Policy Action Within Urban African Food Systems to Promote Healthy Food Consumption: A Realist Synthesis in Ghana and Kenya

Document Type : Review Article


1 School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK

2 School of Public Health, University of Ghana, Accra, Ghana

3 Institute for Health and Society, Newcastle University, Newcastle upon Tyne, UK

4 African Population and Health Research Center (APHRC), Nairobi, Kenya

5 French National Research Institute for Sustainable Development (IRD), NUTRIPASS Unit, IRD-Univ Montpellier, Montpellier, France


Obesity and nutrition-related non-communicable diseases (NR-NCDs) are increasing throughout Africa, driven by urbanisation and changing food environments. Policy action has been limited - and influenced by high income countries. Socio-economic/political environments of African food systems must be considered in order to understand what policy might work to prevent NR-NCDs, for whom, and under what circumstances.
A realist synthesis of five policy areas to support healthier food consumption in urban Africa: regulating trade/foreign investment; regulating health/nutrition claims/labels; setting composition standards for processed foods; restricting unhealthy food marketing; and school food policy. We drew upon Ghana and Kenya to contextualise the evidence base. Programme theories were generated by stakeholders in Ghana/Kenya. A two-stage search interrogated MEDLINE, Web of Science and Scopus. Programme theories were tested and refined to produce a synthesised model.
The five policies operate through complex, inter-connected pathways moderated by global-, national- and local contexts. Consumers and the food environment interact to enable/disable food accessibility, affordability and availability. Consumer relationships with each other and retailers are important contextual influences, along with political/economic interests, stakeholder alliances and globalized trade. Coherent laws/regulatory frameworks and government capacities are fundamental across all policies. The increasing importance of convenience is shaped by demographic and sociocultural drivers. Awareness of healthy diets mediates food consumption through comprehension, education, literacy and beliefs. Contextualised data (especially food composition data) and inter-sectoral collaboration are critical to policy implementation.
Evidence indicates that coherent action across the five policy areas could positively influence the healthiness of food environments and consumption in urban Africa. However, drivers of (un)healthy food environments and consumption reflect the complex interplay of socio-economic and political drivers acting at diverse geographical levels. Stakeholders at local, national, and global levels have important, yet differing, roles to play in ensuring healthy food environments and consumption in urban Africa.



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  1. Steyn NP, McHiza ZJ. Obesity and the nutrition transition in Sub-Saharan Africa. Ann N Y Acad Sci. 2014;1311:88-101. doi:10.1111/nyas.12433
  2. World Health Organization (WHO). The Double Burden of Malnutrition: Policy Brief. WHO; 2016.
  3. Ofori-Asenso R, Agyeman AA, Laar A, Boateng D. Overweight and obesity epidemic in Ghana-a systematic review and meta-analysis. BMC Public Health. 2016;16(1):1239. doi:10.1186/s12889-016-3901-4
  4. Ghana Statistical Service (GSS), Ghana Health Service (GHS), ICF International. Ghana Demographic and Health Survey 2014. Rockville, Maryland, USA: GSS, GHS, ICF International; 2015.
  5. Kenya National Bureau of Statistics. Kenya STEPwise Survey for NonCommunicable Diseases Risk Factors 2015 Report. Nairobi, Kenya: Ministry of Health, Kenya National Bureau of Statistics, WHO; 2015.
  6. Downs S. The multiple burdens of malnutrition. 16 Sight and Life. 2016;30(1):41-46.
  7. Holdsworth M, Landais E. Urban food environments in Africa: implications for policy and research. Proc Nutr Soc. 2019;78(4):513-525. doi:10.1017/s0029665118002938
  8. HLPE. Food Security and Nutrition: Building a Global Narrative Towards 2030. Rome: High Level Panel of Experts on Food Security and Nutrition of the Committee on World Food Security; 2020.
  9. Africa Union. Malabo Declaration on Accelerated Agricultural Growth and Transformation for Shared Prosperity and Improved Livelihoods. Malabo, Equatorial Guinea: Africa Union; 2014.
  10. African Union Commission. Africa Region Nutrition Strategy 2015-2025. Geneva: WHO; 2014.
  11. African Union Commission. Agenda 2063: The Africa We Want. Addis Ababa: Africa Union;2015.
  12. Laar A, Barnes A, Aryeetey R, et al. Implementation of healthy food environment policies to prevent nutrition-related non-communicable diseases in Ghana: national experts' assessment of government action. Food Policy. 2020;93:101907. doi:10.1016/j.foodpol.2020.101907
  13. Asiki G, Wanjohi MN, Barnes A, et al. Benchmarking food environment policies for the prevention of diet-related non-communicable diseases in Kenya: national expert panel's assessment and priority recommendations. PLoS One. 2020;15(8):e0236699. doi:10.1371/journal.pone.0236699
  14. Parsons K. What Transforming Food Systems Means for Policy: From Ideas to Action. Global Food Security; 2019.
  15. Parsons K, Hawkes C. Connecting Food Systems for Co-Benefits: How Can Food Systems Combine Diet-Related Health with Environmental and Economic Policy Goals? London: 2018. Copenhagen, Denmark: WHO Regional Office for Europe, European Observatory on Health Systems and Policies; 2018.
  16. Kenya National Bureau of Statistics, Ministry of Health (Kenya), National AIDS Control Council (Kenya), Kenya Medical Research Institute, National Council for Population and Development (Kenya). Kenya Demographic and Health Survey 2014. Rockville, Maryland, USA: 2015. Nairobi, Kenya: Kenya National Bureau of Statistics, Ministry of Health, National AIDS Control Council, Kenya Medical Research Institute, National Council for Population and Development; 2015.
