Predictors of food variety and food consumption scores of adolescents living in a rural district in Ghana

Michael Akenteng Wiafe; Jessica Ayensu; Georgina Benewaa Yeboah

doi:10.1371/journal.pone.0286477

. 2023 May 31;18(5):e0286477. doi: 10.1371/journal.pone.0286477

Predictors of food variety and food consumption scores of adolescents living in a rural district in Ghana

Michael Akenteng Wiafe ^1,^*, Jessica Ayensu ², Georgina Benewaa Yeboah ³

Editor: Muhammad Khalid Bashir⁴

PMCID: PMC10231777 PMID: 37256891

Abstract

Introduction

There is a dearth of information about the food variety and consumption scores of adolescents in Ghana. This study assessed predictors of food variety and consumption scores of adolescents living in a rural district in Ghana.

Method

In this cross-sectional study, a multi-stage sampling method was used to select one hundred and thirty-seven (137) adolescents from the Asante-Akim South Municipality of Ghana. A structured questionnaire was used to collect data on sociodemographic, food practices and dietary intakes of study participants. Descriptive, chi-square, T-test, partial correlation and binary logistic regression were used for the data analysis.

Results

The mean food variety score was 25.8±6.4 (range 7–42) and food consumption score was 35±5.1 (range 18.6–49.9). Food variety score was significantly (p<0.05) associated with guardian income status. A significant and positive partial correlation existed between food variety score and calcium intake (r = 0.236, p<0.05). About 49% and 51% of adolescents were food insecure and food secure, respectively. Food consumption score had significant association (p<0.05) with gender (X² = 6.1), residence (X² = 7.0), frequency of meal (X² = 6.8) and food variety score (X² = 5.4). Adolescent male (AOR = 2.3, 95% CI (1.2–4.6), p = 0.017), peri-urban residency (AOR = 2.1, 95%CI (1.0–4.4), p = 0.036), having three or more meals per day (AOR = 4.2, 95% CI (1.3–13.6), p = 0.018), and a high food variety score (AOR = 2.1, 95%CI (1.0–4.2), p = 0.041) significantly predicted food consumption scores.

Conclusion

Moderate income status was associated with food variety score in our study participants. Linear relationship existed between food variety and calcium intake. Adolescent males, peri-urban residency, frequency of meals and high food variety score were the predictors of food consumption score. Nutrition-specific and nutrition sensitive programmes aimed at promoting adolescent health should involve guardians.

Introduction

Adolescence is the period in the stages of human development when the growth rate of the human body is very rapid and individuals acquire a substantial proportion of their adult weight and height [1]. The consumption of a poor quality diet among adolescents could consequently affect generations as adolescence is a sensitive period for the development of both productive and reproductive capacities [2,3]. Suboptimal nutrition may predispose adolescents to the consequences of poor diet in adulthood. As no single food group contains all the nutrients required for adolescents’ growth and development, this necessitates the need for adolescents to eat from a variety of sources of food and have acceptable food security.

The food variety score measures the number of distinct foods eaten over a designated period [4]. This is used for the evaluation of the quality of dietary patterns [5]. Variety in essence, is choosing to eat a mixture of foods from different food groups and a mixture from within these food groups. The consumption of a varied diet improves nutritional adequacy, encourages biodiversity and sustainability and minimizes the adverse consequences of food on health, while improving the overall health of an individual [6]. The consumption of a varied diet in the appropriate quantity is important for optimal growth and development, as well as the total wellbeing through all the cycles of life, including adolescence [7]. Food variety was negatively associated with food insecurity, food neophobia, and sensory motive while semi-urban areas, urban areas, meal planning practices and high income had a positive association with food variety [7–9]. Increasing food variety contributed to improved diet quality among adolescents living with type 1 diabetes [10]. Thus, the consumption of a wide array of foods during adolescence cannot be overemphasized, as these individuals are especially prone to malnutrition originating from the increased nutritional needs for optimum growth and development.

A high food variety score has been linked to higher education, more frequent meals, urban residence, adequate micronutrients intake and healthy bone growth [11–13]. A positive and significant relationship has been found between high food variety score and serum ferritin, serum magnesium and vitamin C intakes whiles a negative association was reported to exist between a high food variety score and low intake of sugar, salt and saturated fat [5,14]. However, a low food variety score was observed among young people and has been associated with physical frailty in adulthood [14,15]. Therefore, if adolescents would eat from a wide variety of food groups, this could serve as a cost-effective approach with the potential to promote health, and minimize the occurrence of non-communicable diseases as they age or grow, since this period sets the precedent for health in adulthood. Food variety score had a positive association with dietary micronutrients and an inverse relationship with inadequate micronutrients intakes [16]. These micronutrients are needed to support the physiological and physical developmental processes in adolescents.

The food consumption score is an indicator of how a household or individual is food secured or not. It is based on dietary diversity, food frequency, and the relative nutritional relevance of the distinct food groups [17]. Residency, high-income level, income diversification, high education level, animal source of foods, good dietary practices and religion positively influenced food consumption scores [18–26].

Adolescents in food secure households are less likely to suffer nutritional deficiencies, the detrimental effect of undernutrition on cognitive development, and mental health disorders such as poor mood, anxiety, depression, and behavioural issues [27,28]. Food insecurity has also been documented to pose health challenges such as poor dietary pattern, obesity, asthma and increased the health care cost for adolescents [29–31]. This health issues persist into adulthood [32].

