Systematic review on evidence-based adolescent nutrition interventions

Exploring preconception health in adolescents and young adults: Identifying risk factors and interventions to prevent adverse maternal, perinatal, and child health outcomes-A scoping review

BACKGROUND

Preconception health provides an opportunity to examine a woman's health status and address modifiable risk factors that can impact both a woman's and her child's health once pregnant. In this review, we aimed to investigate the preconception risk factors and interventions of early pregnancy and its impact on adverse maternal, perinatal and child health outcomes.

METHODS

We conducted a scoping review following the PRISMA-ScR guidelines to include relevant literature identified from electronic databases. We included reviews that studied preconception risk factors and interventions among adolescents and young adults, and their impact on maternal, perinatal, and child health outcomes. All identified studies were screened for eligibility, followed by data extraction, and descriptive and thematic analysis.

FINDINGS

We identified a total of 10 reviews. The findings suggest an increase in odds of maternal anaemia and maternal deaths among young mothers (up to 17 years) and low birth weight (LBW), preterm birth, stillbirths, and neonatal and perinatal mortality among babies born to mothers up to 17 years compared to those aged 19-25 years in high-income countries. It also suggested an increase in the odds of congenital anomalies among children born to mothers aged 20-24 years. Furthermore, cancer treatment during childhood or young adulthood was associated with an increased risk of preterm birth, LBW, and stillbirths. Interventions such as youth-friendly family planning services showed a significant decrease in abortion rates. Micronutrient supplementation contributed to reducing anaemia among adolescent mothers; however, human papillomavirus (HPV) and herpes simplex virus (HSV) vaccination had little to no impact on stillbirths, ectopic pregnancies, and congenital anomalies. However, one review reported an increased risk of miscarriages among young adults associated with these vaccinations.

CONCLUSION

The scoping review identified a scarcity of evidence on preconception risk factors and interventions among adolescents and young adults. This underscores the crucial need for additional research on the subject.

Community-based interventions targeting multiple forms of malnutrition among adolescents in low-income and middle-income countries: protocol for a scoping review

BACKGROUND

Adolescent malnutrition is a significant public health challenge in low-income and middle-income countries (LMICs), with long-term consequences for health and development. Community-based interventions have the potential to address multiple forms of malnutrition and improve the health outcomes of adolescents. However, there is a limited understanding of the content, implementation and effectiveness of these interventions. This scoping review aims to synthesise evidence on community-based interventions targeting multiple forms of malnutrition among adolescents in LMICs and describe their effects on nutrition and health.

METHODS AND ANALYSIS

A comprehensive search strategy will be implemented in multiple databases including MEDLINE (through PubMed), Embase, CENTRAL (through Cochrane Library) and grey literature, covering the period from 1 January 2000 to 14 July 2023. We will follow the Participants, Concept and Context model to design the search strategy. The inclusion criteria encompass randomised controlled trials and quasi-experimental studies focusing on adolescents aged 10-19 years. Various types of interventions, such as micronutrient supplementation, nutrition education, feeding interventions, physical activity and community environment interventions, will be considered. Two reviewers will perform data extraction independently, and, where relevant, risk of bias assessment will be conducted using standard Cochrane risk-of-bias tools. We will follow the PRISMA Extension for Scoping Reviews checklist while reporting results.

ETHICS AND DISSEMINATION

The scope of this scoping review is restricted to publicly accessible databases that do not require prior ethical approval for access. The findings of this review will be shared through publications in peer-reviewed journals, and presentations at international and regional conferences and stakeholder meetings in LMICs.

SCOPING REVIEW REGISTRATION

The final protocol was registered prospectively with the Open Science Framework on 19 July 2023 (https://osf.io/t2d78).

What causes obesity in children and adolescents?

OBJECTIVE

To present the different aspects that may be involved in the genesis and maintenance of obesity in children and adolescents.

DATA SOURCE

Narrative review of articles published in the PubMed, Scielo, Lilacs, Scopus and Google Scholar databases, using the search terms: overweight, obesity, pre-conception, prenatal, infants, schoolchildren, children, and adolescents. The search was conducted in studies written in Portuguese, English and Spanish, including narrative, integrative or systematic reviews, meta-analyses, cross-sectional, case-control and cohort studies, published between 2003 and 2023.