  17. Rousham EK, Pradeilles R, Akparibo R, et al. Dietary behaviours in the context of nutrition transition: a systematic review and meta-analyses in two African countries. Public Health Nutr. 2020;23(11):1948-1964. doi:10.1017/s1368980019004014
  18. Ministry of Health. National Policy for the Prevention and Control of NCDs in Ghana. Accra, Ghana: Ministry of Health; 2012.
  19. Ministry of Health Kenya. Kenya National Strategy for the Prevention and Control of Non-Communicable Diseases 2015-2020. Nairobi, Kenya: Ministry of Health Kenya; 2015.
  20. Swinburn B, Vandevijvere S, Kraak V, et al. Monitoring and benchmarking government policies and actions to improve the healthiness of food environments: a proposed Government Healthy Food Environment Policy Index. Obes Rev. 2013;14 Suppl 1:24-37. doi:10.1111/obr.12073
  21. World Health Organization (WHO). Global Action Plan for the Prevention and Control of NCDs 2013-2020. WHO; 2013.
  22. Pawson R, Greenhalgh T, Harvey G, Walshe K. Realist Synthesis: An Introduction. Manchester: ESRC Research Methods Programme, University of Manchester; 2004.
  23. Omoniyi OS, Williams I. Realist synthesis of the international theory and evidence on strategies to improve childhood vaccination in low-and middle-income countries: developing strategies for the Nigerian healthcare system. Int J Health Policy Manag. 2020;9(7):274-285. doi:10.15171/ijhpm.2019.120
  24. HLPE. Nutrition and Food Systems. A Report by the High Level Panel of Experts on Food Security and Nutrition of the Committee on World Food Security. Rome: HLPE; 2017.
  25. Pawson R. Realist synthesis: new protocols for systematic review. In: Evidence-Based Policy. SAGE Publications; 2006.
  26. Wong G, Greenhalgh T, Westhorp G, Buckingham J, Pawson R. RAMESES publication standards: realist syntheses. BMC Med. 2013;11(1):21. doi:10.1186/1741-7015-11-21
  27. Rycroft-Malone J, McCormack B, Hutchinson AM, et al. Realist synthesis: illustrating the method for implementation research. Implement Sci. 2012;7:33. doi:10.1186/1748-5908-7-33
  28. Jagosh J, Macaulay AC, Pluye P, et al. Uncovering the benefits of participatory research: implications of a realist review for health research and practice. Milbank Q. 2012;90(2):311-346. doi:10.1111/j.1468-0009.2012.00665.x
  29. Willett W, Rockström J, Loken B, et al. Food in the Anthropocene: the EAT-Lancet Commission on healthy diets from sustainable food systems. Lancet. 2019;393(10170):447-492. doi:10.1016/s0140-6736(18)31788-4
  30. Ouma C. Using new methods to assess coverage of decentralized nutrition programmes in complex emergencies in east and the horn of Africa. Ann Nutr Metab. 2013;63(Suppl 1):905. doi:10.1159/000354245
  31. Thow AM. Trade liberalisation and the nutrition transition: mapping the pathways for public health nutritionists. Public Health Nutr. 2009;12(11):2150-2158. doi:10.1017/s1368980009005680
  32. Schram A, Labonté R, Sanders D. Urbanization and international trade and investment policies as determinants of noncommunicable diseases in Sub-Saharan Africa. Prog Cardiovasc Dis. 2013;56(3):281-301. doi:10.1016/j.pcad.2013.09.016
  33. Friel S, Hattersley L, Snowdon W, et al. Monitoring the impacts of trade agreements on food environments. Obes Rev. 2013;14 Suppl 1:120-134. doi:10.1111/obr.12081
  34. Labonté R, Ruckert A, Schram A. Trade, investment and the global economy: are we entering a new era for health? Glob Soc Policy. 2017;18(1):28-44. doi:10.1177/1468018117731415
  35. Labonté R. Trade, investment and public health: compiling the evidence, assembling the arguments. Global Health. 2019;15(1):1. doi:10.1186/s12992-018-0425-y
  36. Schram A, Ruckert A, VanDuzer JA, et al. A conceptual framework for investigating the impacts of international trade and investment agreements on noncommunicable disease risk factors. Health Policy Plan. 2018;33(1):123-136. doi:10.1093/heapol/czx133
  37. Mozaffarian D, Angell SY, Lang T, Rivera JA. Role of government policy in nutrition-barriers to and opportunities for healthier eating. BMJ. 2018;361:k2426. doi:10.1136/bmj.k2426
  38. Thow AM, Annan R, Mensah L, Chowdhury SN. Development, implementation and outcome of standards to restrict fatty meat in the food supply and prevent NCDs: learning from an innovative trade/food policy in Ghana. BMC Public Health. 2014;14:249. doi:10.1186/1471-2458-14-249
  39. Annan RA, Apprey C, Oppong NK, Petty-Agamatey V, Mensah L, Thow AM. Public awareness and perception of Ghana's restrictive policy on fatty meat, as well as preference and consumption of meat products among Ghanaian adults living in the Kumasi Metropolis. BMC Nutr. 2018;4:2. doi:10.1186/s40795-018-0209-z
  40. Thow AM, Jones A, Hawkes C, Ali I, Labonté R. Nutrition labelling is a trade policy issue: lessons from an analysis of specific trade concerns at the World Trade Organization. Health Promot Int. 2018;33(4):561-571. doi:10.1093/heapro/daw109
  41. Hawkes C. The role of foreign direct investment in the nutrition transition. Public Health Nutr. 2005;8(4):357-365. doi:10.1079/phn2004706
