A COMBINED LIFESTYLE INTERVENTION TO OPTIMIZE METABOLIC HEALTH AMONG WOMEN OF REPRODUCTIVE AGE IN URBAN UGANDA

Sub-optimal metabolic health is increasing across urban SSA with no signs of receding, and this is largely attributed to the rising prevalence of overweight and obesity. Women of reproductive age (WRA) are disproportionately the most affected. Maternal sub optimal metabolic health is linked to lifelong intergenerational negative health outcomes. It is suggested that the ongoing nutrition transition in urban SSA characterised by a mismatch between dietary and PA behaviours largely explains this metabolic anomaly. This postulates an urgent need for science based preventative strategies to reverse the trend. However, to date there is limited evidence in urban SSA on which strategies to apply. WRA are an opportunity to reduce the risk of sub optimal metabolic health, both in the current and the next generation. The reasons are two-fold: i) WRA are mostly at-risk of metabolic disturbances; and ii) WRA are the family food gatekeepers. Therefore, the overall aim of the PhD study was to develop and evaluate a combined dietary and PA intervention to optimize metabolic health among WRA in urban Uganda. To achieve the overall aim, the well-defined and scientifically proven framework of Intervention Mapping protocol was used. Priority was to have a deeper understanding of the determinants of dietary and PA among WRA in urban SSA. Therefore, the PhD project started with an inquiry into the determinants of dietary and PA behaviour through a systematic review across urban SSA (chapter 4) and qualitative study in urban Uganda (chapter 5), in line with step 1 of the Intervention Mapping protocol. Our results of chapter 4 illustrated that studies with rigorous qualitative and quantitative designs are lacking in urban SSA, most especially within East Africa. We found only 23 studies mainly from the settings of South and West Africa. Nevertheless, from the available literature, we found notable determinants of dietary behaviour to include; convenience, financial barriers, food skills and knowledge gaps at intra-individual level, and food deserts at physical environment level. At social environment level, social networks and cultural beliefs were prevalent. Cultural beliefs include strong relationship between high social status and weight gain, energy-dense confectionery, salt or fat-rich foods. PA is influenced by the fast-changing transport environment, cultural beliefs which instigate unfavourable gender stereotypes, and knowledge, skills and self-efficacy gaps. Applying focus group discussions designed based on a modified theoretical framework; theory of planned behaviour incorporated with constructs of health belief model, precaution adoption process model, social cognitive and social support theory; our results of chapter 5 re-affirmed most of the findings of chapter 4 but also revealed unique determinants. Unique determinants included social-cultural norms like consideration of vegetable consumption as a sign of poverty, fruits as a snack for children and not food, and habitual orientation towards carbohydrate foods. For PA socio-cultural norms relating lifestyle PA to poverty were noted alongside cheap motorized transportation and the sedentary home environment (limited space and sedentary entertainment-social media and TV). In summary our results of chapter 4 and 5 demonstrate that the nutrition transition within urban SSA to a certain extent is fuelled by the prevailing cultural beliefs. In chapter 6: applying steps 1- 6 of the intervention mapping protocol, the PhD thesis systematically developed a theory and evidence-based intervention to optimise metabolic health among WRA in urban Uganda through improving fruit and vegetable intake and PA behaviours. Based on results of step 1; several unhealthy lifestyle behaviours including low intake of fruits and vegetables, energy dense low nutrient diets (e.g., fast foods and habitual/traditional orientation towards carbohydrate rich foods), inadequate PA levels and sedentary behaviour were observed in urban Uganda. These behaviours are fuelled by several socio-cultural misconceptions, notable one being the healthy beauty paradox. Hence, we hypothesised that changing the overall existing behaviours in one intervention may meet strong resistance. Thus, we decided to go for gradual stepwise changes. Hence in step 2, three behavioural intervention objectives were formulated; 1) women evaluate the accuracy of nutrition and PA information., 2) engage in moderate intensity PA for at least 150 minutes a week, and 3) consume at least one portion of vegetables and one portion of fruit every day. Based on the food literacy model, intervention objectives were formulated into performance objectives. The determinants of; skill, knowledge, self-efficacy, subjective norms, and social support were prioritised from results of step 1 as pertinent to accomplish the performance objectives. Accordingly, these