DATA SYNTHESIS

A total of 598 studies were initially screened and 60 of them, which showed the main biopsychosocial aspects related to greater risks of excessive adiposity in the pediatric age, were included in the review. The data were presented taking into account the incidence of risk factors and their consequences in six periods: pre-conception, pre-natal, infant, preschool, school age, and adolescence.

CONCLUSIONS

The causal factors described in the scientific literature that have been shown to be related to obesity in childhood and adolescence are presented.

Determinants of Diet Quality in Adolescents: Results from the Prospective Population-Based EVA-Tyrol and EVA4YOU Cohorts

(1) Background: Unhealthy dietary behaviors are estimated to be one of the leading causes of death globally and are often shaped at a young age. Here, we investigated adolescent diet quality and its predictors, including nutrition knowledge, in two large Central European cohorts. (2) Methods: In 3056 participants of the EVA-Tyrol and EVA4YOU prospective population-based cohort studies aged 14 to 19 years, diet quality was assessed using the AHEI-2010 and DASH scores, and nutrition knowledge was assessed using the questionnaire from Turconi et al. Associations were examined utilizing multivariable linear regression. (3) Results: The mean overall AHEI-2010 score was 42%, and the DASH score was 45%. Female participants (60.6%) had a significantly higher diet quality according to the AHEI-2010 and DASH score. AHEI-2010 and DASH scores were significantly associated (p < 0.001) with sex, school type, smoking, and total daily energy intake. The DASH score was additionally significantly associated (p < 0.001) with age, socioeconomic status, and physical activity. Participants with better nutrition knowledge were more likely to be older, to attend a general high school, to live in a high-income household, to be non-smokers, and to have a higher diet quality according to the AHEI-2010 and DASH score. (4) Conclusions: Predictors of better diet quality included female sex, physical activity, educational level, and nutrition knowledge. These results may aid focused interventions to improve diet quality in adolescents.

School-based supplementation with iron-folic acid or multiple micronutrient tablets to address anemia among adolescents in Burkina Faso: a cluster-randomized trial

BACKGROUND

Iron-deficiency anemia is a leading cause of morbidity among adolescents (aged 10-19 y), especially in low- and middle-income settings. Few policies and programs have targeted adolescent health.

OBJECTIVES

This study aimed to evaluate the effectiveness of school-based supplementation with iron-folic acid (IFA) or multiple micronutrient supplements (MMSs) in addressing anemia among adolescents in Burkina Faso.

METHODS

In this cluster-randomized trial, 3123 secondary school students aged 10 to 18 y in Burkina Faso were either supplemented with weekly IFA, daily MMSs, or received standard nutrition education as controls. Supplementation occurred between April 2021 and April 2022 over 2 supplementation periods (10 wk, then 16 wk) separated by a gap of 20 wk without supplementation. Hemoglobin was evaluated 4 times: at baseline prior to each supplementation period and at the end of each period. Anemia was categorized by the World Health Organization hemoglobin level cutoffs as none, mild, moderate, or severe. Associations between treatment arm and anemia or continuous hemoglobin (g/dL) were assessed using multilevel mixed effects generalized linear models with schools as a random effect, controlling for baseline hemoglobin or anemia status.

RESULTS

Baseline anemia prevalence was similar across study arms, with 32.7% in IFA, 31.2% in MMS, and 29.5% in the control arm. Over the full study period, adolescents provided IFA had hemoglobin levels higher than those in the control arm (adjusted β: 0.32; 95% CI: 0.02, 0.62). No significant associations were observed for MMS or for anemia outcomes; however, the direction and magnitude of nonsignificant associations indicate potential protective effects of IFA and MMSs on anemia.

CONCLUSIONS

The results do not provide strong evidence that weekly IFA or daily MMS alone is effective, but supplementation may play a role in addressing adolescent anemia if combined with cointerventions. Additional research is required to determine the best strategy to address anemia. This trial was registered at clinicaltrials.gov as NCT04657640.

