation.59,65,65,70 Fortification of edible oil, flour and salt was also an important availability of healthy foods policy action in different policy documents.57-59,70,73 and limit in-store availability of unhealthy foods. Food labelling Food trade and Trade agreement impacts on No evidence on policy action investment population nutrition and health found. (n = 6) assessed. Food labelling is mandatory and regulated by the EFDA. It should include a list of all Protect regulatory capacity No evidence on policy action ingredients for commercially produced or imported foods, ‘declaring in numerical regarding public health found. form the amount of nutrients present in the per portion of the product as 5 nutrition. recommended for daily consumption or amount per unit for single use’.59,81 The food Food safety Food hygiene policies are Food safety policy documents are label should not include any health claims,79 which are particularly regulated for (n = 32) robust enough and are being numerous and robust, but infant formula and ‘may not be described or presented on any label or in any enforced, where needed, by enforcement is limited.77,78,80,87,90 labelling in a manner that is false, misleading or discouraging breastfeeding’.80 For national and local government Regulations on food safety of to protect human health and imported foods are in place78,79 the front-of-pack labelling or menu board labelling system, we found limited consumers’ interests in relation and training in food safety for food evidence in one document proposing front-of pack labelling of salt and sugar to food. vendors in and around schools, content of processed foods and drinks without specifying its proposed format.71 hotels, restaurants, street vendors and catering.63,70 Food promotion *Adapted from Refs 28 and 61. We found evidence for policy actions restricting the promotion of breastmilk substitutes targeted at infants but limited evidence of marketing restrictions of Proposed policy actions addressing specific food environment domains unhealthy food for children on broadcast media, although not for non-broadcast media or specific settings. The Food Advertising Directive does not allow advertising Food composition and processing of ‘any food which has a high level sugar, salt and fat on children’s programmes using known personalities and other similar ways’,82 but no nutrient profiling For the Food-EPI good practice indicators of setting ‘food composition threshold is provided to determine foods with high levels of sugar, salt or fat. The standards/targets for content of the nutrients of concern (trans-fats, added sugars, NNP II further called for regulations to prevent the exploitation of children, young salt, saturated fat) in industrially processed foods’ or ‘out of home meals from food people and families by advertising unhealthy foods and beverages.59 service outlets’, limited evidence was found in the policy documents. The Ethiopian For the indicator regarding ‘promotion of unhealthy food in settings where children, Standards Agency set standards for several food items, most of them related to including adolescents, gather’, we only found proposals to regulate advertising at unprocessed fruit, vegetables or cereals, but only a few are for processed foods and schools, such as prohibiting promotions on soft drinks, sweets, and foods due to beverages (such as soft drinks, palm oil and sweets) and not with the aim to their impact on obesity.86 reformulate these foods by minimizing the nutrients of concern. Both the NNP II and 139 Chapter 5 Marketing of breastmilk substitutes is restricted because some components of the smallholder farmers,86,92 market linkages or collaborations with the food industry.68 International Code of Marketing of Breastmilk Substitutes have been adopted.80,82,87 Advertising food for infants, such as formula, is prohibited.78,89,82,87 Furthermore, ‘it Food retail is forbidden to give infant food samples or any food description gift, material or similar thing for pregnant women, infant mothers or family members’ or show any We found no evidence on ‘Zoning laws on the density/location of healthy/unhealthy pictures of children or mothers in child food advertisements.82 food service outlets’ or in-store availability of healthy/unhealthy foods. It was recognized that the ‘availability and access to fast food outlets, school tuck-shops, Food prices food stores and vendors in the vicinity may play a role in adolescents’ decision- making’,74 but no action was specified on how to address this. Good practice indicators related to food prices include reduced taxes or subsidies In addition to the Food-EPI indicators, we identified policy action to improve the on healthy food and increased taxes on unhealthy foods. The identified policy availability of safe and healthy foods at markets. The AGP II aimed to build market actions related to food prices appear incoherent with nutrition objectives and across centres, particularly for perishable foods such as fruit and vegetables, animals, milk policy documents. Instead of subsidizing healthy food, the GTP II proposed price and honey collection and processing.66 stabilization interventions for sugar, edible oil and wheat to low-income households.72 The NSAP for the Prevention and Control of NCDs was the first Food trade and investment document proposing increased taxes for SSB.71 Excise tax on SSB was already in place in 2002 but was reduced from 40% to 30% between 2002 and 2009.91 In 2020, this We found no evidence for the good practice indicator that ‘trade agreement impacts tax was expanded to foods and beverages high in salt, sugar, trans-fats and on population nutrition and health should be assessed’. The GTP II aimed to saturated fats.88 Edible animal or vegetable fats/oils with ≥ 40 g/100 g of saturated undertake negotiations with the World Trade Organization, while strengthening fat, or > 0.5 g/100 g of trans-fat, are taxed at a rate of 30–50%.88 existing regional partnerships within East Africa,64,72 but the impact of trade Food related income support is provided by the fourth Productive Safety Net agreements on population nutrition was not addressed. Programme (PSNP IV), through conditional cash transfers or direct support in terms of cash or food to vulnerable households and individuals,67 but this support is not Food safety specific to healthy foods. The good practice indicator for food safety refers to the robustness of food safety Food provision and hygiene policies. We identified strong policy action on food safety (including hygiene) in numerous documents, which also highlighted the limited enforcement We identified some policy actions in schools for food service activities, but only in of food safety regulations. Food safety standards are regulated by the EFDA through the context of school feeding programmes targeted at primary schoolchildren from registration, licensing and inspection of food.79,81,85,90,93 The EFDA stated that ‘no poor and food-insecure households.59,63,73,86,89 The School Feeding Program aimed food unfit for human consumption or not complying with appropriate safety and to reduce hunger and reduce deficiencies in Vitamin A, iodine and iron.63 School quality standards may be manufactured, imported, exported, stored, distributed, meals should therefore contain energy and macro- and micronutrients by including transported or made available for sale or use to the public’.90 protein-rich cereals, oil and iodized salt.75 We found no evidence of policy action in school feeding programmes or procurement policies that encouraged healthy foods All food items were covered under the Food and Medicine Administration while discouraging or banning unhealthy foods or beverages. Proclamation 2009,77 which was then replaced with the more detailed Proclamation in 2019.78 Following the proclamations, directives have been published specifically Evidence for ‘Support and training systems to help schools and their caterers meet for safe production, processing, packaging and distribution of milk, cereals, edible healthy food service policies and guidelines’ was only identified as part of the School oil, micronutrient supplements and infant formula/complementary Feeding Program, which draws on a team of experts and trainers from teacher food.57,80,81,83,84,94 However, some policy documents highlighted that enforcement of training colleges and federal/regional Ministries of Education and Health to provide existing food safety standards needs strengthening in specific contexts (imported training in health and nutrition.63 foods, school feeding foods prepared in hotels, restaurants or by street In addition to the good practice indicators, we identified relevant information in the vendors).58,70,73 The NNP (I and II) and different directives of the EFDA proposed policy documents regarding the sourcing of foods through school gardens, strengthening the inspection of imported food.58,59,79 The NNP II suggested 140 Policy review Marketing of breastmilk substitutes is restricted because some components of the smallholder farmers,86,92 market linkages or collaborations with the food industry.68 International Code of Marketing of Breastmilk Substitutes have been adopted.80,82,87 Advertising food for infants, such as formula, is prohibited.78,89,82,87 Furthermore, ‘it Food retail is forbidden to give infant food samples or any food description gift, material or similar thing for pregnant women, infant mothers or family members’ or show any We found no evidence on ‘Zoning laws on the density/location of healthy/unhealthy pictures of children or mothers in child food advertisements.82 food service outlets’ or in-store availability of healthy/unhealthy foods. It was recognized that the ‘availability and access to fast food outlets, school tuck-shops, Food prices food stores and vendors in the vicinity may play a role in adolescents’ decision- making’,74 but no action was specified on how to address this. Good practice indicators related to food prices include reduced taxes or subsidies In addition to the Food-EPI indicators, we identified policy action to improve the on healthy food and increased taxes on unhealthy foods. The identified policy availability of safe and healthy foods at markets. The AGP II aimed to build market actions related to food prices appear incoherent with nutrition objectives and across centres, particularly for perishable foods such as fruit and vegetables, animals, milk policy documents. Instead of subsidizing healthy food, the GTP II proposed price and honey collection and processing.66 stabilization interventions for sugar, edible oil and wheat to low-income households.72 The NSAP for the Prevention and Control of NCDs was the first Food trade and investment document proposing increased taxes for SSB.71 Excise tax on SSB was already in place in 2002 but was reduced from 40% to 30% between 2002 and 2009.91 In 2020, this We found no evidence for the good practice indicator that ‘trade agreement impacts tax was expanded to foods and beverages high in salt, sugar, trans-fats and on population nutrition and health should be assessed’. The GTP II aimed to saturated fats.88 Edible animal or vegetable fats/oils with ≥ 40 g/100 g of saturated undertake negotiations with the World Trade Organization, while strengthening 5 fat, or > 0.5 g/100 g of trans-fat, are taxed at a rate of 30–50%.88 existing regional partnerships within East Africa,64,72 but the impact of trade Food related income support is provided by the fourth Productive Safety Net agreements on population nutrition was not addressed. Programme (PSNP IV), through conditional cash transfers or direct support in terms of cash or food to vulnerable households and individuals,67 but this support is not Food safety specific to healthy foods. The good practice indicator for food safety refers to the robustness of food safety Food provision and hygiene policies. We identified strong policy action on food safety (including hygiene) in numerous documents, which also highlighted the limited enforcement We identified some policy actions in schools for food service activities, but only in of food safety regulations. Food safety standards are regulated by the EFDA through the context of school feeding programmes targeted at primary schoolchildren from registration, licensing and inspection of food.79,81,85,90,93 The EFDA stated that ‘no poor and food-insecure households.59,63,73,86,89 The School Feeding Program aimed food unfit for human consumption or not complying with appropriate safety and to reduce hunger and reduce deficiencies in Vitamin A, iodine and iron.63 School quality standards may be manufactured, imported, exported, stored, distributed, meals should therefore contain energy and macro- and micronutrients by including transported or made available for sale or use to the public’.90 protein-rich cereals, oil and iodized salt.75 We found no evidence of policy action in school feeding programmes or procurement policies that encouraged healthy foods All food items were covered under the Food and Medicine Administration while discouraging or banning unhealthy foods or beverages. Proclamation 2009,77 which was then replaced with the more detailed Proclamation in 2019.78 Following the proclamations, directives have been published specifically Evidence for ‘Support and training systems to help schools and their caterers meet for safe production, processing, packaging and distribution of milk, cereals, edible healthy food service policies and guidelines’ was only identified as part of the School oil, micronutrient supplements and infant formula/complementary Feeding Program, which draws on a team of experts and trainers from teacher food.57,80,81,83,84,94 However, some policy documents highlighted that enforcement of training colleges and federal/regional Ministries of Education and Health to provide existing food safety standards needs strengthening in specific contexts (imported training in health and nutrition.63 foods, school feeding foods prepared in hotels, restaurants or by street In addition to the good practice indicators, we identified relevant information in the vendors).58,70,73 The NNP (I and II) and different directives of the EFDA proposed policy documents regarding the sourcing of foods through school gardens, strengthening the inspection of imported food.58,59,79 The NNP II suggested 141 Chapter 5 preparing a manual to inspect and regulate food items, strengthen the capacity of DISCUSSION the Ministry of Trade for regular inspections and monitoring and also strengthen and equip laboratories.59 The objective was to assess how different food environment domains have been addressed in Ethiopian policy documents over time and how this compares to the In addition to the good practice indicator, we found evidence related to water safety Food-EPI good practice benchmarks. We also aimed to understand if food in specific settings, such as the school environment. Several policy documents environment policy actions were coherent with dietary or nutritional goals, and how envisioned an adequate, safe, uninterrupted and inclusive water supply57,73 for all this has evolved over time. In the policy documents, we identified policy actions households and schools.58,60,74,76,95 For school environments, interventions such as addressing diets, different forms of malnutrition and food environments. Over the training to control safe and hygienic storage and the preparation and handling of time period 2008–2020 these efforts have intensified, both in the number of policy food in and around schools were proposed63, 68, 73, 92 for fast food outlets, school tuck documents but also in terms of focus and content.56 Comparing government action shops, street vendors, hotels, restaurants and food catering services.70, 74 over this twelve-year period with global best practices has revealed gaps in all food environment domains but also relevant policy actions that could be added when Policy goals addressing outcomes related to diets or nutritional status benchmarking food environment policies in the context of multiple burdens of malnutrition. Most policy goals referred to dietary outcomes related to safety, quality and diversity. Dietary quantity was rarely mentioned. Improving dietary diversity was a Policy actions addressing the food environment in Ethiopia were dominated by food goal of the FNP, the PSNP IV, the AGP II and the Nutrition Sensitive Agriculture safety, with less evidence identified for other domains. Food processing and trade Strategy.65-67, 70 The School Feeding Strategy aimed to provide children with vitamins were regulated in terms of food safety but not with regard to nutrient content, with and minerals.68 More specific dietary goals to reduce salt intake and increase fruit the exception of food fortification efforts. The prioritization of food safety on the and vegetable consumption were only set for the prevention of NCDs.71 Dietary political agenda could be explained by the high burden of food-borne diseases,98 the quantity was only mentioned in terms of having sufficient food available for acute nature of food safety issues and potential market disruptions for exports.99 consumption.65, 73 While food safety actions were included in different policies and legal documents Reducing stunting and wasting in children and underweight in women of and covered different types of foods, researchers pointed out that food safety reproductive age were the goals of several policy documents.57-59,65,70,73,74,96 In the regulations are not updated sufficiently and identified the need for a comprehensive NNP II in 2016 and the FNP in 2018, these goals were broadened to the reduction of food law.100, 101 However, focusing policies mostly on food safety could limit food malnutrition in different age groups at all stages of life (children, women of environment policymaking to a ‘short-term crisis narrative’, ignoring more long- reproductive age, adolescents and the general population).59, 70 term public health concerns such as overweight and obesity.102 For food prices, marketing, provision, labelling and reformulation, we found limited or conflicting Ending all forms of malnutrition was a goal of the Seqota Declaration, in addition to evidence. For instance, fiscal policies included subsidies for flour, sugar and oil in stunting reduction.73 The NSAP for the Prevention and Control of NCDs specifically 2016, as well as taxation of foods high in salt, sugar, trans-fats and saturated fats aimed to reduce the proportion of people with overweight and obesity.71 Reducing introduced in 2020. Subsidies for flour seem coherent with the focus of agricultural micronutrient deficiencies among vulnerable populations, especially in women of policies on cereal production, which accounts for more than 80% of energy reproductive age and children, was the goal of the National Food Fortification Plan.97 production in Ethiopia.103 Unintended consequences of such policy actions should be considered, as research from Egypt showed that subsidies on bread and flour led to increased overweight and obesity in children and women.104 However, subsidies for healthy foods, such as fruit and vegetables, do not seem to be in place but are urgently needed in view of their escalating price,10 which prevents particularly the poorest households in Ethiopia from consuming the recommended amounts of fruit and vegetables.105 Restrictions on advertising and the promotion of foods and beverages on children’s programmes are in place for breastmilk substitutes or complementary foods,79, 82, 87 as well as foods high in sugar, salt and fat. However, they do not exist in settings 142 Policy review preparing a manual to inspect and regulate food items, strengthen the capacity of DISCUSSION the Ministry of Trade for regular inspections and monitoring and also strengthen and equip laboratories.59 The objective was to assess how different food environment domains have been addressed in Ethiopian policy documents over time and how this compares to the In addition to the good practice indicator, we found evidence related to water safety Food-EPI good practice benchmarks. We also aimed to understand if food in specific settings, such as the school environment. Several policy documents environment policy actions were coherent with dietary or nutritional goals, and how envisioned an adequate, safe, uninterrupted and inclusive water supply57,73 for all this has evolved over time. In the policy documents, we identified policy actions households and schools.58,60,74,76,95 For school environments, interventions such as addressing diets, different forms of malnutrition and food environments. Over the training to control safe and hygienic storage and the preparation and handling of time period 2008–2020 these efforts have intensified, both in the number of policy food in and around schools were proposed63, 68, 73, 92 for fast food outlets, school tuck documents but also in terms of focus and content.56 Comparing government action shops, street vendors, hotels, restaurants and food catering services.70, 74 over this twelve-year period with global best practices has revealed gaps in all food environment domains but also relevant policy actions that could be added when Policy goals addressing outcomes related to diets or nutritional status benchmarking food environment policies in the context of multiple burdens of malnutrition. Most policy goals referred to dietary outcomes related to safety, quality and diversity. Dietary quantity was rarely mentioned. Improving dietary diversity was a Policy actions addressing the food environment in Ethiopia were dominated by food goal of the FNP, the PSNP IV, the AGP II and the Nutrition Sensitive Agriculture safety, with less evidence identified for other domains. Food processing and trade Strategy.65-67, 70 The School Feeding Strategy aimed to provide children with vitamins were regulated in terms of food safety but not with regard to nutrient content, with and minerals.68 More specific dietary goals to reduce salt intake and increase fruit the exception of food fortification efforts. The prioritization of food safety on the 5 and vegetable consumption were only set for the prevention of NCDs.71 Dietary political agenda could be explained by the high burden of food-borne diseases,98 the quantity was only mentioned in terms of having sufficient food available for acute nature of food safety issues and potential market disruptions for exports.99 consumption.65, 73 While food safety actions were included in different policies and legal documents Reducing stunting and wasting in children and underweight in women of and covered different types of foods, researchers pointed out that food safety reproductive age were the goals of several policy documents.57-59,65,70,73,74,96 In the regulations are not updated sufficiently and identified the need for a comprehensive NNP II in 2016 and the FNP in 2018, these goals were broadened to the reduction of food law.100, 101 However, focusing policies mostly on food safety could limit food malnutrition in different age groups at all stages of life (children, women of environment policymaking to a ‘short-term crisis narrative’, ignoring more long- reproductive age, adolescents and the general population).59, 70 term public health concerns such as overweight and obesity.102 For food prices, marketing, provision, labelling and reformulation, we found limited or conflicting Ending all forms of malnutrition was a goal of the Seqota Declaration, in addition to evidence. For instance, fiscal policies included subsidies for flour, sugar and oil in stunting reduction.73 The NSAP for the Prevention and Control of NCDs specifically 2016, as well as taxation of foods high in salt, sugar, trans-fats and saturated fats aimed to reduce the proportion of people with overweight and obesity.71 Reducing introduced in 2020. Subsidies for flour seem coherent with the focus of agricultural micronutrient deficiencies among vulnerable populations, especially in women of policies on cereal production, which accounts for more than 80% of energy reproductive age and children, was the goal of the National Food Fortification Plan.97 production in Ethiopia.103 Unintended consequences of such policy actions should be considered, as research from Egypt showed that subsidies on bread and flour led to increased overweight and obesity in children and women.104 However, subsidies for healthy foods, such as fruit and vegetables, do not seem to be in place but are urgently needed in view of their escalating price,10 which prevents particularly the poorest households in Ethiopia from consuming the recommended amounts of fruit and vegetables.105 Restrictions on advertising and the promotion of foods and beverages on children’s programmes are in place for breastmilk substitutes or complementary foods,79, 82, 87 as well as foods high in sugar, salt and fat. However, they do not exist in settings 143 Chapter 5 where children gather, such as schools. Defining (un)healthy foods through food- defining good practice indicators specific for the school food environment would be based dietary guidelines, which are currently under development,106 would allow a an important stepping stone to implementing food environment policies on a larger more coherent, integrated approach towards food prices, promotion, labelling, scale. Lastly, benchmarking food and water safety, especially in public settings, processing and provision. would be crucial. In conclusion, we recommend expanding the current Food-EPI good practice indicators to policy actions relevant for LMIC, which address multiple The policy goals set in the policy documents appear to be coherent with specific burdens of malnutrition more comprehensively, as well as adding policy actions proposed food environment policy actions. We identified that Ethiopian policy earlier in the food supply chain, which influences the food environment.16 documents mostly aimed at reducing wasting and stunting, which is aligned with the policy focus on food safety.107, 108 Policy actions addressing food promotion, This study provides an overview of the food environment policy context in Ethiopia processing, labelling or trade of unhealthy foods, which could contribute to reducing and proposals for context-specific benchmarks in other LMIC. However, it does not overweight, obesity or diet-related NCDs,16 are only in the early stages in Ethiopian come without limitations. The main limitation of this study is that it only considered policymaking. This was also well reflected in goal setting, which has only addressed government documents that were available online or electronically, therefore multiple forms of malnutrition and obesity as a risk factor for diet-related NCDs since documents may have been missed that were only available as hard copy. In addition, 2014, which also aligns with the observed increases in overweight and obesity from it only captured national government commitments outlined in policy documents 2011.1, 109 The first policy actions on diet-related NCDs were also aligned with goals and not the entire policy process. We therefore cannot make any conclusions in to reduce overweight and the consumption of unhealthy foods such as salt.71 terms of the extent of policy implementation or regional variability. We argue that addressing multiple forms of malnutrition should also be reflected in Our study focused on the document analysis part of the Food-EPI tool because the benchmarking food environment policy actions. In our analysis, we compared food situation with the Covid-19 pandemic did not allow expert interviews or workshops environment policy action in Ethiopia with the Food-EPI good practice indicators, to be held. Therefore, we could not include a rating or priority setting of policy but also searched for additional policy action on the food environment domains. actions by experts, which is an important next step to making food environments in This helped us to identify policy actions relevant for the food environment that could Ethiopia healthier. be considered in global benchmarks in the future. Food processing and composition in the Food-EPI indicators is limited to food reformulation, but we argue that policy Our analysis could also provide useful insights for Ethiopian policymakers. actions on agro-processing and food fortification are also of importance and could Positioning food environment policy actions into the wider food system is crucial for influence what types of foods are available, processed and promoted in value chains more sustainable transformation, considering that actions in the food supply chain and at markets. A good practice indicator could be related to increasing the agro- before food reaches the food environment can influence whether food is safe, processing of healthy foods. We also found that good practice indicators related to available, or affordable to consumers. Only in recent policy documents from 2018 food retail were too narrowly focused on formal food outlets, which is not where has an approach to safer food systems been observed. However, this food systems most consumers in LMIC purchase their food.110 Policy action addressing informal approach would be crucial for all domains of the food environment and could put vendors, as well as open markets, should be analysed in LMIC settings. Potential them into context with food supply actions.9 good practice examples for food safety policies could include incentive-driven training and certification initiatives for informal vendors or policy action beyond the In order to address the double burden of malnutrition, the focus on food safety current focus on standards, inspections and control.24 Also, a food safety should be linked to healthy diets more generally, given that food safety, security and commitment index has been proposed to monitor the level of commitment that nutrition security are all compatible and important parts of a healthy food system.99 LMIC governments are making to food safety.62 The existing legal actions for food safety could be broadened to promote nutritious food and discourage the consumption of unhealthy food. The excise tax is a step in Regarding food prices, subsidies on unhealthy foods should also be monitored and the right direction, but expanding such efforts to regulating the promotion and benchmarked as they could incentivise the consumption of energy-dense availability of unhealthy foods would help leverage efforts to promote healthy diets. unbalanced diets.104 Furthermore, policy actions targeting schools appeared prominent in our analysis. The school setting is ideal to address multiple forms of Applying a food systems approach in policymaking is still in the early stages in most malnutrition23 and probably more feasible to manage and regulate than the countries; the policy dialogues in Ethiopia as part of the preparations for the UN community food environment (although action is required in both). Therefore, Food Systems Summit and the Ethiopian Food System Roadmap 2030 have been 144 Policy review where children gather, such as schools. Defining (un)healthy foods through food- defining good practice indicators specific for the school food environment would be based dietary guidelines, which are currently under development,106 would allow a an important stepping stone to implementing food environment policies on a larger more coherent, integrated approach towards food prices, promotion, labelling, scale. Lastly, benchmarking food and water safety, especially in public settings, processing and provision. would be crucial. In conclusion, we recommend expanding the current Food-EPI good practice indicators to policy actions relevant for LMIC, which address multiple The policy goals set in the policy documents appear to be coherent with specific burdens of malnutrition more comprehensively, as well as adding policy actions proposed food environment policy actions. We identified that Ethiopian policy earlier in the food supply chain, which influences the food environment.16 documents mostly aimed at reducing wasting and stunting, which is aligned with the policy focus on food safety.107, 108 Policy actions addressing food promotion, This study provides an overview of the food environment policy context in Ethiopia processing, labelling or trade of unhealthy foods, which could contribute to reducing and proposals for context-specific benchmarks in other LMIC. However, it does not overweight, obesity or diet-related NCDs,16 are only in the early stages in Ethiopian come without limitations. The main limitation of this study is that it only considered policymaking. This was also well reflected in goal setting, which has only addressed government documents that were available online or electronically, therefore multiple forms of malnutrition and obesity as a risk factor for diet-related NCDs since documents may have been missed that were only available as hard copy. In addition, 2014, which also aligns with the observed increases in overweight and obesity from it only captured national government commitments outlined in policy documents 2011.1, 109 The first policy actions on diet-related NCDs were also aligned with goals and not the entire policy process. We therefore cannot make any conclusions in to reduce overweight and the consumption of unhealthy foods such as salt.71 terms of the extent of policy implementation or regional variability. We argue that addressing multiple forms of malnutrition should also be reflected in Our study focused on the document analysis part of the Food-EPI tool because the benchmarking food environment policy actions. In our analysis, we compared food situation with the Covid-19 pandemic did not allow expert interviews or workshops 5 environment policy action in Ethiopia with the Food-EPI good practice indicators, to be held. Therefore, we could not include a rating or priority setting of policy but also searched for additional policy action on the food environment domains. actions by experts, which is an important next step to making food environments in This helped us to identify policy actions relevant for the food environment that could Ethiopia healthier. be considered in global benchmarks in the future. Food processing and composition in the Food-EPI indicators is limited to food reformulation, but we argue that policy Our analysis could also provide useful insights for Ethiopian policymakers. actions on agro-processing and food fortification are also of importance and could Positioning food environment policy actions into the wider food system is crucial for influence what types of foods are available, processed and promoted in value chains more sustainable transformation, considering that actions in the food supply chain and at markets. A good practice indicator could be related to increasing the agro- before food reaches the food environment can influence whether food is safe, processing of healthy foods. We also found that good practice indicators related to available, or affordable to consumers. Only in recent policy documents from 2018 food retail were too narrowly focused on formal food outlets, which is not where has an approach to safer food systems been observed. However, this food systems most consumers in LMIC purchase their food.110 Policy action addressing informal approach would be crucial for all domains of the food environment and could put vendors, as well as open markets, should be analysed in LMIC settings. Potential them into context with food supply actions.9 good practice examples for food safety policies could include incentive-driven training and certification initiatives for informal vendors or policy action beyond the In order to address the double burden of malnutrition, the focus on food safety current focus on standards, inspections and control.24 Also, a food safety should be linked to healthy diets more generally, given that food safety, security and commitment index has been proposed to monitor the level of commitment that nutrition security are all compatible and important parts of a healthy food system.99 LMIC governments are making to food safety.62 The existing legal actions for food safety could be broadened to promote nutritious food and discourage the consumption of unhealthy food. The excise tax is a step in Regarding food prices, subsidies on unhealthy foods should also be monitored and the right direction, but expanding such efforts to regulating the promotion and benchmarked as they could incentivise the consumption of energy-dense availability of unhealthy foods would help leverage efforts to promote healthy diets. unbalanced diets.104 Furthermore, policy actions targeting schools appeared prominent in our analysis. The school setting is ideal to address multiple forms of Applying a food systems approach in policymaking is still in the early stages in most malnutrition23 and probably more feasible to manage and regulate than the countries; the policy dialogues in Ethiopia as part of the preparations for the UN community food environment (although action is required in both). Therefore, Food Systems Summit and the Ethiopian Food System Roadmap 2030 have been 145 Chapter 5 important steps to put food systems thinking on the agendas of high-level References government officials.111, 112 However, the proposed actions strongly focused on agricultural production and less on food environments. Furthermore, the extent to 1. CSA. Ethiopia Demographic and Health Survey 2000. Addis Ababa, Ethiopia and which the discussed policies are influenced by the current armed conflict in certain Rockville, MD, USA: CSA and ICF; 2000. regions and the impact of Covid-19 in Ethiopia remains to be seen. Food 2. CSA. Ethiopia Demographic and Health Survey 2016. Addis Ababa, Ethiopia and environments are already negatively affected by interrupted supply chains and it is Rockville, MD, USA: CSA and ICF; 2016. likely that acute malnutrition interventions could be prioritized in Ethiopian 3. CSA. Ethiopia Demographic and Health Survey 2019. Addis Ababa, Ethiopia and Rockville, MD, USA: CSA and ICF; 2019. policymaking as a consequence. An important next step following this assessment 4. Institute for Health Metrics and Evaluation (IHME). GBD Compare. Seattle, WA: would be a deliberative priority-setting exercise to generate a set of actions19 to IHME, University of Washington, 2015. Available from address the identified gaps in food environment policy actions in Ethiopia. For global http://vizhub.healthdata.org/gbd-compare (accessed 25 Feburary 2022) benchmarking of food environment policy action, additional indicators should be 5. Herforth A, Ahmed S. The food environment, its effects on dietary consumption, considered to address important issues in the context of multiple forms of and potential for measurement within agriculture-nutrition interventions. Food malnutrition. Secur. 