In Ghana, ‘adolescent nutrition’ receives very little attention, even though this stage of life is critical for development and health. The food variety and the food consumption score, are important indicators of nutritional adequacy and health status. There is however, a dearth of research on the food variety and consumption scores of adolescents. This study will provide information about food variety scores, food consumption scores and its predictors among adolescents. Thus, the study sought to identify predictors of the food variety and the food consumption scores of adolescents living in a rural district in Ghana.

Materials and methods

Study design, area and participants

This cross-sectional study was conducted at the Asante-Akim South municipality in the Ashanti Region of Ghana. It is one of Ghana’s rural districts where farming is the main form of employment. The district has land size of 0.5%, out of the total land area of Ghana. The food crops largely cultivated are cassava, plantain, cocoyam, yam, rice and maize. About 83% of the population lives in the rural areas of the district while rest reside within the peri-urban zone of the district [33,34].

A total of one hundred and thirty-seven (137) healthy adolescents aged 10–14 years were selected using a multi-stage sampling method from the municipality for this study. Adolescents who were sick, on a special diet, on medication or had a chronic condition were excluded from the study.

Data collection

Sociodemographic, food practices, and dietary intake data were collected with the aid of a structured questionnaire.

Food practices

Adolescents provided information about the frequency of meals they had per day and their meal skipping practices.

Dietary intake

Dietary information for three days (one weekend and two working days) was gathered using a 24-hour recall. Participants were asked to tell us how many times (breakfast, mid-morning snack, lunch, mid-afternoon snack, dinner and bed-time snack) they ate a day and the detailed (composition) of the food consumed. Food handy measures were used to estimate how much of the food consumed at each meal. Each food was converted to grams and the nutrients were estimated using the Nutrient Analysis Template developed by the University of Ghana. The averages for the nutrients were recorded.

A validated food frequency questionnaire (FFQ) was used to assess the number of times participants consumed cereals, bread and other staples, rice and pasta dishes, starchy roots and plantain, pulses and lentils, nuts, meat, fish and poultry, dairy products fats and oils, soups and stews sauces, vegetables (fresh, frozen and canned), fruits–fresh, alcoholic and non-alcoholic beverages, and sweets and snacks over a period of seven days.

Food variety score

The food variety score was calculated from 63 selected food items from the FFQ. The list of foods from alcoholic and non-alcoholic beverages (such as ‘pito’, palm wine and coffee), sweets and snacks were excluded from the calculation of the food variety scores. The list of foods exempted were rarely or never consumed. Food item consumed at least once a week were scored ‘1’ and ‘0’ for those not consumed at all. The scores were summed to obtain the food variety score for each participant. The food variety score (FVS) was ranked ‘high’ (≥26) or ‘low’ (≤25) based on the mean food variety scores.

Food consumption score

The foods on the FFQ list were further categorised into eight food groups: starchy staples; pulses; fruits; vegetables; meat, fish and poultry; dairy products; sugary products and edible oils. The frequency of the foods consumed in the same food group was summed. Each food group was multiplied by a weight factor: fruits and vegetables (1); starchy staples (2); pulses (3); meat, fish and poultry products (4); dairy products (4) and sugary and edible oils (0.5) [17]. The weight of the composite food groups was summed to obtain the food consumption score (FCS) of participants. The food consumption scores were classified into food insecure (food insecurity) (poor: 0–21; borderline: 21.5–35) and food secure (food security) (acceptable: >35) [17,21].

Statistical analysis

A statistical package for social sciences (SPSS version 25) was used for the data analysis. Data were presented as means, standard deviation, frequencies and percentages. Descriptive statistics were used in the analysis of food consumption scores and food variety scores. Chi-square and T-test were used to test for the association between sociodemographic, food variety score and food consumption status. Binary logistics regression was used to predict factors related to food security. Partial correlation (r) was used to assess the relationship food variety score, food consumption score and micronutrients. All p-values were significant at p<0.05.

Results

Descriptive statistics

Out of the 137 adolescents who participated in the study, 51.1% were males and 48.9% were females. In terms of residency, 50.4% lived in peri-urban areas and 49.6% lived in rural communities. Majority of participants were in primary school (70.1%) and few (29.9%) at the Junior High School (JHS). Guardians with formal education were 78.1% and those with non-formal education constituted 21.9%. About 14% of adolescents took two meals per day, while 86% took three or more. The affirmative response on meal skipping was 55.5% and the negative was 44.5% (Table 1).

Table 1. Sociodemographic, food practices, food variety score and food consumption score of adolescents.

Variable	N (%)	Food variety score Mean ± Sd p-value	Food consumption score Food insecure Food secure X² p-value
Sex Male Female Community Peri-urban Rural Educational status Participants JHS Primary Guardian Formal education Non-formal education Guardian income status Low (<Ghc490) Moderate (Ghc500-1000) Frequency of meal per day Two Three or more Meal skipping Yes No Food variety status Low High	70(51.1) 67(48.9) 69(50.4) 68(49.6) 41(29.9) 96(70.1) 107(78.1) 30(21.9) 100(73.0) 37(27.0) 19(13.9) 118(86.1) 76(55.5) 61(44.5) 65(47.4) 72(52.6)	24.8±6.2 0.050 26.9±6.3 26.1±7.3 0.573 25.5±5.2 26.9±4.5 0.122 25.3±7.0 26.0±6.1 0.444 24.9±7.2 24.5±6.3 <0.001 29.4±4.9 25.3±6.4 0.692 25.9±6.4 26.0±6.8 0.634 25.5±5.9 20.9±4.7 <0.001 30.3±3.9	27(40.3) 43(61.4) 6.1 0.017 40(59.7) 27(38.6) 26(38.8) 43(61.4) 7.0 0.010 41(61.2) 27(38.6) 23(34.3) 18(25.7) 1.2 0.351 44(65.7) 52(74.3) 52(77.6) 55(78.6) 0.0 1.000 15(22.4) 15(21.4) 47(70.1) 53(75.7) 0.5 0.564 20(29.9) 17(24.3) 4(6.0) 15(21.4) 6.8 0.012 63(94.0) 55(78.6) 42(62.7) 34(48.6) 2.8 0.122 25(37.3) 36(51.4) 25(37.3) 40(57.1) 5.4 0.026 42(62.7) 30(42.9)