Feasibility and impact of school-based nutrition education interventions on the diets of adolescent girls in Ethiopia: a non-masked, cluster-randomised, controlled trial

BACKGROUND

Adolescence is a critical period of physical and psychological development, especially for girls, because poor nutrition can affect their wellbeing as well as that of their children. We aimed to assess the feasibility and impact of a package of nutrition education interventions delivered through public primary schools on the diets of adolescent girls in Ethiopia.

METHODS

In this non-masked, cluster-randomised, controlled trial, primary schools (clusters) in the Southern Nations, Nationalities, and People's Region and Somali region of Ethiopia were randomly allocated to the intervention group (nutrition information provided during flag ceremonies, classroom lessons, school club meetings, peer group mentoring, BMI measurement and counselling, and parent-teacher meetings) or the control group (standard academic curriculum on health and nutrition) by use of computer-generated pseudo-random numbers. Duration of the school-based interventions was 4 months, and the key messages were related to dietary diversity (eating a variety of foods), energy adequacy (eating breakfast and healthy snacks), and healthy food choices (avoiding junk foods). Adolescent girls were eligible for participation if aged 10-14 years and enrolled in grades 4-8 in a study school. Data were collected with two independent cross-sectional surveys: baseline before the start of implementation and endline 1·5 years later. The primary outcome of impact was dietary diversity score, defined as the number of food groups (out of ten) consumed over the previous 24 h using a list-based method, and minimum dietary diversity, defined as the proportion of girls who consumed foods from at least five of the ten food groups, in the intention-to-treat population. We also assessed intervention exposure as a measure of feasibility. We estimated intervention effects using linear regression models for mean differences at endline, with SEs clustered at the school level, and controlled for adolescent age, region, household food security, and wealth. The trial is registered with ClinicalTrials.Gov, NCT04121559, and is complete.

FINDINGS

27 primary schools were randomly allocated to the intervention group and 27 to the control group. Between March 22 and April 29, 2021, 536 adolescent girls participated in the endline survey (270 in the intervention group and 266 in the control group), with median age of 13·3 years (IQR 12·1-14·0). At endline, the dietary diversity score was 5·37 (SD 1·66) food groups in the intervention group and 3·98 (1·43) food groups in the control group (adjusted mean difference 1·33, 95% CI 0·90-1·75, p<0·0001). Increased minimum dietary diversity was also associated with the intervention (182 [67%] of 270 in the intervention group vs 76 [29%] of 266 in the control group; adjusted odds ratio 5·37 [95% CI 3·04-9·50], p<0·0001). 256 (95%) of 270 adolescent girls in the intervention group were exposed to at least one of the five in-school intervention components.

INTERPRETATION

Integrating nutrition interventions into primary schools in Ethiopia was feasible and increased dietary diversity incrementally among adolescent girls, but could be limited in changing other food choice behaviours, such as junk food consumption, based on nutrition education alone.

FUNDING

Bill & Melinda Gates Foundation.

Influence of engaging female caregivers in households with adolescent girls on adopting equitable family eating practices: a quasi-experimental study

Background

In patriarchal societies, female caregivers decide on food allocation within a family based on prevailing gender and age norms, which may lead to inequality that does not favor young adolescent girls. This study evaluated the effect of a community-based social norm intervention involving female caregivers in West Hararghe, Ethiopia. The intervention was engaging female caregivers along with other adult influential community members to deliberate and act on food allocation social norms in a process referred to as Social Analysis and Action (SAA).

Method

We used data from a large quasi-experimental study to compare family eating practices between those who participated in the Social Analyses and Action intervention and those who did not. The respondents were female caregivers in households with young adolescent girls (ages 13 and 14 years). The study's outcome was the practice of family eating together from the same dish. The difference in difference (DID) analysis with the mixed effect logistic regression model was used to examine the effect of the intervention.

Result

The results showed improved family eating practices in both groups, but the improvement was greater in the intervention group. The DID analysis showed an 11.99 percentage points greater improvement in the intervention arm than in the control arm. The mixed-effect regression produced an adjusted odds ratio of 2.08 (95% CI [1.06-4.09]) after controlling selected covariates, p-value 0.033.