2015;7:505-520. doi:10.1007/s12571-015-0455-8 6. Baker P, Machado P, Santos T, et al. Ultra-processed foods and the nutrition transition: Global, regional and national trends, food systems transformations and political economy drivers. Obes Rev. 2020;21(12):e13126. doi:10.1111/obr.13126 7. FAO, IFAD, UNICEF, WFP, WHO. The State of Food Security and Nutrition in the World 2020. Transforming Food Systems for Affordable Healthy Diets. Rome; 2020. 8. Grace D. Food safety in low and middle income countries. Int J Env Res Public Heal. 2015;12(9):10490-10507. doi:10.3390/ijerph120910490 9. Gebru M, Remans R, Brouwer I, et al. Food systems for healthier diets in Ethiopia: Toward a research agenda. IFPRI Discussion Paper 01720. 2018. 10. Bachewe FN, Minten B. The Rising Costs of Nutritious Foods: The Case of Ethiopia. Washington, DC and Addis Ababa, Ethiopia: International Food Policy Research Institute (IFPRI) and Federal Democratic Republic of Ethiopia Policy Studies Institute; 2019. 11. Assefa T, Abebe G, Lamoot I, et al. Urban food retailing and food prices in Africa: The case of Addis Ababa, Ethiopia. J Agribus Dev Emerg Econ. 2016. doi:10.1108/JADEE-02-2015-0009 12. Trübswasser U, Talsma E, Ekubay S, et al. Influencing Factors of School Food Environments in Urban Ethiopia, Abstract at World Public Health Nutrition Association Congress 2020; 2020. 13. Tschirley D, Reardon T, Dolislager M, et al. The rise of a middle class in East and Southern Africa: Implications for food system transformation. J Int Dev. 2015;27(5):628-646. doi:10.1002/jid.3107 14. Trübswasser U, Baye K, Holdsworth M, et al. Assessing factors influencing adolescents’ dietary behaviours in urban Ethiopia using participatory photography. Public Health Nutr. 2020. doi:10.1017/s1368980020002487 15. Birke W, Zawide F. Transforming research results in food safety to community actions: A call for action to advance food safety in Ethiopia. Environ Ecol Res. 2019;7:153-170. doi:10.13189/eer.2019.070305 16. Hawkes C, Walton S, Haddad L, et al. 42 Policies and Actions to Orient Food Systems towards Healthier Diets for All. London; 2020. 17. Food and Agriculture Organization of the United Nations (FAO). Nutrition Guidelines and Standards for School Meals: A Report from 33 Low and Middle-Income Countries. Rome; 2019. 18. Jaime PC, Lock K. Do school based food and nutrition policies improve diet and 146 Policy review important steps to put food systems thinking on the agendas of high-level References government officials.111, 112 However, the proposed actions strongly focused on agricultural production and less on food environments. Furthermore, the extent to 1. CSA. Ethiopia Demographic and Health Survey 2000. Addis Ababa, Ethiopia and which the discussed policies are influenced by the current armed conflict in certain Rockville, MD, USA: CSA and ICF; 2000. regions and the impact of Covid-19 in Ethiopia remains to be seen. Food 2. CSA. Ethiopia Demographic and Health Survey 2016. Addis Ababa, Ethiopia and environments are already negatively affected by interrupted supply chains and it is Rockville, MD, USA: CSA and ICF; 2016. likely that acute malnutrition interventions could be prioritized in Ethiopian 3. CSA. Ethiopia Demographic and Health Survey 2019. Addis Ababa, Ethiopia and Rockville, MD, USA: CSA and ICF; 2019. policymaking as a consequence. An important next step following this assessment 4. Institute for Health Metrics and Evaluation (IHME). GBD Compare. Seattle, WA: would be a deliberative priority-setting exercise to generate a set of actions19 to IHME, University of Washington, 2015. Available from address the identified gaps in food environment policy actions in Ethiopia. For global http://vizhub.healthdata.org/gbd-compare (accessed 25 Feburary 2022) benchmarking of food environment policy action, additional indicators should be 5. Herforth A, Ahmed S. The food environment, its effects on dietary consumption, considered to address important issues in the context of multiple forms of and potential for measurement within agriculture-nutrition interventions. Food malnutrition. Secur. 2015;7:505-520. doi:10.1007/s12571-015-0455-8 6. Baker P, Machado P, Santos T, et al. Ultra-processed foods and the nutrition transition: Global, regional and national trends, food systems transformations and political economy drivers. Obes Rev. 2020;21(12):e13126. doi:10.1111/obr.13126 7. FAO, IFAD, UNICEF, WFP, WHO. The State of Food Security and Nutrition in the World 2020. Transforming Food Systems for Affordable Healthy Diets. Rome; 2020. 8. Grace D. Food safety in low and middle income countries. Int J Env Res Public Heal. 2015;12(9):10490-10507. doi:10.3390/ijerph120910490 5 9. Gebru M, Remans R, Brouwer I, et al. Food systems for healthier diets in Ethiopia: Toward a research agenda. IFPRI Discussion Paper 01720. 2018. 10. Bachewe FN, Minten B. The Rising Costs of Nutritious Foods: The Case of Ethiopia. Washington, DC and Addis Ababa, Ethiopia: International Food Policy Research Institute (IFPRI) and Federal Democratic Republic of Ethiopia Policy Studies Institute; 2019. 11. Assefa T, Abebe G, Lamoot I, et al. Urban food retailing and food prices in Africa: The case of Addis Ababa, Ethiopia. J Agribus Dev Emerg Econ. 2016. doi:10.1108/JADEE-02-2015-0009 12. Trübswasser U, Talsma E, Ekubay S, et al. Influencing Factors of School Food Environments in Urban Ethiopia, Abstract at World Public Health Nutrition Association Congress 2020; 2020. 13. Tschirley D, Reardon T, Dolislager M, et al. The rise of a middle class in East and Southern Africa: Implications for food system transformation. J Int Dev. 2015;27(5):628-646. doi:10.1002/jid.3107 14. Trübswasser U, Baye K, Holdsworth M, et al. Assessing factors influencing adolescents’ dietary behaviours in urban Ethiopia using participatory photography. Public Health Nutr. 2020. doi:10.1017/s1368980020002487 15. Birke W, Zawide F. Transforming research results in food safety to community actions: A call for action to advance food safety in Ethiopia. Environ Ecol Res. 2019;7:153-170. doi:10.13189/eer.2019.070305 16. Hawkes C, Walton S, Haddad L, et al. 42 Policies and Actions to Orient Food Systems towards Healthier Diets for All. London; 2020. 17. Food and Agriculture Organization of the United Nations (FAO). Nutrition Guidelines and Standards for School Meals: A Report from 33 Low and Middle-Income Countries. Rome; 2019. 18. Jaime PC, Lock K. Do school based food and nutrition policies improve diet and 147 Chapter 5 reduce obesity? Prev Med. 2009;48(1):45-53. doi:10.1016/j.ypmed.2008.10.018 Agriculture for Improved Nutrition: Seizing the Momentum; 2019:165. 19. Vandevijvere S, Barquera S, Caceres G, et al. An 11-country study to benchmark the doi:10.1079/9781786399311.0165 implementation of recommended nutrition policies by national governments using 35. Harris J, Frongillo EA, Nguyen PH, et al. Changes in the policy environment for infant the Healthy Food Environment Policy Index, 2015-2018. Obes Rev. 2019;20(S2):57- and young child feeding in Vietnam, Bangladesh, and Ethiopia, and the role of 66. doi:10.1111/obr.12819 targeted advocacy. BMC Public Health. 2017;17. doi:10.1186/s12889-017-4343-3 20. World Health Organization. Global Nutrition Policy Review 2016-2017: Country 36. Nisbett N, Wach E, Haddad L, et al. What drives and constrains effective leadership Progress in Creating Enabling Policy Environments for Promoting Healthy Diets and in tackling child undernutrition? Findings from Bangladesh, Ethiopia, India and Nutrition. Geneva; 2018. Kenya. Food Policy. 2015;53:33-45. doi:10.1016/j.foodpol.2015.04.001 21. Nakhimovsky SS, Feigl AB, Avila C, et al. Taxes on sugar-sweetened beverages to 37. Ayele S, Asfaw E, Nisbett N. Multi-Sectoral Nutrition Policy and Programme Design, reduce overweight and obesity in middle-income countries: A systematic review. Coordination and Implementation in Ethiopia; 2020. PLoS One. 2016;11(9):e0163358. https://doi.org/10.1371/journal.pone.0163358 38. Kennedy E, Tessema M, Hailu T, et al. Multisector nutrition program governance 22. Pan American Health Organization. Sugar-Sweetened Beverage Taxation in the and implementation in Ethiopia: Opportunities and challenges. Food Nutr Bull. Region of the Americas. Washington, DC; 2020. 2015;36(4):534-548. doi:10.1177/0379572115611768 23. Downs S, Demmler KM. Food environment interventions targeting children and 39. Walls H, Johnston D, Vecchione E, et al. The role of evidence in nutrition policy- adolescents: A scoping review. Glob Food Sec. 2020. doi:10.1016/j.gfs.2020.100403 making in Ethiopia: Institutional structures and issue framing. Dev Policy Rev. 24. Grace, D., Alonso, S., Mutua, F., et al. Food Safety Investment Expert Advice: Burkina 2019;37(2):293-310. doi:10.1111/dpr.12385 Faso, Ethiopia, Nigeria. Nairobi, Kenya: ILRI; 2018. 40. Food and Agriculture Organization of the United Nations (FAO). Influencing Food 25. Swinburn B, Sacks G, Vandevijvere S, et al. INFORMAS (International Network for Environments for Healthy Diets. Rome; 2016. Food and Obesity/Non-Communicable Diseases Research, Monitoring and Action 41. HLPE. Nutrition and Food Systems. A Report by the High Level Panel of Experts on Support): Overview and key principles. Obes Rev. 2013. doi:10.1111/obr.12087 Food Security and Nutrition of the Committee on World Food Security. Rome; 2017. 26. Swinburn B, Vandevijvere S, Kraak V, et al. Monitoring and benchmarking 42. HLPE. Food Security and Nutrition: Building a Global Narrative towards 2030. A government policies and actions to improve the healthiness of food environments: Report by the High Level Panel of Experts on Food Security and Nutrition of the A proposed Government Healthy Food Environment Policy Index. Obes Rev. Committee on World Food Security. Rome; 2020. 2013;14(S1):24-37. doi:10.1111/obr.12073 43. Downs SM, Ahmed S, Fanzo J, et al. Food environment typology: Advancing an 27. Asiki G, Wanjohi MN, Barnes A, et al. Benchmarking food environment policies for expanded definition, framework, and methodological approach for improved the prevention of diet-related non-communicable diseases in Kenya: National characterization of wild, cultivated, and built food environments toward expert panel’s assessment and priority recommendations. PLoS One. sustainable diets. Foods. 2020;9(4):532. doi:10.3390/foods9040532 2020;15(8):e0236699. https://doi.org/10.1371/journal.pone.0236699 44. Osei-Kwasi HA, Laar A, Zotor F, et al. The African urban food environment 28. Laar A, Barnes A, Aryeetey R, et al. Implementation of healthy food environment framework for creating healthy nutrition policy and interventions in urban Africa. policies to prevent nutrition-related non-communicable diseases in Ghana: PLoS One. 2021;16(4):e0249621. https://doi.org/10.1371/journal.pone.0249621 National experts’ assessment of government action. Food Policy. 2020;93:101907. 45. Turner C, Aggarwal A, Walls H, et al. Concepts and critical perspectives for food doi:https://doi.org/10.1016/j.foodpol.2020.101907 environment research: A global framework with implications for action in low- and 29. Kennedy E, Mersha GA, Biadgilign S, et al. Nutrition policy and governance in middle-income countries. Glob Food Sec. 2018;18:93-101. Ethiopia: What difference does 5 years make? Food Nutr Bull. 2020;41(4):494-502. doi:https://doi.org/10.1016/j.gfs.2018.08.003 doi:10.1177/0379572120957218 46. Ruben R, Verhagen J, Plaisier C. The challenge of food systems research: What 30. Pelletier DL, Deneke K, Kidane Y, et al. The food-first bias and nutrition policy: difference does it make? Sustainability. 2019;11(1):171. Lessons from Ethiopia. Food Policy. 1995;20(4):279-98. doi:10.1016/0306- https://doi.org/10.3390/su11010171 9192(95)00026-7 47. Global Panel on Agriculture and Food Systems for Nutrition (Glopan). Food Systems 31. Bach A, Gregor E, Sridhar S, et al. Multisectoral integration of nutrition, health, and and Diets: Facing the Challenges of the 21st Century. London; 2016. agriculture: Implementation lessons from Ethiopia. Food Nutr Bull. 2020;41(2):275- 48. Glanz K, Sallis J, Saelens B, et al. Healthy Nutrition environments: Concepts and 292. doi:10.1177/0379572119895097 measures. Am J Health Promot. 2005;19:330-333, ii. doi:10.4278/0890-1171- 32. Chisholm N. Multi-sectoral collaboration for improved nutrition: The problems and 19.5.330 prospects of implementation in Ethiopia. Dev Policy Rev. 2019;37(2):274-292. 49. Candel JJL, Biesbroek R. Toward a processual understanding of policy integration. doi:10.1111/dpr.12347 Policy Sci. 2016;49:211-231. doi:10.1007/s11077-016-9248-y 33. Pelletier D, Gervais S, Hafeez-ur-Rehman H, et al. Boundary-spanning actors in 50. Sibbing L, Candel J, Termeer K. A comparative assessment of local municipal food complex adaptive governance systems: The case of multisectoral nutrition. Int J policy integration in the Netherlands. Int Plan Stud. October 2019:1-14. Health Plann Manage. 2018;33(1):e293-e319. doi:10.1002/hpm.2468 doi:10.1080/13563475.2019.1674642 34. Bossuyt A. Agriculture for improved nutrition: seizing the momentum. In: 51. Knill C, Schulze K, Tosun J. Regulatory policy outputs and impacts: Exploring a 148 Policy review reduce obesity? Prev Med. 2009;48(1):45-53. doi:10.1016/j.ypmed.2008.10.018 Agriculture for Improved Nutrition: Seizing the Momentum; 2019:165. 19. Vandevijvere S, Barquera S, Caceres G, et al. An 11-country study to benchmark the doi:10.1079/9781786399311.0165 implementation of recommended nutrition policies by national governments using 35. Harris J, Frongillo EA, Nguyen PH, et al. Changes in the policy environment for infant the Healthy Food Environment Policy Index, 2015-2018. Obes Rev. 2019;20(S2):57- and young child feeding in Vietnam, Bangladesh, and Ethiopia, and the role of 66. doi:10.1111/obr.12819 targeted advocacy. BMC Public Health. 2017;17. doi:10.1186/s12889-017-4343-3 20. World Health Organization. Global Nutrition Policy Review 2016-2017: Country 36. Nisbett N, Wach E, Haddad L, et al. What drives and constrains effective leadership Progress in Creating Enabling Policy Environments for Promoting Healthy Diets and in tackling child undernutrition? Findings from Bangladesh, Ethiopia, India and Nutrition. Geneva; 2018. Kenya. Food Policy. 2015;53:33-45. doi:10.1016/j.foodpol.2015.04.001 21. Nakhimovsky SS, Feigl AB, Avila C, et al. Taxes on sugar-sweetened beverages to 37. Ayele S, Asfaw E, Nisbett N. Multi-Sectoral Nutrition Policy and Programme Design, reduce overweight and obesity in middle-income countries: A systematic review. Coordination and Implementation in Ethiopia; 2020. PLoS One. 2016;11(9):e0163358. https://doi.org/10.1371/journal.pone.0163358 38. Kennedy E, Tessema M, Hailu T, et al. Multisector nutrition program governance 22. Pan American Health Organization. Sugar-Sweetened Beverage Taxation in the and implementation in Ethiopia: Opportunities and challenges. Food Nutr Bull. Region of the Americas. Washington, DC; 2020. 2015;36(4):534-548. doi:10.1177/0379572115611768 23. Downs S, Demmler KM. Food environment interventions targeting children and 39. Walls H, Johnston D, Vecchione E, et al. The role of evidence in nutrition policy- adolescents: A scoping review. Glob Food Sec. 2020. doi:10.1016/j.gfs.2020.100403 making in Ethiopia: Institutional structures and issue framing. Dev Policy Rev. 24. Grace, D., Alonso, S., Mutua, F., et al. Food Safety Investment Expert Advice: Burkina 2019;37(2):293-310. doi:10.1111/dpr.12385 Faso, Ethiopia, Nigeria. Nairobi, Kenya: ILRI; 2018. 40. Food and Agriculture Organization of the United Nations (FAO). Influencing Food 25. Swinburn B, Sacks G, Vandevijvere S, et al. INFORMAS (International Network for Environments for Healthy Diets. Rome; 2016. Food and Obesity/Non-Communicable Diseases Research, Monitoring and Action 41. HLPE. Nutrition and Food Systems. A Report by the High Level Panel of Experts on Support): Overview and key principles. Obes Rev. 2013. doi:10.1111/obr.12087 Food Security and Nutrition of the Committee on World Food Security. Rome; 2017. 26. Swinburn B, Vandevijvere S, Kraak V, et al. Monitoring and benchmarking 42. HLPE. Food Security and Nutrition: Building a Global Narrative towards 2030. A 5 government policies and actions to improve the healthiness of food environments: Report by the High Level Panel of Experts on Food Security and Nutrition of the A proposed Government Healthy Food Environment Policy Index. Obes Rev. Committee on World Food Security. Rome; 2020. 2013;14(S1):24-37. doi:10.1111/obr.12073 43. Downs SM, Ahmed S, Fanzo J, et al. Food environment typology: Advancing an 27. Asiki G, Wanjohi MN, Barnes A, et al. Benchmarking food environment policies for expanded definition, framework, and methodological approach for improved the prevention of diet-related non-communicable diseases in Kenya: National characterization of wild, cultivated, and built food environments toward expert panel’s assessment and priority recommendations. PLoS One. sustainable diets. Foods. 2020;9(4):532. doi:10.3390/foods9040532 2020;15(8):e0236699. https://doi.org/10.1371/journal.pone.0236699 44. Osei-Kwasi HA, Laar A, Zotor F, et al. The African urban food environment 28. Laar A, Barnes A, Aryeetey R, et al. Implementation of healthy food environment framework for creating healthy nutrition policy and interventions in urban Africa. policies to prevent nutrition-related non-communicable diseases in Ghana: PLoS One. 2021;16(4):e0249621. https://doi.org/10.1371/journal.pone.0249621 National experts’ assessment of government action. Food Policy. 2020;93:101907. 45. Turner C, Aggarwal A, Walls H, et al. Concepts and critical perspectives for food doi:https://doi.org/10.1016/j.foodpol.2020.101907 environment research: A global framework with implications for action in low- and 29. Kennedy E, Mersha GA, Biadgilign S, et al. Nutrition policy and governance in middle-income countries. Glob Food Sec. 2018;18:93-101. Ethiopia: What difference does 5 years make? Food Nutr Bull. 2020;41(4):494-502. doi:https://doi.org/10.1016/j.gfs.2018.08.003 doi:10.1177/0379572120957218 46. Ruben R, Verhagen J, Plaisier C. The challenge of food systems research: What 30. Pelletier DL, Deneke K, Kidane Y, et al. The food-first bias and nutrition policy: difference does it make? Sustainability. 2019;11(1):171. Lessons from Ethiopia. Food Policy. 1995;20(4):279-98. doi:10.1016/0306- https://doi.org/10.3390/su11010171 9192(95)00026-7 47. Global Panel on Agriculture and Food Systems for Nutrition (Glopan). Food Systems 31. Bach A, Gregor E, Sridhar S, et al. Multisectoral integration of nutrition, health, and and Diets: Facing the Challenges of the 21st Century. London; 2016. agriculture: Implementation lessons from Ethiopia. Food Nutr Bull. 2020;41(2):275- 48. Glanz K, Sallis J, Saelens B, et al. Healthy Nutrition environments: Concepts and 292. doi:10.1177/0379572119895097 measures. Am J Health Promot. 2005;19:330-333, ii. doi:10.4278/0890-1171- 32. Chisholm N. Multi-sectoral collaboration for improved nutrition: The problems and 19.5.330 prospects of implementation in Ethiopia. Dev Policy Rev. 2019;37(2):274-292. 49. Candel JJL, Biesbroek R. 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Milk Product Factory Internal Influencing Food Environments in EU Member States. Utrecht; 2020. Quality Management System Guidline. Addis Ababa; 2018. 62. Jaffee, S., Henson, S., Unnevehr, L., et al. The Safe Food Imperative: Accelerating 85. Ethiopian Food and Drug Administration (EFDA). Food Registration Directive No. Progress in Low- and Middle-Income Countries. Agriculture and Food Series. 2019. 42/2011. Addis Ababa; 2019. https://doi.org/doi:10.1596/978-1-4648-134 86. Federal Democratic Republic of Ethiopia. School Health Program. Addis Ababa; 63. Federal Democratic Republic of Ethiopia. National School Health and Nutrition 2017. Strategy. Addis Ababa; 2012. 87. Ethiopian Food and Drug Administration (EFDA). Baby Food Control Directive No. 64. Ministry of Finance and Economic Development of Ethiopia. Growth and 40/2010 E.C. Addis Ababa; 2018. Transformation Plan I (GTP I) 2010/11-2014/15. Addis Ababa; 2010. 88. Federal Democratic Republic of Ethiopia. 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Regul Gov. 2012;6:427-444. doi:10.1111/j.1748- Transformation Plan II (GTP II) (2015/16-2019/20). Addis Ababa; 2016. 5991.2012.01150.x 73. Federal Democratic Republic of Ethiopia. Seqota Declaration – Implementation Plan 52. Law Ethiopia – Ethiopian Law Information Portal. 2016-2030. Addis Ababa; 2016. https://www.lawethiopia.com/index.php (accessed 5 April 2021). 74. Federal Democratic Republic of Ethiopia. National Guideline on Adolescent, 53. Swinburn, B., Vandevijvere, S., Kraak, V., et al. Monitoring and benchmarking Maternal Infant and Young Child Nutrition; 2016. government policies and actions to improve the healthiness of food environments: 75. Ministry of Education of Ethiopia. Emergency School Feeding Program A proposed Government Healthy Food Environment Policy Index. Obes. Rev. Implementation Guideline. Addis Ababa; 2017. 2013;14:24–37. 76. Federal Democratic Republic of Ethiopia. National School Water, Sanitation and 54. Bowen, G. Document analysis as a qualitative research method. Qual Res J. Hygiene (SWASH) Strategy and Implementation Action Plan. Addis Ababa; 2017. 2009;9:27–40. https://doi.org/10.3316/QRJ0902027 77. Federal Democratic Republic of Ethiopia. Food and Medicine Administration 55. Candel J, Daugbjerg C. Overcoming the dependent variable problem in studying Proclamation No. 661/2009. Addis Ababa; 2009. food policy. Food Secur. 2020;12:169-178. doi:10.1007/s12571-019-00991-2 78. Federal Democratic Republic of Ethiopia. Food and Medicine Administration 56. Dupuis J, Biesbroek R. Comparing apples and oranges: The dependent variable Proclamation No.1112/2019. Addis Ababa; 2019. problem in comparing and evaluating climate change adaptation policies. Glob 79. Ethiopian Food and Drug Administration (EFDA). Food Exporters, Importers and Environ Chang. 2013;23(6):1476-1487. doi:10.1016/j.gloenvcha.2013.07.022 Wholesellers Directive No. 32/2009. Addis Ababa; 2014. 57. Ministry of Health of Ethiopia. National Nutrition Strategy. Addis Ababa; 2008. 80. Ethiopian Food and Drug Administration (EFDA). Infant Formula and Follow-up 58. Federal Democratic Republic of Ethiopia. National Nutrition Programme 2013-2015 Formula Directive No.21 /2014. Addis Ababa; 2014. (NNPI). Addis Ababa; 2013. 81. Ethiopian Food and Drug Administration (EFDA). Food Supplement Directive No. 59. Federal Democratic Republic of Ethiopia. National Nutrition Program 2016-2020 31/2016. Addis Ababa; 2016. (NNPII). Addis Ababa; 2016. 82. Ethiopian Food and Drug Administration (EFDA). Food Advertisement Directive No. 60. Ryan GW, Bernard HR. Techniques to identify themes. Field Methods. 33/2015. Addis Ababa; 2015. 5 2003;15(1):85-109. doi:10.1177/1525822X02239569 83. Ethiopian Food and Drug Administration (EFDA). Cereal and Cereal Product 61. Djojosoeparto S, Kamphuis C, Vandevijvere S, et al. The Healthy Food Environment Manufacturers Internal Quality Control Establishment Directive. Addis Ababa; 2017. Policy Index (Food-EPI): European Union. An Overview of EU-Level Policies 84. Ethiopian Food and Drug Administration (EFDA). Milk Product Factory Internal Influencing Food Environments in EU Member States. Utrecht; 2020. Quality Management System Guidline. Addis Ababa; 2018. 62. Jaffee, S., Henson, S., Unnevehr, L., et al. The Safe Food Imperative: Accelerating 85. Ethiopian Food and Drug Administration (EFDA). Food Registration Directive No. Progress in Low- and Middle-Income Countries. Agriculture and Food Series. 2019. 42/2011. Addis Ababa; 2019. https://doi.org/doi:10.1596/978-1-4648-134 86. Federal Democratic Republic of Ethiopia. School Health Program. Addis Ababa; 63. Federal Democratic Republic of Ethiopia. National School Health and Nutrition 2017. Strategy. Addis Ababa; 2012. 87. Ethiopian Food and Drug Administration (EFDA). Baby Food Control Directive No. 64. Ministry of Finance and Economic Development of Ethiopia. Growth and 40/2010 E.C. Addis Ababa; 2018. Transformation Plan I (GTP I) 2010/11-2014/15. Addis Ababa; 2010. 88. Federal Democratic Republic of Ethiopia. The Excise Tax Proclamation No. 65. Ministry of Agriculture of Ethiopia. Nutrition Sensitive Agriculture Strategy. Addis 1186/2020. Addis Ababa; 2020. Ababa; 2016. 89. Ministry of Labour and Social Affairs of Ethiopia. National Social Protection Strategy 66. Ministry of Agriculture of Ethiopia. Agriculture Growth Program (AGP) II – Program of Ethiopia. Addis Ababa; 2016. Design Document. Addis Ababa; 2014. 90. Ethiopian Food and Drug Administration (EFDA). Regulation for Food, Medicine and 67. Ministry of Agriculture of Ethiopia. Productive Safety Net Programme 4 (PSNP IV) – Health Care Administration and Control No 299/2013. Addis Ababa; 2013. Design Document. Addis Ababa; 2014. 91. Federal Democratic Republic of Ethiopia. Excise Tax (Amendment) Proclamation No. 68. Ministry of Education of Ethiopia. National School Feeding Strategy. Addis Ababa; 570/2008. Addis Ababa; 2008. 2017. 92. Ministry of Education of Ethiopia. Home Grown School Feeding (HGSF) Programme 69. Ministry of Health of Ethiopia. Hygiene and Environmental Health Strategy 2016- Implementation Manual. Addis Ababa; 2014. 2020. Addis Ababa; 2016. 93. Ethiopian Food and Drug Administration (EFDA). Food and Medicine Administration 70. Federal Democratic Republic of Ethiopia. Food and Nutrition Policy. Addis Ababa; Procalamation No. 1112/2019. Addis Ababa; 2019. 2018. 94. Ethiopian Food and Drug Administration (EFDA). Quality and Safety Assurance of 71. Federal Democratic Republic of Ethiopia. National Strategic Action Plan for the Edible Oil Production Facilities Directive. Addis Ababa; 2017. Prevention and Control of Non-Communicable Diseases 2018-2025. Addis Ababa; 95. ONE WaSH National Program – Program Operational Manual (POM); 2014. 2019. 96. Ministry of Health of Ethiopia. Health Sector Transformation Plan (HSTP) 2015/16- 72. Ministry of Finance and Economic Development of Ethiopia. Growth and 2019/20. Addis Ababa; 2015. 151 Chapter 5 97. Federal Democratic Republic of Ethiopia. National Food Fortification Program Plan Appendix 5.1. Code book used for food environment policiy analysis of Action 2017/2018-2021/22. Addis Ababa; 2017. 98. Havelaar AH, Kirk MD, Torgerson PR, et al. World Health Organization global estimates and regional comparisons of the burden of foodborne disease in 2010. Code Description PLoS Med. 2015. doi:10.1371/journal.pmed.1001923 Food environment domains 99. Walls H, Baker P, Chirwa E, et al. Food security, food safety & healthy nutrition: Are Food Food composition targets/standards/restrictions for processed they compatible? Glob Food Sec. 2019;21. doi:10.1016/j.gfs.2019.05.005 composition foods: to ensure that, where practicable, processed foods minimise 100. Abebe GK, Kassem II. Food safety regulations and enforcement in Ethiopia. In: and processing the energy density and the nutrients of concern (salt, saturated fat, Reference Module in Food Science; 2018. doi:10.1016/b978-0-08-100596-5.22593- trans fat, added sugar). Also including agro-processing and 6 fortification 101. Amenu D. Standards related foods and food products. Food labelling Consumer-oriented labelling on food packaging and menu boards Int J Adv Res Biol Sci. 2017;4:201-206. doi:10.22192/ijarbs.2017.04.12.020 in restaurants for consumers to make informed food choices and to 102. Béné C, Kawarazuka N, Pham H, et al. Policy framing and crisis narratives around prevent misleading claims food safety in Vietnam. Food Promotion of unhealthy foods to children including adolescents Environ Plan E Nat Sp. July 2020:2514848620941515. doi:10.1177/2514848620941515\ promotion across all media (print, on stores, in environment, social media, 103. Baye K, Hirvonen K, Dereje M, et al. Energy and nutrient production in Ethiopia, TV…), including food promotion, branding, sponsorship and 2011-2015: Implications to supporting healthy diets and food systems. . advertising, including actions related to promotion of breastmilk PLoS One 2019;14(3). https://doi.org/10.1371/journal.pone.0213182 substitutes 104. Ecker O, Al-Riffai P, Breisinger C, et al. Nutrition and Economic Development: Food provision Food provided in schools, early childhood education services, Exploring Egypt’s Exceptionalism and the Role of Food Subsidies. Washington, DC; hospitals, and other public institutions for food service activities 2016. (canteens, food at events, fundraising, promotions, vending 105. Hirvonen K, Wolle A, Minten B. Affordability of Fruits and Vegetables in Ethiopia. machines etc.) Addis Ababa; 2018. Food retail Availability of unhealthy foods in communities (outlet density, 106. Bekele TH, De Vries JJHM, Trijsburg L, et al. Methodology for developing and locations), types of outlets (small (informal) vendors, evaluating food-based dietary guidelines and a Healthy Eating Index for Ethiopia: A supermarkets, open markets etc) and in-store (product placement). study protocol. BMJ Open. 2019;9(7). doi:10.1136/bmjopen-2018-027846 Food prices Food pricing policies (e.g., taxes, subsidies) 107. Black RE, Allen LH, Bhutta ZA, et al. Maternal and child undernutrition: Global and Food trade Global or regional trade agreements, foreign direct investments regional exposures and health consequences. Lancet. 2008;371(9608):243-260. and doi:10.1016/S0140-6736(07)61690-0 investment 108. Hoffmann V, Jones K, Leroy JL. The impact of reducing dietary aflatoxin exposure on Food safety Potential contamination (microbiological, chemical, metals). child linear growth: A cluster randomised controlled trial in Kenya. BMJ Glob Heal. Includes food and water (safe drinking water). Regulations, 2018;3(6):e000983. doi:10.1136/bmjgh-2018-000983 standards to ensure safe production, processing, sale of foods. 