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Junior High School (JHS), Chi-square (X²), Fisher’s exact test, p<0.05, Frequency (N), percentage (%).

On the account of food variety score, adolescents with guardians in the moderate-income category (29.4±4.9) had higher mean food variety scores than those from the low-income category (24.5±6.3) (p<0.001). Females (26.9±6.3) had higher mean food variety scores compared to males (24.8±6.2) (p = 0.050). A higher mean food variety score was also recorded among peri-urban settlers (26.1±7.3), JHS students (26.9±4.5), guardians with formal education (26±6.1) and the consumption of three or more meals per day by study participants (25.9±6.4). The highest food variety score was 52.6% and the lowest food variety score was 47.4% (Table 1).

A large proportion of participants in the food secure category had primary education (74.3%), guardian with formal education (78.6%), low-income status (75.7%) and did not skip meals (51.4%). Nonetheless, none of these factors had a significant association with food security (p>0.05). The study showed that more males (61.4%) relative to females (38.6%), were food secured (X² = 6.1, p = 0.017). The participants with peri-urban residential status (61.4%) were more likely to be food secure compared to those in the rural areas (38.6%) (X² = 7, p = 0.010). Food security was significantly associated with the frequency of meals per day (X² = 6.8, p = 0.012) (three or more -78.6%; two meals -21.4% (Table 1).

Results

Food variety score and food consumption score of participants

Table 2 shows the mean food variety score and food consumption score of participants. The results showed that the mean food variety score was 25.8±6.4, with a minimum and maximum score of 7 and 42, respectively. The mean food consumption score was 35±5.1, with a minimum and maximum score of 18.6 and 49.9, respectively. Adolescents with poor (0.7%) and borderline (48.2%) food insecurity totalled 48.2%. More than half (51.1%) of the participants had acceptable food security status (FCS >35).

Table 2. Food variety score and food consumption score of participants.

Variables	Mean ± Sd min—max N (%)
Food variety score Food consumption score Food consumption status Food insecure Poor Borderline Food secure Acceptable	25.8±6.4 7.0–42.0 35±5.1 18.6–49.9 1(0.7) 66(48.2) 70(51.1)

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Standard deviation = Sd, minimum (min), maximum (max), Frequency (N), Percentage (%).

Predictors of food security

The binary logistics regression for predictors of food consumption status is presented in Table 3. After adjusting for age and/or sex, the outcome indicated that being an adolescent male (AOR = 2.3, 95% CI (1.2–4.6), p = 0.017), living in a peri-urban community (AOR = 2.1, 95%CI (1.0–4.4), p = 0.036) taking three or more meals per day (AOR = 4.2, 95%CI (1.3–13.6), p = 0.036), and having a high food variety score (AOR = 2.1, 95%CI (1.0–4.2), p = 0.041) had higher odds of being food secured.

Table 3. Binary logistics regression for predictors of food consumption status.

Predictors	Food Secure
Predictors	Unadjusted β OR(95%CI) p-value	Adjusted β OR(95%CI) p-value
Sex Male Female Community Peri-urban Rural Frequency of meals per day Thrice or more Twice Food variety status High Low	0.858 2.4(1.2–4.7) 0.014 1 0.921 2.5(1.3–5.0) 0.009 1 1.458 4.3(1.3–13.7) 0.014 1 0.806 2.2(1.1–4.4) 0.021 1	0.836 2.3(1.2–4.6) 0.017 1 0.760 2.1(1.0–4.4) 0.036 1 1.427 4.2(1.3–13.6) 0.018 1 0.731 2.1(1.0–4.2) 0.041 1

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β = Beta coefficient, Odds ratio (OR), p<0.05, After adjusting for age and/or sex.

Partial correlation of food variety and food consumption scores and dietary micronutrient intake

After adjusting for age and sex, a positive partial correlation was found between food variety score and dietary micronutrients intakes except for Vitamin A and Vitamin B₁₂. A significant relationship existed between food variety score and calcium (r = 0.236, p<0.05) (Table 4).

Table 4. Partial correlation of food variety and food consumption scores and dietary micronutrient intake.

Variable	Food variety score	Food consumption score
Food variety score		0.016
Food consumption score	0.016
Vitamin A	-0.009	0.109
Thiamine	0.114	0.063
Riboflavin	0.060	0.001
Niacin	0.144	0.103
Pyridoxine	0.081	-0.021
Vitamin C	0.054	-0.119
Folate	0.118	0.107
Vitamin B₁₂	0.008	0.001
Iron	0.156	0.012
Zinc	0.151	0.058
Calcium	0.236*	0.135
Sodium	0.158	-0.043

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Controlled variables: Age and sex, *Partial correlation is significant at the 0.05 level (2-tailed).