Conclusions

The involvement of influential adult community members significantly improves the family practice of eating together in households where adolescent girls are present in our study. The intervention has great potential to minimize household food allocation inequalities and thus improve the nutritional status of young adolescents. Further studies are necessary to evaluate the effectiveness of the intervention in different social norm contexts to formulate policy and guidelines for scale-up.

Behaviour change interventions improve maternal and child nutrition in sub-Saharan Africa: A systematic review

Evidence that nutrition-specific and nutrition-sensitive interventions can improve maternal and child nutrition status in sub-Saharan Africa is inconclusive. Using behaviour change theory and techniques in intervention design may increase effectiveness and make outcomes more predictable. This systematic review aimed to determine whether interventions that included behaviour change functions were effective. Six databases were searched systematically, using MeSH and free-text terms, for articles describing nutrition-specific and nutrition-sensitive behaviour change interventions published in English until January 2022. Titles, abstracts and full-text papers were double-screened. Data extraction and quality assessments followed Centre for Reviews and Dissemination guidelines. Behaviour change functions of interventions were mapped onto the COM-B model and Behaviour Change Wheel. PROSPERO registered (135054). The search yielded 1193 articles: 79 articles met inclusion criteria, ranging from low (n = 30) to high (n = 11) risk of bias. Many that applied behaviour change theory, communication or counselling resulted in significant improvements in infant stunting and wasting, household dietary intake and maternal psychosocial measures. Interventions with >2 behaviour change functions (including persuasion, incentivisation, environmental restructuring) were the most effective. We recommend incorporating behaviour change functions in nutrition interventions to improve maternal and child outcomes, specifically drawing on the Behaviour Change Wheel, COM-B model (SORT B recommendation). To enhance the designs of these interventions, and ultimately improve the nutritional and psychosocial outcomes for mothers and infants in sub-Saharan Africa, collaborations are recommended between behaviour change and nutrition experts, intervention designers, policy makers and commissioners to fund and roll-out multicomponent behaviour change interventions.

Scaling-up high-impact micronutrient supplementation interventions to improve adolescents' nutrition and health in Burkina Faso and Tanzania: protocol for a cluster-randomised controlled trial

INTRODUCTION

Adolescence is a critical time for growth and development, but this age group is often neglected in research and development of nutrition interventions. Despite recommendations from the WHO to provide nutrient supplements to adolescents, evidence remains scarce on the most effective supplementation strategy. This study aims to compare weekly iron and folic acid (IFA) supplementation with daily multiple micronutrient supplements (MMSs) in prevention of anaemia and improvement of school outcomes among adolescents in Burkina Faso and Tanzania.

METHODS AND ANALYSIS

A three-arm cluster-randomised, school-based supplementation trial will be conducted among 84 schools (42 schools per site) and roughly 4500 students aged 10-17. Schools will be matched on three characteristics: number of students, school ranking profile, distance to main road (Tanzania) or distance to city council (Burkina Faso). Each school will be randomised to receive either weekly IFA, daily MMSs or serve as a control. Supplements will be delivered to students by teachers, who will provide monitoring data to the study team. Baseline and endline surveys will be conducted prior to and after each supplementation cycle (12 weeks in Burkina Faso; 1 year in Tanzania) to assess haemoglobin, anthropometry and sociodemographic variables. The primary outcome of haemoglobin will be analysed continuously using linear regression, and anaemia status will be analysed using logistic or multinomial regression, depending on categorisation level of the outcome. Secondary analyses of school performance indicators will also be conducted with either logistic or linear regression.

ETHICS AND DISSEMINATION

This protocol has been approved by the Institutional Review Board of the Harvard TH Chan School of Public Health (IRB20-1108) and the Research Ethics Committees for the Ministries of Health in Tanzania (Zanzibar) and Burkina Faso. Results will be disseminated during meetings with the Ministries of Health and the participating communities as well as through peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT04657640; NCT05104554.

S. A, Mathew JL, Kar S, Nair S, Rao CR, Pande H, Mahanta BN, Bharti B, Singh CM, Singh K, Bhat MA, A. R. S, Awasthi R, Mahdi AA. Micronutrients and cognitive functions among urban school-going children and adolescents: A cross-sectional multicentric study from India

BACKGROUND

Micronutrient deficiency (MD) is associated with deficits in cognitive functioning of children. However, no comprehensive multicentric study has been conducted in India to explore the role of multiple MD in cognition of children and adolescents. The present study aimed to explore association of MD with level of general intelligence and specific cognitive functions, in urban school-going children and adolescents across ten cities of India.

