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The objective of our study was to reanalyse the Ethiopia STEPwise approach to Surveillance Noncommunicable Disease Risk Factors survey (NCD STEPS), using causal path diagrams constructed using expert subject matter knowledge in conjunction with graphical model theory to map the underlying causal network of modifiable factors associated with prediabetes/diabetes and hypertension. We used data from the 2015 Ethiopia NCD STEPS representative cross‐sectional survey (males; n = 3977 and females; n = 5823 aged 15–69 years) and performed directed acyclic graph‐informed logistic regression analyses. In both sexes, a 1‐unit higher in body mass index (BMI) and waist circumference (WC) were positively associated with prediabetes/diabetes (BMI: males: adjusted odds ratio [aOR]: 1.07 [95% confidence interval: 1.0, 1.1], females aOR: 1.03 [1.0, 1.1]; WC: males: aOR: 1.1 [0.9, 1.2], females: aOR: 1.2 [1.1, 1.3]) and hypertension (BMI: males: aOR: 1.2 [1.1, 1.2], females aOR: 1.1 [1.0, 1.1]; WC: males: aOR: 1.6 [1.4, 1.8], females: aOR: 1.3 [1.2, 1.5]). Although residing in urban settings was associated with higher odds of hypertension in both males (aOR: 1.79 [1.49, 2.16]) and females (aOR: 1.70 [1.49, 1.95]), it was only associated with prediabetes/diabetes in males (aOR: 1.56 [1.25, 1.96]). Males and females in pastoralist areas had lower odds of prediabetes/diabetes compared with their agrarian counterparts (males: aOR: 0.27 [0.14, 0.52], females: aOR: 0.31 [0.16, 0.58]). Physical activity was associated with lower odds of prediabetes/diabetes among females (aOR: 0.75 [0.58, 0.97]). Other diet‐related modifiable factors such as consumption of fruit and vegetable, alcohol or salt were not associated with either prediabetes/diabetes or hypertension. Our findings highlight the need to implement interventions that prevent overweight/obesity and nutrition‐related NCDs, particularly in urban areas. We provide empirical findings relating to the factors associated with hypertension and prediabetes/diabetes among Ethiopian males and females. Our findings highlight the need to implement interventions that promote healthy lifestyles to address the burden of overweight/obesity and Nutrition‐Related Noncommunicable Diseases, particularly in urban areas. Key messages Body mass index and waist circumference were positively associated with hypertension and prediabetes/diabetes for both sexes. Residing in urban settings was associated with increased odds of hypertension in both sexes, and with prediabetes/diabetes in males. Physical activity was associated with lower odds of prediabetes/diabetes among women. Diet‐related factors (consumption of fruit and vegetables, alcohol, and salt) were not associated with either hypertension or prediabetes/diabetes. There is a need for longitudinal, nationally representative dietary surveys, which enable the derivation of relevant indicators of the nutrition transition in Ethiopia.

To explore the perceptions, drivers and potential solutions to the consumption of unhealthy, ultra-processed foods (UPF) and foods high in fat, salt and sugar (HFSS) and their contribution to the double burden of malnutrition among adolescents living in urban slums, Kenya. Qualitative participatory research, through Photovoice, group discussions and community dialogues. Inductive, thematic analysis was undertaken. Three major slums, Nairobi. Adolescents 10-19 years ( 102: 51 boys, 51 girls) and adults ( 62). UPF/HFSS consumption emerged as a predominant theme on foods commonly consumed by adolescents, and the causes of undernutrition and overweight/obesity. Adolescents described UPF/HFSS as junk, oily, sugary or foods with chemicals and associated UPF/HFSS consumption with undernutrition, obesity and non-communicable diseases. They perceived UPF/HFSS as modern, urban, classy and appealing to young people and minimally processed foods as boring and primitive, for older people, and those in rural areas. Individual-level drivers of UPF/HFSS consumption were organoleptic attributes (taste/aroma), body size/shape, illicit drug use, convenience and adolescents' autonomy. Social environment drivers were peer pressure and social status/aspirations. Physical environment drivers were UPF/HFSS availability and accessibility in the slums. Education on healthy eating and the adverse effects of consuming UPF/HFSS, through existing structures (youth groups, school, community health strategy), was proposed as a potential solution to UPF/HFSS consumption. UPF/HFSS were perceived as associated with poor nutrition and health, yet were preferred over unprocessed/minimally processed foods. Interventions to promote healthy diets beyond raising awareness are important, while addressing the underlying perceptions and drivers of UPF/HFSS consumption at the individual level and in the social and physical food environments.