The partial correlation showed a weak positive relationship between food consumption score and most of the dietary vitamins and minerals. An inverse weak correlation was found between food consumption score and pyridoxine, vitamin C and sodium. None of the relationship was significant (p<0.05) (Table 4).

Discussion

Food variety and food consumption scores of adolescents are critical to their health and well-being as it has a significant effect on adulthood and the unborn generation. Adolescents eating from a variety of food groups have the potential to increase nutrient adequacy. The study assessed the predictors of food variety and consumption scores of adolescents living in a rural district in Ghana. The results showed that guardian income status was significantly associated with food variety scores. Food variety score was significantly related to dietary calcium intake. Sex, residence, frequency of meals per day and food variety score were significantly associated with food consumption scores. Food security was significantly related to adolescent males, peri-urban residency, three or more meals per day and high food variety score.

The current study showed a significant association between food variety scores and adolescents living with guardians of moderate-income status. The income level of a household influences the availability of food, the type of foods, nutritional quality of the food and dietary intake [35]. Adolescents from these households also had higher mean food variety scores. This implies that these participants had the wherewithal to purchase a wide range of foods and therefore ate from different sources of food. A study indicated that high income households had the opportunity to purchase and consume from wide sources of food [36]. Our finding is consistent with a study conducted among adolescents in Ethiopia [7]. The majority of adolescents in this study had a higher food variety score. This outcome is contrary to Drewnowski et al. [14] who worked with young people (20–30 years). The differences might be brought on by the age disparities between the research populations, the busy work schedules of young adults compared to adolescents, and the geographical locations. A significant and positive linear relationship existed between food variety score and dietary calcium intake. Dietary variety improved intake of micronutrients such as calcium, vitamin C and vitamin B₂ [37]. There was also a linear relationship between food variety score and dietary micronutrient such as thiamine, niacin, folate, iron, zinc and sodium. The outcome aligns with other studies that established that food variety scores had a positive relationship with micronutrient [5,16]. The ability to eat from a wide range of foods will increase the chances of consuming several micronutrient in the diet, as the various foods within the groups, might contain different micronutrient.

The study outcome on food consumption scores showed a significant association between sex, residency, frequency of meals per day and food variety score. The association between residency and the food consumption score is confirmed by a study among pregnant women in Ethiopia [21]. Results of a recent study in Burkina Faso also supports the findings that rural or urban settlement influences food consumption [20]. One’s geographical location affects the type of food items that can be grown, be available or be accessible, and these can influence the varieties of food that may be available to them.

Food consumption scores were used as indicators of food security, the higher the score, the more food secure the person is. The majority of the participants had acceptable food consumption scores (food security). This outcome is similar to that of Kong et al. [19]. Findings from this study showed that adolescent males, peri-urban settlement, consumption of three or more meals per day and high food variety scores had higher odds for food security. Most of the rural settlers send their produce to urban and peri-urban areas for sale on market days, and this could have contributed to the increased food security situation among participants living in the peri-urban areas. The higher number of participants being food secure may also be attributed to the high food variety scores and the educational status of guardians. A study in Zambia documented that, household heads with high educational status positively contributed to food security in the household [25]. Furthermore, a study in the Northern part of Ghana indicated that improved education (higher formal education) led to high food security status in the adult population [22].

Conclusion

The study showed that majority of adolescents had acceptable food consumption scores and high food variety scores. The income status of guardian had significant impact on the food variety score of adolescents. Factors such as gender, residency, frequency of meals per day and food variety score were significantly associated with food consumption scores. The predictors of food security based on the study outcomes were adolescent males, peri-urban residency, three or more frequency of meals per day and high food variety score. Government and non-governmental organizations are encouraged to implement nutrition education programmes and interventions aimed at providing adolescents with adequate nutrition knowledge, and also empower guardians economically to increase their purchasing power as it will influence their wards to have access to variety of foods for consumption and possibly increase their food consumption scores. A well-nourished adolescent is a potential healthy adult. Nutrition-specific and nutrition sensitive programmes aimed at promoting adolescent health should involve guardians.

As a limitation to this study, the recall bias of the dietary intake methodology could affect the food consumption and variety scores. The subjective weight factor of the food consumption score may not be applicable for all food consumption patterns in all countries. The food consumption score is not able to show the seasonal changes in food and also measure the quantity of food gap.

Ethics

The study protocol was approved by the Ethics Review Board of the Kwame Nkrumah University of Science and Technology, (reference number: CHRPE/AP/585/22), Ghana. Permission was granted by the Asante-Akim South Municipal Health Directorate. The purpose of the study was explained to the adolescents and guardians. Adolescents who gave their assent backed by their guardian’s consent either by signing or thumb printing on the informed consent form qualified to participate in the study.

Acknowledgments

Research assistants, adolescents and guardian are acknowledged.

Data Availability

The data used to support the findings of this study may be assessed by writing to the Chairman Committee on Human Research Publication Ethics, Room 8 Anatomy Block 3, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana, or chrpe.knust.kath@gmail.com.

Funding Statement

The author(s) received no specific funding for this work.