  42. Schram A. When evidence isn't enough: Ideological, institutional, and interest-based constraints on achieving trade and health policy coherence. Glob Soc Policy. 2017;18(1):62-80. doi:10.1177/1468018117744153
  43. García-Dorado SC, Cornselsen L, Smith R, Walls H. Economic globalization, nutrition and health: a review of quantitative evidence. Global Health. 2019;15(1):15. doi:10.1186/s12992-019-0456-z
  44. Labonté R, Mohindra KS, Lencucha R. Framing international trade and chronic disease. Global Health. 2011;7:21. doi:10.1186/1744-8603-7-21
  45. Rayner G, Hawkes C, Lang T, Bello W. Trade liberalization and the diet transition: a public health response. Health Promot Int. 2006;21 Suppl 1:67-74. doi:10.1093/heapro/dal053
  46. Thow AM, Sanders D, Drury E, et al. Regional trade and the nutrition transition: opportunities to strengthen NCD prevention policy in the Southern African Development Community. Glob Health Action. 2015;8:28338. doi:10.3402/gha.v8.28338
  47. Neven D, Reardon T. The rise of Kenyan supermarkets and the evolution of their horticulture product procurement systems. Dev Policy Rev. 2004;22(6):669-699. doi:10.1111/j.1467-7679.2004.00271.x
  48. O’Neill K. Big food without big diets? food regimes and Kenyan diets. Crit Public Health. 2015;25(3):265-279. doi:10.1080/09581596.2015.1007922
  49. Blouin C, Chopra M, van der Hoeven R. Trade and social determinants of health. Lancet. 2009;373(9662):502-507. doi:10.1016/s0140-6736(08)61777-8
  50. Wilhelmina Q, Joost J, George E, Guido R. Globalization vs. localization: global food challenges and local solutions. Int J Consum Stud. 2010;34(3):357-366. doi:10.1111/j.1470-6431.2010.00868.x
  51. Toure D, McClafferty B, Neufeld LM. Shaping markets for better nutrition: insights from the assessment of the marketplace for nutritious foods. Ann Nutr Metab. 2017;71(Suppl 2):94-95. doi:10.1159/000480486
  52. Ouma S. Creating and maintaining global connections: agro-business and the precarious making of fresh-cut markets. J Dev Stud. 2012;48(3):322-334. doi:10.1080/00220388.2011.635201
  53. Anim-Somuah H, Henson S, Humphrey J, Robsinson E. Policy Guidelines: Enhancing Markets for Nutrient-Dense Foods in Ghana. Institute of Development Studies (IDS); 2013.
  54. Stuckler D, McKee M, Ebrahim S, Basu S. Manufacturing epidemics: the role of global producers in increased consumption of unhealthy commodities including processed foods, alcohol, and tobacco. PLoS Med. 2012;9(6):e1001235. doi:10.1371/journal.pmed.1001235
  55. Barlow P, Labonte R, McKee M, Stuckler D. Trade challenges at the World Trade Organization to national noncommunicable disease prevention policies: a thematic document analysis of trade and health policy space. PLoS Med. 2018;15(6):e1002590. doi:10.1371/journal.pmed.1002590
  56. Bird K, Kamau P, Odhiambo W. Trade Policy and Poverty Linkages in Kenya. London: Overseas Development Institute; 2007.
  57. Stevano S, Johnston D, Codjoe E. The urban food question in the context of inequality and dietary change: a study of schoolchildren in Accra. J Dev Stud. 2020;56(6):1177-1189. doi:10.1080/00220388.2019.1632434
  58. Mendez Lopez A, Loopstra R, McKee M, Stuckler D. Is trade liberalisation a vector for the spread of sugar-sweetened beverages? a cross-national longitudinal analysis of 44 low-and middle-income countries. Soc Sci Med. 2017;172:21-27. doi:10.1016/j.socscimed.2016.11.001
  59. Djokoto JG. Effects of foreign direct investment inflows into agriculture on food security in Ghana. J Econ Sustain Dev. 2012;3(2):81-92.
  60. Stuckler D, Nestle M. Big food, food systems, and global health. PLoS Med. 2012;9(6):e1001242. doi:10.1371/journal.pmed.1001242
  61. Johnson MC. Lobbying for trade barriers: a comparison of poultry producers' success in Cameroon, Senegal and Ghana. J Mod Afr Stud. 2011;49(4):575-599. doi:10.1017/s0022278x11000486
  62. Thow AM, Greenberg S, Hara M, Friel S, duToit A, Sanders D. Improving policy coherence for food security and nutrition in South Africa: a qualitative policy analysis. Food Secur. 2018;10(4):1105-1130. doi:10.1007/s12571-018-0813-4
  63. Serem A. International trade opportunities and challenges for small scale horticultural production systems. In: Wesonga J, Kahane R, eds. I All Africa Horticultural Congress. Vol 9112011:53-60.
  64. Battams S, Townsend B. Power asymmetries, policy incoherence and noncommunicable disease control-a qualitative study of policy actor views. Crit Public Health. 2019;29(5):596-609. doi:10.1080/09581596.2018.1492093
  65. Delany L, Signal L, Thomson G. International trade and investment law: a new framework for public health and the common good. BMC Public Health. 2018;18(1):602. doi:10.1186/s12889-018-5486-6
  66. Gleeson D, Friel S. Emerging threats to public health from regional trade agreements. Lancet. 2013;381(9876):1507-1509. doi:10.1016/s0140-6736(13)60312-8
  67. Koivusalo M, Schrecker T, Labonté R. Globalization and policy space for health and social determinants of health. In: Globalization and Health. Routledge; 2009. p. 127-152.