Ethiopia faces a rising problem of overweight and obesity alongside a high prevalence of undernutrition; a double burden of malnutrition (DBM). This study aimed to quantify the magnitude and trends of household‐level DBM—defined as the coexistence of maternal overweight/obesity and child undernutrition (i.e., stunting or anaemia)—in Ethiopia between 2005, 2011 and 2016 and understand the potential drivers influencing DBM and the change in DBM over time. Data come from the Ethiopian Demographic and Health Surveys. National and regional prevalence estimates of the DBM were calculated (n = 13,107). Equiplots were produced to display inequalities in the distribution of DBM. Factors associated with DBM were explored using pooled multivariable logistic regression analyses for 2005, 2011 and 2016 (n = 9358). These were also included in a logistic regression decomposition analysis to understand their contribution to the change in DBM between 2005 and 2016 (n = 5285). The prevalence of household‐level DBM at the national level was low, with a modest increase from 2.4% in 2005% to 3.5% in 2016. This masks important within‐country variability, with substantially higher prevalence in Addis Ababa (22.8%). Factors positively associated with DBM were maternal age (odds ratio [OR] = 1.04 [1.02, 1.06]), urban residence (OR = 3.12 [2.24, 4.36]), wealth (OR = 1.14 [1.06, 1.24]) and the number of children <5 in the household (OR = 1.30 [1.12, 1.49]). Overall, 70.5% of the increase in DBM between 2005 and 2016 was attributed to increased wealth, urban residence and region. Double‐duty actions that address multiple forms of malnutrition are urgently needed in urban settings. The present study has highlighted that a relatively low prevalence of household‐level double burden of malnutrition (DBM) at the national level can mask serious disparities among subpopulations. The prevalence of household‐level DBM is significantly higher in urban areas and in households with higher wealth, calling for double‐duty actions that address both forms of malnutrition, particularly in urban areas. Key messages Despite a low national prevalence, household level DBM is significantly higher in urban areas, particularly in Addis Ababa where nearly a quarter of households are affected. Maternal age, urban residence, wealth and the number of children <5 in the household were positively associated with DBM. Increased wealth and urban residence were the main drivers associated with increases in DBM between 2005 and 2016. Double‐dutyactions addressing multiple forms of malnutrition are required in urban settings. Transforming food systems by regulating the promotion and distribution of unhealthy foods and promoting nutrient‐dense foods is critical.

This study developed, validated, and evaluated a framework of factors influencing dietary behaviours in urban African food environments, to inform research prioritisation and intervention development in Africa. A multi-component methodology, drawing on concept mapping, was employed to construct a framework of factors influencing dietary behaviours in urban Africa. The framework adapted a widely used socio-ecological model (developed in a high-income country context) and was developed using a mixed-methods research approach that comprised: i. Evidence synthesis consisting of a systematic review of 39 papers covering 14 African countries; ii. Qualitative interview data collected for adolescents and adults (n = 144) using photovoice in urban Ghana and Kenya; and iii. Consultation with interdisciplinary African experts (n = 71) from 27 countries, who contributed to at least one step of the framework (creation, validation/evaluation, finalisation). The final framework included 103 factors influencing dietary behaviours. Experts identified the factors influencing dietary behaviours across all the four levels of the food environment i.e. the individual, social, physical and macro levels. Nearly half (n = 48) were individual-level factors and just under a quarter (n = 26) were at the macro environmental level. Fewer factors associated with social (n = 15) and physical (14) environments were identified. At the macro level, the factors ranked as most important were food prices, cultural beliefs and seasonality. Factors ranked as important at the social level were household composition, family food habits and dietary practices. The type of food available in the neighbourhood and convenience were seen as important at the physical level, while individual food habits, food preferences and socioeconomic status were ranked highly at the individual level. About half of the factors (n = 54) overlap with those reported in an existing socio-ecological food environment framework developed in a high-income country context. A further 49 factors were identified that were not reported in the selected high-income country framework, underlining the importance of contextualisation. Our conceptual framework offers a useful tool for research to understand dietary transitions in urban African adolescents and adults, as well as identification of factors to intervene when promoting healthy nutritious diets to prevent multiple forms of malnutrition.