METHOD

Cross-sectional multicentric study, enrolled participants aged 6-16 years. Blood samples were collected for biochemical analysis of calcium, iron, zinc, selenium, folate, vitamin A, D and B12. Colored Progressive Matrices / Standard Progressive Matrices (CPM/SPM), Coding, Digit Span and Arithmetic tests were used for the assessment of cognitive functions of participants. Height and weight measures were collected along with socio-economic status.

RESULTS

From April-2019 to February-2020, 2428 participants were recruited from 60 schools. No MD was found in 7.0% (134/1918), any one MD in 23.8% (457/1918) and ≥ 2 MD in 69.2% (1327/1918) participants. In presence of ≥ 2 MD, adjusted odds ratio (OR) for borderline or dull normal in CPM/SPM was 1.63, (95% CI: 1.05-2.52), coding was 1.66 (95% CI: 1.02-2.71), digit span was 1.55 (95% CI: 1.06-2.25) and arithmetic was 1.72 (95% CI: 1.17-2.53), controlling for gender, socioeconomic status and anthropometric indicators.

CONCLUSION

Since ≥ 2 MD were found in more than 2/3rd of participants and was associated with impairment in cognitive function, attempts must be made to ameliorate them on priority in school going children in India.

TRIAL REGISTRATION NUMBER

CTRI/2019/02/017783.

The Mediating Effects of Food Content Watching Motivation on the between Watching Time and Nutrition Quotient of Adolescents in Seoul, Korea

Food-related content varies widely and is increasingly popular. Using various media, teenagers can easily access food content, which could affect they eating habits. This study was conducted to confirm the effects of watching motivation on the relationship between food content watching time and eating habits among adolescents in Seoul, Korea. Exactly 806 participants were surveyed about their food content watching status, including watching time and watching motivation. The Nutrition Quotient for adolescents (NQ-A) questionnaire was used to confirm eating habits. Exploratory factor analysis was conducted to classify watching motivation’s subfactors. A parallel multimedia model was used to analyze the effect of watching motivation on the relationship between food content watching time and eating habits. As a result of this study, following the factor analysis, watching motivation was classified into information acquisition, emotional satisfaction, and enjoyment. The influence of food content watching time on NQ-A scores through information acquisition motivation was positively significant, whereas that through emotional satisfaction motivation was negatively significant. Enjoyment motivation did not indirectly affect the relationship between food content watching time and NQ-A scores. Hence, attention should be paid to these mediating factors when analyzing the relationship between watching food-related content and eating habits. Developing and distributing content that meets viewing motivations should help improve adolescents’ eating habits.

Changes in retail food environments around schools over 12 years and associations with overweight and obesity among children and adolescents in Flanders, Belgium

BACKGROUND

Children are susceptible to the food environment. This research assessed changes in retail food environments near schools in Flanders between 2008 and 2020 and associations with children's and adolescents' weight status.

METHODS

The food environment within a 500 m and 1000 m road network distance to all primary and secondary schools was mapped using spatial indicators. The commercial Locatus database, including addresses of all food retailers in Flanders, was used to calculate the density of different types of food retailers near the school perimeter, the percentage of schools with at least one food retailer of a certain type near the school perimeter and the shortest distance from the school entrance to the nearest food retailer of a certain type. A generalized linear model was used to explore associations between these indicators and the percentage of children and adolescents with overweight at the school level.

RESULTS

Food environments near schools in Flanders were found to be unhealthy in 2020, with a significant increase in fast food restaurants and convenience stores between 2008 and 2020. The density of fast food restaurants within a 1000 m walking distance from primary and secondary schools increased from 5.3 ±0.3 to 6.3 ±0.4 and from 10.2 ±0.7 to 12.7 ±0.9 respectively between 2008 and 2020, while the density of convenience stores increased from 3.2 ±0.3 to 3.8 ±0.4 and from 6.2 ±0.6 to 7.6 ±0.8 respectively. Food environments near schools with a higher proportion of children from a poor socio-economic background were found unhealthier, regardless of the urbanization level. A significant positive association was found between the density of fast food restaurants as well as the density of convenience stores around primary schools and the percentage of children aged < 6 years and 6-12 years with overweight. A positive, not significant association was found between the density of fast food restaurants as well as the density of convenience stores around secondary schools and the percentage of adolescents, aged 13-14 and 15-18 years with overweight.

