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This paper is about the future role of the commercial sector in global health and health equity. The discussion is not about the overthrow of capitalism nor a full-throated embrace of corporate partnerships. No single solution can eradicate the harms from the commercial determinants of health—the business models, practices, and products of market actors that damage health equity and human and planetary health and wellbeing. But evidence shows that progressive economic models, international frameworks, government regulation, compliance mechanisms for commercial entities, regenerative business types and models that incorporate health, social, and environmental goals, and strategic civil society mobilisation together offer possibilities of systemic, transformative change, reduce those harms arising from commercial forces, and foster human and planetary wellbeing. In our view, the most basic public health question is not whether the world has the resources or will to take such actions, but whether humanity can survive if society fails to make this effort.

Over the last 2 decades, many African countries have undergone dietary and nutrition transitions fueled by globalization, rapid urbanization, and development. These changes have altered African food environments and, subsequently, dietary behaviors, including food acquisition and consumption. Dietary patterns associated with the nutrition transition have contributed to Africa's complex burden of malnutrition—obesity and other diet-related noncommunicable diseases (DR-NCDs)—along with persistent food insecurity and undernutrition. Available evidence links unhealthy or obesogenic food environments (including those that market and offer energy-dense, nutrient-poor foods and beverages) with suboptimal diets and associated adverse health outcomes. Elsewhere, governments have responded with policies to improve food environments. However, in Africa, the necessary research and policy action have received insufficient attention. Contextual evidence to motivate, enable, and create supportive food environments in Africa for better population health is urgently needed. In November 2020, the Measurement, Evaluation, Accountability, and Leadership Support for Noncommunicable Diseases Prevention Project (MEALS4NCDs) convened the first Africa Food Environment Research Network Meeting (FERN2020). This 3-d virtual meeting brought researchers from around the world to deliberate on future directions and research priorities related to improving food environments and nutrition across the African continent. The stakeholders shared experiences, best practices, challenges, and opportunities for improving the healthfulness of food environments and related policies in low- and middle-income countries. In this article, we summarize the proceedings and research priorities identified in the meeting to advance the food environment research agenda in Africa, and thus contribute to the promotion of healthier food environments to prevent DR-NCDs, and other forms of malnutrition.Statement of Significance: In Africa, research and policy action to improve food environments, to reduce intake of suboptimal diets, and associated adverse health outcomes have received insufficient attention. This paper articulates previously unpublished priorities to advance the food environment research agenda, and to generate contextually relevant, fit-for-local purpose evidence to confront unhealthy food environments in Africa.

Over the last 2 decades, many African countries have undergone dietary and nutrition transitions fueled by globalization, rapid urbanization, and development. These changes have altered African food environments and, subsequently, dietary behaviors, including food acquisition and consumption. Dietary patterns associated with the nutrition transition have contributed to Africa's complex burden of malnutrition—obesity and other diet-related noncommunicable diseases (DR-NCDs)—along with persistent food insecurity and undernutrition. Available evidence links unhealthy or obesogenic food environments (including those that market and offer energy-dense, nutrient-poor foods and beverages) with suboptimal diets and associated adverse health outcomes. Elsewhere, governments have responded with policies to improve food environments. However, in Africa, the necessary research and policy action have received insufficient attention. Contextual evidence to motivate, enable, and create supportive food environments in Africa for better population health is urgently needed. In November 2020, the Measurement, Evaluation, Accountability, and Leadership Support for Noncommunicable Diseases Prevention Project (MEALS4NCDs) convened the first Africa Food Environment Research Network Meeting (FERN2020). This 3-d virtual meeting brought researchers from around the world to deliberate on future directions and research priorities related to improving food environments and nutrition across the African continent. The stakeholders shared experiences, best practices, challenges, and opportunities for improving the healthfulness of food environments and related policies in low- and middle-income countries. In this article, we summarize the proceedings and research priorities identified in the meeting to advance the food environment research agenda in Africa, and thus contribute to the promotion of healthier food environments to prevent DR-NCDs, and other forms of malnutrition.