Background The double burden of malnutrition (DBM) in adolescence has adverse short- and long-term, intergenerational health, developmental, and economic consequences. This study aimed to investigate the magnitude, trends, transitions, and drivers of population-level DBM (stunting, thinness, and overweight/obesity) among adolescent girls in urban slums in Nairobi, Kenya. Methods Adolescent girls ( n  = 419) were recruited from two slums and followed up from 2017 to 2019. Socio-demographic and anthropometric data were collected. BMI-for-age (BFAZ) and height-for-age (HFAZ) Z-scores were computed and categorised as thinness (BFAZ < -2.0 SD), overweight/obesity (BFAZ > 1.0 SD), stunting (HFAZ < -2.0 SD) and normal otherwise. Mixed effects logistic regression and continuous-time multi-state models were used to assess the factors associated with, and the transitions across the nutrition indicators respectively, over the three years. Results At recruitment (2017), prevalence of overweight/obesity (12.2%) was slightly higher than thinness (8.6%) and stunting (8.8). Between 2017 and 2019, there was a 5% point and 2% point increase in overweight/obesity and stunting respectively, and a 4% decline in thinness. A higher proportion of transition from normal nutritional status to overweight/obese (7%), compared to thin (2%) and stunted (4%) was observed. Family size (RRR = 0.75; 95% CI = 0.57–0.99) was inversely associated with overweight/obesity. Luo ethnicity (HR = 3.25; 95% CI = 1.12–9.44), Viwandani slum (HR = 2.68; 95% CI = 1.08–6.63), and depression score (HR = 1.33; 95% CI = 1.01–1.75) were positively associated with a transition from normal status to overweight/obesity. Adverse childhood experiences (ACEs) (OR = 1.24; 95% CI = 1.05–1.46), and family size (OR = 1.39; 95% CI = 1.08–1.81) were positively associated with stunting. Public school attendance (HR = 2.89; 95% CI = 1.05–7.94) was positively associated with transition to stunting. Conclusion The prevalence of overweight/obesity, as well as transitions to overweight/obesity were higher compared to undernutrition (stunting and thinness). Double-duty and multi-sectoral interventions that consider demographic (family, ethnicity), environmental (neighbourhood, school), and psychosocial (ACE, depression score) factors that may drive DBM in adolescent girls living in urban slums are recommended, to address DBM and reverse the growing trend in overweight/obesity. Integration of social protection, mental health, and nutrition interventions is important to address DBM in urban slums and similar contexts.

To assess the caloric contribution of ultra-processed foods (UPFs), factors associated with UPFs energy intake and investigate the relationship between UPFs energy intake, diet quality and nutrient intake among adolescents in urban slums, Kenya. A cross-sectional household study amongst adolescents (10-19 years, N = 621) collected socio-demographic and dietary intake data. Global Diet Quality Score (GDQS); mean and percentage total energy intake (%TEI) from UPFs; and nutrient intakes were computed. Regression analysis assessed the factors associated with UPFs energy intake, and the association between %TEI from UPFs and diet quality. Mean daily energy intake was 1,604 kcal (±550), 25.2% from UPFs. Higher leisure screen time (≥2 h/day) [OR = 1.9 (1.2-3.1)] was associated with UPFs energy intake. Household wealth index (quintile five vs. one) [OR = 2.6 (1.3-6.0)] was associated with non-UPFs energy intake. UPFs (%TEI) was inversely associated with GDQS score (quartile four vs. one) [β = -2.9 (-3.4 to -2.1)]. Adolescents with higher %TEI from UPFs (quartile four) had highest total energy, total fat and saturated fat; and lowest protein, fibre, iron, calcium and zinc intake. UPFs contribute substantially to adolescents' energy intake and are linked to poor diet quality and nutrient intake.