CONCLUSION

Food environments around schools in Flanders became unhealthier over time and were associated with children's weight status.

Preconception and periconception interventions to prevent low birth weight, small for gestational age and preterm birth: a systematic review and meta-analysis

Background

Low birth weight (LBW), including preterm birth (PTB) and small for gestational age (SGA), contributes a significant global health burden. We aimed to summarise current evidence on the effect of preconception and periconception interventions on LBW, SGA and PTB.

Methods

In this systematic review and meta-analysis, we searched PubMed, Embase, Cochrane Library and WHO Global Index Medicus for randomised controlled trials and quasi-experimental studies published by 28 November 2020, which assessed interventions delivered in preconception and periconception or preconception and pregnancy. Primary outcomes were LBW, SGA and PTB. Studies were categorised by intervention type and delivery during preconception and periconception or during preconception and pregnancy. Estimates were pooled using fixed-effects or random-effects restricted maximum likelihood method meta-analyses. Quality of evidence for primary outcomes was assessed using the Grades of Recommendations, Assessment, Development and Evaluation approach.

Results

We included 58 studies. Twenty-eight studies examined nutrition interventions (primarily micronutrient or food supplementation). Thirty studies (including one reporting a nutrition intervention) provided health interventions (general preconception health, early adverse pregnancy outcome prevention, non-communicable disease and infectious disease prevention and management). One study assessed a social intervention (reproductive planning). Studies varied in terms of specific interventions, including delivery across preconception or pregnancy, resulting in few studies for any single comparison. Overall, the evidence was generally very uncertain regarding the impact of any intervention on LBW, SGA and PTB. Additionally, preconception and periconception nutritional supplementation containing folic acid was associated with reduced risk of birth defects (10 studies, N=3 13 312, risk ratio: 0.37 (95% CI: 0.24 to 0.55), I²: 74.33%).

Conclusion

We found a paucity of evidence regarding the impact of preconception and periconception interventions on LBW, SGA and PTB. Further research on a wider range of interventions is required to clearly ascertain their potential effectiveness.

Trial registration number

This review was prospectively registered with PROSPERO (CRD42020220915).

Women's health: optimal nutrition throughout the lifecycle

Sex differences are an important consideration when researching and establishing policies for nutrition and optimal health. For women's health, there are important physiologic, neurologic, and hormonal distinctions throughout the lifecycle that impact nutritional needs. Distinct from those for men, these nutritional needs must be translated into appropriate nutrition policy that aims to not only avoid overt nutritional deficiency, but also to promote health and minimize risk for chronic disease. Through a series of webinars, scientific experts discussed the advances in the understanding of the unique nutritional needs, challenges and opportunities of the various life stages for women across the life course and identified emerging nutritional interventions that may be beneficial for women. Nevertheless, there is concern that existing nutrition policy intended for women's health is falling short with examples of programs that are focused more on delivering calories than achieving optimal nutrition. To be locally effective, targeted nutrition needs to offer different proposals for different cultural, socio-economic, and geographic communities, and needs to be applicable at all stages of growth and development. There must be adequate access to nutritious foods, and the information to understand and implement proven nutritional opportunities. Experts provided recommendations for improvement of current entitlement programs that will address accessibility and other social and environmental issues to support women properly throughout the lifecycle.

