Undernutrition and overnutrition, which are used to represent instances where individuals do not get enough or exceed the nutrients requirements respectively, are both considered to be of significant global public health importance [1, 2]. The United Nations Food and Agriculture Organization (FAO) estimated that in 2014-2016, more than 790 million persons or one in nine individuals across the world were suffering from chronic undernourishment [3]. On the other hand, almost 2 billion individuals were estimated to be overweight including 600 million who were obese in 2014 [4]. The 2013 Global Burden of Disease study demonstrated that between 1980 and 2013, the prevalence of overweight and obesity increased across all parts of the world (both developing and developed countries) and reported that no national success in halting the rising trend has been reported over the last three decades [5].

While overnutrition (as depicted by overweight and obesity) is known to be a positive predictor for the occurrence of major non-communicable diseases (NCDs) including hypertension, diabetes, cardiovascular diseases, musculoskeletal disorders and some cancers [6-8], undernourished individuals are also often unable to maintain natural bodily functions, are at greater risk of infections and demonstrate learning and physical work difficulties [9]. Malnutrition has been estimated to cost the global economy as much as $ 3.5 trillion per year including $2.1 trillion from undernutrition and micronutrient deficiencies and $1.4 trillion from obesity and overweight related-NCDs [10] .

In epidemiology, anthropometric measurements have been considered to be efficient and reliable for assessing nutritional status of individuals [11]. Although, there are varied methods for assessing overweight and obesity in adults, the body mass index (BMI) remains the most frequently used [4]. Individuals have been categorized according to BMI as follows; underweight (BMI <18.5 kg/m²); normal (18.5-24.9 kg/m²); overweight (25.0-29.9 kg/m²) and obese (≥30 kg/m²) [4, 12].

In Sub-Saharan Africa (SSA), undernutrition has been documented for decades, although, recent trends indicate significant nutrition transition resulting in overnutrition [13-15]. Dietary patterns have been evolving across many parts of the continent including decline in consumption of plant-based protein sources such as legumes and an increasing consumption of high-fat and energy dense foods [16, 17].

In Ghana, dietary patterns have been changing along with an epidemiological transition that is resulting in a high burden of NCDs [18, 19]. Obesity and overweight are now considered the major issues of public health importance in this country. The WHO estimates that in 2008, around 7.5% of Ghanaians were obese with higher prevalence in women (10.9%) than men (4.1%) [20]. A major meta-analysis recently estimated that nearly 43% of Ghanaians are overweight or obese, further demonstrating a rising prevalence [21]. Yet, research indicates that undernutrition may still pose significant risk to many Ghanaians. A recent report indicates that Ghana lost over $2billion (almost 6% of GDP) in 2012 as a result undernutrition with the highest element in the cost attributed to potential productivity losses due to undernutrition-related mortalities [22].

The temporal changes in anthropometric profile of Ghanaian adults have not been thoroughly researched. While Dake [23], has previously explored the possible future changes in obesity prevalence among Ghanaian women, the consequent changes in undernutrition patterns has not been analyzed. We believe that simultaneous assessments of undernourishment and overnutrition individuals are important to guide policy decisions as government, health professionals and policy makers take steps to ration scarce resources and invest in areas that are likely to yield greater public health impacts. As such, this study seeks to summarize BMI, underweight and obesity patterns in child bearing Ghanaian women (15-49 years) from 1993 to 2014 and to make projections for the years 2020, 2025 and 2030.

The findings of this study reveal a declining prevalence of underweight among Ghanaian women. This is consistent with trends across SSA as prevalence of undernourishment in the region has been estimated to have declined from 33.2% in 1990-92 to 23.2% in 2014-16 [3]. The decline in underweight prevalence in Ghana is a positive development and may highlight the success of the many years of hunger/undernourishment prevention interventions in the country which should give impetus for future directions. The reduction in undernourishment may have positive impacts on women’s health as the risk of infections, osteoporosis, menstrual irregularities, pregnancy complications, and reduced physical activity could all be reduced [9].