Background The double burden of malnutrition (DBM) during adolescence is associated with growth and developmental impairment and risk of non-communicable diseases. There is limited evidence on adolescent’s dietary patterns (DPs), and how they contribute to DBM in urban low income contexts in sub Saharan Africa. This study assessed DPs of adolescents, their drivers and association with DBM in Kenya’s urban slums. Methods Anthropometric, socio-demographic and dietary-intake data were collected through a cross-sectional survey of 621 adolescents from three major urban slums in Nairobi, Kenya. DPs were derived using principal component analysis. Multinomial-logistic-regression was used to assess the association between the DPs, individual and environmental factors and DBM. Results Two DPs were identified: traditional DP (whole grains/cereals, rice, fruits, legumes/nuts, and water) and transitioning DP (refined cereals (maize/wheat), vegetables, meat, tea/coffee, sweet ultra-processed/deep fried snacks). Adolescents from Mathare (the largest slum) were more likely to adhere to the traditional DP (RRR = 3.43; 95% CI 1.85–6.37). Cultural background (Luo) had a positive association (RRR = 4.28; 95% CI 1.97–9.32), while longer residency in the slum (> 10 years) had a negative association (RRR = 0.47; 95% CI 0.25–0.90) with transitioning DP. The transitioning DP had a positive (non-linear) association with overweight/obesity in girls (RRR = 2.79; 95% CI 1.16–6.71). The DPs were not associated with thinness or stunting. Conclusion The DPs indicate various stages of nutrition transition of adolescent diets, which are influenced by cultural background, neighbourhood and duration of stay in the slum. Transitioning DP may expose adolescents to the risks of overweight/obesity in the long-term.

Anemia is a major public health problem in children under 2 years old in Peru and other low- and middle-income countries. We aimed to explore facilitators and barriers to anemia prevention through feeding strategies in the Cuna Mas day-care centers in urban Peru among infants and young children (IYC) aged 6-23 months. Qualitative research in day-care services (  = 14) in Peru. We conducted direct observations and semi-structured interviews about consumption of animal source foods (ASF) and iron supplementation with day-care staff (technical managers, nursery caregivers and 'mother guides') and caregivers of IYC. We applied a grounded approach to data analysis. Cuna Mas staff facilitated ASF consumption by introducing small portions of iron-rich foods and serving organ meats in tasty stews. Staff also avoided giving carbohydrate-rich foods to IYC prior to giving organ meats. Staff facilitated giving daily iron supplement by using standardized and personalized strategies, such as using a timed reminder, praising and cheering a child or giving supplements whilst washing a child's hands and face. These strategies were also shared with primary caregivers to use at home. Some barriers reported by caregivers included difficulties in accessing and preparing specific ASF at home. The Peruvian Cuna Mas complementary feeding program facilitated consumption of iron-rich ASF and iron supplements through a range of strategies which they then shared with caregivers for implementation at home. These institutional behavioral change initiatives could be replicated in other settings whilst considering the facilitators and barriers identified in this study.