  68. Koivusalo M. Policy space for health and trade and investment agreements. Health Promot Int. 2014;29 Suppl 1:i29-47. doi:10.1093/heapro/dau033
  69. Friel S, Hattersley L, Townsend R. Trade policy and public health. Annu Rev Public Health. 2015;36:325-344. doi:10.1146/annurev-publhealth-031914-122739
  70. Walls H, Baker P, Parkhurst J. Addressing trade policy as a macro-structural determinant of health: the role of institutions and ideas. Glob Soc Policy. 2018;18(1):94-101. doi:10.1177/1468018117748700
  71. Ouma S, Boeckler M, Lindner P. Extending the margins of marketization: frontier regions and the making of agro-export markets in northern Ghana. Geoforum. 2013;48:225-235. doi:10.1016/j.geoforum.2012.01.011
  72. Burke WJ, Myers RJ, Jayne TS. A triple-hurdle model of production and market participation in Kenya's dairy market. Am J Agric Econ. 2015;97(4):1227-1246. doi:10.1093/ajae/aav009
  73. Barlow P. Exporting Pandemics: Free Trade Agreements and the Global Diffusion of Unhealthy Behaviours [dissertation]. University of Oxford; 2018.
  74. Townsend B, Schram A, Baum F, Labonté R, Friel S. How does policy framing enable or constrain inclusion of social determinants of health and health equity on trade policy agendas? Crit Public Health. 2020;30(1):115-126. doi:10.1080/09581596.2018.1509059
  75. Bosu WK. An overview of the nutrition transition in West Africa: implications for non-communicable diseases. Proc Nutr Soc. 2015;74(4):466-477. doi:10.1017/s0029665114001669
  76. Bovell-Benjamin AC, Bromfield E. Nutrition and Bioavailability. In: Ensuring Global Food Safety. Elsevier; 2010. p. 289-309.
  77. Campos S, Doxey J, Hammond D. Nutrition labels on pre-packaged foods: a systematic review. Public Health Nutr. 2011;14(8):1496-1506. doi:10.1017/s1368980010003290
  78. Cannoosamy K, Pugo-Gunsam P, Jeewon R. Consumer knowledge and attitudes toward nutritional labels. J Nutr Educ Behav. 2014;46(5):334-340. doi:10.1016/j.jneb.2014.03.010
  79. Dolgopolova I, Teuber R. Consumers’ willingness to pay for health benefits in food products: a meta-analysis. Appl Econ Perspect Policy. 2018;40(2):333-352. doi:10.1093/aepp/ppx036
  80. Drichoutis AC, Lazaridis P, Nayga RM. Consumers' use of nutritional labels: a review of research studies and issues. Acad Mark Sci Rev. 2006;9(9):1-22.
  81. Hawkes C. Government and voluntary policies on nutrition labelling: a global overview. In: Albert J, ed. Innovations in Food Labelling. Elsevier; 2010:37-58. doi:10.1533/9781845697594.37
  82. Ikonen I, Sotgiu F, Aydinli A, Verlegh PWJ. Consumer effects of front-of-package nutrition labeling: an interdisciplinary meta-analysis. J Acad Mark Sci. 2020;48(3):360-383. doi:10.1007/s11747-019-00663-9
  83. Kasapila W, Shaarani SM. Legislation--impact and trends in nutrition labeling: a global overview. Crit Rev Food Sci Nutr. 2016;56(1):56-64. doi:10.1080/10408398.2012.710277
  84. Koen N, Blaauw R, Wentzel-Viljoen E. Food and nutrition labelling: the past, present and the way forward. South Afr J Clin Nutr. 2016;29(1):13-21. doi:10.1080/16070658.2016.1215876
  85. Mandle J, Tugendhaft A, Michalow J, Hofman K. Nutrition labelling: a review of research on consumer and industry response in the global South. Glob Health Action. 2015;8:25912. doi:10.3402/gha.v8.25912
  86. Réquillart V, Soler LG. Is the reduction of chronic diseases related to food consumption in the hands of the food industry? Eur Rev Agric Econ. 2014;41(3):375-403. doi:10.1093/erae/jbu010
  87. Smit W. Urban governance and urban food systems in Africa: examining the linkages. Cities. 2016;58:80-86. doi:10.1016/j.cities.2016.05.001
  88. World Health Organization (WHO). The Double Burden of Malnutrition: Case Studies from Six Developing Countries. Vol 84. Food and Agriculture Organization; 2006.
  89. Ababio PF, Adi DD, Amoah M. Evaluating the awareness and importance of food labelling information among consumers in the Kumasi metropolis of Ghana. Food Control. 2012;26(2):571-574. doi:10.1016/j.foodcont.2012.02.015
  90. Affram PC, Darkwa S. Consumersknowledge, understanding and use of food label information, and how it affects purchasing decision in ho, Ghana. Asian J Empir Res. 2015;5(3):24-39.
  91. Azila-Gbettor EM, Avorgah SMK, Adigbo ED. Exploring consumer knowledge and usage of label information in Ho Municipality of Ghana. Eur Sci J. 2013;9(28):297-311.
  92. Darkwa S. Knowledge of nutrition facts on food labels and their impact on food choices on consumers in Koforidua, Ghana: a case study. South Afr J Clin Nutr. 2014;27(1):13-17.
  93. Hayford F, Steiner-Asiedu M, Sakyi-Dawson E. Food choice behaviour among Ghanaians: implications for health promotion. World J Nutr Health. 2015;3(1):22-28. doi:10.12691/jnh-3-1-4
  94. Kwesi Saalia F, Mankanta C, Budu A, Essilfie G. Knowledge and consumption patterns of coffee creamers in Accra, Ghana. Nutr Food Sci. 2013;43(1):23-30. doi:10.1108/00346651311295879
  95. Osei MJ, Lawer DR, Aidoo R. Consumers' use and understanding of food label information and effect on their purchasing decision in Ghana; a case study of Kumasi metropolis. Asian Journal of Agriculture and Rural Development. 2013;2(3):351-365. doi:10.22004/ag.econ.197981
  96. Juma CN, Otieno DJ, Oluouch-Kosura W, Gyau A, Oduol JA. A Survey of Consumer Perceptions and Preferences for Geographical Indication and Quality Attributes of Honey in Kenya. African Association of Agricultural Economists (AAAE); 2016.
