Adolescent-Selected Food Intake and Engagement with the External Food Environment Contribute to Unhealthy Diets in Accra, Ghana.

BACKGROUND: As adolescents gain autonomy, they interact more independently with their food environments, increasing their vulnerability to rapidly changing and often unhealthy food environments. In Accra, Ghana, unhealthy foods and beverages are widely available and heavily marketed. OBJECTIVES: This study aimed to assess the healthiness and nutrient adequacy of adolescents' diets in Accra and to examine whether diet healthiness is associated with independent adolescent food selection and their engagement with home, school, and outlet food environments. METHODS: We conducted a cross-sectional study using quantitative 24-h dietary recalls among 911 adolescents aged 12 to 18 y living in 5 low- and 5 middle-class neighborhoods in Accra. For each food and beverage consumed, we documented who selected it and where it was obtained and consumed. We calculated the global diet quality score (GDQS) and the prevalence of adequate intake for fruits and vegetables, protein, fiber, total sugar, total fat, saturated fat, and 11 micronutrients. Mixed-effects models assessed associations between independent adolescent food selection and food acquisition location (home, school, or other food outlets), and diet healthiness and macronutrient and micronutrient intake. RESULTS: A large proportion of adolescents consumed excessive amounts of total sugar (49%) and total fat (44%) and inadequate amounts of fruits and vegetables (98%), fiber (45%), and 8 of the 11 micronutrients assessed (39%‒100%). Greater adolescent-selected food intake (mean, 62% of energy intake) was associated with lower GDQS and intakes of fruit and vegetables, protein, fiber, and 6 micronutrients and with higher sugar intake (P < 0.05). Greater reliance on foods from the external food environment (school: 14%; other outlets: 46%) showed similar associations with poorer dietary indicators. CONCLUSIONS: Strengthening the design, implementation, and enforcement of coordinated food policy bundles is needed to shift adolescents' preferences toward healthy foods and reduce the availability, accessibility, and appeal of unhealthy options in their food environments.