109. CSA. Ethiopia Demographic and Health Survey 2011. Addis Ababa, Ethiopia and Food This refers to foods or drinks availability more broadly, it could Rockville, MD, USA: CSA and ICF; 2011. availability include schools, retail, the wider community or if policy documents 110. Roesel K, Grace D, eds. Food Safety and Informal Markets: Animal Products in Sub- do not specify the setting or what they mean with availability. Saharan Africa. London: Routledge; 2015. Dietary and nutritional goals 111. Ministry of Agriculture of Ethiopia. Transforming Ethiopian Food Systems: Better Dietary Diets that contain adequate food energy, macro- and Diet Quality, Prosperity, and Sustainability in a Changing Climate. quantity micronutrients to meet nutrition and health needs, support http://www.moa.gov.et/documents/20181/35819/EFS+Background+paper.pdf/e9 physical activity and achieve and maintain a healthy body weight. 756478-9b80-4a7a-9bb6-128b8889f93b (accessed 8 August 2021). Dietary quality Diets that contain the necessary macro- and micronutrients 112. Federal Democratic Republic of Ethiopia. Food Systems Pathway Commitment and without unhealthy additives such as transfats. Diet quality is Position Statement. Addis Ababa; 2021. associated with malnutrition but also with noncommunicable diseases, including diabetes, heart disease, stroke or cancer. Dietary Diets that include a variety of nutrient-dense foods, which are diversity usually grouped into (Vitamin A rich or dark green leafy) vegetables, (Vitamin A rich) fruits, grains and cereals, dairy foods and animal-source foods and plant-based protein foods such as legumes. 152 Policy review 97. Federal Democratic Republic of Ethiopia. National Food Fortification Program Plan Appendix 5.1. Code book used for food environment policiy analysis of Action 2017/2018-2021/22. Addis Ababa; 2017. 98. Havelaar AH, Kirk MD, Torgerson PR, et al. World Health Organization global estimates and regional comparisons of the burden of foodborne disease in 2010. Code Description PLoS Med. 2015. doi:10.1371/journal.pmed.1001923 Food environment domains 99. Walls H, Baker P, Chirwa E, et al. Food security, food safety & healthy nutrition: Are Food Food composition targets/standards/restrictions for processed they compatible? Glob Food Sec. 2019;21. doi:10.1016/j.gfs.2019.05.005 composition foods: to ensure that, where practicable, processed foods minimise 100. Abebe GK, Kassem II. Food safety regulations and enforcement in Ethiopia. In: and processing the energy density and the nutrients of concern (salt, saturated fat, Reference Module in Food Science; 2018. doi:10.1016/b978-0-08-100596-5.22593- trans fat, added sugar). Also including agro-processing and 6 fortification 101. Amenu D. Standards related foods and food products. Int J Adv Res Biol Sci. Food labelling Consumer-oriented labelling on food packaging and menu boards 2017;4:201-206. doi:10.22192/ijarbs.2017.04.12.020 in restaurants for consumers to make informed food choices and to 102. Béné C, Kawarazuka N, Pham H, et al. Policy framing and crisis narratives around prevent misleading claims food safety in Vietnam. Environ Plan E Nat Sp. July 2020:2514848620941515. Food Promotion of unhealthy foods to children including adolescents doi:10.1177/2514848620941515\ promotion across all media (print, on stores, in environment, social media, 103. Baye K, Hirvonen K, Dereje M, et al. Energy and nutrient production in Ethiopia, TV…), including food promotion, branding, sponsorship and 2011-2015: Implications to supporting healthy diets and food systems. . advertising, including actions related to promotion of breastmilk PLoS One 2019;14(3). https://doi.org/10.1371/journal.pone.0213182 substitutes 104. Ecker O, Al-Riffai P, Breisinger C, et al. Nutrition and Economic Development: Food provision Food provided in schools, early childhood education services, Exploring Egypt’s Exceptionalism and the Role of Food Subsidies. Washington, DC; hospitals, and other public institutions for food service activities 2016. (canteens, food at events, fundraising, promotions, vending 5 105. Hirvonen K, Wolle A, Minten B. Affordability of Fruits and Vegetables in Ethiopia. machines etc.) Addis Ababa; 2018. Food retail Availability of unhealthy foods in communities (outlet density, 106. Bekele TH, De Vries JJHM, Trijsburg L, et al. Methodology for developing and locations), types of outlets (small (informal) vendors, evaluating food-based dietary guidelines and a Healthy Eating Index for Ethiopia: A supermarkets, open markets etc) and in-store (product placement). study protocol. BMJ Open. 2019;9(7). doi:10.1136/bmjopen-2018-027846 Food prices Food pricing policies (e.g., taxes, subsidies) 107. Black RE, Allen LH, Bhutta ZA, et al. Maternal and child undernutrition: Global and Food trade Global or regional trade agreements, foreign direct investments regional exposures and health consequences. Lancet. 2008;371(9608):243-260. and doi:10.1016/S0140-6736(07)61690-0 investment 108. Hoffmann V, Jones K, Leroy JL. The impact of reducing dietary aflatoxin exposure on Food safety Potential contamination (microbiological, chemical, metals). child linear growth: A cluster randomised controlled trial in Kenya. BMJ Glob Heal. Includes food and water (safe drinking water). Regulations, 2018;3(6):e000983. doi:10.1136/bmjgh-2018-000983 standards to ensure safe production, processing, sale of foods. 109. CSA. Ethiopia Demographic and Health Survey 2011. Addis Ababa, Ethiopia and Food This refers to foods or drinks availability more broadly, it could Rockville, MD, USA: CSA and ICF; 2011. availability include schools, retail, the wider community or if policy documents 110. Roesel K, Grace D, eds. Food Safety and Informal Markets: Animal Products in Sub- do not specify the setting or what they mean with availability. Saharan Africa. London: Routledge; 2015. Dietary and nutritional goals 111. Ministry of Agriculture of Ethiopia. Transforming Ethiopian Food Systems: Better Dietary Diets that contain adequate food energy, macro- and Diet Quality, Prosperity, and Sustainability in a Changing Climate. quantity micronutrients to meet nutrition and health needs, support http://www.moa.gov.et/documents/20181/35819/EFS+Background+paper.pdf/e9 physical activity and achieve and maintain a healthy body weight. 756478-9b80-4a7a-9bb6-128b8889f93b (accessed 8 August 2021). Dietary quality Diets that contain the necessary macro- and micronutrients 112. Federal Democratic Republic of Ethiopia. Food Systems Pathway Commitment and without unhealthy additives such as transfats. Diet quality is Position Statement. Addis Ababa; 2021. associated with malnutrition but also with noncommunicable diseases, including diabetes, heart disease, stroke or cancer. Dietary Diets that include a variety of nutrient-dense foods, which are diversity usually grouped into (Vitamin A rich or dark green leafy) vegetables, (Vitamin A rich) fruits, grains and cereals, dairy foods and animal-source foods and plant-based protein foods such as legumes. 153 Chapter 5 Code Description Dietary safety Diets that contain foods and beverages that are safe to consume with foods and beverages free from contamination with pathogens, mycotoxins or chemicals. Micronutrient A form of malnutrition caused by deficiencies of individual deficiencies nutrients (Vit a, iodine, iron etc) or combinations of nutrients. Overweight Reflects excess dietary energy with a body mass index above and obesity 25m2/kg or in children with weight greater than 2 standard deviations above normal weight for their height. Undernutrition Wasting (acute malnutrition, reflecting recent or severe weight loss associated with lack of calories, defined as child’s weight two standard deviations below normal weight for their height), stunting (or chronic malnutrition reflects long-term effects of dietary deficiencies, defined as a child’s height being two standard deviations below the normal height for their age) 154 Policy review 5 155 CHAPTER 6 General discussion Chapter 6 INTRODUCTION healthy food groups. We found no association between the food environment and dietary indicators or BMI status. Multiple factors can lead to overweight and obesity but unhealthy diets remain one of the key contributors. Diets in turn are influenced by diverse factors. Using the The results of the analysis of Ethiopian policy documents (Chapter 5) showed that example of Ethiopia, especially with regard to adolescents, we aimed to assess these all food environment domains have been addressed to some extent but that gaps factors and how they are addressed in Ethiopian policies. The first chapter provides remain compared to global best practice, especially in food promotion, processing, an introduction to the key issues covered in the research. retail, price, and trade. Since 2018, policy has begun to embrace the wider food system, with more explicit food environment interventions becoming apparent. The research consisted of an evidence synthesis of dietary behaviour in all low- and middle-income countries (Chapter 2), focused on adolescents and school food Table 6.1. Summary of main findings environments in Chapters 3 and 4 and Ethiopian policy actions in Chapter 5. This thesis has contributed to understanding the factors influencing dietary behaviours Chapter Objectives and main findings of adolescents in Ethiopia and how policies address the different factors of the food 2. Objective: To synthesise the qualitative evidence on factors influencing obesogenic environment. This last chapter summarises the main findings per chapter and behaviours among women and adolescent girls in LMIC presents the key synthesised results. Furthermore, after methodological reflection, Main findings: several recommendations for future research and programming are suggested. • Good awareness of the value of a healthy diet and physical activity for good health, which was also perceived as beyond an individual’s control or a potential concern for adolescent girls in the future Summary of main findings • Unhealthy food was associated with ‘unsafe’, leading to the perceived safety of packaged food but concerns over fresh fruit and vegetables and street food A summary of the key findings can be found in Table 6.1. • Strong preference for taste of snack and fast food • Modern foods and sedentary lifestyle associated with higher social status; The evidence synthesis found that obesogenic behaviours of adolescent girls and traditional and homecooked foods perceived as safer and healthier women of reproductive age are influenced by factors at individual, social, physical, • Husbands and children strongly influenced dietary choices of women; parents, and environmental levels (Chapter 2). The study identified gender norms and failure mostly mothers, influence adolescents’ diets to recognise the importance of healthy behaviours across the lifecycle as important • Healthy foods perceived as unaffordable and unavailable in neighbourhoods and within and around schools factors. The abundance and promotion of affordable but unhealthy food, food • Advertising was mostly associated with unhealthy food but also used as a safety concerns, taste preferences and social desirability of foods also drive the source of information consumption of unhealthy foods. 3. Objective: To assess factors influencing dietary behaviours of adolescents in Addis Ababa, Ethiopia Findings from the Photovoice study (Chapter 3) indicated that concerns over food Main findings: safety, hygiene, and affordability appear to be the major influencing factors for • Good knowledge about dietary diversity and healthy/unhealthy foods; healthy adolescents’ dietary choices. Participants considered the foods available in their is associated with ‘safe’ environments to be generally unsafe. Adolescents’ concerns, together with limited • Fried food, fruit and vegetables sold on the side of the road perceived as unsafe; nutrition knowledge and preference for packaged foods, could make cheap, ultra- packaged food with visible expiration date perceived as safe processed packaged foods appear more desirable to them. • Homecooked food perceived as safe, healthy, and clean but street food is still consumed due to taste preferences and lack of safer/affordable options The study on school food environments found pervasive advertising and availability • Parents, especially mothers, do most of the cooking and are perceived as a strong influence of unhealthy foods and beverages around urban schools in Ethiopia (Chapter 4). • Peers are a strong influence, especially in buying fried snack food around school Almost all the advertisements were of ultra-processed foods, mostly sugar- • Healthy foods, such as fish and meat, are perceived as unaffordable and fried sweetened beverages. The dietary diversity of adolescents was low and ultra- food/sweets as cheap processed foods and beverages were consumed by 23.5% of adolescents 24 hours • Bigger, more affordable, and safer outlets are difficult to access, therefore no prior to the assessment. Our analysis found that higher assets in adolescents’ choice but to purchase affordable but potentially unsafe food in the households were associated with higher dietary diversity and consumption of neighbourhood 158 General discussion INTRODUCTION healthy food groups. We found no association between the food environment and dietary indicators or BMI status. Multiple factors can lead to overweight and obesity but unhealthy diets remain one of the key contributors. Diets in turn are influenced by diverse factors. Using the The results of the analysis of Ethiopian policy documents (Chapter 5) showed that example of Ethiopia, especially with regard to adolescents, we aimed to assess these all food environment domains have been addressed to some extent but that gaps factors and how they are addressed in Ethiopian policies. The first chapter provides remain compared to global best practice, especially in food promotion, processing, an introduction to the key issues covered in the research. retail, price, and trade. Since 2018, policy has begun to embrace the wider food system, with more explicit food environment interventions becoming apparent. The research consisted of an evidence synthesis of dietary behaviour in all low- and middle-income countries (Chapter 2), focused on adolescents and school food Table 6.1. Summary of main findings environments in Chapters 3 and 4 and Ethiopian policy actions in Chapter 5. This thesis has contributed to understanding the factors influencing dietary behaviours Chapter Objectives and main findings of adolescents in Ethiopia and how policies address the different factors of the food 2. Objective: To synthesise the qualitative evidence on factors influencing obesogenic environment. This last chapter summarises the main findings per chapter and behaviours among women and adolescent girls in LMIC presents the key synthesised results. Furthermore, after methodological reflection, Main findings: several recommendations for future research and programming are suggested. • Good awareness of the value of a healthy diet and physical activity for good health, which was also perceived as beyond an individual’s control or a potential concern for adolescent girls in the future Summary of main findings • Unhealthy food was associated with ‘unsafe’, leading to the perceived safety of packaged food but concerns over fresh fruit and vegetables and street food A summary of the key findings can be found in Table 6.1. • Strong preference for taste of snack and fast food • Modern foods and sedentary lifestyle associated with higher social status; The evidence synthesis found that obesogenic behaviours of adolescent girls and traditional and homecooked foods perceived as safer and healthier women of reproductive age are influenced by factors at individual, social, physical, • Husbands and children strongly influenced dietary choices of women; parents, 6 and environmental levels (Chapter 2). The study identified gender norms and failure mostly mothers, influence adolescents’ diets to recognise the importance of healthy behaviours across the lifecycle as important • Healthy foods perceived as unaffordable and unavailable in neighbourhoods and within and around schools factors. The abundance and promotion of affordable but unhealthy food, food • Advertising was mostly associated with unhealthy food but also used as a safety concerns, taste preferences and social desirability of foods also drive the source of information consumption of unhealthy foods. 3. Objective: To assess factors influencing dietary behaviours of adolescents in Addis Ababa, Ethiopia Findings from the Photovoice study (Chapter 3) indicated that concerns over food Main findings: safety, hygiene, and affordability appear to be the major influencing factors for • Good knowledge about dietary diversity and healthy/unhealthy foods; healthy adolescents’ dietary choices. Participants considered the foods available in their is associated with ‘safe’ environments to be generally unsafe. Adolescents’ concerns, together with limited • Fried food, fruit and vegetables sold on the side of the road perceived as unsafe; nutrition knowledge and preference for packaged foods, could make cheap, ultra- packaged food with visible expiration date perceived as safe processed packaged foods appear more desirable to them. • Homecooked food perceived as safe, healthy, and clean but street food is still consumed due to taste preferences and lack of safer/affordable options The study on school food environments found pervasive advertising and availability • Parents, especially mothers, do most of the cooking and are perceived as a strong influence of unhealthy foods and beverages around urban schools in Ethiopia (Chapter 4). • Peers are a strong influence, especially in buying fried snack food around school Almost all the advertisements were of ultra-processed foods, mostly sugar- • Healthy foods, such as fish and meat, are perceived as unaffordable and fried sweetened beverages. The dietary diversity of adolescents was low and ultra- food/sweets as cheap processed foods and beverages were consumed by 23.5% of adolescents 24 hours • Bigger, more affordable, and safer outlets are difficult to access, therefore no prior to the assessment. Our analysis found that higher assets in adolescents’ choice but to purchase affordable but potentially unsafe food in the households were associated with higher dietary diversity and consumption of neighbourhood 159 Chapter 6 4. Objective: To assess whether food environments in and around schools in urban SYNTHESIS OF FINDINGS Ethiopia influence dietary diversity, quality, BMI status or perceptions of adolescents Main findings: The influencing factors of dietary behaviours are diverse, including individual • Average dietary diversity of adolescents was 3.6/10 food groups, with most preferences, environmental factors, and cross-cutting issues such as gender norms. consuming grains, pulses, and vegetables but few consuming eggs, dairy, fruit, Below, specific factors cutting across the different chapters are discussed and, or green leafy vegetables; 23% consumed ultra-processed foods where applicable, compared with the policy actions identified in Chapter 5. • Private school adolescents and adolescents with more assets in the household had higher dietary diversity and consumption of meat and healthy food groups Food safety concerns can overshadow issues related to food and nutrition security • Adolescents spent their pocket money mostly on fried food, SSB or sweets • Adolescents perceived that unhealthy snack food and healthy food was available around the school; they perceived most advertising as unhealthy and Fear of food safety was an important factor identified in Chapters 2 and 3. This fear private school adolescents reported always having fruit, vegetables, SSB and was mostly related to fresh, perishable food such as fruit and vegetables. A multi- snacks in their homes country study found that adolescents did not trust vegetables sold in larger • Within the compounds of the 12 schools, all but 2 sold SSB on the premises and markets,1 which could be linked to the unhygienic surroundings of the vendors or a 3 schools advertised SSB fear of pesticides.2 Studies included in our evidence synthesis (Chapter 2) hint • In a 0.5-km radius around the schools, 113–924 food outlets were identified, of towards the risk of these concerns leading to a higher consumption of ultra- which most were kiosks. Kiosks had the most SSB adverts and displays. Around processed foods, which were preferred due to their hygienic packaging and labels the schools, 44–720 food and beverage adverts were identified, of which 89.9% displaying expiry dates. A recent systematic review of food safety concerns found were for SSB that these concerns can shift purchasing and consumption behaviours away from • Density of the food environment in terms of outlets and advertising was not associated with the adolescents’ diets, BMI, or perceptions fresh fruit and vegetables or animal-source foods towards packaged, ultra- 2 5. Objective: To assess how different food environment domains have been addressed processed foods. A potential solution identified by study participants of the in Ethiopian policy goals and actions over time and how they compare with global Photovoice study (Chapter 3) was to ban informal food outlets and replace them good practice benchmarks with more modern, safer outlets. However, in Addis Ababa these small outlets may Main findings: contribute to the easy access and availability of fruit and vegetables.3 Supermarkets • Policy goals have broadened from a focus on undernutrition to a might be considered safer due to private food safety standards and management recognition of the double burden of malnutrition across the lifecycle systems,4,5 which has led Asian governments especially to introduce the • All the 8 food environment domains were addressed to some extent, but modernization of food retail through ‘supermarketization’.6 However, studies from gaps remain in food promotion, processing, retail, price, and trade Vietnam have shown that policy action aiming to ban or formalise informal vendors • Food composition and processing: proposal to replace trans-fat and or markets into modern markets has negatively affected the affordability and saturated fats with mono- and polyunsaturated fats, and to reduce salt desirability of vegetables in particular.7 • Food labelling: packaged food must include an ingredient list; proposal to label salt and sugar content on front of packaged foods and drinks • Food promotion: provisions of the International Code of Marketing of Furthermore, if food safety policies punish informal vendors without providing Breastmilk Substitutes adopted; restrictions on advertising of food with sufficient support or training on how to comply with the regulations, they could high levels of sugar, salt, and fat (on children’s TV programmes) harm the vendors’ livelihoods.8 Street vending can help to alleviate poverty,9 • Food prices: no subsidies on healthy foods; tax on food and beverages especially for women, who have an important role in many traditional food value high in salt, sugar, trans- and saturated fats; food-related support for chains.10 For instance: in Harare, Zimbabwe, about 81% of people involved in street food-insecure households food vending are women; and in Pretoria, South Africa, most informal vendors • Food retail: no policy action for zoning laws on density/location of involved in the sale of ready-to-eat chicken and chicken by-products are women.11 un/healthy food service outlets or in-store availability of un/healthy foods Informal food production, processing and marketing is therefore very important to • Food trade: regulations on food safety and quality but no assessment of women’s livelihoods. Participants in the Photovoice study (Chapter 3) also talked impact of trade agreements on nutrition and health about women’s struggle in the informal sector, the harassment caused by policy and • Food safety: numerous policy actions, but enforcement is limited • Since 2018, policy began to embrace the wider food system, with more the limited options for women to make a living. explicit food environment interventions becoming apparent 160 General discussion 4. Objective: To assess whether food environments in and around schools in urban SYNTHESIS OF FINDINGS Ethiopia influence dietary diversity, quality, BMI status or perceptions of adolescents Main findings: The influencing factors of dietary behaviours are diverse, including individual • Average dietary diversity of adolescents was 3.6/10 food groups, with most preferences, environmental factors, and cross-cutting issues such as gender norms. consuming grains, pulses, and vegetables but few consuming eggs, dairy, fruit, Below, specific factors cutting across the different chapters are discussed and, or green leafy vegetables; 23% consumed ultra-processed foods where applicable, compared with the policy actions identified in Chapter 5. • Private school adolescents and adolescents with more assets in the household had higher dietary diversity and consumption of meat and healthy food groups Food safety concerns can overshadow issues related to food and nutrition security • Adolescents spent their pocket money mostly on fried food, SSB or sweets • Adolescents perceived that unhealthy snack food and healthy food was available around the school; they perceived most advertising as unhealthy and Fear of food safety was an important factor identified in Chapters 2 and 3. This fear private school adolescents reported always having fruit, vegetables, SSB and was mostly related to fresh, perishable food such as fruit and vegetables. A multi- snacks in their homes country study found that adolescents did not trust vegetables sold in larger • Within the compounds of the 12 schools, all but 2 sold SSB on the premises and markets,1 which could be linked to the unhygienic surroundings of the vendors or a 3 schools advertised SSB fear of pesticides.2 Studies included in our evidence synthesis (Chapter 2) hint • In a 0.5-km radius around the schools, 113–924 food outlets were identified, of towards the risk of these concerns leading to a higher consumption of ultra- which most were kiosks. Kiosks had the most SSB adverts and displays. Around processed foods, which were preferred due to their hygienic packaging and labels the schools, 44–720 food and beverage adverts were identified, of which 89.9% displaying expiry dates. A recent systematic review of food safety concerns found were for SSB that these concerns can shift purchasing and consumption behaviours away from • Density of the food environment in terms of outlets and advertising was not associated with the adolescents’ diets, BMI, or perceptions fresh fruit and vegetables or animal-source foods towards packaged, ultra- 2 5. Objective: To assess how different food environment domains have been addressed processed foods. A potential solution identified by study participants of the in Ethiopian policy goals and actions over time and how they compare with global Photovoice study (Chapter 3) was to ban informal food outlets and replace them good practice benchmarks with more modern, safer outlets. However, in Addis Ababa these small outlets may Main findings: contribute to the easy access and availability of fruit and vegetables.3 Supermarkets 6 • Policy goals have broadened from a focus on undernutrition to a might be considered safer due to private food safety standards and management recognition of the double burden of malnutrition across the lifecycle systems,4,5 which has led Asian governments especially to introduce the • All the 8 food environment domains were addressed to some extent, but modernization of food retail through ‘supermarketization’.6 However, studies from gaps remain in food promotion, processing, retail, price, and trade Vietnam have shown that policy action aiming to ban or formalise informal vendors • Food composition and processing: proposal to replace trans-fat and or markets into modern markets has negatively affected the affordability and saturated fats with mono- and polyunsaturated fats, and to reduce salt desirability of vegetables in particular.7 • Food labelling: packaged food must include an ingredient list; proposal to label salt and sugar content on front of packaged foods and drinks • Food promotion: provisions of the International Code of Marketing of Furthermore, if food safety policies punish informal vendors without providing Breastmilk Substitutes adopted; restrictions on advertising of food with sufficient support or training on how to comply with the regulations, they could high levels of sugar, salt, and fat (on children’s TV programmes) harm the vendors’ livelihoods.8 Street vending can help to alleviate poverty,9 • Food prices: no subsidies on healthy foods; tax on food and beverages especially for women, who have an important role in many traditional food value high in salt, sugar, trans- and saturated fats; food-related support for chains.10 For instance: in Harare, Zimbabwe, about 81% of people involved in street food-insecure households food vending are women; and in Pretoria, South Africa, most informal vendors • Food retail: no policy action for zoning laws on density/location of involved in the sale of ready-to-eat chicken and chicken by-products are women.11 un/healthy food service outlets or in-store availability of un/healthy foods Informal food production, processing and marketing is therefore very important to • Food trade: regulations on food safety and quality but no assessment of women’s livelihoods. Participants in the Photovoice study (Chapter 3) also talked impact of trade agreements on nutrition and health about women’s struggle in the informal sector, the harassment caused by policy and • Food safety: numerous policy actions, but enforcement is limited • Since 2018, policy began to embrace the wider food system, with more the limited options for women to make a living. explicit food environment interventions becoming apparent 161 Chapter 6 Our policy analysis (Chapter 5) identified food safety as a dominant area of food to their society's feminine ideals, which for girls mostly meant being thin (Chapter environment policy action. While data on the food-borne disease burden in Ethiopia 2). Contrary to urban areas, rural women, especially in Africa, associated larger body are limited, sub-Saharan Africa is the WHO region with the highest estimated food- sizes with maturity, dignity, wealth, good health, and beauty.21 Our study in urban borne disease hazards.12 Policy action on food safety is therefore crucial, but Ethiopia also found that mothers might push girls to fit into an ideal body image investments in food-borne disease management are insufficient and skewed to which in African countries is refers to larger and in Asia and South America to thinner issues of lesser health importance, such as food exports, formal markets and bodies. (Chapter 3). chemical hazards,13 and are overfocused on control and command approaches (such as harassment of small-scale farmers or traders by authorities, bribes to police or Socio-economic status influences obesogenic behaviours confiscation of equipment).14 In Kenya, attempts to enforce the pasteurization of milk threaten the livelihoods of smallholder farmers and small-scale value chain Our qualitative evidence synthesis (Chapter 2) identified specific perceptions actors, while also reducing the accessibility of milk to poor households.14,15 Policies associated with different socio-economic backgrounds: wealth was associated with should therefore broaden their current focus on standards, inspections and trade the consumption of ‘modern’ unhealthy food, a larger body image and a sedentary control to also empower consumers and vendors while avoiding unintended lifestyle. Data show that people of higher socio-economic status living in urban areas consequences for food and nutrition security outcomes.13 Incoherent food safety are more likely to be obese, but a shift to lower socio-economic groups in rural policymaking could also distract from equally pressing issues related to the dietary settings becoming overweight and obese is already taking place in countries with an transition and result in an increase in overweight and obesity.6 increasing income level.22,23, Although in Ethiopia it is still mostly the wealthy and urban populations that are affected by overweight and obesity,24 this could shift as Gender norms are obstacles to healthy dietary behaviours in other countries.22 Also, in our Photovoice study (Chapter 3), the issue of an ideal feminine body image was discussed only by private school students but not Existing gender roles in society and also physical obstacles due to safety appear to government school students. hinder girls and women from being physically active and from consuming healthy food (Chapter 2). In the reviewed studies, women tended to conform to their In our study on the school food environment (Chapter 4), we found that adolescents husband’s dietary choices, which kept them from eating the healthy food they from households with more assets had higher dietary diversity and a higher would have preferred. The traditional gender roles that women have to fulfil in the consumption of healthy food groups. They also reported always having both healthy household can limit their time and further affect their dietary behaviours. Both the foods (fruit and vegetables) and unhealthy foods (snacks and SSB) in their homes, evidence synthesis (Chapter 2) and the Photovoice study (Chapter 3) identified that which might explain their more diverse diets. A national survey of Ethiopian mostly women prepared the food while fathers earned most of the household households in 2011 found that urban households of the higher and middle socio- income. These findings were consistent between government and private schools. economic strata had higher dietary diversity but were also more likely to consume sweets, meat, fruit and eggs.25 Government school students from poorer Although fathers were identified as the breadwinners, half of the mothers households with fewer assets reported that certain foods such as meat and fish reportedly were employed in our study (Chapter 4). Women in urban areas often were unaffordable for their families (Chapter 3), which is not surprising given that carry the double burden of earning an income while also taking care of the children prices of healthy foods such as fruit, vegetables and unprocessed meat in Ethiopia and the household.16 Time constraints of urban women who also face less family have increased by 21–74% between 2005 and 2018.26 This phenomenon of people support compared to rural areas, leave little time for these women to prepare spending more money on alternative, more diverse food sources as they become healthy food for their children.17 To compensate the lack of time, women