Editorial [Volume 22 No. 2 (2022)]

Developing Ghana’s first Food-based dietary guidelines: An evidence-informed process

Globally, sub-optimal diets across the entire lifecycle have been identified as an important driver of malnutrition in all its forms (global panel, Global burden of disease). The 2020 Global nutrition indicates that several countries on the African continent are off course in their efforts to address malnutrition in all its forms. Food-based dietary guidelines (FBDGs) have been recommended as a necessary public health tool for creating awareness and promoting the consumption of optimal diets. Evidence-informed FBDGs can serve as a communication tool for enabling healthier dietary and lifestyle choices among the lay population. They can also be used by governments and other institutional actors as a policy tool for population-level interventions that improve the nutrition-sensitivity of food systems as well as food environments.

However, at the end of June 2021, only seven out of the 54 African countries had developed and implemented food-based dietary guidelines (FBDGs). In 2016, Ghana’s Ministry of Food and Agriculture, in partnership with the University of Ghana, initiated a process for developing national FBDGs. This process was carried with technical support from the Food and Agriculture Organization. This special edition reports the processes and the findings of the systematic evidence review that was carried out to inform the process of FBDGs development for Ghana. In this special edition, we present thirteen papers. Ten of the papers are the result of scoping reviews that were conducted to answer questions that are relevant for characterizing and prioritizing the food and nutrition situation and associated risk factors in Ghana, across diverse population subgroups. Two of the papers were primary research that provided useful evidence for the FBDGs development process and thus, has been included in this special issue. The final paper provides a descriptive overview, detailing how the process of FBDGs has evolved in Ghana and providing lessons for other countries that are planning to implement FBDGs.

Using a scoping review of existing literature (including survey reports, peer-reviewed literature, and other graduate student theses), Coomson and Aryeetey identified high rates of childhood stunting, anemia across all age groups, and maternal overweight as the most common nutrition outcomes affecting persons living in Ghana. They also pointed to the rapid evolution of diet-related non-communicable diseases in Ghana. A primary study by Egbi reported anemia rates among school-age and adolescent children and reported a rate of about 20%. In a second paper, Aryeetey and Coomson reported the evolution of nutrition-relevant policies and programs during the decade spanning 2010 and 2020. The policy analysis demonstrated that almost all the policies/programs that were developed or implemented in the decade under review were aimed at addressing undernutrition and food insecurity. There is limited focus on overweight and diet-related NCDs. The findings from the two studies form the basis for the recommendations by the authors for a national nutrition implementation plan that focuses on addressing the emerging double-burden of malnutrition in Ghana. In another review, Tandoh and colleagues specifically reviewed the policies and programs linking nutrition with education and social protection in Ghana. This review outlines the pathways and principles underlying the use of education and social protection to promote the nutrition of school-age children.

Boadi and colleagues assessed the food supply, disposition, and utilization by Ghanaians using a combination of FAO’s food balance sheet data and a systematic search of peer-reviewed journal articles. The study reported that across most food crops, per capita production exceeds per capita demand, except for vegetables and fish. A key finding is that in the past decade, food imports have exceeded exports in all food categories, with some exceptions. Also, fruit and vegetable consumption has been declining since 2013. The study also identified key food safety challenges that serve as important guideposts for the FBDGs being developed. Colecraft and colleagues also reported the role of socio-cultural beliefs, perceptions, and practices that influence food choice based on a scoping review of peer-reviewed literature. A key finding of this study is that culture and religion play a key role in the choice of foods consumed by the Ghanaian population.

Annan and colleagues have systematically reviewed the existing literature on food environments in Ghana over the past decade. Their findings report that traditional food markets remain the main source for households. Also, when food is purchased from outside the home, street food vendors are the preferred source. Perhaps, the most important finding from this study is that food price and household income is the most influential driver of healthy diet consumption. A primary study by Asalu and colleagues reported evidence on labeling of pre-packaged foods, analyzed using the INFORMAS (International Network for Food and Obesity/Non-Communicable Diseases Research, Monitoring and Action Support) protocol. The study highlighted the level of sub-optimal compliance of labeling concerning nutrient declarations and ingredient list information. About a fifth of labeled food products displayed nutrition claims which have relevance for consumer food choice.

In another scoping review, Agyapong and colleagues reviewed the literature on food systems sustainability and identified three key challenges to environmental sustainability in Ghanaian food systems: 1) high prevalence of fuelwood use as the main source of cooking fuel in rural areas; 2) overexploitation of fish and forest food resources; and 3) the growing challenge of single-use plastics and the associated challenges of waste disposal, especially in urban communities.

Parbey and Aryeetey reviewed the existing literature on nutrition communication and reported that there is limited information on nutrition communication in the popular media. On the other hand, advertising of unhealthy highly processed foods is common across various media and frequently targets young children. The most reported sources of health and nutrition information were identified as television, radio, social media, health professionals, family, and friends. Social media use is growing rapidly in urban settings, particularly among young adults.

Ainuson-Quampah and colleagues reviewed FBDGs from all seven countries with dietary guidelines listed in the FAO FBDGs repository in 2020. Common characteristics of the FBDGs included the role of multisectoral working groups involved in FBDGs development, use of the FBDGs as a communication tool, inclusion of between four and six food groups in the FBDGs, and promotion of a diverse diet as a key message. Not all the food-based dietary guidelines had included graphical food guides. None of the African FBDGs addressed environmental sustainability.

A scoping review by Mensah and colleagues focused on physical activity and sedentary lifestyle in Ghana. The study reports that most Ghanaian adults are physically active; studies on sedentary lifestyles also report that majority are minimally sedentary. Adequate activity is, however, lower among children. Across all age groups, boys and men are more physically active than girls. Most of the activity is accrued through active transportation and occupations.

Altogether, these studies have provided valuable evidence that has guided the decisions of the FBDGs development task team. The studies have identified important gaps in the literature that should become a focus for future studies in Ghana and elsewhere. Future efforts to revise the guidelines must build on the lessons that have been learned from implementing these studies. In congratulating the reviewers on this extensive work carried out during a challenging COVID-19 pandemic period, the use of more rigorous systematic review approaches will be critical in future FBDGs development processes.

Richmond Aryeetey
University of Ghana, School of Public Health
Legon, Accra, Ghana
raryeetey@ug.edu.gh