On the other hand, the mean BMI and obesity rates among Ghanaian women have increased, and if the observed trends persist then further increases are expected in the future. The increasing obesity is consistent with trends reported across many parts of Africa and globally [5]. The high rates of obesity seen in Ghanaian women is consistent with global trends which indicate obesity to be more prevalent in women [5]. A recent meta-analysis by Ofori-Asenso et al. reported a 1.3 times higher prevalence of overweight and about 3.7 times higher prevalence of obesity in Ghanaian women as compared to men [21]. The gender differences in obesity prevalence in Ghana have been attributed to a myriad of factors including occupational patterns (e.g. many women tend to settle for less physically demanding jobs. e.g., table-top trading) [34], social-cultural construction (women may perceive larger body size as a sign of beauty, happiness in marriage etc., while men may see it as a sign of affluence), appreciation of body size [34-36] and physical activity levels (which are often lower in Ghanaian women than men) [37].

The rising prevalence of obesity could be attributed to megatrends such as globalization along with rapid economic development and urbanization which are contributing to significant shifts in lifestyle across Ghana [18, 38]. Over the last few decades, Ghanaians have witnessed increased accessibility to telecommunication tools including internet, telephone and other communication channels. These have facilitated exposure to western lifestyle and cross-country marketing that promote products such as fatty-rich foods, alcoholic beverages and cigarette [38]. Before independence (late 50s) the Ghanaian diet had low fat content (most of which were plant based) as high-fat rich foods were deemed more expensive compared to high carbohydrate staples. In recent years, this has changed due to increased availability and access to fat-rich products as a result of widespread importation and marketing and this has increased consumption. Ghana still remains a net importer of food and agricultural products spending more than $1.2billion on food importation in 2012 [39]. The country’s dependence on importation is often traced to the lack of subsidies to local farmers and the interventions of institutions like the World Bank and IMF that encouraged governments in poor countries like Ghana in the period 1980-2000 to prioritize cash crop (e.g. cocoa) production in an effort to drive export oriented economic growth [18].

Improved economic environment in recent years also means that many Ghanaians now own cars and walk less. Studies have pointed out that “the nutrition transition and the rise in technology-aided, sedentary lifestyles (cars, computers at home and in internet cafes, games consoles for elite and middle class youth) are strongly implicated in Ghana’s obesity and chronic disease epidemics” [40]. Additionally, as Ofori-Asenso and Garcia [38] discussed, the built environment in many urban centres in Ghana has not evolved to meet the expanding population; roads are usually congested and there are not many sidewalks or parks that could encourage physical activities like running and walking. These poor urban planning if not properly addressed could be a catalyst for further escalation of obesity in the country even as other factors drive an obesogenic environment.

The health, social and economic consequences of a rising obesity prevalence could be far-reaching. Already, NCDs like hypertension have assumed greater prevalence among Ghanaians. In a systematic review, the prevalence of hypertension among Ghanaians was estimated to range from 19.3% in rural areas to 54.6% in urban centres with factors such as increased salt intake and raised BMI singled out as major contributors to the rise in prevalence [41]. The prevalence of type 2 diabetes, another condition in which obesity is known to significantly increase risk [42], has increased by about 15 times from 0.4% in 1956 to 6% in 2014 [19]. The impacts of all these changes on productivity losses when estimated could be enormous.

In terms of current and future outlook, our results indicate that obesity has now outstripped undernourishment in terms of public health significance. Yet in Ghana, government’s efforts have continually targeted at reducing hunger and often neglect the growing rate of obesity in the country. This has been compounded by the longstanding misconception that NCDs and risk factors like obesity do not pose significant health challenges [43]. Greater attention and emphasis will be needed from all stakeholders within the country to address the rising obesity prevalence. While more resources should be channelled into this area, issues of rationing are likely to emerge. The approach adopted should not in any way undermine undernutrition prevention efforts, as preventing undernourishment is still a good investment for this country. The perspective proposed is therefore to holistically address undernutrition and overnutrition in a broader “health for all” approach.

Among Ghanaian women, obesity has outstripped undernourishment in terms of public health relevance. The rising obesity will require stronger efforts from government, health care professionals and all stakeholders to institute appropriate policies as well as identify innovative interventions that fit into the Ghanaian health system, which are cost-effective, culturally acceptable and financially sustainable. While the results presented should inform future healthcare planning and resource allocation, this should in no way lead to neglect hunger prevention. Rather, a broader perspective that seeks to address all forms of malnutrition (both undernutrition and overnutrition individuals) within a “health of all” approach should be rigorously pursued.