  97. Kunyanga C, Imungi J, Okoth M, Vadivel V, Biesalski HK. Development, acceptability, and nutritional characteristics of a low-cost, shelf-stable supplementary food product for vulnerable groups in Kenya. Food Nutr Bull. 2012;33(1):43-52. doi:10.1177/156482651203300104
  98. Ndiema BC. Status of Utilization of Nutrition Information on Processed Meat Products in Making Purchasing Decisions Among Consumers in Nakuru Town, Kenya. Kenyatta University; 2017.
  99. Codex Alimentarius Commission. Current official standards 2012. URL: http://www.fao.org/fao-who-codexalimentarius/codex-texts/list-standards/en/ Accessed on: 08/01/21.
  100. EUFIC. Global Update on Nutrition Labelling The 2018 edition. 2018. URL: https://www.eufic.org/images/uploads/healthy-living/Executive-Summary-GUNL-2018-V2.pdf Accessed on: 08/01/21.
  101. Food and Agriculture Organization, World Health Organization. Human Vitamin and Mineral Requirements, Report of a Joint FAO/WHO Expert Consultation, Bangkok, Thailand. Rome, Italy: Food and Nutrition Division FAO; 2002.
  102. Food and Agriculture Organization of the United Nations, World Health Organization (WHO). Codex Alimentarius: Food labelling. Rome: Food and Agriculture Organization of the United Nations; 2007.
  103. Hawkes C, World Health Organization (WHO). Nutrition Labels and Health Claims: The Global Regulatory Environment. WHO; 2004.
  104. Igumbor EU, Sanders D, Puoane TR, et al. "Big food," the consumer food environment, health, and the policy response in South Africa. PLoS Med. 2012;9(7):e1001253. doi:10.1371/journal.pmed.1001253
  105. Kasapila W, Shaarani SM. A survey of nutrition labelling on packaged foodstuffs sold in Malawi: manufacturer practices and legislative issues. Food Control. 2013;30(2):433-438. doi:10.1016/j.foodcont.2012.08.006
  106. Koen N, Wentzel-Viljoen E, Blaauw R. Price rather than nutrition information the main influencer of consumer food purchasing behaviour in South Africa: a qualitative study. Int J Consum Stud. 2018;42(4):409-418. doi:10.1111/ijcs.12434
  107. Koen N, Wentzel-Viljoen E, Nel D, Blaauw R. Consumer knowledge and use of food and nutrition labelling in South Africa: a cross-sectional descriptive study. Int J Consum Stud. 2018;42(3):335-346. doi:10.1111/ijcs.12422
  108. Lartey A, Hemrich G, Amoroso L. Influencing Food Environments for Healthy Diets. Rome: Food and Agriculture Organization of the United Nations; 2016.
  109. Olatona FA, Nwankwo CO, Ogunyemi AO, Nnoaham KE. Consumer knowledge and utilization of food labels on prepackaged food products in Lagos State. Res J Health Sci. 2019;7(1):28-38. doi:10.4314/rejhs.v7i1.4
  110. Wansink B. How do front and back package labels influence beliefs about health claims? J Consum Aff. 2003;37(2):305-316. doi:10.1111/j.1745-6606.2003.tb00455.x
  111. Becker MW, Bello NM, Sundar RP, Peltier C, Bix L. Front of pack labels enhance attention to nutrition information in novel & commercial brands. Food Policy. 2015;56:76-86. doi:10.1016/j.foodpol.2015.08.001
  112. Draper AK, Adamson AJ, Clegg S, Malam S, Rigg M, Duncan S. Front-of-pack nutrition labelling: are multiple formats a problem for consumers? Eur J Public Health. 2013;23(3):517-521. doi:10.1093/eurpub/ckr144
  113. Egnell M, Talati Z, Hercberg S, Pettigrew S, Julia C. Objective understanding of front-of-package nutrition labels: an international comparative experimental study across 12 countries. Nutrients. 2018;10(10):1542. doi:10.3390/nu10101542
  114. Goodman S, Vanderlee L, Acton R, Mahamad S, Hammond D. The impact of front-of-package label design on consumer understanding of nutrient amounts. Nutrients. 2018;10(11):1624. doi:10.3390/nu10111624
  115. Grunert KG, Wills JM, Fernández-Celemín L. Nutrition knowledge, and use and understanding of nutrition information on food labels among consumers in the UK. Appetite. 2010;55(2):177-189. doi:10.1016/j.appet.2010.05.045
  116. Kanter R, Vanderlee L, Vandevijvere S. Front-of-package nutrition labelling policy: global progress and future directions. Public Health Nutr. 2018;21(8):1399-1408. doi:10.1017/s1368980018000010
  117. Kempen E, Bosman M, Bouwer C, Klein R, van der Merwe D. An exploration of the influence of food labels on South African consumers' purchasing behaviour. Int J Consum Stud. 2011;35(1):69-78. doi:10.1111/j.1470-6431.2010.00928.x
  118. Kozup JC, Creyer EH, Burton S. Making healthful food choices: the influence of health claims and nutrition information on consumers' evaluations of packaged food products and restaurant menu items. J Mark. 2003;67(2):19-34.
  119. Olatona FA, Sosanya A, Sholeye OO, Obrutu OE, Nnoaham KE. Knowledge of fruits and vegetables, consumption pattern and associated factors among adults in Lagos State, Nigeria. Res J Health Sci. 2018;6(2):50. doi:10.4314/rejhs.v6i2.2
  120. Papoutsi GS, Klonaris S, Drichoutis AC. The health-taste trade-off in consumer decision making: an experimental approach. Br Food J. 2019. doi:10.1108/bfj-10-2018-0694
  121. Traill WB. Trends towards overweight in lower-and middle-income countries: some causes and economic policy options. http://www.fao.org/tempref/docrep/fao/009/a0442e/a0442e03.pdf.  Published 2006.
