“We should be able to decide” : Obesogenic factors influencing dietary behaviours of women and adolescents in Ethiopia

Multiple factors can lead to overweight and obesity but unhealthy diets remain one of the key contributors. Diets in turn are influenced by diverse factors. The overall objective of this thesis was to understand the factors influencing dietary behaviours of women and adolescents in low- to middle-income countries, and specifically of adolescents in Ethiopia. Additionally, it aims to explore how these adolescents perceive their food environment and how policies address the different factors of the food environment.This study adopted a mixed-method approach and included a wide range of methods. This thesis starts with a global perspective of obesogenic behaviours (Chapter 2) as part of a qualitative evidence synthesis (QES) following a framework synthesis methodology to extract, analyse and synthesise qualitative data from primary research studies. The two studies described in Chapters 3 and 4 focus on specific settings in urban Ethiopia, both in terms of quantitative mapping of the food environment (Chapter 4) as well as qualitative assessment of adolescents’ perceptions, applying the Photovoice method, which is a community-based participatory method (Chapter 3). For Chapter 5, a policy analysis was conducted using the INFORMAS Healthy Food Environment Policy Index (Food-EPI) framework as a basis.Our findings suggest that the influencing factors of dietary behaviours include individual-, social-, physical- and macro-level factors. Food safety concerns, body ideals, socio-cultural norms, media influence and limited time to prepare healthy food could negatively influence diets and increase exposure to multiple burdens of malnutrition. Perceptions related to the unhealthy diets and bigger body images of wealthy people, combined with healthy food being more difficult to access or afford, are major challenges for people of low socio-economic status to eat healthily. Our findings also suggest that adolescents’ agency to make dietary choices depends not only on their knowledge but on the complexity of their physical and social surroundings and the confidence they have in their future. A nutrition transition is taking place in Ethiopia, with the high presence and advertising of ultra-processed foods and beverages. However, policies are not yet sufficiently in place to coherently address this unhealthy dietary transition in Ethiopia.This thesis has identified several entry points for future research and policymaking related to the dietary behaviours of adolescents and their food environments. Future research should aim to engage adolescents as active participants in research using creative participatory methods and to empower adolescents by including them in the design, data collection and analysis. Adolescents should also be part of the programming and policy process as they can be effective agents of change, influencing the diet and health of their family and the community. Comprehensive, multicomponent school programmes are needed to promote healthy school food environments with safe and nutritious meals, inclusive and sustainable food procurement and food and nutrition education throughout the school system, supported by regulations on the foods sold and advertised in and around schools. Future studies on food environments should apply further mixed-method studies for more comprehensive and nuanced assessments of food environments. Specific aspects of the food environment, such as food safety and socio-ecological processes, have been limited in food environment research. Our studies identified multiple influencing factors for dietary behaviours that would need to be addressed using a systems approach. A food systems approach to policymaking would consider potential interlinkages or unintended consequences of policies on different outcomes while identifying appropriate policy actions.&nbsp