are wealthier is not new.27 The shift from starchy staples towards more sugar, fat and tempted to purchase more convenient, often ultra-processed food for their animal products as finances increase has also been defined as the ‘nutrition children.17,18 Furthermore, women’s physical access to food can be limited due to transition’.28 poor safety and gender-based violence in urban built environments and public transport.19,20 Women therefore face multiple burden trying support healthy diets In terms of the food environment, both private and government school students for their children and themselves. agreed that unhealthy foods were widely available (Chapter 4). Contrasting studies found different perceptions of the food environment based on socio-economic Women also face pressure from the media and society to fit into certain body ideals. status, with more disadvantaged people in more disadvantaged neighbourhoods Girls and women from urban South America and Asia reported pressure to conform having more negative perceptions of healthy foods being available.29 In our studies 162 General discussion Our policy analysis (Chapter 5) identified food safety as a dominant area of food to their society's feminine ideals, which for girls mostly meant being thin (Chapter environment policy action. While data on the food-borne disease burden in Ethiopia 2). Contrary to urban areas, rural women, especially in Africa, associated larger body are limited, sub-Saharan Africa is the WHO region with the highest estimated food- sizes with maturity, dignity, wealth, good health, and beauty.21 Our study in urban borne disease hazards.12 Policy action on food safety is therefore crucial, but Ethiopia also found that mothers might push girls to fit into an ideal body image investments in food-borne disease management are insufficient and skewed to which in African countries is refers to larger and in Asia and South America to thinner issues of lesser health importance, such as food exports, formal markets and bodies. (Chapter 3). chemical hazards,13 and are overfocused on control and command approaches (such as harassment of small-scale farmers or traders by authorities, bribes to police or Socio-economic status influences obesogenic behaviours confiscation of equipment).14 In Kenya, attempts to enforce the pasteurization of milk threaten the livelihoods of smallholder farmers and small-scale value chain 14,15 Our qualitative evidence synthesis (Chapter 2) identified specific perceptions actors, while also reducing the accessibility of milk to poor households. Policies associated with different socio-economic backgrounds: wealth was associated with should therefore broaden their current focus on standards, inspections and trade the consumption of ‘modern’ unhealthy food, a larger body image and a sedentary control to also empower consumers and vendors while avoiding unintended lifestyle. Data show that people of higher socio-economic status living in urban areas consequences for food and nutrition security outcomes.13 Incoherent food safety are more likely to be obese, but a shift to lower socio-economic groups in rural policymaking could also distract from equally pressing issues related to the dietary 6 settings becoming overweight and obese is already taking place in countries with an transition and result in an increase in overweight and obesity. increasing income level.22,23, Although in Ethiopia it is still mostly the wealthy and urban populations that are affected by overweight and obesity,24 this could shift as Gender norms are obstacles to healthy dietary behaviours in other countries.22 Also, in our Photovoice study (Chapter 3), the issue of an ideal feminine body image was discussed only by private school students but not Existing gender roles in society and also physical obstacles due to safety appear to government school students. hinder girls and women from being physically active and from consuming healthy food (Chapter 2). In the reviewed studies, women tended to conform to their In our study on the school food environment (Chapter 4), we found that adolescents husband’s dietary choices, which kept them from eating the healthy food they from households with more assets had higher dietary diversity and a higher would have preferred. The traditional gender roles that women have to fulfil in the 6 consumption of healthy food groups. They also reported always having both healthy household can limit their time and further affect their dietary behaviours. Both the foods (fruit and vegetables) and unhealthy foods (snacks and SSB) in their homes, evidence synthesis (Chapter 2) and the Photovoice study (Chapter 3) identified that which might explain their more diverse diets. A national survey of Ethiopian mostly women prepared the food while fathers earned most of the household households in 2011 found that urban households of the higher and middle socio- income. These findings were consistent between government and private schools. economic strata had higher dietary diversity but were also more likely to consume sweets, meat, fruit and eggs.25 Government school students from poorer Although fathers were identified as the breadwinners, half of the mothers households with fewer assets reported that certain foods such as meat and fish reportedly were employed in our study (Chapter 4). Women in urban areas often were unaffordable for their families (Chapter 3), which is not surprising given that carry the double burden of earning an income while also taking care of the children prices of healthy foods such as fruit, vegetables and unprocessed meat in Ethiopia and the household.16 Time constraints of urban women who also face less family have increased by 21–74% between 2005 and 2018.26 This phenomenon of people support compared to rural areas, leave little time for these women to prepare spending more money on alternative, more diverse food sources as they become healthy food for their children.17 To compensate the lack of time, women are wealthier is not new.27 The shift from starchy staples towards more sugar, fat and tempted to purchase more convenient, often ultra-processed food for their animal products as finances increase has also been defined as the ‘nutrition children.17,18 Furthermore, women’s physical access to food can be limited due to transition’.28 poor safety and gender-based violence in urban built environments and public transport.19,20 Women therefore face multiple burden trying support healthy diets In terms of the food environment, both private and government school students for their children and themselves. agreed that unhealthy foods were widely available (Chapter 4). Contrasting studies found different perceptions of the food environment based on socio-economic Women also face pressure from the media and society to fit into certain body ideals. status, with more disadvantaged people in more disadvantaged neighbourhoods Girls and women from urban South America and Asia reported pressure to conform having more negative perceptions of healthy foods being available.29 In our studies 163 Chapter 6 the findings imply that, in the neighbourhoods, the food environment might not be that different because private and government school students mostly lived in Weller et al.39 defined influencing factors for adolescents’ diets in terms of similar neighbourhoods. Government students in the Photovoice study (Chapter 3) opportunity (depending on the surroundings), resources (depending on financial as stated that supermarkets with safe and healthy foods were too far away and well as environmental factors) and autonomy (depending on the debate or therefore difficult to reach, whereas more private school students reported having negotiation between adolescents and their caregivers). Negotiations between a car so this should be less of an obstacle (Chapter 4). Study participants in the parents and children seem more apparent in urban areas, where dietary choices evidence synthesis (Chapter 2) reported limited access to safe pavements and were more abundant and adolescents had more autonomy over their purchasing transport, therefore this could be a crucial obstacle for government students to choices.39 However, in our study (Chapter 3), adolescents reported having debates access affordable food. A literature review found that in cities in LMIC, a high with parents because the parents seemed to be deciding most of what the proportion of the poor either walk or use non-motorised transport, which in Addis adolescents ate, leaving them little room to make their own choices. This influence Ababa accounts for about 40% of trips.30 However, in many cities there are few from parents was described as positive from mothers, who were perceived as more pavements and pedestrians have to share the crowded roads with vehicles, which health conscious and aware of food safety risks (Chapter 3). further limits the physical food access of people with low socio-economic status. Furthermore, caregivers often underestimated adolescents’ health-related Policy actions to improve the affordability of or access to healthy foods have not knowledge. A study in LMIC showed that adolescents had greater understanding of been identified in our policy analysis (Chapter 5). On the contrary, instead of diets and health than their parents.39 Participants in our Photovoice study (Chapter subsidizing healthy foods, policy actions included subsidies for sugar, flour, and oil. 3) also expressed that they felt not listened to by their parents, who wanted to teach The Productive Safety Net Programme of the Ethiopian government includes them what they knew. As well as parents, adolescents’ agency to make choices is conditional cash transfers or direct support in terms of cash or food to vulnerable defined by their wider social and physical environment. Similar to our study, a study households and individuals, but this support is not specific to healthy foods.31 If such on adolescents in Ethiopia43 found that affordability was a major factor in their transfer programmes directly provide or subsidise foods high in energy, sugar, fat dietary choices. Furthermore, knowledge translation into the consumption of and salt, or are implemented in the context of unhealthy food environments, the healthier foods is affected by the social aspect of eating together with peers and the cash could be used to purchase unhealthy foods.32 While studies on cash and food lack of trust in food safety and hygiene.38 Adolescent participants in our studies were transfer programmes found that beneficiaries had more diverse, nutrient-rich diets, also influenced by the hygiene in their environment and by their peers, both of they also reported increased consumption of processed foods high in energy and which affected their healthy choices despite the knowledge they had (Chapters 2 saturated fats.32,33 Some programmes could therefore undermine healthy diets and and 3). even lead to increased overweight in beneficiaries34-37 if factors in the food environment are not addressed. Despite these factors in adolescents’ physical or social surroundings that prevent them from acting on their knowledge, our evidence synthesis (Chapter 2) further Good nutrition knowledge is not sufficient to make healthy choices revealed that even when adolescents were able to decide, they might have lacked the motivation to do so. A study on adolescents’ aspirations to eat healthily found The studies identified by the evidence synthesis (Chapter 2), as well as our studies that eating healthily was seen as a vehicle to achieving a goal, such as a good future, in Addis Ababa (Chapters 3 and 4), showed that adolescents had good knowledge of but less as something to aspire to.44 Eating healthily might therefore feel more like the importance of dietary diversity, food safety and the healthiness of foods such as a ‘must’ than in line with their preferences. However, having a more positive outlook fruit and vegetables. Other studies also reported that adolescents had good for the future about possible outcomes, for instance in terms of their health goals, knowledge and awareness of the importance of healthy diets.38-40 However, could help adolescents with long-term goal setting.45 exercising agency to make decisions and choices depends on the context, relationships and the social power dynamics that an adolescent faces.41,42 Food choice is therefore an expression and negotiation of agency between the supervised spaces of home and school.38 Our studies found that exercising agency in food purchases was restrained by parents’ decisions, financial means, lack of food availability, safety and affordability in the environment that adolescents interacted with (Chapters 2 and 3). 164 General discussion the findings imply that, in the neighbourhoods, the food environment might not be that different because private and government school students mostly lived in Weller et al.39 defined influencing factors for adolescents’ diets in terms of similar neighbourhoods. Government students in the Photovoice study (Chapter 3) opportunity (depending on the surroundings), resources (depending on financial as stated that supermarkets with safe and healthy foods were too far away and well as environmental factors) and autonomy (depending on the debate or therefore difficult to reach, whereas more private school students reported having negotiation between adolescents and their caregivers). Negotiations between a car so this should be less of an obstacle (Chapter 4). Study participants in the parents and children seem more apparent in urban areas, where dietary choices evidence synthesis (Chapter 2) reported limited access to safe pavements and were more abundant and adolescents had more autonomy over their purchasing transport, therefore this could be a crucial obstacle for government students to choices.39 However, in our study (Chapter 3), adolescents reported having debates access affordable food. A literature review found that in cities in LMIC, a high with parents because the parents seemed to be deciding most of what the proportion of the poor either walk or use non-motorised transport, which in Addis adolescents ate, leaving them little room to make their own choices. This influence Ababa accounts for about 40% of trips.30 However, in many cities there are few from parents was described as positive from mothers, who were perceived as more pavements and pedestrians have to share the crowded roads with vehicles, which health conscious and aware of food safety risks (Chapter 3). further limits the physical food access of people with low socio-economic status. Furthermore, caregivers often underestimated adolescents’ health-related Policy actions to improve the affordability of or access to healthy foods have not knowledge. A study in LMIC showed that adolescents had greater understanding of been identified in our policy analysis (Chapter 5). On the contrary, instead of diets and health than their parents.39 Participants in our Photovoice study (Chapter subsidizing healthy foods, policy actions included subsidies for sugar, flour, and oil. 3) also expressed that they felt not listened to by their parents, who wanted to teach The Productive Safety Net Programme of the Ethiopian government includes them what they knew. As well as parents, adolescents’ agency to make choices is conditional cash transfers or direct support in terms of cash or food to vulnerable defined by their wider social and physical environment. Similar to our study, a study households and individuals, but this support is not specific to healthy foods.31 If such on adolescents in Ethiopia43 found that affordability was a major factor in their transfer programmes directly provide or subsidise foods high in energy, sugar, fat dietary choices. Furthermore, knowledge translation into the consumption of and salt, or are implemented in the context of unhealthy food environments, the healthier foods is affected by the social aspect of eating together with peers and the cash could be used to purchase unhealthy foods.32 While studies on cash and food lack of trust in food safety and hygiene.38 Adolescent participants in our studies were transfer programmes found that beneficiaries had more diverse, nutrient-rich diets, also influenced by the hygiene in their environment and by their peers, both of 6 they also reported increased consumption of processed foods high in energy and which affected their healthy choices despite the knowledge they had (Chapters 2 saturated fats.32,33 Some programmes could therefore undermine healthy diets and and 3). even lead to increased overweight in beneficiaries34-37 if factors in the food environment are not addressed. Despite these factors in adolescents’ physical or social surroundings that prevent them from acting on their knowledge, our evidence synthesis (Chapter 2) further Good nutrition knowledge is not sufficient to make healthy choices revealed that even when adolescents were able to decide, they might have lacked the motivation to do so. A study on adolescents’ aspirations to eat healthily found The studies identified by the evidence synthesis (Chapter 2), as well as our studies that eating healthily was seen as a vehicle to achieving a goal, such as a good future, in Addis Ababa (Chapters 3 and 4), showed that adolescents had good knowledge of but less as something to aspire to.44 Eating healthily might therefore feel more like the importance of dietary diversity, food safety and the healthiness of foods such as a ‘must’ than in line with their preferences. However, having a more positive outlook fruit and vegetables. Other studies also reported that adolescents had good for the future about possible outcomes, for instance in terms of their health goals, knowledge and awareness of the importance of healthy diets.38-40 However, could help adolescents with long-term goal setting.45 exercising agency to make decisions and choices depends on the context, relationships and the social power dynamics that an adolescent faces.41,42 Food choice is therefore an expression and negotiation of agency between the supervised spaces of home and school.38 Our studies found that exercising agency in food purchases was restrained by parents’ decisions, financial means, lack of food availability, safety and affordability in the environment that adolescents interacted with (Chapters 2 and 3). 165 Chapter 6 The dietary transition is taking place in Ethiopia, but policy actions are limited number of supermarkets in rural and traditional food systems such as that in Ethiopia is low,47 which we also found in our study (Chapter 3), with supermarkets The nutrition transition has been associated with an increasing availability of being the least common food outlet category in the areas around the schools. unhealthy foods, such as ultra-processed foods. Furthermore, annual growth in the Furthermore, in sub-Saharan Africa, the proportion of households shopping at retail value of ultra-processed food sales during 2013–2018 was highest in rural and supermarkets is reportedly low.52 Also in our study (Chapter 4), adolescents traditional food systems like that in Ethiopia.46,47 This transition has been described reported that their families purchased most food at markets, speciality stores such by studies in the evidence synthesis (Chapter 2) in terms of a rural–urban transition as butchers or bakeries, or small kiosks. Considering the amount of advertising and but also as a transition across generations, with the grandparents’ generation the availability of SSB that we found at kiosks, which dominate in the retail sector of preferring more traditional foods and the younger generation favouring so-called Addis Ababa, outlets other than supermarkets could contribute to the nutrition ‘modern foods’. transition in Ethiopia. Traditional dishes have been associated with social stigma in some countries However, policies in Ethiopia are not yet sufficiently addressing the nutrition (Chapter 2). However, traditional Ethiopian food and eating has a positive transition. The policy analysis (Chapter 5) found that while advertising of unhealthy connotation due to sharing food with family and friends from one plate, which food was recognised as a challenge, measures to ban it were limited to children’s TV adolescents perceived as positive (Chapter 3). Ethiopian dishes can also provide a programmes. No regulations were proposed to limit or restrict advertising of healthy diversity of legumes and green leafy vegetables. However, the preparation unhealthy foods or beverages around schools or social media, which is increasingly of Ethiopian food can be cumbersome and convenience options are appearing in the popular with adolescents in LMIC.40 Furthermore, most policy goals in Ethiopia still market, such as dried injera or powders for the sauces.48 Despite the cultural and only refer to reducing stunting or wasting or improving dietary diversity. Only three traditional importance of Ethiopian dishes, ultra-processed convenience food could policy documents aimed to end all forms of malnutrition, mentioning overweight or replace these traditional meals, as has been the case in other countries.49 obesity solely as a risk factor for diet-related non-communicable diseases (NCD). Policy actions addressing food promotion, processing, labelling or trade of Consuming non-traditional foods outside the home can also be considered unhealthy foods, which could contribute to reducing overweight, obesity or diet- prestigious by adolescents, and something they aspire to.38,44 Adolescents in our related NCD, are only in the early stages in Ethiopian policymaking. study mostly spent the little pocket money they had on fried food, SSB and sweets (Chapter 4). Other studies from LMIC found that as soon as adolescents had any METHODOLOGICAL REFLECTIONS financial means, they chose to spend it on unhealthy foods, which were also more affordable, accessible and desirable to them.38 These aspirations to be more modern Strengths and limitations might be further triggered by the advertising of non-traditional foods.38 This study adopted a mixed-method approach and included a wide range of Advertising of unhealthy foods such as SSB has been found to be omnipresent within methods. Collecting both qualitative and quantitative data and combining different and around schools in Addis Ababa (Chapter 4). Participants from different studies methods and sources of evidence allowed the data to be triangulated and identified in the evidence synthesis (Chapter 2), including our studies in Chapters 3 integrated.53 The qualitative analysis allowed a deeper understanding of the and 4, agreed that unhealthy food was more available, affordable, and advertised. complex reality of food environments and adolescent behaviours, providing insights However, in the school food environment study (Chapter 4), students did not that quantitative assessment of the school food environment by itself would not perceive advertising to be very prominent around the school, even though objective have shown. assessment of the food environment found a high number of adverts (246 in a 0.5 km radius around schools), with 89.9% promoting SSB. This percentage is higher Starting with a global perspective of obesogenic behaviours helped to position the than that found in similar studies: 48% in urban Kenya and Ghana50 and 25% in urban Ethiopian data in a broader context. The two studies described in Chapters 3 and 4 Mozambique.51 then focused on specific settings in urban Ethiopia, both in terms of quantitative mapping of the food environment as well as qualitative assessment of adolescents’ Changes in the retail environment, especially the increase in supermarkets, have perceptions. An important strength of this thesis is that the analysis of Ethiopian also been associated with the nutrition transition. Supermarkets were often policy documents allows some of the findings to be linked to the policies that associated with more diversity but also with more unhealthy food.4 However, the address these aspects. 166 General discussion The dietary transition is taking place in Ethiopia, but policy actions are limited number of supermarkets in rural and traditional food systems such as that in Ethiopia is low,47 which we also found in our study (Chapter 3), with supermarkets The nutrition transition has been associated with an increasing availability of being the least common food outlet category in the areas around the schools. unhealthy foods, such as ultra-processed foods. Furthermore, annual growth in the Furthermore, in sub-Saharan Africa, the proportion of households shopping at retail value of ultra-processed food sales during 2013–2018 was highest in rural and supermarkets is reportedly low.52 Also in our study (Chapter 4), adolescents traditional food systems like that in Ethiopia.46,47 This transition has been described reported that their families purchased most food at markets, speciality stores such by studies in the evidence synthesis (Chapter 2) in terms of a rural–urban transition as butchers or bakeries, or small kiosks. Considering the amount of advertising and but also as a transition across generations, with the grandparents’ generation the availability of SSB that we found at kiosks, which dominate in the retail sector of preferring more traditional foods and the younger generation favouring so-called Addis Ababa, outlets other than supermarkets could contribute to the nutrition ‘modern foods’. transition in Ethiopia. Traditional dishes have been associated with social stigma in some countries However, policies in Ethiopia are not yet sufficiently addressing the nutrition (Chapter 2). However, traditional Ethiopian food and eating has a positive transition. The policy analysis (Chapter 5) found that while advertising of unhealthy connotation due to sharing food with family and friends from one plate, which food was recognised as a challenge, measures to ban it were limited to children’s TV adolescents perceived as positive (Chapter 3). Ethiopian dishes can also provide a programmes. No regulations were proposed to limit or restrict advertising of healthy diversity of legumes and green leafy vegetables. However, the preparation unhealthy foods or beverages around schools or social media, which is increasingly of Ethiopian food can be cumbersome and convenience options are appearing in the popular with adolescents in LMIC.40 Furthermore, most policy goals in Ethiopia still market, such as dried injera or powders for the sauces.48 Despite the cultural and only refer to reducing stunting or wasting or improving dietary diversity. Only three traditional importance of Ethiopian dishes, ultra-processed convenience food could policy documents aimed to end all forms of malnutrition, mentioning overweight or replace these traditional meals, as has been the case in other countries.49 obesity solely as a risk factor for diet-related non-communicable diseases (NCD). Policy actions addressing food promotion, processing, labelling or trade of Consuming non-traditional foods outside the home can also be considered unhealthy foods, which could contribute to reducing overweight, obesity or diet- prestigious by adolescents, and something they aspire to.38,44 Adolescents in our related NCD, are only in the early stages in Ethiopian policymaking. study mostly spent the little pocket money they had on fried food, SSB and sweets 6 (Chapter 4). Other studies from LMIC found that as soon as adolescents had any METHODOLOGICAL REFLECTIONS financial means, they chose to spend it on unhealthy foods, which were also more affordable, accessible and desirable to them.38 These aspirations to be more modern Strengths and limitations might be further triggered by the advertising of non-traditional foods.38 This study adopted a mixed-method approach and included a wide range of Advertising of unhealthy foods such as SSB has been found to be omnipresent within methods. Collecting both qualitative and quantitative data and combining different and around schools in Addis Ababa (Chapter 4). Participants from different studies methods and sources of evidence allowed the data to be triangulated and identified in the evidence synthesis (Chapter 2), including our studies in Chapters 3 integrated.53 The qualitative analysis allowed a deeper understanding of the and 4, agreed that unhealthy food was more available, affordable, and advertised. complex reality of food environments and adolescent behaviours, providing insights However, in the school food environment study (Chapter 4), students did not that quantitative assessment of the school food environment by itself would not perceive advertising to be very prominent around the school, even though objective have shown. assessment of the food environment found a high number of adverts (246 in a 0.5 km radius around schools), with 89.9% promoting SSB. This percentage is higher Starting with a global perspective of obesogenic behaviours helped to position the than that found in similar studies: 48% in urban Kenya and Ghana50 and 25% in urban Ethiopian data in a broader context. The two studies described in Chapters 3 and 4 Mozambique.51 then focused on specific settings in urban Ethiopia, both in terms of quantitative mapping of the food environment as well as qualitative assessment of adolescents’ Changes in the retail environment, especially the increase in supermarkets, have perceptions. An important strength of this thesis is that the analysis of Ethiopian also been associated with the nutrition transition. Supermarkets were often policy documents allows some of the findings to be linked to the policies that associated with more diversity but also with more unhealthy food.4 However, the address these aspects. 