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PLoS One. doi: 10.1371/journal.pone.0286477.r001

Decision Letter 0

Callam Davidson

20 Dec 2022

PONE-D-22-28451PREDICTORS OF FOOD VARIETY AND FOOD CONSUMPTION SCORES OF ADOLESCENTS LIVING IN A RURAL DISTRICT IN GHANAPLOS ONE

Dear Dr. Wiafe,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This is an important topic of the life cycle because adolescence as stated by the authors is the stage where physical, psychosocial, and cognitive maturity are largely accomplished and the dramatic growth increases nutrient needs, making the study of food variety and consumption in nutritional status crucial.

There are several points that need to be clarified in a major revision to improve the paper, particularly:

1) Introduction – this area needs to be further developed (expand the literature review) with more articles or studies centered on adolescents’ food variety and consumption scores. You can include more information about the evidence that exists around the relevance/impact of food variety and consumption score in adolescent nutritional status, health, and growth. It would be good to see more description of the studies conducted around this with respect to adolescents specifically than in general (using adults, pregnant women, etc.) and then describe the gap with respect to food variety and consumption score in adolescents in Africa/Ghana.

You can expand the food consumption score also which is only 4 lines on a stand-alone paragraph.

2) Materials and methods –

• The authors will have to describe in detail the study area. In the topic, “Rural District” is used, which immediately causes the reader to assume the study was conducted in mainly a rural area. However, in the Abstract and Results, peri-urban residency has been used, which is not a rural area because it is a different classification on its own. The authors should be clear about what factors were taken into consideration in classifying the areas the study took place. This is connection with this statement in the Discussion – “Most of the rural settlers send their produce to urban and peri-urban areas for sale on market days, and this could have contributed to the increased food security situation among participants living in these areas.”

• The authors should explain why the exclusion was made in this sentence, especially with the adolescence stage associated with poor food choices due to increased autonomy and more time spent out of the home with peers. “The food variety score was calculated from 63 selected food items. The list of foods from alcoholic and non-alcoholic beverages, sweets and snacks were excluded from the calculation of the food variety scores.”

• “Each food group was multiplied by a weight factor.” How was the determination of this weight factor done (explain) – what is the basis of assigning the numbers or what determines the number that a food group needs to be assigned?

•

3) Results –

• “A large proportion of participants were food secure; primary education (74.3%), having a guardian with formal education (78.6%), low-income status (75.7%) and not skipping meals (51.4%).” – The use of semicolon after the food secure in this sentence means it is related to the variables following it. This is incorrect for low-income status in relation to food security. Based on the literature, food security is associated with moderate to high-income status. The authors should revise the statement.

• Table 4: If there is nothing interesting to talk about for the partial correlation of the food consumption score, for example the negative values or non-significance, that column should be omitted.

4) Discussion –

• Add a reference to this sentence, “It is believed that people living in rural communities, especially farming communities, have access to a wide variety of foods compared to those in urban areas. Similarly, individuals with busy schedules may depend on fast foods which may be monotonous if they don’t take pains to plan their meals.

• The sentence above contradicts this statement, “The association between residency and the food consumption score is confirmed by a study among pregnant women in Ethiopia [21]. Results of a recent study in Burkina Faso also supports the findings that rural or urban settlement influences food consumption [20]. One’s geographical location affects the type of food items that can be grown, be available or be accessible, and these can influence the varieties of food that may be available to them.” The authors should rephrase this statement. Again, the definition of rural, peri-urban, urban in relation to the title of the manuscript will be helpful.

• The authors should give interpretation of the results of food consumption score with male gender.

5) Conclusion – this section should be re-written. It is just a repetition of the same information from the Results. The authors should in addition, provide the public health implication of the study here, the strengths and weaknesses or study limitations, etc.

**********

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Reviewer #1: No

**********

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PLoS One. 2023 May 31;18(5):e0286477. doi: 10.1371/journal.pone.0286477.r002

Author response to Decision Letter 0

26 Dec 2022

Manuscript ID: PONE-D-22-28451

Response to Reviewers

Dear Sir/Madam,

Thank you for giving us the opportunity to submit a revised draft of the manuscript titled, " PREDICTORS OF FOOD VARIETY AND FOOD CONSUMPTION SCORES OF ADOLESCENTS LIVING IN A RURAL DISTRICT IN GHANA" for publication in PLOS ONE. We appreciate the time and effort that you and the reviewers dedicated to providing feedback on our manuscript and are grateful for the insightful comments on and valuable improvements to our paper. We have incorporated suggestions made by the reviewers. Those changes are highlighted within the revised manuscript. Please see below, for a point-by-point response to the reviewers’ comments and concerns.

Reviewer(s)' comments to the Authors:

Reviewer: 1

Comments to the Author

1. Introduction – this area needs to be further developed (expand the literature review) with more articles or studies centered on adolescents’ food variety and consumption scores. You can include more information about the evidence that exists around the relevance/impact of food variety and consumption score in adolescent nutritional status, health, and growth. It would be good to see more description of the studies conducted around this with respect to adolescents specifically than in general (using adults, pregnant women, etc.) and then describe the gap with respect to food variety and consumption score in adolescents in Africa/Ghana.

You can expand the food consumption score also which is only 4 lines on a stand-alone paragraph.

Response: Thank you.

Additional information has been added introduction.

The paragraph 5 in the introduction now reads:

Adolescents living in food secure household have a reduced prevalence of poor nutritional status, negative consequences of undernutrition on cognitive development and mental health disorders such as poor mood, anxiety, depression and behavioural problems [27, 28]. This psychological distress transcends into adulthood [29]. Food insecurity has also been documented to pose health challenges such as poor dietary pattern, obesity, asthma and increased the health care cost for adolescents [30-32].