Optimal nutrition is a determinant of health in all persons. In persons living with HIV (PLHIV), nutrition is particularly important. Various factors, including dietary practices, play a role in guaranteeing nutritional health. We investigated multiple non-prescription drugs use among HIV-positive persons receiving antiretroviral therapy (ART) from four treatment centers in southern Ghana. This paper, however, focuses on nutrient supplement use, food elimination, and food substitution practices by the PLHIV. Using quantitative and qualitative methods, we collected data from 540 HIV-positive persons at the health facility level. This paper focuses on only the quantitative data. Individual study participants were selected using a systematic random sampling procedure. Participants were interviewed after informed consent. We used univariate analysis to generate descriptive tabulations for key variables. Multivariable logistic regression modeling identified predictors of three practices (nutrient supplementation, food elimination, and food substitution). Pvalue less than 0.05 or 95% confidence intervals facilitated determination of statistical significance. All analyses were performed using IBM SPSS Statistics for Windows, version 20.0. The use of nutrient supplements was a popular practice; 72% of the PLHIV used various kinds. The primary motive for the practice was to boost appetite and to gain weight. A little over 20% of the participants reportedly eliminated certain foods and beverages, while 17% introduced new foods since their initial HIV diagnosis. All the three practices were largely driven by the quest for improved health status. We determined predictors of nutrient supplementation to be ART clinic location and having an ART adherence monitor. Having an ART adherence monitor was significantly associated with reduced odds of nutrient supplementation (AOR = 0.34; 95% CI 0.12–0.95). The only predictor for food elimination was education level (AOR = 0.29; 95% CI 0.30–0.92); predictors of food substitution were ART clinic location (AOR = 0.11; 95% CI 0.02–0.69) and anemia (defined as hemoglobin concentration less than 11.0 g/dl) (AOR = 0.21; 95% CI 0.12–0.85). The practice of supplementation is popular among this group of PLHIV. Food elimination and substitution are practiced, albeit in moderation. The predictors identified may prove helpful in provider-client encounters as well as local HIV programming.

Background: Meeting the nutritive needs of infants and young children is a challenge in Ghana. Alternative animal source foods, including insects, could enhance infant and young child dietary quality while also improving livelihoods.Objective: To investigate the perspectives of Ghanaian stakeholders on the acceptability of the palm weevil larvae (akokono) as a food source and the feasibility of micro-farming this local edible insect as a complementary food for infants and young children.Methods: We conducted an ethnographic study in the Brong-Ahafo Region of Ghana. First, 48 caregivers were asked questions about feeding and care practices, including attitudes toward production and consumption of akokono. Then, a selection of previously interviewed respondents joined 1 of 8 focus group discussions to provide further insight on key themes that emerged from earlier interviews. Concurrently, interviews with 25 other key local stakeholders were conducted.Results: Respondents generally had favorable perceptions of akokono as a nutritious food. A small minority would not consume akokono for religious reasons. Key factors positively influencing the acceptability of akokono as a complementary food were familiarity with the consumption of akokono by the primary caregiver and health worker endorsement of akokono. Stakeholders consider the larvae farmable and were open to its domestication.Conclusions: Anticipated barriers to scaling up akokono micro-farming include a need for greater familiarity with and acceptance of the insect as food for infants and young children and creation of a sustainable market. Engagement with stakeholders, including health workers, will facilitate use of akokono as a complementary food.

Poor nutrition is a determinant of death particularly among persons living with HIV (PLHIV). This paper discusses the state of food and nutrition assistance to PLHIV in Ghana. A review of published articles and program reports was done and supported by in-depth interviews with key stakeholders. Data were qualitatively analyzed. A matrix highlighting problems that need to be addressed, possible attributable factors, strengths, and opportunities of existing actions metamorphosed from the analysis. Although stakeholders agree that adequate nutrition is critically important for PLHIV, food and nutrition interventions to PLHIV are inadequate.

Grains have historically represented a major component of human diets and were predominantly consumed in whole form until the first half of the 19th century, when a combination of technological innovations and market dynamics made refined grains, hitherto a premium product, affordable and available to the masses. Grains still account for more than half of the total caloric intake among vulnerable populations worldwide, and their dominant consumption in refined form turns a nutrient-dense, protective food into a nutrient-poor one contributing to growing rates of obesity and noncommunicable disease. Shifting a substantial portion of global grain consumption to whole grains is potentially one of the most significant and achievable improvements to diets and food systems worldwide. In countries with significant micronutrient deficiencies, a switch from refined to fortified whole grain foods can enable institutional channels such as school feeding programs to measurably improve diet quality in a budget-neutral way.