167 Chapter 6 Assessment of diets and nutritional status in adolescents The four research projects were mostly independent, as data collection of one did not depend on the findings of another. However, the findings from the qualitative Our study used the Minimum Dietary Diversity for Women (MDD-W) and Global evidence review helped to shape the data collection of the two projects in Addis Dietary Recommendations (GDR) scores to describe the adolescents’ diets. Ababa. We applied both the socio-ecological framework originating from public Indicators such as the MDD-W can be used to assess nutrient adequacy or diet health disciplines, which has also been adapted to the African context54 and linked quality.56 However, although it has been validated for women of reproductive age, to the studies in Addis Ababa and the policy analysis, and the wider food systems which includes the age range of 15–19 years, the cut-off point of a minimum of 5/10 approach as part of A4NH ‘Food Systems for Healthier Diets’ flagship programme.55 food groups is not appropriate for adolescent boys.56 Therefore, we calculated the This allowed an interdisciplinary view, which was a major strength of the studies. average number of food groups consumed. Despite these strengths, this thesis does not come without limitations. One Because the MDD-W does not indicate risk related to NCD, we also categorised the limitation was the design of the study described in Chapter 4. A cross-sectional dietary data using the GDR score, which is a proxy for NCD risk and can be design can only provide a snapshot of the prevailing food environment and dietary administered to 15–19-year-olds.57 The GDR scores compare consumed food groups diversity at the time of the study, which does not allow causal inferences to be with recommendations for healthy foods as well as foods that should be limited, made. The food environment is a dynamic space that changes with the seasons, the such as snacks, ultra-processed foods/beverages and deep-fried foods.57 In addition, time of day or even exact location in the case of mobile vendors. Dietary behaviours foods and beverages consumed by our study participants were assigned to one of also differ throughout the year and adolescents’ behaviours and preferences can the four categories of the NOVA classification based on their level of processing.58 change quickly. Our study was not able to assess these variabilities in diets and the Our study focused on diet quality using these three different indicators to describe food environment, which could be the reason why no associations were found adolescents’ diets in the absence of validated indicators for the study population.59 between dietary behaviours and the factors in the physical environment. However, Considering how little is known about optimal diets during adolescence, which is a time and financial constraints did not allow for more than a cross-sectional study. key period of growth and development, our study contributed to that knowledge. However, considering that our study was the first to assess the school food environment in Addis Ababa, we considered it worthwhile to search for potential For our study we measured the weight and height of adolescents to calculate the associations. ‘BMI for age’ score, using WHO Anthro software to compare the mean height and BMI with the median of the WHO growth reference for 5–19-year-olds. The BMI has The design of the policy analysis was limited by only considering documents that been suggested for post-pubertal adolescents60 and is the reference currently used cover intentions rather than actual implementation of policy actions. Furthermore, for international comparison.61 It is an anthropometric measure of the quality of the evidence synthesis only focused on adolescent girls and women, which could nutrition and healthiness of the living environment during childhood and have limited the scope of the findings. In the studies in urban Ethiopia, we therefore adolescence and therefore is predictive of health and developmental outcomes included boys and girls to allow for different perspectives. throughout life.62 However, the references for adolescents (unlike those for children under 5 years of age) are not based on a multi-country sample but on a mostly Lastly, our focus solely on obesogenic behaviours and environments, especially in healthy, well-nourished sample,61 which could underestimate overweight rates in a the first study (Chapter 2), might have limited the findings related to factors population facing stunting and wasting and exposure to infectious diseases. influencing underweight, bearing in mind that countries such as Ethiopia (i.e. LMIC) Furthermore, growth spurts and age of puberty onset in adolescents can influence still suffer from a high burden of chronic and acute malnutrition, which was not weight gain and complicate assessment of the true prevalence of over- or addressed. It is therefore important to look at influencing factors of malnutrition underweight, requiring careful interpretation.63 With WHO growth references only more broadly, which we attempted in the Photovoice study by not being restrictive applicable up to age 19 years and BMI cut-offs applying to adults over 20 years,61 about the types of dietary behaviours of interest. Limiting our scope to solely study participants older than 19 years had to be excluded. overweight and obesity would have prevented the crucial findings related to food safety and hygiene. Also, in the policy analysis, we extracted data relevant to under- Besides diet, the BMI can be influenced by various factors contributing to energy and overweight, in terms of both goal setting and actions related to the food expenditure that our study did not assess, such as physical activity at home environment. (including heavy workloads), and by intergenerational factors such as exposures and 168 General discussion Assessment of diets and nutritional status in adolescents The four research projects were mostly independent, as data collection of one did not depend on the findings of another. However, the findings from the qualitative Our study used the Minimum Dietary Diversity for Women (MDD-W) and Global evidence review helped to shape the data collection of the two projects in Addis Dietary Recommendations (GDR) scores to describe the adolescents’ diets. Ababa. We applied both the socio-ecological framework originating from public Indicators such as the MDD-W can be used to assess nutrient adequacy or diet health disciplines, which has also been adapted to the African context54 and linked quality.56 However, although it has been validated for women of reproductive age, to the studies in Addis Ababa and the policy analysis, and the wider food systems which includes the age range of 15–19 years, the cut-off point of a minimum of 5/10 approach as part of A4NH ‘Food Systems for Healthier Diets’ flagship programme.55 food groups is not appropriate for adolescent boys.56 Therefore, we calculated the This allowed an interdisciplinary view, which was a major strength of the studies. average number of food groups consumed. Despite these strengths, this thesis does not come without limitations. One Because the MDD-W does not indicate risk related to NCD, we also categorised the limitation was the design of the study described in Chapter 4. A cross-sectional dietary data using the GDR score, which is a proxy for NCD risk and can be design can only provide a snapshot of the prevailing food environment and dietary administered to 15–19-year-olds.57 The GDR scores compare consumed food groups diversity at the time of the study, which does not allow causal inferences to be with recommendations for healthy foods as well as foods that should be limited, made. The food environment is a dynamic space that changes with the seasons, the such as snacks, ultra-processed foods/beverages and deep-fried foods.57 In addition, time of day or even exact location in the case of mobile vendors. Dietary behaviours foods and beverages consumed by our study participants were assigned to one of also differ throughout the year and adolescents’ behaviours and preferences can the four categories of the NOVA classification based on their level of processing.58 change quickly. Our study was not able to assess these variabilities in diets and the Our study focused on diet quality using these three different indicators to describe food environment, which could be the reason why no associations were found adolescents’ diets in the absence of validated indicators for the study population.59 between dietary behaviours and the factors in the physical environment. However, Considering how little is known about optimal diets during adolescence, which is a time and financial constraints did not allow for more than a cross-sectional study. key period of growth and development, our study contributed to that knowledge. However, considering that our study was the first to assess the school food environment in Addis Ababa, we considered it worthwhile to search for potential For our study we measured the weight and height of adolescents to calculate the associations. ‘BMI for age’ score, using WHO Anthro software to compare the mean height and 6 BMI with the median of the WHO growth reference for 5–19-year-olds. The BMI has The design of the policy analysis was limited by only considering documents that been suggested for post-pubertal adolescents60 and is the reference currently used cover intentions rather than actual implementation of policy actions. Furthermore, for international comparison.61 It is an anthropometric measure of the quality of the evidence synthesis only focused on adolescent girls and women, which could nutrition and healthiness of the living environment during childhood and have limited the scope of the findings. In the studies in urban Ethiopia, we therefore adolescence and therefore is predictive of health and developmental outcomes included boys and girls to allow for different perspectives. throughout life.62 However, the references for adolescents (unlike those for children under 5 years of age) are not based on a multi-country sample but on a mostly Lastly, our focus solely on obesogenic behaviours and environments, especially in healthy, well-nourished sample,61 which could underestimate overweight rates in a the first study (Chapter 2), might have limited the findings related to factors population facing stunting and wasting and exposure to infectious diseases. influencing underweight, bearing in mind that countries such as Ethiopia (i.e. LMIC) Furthermore, growth spurts and age of puberty onset in adolescents can influence still suffer from a high burden of chronic and acute malnutrition, which was not weight gain and complicate assessment of the true prevalence of over- or addressed. It is therefore important to look at influencing factors of malnutrition underweight, requiring careful interpretation.63 With WHO growth references only more broadly, which we attempted in the Photovoice study by not being restrictive applicable up to age 19 years and BMI cut-offs applying to adults over 20 years,61 about the types of dietary behaviours of interest. Limiting our scope to solely study participants older than 19 years had to be excluded. overweight and obesity would have prevented the crucial findings related to food safety and hygiene. Also, in the policy analysis, we extracted data relevant to under- Besides diet, the BMI can be influenced by various factors contributing to energy and overweight, in terms of both goal setting and actions related to the food expenditure that our study did not assess, such as physical activity at home environment. (including heavy workloads), and by intergenerational factors such as exposures and 169 Chapter 6 experiences during pregnancy, mediated through birth length and weight or the environment, social factors, behaviours and preferences.70 Our study was therefore occurrence of infections.62 focused on schools, where adolescents spend a major part of their day. Furthermore, as identified by our evidence synthesis (Chapter 2), adolescent girls in At the same time, we assessed the adolescents’ perceptions of the school and home LMIC face several obstacles to being physically active. Assessing these factors as part environment. However, our method did not account for their mobility and potential of our study in Ethiopia could have helped in the interpretation of data on the movement outside the area that we assessed around the school. Using GPS nutritional status of the adolescents. However, because data on factors influencing approaches would have been more appropriate to assess adolescents’ mobility than adolescents’ dietary behaviours in urban Ethiopia are lacking, we decided to focus the traditional neighbourhood approach.71 solely on diets. Lastly, the interaction of adolescents with the food environment was limited, given Assessment of the food environment the little pocket money they had available. Other methods, that assess perceptions of the food environment as a mediating factor of dietary behaviours, could therefore Our assessment of the food environment around schools was limited to the density be more informative. However, no standardised tool has been validated for 72 of food outlets and advertising. We did not conduct any food inventories to measure perceptions in LMIC. In our studies, we therefore combined elements of different the types of foods and beverages sold by an outlet in order to categorise outlets into tools to assess perceptions of the home and school environment but also several healthy and unhealthy. Only focusing on outlet type and ignoring other store other issues related to adolescents’ dietary behaviours. In essence, validated tools characteristics did not allow a detailed assessment of the food environment or the with key questions specific for adolescents about the food environment would be specific factors influencing individuals:64 for instance, a study in urban Kenya found useful to better triangulate the information. that food outlet types differed based on the foods sold and advertised.50 However, detailed store inventories are costly and time intensive,62 and were not possible in Implications for future research our study. Categorizing food outlets solely as healthy or unhealthy is important but might still be insufficient to reflect the heterogeneity of the different outlets.64,65 Our studies have identified entry points for future research on adolescents’ dietary Our study also identified mobile vendors, for which GPS approaches would have behaviours and food environments. been helpful to monitor their movements66 as GIS-based measures of store locations do not describe the food environment sufficiently. Furthermore, the dimension of Assessing dietary behaviours of adolescent girls and boys in LMIC. access does not solely refer to store locations but also to access to transport,64 which we also found to be relevant, especially for lower socio-economic groups (Chapter This will contribute to filling existing data gaps in dietary data and influencing 4). Overall, the methods that our studies applied were mostly developed in high- factors.59 While data collection on dietary diversity of adolescent girls (15-19y) is income countries and were not developed, adapted or validated for the informal planned as part of national DHS,59 for adolescent boys and adolescents 10-14 years retail environment in LMIC.67 old, dietary data gaps remain. Reporting data attributable to the participants’ demographics and socio-eocnomic situation would be an important starting point We combined and adapted different methods to capture the complexity of the food to better understand influencing factors on the individual and household level. environment and also tried to combine the purely density-based measures with Better knowledge on their behaviours and respective influencing factors further will adolescents’ perceptions and questions about their transport options. However, help translate the Ethiopian FBDG into appropriate age-specific educational different environmental assessment techniques could also have been considered, messages.73 such as a mix of store audits and GIS-based methods, as well as GPS to capture the mobility within the food environment.64 Engaging adolescents as active participants using participatory, creative methods. Mobility is also an important factor regarding adolescents as they move between Adolescents in our studies have shown good knowledge of nutrition and food safety their homes, schools, friends and work and consume a lot of their energy outside but often cannot act on their knowledge to translate it into healthy behaviours. the house.68,69 Traditional methods describing residential neighbourhoods could Research should go ‘beyond the perspectives’ of the adolescents and aim to therefore be misleading or limiting.69 Furthermore, exposure within a food understand the factors that influence their agency to make decisions depending on environment can be contaminated by other elements, such as the household food 170 General discussion experiences during pregnancy, mediated through birth length and weight or the environment, social factors, behaviours and preferences.70 Our study was therefore occurrence of infections.62 focused on schools, where adolescents spend a major part of their day. Furthermore, as identified by our evidence synthesis (Chapter 2), adolescent girls in At the same time, we assessed the adolescents’ perceptions of the school and home LMIC face several obstacles to being physically active. Assessing these factors as part environment. However, our method did not account for their mobility and potential of our study in Ethiopia could have helped in the interpretation of data on the movement outside the area that we assessed around the school. Using GPS nutritional status of the adolescents. However, because data on factors influencing approaches would have been more appropriate to assess adolescents’ mobility than adolescents’ dietary behaviours in urban Ethiopia are lacking, we decided to focus the traditional neighbourhood approach.71 solely on diets. Lastly, the interaction of adolescents with the food environment was limited, given Assessment of the food environment the little pocket money they had available. Other methods, that assess perceptions of the food environment as a mediating factor of dietary behaviours, could therefore Our assessment of the food environment around schools was limited to the density be more informative. However, no standardised tool has been validated for 72 of food outlets and advertising. We did not conduct any food inventories to measure perceptions in LMIC. In our studies, we therefore combined elements of different the types of foods and beverages sold by an outlet in order to categorise outlets into tools to assess perceptions of the home and school environment but also several healthy and unhealthy. Only focusing on outlet type and ignoring other store other issues related to adolescents’ dietary behaviours. In essence, validated tools characteristics did not allow a detailed assessment of the food environment or the with key questions specific for adolescents about the food environment would be specific factors influencing individuals:64 for instance, a study in urban Kenya found useful to better triangulate the information. that food outlet types differed based on the foods sold and advertised.50 However, detailed store inventories are costly and time intensive,62 and were not possible in Implications for future research our study. Categorizing food outlets solely as healthy or unhealthy is important but might still be insufficient to reflect the heterogeneity of the different outlets.64,65 Our studies have identified entry points for future research on adolescents’ dietary Our study also identified mobile vendors, for which GPS approaches would have behaviours and food environments. 6 been helpful to monitor their movements66 as GIS-based measures of store locations do not describe the food environment sufficiently. Furthermore, the dimension of Assessing dietary behaviours of adolescent girls and boys in LMIC. access does not solely refer to store locations but also to access to transport,64 which we also found to be relevant, especially for lower socio-economic groups (Chapter This will contribute to filling existing data gaps in dietary data and influencing 4). Overall, the methods that our studies applied were mostly developed in high- factors.59 While data collection on dietary diversity of adolescent girls (15-19y) is income countries and were not developed, adapted or validated for the informal planned as part of national DHS,59 for adolescent boys and adolescents 10-14 years retail environment in LMIC.67 old, dietary data gaps remain. Reporting data attributable to the participants’ demographics and socio-eocnomic situation would be an important starting point We combined and adapted different methods to capture the complexity of the food to better understand influencing factors on the individual and household level. environment and also tried to combine the purely density-based measures with Better knowledge on their behaviours and respective influencing factors further will adolescents’ perceptions and questions about their transport options. However, help translate the Ethiopian FBDG into appropriate age-specific educational different environmental assessment techniques could also have been considered, messages.73 such as a mix of store audits and GIS-based methods, as well as GPS to capture the mobility within the food environment.64 Engaging adolescents as active participants using participatory, creative methods. Mobility is also an important factor regarding adolescents as they move between Adolescents in our studies have shown good knowledge of nutrition and food safety their homes, schools, friends and work and consume a lot of their energy outside but often cannot act on their knowledge to translate it into healthy behaviours. the house.68,69 Traditional methods describing residential neighbourhoods could Research should go ‘beyond the perspectives’ of the adolescents and aim to therefore be misleading or limiting.69 Furthermore, exposure within a food understand the factors that influence their agency to make decisions depending on environment can be contaminated by other elements, such as the household food 171 Chapter 6 their socio-cultural system in which they live.41 Research should also contribute to school system, supported by regulations on the foods sold and advertised in and empower adolescents by including them in the design, data collection and analysis. around schools.38,78,79 Applying more mixed-method studies in food environment research Equality issues need to be addressed comprehensively Mixed-methods approaches will allow more comprehensive and nuanced Women seem to be stuck in traditional gender roles in the household, leaving them assessments of food environments.72 Specific aspects of the food environment, such little time to look after their own health. Interventions solely targeting women as food safety, have been lacking in food environment definitions and typologies;47 through empowerment or income generation activities could add further pressure there is also a need to benchmark food safety policy actions as part of food on their already limited time. However, policy actions to improve nutrition should environment policies.74 Socio-ecological processes need to be considered more in not reduce female employment but address social protection and workplace policies food environment research and there is a need to develop validated assessments of that promote work–life balance and provide care services. Gender equality perceptions of availability and accessibility to accurately depict the food therefore needs a societal approach, with men and fathers being involved and environment.72 Policy actions targeting the food environment could have negative playing their part.8 Our findings related to food affordability, especially of people outcomes for women, sustainability or livelihoods, therefore studies are needed to with low socio-economic status, need to be coherently addressed by policies. assess the potential unintended consequences of such policies and interventions Healthy foods that are missing in Ethiopian diets, such as fruit, vegetables, and on.8 animal-source foods, should be subsidised and social protection programmes providing cash or food need to consider access to healthy foods.8 Implications for policymaking and programming Taking a systems approach to address all forms of malnutrition Our research identified different entry points for policymaking and interventions. Our studies identified multiple factors influencing dietary behaviours that would Recognizing adolescents’ agency to improve their diets need to be addressed using a systems approach. The example of food safety showed that solely improving the safety and hygiene of food might neglect other important Global goals currently have a limited focus on adolescents.75 The disconnect issues. Food policies overfocused on regulatory approaches or formalization of the between the amount of investment on improving nutrition for children under 5 retail sector to improve food safety could have detrimental effects on the livelihoods 5,6 years and investments for older children or adolescents62 needs to be addressed of vendors and also on food affordability and availability. Risk analysis frameworks with interventions targeting the whole lifecycle.75,76 Adolescents should be part of with risk communication to help people make informed judgements about food the programming and policy process because they can be effective agents of change, safety hazards and risks are crucial in view of the many concerns that our studies 80 influencing their family’s and community’s diet and health.1 Programmes must revealed. A food systems approach to policymaking would consider potential recognise and leverage adolescents’ agency to make healthy choices, limiting interlinkages or unintended consequences of policies on different outcomes while 81 nutrient-poor and energy-dense foods38 and should also help adolescents to identifying appropriate policy actions. However, governments also have strengthen relationships and skills within the positive networks of supportive adults, competing roles and have to navigate with different power dynamics between allowing them a more positive view of their future and motivating them to work public health and the interests of the food industry, which could have positive 82,83 towards their health goals.45,77 Schools are an important setting for adolescent impacts on economic development. A systems approach to policymaking that is nutrition, where most interventions aim to increase the availability of healthy food tailored to address the double burden of malnutrition could save money and also be while removing unhealthy food items from vendors within and outside the school more efficient than single-duty interventions.32,84 property.70 Nutrition guidelines and standards that go beyond the energy and micronutrient requirements for food served within schools are crucial to ensure that school food programmes address the double burden of malnutrition.78 Comprehensive, multicomponent school programmes are therefore needed to promote healthy school food environments with safe and nutritious meals, inclusive and sustainable food procurement and food and nutrition education throughout the 172 General discussion their socio-cultural system in which they live.41 Research should also contribute to school system, supported by regulations on the foods sold and advertised in and empower adolescents by including them in the design, data collection and analysis. around schools.38,78,79 Applying more mixed-method studies in food environment research Equality issues need to be addressed comprehensively Mixed-methods approaches will allow more comprehensive and nuanced Women seem to be stuck in traditional gender roles in the household, leaving them assessments of food environments.72 Specific aspects of the food environment, such little time to look after their own health. Interventions solely targeting women as food safety, have been lacking in food environment definitions and typologies;47 through empowerment or income generation activities could add further pressure there is also a need to benchmark food safety policy actions as part of food on their already limited time. However, policy actions to improve nutrition should environment policies.74 Socio-ecological processes need to be considered more in not reduce female employment but address social protection and workplace policies food environment research and there is a need to develop validated assessments of that promote work–life balance and provide care services. Gender equality perceptions of availability and accessibility to accurately depict the food therefore needs a societal approach, with men and fathers being involved and environment.72 Policy actions targeting the food environment could have negative playing their part.8 Our findings related to food affordability, especially of people outcomes for women, sustainability or livelihoods, therefore studies are needed to with low socio-economic status, need to be coherently addressed by policies. assess the potential unintended consequences of such policies and interventions Healthy foods that are missing in Ethiopian diets, such as fruit, vegetables, and on.8 animal-source foods, should be subsidised and social protection programmes providing cash or food need to consider access to healthy foods.8 Implications for policymaking and programming Taking a systems approach to address all forms of malnutrition Our research identified different entry points for policymaking and interventions. Our studies identified multiple factors influencing dietary behaviours that would Recognizing adolescents’ agency to improve their diets need to be addressed using a systems approach. The example of food safety showed that solely improving the safety and hygiene of food might neglect other important Global goals currently have a limited focus on adolescents.75 The disconnect issues. Food policies overfocused on regulatory approaches or formalization of the 6 between the amount of investment on improving nutrition for children under 5 retail sector to improve food safety could have detrimental effects on the livelihoods years and investments for older children or adolescents62 needs to be addressed of vendors and also on food affordability and availability.5,6 Risk analysis frameworks with interventions targeting the whole lifecycle.75,76 Adolescents should be part of with risk communication to help people make informed judgements about food the programming and policy process because they can be effective agents of change, safety hazards and risks are crucial in view of the many concerns that our studies 80 influencing their family’s and community’s diet and health.1 Programmes must revealed. A food systems approach to policymaking would consider potential recognise and leverage adolescents’ agency to make healthy choices, limiting interlinkages or unintended consequences of policies on different outcomes while 81 nutrient-poor and energy-dense foods38 and should also help adolescents to identifying appropriate policy actions. However, governments also have strengthen relationships and skills within the positive networks of supportive adults, competing roles and have to navigate with different power dynamics between allowing them a more positive view of their future and motivating them to work public health and the interests of the food industry, which could have positive 82,83 towards their health goals.45,77 Schools are an important setting for adolescent impacts on economic development. A systems approach to policymaking that is nutrition, where most interventions aim to increase the availability of healthy food tailored to address the double burden of malnutrition could save money and also be 32,84 while removing unhealthy food items from vendors within and outside the school more efficient than single-duty interventions. property.70 Nutrition guidelines and standards that go beyond the energy and micronutrient requirements for food served within schools are crucial to ensure that school food programmes address the double burden of malnutrition.78 Comprehensive, multicomponent school programmes are therefore needed to promote healthy school food environments with safe and nutritious meals, inclusive and sustainable food procurement and food and nutrition education throughout the 173 Chapter 6 CONCLUSION References Our findings show that the influencing factors of dietary behaviours are diverse and 1. Bridging the Gap: Engaging Adolescents for Nutrition, Health and Sustainable include individual-, social-, physical- and macro-level factors. Our research found Development.; World Food Programme, 2018. that food safety concerns could negatively affect diets and therefore deserve 2. Liguori J, Trübswasser U, Pradeilles R, et al. How do food safety concerns affect coherent policy action to address the relevant public health risks without doing consumer behaviors and diets in low- and middle-income countries? A systematic harm. Body ideals, socio-cultural norms, media influence and limited time to review. Glob Food Secur 2022; 32; https://doi.org/10.1016/j.gfs.2021.100606 85 3. Assefa T, Abebe G, Lamoot I, et al. Urban food retailing and food prices in Africa: the prepare healthy food could push adolescent girls into unhealthy dieting behaviour case of Addis Ababa, Ethiopia. J Agribus Dev Emerg Econ. 2016. doi:10.1108/JADEE- and expose women more strongly to multiple burdens of malnutrition.86 Therefore, 02-2015-0009 unless gender norms and beliefs are addressed, women’s increased access to 4. Reardon T, Henson S, Gulati A. Links between supermarkets and food prices, diet resources will neither solve gender inequalities nor reduce the burden of women. diversity and food safety in developing countries. Trade, Food, Diet Heal Perspect Policy Options. January 2010:111-130. Perceptions related to the unhealthy diets and larger body images of wealthy 5. Wertheim-Heck SCO, Vellema S, Spaargaren G. Food safety and urban food markets people, combined with healthy food being more difficult to access or afford, are in Vietnam: The need for flexible and customized retail modernization policies. Food major challenges for people of low socio-economic status to eat healthily. Our Policy. 2015. doi:10.1016/j.foodpol.2015.05.002 findings also conclude that adolescents’ agency to make dietary choices depends 6. Béné C, Kawarazuka N, Pham H, et al. Policy framing and crisis narratives around food safety in Vietnam. Environ Plan E Nat Sp. July 2020:2514848620941515. not only on their knowledge but also on the complexity of their physical and social doi:10.1177/2514848620941515 surroundings and the confidence they have in their future. 7. Wertheim-Heck S, Spaargaren G, Vellema S. Food safety in everyday life: Shopping for vegetables in a rural city in Vietnam. J Rural Stud. 2014;35:37–48. The nutrition transition is taking place in Ethiopia with a high presence and doi:10.1016/j.jrurstud.2014.04.002 advertising of ultra-processed foods and beverages. Such unhealthy food 8. Centre for Food Policy at City, University of London and Results for Development environments, combined with concerns about food safety and adolescents’ (R4D), Taking a Food Systems Approach to Policymaking: A Resource for Policymakers aspirations for “modern” foods, could tempt adolescents to consume packaged, London, UK and Washington D.C. 2022. often ultra-processed foods. Policies in Ethiopia are not yet sufficiently and 9. Roever S. Street Vendors and Legal Reform in India, South Africa, and Peru. Cityscape. coherently addressing the food environment to promote healthy and safe diets in 2016;18(1):27-46. http://www.jstor.org/stable/26328239. 10. Grace D, Roesel K, Kang’ethe E, et al, Theis S. Gender Roles and Food Safety in 20 Ethiopia. A food systems approach to food environment policymaking would Informal Livestock and Fish Value Chains.; 2015. facilitate identifying potential interlinkages or unintended consequences of policies 11. Roesel K, Grace D, eds. Food Safety and Informal Markets: Animal Products in Sub- on different outcomes while identifying appropriate policy actions. Saharan Africa. London: Routledge; 2015. 12. Havelaar AH, Kirk MD, Torgerson PR, et al. World Health Organization Global Estimates and Regional Comparisons of the Burden of Foodborne Disease in 2010. PLoS Med. 2015. doi:10.1371/journal.pmed.1001923 13. Grace D, Alonso S, Mutua F, et al. Food Safety Investment Expert Advice: Burkina Faso, Ethiopia, Nigeria. Nairobi, Kenya; 2018. 14. Grace D, Makita K, Kang’ethe, EK et al. Safe Food, Fair Food: Participatory Risk Analysis for improving the safety of informally produced and marketed food in sub Saharan Africa. Rev Africaine Santé Prod Anim. 2010;8:3-11. 15. Alonso S, Muunda E, Ahlberg S, et al. Beyond food safety: Socio-economic effects of training informal dairy vendors in Kenya. Glob Food Sec. 2018;18:86-92. doi:https://doi.org/10.1016/j.gfs.2018.08.006 16. Pozarny P. Gender Roles and Opportunities for Women in Urban Environments (GSDRC Helpdesk Research Report 1337). Birmingham, UK; 2016. 17. Chaturvedi, S., Ramji, S., Arora, N.K. et al. Time-constrained mother and expanding market: emerging model of under-nutrition in India. BMC Public Health 2016; 16, 632. https://doi.org/10.1186/s12889-016-3189-4 18. Berhane, H. Y., Ekström, E.-C., Jirström, M., et al. Mixed blessings: A qualitative 174 General discussion CONCLUSION References Our findings show that the influencing factors of dietary behaviours are diverse and 1. Bridging the Gap: Engaging Adolescents for Nutrition, Health and Sustainable include individual-, social-, physical- and macro-level factors. Our research found Development.; World Food Programme, 2018. that food safety concerns could negatively affect diets and therefore deserve 2. Liguori J, Trübswasser U, Pradeilles R, et al. How do food safety concerns affect coherent policy action to address the relevant public health risks without doing consumer behaviors and diets in low- and middle-income countries? A systematic harm. Body ideals, socio-cultural norms, media influence and limited time to review. Glob Food Secur 2022; 32; https://doi.org/10.1016/j.gfs.2021.100606 85 3. Assefa T, Abebe G, Lamoot I, et al. Urban food retailing and food prices in Africa: the prepare healthy food could push adolescent girls into unhealthy dieting behaviour case of Addis Ababa, Ethiopia. J Agribus Dev Emerg Econ. 2016. doi:10.1108/JADEE- and expose women more strongly to multiple burdens of malnutrition.86 Therefore, 02-2015-0009 unless gender norms and beliefs are addressed, women’s increased access to 4. Reardon T, Henson S, Gulati A. Links between supermarkets and food prices, diet resources will neither solve gender inequalities nor reduce the burden of women. diversity and food safety in developing countries. Trade, Food, Diet Heal Perspect Policy Options. January 2010:111-130. Perceptions related to the unhealthy diets and larger body images of wealthy 5. Wertheim-Heck SCO, Vellema S, Spaargaren G. Food safety and urban food markets people, combined with healthy food being more difficult to access or afford, are in Vietnam: The need for flexible and customized retail modernization policies. Food major challenges for people of low socio-economic status to eat healthily. Our Policy. 