  122. Schönfeldt HC, Hall N, Pretorius B. The important role of food composition in policies and programmes for better public health: a South African case study. Food Chem. 2018;238:94-100. doi:10.1016/j.foodchem.2016.12.067
  123. Schönfeldt HC, Gibson Hall N. Dietary protein quality and malnutrition in Africa. Br J Nutr. 2012;108 Suppl 2:S69-76. doi:10.1017/s0007114512002553
  124. Wolmarans P, Kunneke E, Laubscher R. Use of the South African Food Composition Database System (SAFOODS) and its products in assessing dietary intake data: Part II. South Afr J Clin Nutr. 2009;22(2):59-67. doi:10.1080/16070658.2009.11734220
  125. Ene-Obong H, Schönfeldt HC, Campaore E, et al. Importance and use of reliable food composition data generation by nutrition/dietetic professionals towards solving Africa's nutrition problem: constraints and the role of FAO/INFOODS/AFROFOODS and other stakeholders in future initiatives. Proc Nutr Soc. 2019;78(4):496-505. doi:10.1017/s0029665118002926
  126. Schönfeldt HC. Food composition program of AFROFOODS. J Food Compost Anal. 2002;15(4):473-479. doi:10.1006/jfca.2002.1093
  127. Wolmarans P, Chetty J, Danster-Christians N. Food composition activities in South Africa. Food Chem. 2013;140(3):447-450. doi:10.1016/j.foodchem.2012.10.064
  128. Progress with a global branded food composition database. Food Chem. 2013;140(3):451-457. doi:10.1016/j.foodchem.2012.10.065
  129. Schönfeldt HC, Hall N, Pretorius B. Nutrition-Sensitive Agricultural Development for Food Security in Africa: A Case Study of South Africa. In: International Development. IntechOpen; 2017. doi:10.5772/67110
  130. Stadlmayr B, Charrondière UR, Burlingame B. Development of a regional food composition table for West Africa. Food Chem. 2013;140(3):443-446. doi:10.1016/j.foodchem.2012.09.107
  131. Baingana RK. The need for food composition data in Uganda. J Food Compost Anal. 2004;17(3):501-507. doi:10.1016/j.jfca.2004.03.012
  132. de Bruyn J, Ferguson E, Allman-Farinelli M, et al. Food composition tables in resource-poor settings: exploring current limitations and opportunities, with a focus on animal-source foods in sub-Saharan Africa. Br J Nutr. 2016;116(10):1-11. doi:10.1017/s0007114516003706
  133. Food and Agriculture Organization of the United Nations/Government of Kenya. Kenya Food Composition Tables. Nairobi: Food and Agriculture Organization of the United Nations, The Ministry of Health, Republic of Kenya and The Ministry of Agriculture and Irrigation, Republic of Kenya; 2018.
  134. Greenfield H, Southgate DA. Food Composition Data: Production, Management and Use. Food and Agriculture Organization; 2003.
  135. Pivk Kupirovič U, Miklavec K, Hribar M, Kušar A, Žmitek K, Pravst I. Nutrient profiling is needed to improve the nutritional quality of the foods labelled with health-related claims. Nutrients. 2019;11(2). doi:10.3390/nu11020287
  136. Stadlmayr B, Charrondiere U, Enujiugha V, et al. West African Food Composition Table/Table De composition Des Aliments D'afrique De L'ouest. Food and Agriculture Organization of the United Nations; 2012.
  137. Boyland EJ, Nolan S, Kelly B, et al. Advertising as a cue to consume: a systematic review and meta-analysis of the effects of acute exposure to unhealthy food and nonalcoholic beverage advertising on intake in children and adults. Am J Clin Nutr. 2016;103(2):519-533. doi:10.3945/ajcn.115.120022
  138. Cairns G, Angus K, Hastings G, Caraher M. Systematic reviews of the evidence on the nature, extent and effects of food marketing to children. A retrospective summary. Appetite. 2013;62:209-215. doi:10.1016/j.appet.2012.04.017
  139. Galbraith-Emami S, Lobstein T. The impact of initiatives to limit the advertising of food and beverage products to children: a systematic review. Obes Rev. 2013;14(12):960-974. doi:10.1111/obr.12060
  140. Hastings G, Stead M, McDermott L, et al. Does Food Promotion Influence Children? A Systematic Review of the Evidence. London: Food Standards Agency; 2003.
  141. Hastings G, Stead M, McDermott L. From the billboard to the school canteen: how food promotion influences children. Educ Rev. 2004;17(2):17-23.
  142. Hawkes C. Regulating and litigating in the public interest: regulating food marketing to young people worldwide: trends and policy drivers. Am J Public Health. 2007;97(11):1962-1973. doi:10.2105/ajph.2006.101162
  143. Sadeghirad B, Duhaney T, Motaghipisheh S, Campbell NR, Johnston BC. Influence of unhealthy food and beverage marketing on children's dietary intake and preference: a systematic review and meta-analysis of randomized trials. Obes Rev. 2016;17(10):945-959. doi:10.1111/obr.12445
  144. Kumi IA. Healthiness of Foods and Beverages Advertised on Ghanaian Television Programmes Targeting Children [dissertation]. University of Ghana; 2018.
  145. Laar A, Barnes A, Tandoh A, et al. Benchmarking Ghana’s Food Environment Policies Against International Examples and Progress Within Development Cycle: The Ghana Healthy Food Environment Policy Index (Food-EPI) Evidence Paper. Accra, Ghana: September 2018 2018.