2. Materials and methods –

Response: Thank you

‘Rural district’ differs from ‘Rural Ghana’ or ‘rural communities.’

The rural district does not entirely mean a cluster of rural areas. What it means is that majority (55-65%) of the areas under this district is rural. Development is also very low in those areas. This particular district is very far from the regional capital, Kumasi.

This district has a capital with better or more amenities or infrastructure compared to the other areas in the district hence it is classified as peri-urban by the Asante-Akim South Municipal Assembly. The district capital cannot also be compared to the regional capital in terms of development, education, health amenities etc.

In Ghana, most of the farmers in the rural areas send their produce to the urban and peri-urban areas for sales. This will enable the farmers to buy other items that are not available in the area where they live.

Additional information has been added to the study design, area and participants (paragraph 1) under the materials and method as recommended. It now reads:

Study design, area and participants

This cross-sectional study was conducted at the Asante-Akim South municipality in the Ashanti Region of Ghana. It is one of the rural districts in Ghana with farming as the major occupation of the people. The district has land size of 0.5% of the total land in Ghana. The food crops largely cultivated are cassava, plantain, cocoyam, yam, rice and maize. About 83% of the population lives in the rural areas of the district while rest reside within the peri-urban zone of the district [33, 34].

Response: Thank you

Reasons for the exclusion: The food list for alcoholic and non-alcoholic beverages (such as ‘pito’, palm wine, coffee etc), sweets and snacks exempted because they were rarely or never consumed. Also, most of the participants did not provide response to the foods under this section.

Additional information has been added to the food variety score under the materials and methods. It now reads:

Food variety score

The food variety score was calculated from 63 selected food items. The list of foods from alcoholic and non-alcoholic beverages (such as ‘pito’, palm wine and coffee), sweets and snacks were excluded from the calculation of the food variety scores. The list of foods exempted were rarely or never consumed. Food item consumed at least once a week was scored ‘1’ and ‘0’ for those not consumed at all. The scores were summed to obtain the food variety score. The food variety score (FVS) was ranked ‘high’ (≥26) or ‘low’ (≤25) based on the mean food variety scores.

Response: Thank you.

The weight factors and its assignment to food groups were adopted from the World Food Program document (The full paper or document can be found in reference 17 in the manuscript). It is an acceptable method adopted and used by other researchers.

3. Results –

Response: Thank you

The semicolon has been deleted.

In terms of low-income status and food security percentage, the reviewer is encouraged to kindly make time to read from table 1.

Additional information has been added, the sentence now reads:

A large proportion of participants in the food secure category had primary education (74.3%), guardian with formal education (78.6%), low-income status (75.7%) and did not skip meals (51.4%).

Response: Thank you

Additional information has been added to the results description of table 4 (paragraph 2). It reads:

4. Discussion –

Response: Thank you

The sentence is deleted from the paragraph two of the manuscript.

Response: Thank you

The referred or said sentence has been deleted from the manuscript.

5. Conclusion – this section should be re-written. It is just a repetition of the same information from the Results. The authors should in addition, provide the public health implication of the study here, the strengths and weaknesses or study limitations, etc.

Response: Thank you

The conclusion has been revised. It now reads:

Conclusion

The study showed that majority of adolescents had acceptable food consumption scores and high food variety scores. The income status of guardian had significant impact on the food variety score of adolescents. Factors such as gender, residency, frequency of meals per day and food variety score were significantly associated with food consumption scores. The predictors of food security based on the study outcome were adolescent males, peri-urban residency, three or more frequency of meals per day and high food variety score. Governments and non-governmental organization are encouraged to implement nutrition education programmes and interventions aimed at providing adolescents with adequate nutrition knowledge, and also empower guardians economically to increase their purchasing power as it will influence their wards to have access to variety of foods for consumption and possibly increase their food consumption scores. A well-nourished adolescent is a potential healthy adult. Nutrition specific and nutrition sensitive programmes aimed at promoting adolescent health should involve guardians.

Journal Requirement

Response: Thank you

Additional information has been added to the Ethics Section under the material and methods: it now reads

Ethics

6. Some grammatical errors sighted have been corrected.

Thank you in anticipation for a favourable response.

Yours faithfully,

Dr Michael A. Wiafe.

Attachment

Submitted filename: Response to Reviewers.docx

Click here for additional data file.^{(28.3KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0286477.r003

Decision Letter 1

Muhammad Khalid Bashir

3 Apr 2023

PONE-D-22-28451R1PREDICTORS OF FOOD VARIETY AND FOOD CONSUMPTION SCORES OF ADOLESCENTS LIVING IN A RURAL DISTRICT IN GHANAPLOS ONE

Dear Dr. Wiafe,

Both the reviewers have made some serious queries. While preparing the revision, please go over the comments and suggestions of reviewer 2 and incorporate the suggestions.

Please submit your revised manuscript by May 18 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Muhammad Khalid Bashir, PhD

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: (No Response)

Reviewer #2: No

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: (No Response)

Reviewer #2: No

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: (No Response)

Reviewer #2: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: (No Response)

Reviewer #2: No

**********

6. Review Comments to the Author

Reviewer #1: (No Response)

Reviewer #2: Thank you for providing an opportunity to review this paper. I read this manuscript with interest but found a number of issues with it. In my opinion, this work requires special attention from the authors before resubmission. Please find my suggestions and comments as follows, and I hope these will assist authors in improving the quality of the paper.