2015. doi:10.1016/j.foodpol.2015.05.002 findings also conclude that adolescents’ agency to make dietary choices depends 6. Béné C, Kawarazuka N, Pham H, et al. Policy framing and crisis narratives around food safety in Vietnam. Environ Plan E Nat Sp. July 2020:2514848620941515. not only on their knowledge but also on the complexity of their physical and social doi:10.1177/2514848620941515 surroundings and the confidence they have in their future. 7. Wertheim-Heck S, Spaargaren G, Vellema S. Food safety in everyday life: Shopping for vegetables in a rural city in Vietnam. J Rural Stud. 2014;35:37–48. The nutrition transition is taking place in Ethiopia with a high presence and doi:10.1016/j.jrurstud.2014.04.002 advertising of ultra-processed foods and beverages. Such unhealthy food 8. Centre for Food Policy at City, University of London and Results for Development environments, combined with concerns about food safety and adolescents’ (R4D), Taking a Food Systems Approach to Policymaking: A Resource for Policymakers aspirations for “modern” foods, could tempt adolescents to consume packaged, London, UK and Washington D.C. 2022. often ultra-processed foods. Policies in Ethiopia are not yet sufficiently and 9. Roever S. Street Vendors and Legal Reform in India, South Africa, and Peru. Cityscape. 6 coherently addressing the food environment to promote healthy and safe diets in 2016;18(1):27-46. http://www.jstor.org/stable/26328239. 10. Grace D, Roesel K, Kang’ethe E, et al, Theis S. Gender Roles and Food Safety in 20 Ethiopia. A food systems approach to food environment policymaking would Informal Livestock and Fish Value Chains.; 2015. facilitate identifying potential interlinkages or unintended consequences of policies 11. Roesel K, Grace D, eds. Food Safety and Informal Markets: Animal Products in Sub- on different outcomes while identifying appropriate policy actions. Saharan Africa. London: Routledge; 2015. 12. Havelaar AH, Kirk MD, Torgerson PR, et al. World Health Organization Global Estimates and Regional Comparisons of the Burden of Foodborne Disease in 2010. PLoS Med. 2015. doi:10.1371/journal.pmed.1001923 13. Grace D, Alonso S, Mutua F, et al. Food Safety Investment Expert Advice: Burkina Faso, Ethiopia, Nigeria. Nairobi, Kenya; 2018. 14. Grace D, Makita K, Kang’ethe, EK et al. Safe Food, Fair Food: Participatory Risk Analysis for improving the safety of informally produced and marketed food in sub Saharan Africa. Rev Africaine Santé Prod Anim. 2010;8:3-11. 15. Alonso S, Muunda E, Ahlberg S, et al. Beyond food safety: Socio-economic effects of training informal dairy vendors in Kenya. Glob Food Sec. 2018;18:86-92. doi:https://doi.org/10.1016/j.gfs.2018.08.006 16. Pozarny P. Gender Roles and Opportunities for Women in Urban Environments (GSDRC Helpdesk Research Report 1337). Birmingham, UK; 2016. 17. Chaturvedi, S., Ramji, S., Arora, N.K. et al. Time-constrained mother and expanding market: emerging model of under-nutrition in India. BMC Public Health 2016; 16, 632. https://doi.org/10.1186/s12889-016-3189-4 18. Berhane, H. Y., Ekström, E.-C., Jirström, M., et al. Mixed blessings: A qualitative 175 Chapter 6 exploration of mothers’ experience of child care and feeding in the rapidly urbanizing 35. Leroy JL, Gadsden P, González de Cossío T, et al. Cash and in-Kind Transfers Lead to city of Addis Ababa, Ethiopia. PLoS ONE, 2018; 13(11). Excess Weight Gain in a Population of Women with a High Prevalence of Overweight https://doi.org/10.1371/journal.pone.0207685 in Rural Mexico. J Nutr. 2013;143(3):378-383. doi:10.3945/jn.112.167627 19. Tanzarn, N. (2017). Scaling Up Gender Mainstreaming in Rural Transport: Policies, 36. Chaparro MP, Bernabe-Ortiz A, Harrison G. Association between food assistance Practices, Impacts and Monitoring Processes. International Forum for Rural Transport program participation and overweight Associação entre participação em programa de and Development (IFRTD); 2017 assistência alimentar e sobrepeso. Rev Saude Publica. 2014;48:889-898. 20. Aberman N, Meerman J, and van de Riet A. Integrating Gender into the Governance doi:10.1590/S0034-8910.2014048005359 of Urban Food Systems for Improved Nutrition. Global Alliance for Improved Nutrition 37. Fernald L, Gertler P, Hou X. Cash Component of Conditional Cash Transfer Program Is (GAIN). Working Paper #25. Geneva, Switzerland, 2021. DOI: Associated with Higher Body Mass Index and Blood Pressure in Adults. J Nutr. https://doi.org/10.36072/wp.25 2008;138:2250-2257. doi:10.3945/jn.108.090506 21. Ozodiegwu ID, Littleton MA, Nwabueze C, et al. A qualitative research synthesis of 38. Neufeld LM, Andrade EB, Ballonoff Suleiman A, et al. Food choice in transition: contextual factors contributing to female overweight and obesity over the life course adolescent autonomy, agency, and the food environment. Lancet. in sub-Saharan Africa. PLoS One. 2019;14(11):e0224612. 2022;399(10320):185-197. doi:10.1016/S0140-6736(21)01687-1 doi:10.1371/journal.pone.0224612 39. Weller S, Hardy-Johnson P, Strommer S, et al. ‘I should be disease free, healthy and 22. Dinsa GD, Goryakin Y, Fumagalli E, et al. Obesity and socioeconomic status in be happy in whatever I do’: a cross-country analysis of drivers of adolescent diet and developing countries: a systematic review. Obes Rev. 2012;13(11):1067-1079. physical activity in different low- and middle-income contexts. Public Health Nutr. doi:10.1111/j.1467-789X.2012.01017.x 2021;24(16):5238-5248. doi:DOI: 10.1017/S1368980020001810 23. Monteiro CA, MH DB, Conde WL, Popkin BM. Shifting obesity trends in Brazil. Eur J 40. Ali Z, Lelijveld N, Wrottesley S, et al. Adolescent Nutrition Mapping Study: A Global Clin Nutr. 2000;54(4):342-346. doi:10.1038/sj.ejcn.1600960 Stakeholder Survey of Policies, Research, Interventions and Data Gaps.; 2020. 24. CSA. Ethiopia Demographic and Health Survey 2019. Addis Ababa, Ethiopia and 41. Edmonds R. Making children’s ‘agency’ visible: Towards the localisation of a concept Rockville, Maryland; 2019. in theory and practice. Glob Stud Child. 2019;9(3):200-211. 25. Workicho A, Belachew T, Feyissa GT, et al. Household dietary diversity and Animal doi:10.1177/2043610619860994 Source Food consumption in Ethiopia: evidence from the 2011 Welfare Monitoring 42. Gallagher M. Rethinking children’s agency: Power, assemblages, freedom and Survey. BMC Public Health. 2016;16(1):1192. doi:10.1186/s12889-016-3861-8 materiality. Glob Stud Child. 2019;9(3):188-199. doi:10.1177/2043610619860993 26. Ameye H, Bachewe FN, Minten B. The rising price of nutritious foods: The case of 43. Abera M, Hardy-Johnson P, Abdissa A, et al. Social, economic and cultural influences Ethiopia. Glob Food Sec. 2021;31:100582. on adolescent nutrition and physical activity in Jimma, Ethiopia: perspectives from doi:https://doi.org/10.1016/j.gfs.2021.100582 adolescents and their caregivers. Public Health Nutr. 2021;24(16):5218-5226. doi:DOI: 27. Bennett MK. Population and Food Supply: The Current Scare. Sci Mon. 1949;68(1):17- 10.1017/S1368980020001664 26. http://www.jstor.org.ezproxy.library.wur.nl/stable/19802. 44. Madjdian D, Talsma E, Shrestha N, et al. ‘Like a frog in a well’’. A qualitative study of 28. Popkin BM. The nutrition transition and obesity in the developing world. J Nutr. adolescent girls’ life aspirations in Western Nepal.’ J Youth Stud. February 2022. 2001;131(3):871S-873S. doi:10.1093/jn/131.3.871S doi:10.1080/13676261.2022.2038782 29. Williams LK, Thornton L, Ball K, et al. Is the objective food environment associated 45. Gavin LE, Catalano RF, David-Ferdon C, et al. A Review of Positive Youth Development with perceptions of the food environment? Public Health Nutr. 2012;15(2):291-298. Programs That Promote Adolescent Sexual and Reproductive Health. J Adolesc Heal. doi:DOI: 10.1017/S1368980011001947 2010;46(3):S75-S91. doi:10.1016/j.jadohealth.2009.11.215 30. Starkey P, Hine J. Poverty and Sustainable Transport: How Transport Affects Poor 46. Baker P, Machado P, Santos T, et al. Ultra-processed foods and the nutrition People with Policy Implications for Poverty Reduction: A Literature Review.; 2014. transition: Global, regional and national trends, food systems transformations and 31. Ministry of Agriculture of Ethiopia. Productive Safety Net Programme 4 (PSNP IV)- political economy drivers. Obes Rev. 2020. doi:10.1111/obr.13126 Design Document. Addis Ababa; 2014. 47. Marshall Q, Fanzo J, Barrett CB, et al. Building a Global Food Systems Typology: A New 32. Hawkes C, Ruel MT, Salm L, et al. Double-duty actions: seizing programme and policy Tool for Reducing Complexity in Food Systems Analysis . Front Sustain Food Syst . opportunities to address malnutrition in all its forms. Lancet. 2020;395(10218):142- 2021;5:432. https://www.frontiersin.org/article/10.3389/fsufs.2021.746512. 155. doi:10.1016/S0140-6736(19)32506-1 48. Weaver LJ, Tadess Y, Stevenson EGJ, et al. “I want variety!”: Dietary variety as 33. Kronebusch N, Damon A. The impact of conditional cash transfers on nutrition aesthetic pursuit, social signal, and nutritional vehicle in Brazil and Ethiopia. Hum outcomes: Experimental evidence from Mexico. Econ Hum Biol. 2019;33:169-180. Organ. 2019;78(2):122-132. doi:10.17730/0018-7259.78.2.122 doi:https://doi.org/10.1016/j.ehb.2019.01.008 49. Cockx L, Colen L, De Weerdt J. From corn to popcorn? Urbanization and dietary 34. Leroy JL, Gadsden P, Rodríguez-Ramírez S, et al. Cash and In-Kind Transfers in Poor change: Evidence from rural-urban migrants in Tanzania. World Dev. 2018;110:140- Rural Communities in Mexico Increase Household Fruit, Vegetable, and Micronutrient 159. doi:https://doi.org/10.1016/j.worlddev.2018.04.018 Consumption but Also Lead to Excess Energy Consumption. J Nutr. 2010;140(3):612- 50. Green MA, Pradeilles R, Laar A, et al. Investigating foods and beverages sold and 617. doi:10.3945/jn.109.116285 advertised in deprived urban neighbourhoods in Ghana and Kenya: a cross-sectional 176 General discussion exploration of mothers’ experience of child care and feeding in the rapidly urbanizing 35. Leroy JL, Gadsden P, González de Cossío T, et al. Cash and in-Kind Transfers Lead to city of Addis Ababa, Ethiopia. PLoS ONE, 2018; 13(11). Excess Weight Gain in a Population of Women with a High Prevalence of Overweight https://doi.org/10.1371/journal.pone.0207685 in Rural Mexico. J Nutr. 2013;143(3):378-383. doi:10.3945/jn.112.167627 19. Tanzarn, N. (2017). Scaling Up Gender Mainstreaming in Rural Transport: Policies, 36. Chaparro MP, Bernabe-Ortiz A, Harrison G. Association between food assistance Practices, Impacts and Monitoring Processes. International Forum for Rural Transport program participation and overweight Associação entre participação em programa de and Development (IFRTD); 2017 assistência alimentar e sobrepeso. Rev Saude Publica. 2014;48:889-898. 20. Aberman N, Meerman J, and van de Riet A. Integrating Gender into the Governance doi:10.1590/S0034-8910.2014048005359 of Urban Food Systems for Improved Nutrition. Global Alliance for Improved Nutrition 37. Fernald L, Gertler P, Hou X. Cash Component of Conditional Cash Transfer Program Is (GAIN). Working Paper #25. Geneva, Switzerland, 2021. DOI: Associated with Higher Body Mass Index and Blood Pressure in Adults. J Nutr. https://doi.org/10.36072/wp.25 2008;138:2250-2257. doi:10.3945/jn.108.090506 21. Ozodiegwu ID, Littleton MA, Nwabueze C, et al. A qualitative research synthesis of 38. Neufeld LM, Andrade EB, Ballonoff Suleiman A, et al. Food choice in transition: contextual factors contributing to female overweight and obesity over the life course adolescent autonomy, agency, and the food environment. Lancet. in sub-Saharan Africa. PLoS One. 2019;14(11):e0224612. 2022;399(10320):185-197. doi:10.1016/S0140-6736(21)01687-1 doi:10.1371/journal.pone.0224612 39. Weller S, Hardy-Johnson P, Strommer S, et al. ‘I should be disease free, healthy and 22. Dinsa GD, Goryakin Y, Fumagalli E, et al. Obesity and socioeconomic status in be happy in whatever I do’: a cross-country analysis of drivers of adolescent diet and developing countries: a systematic review. Obes Rev. 2012;13(11):1067-1079. physical activity in different low- and middle-income contexts. Public Health Nutr. doi:10.1111/j.1467-789X.2012.01017.x 2021;24(16):5238-5248. doi:DOI: 10.1017/S1368980020001810 23. Monteiro CA, MH DB, Conde WL, Popkin BM. Shifting obesity trends in Brazil. Eur J 40. Ali Z, Lelijveld N, Wrottesley S, et al. Adolescent Nutrition Mapping Study: A Global Clin Nutr. 2000;54(4):342-346. doi:10.1038/sj.ejcn.1600960 Stakeholder Survey of Policies, Research, Interventions and Data Gaps.; 2020. 24. CSA. Ethiopia Demographic and Health Survey 2019. Addis Ababa, Ethiopia and 41. Edmonds R. Making children’s ‘agency’ visible: Towards the localisation of a concept Rockville, Maryland; 2019. in theory and practice. Glob Stud Child. 2019;9(3):200-211. 25. Workicho A, Belachew T, Feyissa GT, et al. Household dietary diversity and Animal doi:10.1177/2043610619860994 Source Food consumption in Ethiopia: evidence from the 2011 Welfare Monitoring 42. Gallagher M. Rethinking children’s agency: Power, assemblages, freedom and Survey. BMC Public Health. 2016;16(1):1192. doi:10.1186/s12889-016-3861-8 materiality. Glob Stud Child. 2019;9(3):188-199. doi:10.1177/2043610619860993 26. Ameye H, Bachewe FN, Minten B. The rising price of nutritious foods: The case of 43. Abera M, Hardy-Johnson P, Abdissa A, et al. Social, economic and cultural influences Ethiopia. Glob Food Sec. 2021;31:100582. on adolescent nutrition and physical activity in Jimma, Ethiopia: perspectives from 6 doi:https://doi.org/10.1016/j.gfs.2021.100582 adolescents and their caregivers. Public Health Nutr. 2021;24(16):5218-5226. doi:DOI: 27. Bennett MK. Population and Food Supply: The Current Scare. Sci Mon. 1949;68(1):17- 10.1017/S1368980020001664 26. http://www.jstor.org.ezproxy.library.wur.nl/stable/19802. 44. Madjdian D, Talsma E, Shrestha N, et al. ‘Like a frog in a well’’. A qualitative study of 28. Popkin BM. The nutrition transition and obesity in the developing world. J Nutr. adolescent girls’ life aspirations in Western Nepal.’ J Youth Stud. February 2022. 2001;131(3):871S-873S. doi:10.1093/jn/131.3.871S doi:10.1080/13676261.2022.2038782 29. Williams LK, Thornton L, Ball K, et al. Is the objective food environment associated 45. Gavin LE, Catalano RF, David-Ferdon C, et al. A Review of Positive Youth Development with perceptions of the food environment? Public Health Nutr. 2012;15(2):291-298. Programs That Promote Adolescent Sexual and Reproductive Health. J Adolesc Heal. doi:DOI: 10.1017/S1368980011001947 2010;46(3):S75-S91. doi:10.1016/j.jadohealth.2009.11.215 30. Starkey P, Hine J. Poverty and Sustainable Transport: How Transport Affects Poor 46. Baker P, Machado P, Santos T, et al. Ultra-processed foods and the nutrition People with Policy Implications for Poverty Reduction: A Literature Review.; 2014. transition: Global, regional and national trends, food systems transformations and 31. Ministry of Agriculture of Ethiopia. Productive Safety Net Programme 4 (PSNP IV)- political economy drivers. Obes Rev. 2020. doi:10.1111/obr.13126 Design Document. Addis Ababa; 2014. 47. Marshall Q, Fanzo J, Barrett CB, et al. Building a Global Food Systems Typology: A New 32. Hawkes C, Ruel MT, Salm L, et al. Double-duty actions: seizing programme and policy Tool for Reducing Complexity in Food Systems Analysis . Front Sustain Food Syst . opportunities to address malnutrition in all its forms. Lancet. 2020;395(10218):142- 2021;5:432. https://www.frontiersin.org/article/10.3389/fsufs.2021.746512. 155. doi:10.1016/S0140-6736(19)32506-1 48. Weaver LJ, Tadess Y, Stevenson EGJ, et al. “I want variety!”: Dietary variety as 33. Kronebusch N, Damon A. The impact of conditional cash transfers on nutrition aesthetic pursuit, social signal, and nutritional vehicle in Brazil and Ethiopia. Hum outcomes: Experimental evidence from Mexico. Econ Hum Biol. 2019;33:169-180. Organ. 2019;78(2):122-132. doi:10.17730/0018-7259.78.2.122 doi:https://doi.org/10.1016/j.ehb.2019.01.008 49. Cockx L, Colen L, De Weerdt J. From corn to popcorn? Urbanization and dietary 34. Leroy JL, Gadsden P, Rodríguez-Ramírez S, et al. Cash and In-Kind Transfers in Poor change: Evidence from rural-urban migrants in Tanzania. 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Public Heal Nutr (In 71. Wiehe SE, Hoch SC, Liu GC, et al. Adolescent Travel Patterns: Pilot Data Indicating Press. 2020. Distance from Home Varies by Time of Day and Day of Week. J Adolesc Heal. 55. Flagship 1 Food Systems for Healthier Diets, 2017. 2008;42(4):418-420. doi:10.1016/j.jadohealth.2007.09.018 https://a4nh.cgiar.org/files/2017/09/ PN_2016_A4NH_flagship_01_web.pdf 72. Turner C, Kalamatianou S, Drewnowski A, et al. Food Environment Research in Low- 56. FAO. Minimum Dietary Diversity for Women. Rome; 2021. and Middle-Income Countries: A Systematic Scoping Review. Adv Nutr. 2020. 57. Herforth AW, Wiesmann D, Martínez-Steele E, et al. Introducing a Suite of Low- doi:10.1093/advances/nmz031 Burden Diet Quality Indicators That Reflect Healthy Diet Patterns at Population Level. 73. Bekele, T. H., De Vries, J. J. H. M., Trijsburg, L., et al. Methodology for developing and Curr Dev Nutr. 2020;4(12):168-168. doi:10.1093/cdn/nzaa168 evaluating food-based dietary guidelines and a Healthy Eating Index for Ethiopia: A 58. Monteiro CA, Moubarac JC, Cannon G, et al. Ultra-processed products are becoming study protocol. BMJ Open, 2019; 9(7). https://doi.org/10.1136/bmjopen-2018- dominant in the global food system. Obes Rev. 2013;14 Suppl 2:21-28. 027846 doi:10.1111/obr.12107 74. Jaffee S, Henson S, Unnevehr L, et al. The Safe Food Imperative: Accelerating Progress 59. Kupka R, Siekmans K, Beal T. The diets of children: Overview of available data for in Low- and Middle-Income Countries. Agriculture and Food Series. Washington D.C.; children and adolescents. Glob Food Sec. 2020;27:100442. 2019. doi:doi:10.1596/978-1-4648-134 doi:10.1016/j.gfs.2020.100442 75. Patton GC, Neufeld LM, Dogra S, et al. Nourishing our future: the Lancet Series on 60. Woodruff BA, Duffield A. Anthropometric assessment of nutritional status in adolescent nutrition. Lancet. 2022;399(10320):123-125. doi:10.1016/S0140- adolescent populations in humanitarian emergencies. Eur J Clin Nutr. 6736(21)02140-1 2002;56(11):1108-1118. doi:10.1038/sj.ejcn.1601456 76. Madjdian DS, Azupogo F, Osendarp SJM, et al. Socio-cultural and economic 61. de Onis M, Onyango AW, Borghi E, et al. Development of a WHO growth reference for determinants and consequences of adolescent undernutrition and micronutrient school-aged children and adolescents. Bull World Health Organ. 2007;85(9):660-667. deficiencies in LLMICs: a systematic narrative review. Ann N Y Acad Sci. doi:10.2471/blt.07.043497 2018;1416(1):117-139. 62. Rodriguez-Martinez A, Zhou B, Sophiea MK, et al. Height and body-mass index 77. Benson P, Scales P, Hamilton S, et al. Positive Youth Development: Theory, Research, trajectories of school-aged children and adolescents from 1985 to 2019 in 200 and Applications. In: Handbook of Child Psychology: Theoretical Models of Human countries and territories: a pooled analysis of 2181 population-based studies with 65 Development. Volume 1. Vol 1. ; 2007. doi:10.1002/9780470147658.chpsy0116 million participants. Lancet. 2020;396(10261):1511-1524. doi:10.1016/S0140- 78. Food and Agriculture Organization of the United Nations (FAO). Nutrition Guidelines 6736(20)31859-6 and Standards for School Meals: A Report from 33 Low and Middle-Income Countries. 63. Tumilowicz A, Beal T, Neufeld LM, et al. Perspective: Challenges in Use of Adolescent Rome; 2019. Anthropometry for Understanding the Burden of Malnutrition. Adv Nutr. 79. Nutrition Action in Schools: A Review of Evidence Related to the Nutrition-Friendly 2019;10(4):563-575. doi:10.1093/advances/nmy133 Schools Initiative. Geneva; 2020. 64. Caspi CE, Sorensen G, Subramanian S V, Kawachi I. The local food environment and 80. Food and Agriculture Organization of the United Nations (FAO) and World Health diet: a systematic review. Health Place. 2012;18(5):1172-1187. Organization (WHO). Risk Communication Applied to Food Safety Handbook. Rome; doi:10.1016/j.healthplace.2012.05.006 2016. 65. An R, Sturm R. School and Residential Neighborhood Food Environment and Diet 81. Global Panel on Agriculture and Food Systems for Nutrition (Glopan). Food Systems Among California Youth. Am J Prev Med. 2012;42(2):129-135. Policy Tool.; 2021. doi:10.1016/j.amepre.2011.10.012 82. Wanjohi MN, Thow AM, Abdool Karim S, et al. Nutrition-related non-communicable 66. Peres C, Gardone D, Mendes L, et al. Retail food environment around schools and disease and sugar-sweetened beverage policies: a landscape analysis in Kenya. Glob overweight: a systematic review. Nutr Rev. 2020;78. doi:10.1093/nutrit/nuz110 Health Action. 2021;14(1):1902659. doi:10.1080/16549716.2021.1902659 67. Ahmed S, Kennedy G, Crum J, et al. Suitability of Data-Collection Methods, Tools, and Metrics for Evaluating Market Food Environments in Low- and Middle-Income 178 General discussion study. BMJ Open. 2020;10(6):e035680. doi:10.1136/bmjopen-2019-035680 Countries. Foods . 2021;10(11). doi:10.3390/foods10112728 51. Sousa S, Gelormini M, Damasceno A, et al. Billboard food advertising in Maputo, 68. Fox EL, Timmer A. Children’s and adolescents’ characteristics and interactions with Mozambique: a sign of nutrition transition. J Public Health (Oxf). 2020. the food system. Glob Food Sec. 2020. doi:10.1016/j.gfs.2020.100419 doi:10.1093/pubmed/fdz041 69. Shearer C, Rainham D, Blanchard C, et al. Measuring food availability and accessibility 52. Battersby J. Food System transformation in the Absence of Food System Planning: The among adolescents: Moving beyond the neighbourhood boundary. Soc Sci Med. Case of Supermarket and Shopping Mall Retail Expansion in Cape Town, South Africa. 2015;133:322-330. doi:https://doi.org/10.1016/j.socscimed.2014.11.019 Built Environ. 2017;43:417-430. doi:10.2148/benv.43.3.417 70. Carducci B, Oh C, Keats EC, et al. Effect of Food Environment Interventions on 53. Creswell J, Plano Clark VL. Designing and Conducting Mixed Methods Research. Third Anthropometric Outcomes in School-Aged Children and Adolescents in Low- and Edition. Los Angeles: SAGE Publications.; 2017. Middle-Income Countries: A Systematic Review and Meta-Analysis. Curr Dev Nutr. 54. Osei-Kwasi HA, Mohindra A, Booth A, et al. Factors influencing dietary behaviours in 2020;4(7):nzaa098. doi:10.1093/cdn/nzaa098 urban food environments in Africa: a systematic mapping review. Public Heal Nutr (In 71. Wiehe SE, Hoch SC, Liu GC, et al. Adolescent Travel Patterns: Pilot Data Indicating Press. 2020. Distance from Home Varies by Time of Day and Day of Week. J Adolesc Heal. 55. Flagship 1 Food Systems for Healthier Diets, 2017. 2008;42(4):418-420. doi:10.1016/j.jadohealth.2007.09.018 https://a4nh.cgiar.org/files/2017/09/ PN_2016_A4NH_flagship_01_web.pdf 72. Turner C, Kalamatianou S, Drewnowski A, et al. Food Environment Research in Low- 56. FAO. Minimum Dietary Diversity for Women. Rome; 2021. and Middle-Income Countries: A Systematic Scoping Review. Adv Nutr. 2020. 57. Herforth AW, Wiesmann D, Martínez-Steele E, et al. Introducing a Suite of Low- doi:10.1093/advances/nmz031 Burden Diet Quality Indicators That Reflect Healthy Diet Patterns at Population Level. 73. Bekele, T. H., De Vries, J. J. H. M., Trijsburg, L., et al. Methodology for developing and Curr Dev Nutr. 2020;4(12):168-168. doi:10.1093/cdn/nzaa168 evaluating food-based dietary guidelines and a Healthy Eating Index for Ethiopia: A 58. Monteiro CA, Moubarac JC, Cannon G, et al. Ultra-processed products are becoming study protocol. BMJ Open, 2019; 9(7). https://doi.org/10.1136/bmjopen-2018- dominant in the global food system. Obes Rev. 2013;14 Suppl 2:21-28. 027846 doi:10.1111/obr.12107 74. Jaffee S, Henson S, Unnevehr L, et al. The Safe Food Imperative: Accelerating Progress 59. Kupka R, Siekmans K, Beal T. The diets of children: Overview of available data for in Low- and Middle-Income Countries. Agriculture and Food Series. Washington D.C.; children and adolescents. Glob Food Sec. 2020;27:100442. 2019. doi:doi:10.1596/978-1-4648-134 doi:10.1016/j.gfs.2020.100442 75. Patton GC, Neufeld LM, Dogra S, et al. Nourishing our future: the Lancet Series on 60. Woodruff BA, Duffield A. Anthropometric assessment of nutritional status in adolescent nutrition. Lancet. 2022;399(10320):123-125. doi:10.1016/S0140- adolescent populations in humanitarian emergencies. Eur J Clin Nutr. 6736(21)02140-1 6 2002;56(11):1108-1118. doi:10.1038/sj.ejcn.1601456 76. Madjdian DS, Azupogo F, Osendarp SJM, et al. Socio-cultural and economic 61. de Onis M, Onyango AW, Borghi E, et al. Development of a WHO growth reference for determinants and consequences of adolescent undernutrition and micronutrient school-aged children and adolescents. Bull World Health Organ. 2007;85(9):660-667. deficiencies in LLMICs: a systematic narrative review. Ann N Y Acad Sci. doi:10.2471/blt.07.043497 2018;1416(1):117-139. 62. Rodriguez-Martinez A, Zhou B, Sophiea MK, et al. Height and body-mass index 77. Benson P, Scales P, Hamilton S, et al. Positive Youth Development: Theory, Research, trajectories of school-aged children and adolescents from 1985 to 2019 in 200 and Applications. In: Handbook of Child Psychology: Theoretical Models of Human countries and territories: a pooled analysis of 2181 population-based studies with 65 Development. Volume 1. Vol 1. ; 2007. doi:10.1002/9780470147658.chpsy0116 million participants. Lancet. 2020;396(10261):1511-1524. doi:10.1016/S0140- 78. Food and Agriculture Organization of the United Nations (FAO). Nutrition Guidelines 6736(20)31859-6 and Standards for School Meals: A Report from 33 Low and Middle-Income Countries. 63. Tumilowicz A, Beal T, Neufeld LM, et al. Perspective: Challenges in Use of Adolescent Rome; 2019. Anthropometry for Understanding the Burden of Malnutrition. Adv Nutr. 79. Nutrition Action in Schools: A Review of Evidence Related to the Nutrition-Friendly 2019;10(4):563-575. doi:10.1093/advances/nmy133 Schools Initiative. Geneva; 2020. 64. Caspi CE, Sorensen G, Subramanian S V, Kawachi I. The local food environment and 80. Food and Agriculture Organization of the United Nations (FAO) and World Health diet: a systematic review. Health Place. 2012;18(5):1172-1187. Organization (WHO). Risk Communication Applied to Food Safety Handbook. Rome; doi:10.1016/j.healthplace.2012.05.006 2016. 65. An R, Sturm R. School and Residential Neighborhood Food Environment and Diet 81. Global Panel on Agriculture and Food Systems for Nutrition (Glopan). Food Systems Among California Youth. Am J Prev Med. 2012;42(2):129-135. Policy Tool.; 2021. doi:10.1016/j.amepre.2011.10.012 82. Wanjohi MN, Thow AM, Abdool Karim S, et al. Nutrition-related non-communicable 66. Peres C, Gardone D, Mendes L, et al. Retail food environment around schools and disease and sugar-sweetened beverage policies: a landscape analysis in Kenya. Glob overweight: a systematic review. Nutr Rev. 2020;78. doi:10.1093/nutrit/nuz110 Health Action. 2021;14(1):1902659. doi:10.1080/16549716.2021.1902659 67. Ahmed S, Kennedy G, Crum J, et al. Suitability of Data-Collection Methods, Tools, and Metrics for Evaluating Market Food Environments in Low- and Middle-Income 179 Chapter 6 83. Laar A. The role of food environment policies in making unhealthy foods unattractive and healthy foods available in Africa. eClinicalMedicine. 2021;36. doi:10.1016/j.eclinm.2021.100908 84. Nugent R, Levin C, Hale J, et al. Economic effects of the double burden of malnutrition. Lancet. 2020;395(10218):156-164. doi:10.1016/S0140-6736(19)32473-0 85. Spencer RA, Rehman L, Kirk SFL. Understanding gender norms, nutrition, and physical activity in adolescent girls: a scoping review. Int J Behav Nutr Phys Act. 2015;12:6. doi:10.1186/s12966-015-0166-8 86. Wells JCK, Marphatia AA, Cole TJ, et al. Associations of economic and gender inequality with global obesity prevalence: Understanding the female excess. Soc Sci Med. 2012;75(3):482-490. doi:https://doi.org/10.1016/j.socscimed.2012.03.029 180 General discussion 83. Laar A. The role of food environment policies in making unhealthy foods unattractive and healthy foods available in Africa. eClinicalMedicine. 2021;36. doi:10.1016/j.eclinm.2021.100908 84. Nugent R, Levin C, Hale J, et al. Economic effects of the double burden of malnutrition. Lancet. 2020;395(10218):156-164. doi:10.1016/S0140-6736(19)32473-0 85. Spencer RA, Rehman L, Kirk SFL. Understanding gender norms, nutrition, and physical activity in adolescent girls: a scoping review. Int J Behav Nutr Phys Act. 2015;12:6. doi:10.1186/s12966-015-0166-8 86. Wells JCK, Marphatia AA, Cole TJ, et al. Associations of economic and gender inequality with global obesity prevalence: Understanding the female excess. Soc Sci Med. 2012;75(3):482-490. doi:https://doi.org/10.1016/j.socscimed.2012.03.029 6 181 SUMMARY Summary Background Healthy food is often associated with food safety and hygiene, which in an LMIC setting could lead to a preference for packaged foods at the expense of fresh fruit Multiple factors can lead to overweight and obesity but unhealthy diets remain one and vegetables. Despite the fears of poor hygiene, street food was often preferred of the key contributors. Diets in turn are influenced by diverse factors. Using the for its taste and convenience. Adolescent girls and women associated social status example of Ethiopia, especially with regard to adolescents, we aimed to assess these with modern snack food and a sedentary lifestyle; thus, consuming traditional foods, factors and how they are addressed in Ethiopian policies. was risking ridicule, even though homecooked meals were associated with healthier, safe, and clean food. Women’s dietary behaviours were strongly Objectives influenced by their husbands or children, to the extent that instead of their preferred healthy foods they purchased snacks that they perceived as tasty but unhealthy. Mothers, who cook most of the food, are seen as a positive influence on The overall objective of this thesis is to understand the factors influencing dietary adolescents’ diets. Healthy foods were generally perceived as unaffordable and behaviours of women and adolescents in low- to middle-income countries, and inaccessible in the neighbourhoods, with safer, healthier, more affordable foods specifically of adolescents in Ethiopia. Additionally, it aims to explore how these from supermarkets usually out of reach. Food at school cafeterias was described as adolescents perceive their food environment and how policies address the different healthy, but neither safe nor tasty, which made snack food around schools a more factors of the food environment. attractive choice. Food and beverage advertising was mostly associated with unhealthy food but also used as a source of information. Methods The study described in Chapter 3 assessed factors influencing dietary behaviours of This thesis applied a mixed-method research approach, employing both quantitative adolescents in Addis Ababa using a participatory method called Photovoice. The and qualitative methods. For Chapter 2, a qualitative evidence synthesis (QES) was interviews, focus group discussions and photographs revealed that adolescents had used to bring together the different types of qualitative evidence. This systematic good knowledge about the importance of a diverse, healthy diet while also realizing review followed a framework synthesis methodology to extract, analyse and that foods such as meat and sweets should be consumed in moderation. However, synthesise the qualitative data from primary research studies. For Chapter 3, we food safety appeared to be a bigger concern than nutrient content: healthy fruit and applied participatory action research using the Photovoice method, which is a vegetables sold on the side of the road were perceived as unhealthy due to the poor community-based participatory method in which participants take photographs of hygiene of their surroundings and packaged foods with a visible expiration date as their local environment to document and represent their community in relation to safe. Adolescents recognised fried street food as unsafe and unhealthy, but they a specific topic. A cross-sectional approach was used in Chapter 4. Using interview- liked its taste and associated it with the company of their peers after school; they administered questionnaires, adolescent participants were interviewed on socio- also perceived that they had no safe, affordable alternatives. However, homecooked demographic characteristics and food consumption. Height and weight were also food was considered safe, healthy, and clean. Mothers did most of the cooking and measured to assess the body mass index (BMI) status. In addition, the external and were therefore a strong influence, perceived as positive by private school students internal food environment in and around 12 selected schools was assessed using but negative by some government school students. Affordability also played an protocols from INFORMAS (the International Network for Food and Obesity/Non- important role: healthy foods (e.g. fish and meat) were seen as too expensive but Communicable Diseases Research, Monitoring and Action Support). For Chapter 5, fried foods and sweets as affordable; and bigger, more affordable, safer outlets such a policy analysis was conducted using the INFORMAS Healthy Food Environment as supermarkets were difficult to access, leaving no choice but to purchase the Policy Index (Food-EPI) framework as a basis. This study analysed Ethiopian policy affordable, potentially unsafe food in the neighbourhood. documents with regard to policy goals and actions addressing food environments and the respective dietary and nutritional outcomes. Chapter 4 describes a study on whether food environments in and around schools in urban Ethiopia influence dietary diversity, quality, BMI status or adolescents’ Results perception of the food and home environment. The mean dietary diversity of adolescents was only 3.6/10 food groups: most consumed grains, pulses, and vegetables; hardly any consumed eggs, dairy, fruit, or green leafy vegetables; and The review in Chapter 2 sought to synthesise qualitative evidence on individual-, 23% consumed ultra-processed foods such