  146. Freidberg S, Goldstein L. Alternative food in the global south: reflections on a direct marketing initiative in Kenya. J Rural Stud. 2011;27(1):24-34. doi:10.1016/j.jrurstud.2010.07.003
  147. Advertising Standards Body of Kenya. Code of Advertising Practice and Direct Marketing. In: Advertising Standards Body of Kenya ed2003.
  148. Bannon K, Schwartz MB. Impact of nutrition messages on children's food choice: pilot study. Appetite. 2006;46(2):124-129. doi:10.1016/j.appet.2005.10.009
  149. Collier N, Boedhihartono AK, Sayer J. Indigenous Livelihoods and the Global Environment: Understanding Relationships. 2009.
  150. Food and Drugs Authority (FDA). Guidelines for the Advertisement of Foods Accra Ghana. FDA; 2013.
  151. Garde A, Xuereb G. The WHO recommendations on the marketing of food and non-alcoholic beverages to children. Eur J Risk Regul. 2017;8(2):211-223. doi:10.1017/err.2017.20
  152. Green MA, Pradeilles R, Laar A, et al. Investigating foods and beverages sold and advertised in deprived urban neighbourhoods in Ghana and Kenya: a cross-sectional study. BMJ Open. 2020;10(6):e035680. doi:10.1136/bmjopen-2019-035680
  153. Hastings G, McDermott L, Angus K, Stead M, Thomson S. The Extent, Nature and Effects of Food Promotion to Children: A Review of The Evidence. WHO; 2007.
  154. Hawkes C, Lobstein T. Regulating the commercial promotion of food to children: a survey of actions worldwide. Int J Pediatr Obes. 2011;6(2):83-94. doi:10.3109/17477166.2010.486836
  155. Hayford FEA, Issah R, Ainuson-Quampah J. Association between dietary habits, body composition indices and HbA1c of adult type-2 diabetes patients attending routine out-patient clinic review: a cross-sectional study. Ann Nutr Metab. 2017;71(Suppl 2):918. doi:10.1159/000480486
  156. Kelly B, King L, Baur L, et al. Monitoring food and non-alcoholic beverage promotions to children. Obes Rev. 2013;14 Suppl 1:59-69. doi:10.1111/obr.12076
  157. Laar AK, Aryeetey RNO, Annan R, et al. Contribution of scaling up nutrition Academic Platforms to nutrition capacity strengthening in Africa: local efforts, continental prospects and challenges. Proc Nutr Soc. 2017;76(4):524-534. doi:10.1017/s0029665117001124
  158. Ministry of Health. Policy for the Prevention and Control of Non-Communicable Diseases in Ghana 2020. Accra, Ghana: Ministry of Health; 2020.
  159. Muthuri SK, Onywera VO, Tremblay MS, et al. Relationships between parental education and overweight with childhood overweight and physical activity in 9-11 year old children: results from a 12-country study. PLoS One. 2016;11(8):e0147746. doi:10.1371/journal.pone.0147746
  160. Reeve B. Self regulation of food advertising to children: an effective tool for improving the food marketing environment. Monash Univ Law Rev. 2016;42:419.
  161. Reeve E, Thow AM, Bell C, et al. Implementation lessons for school food policies and marketing restrictions in the Philippines: a qualitative policy analysis. Global Health. 2018;14(1):8. doi:10.1186/s12992-017-0320-y
  162. Sharma LL, Teret SP, Brownell KD. The food industry and self-regulation: standards to promote success and to avoid public health failures. Am J Public Health. 2010;100(2):240-246. doi:10.2105/ajph.2009.160960
  163. Smith R, Kelly B, Yeatman H, Boyland E. Food marketing influences children's attitudes, preferences and consumption: a systematic critical review. Nutrients. 2019;11(4):875. doi:10.3390/nu11040875
  164. World Health Organization (WHO). Noncommunicable Diseases: Progress Monitor 2020. Geneva: WHO; 2020.
  165. Abizari AR, Buxton C, Kwara L, Mensah-Homiah J, Armar-Klemesu M, Brouwer ID. School feeding contributes to micronutrient adequacy of Ghanaian schoolchildren. Br J Nutr. 2014;112(6):1019-1033. doi:10.1017/s0007114514001585
  166. Amidu N, Owiredu WKBA, Saaka M, et al. Determinants of childhood obesity among basic school children aged 6-12 years in Tamale Metropolis. J Med Biomed Sci. 2013;2(3):26-34. doi:10.4314/jmbs.v2i3.5
  167. Awojobi ON. A systematic review of the impact of Ghana's school feeding programme on educational and nutritional outcomes. Agro-Science. 2019;18(2):42-50. doi:10.4314/as.v18i2.8
  168. Bosu WK. A comprehensive review of the policy and programmatic response to chronic non-communicable disease in Ghana. Ghana Med J. 2012;46(2 Suppl):69-78.
  169. Ernst & Young. End of Programme Evaluation for the Ghana School Feeding Programme. Accra, Ghana: Ernst & Young; 2012.
  170. Fernandes M, Folson G, Aurino E, Gelli A. A free lunch or a walk back home? the school food environment and dietary behaviours among children and adolescents in Ghana. Food Secur. 2017;9:1073-1090. doi:10.1007/s12571-017-0712-0
  171. Gelli A, Masset E, Folson G, et al. Evaluation of alternative school feeding models on nutrition, education, agriculture and other social outcomes in Ghana: rationale, randomised design and baseline data. Trials. 2016;17:37. doi:10.1186/s13063-015-1116-0
  172. Ghana School Feeding Programme (GSFP). Programme Document 2007-2010. Accra, Ghana: GSFP; 2006.
  173. Netherlands Development Organisation. Food for Development: An inventory of the implementation of the Ghana Schoolfeeding Programme in Northern, Upper East, Volta, Central, and Western Region. December 2007. 2007.