determinants were mapped with performance objectives to create matrices of change objectives. In step 3 a combination of eleven behavioural change techniques were selected and translated into practical strategies to effect changes in determinants. In step 4, intervention components and materials were developed. The intervention consists of five interactive group sessions, 150 minutes each. Infographics on benefits/recommendations, vegetable recipes, and practical tips to eat more fruits, vegetables, and to engage more in PA are included. Personalised goals and action plans tailored to personal metabolic health and lifestyle needs, and environmental opportunities form the basis of the intervention. Finally in step 6, a randomized controlled trial to evaluate the intervention was designed. To the best of our knowledge, this is the first systematically designed theory and evidence-based lifestyle intervention to optimise cardio-metabolic health among WRA in urban Uganda and SSA at large. In chapter 7, applying a mixed approach consisting of two phases; 1) item development based on literature, expert and target group insights, and 2) a cascade of validation steps; test-retest reliability, construct, criterion, and concurrent, we developed and validated a food literacy scale for use in adult population in urban Uganda. A 40 item Food Literacy-scale covering the five domains of food literacy (information evaluation, plan, select, prepare, and eat) was developed. The Food Literacy-scale has a good reliability (0.705 (0.594; 0.789) p<0.001) and internal consistency (Cronbach's α = 0.827 (0.746; 0.882) p<0.001). The FL-scale is positively correlated with the dietary quality assessed by the prime dietary quality score (r=0.282 p=0.004) and healthy eating self-efficacy (r=0.351, p<0.001). At the same time, it has ability to distinguish populations with higher food literacy from those with lower food literacy (β=15.70 (9.97; 11.44) p<0.001). The scale has potential to predict fruit and vegetable consumption; a higher fruit consumption (≥ 1 time/day) was associated with a higher food literacy (β = 5.03 (0.69; 9.37) p = 0.023) while for vegetables a positive trend was observed (β = 4.27 (-0.46; 8.99) p = 0.077). As the Food Literacy-scale has good reliability and validity, it has a potential for application across a range of studies, particularly those evaluating interventions targeted at improving food literacy in urban Uganda. In addition, with minimal adaptation, the scale can be applied across urban SSA. In chapter 8, we evaluated the newly developed lifestyle intervention for its efficacy towards optimisation of dietary and PA behaviours and cardiometabolic health through a randomised controlled trial. Our results showed that the intervention had a minimal effect on cardiometabolic health. We observed a reduction trend in waist circumference (-1.48cm (-3.05; 0.10), p=0.060) in the intervention arm at the end-line (3 months) which only became statistically significant (-1.87 cm (-3.32; -0.44), p=0.011) at post follow up (6 months). At the end line, the intervention only showed effect on FBG (-6.95mg/dl (-13.37; -0.53) p=0.034) while at post follow-up, effects were only observed for FBG (-6.48mg/dl (-12.76; -0.21) p=0.043), DBP (-6.67mm/Hg (-11.24; -2.11) p=0.004) and TC (-11.74mg/dl (-20.47; -3.01) p=0.009). However, regarding food literacy and lifestyle behaviours, we observed substantial improvements both at the end-line and post-follow up. At end-line, participants in the intervention arm were more food literate (6.85% (2.49; 11.21) p=0.002) and consumed more fruits (62.60g (1.86; 123.34) p=0.046) and vegetables (66.15g (25.47; 106.83) p = 0.002) while PA increased with no notable differences across the study groups. Improvements in food literacy and fruit consumption was sustained at post follow up, but no difference was observed for vegetables. On the other hand, participants in the intervention group were more active 2675.06 MET- mins/week (1045.68; 4304.44) p=0.001. Overall, the PhD project has developed and evaluated a lifestyle intervention to optimise cardiometabolic health in urban Uganda, which to the best of our knowledge is the first of the kind in urban SSA. The intervention has potential to improve PA, fruit, and vegetables intake. However, substantial effects on metabolic health may necessitate a direct focus on weight loss. Nevertheless, going forward the developed intervention can be included as strategy to optimise PA, and fruit and vegetable intake behaviours in urban Uganda as there is currently no intervention. The PhD has created relevant infographics like the PA triangle and healthy eating plate contextualised to the urban Ugandan setting. The detailed description of our intervention can guide future intervention development in urban SSA. Additionally, a Food Literacy-scale has been developed and validated for use in urban Uganda and SSA region at large.

Publication year:2022

Accessibility:Open