General comments

The current form of the manuscript has issues in all its sections, starting with the introduction and ending with the conclusion. Both the methodology and the section were poorly written. Discussion is merely repeating the results.

Specific comments

1. Mention the country name in the abstract (method) section of the manuscript.

2. Please don't use the same words as the study's keywords, which are already in the title of the paper.

3. Please describe the gap in the prior literature and the contribution that this study intends to make. Additionally, please include the contribution of this study in the literature.

4. I could not find the hypotheses of the study.

5. I could not find the details of the study beneficiaries in the manuscript.

6. Why did you select the Asante-Akim South municipality in the Ashanti Region of Ghana? Please talk about how important it is for Ghana's food security. Also discuss the other characteristics of the study area.

7. How did you estimate the total sample size (137)? Did you use any sampling formula to reach this sample size?

8. Explain the sampling section criteria in more detail.

9. I am wondering about the time period during which food related information was obtained.

10. Please explain your questionnaire in your revised manuscript.

11. How did you check the reliability of the data collection instrument?

12. Explain in full detail how food scores were calculated.

13. Please explain how you decided to use binary logistic regression. Put its formulas together and explain the explanatory and dependent variables.

14. The ethics section could be taken out of the manuscript and placed with other statements, according to the journal's rules.

15. A subheading "descriptive statistics" should be added immediately after "Results."

16. The interpretation of descriptive statistics needs extensive revision. Please revise it. Look for high-quality papers to help you with your writing.

17. The legend in Table 1 should be revised as it does not present an association.

18. Please present the results of binary logistic regression in a proper way. Get help from relaxant literature. What is the reason for selecting only four variables in the logistic model? The interpretation of the model results is not enough.

19. How did you estimate micronutrients? No information is provided about it in the methodology section, or I am missing something (Table 4).

20. I could see a number of limitations with the study. Why did the author not include it in the manuscript?

21. Most of the discussion is repeating the results. Please discuss the results by repeating them.

22. The table data presentation is totally absurd. Improve the table data presentation.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Dr. POMI SHAHBAZ

**********

PLoS One. 2023 May 31;18(5):e0286477. doi: 10.1371/journal.pone.0286477.r004

Author response to Decision Letter 1

7 Apr 2023

Manuscript ID: PONE-D-22-28451R1

Response to Reviewers

Dear Sir/Madam,

Thank you for giving us the opportunity to submit a revised draft of the manuscript titled, " PREDICTORS OF FOOD VARIETY AND FOOD CONSUMPTION SCORES OF ADOLESCENTS LIVING IN A RURAL DISTRICT IN GHANA" for publication in PLOS ONE. We appreciate the time and effort that you and the reviewers dedicated to providing feedback on our manuscript and are grateful for the insightful comments on and valuable improvements to our paper. We have incorporated some of the suggestions made by the reviewers and also provided some rebuttals on the comments. Those changes are highlighted within the revised manuscript. Please see below, for a point-by-point response to the reviewers’ comments and concerns.

Reviewer(s)' comments to the Authors:

Reviewer: 1

Comments to the Author

1.Mention the country name in the abstract (method) section of the manuscript.

Response: Thank you.

Additional information has been added introduction.

The country’s name has been mentioned in the abstract as suggested. It is highlighted in the manuscript

2.Please don't use the same words as the study's keywords, which are already in the title of the paper.

Response: Thank you

keywords are words provided to make the article easily discoverable and must also be related to the work. Among the keywords already provided, the authors want to know which of them are outside the domain of the article or the work?

The reviewer(s) can suggest alternative keywords and if they worth being used as keywords by the authors we will fix it/them in the manuscript.

3.Please describe the gap in the prior literature and the contribution that this study intends to make. Additionally, please include the contribution of this study in the literature.

Response: Thank you

The last paragraph of the introduction addresses the comments 3. There is paucity of knowledge about food variety and food consumption scores of adolescents in rural communities in Ghana. Additional information has also been added to the last paragraph of the introduction.

4.I could not find the hypotheses of the study.

Response: Thank you.

5.I could not find the details of the study beneficiaries in the manuscript.

Response: Thank you.

Information about the study beneficiaries are provided under the study design, area and participants of the materials and method section.

Response: Thank you

The reasons for the selection of the Municipality is based on the title (living in rural district) and dwellings of the percentage (83%) of the population.

The information under the study design, area and participants of the materials and methods section clearly explains the comment 6.

The reviewer(s) should kindly indicate the specific characteristics of the study area that need to be added .

7. How did you estimate the total sample size (137)? Did you use any sampling formula to reach this sample size?

Response: Thank you

The sample size used for this study was that calculated for an intervention study. The data used for this paper was collected as part of baseline data of an intervention study. For the calculation of the sample size, assess the published protocol via https://doi.org/10.1177/02601060221074433

8. Explain the sampling section criteria in more detail.

Response: Thank you

Additional information has been added to the sampling technique in the manuscript. It now reads:

A total of one hundred and thirty-seven (137) healthy adolescents aged 10-14 years were selected using a multi-stage sampling method from the municipality for this study.

9. I am wondering about the time period during which food related information was obtained.

Response: Thank you

Since this study is cross-sectional all information were collected once and at the same time.

10. Please explain your questionnaire in your revised manuscript.

Response: Thank you

The authors would want to know how the reviewer(s) want the questionnaire to be explained?

For instance:

1)how many times do you eat a day? 1. once 2. twice

2)Age: …………..