What can work and how? An overview of evidence-based interventions and delivery strategies to support health and human development from before conception to 20 years

Progress has been made globally in improving the coverage of key maternal, newborn, and early childhood interventions in low-income and middle-income countries, which has contributed to a decrease in child mortality and morbidity. However, inequities remain, and many children and adolescents are still not covered by life-saving and nurturing care interventions, despite their relatively low costs and high cost-effectiveness. This Series paper builds on a large body of work from the past two decades on evidence-based interventions and packages of care for survival, strategies for delivery, and platforms to reach the most vulnerable. We review the current evidence base on the effectiveness of a variety of essential and emerging interventions that can be delivered from before conception until age 20 years to help children and adolescents not only survive into adulthood, but also to grow and develop optimally, support their wellbeing, and help them reach their full developmental potential. Although scaling up evidence-based interventions in children younger than 5 years might have the greatest effect on reducing child mortality rates, we highlight interventions and evidence gaps for school-age children (5-9 years) and the transition from childhood to adolescence (10-19 years), including interventions to support mental health and positive development, and address unintentional injuries, neglected tropical diseases, and non-communicable diseases.

The importance of nutrition in pregnancy and lactation: lifelong consequences

Most women in the United States do not meet the recommendations for healthful nutrition and weight before and during pregnancy. Women and providers often ask what a healthy diet for a pregnant woman should look like. The message should be “eat better, not more.” This can be achieved by basing diet on a variety of nutrient-dense, whole foods, including fruits, vegetables, legumes, whole grains, healthy fats with omega-3 fatty acids that include nuts and seeds, and fish, in place of poorer quality highly processed foods. Such a diet embodies nutritional density and is less likely to be accompanied by excessive energy intake than the standard American diet consisting of increased intakes of processed foods, fatty red meat, and sweetened foods and beverages. Women who report “prudent” or “health-conscious” eating patterns before and/or during pregnancy may have fewer pregnancy complications and adverse child health outcomes. Comprehensive nutritional supplementation (multiple micronutrients plus balanced protein energy) among women with inadequate nutrition has been associated with improved birth outcomes, including decreased rates of low birthweight. A diet that severely restricts any macronutrient class should be avoided, specifically the ketogenic diet that lacks carbohydrates, the Paleo diet because of dairy restriction, and any diet characterized by excess saturated fats. User-friendly tools to facilitate a quick evaluation of dietary patterns with clear guidance on how to address dietary inadequacies and embedded support from trained healthcare providers are urgently needed.

Recent evidence has shown that although excessive gestational weight gain predicts adverse perinatal outcomes among women with normal weight, the degree of prepregnancy obesity predicts adverse perinatal outcomes to a greater degree than gestational weight gain among women with obesity. Furthermore, low body mass index and insufficient gestational weight gain are associated with poor perinatal outcomes. Observational data have shown that first-trimester gain is the strongest predictor of adverse outcomes. Interventions beginning in early pregnancy or preconception are needed to prevent downstream complications for mothers and their children. For neonates, human milk provides personalized nutrition and is associated with short- and long-term health benefits for infants and mothers. Eating a healthy diet is a way for lactating mothers to support optimal health for themselves and their infants.

Evidence-Based Nutrition Interventions Improved Adolescents' Knowledge and Behaviors in Indonesia

Adolescence is a nutritionally vulnerable and critical life stage. However, few programs and policies focus on improving adolescent nutrition in Indonesia. To address this gap, we implemented a gender-responsive package of interventions: (1) breakfast and weekly iron-folic acid supplementation (WIFS), (2) a school-based nutrition education program, and (3) a social behavior change communication strategy. We surveyed 514 adolescents at baseline (2019) and endline (2020) in Klaten and Lombok Barat districts in Indonesia. The survey included a knowledge assessment on nutrition, as well as indicators of attitudes and behaviors on diet, physical activity, and WIFS. We employed multivariable linear and logistic regression to test for pre-post intervention differences. Overall knowledge was significantly higher post-intervention (β: 3.3; 95% confidence interval [CI]: 2.6, 3.9). Diet diversity was high at both timepoints, however, at post-intervention there was significantly higher odds of consuming vitamin A-rich fruits and vegetables (Odds Ratio [OR]: 1.5; 95% CI: 1.1, 2.0) and lower odds of consuming sugar-sweetened beverages (OR: 0.4; 95% CI: 0.3, 0.5). Post-intervention, there was higher odds of reporting 60 min of daily physical activity (OR: 2.3; 95% CI: 1.7, 3.2) and WIFS among girls (OR: 6.7; 95% CI: 1.5, 30.9). The package of interventions may be a promising first step to improving adolescent nutrition in Indonesia.