as SSB. Private school adolescents were social-, physical- and macro-level factors influencing obesogenic behaviours (eating more likely to have pocket money, which they mostly spent on fried food, SSB or and physical activity) in adolescent girls and women of reproductive age in LMIC. 184 Summary Background Healthy food is often associated with food safety and hygiene, which in an LMIC setting could lead to a preference for packaged foods at the expense of fresh fruit Multiple factors can lead to overweight and obesity but unhealthy diets remain one and vegetables. Despite the fears of poor hygiene, street food was often preferred of the key contributors. Diets in turn are influenced by diverse factors. Using the for its taste and convenience. Adolescent girls and women associated social status example of Ethiopia, especially with regard to adolescents, we aimed to assess these with modern snack food and a sedentary lifestyle; thus, consuming traditional foods, factors and how they are addressed in Ethiopian policies. was risking ridicule, even though homecooked meals were associated with healthier, safe, and clean food. Women’s dietary behaviours were strongly Objectives influenced by their husbands or children, to the extent that instead of their preferred healthy foods they purchased snacks that they perceived as tasty but unhealthy. Mothers, who cook most of the food, are seen as a positive influence on The overall objective of this thesis is to understand the factors influencing dietary adolescents’ diets. Healthy foods were generally perceived as unaffordable and behaviours of women and adolescents in low- to middle-income countries, and inaccessible in the neighbourhoods, with safer, healthier, more affordable foods specifically of adolescents in Ethiopia. Additionally, it aims to explore how these from supermarkets usually out of reach. Food at school cafeterias was described as adolescents perceive their food environment and how policies address the different healthy, but neither safe nor tasty, which made snack food around schools a more factors of the food environment. attractive choice. Food and beverage advertising was mostly associated with unhealthy food but also used as a source of information. Methods The study described in Chapter 3 assessed factors influencing dietary behaviours of This thesis applied a mixed-method research approach, employing both quantitative adolescents in Addis Ababa using a participatory method called Photovoice. The and qualitative methods. For Chapter 2, a qualitative evidence synthesis (QES) was interviews, focus group discussions and photographs revealed that adolescents had used to bring together the different types of qualitative evidence. This systematic good knowledge about the importance of a diverse, healthy diet while also realizing review followed a framework synthesis methodology to extract, analyse and that foods such as meat and sweets should be consumed in moderation. However, synthesise the qualitative data from primary research studies. For Chapter 3, we food safety appeared to be a bigger concern than nutrient content: healthy fruit and applied participatory action research using the Photovoice method, which is a vegetables sold on the side of the road were perceived as unhealthy due to the poor community-based participatory method in which participants take photographs of hygiene of their surroundings and packaged foods with a visible expiration date as their local environment to document and represent their community in relation to safe. Adolescents recognised fried street food as unsafe and unhealthy, but they a specific topic. A cross-sectional approach was used in Chapter 4. Using interview- liked its taste and associated it with the company of their peers after school; they administered questionnaires, adolescent participants were interviewed on socio- also perceived that they had no safe, affordable alternatives. However, homecooked demographic characteristics and food consumption. Height and weight were also food was considered safe, healthy, and clean. Mothers did most of the cooking and measured to assess the body mass index (BMI) status. In addition, the external and were therefore a strong influence, perceived as positive by private school students internal food environment in and around 12 selected schools was assessed using but negative by some government school students. Affordability also played an protocols from INFORMAS (the International Network for Food and Obesity/Non- important role: healthy foods (e.g. fish and meat) were seen as too expensive but Communicable Diseases Research, Monitoring and Action Support). For Chapter 5, fried foods and sweets as affordable; and bigger, more affordable, safer outlets such a policy analysis was conducted using the INFORMAS Healthy Food Environment as supermarkets were difficult to access, leaving no choice but to purchase the Policy Index (Food-EPI) framework as a basis. This study analysed Ethiopian policy affordable, potentially unsafe food in the neighbourhood. documents with regard to policy goals and actions addressing food environments and the respective dietary and nutritional outcomes. Chapter 4 describes a study on whether food environments in and around schools in urban Ethiopia influence dietary diversity, quality, BMI status or adolescents’ Results perception of the food and home environment. The mean dietary diversity of adolescents was only 3.6/10 food groups: most consumed grains, pulses, and vegetables; hardly any consumed eggs, dairy, fruit, or green leafy vegetables; and The review in Chapter 2 sought to synthesise qualitative evidence on individual-, 23% consumed ultra-processed foods such as SSB. Private school adolescents were social-, physical- and macro-level factors influencing obesogenic behaviours (eating more likely to have pocket money, which they mostly spent on fried food, SSB or and physical activity) in adolescent girls and women of reproductive age in LMIC. 185 Summary sweets. Assessing adolescents’ perceptions of their home and school environment Conclusion and Implication revealed that they perceived unhealthy snack food as well as healthy food to be available around the school. They also recognised most advertising as unhealthy but Our findings suggest that the influencing factors of dietary behaviours include did not consider there to be a lot of advertising. Private school adolescents reported individual-, social-, physical- and macro-level factors. Food safety concerns, body always having fruit, vegetables, SSB and snacks available in their homes. Within the ideals, socio-cultural norms, media influence and limited time to prepare healthy premises of the 12 assessed schools, SSB were advertised in three schools and food could negatively influence diets and increase exposure to multiple burdens of available in all but two schools. Within a 0.5-km radius around the schools we malnutrition. Perceptions related to the unhealthy diets and bigger body images of identified 113–924 different food outlets (mostly kiosks, with SSB on display and wealthy people, combined with healthy food being more difficult to access or afford, advertised) and 44–720 food and beverage adverts (89.9% for SSB). Our study could are major challenges for people of low socio-economic status to eat healthily. Our not find an association between the density of the food environment (outlets and findings also suggest that adolescents’ agency to make dietary choices depends not advertising) and adolescents’ diets or BMI. However, having more assets in the only on their knowledge but on the complexity of their physical and social households was associated with the higher consumption of a diverse diet and surroundings and the confidence they have in their future. A nutrition transition is healthy food groups. taking place in Ethiopia, with the high presence and advertising of ultra-processed foods and beverages. However, policies are not yet sufficiently in place to coherently The policy analysis in Chapter 5 aimed to assess how different food environment address this unhealthy dietary transition in Ethiopia. domains are addressed in Ethiopian policy goals and actions over time and how they compare with global good practice benchmarks. The analysis identified 38 policy This thesis has identified several entry points for future research and policymaking outputs (published strategies, plans or policies) from nine different government related to the dietary behaviours of adolescents and their food environments. ministries or institutions. All eight food environment domains (food composition Future research should aim to engage adolescents as active participants in research and processing; labelling; provision; retail; prices; trade and investment; food using creative participatory methods and to empower adolescents by including quality; food safety) were addressed but gaps remained in food promotion, them in the design, data collection and analysis. Adolescents should also be part of processing, retail, price and trade: no policy actions identified for minimizing the programming and policy process as they can be effective agents of change, nutrients of concern (trans-fats, added sugars, salt, saturated fat); replacing trans- influencing the diet and health of their family and the community. Comprehensive, and saturated fats with mono- and polyunsaturated fats and reducing salt was multicomponent school programmes are needed to promote healthy school food proposed in only one document; regulations on ingredient lists and health claims on environments with safe and nutritious meals, inclusive and sustainable food food products were found; and a proposal for front-of-pack labelling of salt and procurement and food and nutrition education throughout the school system, sugar content of packed foods and drinks was identified. Food promotion is supported by regulations on the foods sold and advertised in and around schools. restricted regarding breastmilk substitutes and foods high in sugar, salt, and fat on Future studies on food environments should apply further mixed-method studies children’s TV programmes but not for online media or at schools. None of the policy for more comprehensive and nuanced assessments of food environments. Specific documents included subsidies or reduced taxes for healthy foods but in 2020 an aspects of the food environment, such as food safety and socio-ecological processes, excise tax was introduced on food and beverages high in salt, sugar, and trans- have been limited in food environment research. Our studies identified multiple /saturated fats. Ethiopia also has a social safety net programme in place, providing influencing factors for dietary behaviours that would need to be addressed using a food-related support for food-insecure households. Our analysis could not identify systems approach. A food systems approach to policymaking would consider policy actions on zoning laws regarding density or location of (un)healthy food potential interlinkages or unintended consequences of policies on different outlets or in-store availability of (un)healthy foods. No policy document referred to outcomes while identifying appropriate policy actions. the potential negative impact of trade agreements on nutrition and health. We identified strong policy action on food safety and hygiene in numerous documents, which also highlighted the limited enforcement of food safety regulations. Between 2008 and 2020, the different food environment domains have been increasingly addressed, along with policies to embrace a wider food system approach with more explicit food environment interventions. Policy goals have also broadened, from a focus on undernutrition (mostly in children <5 years and women of reproductive age) to recognition of the double burden of malnutrition across the lifecycle. 186 Summary sweets. Assessing adolescents’ perceptions of their home and school environment Conclusion and Implication revealed that they perceived unhealthy snack food as well as healthy food to be available around the school. They also recognised most advertising as unhealthy but Our findings suggest that the influencing factors of dietary behaviours include did not consider there to be a lot of advertising. Private school adolescents reported individual-, social-, physical- and macro-level factors. Food safety concerns, body always having fruit, vegetables, SSB and snacks available in their homes. Within the ideals, socio-cultural norms, media influence and limited time to prepare healthy premises of the 12 assessed schools, SSB were advertised in three schools and food could negatively influence diets and increase exposure to multiple burdens of available in all but two schools. Within a 0.5-km radius around the schools we malnutrition. Perceptions related to the unhealthy diets and bigger body images of identified 113–924 different food outlets (mostly kiosks, with SSB on display and wealthy people, combined with healthy food being more difficult to access or afford, advertised) and 44–720 food and beverage adverts (89.9% for SSB). Our study could are major challenges for people of low socio-economic status to eat healthily. Our not find an association between the density of the food environment (outlets and findings also suggest that adolescents’ agency to make dietary choices depends not advertising) and adolescents’ diets or BMI. However, having more assets in the only on their knowledge but on the complexity of their physical and social households was associated with the higher consumption of a diverse diet and surroundings and the confidence they have in their future. A nutrition transition is healthy food groups. taking place in Ethiopia, with the high presence and advertising of ultra-processed foods and beverages. However, policies are not yet sufficiently in place to coherently The policy analysis in Chapter 5 aimed to assess how different food environment address this unhealthy dietary transition in Ethiopia. domains are addressed in Ethiopian policy goals and actions over time and how they compare with global good practice benchmarks. The analysis identified 38 policy This thesis has identified several entry points for future research and policymaking outputs (published strategies, plans or policies) from nine different government related to the dietary behaviours of adolescents and their food environments. ministries or institutions. All eight food environment domains (food composition Future research should aim to engage adolescents as active participants in research and processing; labelling; provision; retail; prices; trade and investment; food using creative participatory methods and to empower adolescents by including quality; food safety) were addressed but gaps remained in food promotion, them in the design, data collection and analysis. Adolescents should also be part of processing, retail, price and trade: no policy actions identified for minimizing the programming and policy process as they can be effective agents of change, nutrients of concern (trans-fats, added sugars, salt, saturated fat); replacing trans- influencing the diet and health of their family and the community. Comprehensive, and saturated fats with mono- and polyunsaturated fats and reducing salt was multicomponent school programmes are needed to promote healthy school food proposed in only one document; regulations on ingredient lists and health claims on environments with safe and nutritious meals, inclusive and sustainable food food products were found; and a proposal for front-of-pack labelling of salt and procurement and food and nutrition education throughout the school system, sugar content of packed foods and drinks was identified. Food promotion is supported by regulations on the foods sold and advertised in and around schools. restricted regarding breastmilk substitutes and foods high in sugar, salt, and fat on Future studies on food environments should apply further mixed-method studies children’s TV programmes but not for online media or at schools. None of the policy for more comprehensive and nuanced assessments of food environments. Specific documents included subsidies or reduced taxes for healthy foods but in 2020 an aspects of the food environment, such as food safety and socio-ecological processes, excise tax was introduced on food and beverages high in salt, sugar, and trans- have been limited in food environment research. Our studies identified multiple /saturated fats. Ethiopia also has a social safety net programme in place, providing influencing factors for dietary behaviours that would need to be addressed using a food-related support for food-insecure households. Our analysis could not identify systems approach. A food systems approach to policymaking would consider policy actions on zoning laws regarding density or location of (un)healthy food potential interlinkages or unintended consequences of policies on different outlets or in-store availability of (un)healthy foods. No policy document referred to outcomes while identifying appropriate policy actions. the potential negative impact of trade agreements on nutrition and health. We identified strong policy action on food safety and hygiene in numerous documents, which also highlighted the limited enforcement of food safety regulations. Between 2008 and 2020, the different food environment domains have been increasingly addressed, along with policies to embrace a wider food system approach with more explicit food environment interventions. Policy goals have also broadened, from a focus on undernutrition (mostly in children <5 years and women of reproductive age) to recognition of the double burden of malnutrition across the lifecycle. 187 SUMMARY IN AMHARIC Summary in Amharic በምዕራፍ ሶስት ፎቶቮይስ በተባለዉን አሳታፊ ጥናት አማካኝነት በአዲስ አባባ የሚገኙ ወጣት ዓላማዎች ተማሪዎች አመጋገብ ላይ ተጽዕኖ ያላቸዉን ጉዳዮች በመለየት ቀርቧል፡፡ የተናጥል ቃለመጠይቆቹ፡ የቡድን ዉይይቶቹ፤ እንዲሁም የፎቶ ቮይስ ዉጤቶቹ በጥቅሉ ወጣት ተማሪዎቹ ጥሩ የሚባል የስነ የመመረቂያ ጥናቱ ዎና ዓላማዎች የአዎቂ ሴቶችና በጉርምስና ወቅት የሚጉኙ ወጣቶች የአመጋገብ ምግብ እዉቀት እንዳላቸዉ አሳይትዎል፡፡ ከተለያዩ የምግብ አይነቶች አሰበጣጥሮ የመመገብን ስረዓትን የሚወስኑ ምክኒያቶችን በኢትዮጵያ ብሎም በታዳጊ የዓለም ሃገራት መረዳት ነዉ፡፡ ጥቅም፤ እንዲሁም ስጋና ጣፋጭ ምግቦችን መገደብ ወይንም በመጠኑ የመመገብን አስፈላጊነት በተጨማሪም ወጣቶች የምግብ ከባቢያቸዉን እንዴት እንደሚረዱ ብሎም የሃገሪቱ ፖሊሲዎች ለይተዎል፡፡ የምግብ ደህንነት ጉዳይ ዎነኛዉ የወጣቶቹ ስጋት ሲሆን ይህም ምንም እንኳን የምግብ ከባቢ ጉዳዮችን በምን መልኩ እንደሚዳስሱ ማጥናት ነዉ፡፡ የፍራፍሬና አታክልት ጥቅምን ቢያውቁም ከመመገብ ግን ገድቧቸዎል፡፡ ይልቁንም በፋብሪካ ተመርተዉ የታሸጉና የአገልግሎት ጊዜአቸዉ በግልጽ የተለጠፈባቸዉን ምግቦች እንዲመርጡ የጥናቱ ዘዴዎች አስገድዷቸዎል፡፡ በቤት የተዘጋጁ ምግቦች ጤናማ ንጹህና ደህንነታቸዉ የተጠበቁ እንደሆኑ አብዛኞቹ ወጣቶች የስማማሉ፡፡ የምግብ ዎጋና የመግዛት አቅም በምግብ ምርጫና አመጋገብ ላይ ይህ የመመረቂያ ጥናት አይነተታዊና ምጣኒያዉ ቅይጥ የአጠናን ዘዴን የተከተለ ነዉ፡፡ ተጽዕኖ ያደርጋሉ፡፡ እንደ አሳና ስጋ ያሉ ምግቦች ዉድ ሲሆኑ በምትኩ የተጠበሱና ጣፋጭ ምግቦች ምዕራፍ ሁለት የአይነታዊ የአጠናን ዘዴን በመከተል የተለያዩ የጥናት ዉጤቶችና መረጃዎችን ርካሽና ተደራሽ እንደሆኑ ወጣቶቹ ይግልጻሉ፡፡ በመለየት፤ በማጠናቀር፤ ሳይንሳዊና ስልታዊ መንገድ በመከተል ይተነትናል፡፡ ምዕራፍ ሶስት ፎቶቮይስ የሚባል አሳታፊ የጥናት ስልት በመከተል የጥናት ተሳታፊዎች በከባቢያቸዉ ምዕራፍ ዐራት የትምህርት ቤት ዉጭና ዉስጣዊ የምግብ ከባቢ እንዴት የወጣት ተማሪዎችን የምግብ ምርጫቸዉን ይወስናሉ ብለዉ የሚያስቡአቸዉን ጉዳዮች በፎቶ የገለጹበት ጥናት ነዉ፡፡ የተሰበጣጠረና ጥራት ያልዉ አመጋገብን እንደሚወስን ያሳያል፡፡ በአማካይ ወጣት ተማሪዎች ምዕራፍ አራት በቃለ መጠይቅ የተደገፈ የመስክ ጥናት ዉጤትን ያቀርባል፡፡ ጥናቱ ወጣት ከአጠቃላይ 10 ይምግብ አይነቶች 3.6 ብቻ ያህሉን ነዉ የተመገቡት፡፡ ይህም ከጥራጥሬ፤ ከአገዳ ተማሪዎችን ስለ አጠቃላይ የኑሮ ሁኔታቸዉ፤ አመጋገባቸዉና በትምህርት ቤታቸዉ ወስጥና ዉጭ እህልና አታክልት የምግብ አይነቶች የተዉጣጡ ሲሆን እንቁላል፤ የወተጥ ተዎጽዎና አረንጎዴ ያለዉን የምግብ ካባቢ የኢነፎርማስ መስፈርትን በመከተል አጥንትዎል፡፡ በተጨማሪም የወጣት ቅጠላማ አታክልት የበሉ በቁጠጥር በጣም ዉስን ነበሩ፡፡ ይሁን እንጂ 23 በመቶ በከፍተኛ ደረጃ ተማሪዎቹን የቁምትና ክብደት ልኬት በመዉስድ የዉፈረትና ቅጥነት መጠንን ገምግምዎል፡፡ በፋብሪካ የተብላላ (አልትራ ፕሮሰስድ) ምግብ ተመግበዎል፡፡ በግል ትምህርት ቤት የሚማሩ ምዕራፍ አምስት በኢንፎርማስ የምገብ ከባቢ ፖሊሲ ኢንዴክስ መሰረት የአትዮጵያን የምግብ ነክ ወጣቶች የተሻለ የኪስ ገንዘብ ሲኖራቸዉ ይህንንም የተጠበሱ ምግቦች፤ ለስላሳ መጠጦች እና ፖሊሲዎች ትንተና ዉጤትን ያቀርባል፡፡ጥናቱ የሃገሪቱን ፖሊሲ አላማ፤ግብና ትግበራቸዉን ጣፋጭ ምግቦች ላይ ገንዘባቸዉን ያዉላሉ፡፡ ከምግብ ከባቢና አመጋገብና ስነምግብ እይታ ገምግሟል፡፡ ወጣት ተማሪዎች በትምህርት ቤት ዉሰጥና ዉጫዊ ከባቢ ጤናማ የሆኑም ያልሆኑም መግቦች እንዳሉ ይገነዘባሉ፡፡ ባብዛኛዉ በማስታወቂያ ሲተዎወቁ የሚመለከቷቸዉም ምግቦችም ለጤና ጎጂ የጥናቱ ዉጤቶች እንደሆኑ ይገልጻሉ፡፡ሆኖም የማስታወቂያወቹን ብዛት እምብዛም እንዳልተገነዘቡ መረዳት ተችሏል፡፡በጥናቱ በተካተቱት 12 ትምህርት ቤቶች ለስላሳ መጠጦች በሁሉም የሚገኙ ሲሆን በሶስቱ ምዕራፍ ሁለት ለይ የቀረበዉ አይነታዊ ትንተና በግለሰብ፤ማህበረሰብ፤ እንዲሁም በማክሮ ደረጃ ድግሞ የለስላሳ መጠጥ ማስታወቂያ ሊታይ ችሏል፡፡ ከትመህርት ቤቶቹ በ0.5 ኪ ሜ ዙሪያ 113- የወጣት ልጃገረዶችና ሴቶች አመጋገብና አካላዊ እንቅስቃሴ ላይ ተጽዕኖ ያላቸዉን ጉዳዮች 924 የምግብ መሸጫወች ያሉ ሲሆን ከ44-720 የሚሆኑት የምግብና መጠጥ ማሰታወቂያ (89.9 ለይትዎል፡፡ የጥናቱ ተሳታፊዎች የምግብን ጤናማነት በዎነኝነት ከምግብ ደህንነት አንጻር የሚያዩ የለስለሳ መጠጦች ማስታወቂያ) የለጠፉ ናቸዉ፡፡ ጥናታችን በማስታወቂያ ብዛት ወይንም የምግብ ሲሆን የህም እንደ ኢትዮጵያ ላሉ ታዳጊ ሃገራት በፋብሪካ የተመረቱ የታሸጉ ምግቦችን እነደ መደብር መሸጫ ብዛት ከወጣቶቹ አመጋገብና የሰዉነት ዉፍረት/ቅጥነት ጋር ግንኑነት አላገኘንም፡፡ ፍራፍሬና አታክልት ካሉ ምገግቦች በተሻለ እንዲመረጡ ሊያደርግ ይችላል፡፡ ይህም የታሸጉ ምግቦች ይሁን እንጂ ጥናታችን የተሸለ የኢኮኖሚ ሁኔታ ከተሻለ የምግብ ስብጥርና ጤናማ አመጋገብ ጋር ድህንነት የተሻለ ነዉ ብሎ ከማመን ይመነጫል፡፡ የሁን እንጂ የወጣቶቹ የምግብ ደህንተት ስጋት ግንኙነት እንዳለዉ ማሳየት ችሏል፡፡ በመንገድ ዳር የሚሸጡ ምግቦችን ከመመገብ አላገዳቸዉም፡፡ የምግቦቹ ጣዕምና ለአመጋገብ ምቹ መሆን እነኚህን ምግቦች ለመመገብ ዎነኞቹ መነስኤዎች እንደሆኑ ተገልጽዋል፡፡ በሌላ በኩል በዕራፍ አምስት የኢትዮጵያ ፖሊሲዎች ሂደትና በግቦቻቸዉ የምግብ ከባቢ የተመለከቱ የመክሰስ (የታሸጉ) ምግቦችን መመገብ እንዲሁም በቂ የአካል እንቅስቃሴ አለማድረግን ከተሻለ የተካተቱ/ያልተካተቱ ጉዳዮችን መርምሯል፡፡ ትንተናዉ ከዘጠኝ የመንግስት ሴክተር መስሪያ ቤቶች የኑሮ ደረጃ ጋር በመያያዙ ምክኒያት በቤት የተሰሩ ባህላዊ ምግቦችን ምንም እንክዎን ጤናማ 38 የፖሊሲ ሰነዶችን ገምግሟል፡፡ አብዛኛዉ የምግብ ከባቢ መደቦች በፖሊሲዎቹ የተካተቱ ሲሆን ቢሆኑም እንኚህን ምግቦች መመገብ እንደ ኋላ ቀርነት የመታየት ዕድል ከፍቷል፡፡ እናቶች ጉድለት ያለባቸዉ መደቦችም ተለይተዎል፡፡ ለምሳሌ ማናቸዉም የፖሊሲ ሰነዶች ስለ ጤናማ በበኩላቸዉ የግል አመጋገባቸዉን የሚወስነዉ የባለቸዉና ልጆቻቸዉ የምግብ ምርጫ እንደሆነና ያለሆኑ ስቦች (ትራንስ ፋት)፤ ስኳር፤ ጨዉና ስብ ምንም አይገልጹም፡፡ ይሁን እንጂ የፎሙላ የህም ጣፋጭና በቀላሉ የሚበሉ ምግቦችን እንዲያዘወትሩ ምክኒያት እንደሆነ ይገልጻሉ፡፡ ይሁን ወተትና በስኳርና ጨዉ የዳበሩ ምግብና መጠጦች በልጆች የቴሌቪዥን ፕሮግራም እንዳይተዎወቁ እንጂ በቤት ምግብ የሚያዘጋጁ እናቶች በወጣት ልጆቻቸዉ አመጋገብ ላይ በጎ ተጽዕኖ አላቸዉ፡፡ ቢደነግግም በስነ መህዳር (ኢንተርኔት) ወይም በትምህርት ቤቶች ስለሚደረጉ ማስታወቂያወች በጥቅሉ ጤናማ የሆኑ ምግቦች ወድና ተደራሽ ያልሆኑ እንደሆኑ ተገልጽዎል፡፡ በሌላ በኩል ምንም አይደነግግም፡፡ እንዲሁም ጤናማ ምግቦች ላይ ድጎማ ወይንም የግብር ቅነሳ በምትኩ ለጤና በትምህርት ቤት ካፌቴሪያ የሚገኙት ምግቦች ምንም እንኳን ጤናማ ናቸዉ ተብሎ ቢታሰቡም ጎጂ የሆኑ ምግቦች ላይ ደግሞ ተጨማሪ ግብር ስለመጣል የፖሊሲ ሰነዶቹ ምንም አይሉም፡፡ ይሁን ተማሪዎቹ የምግብ ደህንነት ችግርና ጥፍጥና እንደሚጎላቸዉ ገልጸዎል፡፡ይህም በትምህርት ቤት እንጂ በ2020 ተጨማሪ እሴት ታክስ በከፍተኛ ስኳር፤ ጨዉና ስብ ባላቸዉ ምግብ ላይ ተጥሏል፡፡ ዙሪያ የሚሸጡ ጣፋጭና የታሸጉ ምግቦችን መመገብን እንደአማረጭ እንዲታይ ምግብ ደህንነትን በተመለከተ በእጅጉ የተሻለ ትኩረት በፖሊሲዎቹ እንደተሰጠ መገንዘብ ተችሏል፡፡ አድርግዎል፡፡የምግብና መጠጥ ማስታወቂያዎች በአብዛኛዉ ጤናማ ያልሆን ምግቦችን ነዉ ይሁን እንጂ የፖሊሲዎቹ አተገባበር ላይ ጉድለቶች እንዳሉ ማየት ተችሏል፡፡ የሚያሰተዎዉቁት፡፡ በጊዜ ኂደት (2008-2020) ፖሊሲዎቹ እየዳበሩ ተጨማሪ የምግብ ከባቢ መደቦችን ማካተት ችለዋል፡፡ በተጨማሪም ፖሊሲዎቹ ከህጻናት የምግብ እጥረት በተጨማሪ ያለቅጥ ዉፍረትና ተያያዥ 190 Summary in Amharic በምዕራፍ ሶስት ፎቶቮይስ በተባለዉን አሳታፊ ጥናት አማካኝነት በአዲስ አባባ የሚገኙ ወጣት ዓላማዎች ተማሪዎች አመጋገብ ላይ ተጽዕኖ ያላቸዉን ጉዳዮች በመለየት ቀርቧል፡፡ የተናጥል ቃለመጠይቆቹ፡ የቡድን ዉይይቶቹ፤ እንዲሁም የፎቶ ቮይስ ዉጤቶቹ በጥቅሉ ወጣት ተማሪዎቹ ጥሩ የሚባል የስነ የመመረቂያ ጥናቱ ዎና ዓላማዎች የአዎቂ ሴቶችና በጉርምስና ወቅት የሚጉኙ ወጣቶች የአመጋገብ ምግብ እዉቀት እንዳላቸዉ አሳይትዎል፡፡ ከተለያዩ የምግብ አይነቶች አሰበጣጥሮ የመመገብን ስረዓትን የሚወስኑ ምክኒያቶችን በኢትዮጵያ ብሎም በታዳጊ የዓለም ሃገራት መረዳት ነዉ፡፡ ጥቅም፤ እንዲሁም ስጋና ጣፋጭ ምግቦችን መገደብ ወይንም በመጠኑ የመመገብን አስፈላጊነት በተጨማሪም ወጣቶች የምግብ ከባቢያቸዉን እንዴት እንደሚረዱ ብሎም የሃገሪቱ ፖሊሲዎች ለይተዎል፡፡ የምግብ ደህንነት ጉዳይ ዎነኛዉ የወጣቶቹ ስጋት ሲሆን ይህም ምንም እንኳን የምግብ ከባቢ ጉዳዮችን በምን መልኩ እንደሚዳስሱ ማጥናት ነዉ፡፡ የፍራፍሬና አታክልት ጥቅምን ቢያውቁም ከመመገብ ግን ገድቧቸዎል፡፡ ይልቁንም በፋብሪካ ተመርተዉ የታሸጉና የአገልግሎት ጊዜአቸዉ በግልጽ የተለጠፈባቸዉን ምግቦች እንዲመርጡ የጥናቱ ዘዴዎች አስገድዷቸዎል፡፡ በቤት የተዘጋጁ ምግቦች ጤናማ ንጹህና ደህንነታቸዉ የተጠበቁ እንደሆኑ አብዛኞቹ ወጣቶች የስማማሉ፡፡ የምግብ ዎጋና የመግዛት አቅም በምግብ ምርጫና አመጋገብ ላይ ይህ የመመረቂያ ጥናት አይነተታዊና ምጣኒያዉ ቅይጥ የአጠናን ዘዴን የተከተለ ነዉ፡፡ ተጽዕኖ ያደርጋሉ፡፡ እንደ አሳና ስጋ ያሉ ምግቦች ዉድ ሲሆኑ በምትኩ የተጠበሱና ጣፋጭ ምግቦች ምዕራፍ ሁለት የአይነታዊ የአጠናን ዘዴን በመከተል የተለያዩ የጥናት ዉጤቶችና መረጃዎችን ርካሽና ተደራሽ እንደሆኑ ወጣቶቹ ይግልጻሉ፡፡ በመለየት፤ በማጠናቀር፤ ሳይንሳዊና ስልታዊ መንገድ በመከተል ይተነትናል፡፡ ምዕራፍ ሶስት ፎቶቮይስ የሚባል አሳታፊ የጥናት ስልት በመከተል የጥናት ተሳታፊዎች በከባቢያቸዉ ምዕራፍ ዐራት የትምህርት ቤት ዉጭና ዉስጣዊ የምግብ ከባቢ እንዴት የወጣት ተማሪዎችን የምግብ ምርጫቸዉን ይወስናሉ ብለዉ የሚያስቡአቸዉን ጉዳዮች በፎቶ የገለጹበት ጥናት ነዉ፡፡ የተሰበጣጠረና ጥራት ያልዉ አመጋገብን እንደሚወስን ያሳያል፡፡ በአማካይ ወጣት ተማሪዎች ምዕራፍ አራት በቃለ መጠይቅ የተደገፈ የመስክ ጥናት ዉጤትን ያቀርባል፡፡ ጥናቱ ወጣት ከአጠቃላይ 10 ይምግብ አይነቶች 3.6 ብቻ ያህሉን ነዉ የተመገቡት፡፡ ይህም ከጥራጥሬ፤ ከአገዳ ተማሪዎችን ስለ አጠቃላይ የኑሮ ሁኔታቸዉ፤ አመጋገባቸዉና በትምህርት ቤታቸዉ ወስጥና ዉጭ እህልና አታክልት የምግብ አይነቶች የተዉጣጡ ሲሆን እንቁላል፤ የወተጥ ተዎጽዎና አረንጎዴ ያለዉን የምግብ ካባቢ የኢነፎርማስ መስፈርትን በመከተል አጥንትዎል፡፡ በተጨማሪም የወጣት ቅጠላማ አታክልት የበሉ በቁጠጥር በጣም ዉስን ነበሩ፡፡ ይሁን እንጂ 23 በመቶ በከፍተኛ ደረጃ ተማሪዎቹን የቁምትና ክብደት ልኬት በመዉስድ የዉፈረትና ቅጥነት መጠንን ገምግምዎል፡፡ በፋብሪካ የተብላላ (አልትራ ፕሮሰስድ) ምግብ ተመግበዎል፡፡ በግል ትምህርት ቤት የሚማሩ ምዕራፍ አምስት በኢንፎርማስ የምገብ ከባቢ ፖሊሲ ኢንዴክስ መሰረት የአትዮጵያን የምግብ ነክ ወጣቶች የተሻለ የኪስ ገንዘብ ሲኖራቸዉ ይህንንም የተጠበሱ ምግቦች፤ ለስላሳ መጠጦች እና ፖሊሲዎች ትንተና ዉጤትን ያቀርባል፡፡ጥናቱ የሃገሪቱን ፖሊሲ አላማ፤ግብና ትግበራቸዉን ጣፋጭ ምግቦች ላይ ገንዘባቸዉን ያዉላሉ፡፡ ከምግብ ከባቢና አመጋገብና ስነምግብ እይታ ገምግሟል፡፡ ወጣት ተማሪዎች በትምህርት ቤት ዉሰጥና ዉጫዊ ከባቢ ጤናማ የሆኑም ያልሆኑም መግቦች እንዳሉ ይገነዘባሉ፡፡ ባብዛኛዉ በማስታወቂያ ሲተዎወቁ የሚመለከቷቸዉም ምግቦችም ለጤና ጎጂ የጥናቱ ዉጤቶች እንደሆኑ ይገልጻሉ፡፡ሆኖም የማስታወቂያወቹን ብዛት እምብዛም እንዳልተገነዘቡ መረዳት ተችሏል፡፡በጥናቱ በተካተቱት 12 ትምህርት ቤቶች ለስላሳ መጠጦች በሁሉም የሚገኙ ሲሆን በሶስቱ ምዕራፍ ሁለት ለይ የቀረበዉ አይነታዊ ትንተና በግለሰብ፤ማህበረሰብ፤ እንዲሁም በማክሮ ደረጃ ድግሞ የለስላሳ መጠጥ ማስታወቂያ ሊታይ ችሏል፡፡ ከትመህርት ቤቶቹ በ0.5 ኪ ሜ ዙሪያ 113- የወጣት ልጃገረዶችና ሴቶች አመጋገብና አካላዊ እንቅስቃሴ ላይ ተጽዕኖ ያላቸዉን ጉዳዮች 924 የምግብ መሸጫወች ያሉ ሲሆን ከ44-720 የሚሆኑት የምግብና መጠጥ ማሰታወቂያ (89.9 ለይትዎል፡፡ የጥናቱ ተሳታፊዎች የምግብን ጤናማነት በዎነኝነት ከምግብ ደህንነት አንጻር የሚያዩ የለስለሳ መጠጦች ማስታወቂያ) የለጠፉ ናቸዉ፡፡ ጥናታችን በማስታወቂያ ብዛት ወይንም የምግብ ሲሆን የህም እንደ ኢትዮጵያ ላሉ ታዳጊ ሃገራት በፋብሪካ የተመረቱ የታሸጉ ምግቦችን እነደ መደብር መሸጫ ብዛት ከወጣቶቹ አመጋገብና የሰዉነት ዉፍረት/ቅጥነት ጋር ግንኑነት አላገኘንም፡፡ ፍራፍሬና አታክልት ካሉ ምገግቦች በተሻለ እንዲመረጡ ሊያደርግ ይችላል፡፡ ይህም የታሸጉ ምግቦች ይሁን እንጂ ጥናታችን የተሸለ የኢኮኖሚ ሁኔታ ከተሻለ የምግብ ስብጥርና ጤናማ አመጋገብ ጋር ድህንነት የተሻለ ነዉ ብሎ ከማመን ይመነጫል፡፡ የሁን እንጂ የወጣቶቹ የምግብ ደህንተት ስጋት ግንኙነት እንዳለዉ ማሳየት ችሏል፡፡ በመንገድ ዳር የሚሸጡ ምግቦችን ከመመገብ አላገዳቸዉም፡፡ የምግቦቹ ጣዕምና ለአመጋገብ ምቹ መሆን እነኚህን ምግቦች ለመመገብ ዎነኞቹ መነስኤዎች እንደሆኑ ተገልጽዋል፡፡ በሌላ በኩል በዕራፍ አምስት የኢትዮጵያ ፖሊሲዎች ሂደትና በግቦቻቸዉ የምግብ ከባቢ የተመለከቱ የመክሰስ (የታሸጉ) ምግቦችን መመገብ እንዲሁም በቂ የአካል እንቅስቃሴ አለማድረግን ከተሻለ የተካተቱ/ያልተካተቱ ጉዳዮችን መርምሯል፡፡ ትንተናዉ ከዘጠኝ የመንግስት ሴክተር መስሪያ ቤቶች የኑሮ ደረጃ ጋር በመያያዙ ምክኒያት በቤት የተሰሩ ባህላዊ ምግቦችን ምንም እንክዎን ጤናማ 38 የፖሊሲ ሰነዶችን ገምግሟል፡፡ አብዛኛዉ የምግብ ከባቢ መደቦች በፖሊሲዎቹ የተካተቱ ሲሆን ቢሆኑም እንኚህን ምግቦች መመገብ እንደ ኋላ ቀርነት የመታየት ዕድል ከፍቷል፡፡ እናቶች ጉድለት ያለባቸዉ መደቦችም ተለይተዎል፡፡ ለምሳሌ ማናቸዉም የፖሊሲ ሰነዶች ስለ ጤናማ በበኩላቸዉ የግል አመጋገባቸዉን የሚወስነዉ የባለቸዉና ልጆቻቸዉ የምግብ ምርጫ እንደሆነና ያለሆኑ ስቦች (ትራንስ ፋት)፤ ስኳር፤ ጨዉና ስብ ምንም አይገልጹም፡፡ ይሁን እንጂ የፎሙላ የህም ጣፋጭና በቀላሉ የሚበሉ ምግቦችን እንዲያዘወትሩ ምክኒያት እንደሆነ ይገልጻሉ፡፡ ይሁን ወተትና በስኳርና ጨዉ የዳበሩ ምግብና መጠጦች በልጆች የቴሌቪዥን ፕሮግራም እንዳይተዎወቁ እንጂ በቤት ምግብ የሚያዘጋጁ እናቶች በወጣት ልጆቻቸዉ አመጋገብ ላይ በጎ ተጽዕኖ አላቸዉ፡፡ ቢደነግግም በስነ መህዳር (ኢንተርኔት) ወይም በትምህርት ቤቶች ስለሚደረጉ ማስታወቂያወች በጥቅሉ ጤናማ የሆኑ ምግቦች ወድና ተደራሽ ያልሆኑ እንደሆኑ ተገልጽዎል፡፡ በሌላ በኩል ምንም አይደነግግም፡፡ እንዲሁም ጤናማ ምግቦች ላይ ድጎማ ወይንም የግብር ቅነሳ በምትኩ ለጤና በትምህርት ቤት ካፌቴሪያ የሚገኙት ምግቦች ምንም እንኳን ጤናማ ናቸዉ ተብሎ ቢታሰቡም ጎጂ የሆኑ ምግቦች ላይ ደግሞ ተጨማሪ ግብር ስለመጣል የፖሊሲ ሰነዶቹ ምንም አይሉም፡፡ ይሁን ተማሪዎቹ የምግብ ደህንነት ችግርና ጥፍጥና እንደሚጎላቸዉ ገልጸዎል፡፡ይህም በትምህርት ቤት እንጂ በ2020 ተጨማሪ እሴት ታክስ በከፍተኛ ስኳር፤ ጨዉና ስብ ባላቸዉ ምግብ ላይ ተጥሏል፡፡ ዙሪያ የሚሸጡ ጣፋጭና የታሸጉ ምግቦችን መመገብን እንደአማረጭ እንዲታይ ምግብ ደህንነትን በተመለከተ በእጅጉ የተሻለ ትኩረት በፖሊሲዎቹ እንደተሰጠ መገንዘብ ተችሏል፡፡ አድርግዎል፡፡የምግብና መጠጥ ማስታወቂያዎች በአብዛኛዉ ጤናማ ያልሆን ምግቦችን ነዉ ይሁን እንጂ የፖሊሲዎቹ አተገባበር ላይ ጉድለቶች እንዳሉ ማየት ተችሏል፡፡ የሚያሰተዎዉቁት፡፡ በጊዜ ኂደት (2008-2020) ፖሊሲዎቹ እየዳበሩ ተጨማሪ የምግብ ከባቢ መደቦችን ማካተት ችለዋል፡፡ በተጨማሪም ፖሊሲዎቹ ከህጻናት የምግብ እጥረት በተጨማሪ ያለቅጥ ዉፍረትና ተያያዥ 191 Summary in Amharic ችግሮችነ ወደ ማካተት አድጓል፡፡እንዲሁም ከልጆችና እናቶች ወደ ሁሉም የእድሜ ክልል የትኩረተ አድማሱን አስፍትዎል፡፡ ማጠቃለያና የጥናቱ አንድምታወች ይህ ጥናታዊ ጽሁፍ በአመጋገብ ባህሪያ ላይ ተጽዕኖ የሚያስከትሉ ግለሰባዊ፤ ማህበራዊ፤ አካላዊና በማክሮ ደረጃ ያሉ ምክኒያቶችን መለየት ችሏል፡፡የምግብ ደህንነት ስጋቶች ከሆኑት ምክኒያቶች፤ አመለካከቶች፤ ማህበራዊና ባህላዊ ደንቦች፤ የመገናኛ ብዙሃን እና ጤናማ ምግብ ለማዘጋጀት በቂ ጊዜ አለመስጠት በአመጋገብ ስርዓታችንና ለተለያዩ የምግብ እጥረት ጫናዎች አሉታዊ ተጽእኖ አላቸዉ፡፡ ጤናማ ያልሆኑ ምግቦች ጋር ተጓጓደኝነት ያላቸዉ አመለካከቶች ልመሳሌ ዉፈረት የሃብት መገለጫ መሆኑና በዝቅተኛ ኑሮ ለሚገኙ ሰዎች ጤናማ ምግብን ለማግኘት ከባድ መሆኑ ዎና ዎና ችግሮች ናቸዉ፡ ጥናታችን የወጣት ተማሪዎችን የአመጋገብና የምግብ ምርጫ እዉቀት ብቻ ሳይሀኖነ ዉስብስብ የሆኑ መዎቅራዊና ማህበራዊ ጉዳዮች እንዲሁም በራስ የመተማመን ክህሎት እንደሆነ ይጠቁማል፡፡በኢትዮጵያ የታሸጉ ምግቦችና መጠጦች ማስታወቂያ በስፋት የሚታዩ ሲሆን ለሚታየዉ የአመጋገብ ሽግግር (ኒዉትሪሽን ትራንዚሽን) የራሱን አስዋጽዎ እያበረከተ ይገኛል፡፡ ይህ የመመረቂያ ጽሁፍ በወጣቶች የአመጋገብ ባህሪያቶች ለይ ሊሰሩ ስለሚገባቸዉ ጉዳዮች ለቀጣይ ጥናቶችና ፖሊሲ አዉጪዎች ብዙ የመነሻ ሃሳቦች ለይቶ አስቀምጧል፡፡ወጣቶችን በፖሊሲ ማዉጣት ሂደት ላይ እንዲሳተፉና የራሳቸዉን ግብዓት እንዲያበረክቱ ማመቻቸት ያስፈልጋል፡፡ ጤናማ አመጋገብን የሚያበረታቱ ሁሉን አቀፍ የትምህርት ስነ ምግብ ፕሮግራሞች ያስፈልጋሉ፡፡ እነኚህ ፕሮግራሞች ጤናማና ዘላቂ አመጋገብን ለማምጣት ከምግብ ግዢ እስከ ስነ ምግብ ትምህርት ሊይዙ እንደሚገባ ይሁም በመመሪያና ህጎች መደገፍ የገባዎል፡፡ ሁለንተናዊ የምግብ ስረዓትን ያገናዘበ እንዲሁም የፖሊሲ መናብብን የሚያመጣ አካሄድ መተግበር የተሻለ ዉጤት ሊያሰገኝ ይችላል፡፡ 192 Summary in Amharic ችግሮችነ ወደ ማካተት አድጓል፡፡እንዲሁም ከልጆችና እናቶች ወደ ሁሉም የእድሜ ክልል የትኩረተ አድማሱን አስፍትዎል፡፡ ማጠቃለያና የጥናቱ አንድምታወች ይህ ጥናታዊ ጽሁፍ በአመጋገብ ባህሪያ ላይ ተጽዕኖ የሚያስከትሉ ግለሰባዊ፤ ማህበራዊ፤ አካላዊና በማክሮ ደረጃ ያሉ ምክኒያቶችን መለየት ችሏል፡፡የምግብ ደህንነት ስጋቶች ከሆኑት ምክኒያቶች፤ አመለካከቶች፤ ማህበራዊና ባህላዊ ደንቦች፤ የመገናኛ ብዙሃን እና ጤናማ ምግብ ለማዘጋጀት በቂ ጊዜ አለመስጠት በአመጋገብ ስርዓታችንና ለተለያዩ የምግብ እጥረት ጫናዎች አሉታዊ ተጽእኖ አላቸዉ፡፡ ጤናማ ያልሆኑ ምግቦች ጋር ተጓጓደኝነት ያላቸዉ አመለካከቶች ልመሳሌ ዉፈረት የሃብት መገለጫ መሆኑና በዝቅተኛ ኑሮ ለሚገኙ ሰዎች ጤናማ ምግብን ለማግኘት ከባድ መሆኑ ዎና ዎና ችግሮች ናቸዉ፡ ጥናታችን የወጣት ተማሪዎችን የአመጋገብና የምግብ ምርጫ እዉቀት ብቻ ሳይሀኖነ ዉስብስብ የሆኑ መዎቅራዊና ማህበራዊ ጉዳዮች እንዲሁም በራስ የመተማመን ክህሎት እንደሆነ ይጠቁማል፡፡በኢትዮጵያ የታሸጉ ምግቦችና መጠጦች ማስታወቂያ በስፋት የሚታዩ ሲሆን ለሚታየዉ የአመጋገብ ሽግግር (ኒዉትሪሽን ትራንዚሽን) የራሱን አስዋጽዎ እያበረከተ ይገኛል፡፡ ይህ የመመረቂያ ጽሁፍ በወጣቶች የአመጋገብ ባህሪያቶች ለይ ሊሰሩ ስለሚገባቸዉ ጉዳዮች ለቀጣይ ጥናቶችና ፖሊሲ አዉጪዎች ብዙ የመነሻ ሃሳቦች ለይቶ አስቀምጧል፡፡ወጣቶችን በፖሊሲ ማዉጣት ሂደት ላይ እንዲሳተፉና የራሳቸዉን ግብዓት እንዲያበረክቱ ማመቻቸት ያስፈልጋል፡፡ ጤናማ አመጋገብን የሚያበረታቱ ሁሉን አቀፍ የትምህርት ስነ ምግብ ፕሮግራሞች ያስፈልጋሉ፡፡ እነኚህ ፕሮግራሞች ጤናማና ዘላቂ አመጋገብን ለማምጣት ከምግብ ግዢ እስከ ስነ ምግብ ትምህርት ሊይዙ እንደሚገባ ይሁም በመመሪያና ህጎች መደገፍ የገባዎል፡፡ ሁለንተናዊ የምግብ ስረዓትን ያገናዘበ እንዲሁም የፖሊሲ መናብብን የሚያመጣ አካሄድ መተግበር የተሻለ ዉጤት ሊያሰገኝ ይችላል፡፡ 193 ACKNOWLEDGEMENTS Acknowledgements I feel very privileged to have been able to do a PhD. While a lot of privilege has to Michelle Holdsworth, once I knew I was working on food environments in Africa and do with the luck of where you are born in the world, I was also lucky to be searched for information, your name popped up all over the internet. How lucky was surrounded by people who believed in me and lifted me up. I that you not only responded to my out-of-the-blue email but also agreed to supervise me?! You opened a lot of doors for me, connecting me with other Both my parents, Helga and Gerhard Trübswasser would have been smart enough researchers, including me in another review team and spending so much time with to go to university, but they could not afford to stay in school beyond 9th grade and me in Sheffield, deconstructing frameworks and helping me think through my had to start working when they were 15 years old. I am forever grateful that my research design. parents gave me the chance to study and trusted me one hundred percent in Kaleab Baye, five minutes with you usually answered all my questions and solved all whatever choice I made (when I myself was doubting many of them). my problems (at least the PhD related ones!). You were also the one giving me the Danke Mama, Danke Papa, dass ihr immer an mich geglaubt hab, auch wenn ich last push to decide for the PhD when I told you sometime in 2017, that I want to do manchmal den Glauben an mich verloren hab. Ihr habt all meine Ideen unterstützt, “some research” and you said “Why don’t you do a PhD then?” You were so auch wenn ihr es selbst ganz anders gemacht hättet! convincing that when walking out of that meeting, I called Josh and said “I’m doing a PhD!”. So, I owe you this first push and constant encouragement during my time Besides privilege and education, you also need a lot of time and patience to do a in Addis and also for the super speedy last minute translation of the summary! PhD. Both of which and so much more I was lucky to get from Tilly, Felix and Josh. I Inge Brouwer, you were the first person I met from the Wageningen team and when want to thank Josh for, well, everything. You’ve been my constant companion, on I told you I wanted to do “something on food systems”, you didn’t laugh in my face, the good PhD days and the bad ones. You have been everything from the editor of but politely suggested to focus on something more specific, maybe on food my grammar mistakes, my therapist for any misery I went through, to my advisor environments and adolescents. And this is what I did! Thank you for your spot-on thinking through conceptual issues. Your patience, listening to every boring detail, inputs from the beginning, helping me keep a sharp focus and also helping me get that you heard over and over again, meant the world to me. Tilly and Felix, you have funding for my work. sacrificed a lot in the past years with a mom who was often absent, stressed or just too tired to play. Your patience with me, your interest in my research, how you I was also very lucky to have amazing co-authors from whom I learnt so much. Roos wanted to understand every single step and your anger at reviewers who rejected Verstraeten, I am so grateful that I could do the evidence review with you, that you my manuscript, kept me going every single day. guided me step-by-step through every turn that a review can take. And whenever we got stuck, there was Andrew Booth, who is my hero of systematic reviews. His Another crucial ingredient you need for a PhD is, obviously, knowledge and I would incredible knowledge and interesting courses were always good excuses to go to not be where I am now without the support, conceptual discussions, technical lovely Sheffield. Receiving comments on your writing is usually hard, but getting guidance but also caring thoughts I got from my supervisors: comments from Andrew was a pure delight! With your kind and witty attitude, you Elise Talsma, you have paved the way for me from the beginning, from pushing the taught me a lot. Jeroen Candel you are a great teacher and helped me wrap my head right papers with the right people, helping me get financial support, lifting me up in around policy science, challenging my thinking, and motivating me to do better. tricky times, being available to listening to my frustrations from the data collection Leah Salm, Maartje Poelman and Stuart Gillespie thank you for bringing your to rejected papers. You helped me improve my work, asking the critical questions expertise to my papers! that helped me focus and think scientifically while also empowering, praising, and motivating me! I also really appreciated spending time in Addis and Wageningen I want to thank my opponents: Yemane Berhane, Christopher Béné, Lenneke with you beyond the PhD. Vaandrager and Sigrid Wertheim-Heck for reviewing my thesis and providing Edith Feskens, you were always there at the right moment to answer the tricky constructive comments and questions as part of the process. I appreciate the time questions and take the time to help me, from basic library access questions to you have spent. complicated statistical queries. I would have not been able to do my PhD studies without the financial support you helped me with. I liked when you challenged my I started this PhD late in my career, which made me feel that I might not quite fit in views, making me go back to the literature and get my arguments lined up. You are with all the other PhDs. But over the seven visits to Wageningen, starting with 2, 3 an incredibly positive person, and you encouraged and motivated me whenever I people I had lunch with on the first trip, I ended up with quite a busy social life and had doubts. a lovely group of friends. While there are many PhD colleagues I met over the years, I especially want to mention Giulia, Tesfaye, Mahsina, Tsitsi, Donya, Son, Arli, 196 Acknowledgements I feel very privileged to have been able to do a PhD. While a lot of privilege has to Michelle Holdsworth, once I knew I was working on food environments in Africa and do with the luck of where you are born in the world, I was also lucky to be searched for information, your name popped up all over the internet. How lucky was surrounded by people who believed in me and lifted me up. I that you not only responded to my out-of-the-blue email but also agreed to supervise me?! You opened a lot of doors for me, connecting me with other Both my parents, Helga and Gerhard Trübswasser would have been smart enough researchers, including me in another review team and spending so much time with to go to university, but they could not afford to stay in school beyond 9th grade and me in Sheffield, deconstructing frameworks and helping me think through my had to start working when they were 15 years old. I am forever grateful that my research design. parents gave me the chance to study and trusted me one hundred percent in Kaleab Baye, five minutes with you usually answered all my questions and solved all whatever choice I made (when I myself was doubting many of them). my problems (at least the PhD related ones!). You were also the one giving me the Danke Mama, Danke Papa, dass ihr immer an mich geglaubt hab, auch wenn ich last push to decide for the PhD when I told you sometime in 2017, that I want to do manchmal den Glauben an mich verloren hab. Ihr habt all meine Ideen unterstützt, “some research” and you said “Why don’t you do a PhD then?” You were so auch wenn ihr es selbst ganz anders gemacht hättet! convincing that when walking out of that meeting, I called Josh and said “I’m doing a PhD!”