Multiple recent global nutrition initiatives have recommended actions to transform food systems to improve food environments and food choice. This study aimed to identify actions recommended by these initiatives and understand their similarities and differences. Twelve global nutrition initiatives were reviewed, collectively spanning 13 action themes and accompanying strategies. Action themes were analyzed according to primary focus on either food environments and their food system drivers or food choice. Representation of the 13 actions varied across initiatives. Some actions overlapped; others were infrequently represented. Strategies targeting food environments and their food system drivers were more frequently recommended than strategies targeting food choice for 11 of the 13 action themes. Although these global initiatives share a mission to improve nutrition through food systems and food environments, less attention has been allocated to individual food choice and sustainability.

Both food safety and dietary behaviors are major contributors to the global burden of disease, especially in rapidly urbanising environments. The impact that food safety concerns have on dietary behaviors in low- and middle-income countries (LMICs) is insufficiently documented. Therefore, we examined whether food safety concerns influence consumer behaviors/diets in LMICs. A systematic review identified 46 relevant studies from 20 LMICs for inclusion. A socio-ecological food environment framework was used to map food safety factors that influence consumer behaviors (food acquisition/purchase, eating out of home, food preparation/storage) and diets (consumption of nutrient rich/poor foods). Several studies (n = 11) reported that despite food safety concerns, consumers could not always ensure that they consumed safe food; barriers were affordability, accessibility and appeal. Key concerns included fear of pesticides, fertilizers, hygiene in/around food outlets, unhygienic vendor practices and household storage/preparation methods. These concerns may reduce consumption of animal sourced food and fresh fruit and vegetables; and increase consumption of starchy staples and processed/packaged foods. Policies such as upgrading urban market infrastructure to enhance food safety, accompanied by nutrition and hygiene education, could lead to increased accessibility, affordability and appeal of safe, nutrient-rich foods. Thus, reducing the appeal of packaged/processed food as a means to mitigate food safety risk; thereby contributing to preventing foodborne disease and multiple forms of malnutrition.

Growing urbanisation in Africa is accompanied by rapid changes in food environments, with potential shifts towards unhealthy food/beverage consumption, including in socio-economically disadvantaged populations. This study investigated how unhealthy food and beverages are embedded in everyday life in deprived areas of two African countries, to identify levers for context relevant policy. Deprived neighbourhoods (Ghana: 2 cities, Kenya: 1 city) were investigated (total = 459 female/male, adolescents/adults aged ≥13 y). A qualitative 24hr dietary recall was used to assess the healthiness of food/beverages in relation to eating practices: time of day and frequency of eating episodes (periodicity), length of eating episodes (tempo), and who people eat with and where (synchronisation). Five measures of the healthiness of food/beverages in relation to promoting a nutrient-rich diet were developed: i. nutrients (energy-dense and nutrient-poor -EDNP/energy-dense and nutrient-rich -EDNR); and ii. unhealthy food types (fried foods, sweet foods, sugar sweetened beverages (SSBs). A structured meal pattern of three main meals a day with limited snacking was evident. There was widespread consumption of unhealthy food/beverages. SSBs were consumed at three-quarters of eating episodes in Kenya (78.5%) and over a third in Ghana (36.2%), with those in Kenya coming primarily from sweet tea/coffee. Consumption of sweet foods peaked at breakfast in both countries. When snacking occurred (more common in Kenya), it was in the afternoon and tended to be accompanied by a SSB. In both countries, fried food was an integral part of all mealtimes, particularly common with the evening meal in Kenya. This includes consumption of nutrient-rich traditional foods/dishes (associated with cultural heritage) that were also energy-dense: (>84% consumed EDNR foods in both countries). The lowest socio-economic groups were more likely to consume unhealthy foods/beverages. Most eating episodes were <30 min (87.1% Ghana; 72.4% Kenya). Families and the home environment were important: >77% of eating episodes were consumed at home and >46% with family, which tended to be energy dense. Eating alone was also common as >42% of eating episodes were taken alone. In these deprived settings, policy action to encourage nutrient-rich diets has the potential to prevent multiple forms of malnutrition, but action is required across several sectors: enhancing financial and physical access to healthier foods that are convenient (can be eaten quickly/alone) through, for example, subsidies and incentives/training for local food vendors. Actions to limit access to unhealthy foods through, for example, fiscal and advertising policies to dis-incentivise unhealthy food consumption and SSBs, especially in Ghana. Introducing or adapting food-based dietary guidelines to incorporate advice on reducing sugar and fat at mealtimes could be accompanied by cooking skills interventions focussing on reducing frying/oil used when preparing meals, including ‘traditional’ dishes and reducing the sugar content of breakfast.