Background Ghana has reached an advanced stage of nutrition transition, contributing to an increase in nutrition-related non-communicable diseases, particularly amongst urban women. Community involvement is an important factor in the success of efforts to promote healthy eating. The readiness of populations to accept a range of interventions needs to be understood before appropriate interventions can be implemented. Therefore, this study assessed how ready urban communities are to improve diets of women of reproductive age in Ghana. Methods Using the Community Readiness Model (CRM), in-depth interviews were conducted with 24 key informants from various sectors in low income communities across two cities in Ghana: Accra and Ho. The CRM consists of 36 open questions addressing five readiness dimensions (community knowledge of efforts, leadership, community climate, knowledge of the issue and resources). Interviews were scored using the CRM protocol with a maximum of 9 points per dimension (from 1 = no awareness to 9 = high level of community ownership). Thematic analysis was undertaken to gain insights of community factors that could affect the implementation of interventions to improve diets. Results The mean community readiness scores indicated that both communities were in the “vague awareness stage” (3.35 ± 0.54 (Accra) and 3.94 ± 0.41 (Ho)). CRM scores across the five dimensions ranged from 2.65–4.38/9, ranging from denial/resistance to pre-planning. In both communities, the mean readiness score for ‘knowledge of the issue’ was the highest of all dimensions (4.10 ± 1.61 (Accra); 4.38 ± 1.81 (Ho)), but was still only at the pre-planning phase. The lowest scores were found for community knowledge of efforts (denial/resistance; 2.65 ± 2.49 (Accra)) and resources (vague awareness; 3.35 ± 1.03 (Ho)). The lack of knowledge of the consequences of unhealthy diets, misconceptions of the issue partly from low education, as well as challenges faced from a lack of resources to initiate/sustain programmes explained the low readiness. Conclusions Despite recognising that unhealthy diets are a public health issue in these urban Ghanaian communities, it is not seen as a priority. The low community readiness ratings highlight the need to increase awareness of the issue prior to intervening to improve diets.

Evidence on the individual‐level drivers of dietary behaviours in deprived urban contexts in Africa is limited. Understanding how to best inform the development and delivery of interventions to promote healthy dietary behaviours is needed. As noncommunicable diseases account for over 40% of deaths in Ghana, the country has reached an advanced stage of nutrition transition. The aim of this study was to identify individual‐level factors (biological, demographic, cognitive, practices) influencing dietary behaviours among adolescent girls and women at different stages of the reproductive life course in urban Ghana with the goal of building evidence to improve targeted interventions. Qualitative Photovoice interviews (n = 64) were conducted in two urban neighbourhoods in Accra and Ho with adolescent girls (13–14 years) and women of reproductive age (15–49 years). Data analysis was both theory‐ and data‐driven to allow for emerging themes. Thirty‐seven factors, across four domains within the individual‐level, were identified as having an influence on dietary behaviours: biological (n = 5), demographic (n = 8), cognitions (n = 13) and practices (n = 11). Several factors emerged as facilitators or barriers to healthy eating, with income/wealth (demographic); nutrition knowledge/preferences/risk perception (cognitions); and cooking skills/eating at home/time constraints (practices) emerging most frequently. Pregnancy/lactating status (biological) influenced dietary behaviours mainly through medical advice, awareness and willingness to eat foods to support foetal/infant growth and development. Many of these factors were intertwined with the wider food environment, especially concerns about the cost of food and food safety, suggesting that interventions need to account for individual‐level as well as wider environmental drivers of dietary behaviours. The aim of this study was to identify individual‐level factors influencing dietary behaviours among adolescent girls (13–14 years) and women of reproductive age (15–49 years) in urban Ghana with the goal of building evidence to improve targeted interventions. Qualitative Photovoice interviews (n= 64) were conducted in two urban neighbourhoods in Accra and Ho. Thirty‐seven factors, were identified as having an influence on dietary behaviours: biological (n = 5), demographic (n = 8), cognitions (n = 13) and practices (n = 11) with income/wealth (demographic); nutrition knowledge/preferences/risk perception (cognitions); and cooking skills/eating at home/time constraints (practices) emerging most frequently, thus meriting consideration when planning interventions. Key messages Time constraints, eating at home, eating out, cooking skills, food preferences and food safety concerns were identified as key factors influencing dietary behaviours at the individual level in urban Ghana. Ability to eat nutritious, safe food was largely mediated by income and wealth. Biological factors, such as pregnancy/lactating status influenced behaviours through medical advice, nutrition knowledge and willingness to promote foetal/infant development. Many individual‐level factors were intertwined with the wider food environment. Factors influencing dietary behaviour at different levels need to be considered together when developing interventions/policies for healthier diets.