. So, I owe you this first push and constant encouragement during my time Besides privilege and education, you also need a lot of time and patience to do a in Addis and also for the super speedy last minute translation of the summary! PhD. Both of which and so much more I was lucky to get from Tilly, Felix and Josh. I Inge Brouwer, you were the first person I met from the Wageningen team and when want to thank Josh for, well, everything. You’ve been my constant companion, on I told you I wanted to do “something on food systems”, you didn’t laugh in my face, the good PhD days and the bad ones. You have been everything from the editor of but politely suggested to focus on something more specific, maybe on food my grammar mistakes, my therapist for any misery I went through, to my advisor environments and adolescents. And this is what I did! Thank you for your spot-on thinking through conceptual issues. Your patience, listening to every boring detail, inputs from the beginning, helping me keep a sharp focus and also helping me get that you heard over and over again, meant the world to me. Tilly and Felix, you have funding for my work. sacrificed a lot in the past years with a mom who was often absent, stressed or just too tired to play. Your patience with me, your interest in my research, how you I was also very lucky to have amazing co-authors from whom I learnt so much. Roos wanted to understand every single step and your anger at reviewers who rejected Verstraeten, I am so grateful that I could do the evidence review with you, that you my manuscript, kept me going every single day. guided me step-by-step through every turn that a review can take. And whenever we got stuck, there was Andrew Booth, who is my hero of systematic reviews. His Another crucial ingredient you need for a PhD is, obviously, knowledge and I would incredible knowledge and interesting courses were always good excuses to go to not be where I am now without the support, conceptual discussions, technical lovely Sheffield. Receiving comments on your writing is usually hard, but getting guidance but also caring thoughts I got from my supervisors: comments from Andrew was a pure delight! With your kind and witty attitude, you Elise Talsma, you have paved the way for me from the beginning, from pushing the taught me a lot. Jeroen Candel you are a great teacher and helped me wrap my head right papers with the right people, helping me get financial support, lifting me up in around policy science, challenging my thinking, and motivating me to do better. tricky times, being available to listening to my frustrations from the data collection Leah Salm, Maartje Poelman and Stuart Gillespie thank you for bringing your to rejected papers. You helped me improve my work, asking the critical questions expertise to my papers! that helped me focus and think scientifically while also empowering, praising, and motivating me! I also really appreciated spending time in Addis and Wageningen I want to thank my opponents: Yemane Berhane, Christopher Béné, Lenneke with you beyond the PhD. Vaandrager and Sigrid Wertheim-Heck for reviewing my thesis and providing Edith Feskens, you were always there at the right moment to answer the tricky constructive comments and questions as part of the process. I appreciate the time questions and take the time to help me, from basic library access questions to you have spent. complicated statistical queries. I would have not been able to do my PhD studies without the financial support you helped me with. I liked when you challenged my I started this PhD late in my career, which made me feel that I might not quite fit in views, making me go back to the literature and get my arguments lined up. You are with all the other PhDs. But over the seven visits to Wageningen, starting with 2, 3 an incredibly positive person, and you encouraged and motivated me whenever I people I had lunch with on the first trip, I ended up with quite a busy social life and had doubts. a lovely group of friends. While there are many PhD colleagues I met over the years, I especially want to mention Giulia, Tesfaye, Mahsina, Tsitsi, Donya, Son, Arli, 197 Acknowledgements Taonga, Hongyi, Inga, Koen, Claudia, Marion, Ilse, Umi, Duong, Asrul and Fusta. A Besides doing my PhD, I had the opportunity and honour to work with Corinna special thanks to my two paranymphs, Giulia and Tesfaye, who have been so Hawkes. I have learned so much during my time with Corinna, learning to think generous with their time, helping with all the little and big and mostly boring admin outside the box, to look at the bigger picture and to consider different angels. And stuff in the end, but more importantly, being so encouraging and supportive, besides thinking about food systems transformations, I have learned so much about reading my discussion section, and thinking through the propositions. I also wanted inclusive, uplifting leadership from her. Talking of amazing leaders, Francesco to thank my Ethiopian PhD friends, Tesfaye, Aregash, Tibebu, Kifle, and Masresha, Branca, Trudy Wijnhoven, Karin Schindler and Oladapo Walker, you have been my who have made me feel part of their group, which helped me whenever I missed early teachers, supporters and inspirations for nutrition. Ethiopia. Donya, I so enjoyed our scientific discussions from the first moment we met. You motivated me to get into qualitative research and I cannot thank you There were so many other people along the way, who helped at different stages, enough for opening my eyes to this amazing new world! I also want to thank Megan but I want to mention the most important by name: Roseline Remans, this PhD who did her Master study research as part of my project. We met during the most would have never happened without you pushing to book my very first meeting with challenging phase of the data collection, when we were trying to figure it all out. Inge, when I passed through Wageningen the first time. Anne Bossuyt, you were Thanks for helping in these crazy, but also most exciting, times of my PhD. Julia, it always there for a chat, keeping me grounded with nutrition in the real world was so nice meeting you in Addis and Wageningen, chatting and laughing about our beyond all the papers I was often drowning in. Kalle Hirvonen, you have been the research and all the problems we faced. Also, thanks to the Newtrition editorial saviour at the last minute providing the all-time best instructions to complicated board, Matjaz, Eva and Mamadou, with whom I enjoyed working for a year. statistics questions as well as at the stage of my first thoughts on the proposal. Gea, Jasmijn and Jeannine helped me from the first minute that I arrived, looking for Barbara Stadlmayr, my Viennese nutrition buddy, thanks for all the moral support, a desk, getting settled, finding my way around, booking meetings, getting the right inspiring discussions about doing nutrition differently, as well as your open ear for project number and chasing people down for signatures. A huge thank you to my ranting fits! Kirsten Wandschneider, thanks for helping with the propositions and Jasmijn, you were the superstar at the right minute to book my defense date in the general research survival advice. middle of your holidays! Vesna, you have been very helpful along the whole way of my PhD and thought of I also want to thank my sisters Barbara, Annemarie and Veronika and my niece Julia me when funding opportunities crossed your desk and always had an open ear for for her interest in my research and my friends in Vienna, Addis and wherever they all my random questions. Jacco, thank you for your creative guidance to develop my are in the world. I am also grateful to my parents-in-law Carol and Dennis for their story for the defense. Jeanne, Alida and Karin, it was always nice to chat with you in constant encouragement. between and even though you were not involved in my project, you always showed interest, which was very motivating. I am thankful for the funding I received from A4NH, IFPRI, AON and the Chairgroup which allowed me to collect the data and focus better on my studies. A sincere thank you to all the students who participated in the data collection, which was the absolute highlight of my whole PhD. Hearing your thoughts and ideas Lastly, a big thank you to anybody who asked, “how is it going with the PhD?” or brought the theoretical research questions to life. I also want to thank the people “what is your PhD actually about?” or even “Are you done yet?” you might not have who helped get the students to talk, especially Esete, Dawit, Fikre, Ferehiwot and been interested, but it meant a lot that you asked. Selamawit. Selamawit you have also been my admin assistant, translator and coordinator during the data collection. Also, I am grateful to the school headmasters and teachers who facilitated access to the students and provided their premises. Abebe, you have been more than a driver, you have been basically the logistics manager during the data collection. You cared so much about my research that you got almost angrier than I did when cameras were stolen from the study. Thanks to my Addis PhD partners-in-crime Daisy and Justin, I will never forget our morning coffee at the French bakery, when Daisy and I convinced ourselves to also do a PhD and every time I entered my log in password “I’m in it to win it”, I thought of you Daisy! 198 Acknowledgements Taonga, Hongyi, Inga, Koen, Claudia, Marion, Ilse, Umi, Duong, Asrul and Fusta. A Besides doing my PhD, I had the opportunity and honour to work with Corinna special thanks to my two paranymphs, Giulia and Tesfaye, who have been so Hawkes. I have learned so much during my time with Corinna, learning to think generous with their time, helping with all the little and big and mostly boring admin outside the box, to look at the bigger picture and to consider different angels. And stuff in the end, but more importantly, being so encouraging and supportive, besides thinking about food systems transformations, I have learned so much about reading my discussion section, and thinking through the propositions. I also wanted inclusive, uplifting leadership from her. Talking of amazing leaders, Francesco to thank my Ethiopian PhD friends, Tesfaye, Aregash, Tibebu, Kifle, and Masresha, Branca, Trudy Wijnhoven, Karin Schindler and Oladapo Walker, you have been my who have made me feel part of their group, which helped me whenever I missed early teachers, supporters and inspirations for nutrition. Ethiopia. Donya, I so enjoyed our scientific discussions from the first moment we met. You motivated me to get into qualitative research and I cannot thank you There were so many other people along the way, who helped at different stages, enough for opening my eyes to this amazing new world! I also want to thank Megan but I want to mention the most important by name: Roseline Remans, this PhD who did her Master study research as part of my project. We met during the most would have never happened without you pushing to book my very first meeting with challenging phase of the data collection, when we were trying to figure it all out. Inge, when I passed through Wageningen the first time. Anne Bossuyt, you were Thanks for helping in these crazy, but also most exciting, times of my PhD. Julia, it always there for a chat, keeping me grounded with nutrition in the real world was so nice meeting you in Addis and Wageningen, chatting and laughing about our beyond all the papers I was often drowning in. Kalle Hirvonen, you have been the research and all the problems we faced. Also, thanks to the Newtrition editorial saviour at the last minute providing the all-time best instructions to complicated board, Matjaz, Eva and Mamadou, with whom I enjoyed working for a year. statistics questions as well as at the stage of my first thoughts on the proposal. Gea, Jasmijn and Jeannine helped me from the first minute that I arrived, looking for Barbara Stadlmayr, my Viennese nutrition buddy, thanks for all the moral support, a desk, getting settled, finding my way around, booking meetings, getting the right inspiring discussions about doing nutrition differently, as well as your open ear for project number and chasing people down for signatures. A huge thank you to my ranting fits! Kirsten Wandschneider, thanks for helping with the propositions and Jasmijn, you were the superstar at the right minute to book my defense date in the general research survival advice. middle of your holidays! Vesna, you have been very helpful along the whole way of my PhD and thought of I also want to thank my sisters Barbara, Annemarie and Veronika and my niece Julia me when funding opportunities crossed your desk and always had an open ear for for her interest in my research and my friends in Vienna, Addis and wherever they all my random questions. Jacco, thank you for your creative guidance to develop my are in the world. I am also grateful to my parents-in-law Carol and Dennis for their story for the defense. Jeanne, Alida and Karin, it was always nice to chat with you in constant encouragement. between and even though you were not involved in my project, you always showed interest, which was very motivating. I am thankful for the funding I received from A4NH, IFPRI, AON and the Chairgroup which allowed me to collect the data and focus better on my studies. A sincere thank you to all the students who participated in the data collection, which was the absolute highlight of my whole PhD. Hearing your thoughts and ideas Lastly, a big thank you to anybody who asked, “how is it going with the PhD?” or brought the theoretical research questions to life. I also want to thank the people “what is your PhD actually about?” or even “Are you done yet?” you might not have who helped get the students to talk, especially Esete, Dawit, Fikre, Ferehiwot and been interested, but it meant a lot that you asked. Selamawit. Selamawit you have also been my admin assistant, translator and coordinator during the data collection. Also, I am grateful to the school headmasters and teachers who facilitated access to the students and provided their premises. Abebe, you have been more than a driver, you have been basically the logistics manager during the data collection. You cared so much about my research that you got almost angrier than I did when cameras were stolen from the study. Thanks to my Addis PhD partners-in-crime Daisy and Justin, I will never forget our morning coffee at the French bakery, when Daisy and I convinced ourselves to also do a PhD and every time I entered my log in password “I’m in it to win it”, I thought of you Daisy! 199 ABOUT THE AUTHOR About the author Ursula Trübswasser is a public health nutritionist who specializes in food and List of publications nutrition policies and programs, infant and young child feeding, adolescent nutrition and food systems. She has more than 15 years of experience in management, Trübswasser U, Talsma EF, Ekubay S, Poelman MP, Holdsworth M, Feskens EJM, implementation and research in Europe, Asia and Africa. Baye K. Factors Influencing Adolescents' Dietary Behaviors in the School and Home Environment in Addis Ababa, Ethiopia, Frontiers in Public Health, 2022. Ursula was born in Vienna, Austria. She studied nutritional sciences at the University https://www.frontiersin.org/articles/10.3389/fpubh.2022.861463/full of Vienna. After her studies, she worked on clinical nutrition in a hospital in Bucharest, Romania and the General Hospital in Vienna. She then worked for six Liguori J, Trübswasser U, Pradeilles R, Le Port A, Landais E, Talsma EF, Lundy M, Bene years at the World Health Organization (WHO), first in the Regional Office to the C, Bricas N, Laar A, Amiot MJ, Brouwer ID, Holdsworth M. How do food safety European Region on nutrition policies; then in Tajikistan and Uzbekistan, focusing concerns affect consumer behaviors and diets in low- and middle-income countries? on infant and young child nutrition; and finally in the Eastern and Southern African A systematic review, Global Food Security, 2022. Region supporting 19 countries on a variety of nutrition programmes and strategies. https://doi.org/10.1016/j.gfs.2021.100606 Over the following years, Ursula worked as a consultant for NGOs (Mercy Corps, Concern Worldwide, FHI 360) and the UN (FAO, WHO) in Tajikistan and Ethiopia on Trübswasser U, Verstraeten R, Salm L, Holdsworth M, Baye K, Booth A, Feskens EJ, nutrition guidelines and training materials and testing of the dietary diversity score Gillespie S, Talsma EF. Factors influencing obesogenic behaviours of adolescent girls for women. and women in low- and middle-income countries: a qualitative evidence synthesis, Obesity Reviews, 2021. https://onlinelibrary.wiley.com/doi/10.1111/obr.13163 From 2015-19, Ursula supported the EU Delegation and its Member States designing, implementing and evaluating nutrition-sensitive programmes and Trübswasser U, Genye T, Bossuyt A. Review of nutrition policies in Ethiopia 2010- policies in Ethiopia. She also contributed to the EU Strategy on nutrition and to the 2020. IFPRI and EPHI, 2020. http://www.nipn.ephi.gov.et/sites/default/files/inline- Ethiopian Agricultural Growth Program and the Productive Safety Net Program, as files/Nutrition_Policy_Landscape_FINAL_Report.pdf well as helping to set up information platforms on nutrition-sensitive agriculture and nutrition in pastoralist communities. Trübswasser U, Baye K, Holdsworth M, Loeffen M, Feskens EJ, Talsma EF. Assessing factors influencing adolescents’ dietary behaviours in urban Ethiopia using As part of her PhD research, Ursula had the opportunity to work with International participatory photography. Public Health Nutrition, 2020. Food Policy Research Institute (IFPRI) on a nutrition policy review in Ethiopia as part https://doi.org/10.1017/S1368980020002487 of the National Information Platform on Nutrition and a qualitative evidence synthesis for Transform Nutrition West Africa. Gebru M, Remans R, Brouwer I, Baye K, Melesse M, Covic N, Habtamu F, Abay A, Hailu T, Hirvonen K, Kassaye T, Kennedy G, Lachat C, Lemma F, McDermott J, Minten In 2020 and 2021, Ursula worked as a researcher at the National Research Institute B, Moges T, Reta F, Tadesse E, Taye T, Trübswasser U, and Vandenberg M. 2018. for Agriculture, Food and Environment (INRAE) in France and at the Centre for Food Food systems for healthier diets in Ethiopia: Toward a research agenda. IFPRI Policy at City, University of London, preparing literature reviews on food safety and Discussion Paper 1720. Washington, DC: International Food Policy Research dietary behaviours and on benefits and risks of food system policies for diets, Institute (IFPRI). http://ebrary.ifpri.org/cdm/ref/collection/p15738coll2/id/132417 environmental sustainability, livelihoods and gender in different contexts. Trübswasser U and Flintan F, Extensive (pastoralist) cattle: contributions to food and nutrition security, in Elsevier Encyclopedia for Food and Nutrition security and sustainability, 2018. https://www.sciencedirect.com/science/article/pii/B9780081005965215291 202 About the author Ursula Trübswasser is a public health nutritionist who specializes in food and List of publications nutrition policies and programs, infant and young child feeding, adolescent nutrition and food systems. She has more than 15 years of experience in management, Trübswasser U, Talsma EF, Ekubay S, Poelman MP, Holdsworth M, Feskens EJM, implementation and research in Europe, Asia and Africa. Baye K. Factors Influencing Adolescents' Dietary Behaviors in the School and Home Environment in Addis Ababa, Ethiopia, Frontiers in Public Health, 2022. Ursula was born in Vienna, Austria. She studied nutritional sciences at the University https://www.frontiersin.org/articles/10.3389/fpubh.2022.861463/full of Vienna. After her studies, she worked on clinical nutrition in a hospital in Bucharest, Romania and the General Hospital in Vienna. She then worked for six Liguori J, Trübswasser U, Pradeilles R, Le Port A, Landais E, Talsma EF, Lundy M, Bene years at the World Health Organization (WHO), first in the Regional Office to the C, Bricas N, Laar A, Amiot MJ, Brouwer ID, Holdsworth M. How do food safety European Region on nutrition policies; then in Tajikistan and Uzbekistan, focusing concerns affect consumer behaviors and diets in low- and middle-income countries? on infant and young child nutrition; and finally in the Eastern and Southern African A systematic review, Global Food Security, 2022. Region supporting 19 countries on a variety of nutrition programmes and strategies. https://doi.org/10.1016/j.gfs.2021.100606 Over the following years, Ursula worked as a consultant for NGOs (Mercy Corps, Concern Worldwide, FHI 360) and the UN (FAO, WHO) in Tajikistan and Ethiopia on Trübswasser U, Verstraeten R, Salm L, Holdsworth M, Baye K, Booth A, Feskens EJ, nutrition guidelines and training materials and testing of the dietary diversity score Gillespie S, Talsma EF. Factors influencing obesogenic behaviours of adolescent girls for women. and women in low- and middle-income countries: a qualitative evidence synthesis, Obesity Reviews, 2021. https://onlinelibrary.wiley.com/doi/10.1111/obr.13163 From 2015-19, Ursula supported the EU Delegation and its Member States designing, implementing and evaluating nutrition-sensitive programmes and Trübswasser U, Genye T, Bossuyt A. Review of nutrition policies in Ethiopia 2010- policies in Ethiopia. She also contributed to the EU Strategy on nutrition and to the 2020. IFPRI and EPHI, 2020. http://www.nipn.ephi.gov.et/sites/default/files/inline- Ethiopian Agricultural Growth Program and the Productive Safety Net Program, as files/Nutrition_Policy_Landscape_FINAL_Report.pdf well as helping to set up information platforms on nutrition-sensitive agriculture and nutrition in pastoralist communities. Trübswasser U, Baye K, Holdsworth M, Loeffen M, Feskens EJ, Talsma EF. Assessing factors influencing adolescents’ dietary behaviours in urban Ethiopia using As part of her PhD research, Ursula had the opportunity to work with International participatory photography. Public Health Nutrition, 2020. Food Policy Research Institute (IFPRI) on a nutrition policy review in Ethiopia as part https://doi.org/10.1017/S1368980020002487 of the National Information Platform on Nutrition and a qualitative evidence synthesis for Transform Nutrition West Africa. Gebru M, Remans R, Brouwer I, Baye K, Melesse M, Covic N, Habtamu F, Abay A, Hailu T, Hirvonen K, Kassaye T, Kennedy G, Lachat C, Lemma F, McDermott J, Minten In 2020 and 2021, Ursula worked as a researcher at the National Research Institute B, Moges T, Reta F, Tadesse E, Taye T, Trübswasser U, and Vandenberg M. 2018. for Agriculture, Food and Environment (INRAE) in France and at the Centre for Food Food systems for healthier diets in Ethiopia: Toward a research agenda. IFPRI Policy at City, University of London, preparing literature reviews on food safety and Discussion Paper 1720. Washington, DC: International Food Policy Research dietary behaviours and on benefits and risks of food system policies for diets, Institute (IFPRI). http://ebrary.ifpri.org/cdm/ref/collection/p15738coll2/id/132417 environmental sustainability, livelihoods and gender in different contexts. Trübswasser U and Flintan F, Extensive (pastoralist) cattle: contributions to food and nutrition security, in Elsevier Encyclopedia for Food and Nutrition security and sustainability, 2018. https://www.sciencedirect.com/science/article/pii/B9780081005965215291 203 About the author Flinton F and Trübswasser U, Extensive pastoralist (cattle): leveraging for food and Overview of completed training activities nutrition security, in Elsevier Encyclopedia for Food and Nutrition security and sustainability, 2018. https://www.sciencedirect.com/science/article/pii/B9780081005965215461?via% Name of the course/meeting Organizing institute(s) Year 3Dihub A. Discipline specific activities Workshop March 2018, Presentation on Alive and Thrive 2018 adolescent nutrition lit review Trübswasser U, Nishida C, Engesveen K, Coulibaly-Zebo F, Landscape analysis – Conference on ‘Critical Public Health Public Health Resource 2018 assessing countries' readiness to scale up nutrition actions in the WHO African Consequences of the Network, the Peoples’ Health Region, African Journal of Food, Agriculture, Nutrition and Development, 2012. Double Burden of Malnutrition and the Movement, Jan Swasthya, http://www.ajol.info/index.php/ajfand/article/view/80414 Changing Food Environment in South Abhiyan, WPHNA, Narotam and South East Asia’ Sekhsaria Foundation Adrianopoli M, D’Acapito P, Ferrari M, Mistura L, Toti E, Maiani G, Trübswasser U, and IFPRI Boymatova K and Severoni S, Optimized feeding recommendations and in-home 8th African Nutritional Epidemiology African Nutrition Society and 2018 fortification to improve the iron status in infants and young children in Tajikistan, Conference 2018 Food and Nutrition Society of 2014. http://www.cabi.org/nutrition/ebook/20143140804 Ethiopia International Symposium on IAEA 2018 Trübswasser U and Branca F. Nutrition policy is taking shape in Europe, Public Health Understanding the Double Burden of Nutrition, 2009. https://doi.org/10.1017/S1368980009004753 Malnutrition for Effective Interventions, Exposure assessment in nutrition VLAG 2018 Branca F, Trübswasser U, Kruse HD. Tackling acute and chronic diseases from food research and nutrition with a comprehensive approach – the Second Action Plan for Food and Agriculture, Nutrition, and Health ANH 2019 Nutrition Policy, 2007–2012. Public Health Nutrition, 12, 293 – 294, 2009. (ANH) Academy’s fourth annual Study visit to Sheffield to work on QES Sheffield University 2019 protocol Trübswasser U. National policies in the European Region, chapter in The challenge Ethiopia National Nutrition Conference IFPRI, Compact2025, CGIAR, 2019 of obesity in the WHO European Region and the strategies for response, WHO EURO, "Diets, Affordability and Policy in Ethiopian Public Health 2007. http://www.euro.who.int/__data/assets/pdf_file/ 0010/74746/E90711.pdf Ethiopia: From Evidence to Action” Institute WPHNA Congress WPHNA 2020 Agriculture, Nutrition, and Health ANH 2020 (ANH) Academy’s fifth annual A4NH Food systems for healthier diets WUR 2020 African Food environment conference Ghana university 2020 2nd Africa Food Environment Research INFORMAS/FERN 2021 Network (FERN2021) eSymposium B. General courses VLAG PhD week VLAG 2018 Library course WGS 2019 Presentation training IFPRI 2019 Data vizualization 1 Coursera 2020 Data vizualization 2 Coursera 2020 Research Data Management WUR library 2020 Scientific writing WUR VLAG 2020 204 About the author Flinton F and Trübswasser U, Extensive pastoralist (cattle): leveraging for food and Overview of completed training activities nutrition security, in Elsevier Encyclopedia for Food and Nutrition security and sustainability, 2018. https://www.sciencedirect.com/science/article/pii/B9780081005965215461?via% Name of the course/meeting Organizing institute(s) Year 3Dihub A. Discipline specific activities Workshop March 2018, Presentation on Alive and Thrive 2018 adolescent nutrition lit review Trübswasser U, Nishida C, Engesveen K, Coulibaly-Zebo F, Landscape analysis – Conference on ‘Critical Public Health Public Health Resource 2018 assessing countries' readiness to scale up nutrition actions in the WHO African Consequences of the Network, the Peoples’ Health Region, African Journal of Food, Agriculture, Nutrition and Development, 2012. Double Burden of Malnutrition and the Movement, Jan Swasthya, http://www.ajol.info/index.php/ajfand/article/view/80414 Changing Food Environment in South Abhiyan, WPHNA, Narotam and South East Asia’ Sekhsaria Foundation Adrianopoli M, D’Acapito P, Ferrari M, Mistura L, Toti E, Maiani G, Trübswasser U, and IFPRI Boymatova K and Severoni S, Optimized feeding recommendations and in-home 8th African Nutritional Epidemiology African Nutrition Society and 2018 fortification to improve the iron status in infants and young children in Tajikistan, Conference 2018 Food and Nutrition Society of 2014. http://www.cabi.org/nutrition/ebook/20143140804 Ethiopia International Symposium on IAEA 2018 Trübswasser U and Branca F. Nutrition policy is taking shape in Europe, Public Health Understanding the Double Burden of Nutrition, 2009. https://doi.org/10.1017/S1368980009004753 Malnutrition for Effective Interventions, Exposure assessment in nutrition VLAG 2018 Branca F, Trübswasser U, Kruse HD. Tackling acute and chronic diseases from food research and nutrition with a comprehensive approach – the Second Action Plan for Food and Agriculture, Nutrition, and Health ANH 2019 Nutrition Policy, 2007–2012. Public Health Nutrition, 12, 293 – 294, 2009. (ANH) Academy’s fourth annual Study visit to Sheffield to work on QES Sheffield University 2019 protocol Trübswasser U. National policies in the European Region, chapter in The challenge Ethiopia National Nutrition Conference IFPRI, Compact2025, CGIAR, 2019 of obesity in the WHO European Region and the strategies for response, WHO EURO, "Diets, Affordability and Policy in Ethiopian Public Health 2007. http://www.euro.who.int/__data/assets/pdf_file/ 0010/74746/E90711.pdf Ethiopia: From Evidence to Action” Institute WPHNA Congress WPHNA 2020 Agriculture, Nutrition, and Health ANH 2020 (ANH) Academy’s fifth annual A4NH Food systems for healthier diets WUR 2020 African Food environment conference Ghana university 2020 2nd Africa Food Environment Research INFORMAS/FERN 2021 Network (FERN2021) eSymposium B. General courses VLAG PhD week VLAG 2018 Library course WGS 2019 Presentation training IFPRI 2019 Data vizualization 1 Coursera 2020 Data vizualization 2 Coursera 2020 Research Data Management WUR library 2020 Scientific writing WUR VLAG 2020 205 About the author Name of the course/meeting Organizing institute(s) Year Statistical analysis with SPSS BOKU, University of Natural 2020 resources and life sciences C. Other activities Preparation of PhD proposal Research group 2017 ESQUIRE course Sheffield university 2018 The Science of Weight Loss: Dispelling edx 2018 Diet Myths Global adolescent health Coursera 2018 CGIAR food environment meeting A4NH 2019 Colophon The advisory committee for this research included: Prof. Dr Michelle Holdsworth, IRD: French National Research Institute for Sustainable Development, Montpellier, France Prof. Dr Kaleab Baye, Addis Ababa University, Ethiopia Financial disclosure The research described in this thesis was financially supported by by the CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), Research Flagship on Food Systems for Healthier Diets (FSHD). I also received funding from Ethiopia NIPN Technical Assistance Project (ENTAP), International Food Policy Research Institute and the Agriculture for Nutrition and Health (A4NH) Supporting Policies, Programs, and Enabling Action through Research (SPEAR) Flagship and a scholarship from AON Financial support from Wageningen University for printing this thesis is gratefully acknowledged. Cover design Ursula Trübswasser, Brook Getachew, www.brookand.co and Proefschriftmaken.nl Printed by Proefschriftmaken.nl Copyright: Ursula Trübswasser, 2022 206 Name of the course/meeting Organizing institute(s) Year Statistical analysis with SPSS BOKU, University of Natural 2020 resources and life sciences C. Other activities Preparation of PhD proposal Research group 2017 ESQUIRE course Sheffield university 2018 The Science of Weight Loss: Dispelling edx 2018 Diet Myths Global adolescent health Coursera 2018 CGIAR food environment meeting A4NH 2019 Colophon The advisory committee for this research included: Prof. Dr Michelle Holdsworth, IRD: French National Research Institute for Sustainable Development, Montpellier, France Prof. Dr Kaleab Baye, Addis Ababa University, Ethiopia Financial disclosure The research described in this thesis was financially supported by by the CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), Research Flagship on Food Systems for Healthier Diets (FSHD). I also received funding from Ethiopia NIPN Technical Assistance Project (ENTAP), International Food Policy Research Institute and the Agriculture for Nutrition and Health (A4NH) Supporting Policies, Programs, and Enabling Action through Research (SPEAR) Flagship and a scholarship from AON Financial support from Wageningen University for printing this thesis is gratefully acknowledged. Cover design Ursula Trübswasser, Brook Getachew, www.brookand.co and Proefschriftmaken.nl Printed by Proefschriftmaken.nl Copyright: Ursula Trübswasser, 2022 weeshhoouulldd bbe ablle tto decide OObbeessooggenic facttorrss inifnlufleuenncciningg ddiiettarry behhaavvioiouursr s oof fa addoolelesscceennttss iinn EEtthhiiooppiaia Ursula Trübswasser Ursula Trübswasser “We should be able to decide” - Obesogenic factors influencing dietary behaviours of women and adolescents in Ethiopia Ursula Trübswasser