3)Sex: 1. male 2. female

4)Do you skip any meal? 1. Yes 2. No

11. How did you check the reliability of the data collection instrument?

Response: Thank you

A pilot study was conducted with the questionnaire before the actual data collection.

12. Explain in full detail how food scores were calculated.

Response: Thank you

Additional information has been added to the calculations of the food scores in the manuscript.

13. Please explain how you decided to use binary logistic regression. Put its formulas together and explain the explanatory and dependent variables.

Response: Thank you

Binary logistic regression is a regression model where the target variable is binary, that is, it can take only two values, (0 or 1) or (Yes or No). The analysis was not done manually hence provision of the formula may not be necessary. SPSS software was used in the data analysis.

The independent variables or predictors were sex, community, frequency of meals per day and food variety status. The dependent or outcome variable was food secure.

14. The ethics section could be taken out of the manuscript and placed with other statements, according to the journal's rules.

Response: Thank you for bringing it to our attention

15. A subheading "descriptive statistics" should be added immediately after "Results."

Response: Thank you

Recommendation has been implemented in the manuscript.

Other sub-headings have also been introduced in the results to maintain consistency.

16. The interpretation of descriptive statistics needs extensive revision. Please revise it. Look for high-quality papers to help you with your writing.

Response: Thank you

Some revisions have been made as requested in the descriptive statistics. The authors request the reviewer(s) to be kind to indicate any other specific revision.

17. The legend in Table 1 should be revised as it does not present an association.

Response: Thank you

The authors do not agree entirely. The chi-square test is a test of association.

A revision has been made in the heading for Table 1.

Response: Thank you

The position of the constant (1) has been changed in Table 3.

The authors wanted to know whether the same factors that produced significant relationship between food consumption score were also able to significantly predict food security. Hence the four variables.

19. How did you estimate micronutrients? No information is provided about it in the methodology section, or I am missing something (Table 4).

Response: Thank you bring this to our attention

Additional information has been added to the dietary intake under the materials and methods sections. It reads:

A 24-hour recall was used to collect three days (one weekend and two working days) dietary data. Participants were asked to tell us how many times (breakfast, mid-morning snack, lunch, mid-afternoon snack, dinner and bed-time snack) they eat a day and the detailed of the food consumed. Participants were shown food handy measures to estimate how much of the food consumed at each meal. Each food was converted to grams and the nutrients were estimated using the Nutrient Analysis Template developed by the University of Ghana. The averages for the nutrients were recorded.

20. I could see a number of limitations with the study. Why did the author not include it in the manuscript?

Response: Thank you

Currently, the few limitations identified were the ones written in the manuscript. The authors are open to further suggestions on limitations by the reviewer(s).

21. Most of the discussion is repeating the results. Please discuss the results by repeating them.

Response: Thank you

In discussion, it is expected that the main outcome(s) of the current study is stated and compared or contrast with other studies findings. Probably given reasons for the otherwise of contrary outcomes between the current and the previous or other(s) studies.

The authors did exactly the suggestion above in the manuscript, however the authors are ready to accept suggestion(s) from the reviewer(s) that will add value to the discussion.

Additional information has been added to the discussion and highlighted.

22. The table data presentation is totally absurd. Improve the table data presentation.

Response: Thank you

The reviewer(s) must be specific about the specific table(s) that is/are not well presented, and the authors will be ready to address it.

Some grammatical errors sighted have been corrected.

Thank you in anticipation for a favourable response.

Yours faithfully,

Michael A. Wiafe, PhD.

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PLoS One. doi: 10.1371/journal.pone.0286477.r005

Decision Letter 2

Muhammad Khalid Bashir

17 May 2023

Predictors of Food Variety and Food Consumption Scores of Adolescents Living in a Rural District in Ghana

PONE-D-22-28451R2

Dear Dr. Wiafe,

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Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #2: Partly

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

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Reviewer #2: No

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PLoS One. doi: 10.1371/journal.pone.0286477.r006

Acceptance letter

Muhammad Khalid Bashir

22 May 2023

PONE-D-22-28451R2

Predictors of Food Variety and Food Consumption Scores of Adolescents Living in a Rural District in Ghana

Dear Dr. Wiafe:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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Thank you for submitting your work to PLOS ONE and supporting open access.

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on behalf of

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Data Availability Statement

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PERMALINK

Predictors of food variety and food consumption scores of adolescents living in a rural district in Ghana

Michael Akenteng Wiafe

Jessica Ayensu

Georgina Benewaa Yeboah

Roles

Abstract

Introduction

Method

Results

Conclusion

Introduction

Materials and methods

Study design, area and participants

Data collection

Food practices

Dietary intake

Food variety score

Food consumption score

Statistical analysis

Results

Descriptive statistics

Table 1. Sociodemographic, food practices, food variety score and food consumption score of adolescents.

Results

Food variety score and food consumption score of participants

Table 2. Food variety score and food consumption score of participants.

Predictors of food security

Table 3. Binary logistics regression for predictors of food consumption status.

Partial correlation of food variety and food consumption scores and dietary micronutrient intake

Table 4. Partial correlation of food variety and food consumption scores and dietary micronutrient intake.

Discussion

Conclusion

Ethics

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Callam Davidson

Roles

Author response to Decision Letter 0

Decision Letter 1

Muhammad Khalid Bashir

Roles

Author response to Decision Letter 1

Decision Letter 2

Muhammad Khalid Bashir

Roles

Acceptance letter

Muhammad Khalid Bashir

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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