  174. Khatete I, Pendo S, Oyabi J. School feeding program and pupils' participation in primary schools in Kenya. A study of Taita Taveta and Nairobi districts. Journal of Emerging Trends in Educational Research and Policy Studies. 2013;4(6):895-900.
  175. Kigaru DMD, Loechl C, Moleah T, Macharia-Mutie CW, Ndungu ZW. Nutrition knowledge, attitude and practices among urban primary school children in Nairobi city, Kenya: a KAP study. BMC Nutr. 2015;1(1):44. doi:10.1186/s40795-015-0040-8
  176. Kimwele AM, Ochola SA, Mugambi MN. School Feeding Programmes, National Food Policies, Action Plan and Strategies on School Meals and Food Security Among School Children in Kenya (Review). Machakos, Kenya: Machakos University; 2019.
  177. Kyallo F, Makokha A, Mwangi AM. Overweight and obesity among public and private primary school children in Nairobi, Kenya. Health. 2013;5(8):85-90. doi:10.4236/health.2013.58a3012
  178. Mohamed AO. Influence of feeding programs on the participation of learners at early childhood development education institutions: a case of Bungoma South district. Int Acad J Soc Sci Educ. 2015;1(4):1-14.
  179. Muthuri SK, Wachira LJ, Onywera VO, Tremblay MS. Correlates of objectively measured overweight/obesity and physical activity in Kenyan school children: results from ISCOLE-Kenya. BMC Public Health. 2014;14:436. doi:10.1186/1471-2458-14-436
  180. Langinger N. School feeding programs in Kenya: transitioning to a homegrown approach. Stanford Journal of International Relations. 2011;13(1):30-37.
  181. Walingo MK, Ekesa BN. Nutrient intake, morbidity and nutritional status of preschool children are influenced by agricultural and dietary diversity in Western Kenya. Pak J Nutr. 2013;12(9):854-859. doi:10.3923/pjn.2013.854.859
  182. Walingo MK, Musamali B. Nutrient intake and nutritional status indicators of participant and nonparticipant pupils of a parent-supported school lunch program in Kenya. J Nutr Educ Behav. 2008;40(5):298-304. doi:10.1016/j.jneb.2008.04.353
  183. Engler-Stringer R, Le H, Gerrard A, Muhajarine N. The community and consumer food environment and children's diet: a systematic review. BMC Public Health. 2014;14:522. doi:10.1186/1471-2458-14-522
  184. Jaime PC, Lock K. Do school based food and nutrition policies improve diet and reduce obesity? Prev Med. 2009;48(1):45-53. doi:10.1016/j.ypmed.2008.10.018
  185. Ochola S, Masibo PK. Dietary intake of schoolchildren and adolescents in developing countries. Ann Nutr Metab. 2014;64 Suppl 2:24-40. doi:10.1159/000365125
  186. African Union. The New Partnership for Africa's Development (NEPAD): Health Strategy. Addis Ababa: African Union; 2007.
  187. Buhl A. Meeting Nutritional Needs Through School Feeding: A Snapshot of Four African Nations. Global Child Nutrition Foundation; 2010.
  188. Bundy D, Burbano C, Grosh M, Gelli A, Jukes M, Drake L. Rethinking School Feeding: Social Safety Nets, Child Development, and the Education Sector. Joint Publication of the World Food Programme and the World Bank. Washington, DC: The World Bank; 2009.
  189. Sumberg J, Sabates-Wheeler R. Linking agricultural development to school feeding in sub-Saharan Africa: theoretical perspectives. Food Policy. 2011;36(3):341-349. doi:10.1016/j.foodpol.2011.03.001
  190. Gleason P, Suitor C. Food for Thought: Children's Diets in the 1990s. Princeton, NJ: Mathematica Policy Research; 2001.
  191. Gorski MT, Roberto CA. Public health policies to encourage healthy eating habits: recent perspectives. J Healthc Leadersh. 2015;7:81-90. doi:10.2147/jhl.s69188
  192. Skar M, Kirstein E, Kapur A. Lessons learnt from school-based health promotion projects in low- and middle-income countries. Child Care Health Dev. 2015;41(6):1114-1123. doi:10.1111/cch.12231
  193. Vepsäläinen H, Mikkilä V, Erkkola M, et al. Association between home and school food environments and dietary patterns among 9-11-year-old children in 12 countries. Int J Obes Suppl. 2015;5(Suppl 2):S66-73. doi:10.1038/ijosup.2015.22
  194. Hawkes C, Smith TG, Jewell J, et al. Smart food policies for obesity prevention. Lancet. 2015;385(9985):2410-2421. doi:10.1016/s0140-6736(14)61745-1
  195. Bazza T. Morocco to Cancel Increased Soft Drink Taxes Under Manufacturer Pressure. Morocco World News; 2018, 2019. URL: https://www.moroccoworldnews.com/2018/12/259398/morocco-taxes-soft-drink/ Accessed on 08/01/2021.
  196. Du M, Tugendhaft A, Erzse A, Hofman KJ. Sugar-sweetened beverage taxes: industry response and tactics. Yale J Biol Med. 2018;91(2):185-190.
  197. Gupta S, Tutu RA, Boateng J, Busingye JD, Elavarthi S. Self-reported functional, communicative, and critical health literacy on foodborne diseases in Accra, Ghana. Trop Med Health. 2018;46:15. doi:10.1186/s41182-018-0097-6
  198. Lim GY. One Year on: Morocco Still Debating Introducing Sugar Tax on Soft Drinks. Food Navigator (Asia); 2019.
  199. Pelletier D, Gervais S, Hafeez-Ur-Rehman H, Sanou D, Tumwine J. Boundary-spanning actors in complex adaptive governance systems: the case of multisectoral nutrition. Int J Health Plann Manage. 2018;33(1):e293-e319. doi:10.1002/hpm.2468