Experiences Engaging Family Members in Maternal, Child, and Adolescent Nutrition: A Survey of Global Health Professionals

BACKGROUND

Family members influence maternal, child, and adolescent nutrition and are increasingly engaged in nutrition interventions and research. However, there remain gaps in the literature related to programmatic experiences and lessons learned from engaging these key influencers in nutrition activities.

OBJECTIVES

This research aimed to document global health professionals' experiences engaging family members in nutrition activities, and their perceived barriers, facilitators, and recommendations for nutrition activities that engage family members.

METHODS

Global health and nutrition professionals were invited to complete an online survey about their experiences engaging family members in nutrition activities. The survey included 42 multiple-choice questions tabulated by frequency and 4 open-response questions, which were analyzed thematically.

RESULTS

More than 180 respondents (n = 183) in 49 countries with experience engaging fathers, grandmothers, and other family members in nutrition activities participated in the survey. Participants highlighted the importance of conducting formative research with all members of the family system and using participatory processes in intervention design and implementation. Respondents reported engaging family members increases support for recommended behaviors, improves program sustainability, and facilitates family and community ownership. Some respondents also shared experiences with positive and negative unintended consequences when engaging family members; for example, one-fifth of participants reported that mothers were uncomfortable with involving men in discussions. Common challenges centered on limited resources for program delivery, not involving all influential family members, and traditional gender norms. Recommendations included incorporating family members in the project design phase and ensuring sufficient project resources to engage family members throughout the project lifecycle.

CONCLUSIONS

Surveying global health professionals provides an opportunity to learn from their experiences and fill gaps in the peer-reviewed literature to strengthen intervention design and implementation. Community ownership and sustainability emerged as key benefits of family engagement not previously reported in the literature, but responses also highlighted potential negative unintended consequences.

Strategies and interventions for healthy adolescent growth, nutrition, and development

Adolescence is a pivotal point in the life course, characterised by transformative physical, cognitive, and emotional growth, an openness to change, and a drive to reshape the social environment. It offers unique opportunities to adopt changes in diet and physical activity that can persist into later life. Yet pre-existing nutritional problems, including micronutrient deficiencies, food insecurity, and poor-quality diets, persist at the same time as adolescents face the rapid emergence of an obesity epidemic. Adolescent growth and nutrition has been largely overlooked in intervention and policy research. Most intervention studies have emphasised micronutrient supplementation, with few taking into account the multiple drivers of adolescent diets. This Series paper highlights that effective interventions and policies will need to cut across sectors; be supported by multifaceted and multilevel policy; and extend across education, health, food systems, social protection, and digital media. Better data standardisation and systems will be essential in coordinating and monitoring these responses. In a context of shifts in planetary ecosystems and commercial drivers, resilient food systems will need to both ensure access to healthy and affordable foods and provide the infrastructure and incentives for continuing physical activity. Intergenerational partnerships with young people will be essential in bringing about transformative change and ensuring that food policies reflect their needs and aspirations.

Effect of a nutritional supplementation on growth and body composition in short and lean preadolescent boys: A randomised, double-blind, placebo-controlled study

AIM

To evaluate the effect of nutritional supplementation on height, weight and body composition in short and lean male preadolescents.

METHODS

A randomised, double-blinded, placebo-controlled trial of nutritional supplementation of short and lean prepubertal 10-14.5-year-old boys. Primary outcomes included Δheight-SDS and Δweight-SDS. Secondary outcomes included changes in body composition and BMI-SDS.

RESULTS

Of 160 boys enrolled, 126 (80%) completed 6 months' intervention. Baseline age, height-SDS, weight-SDS, BMI-SDS, body composition and dietary intake were similar in the formula and placebo groups. 'Good' formula consumers (intake of ≥50% of the recommended dose, n = 30) gained significantly more in weight-SDS, BMI-SDS, fat-free-mass and muscle mass (p < 0.05) than did 'poor' consumers (n = 35) and the placebo group (n = 61). Only in the formula group, positive dose-response correlations were found between consumption of the formula and changes in the outcome parameters examined, including Δheight-SDS (r = 0.301, p = 0.015). Boys aged >11.4 years who were 'good' formula consumers maintained their Δheight-SDS, while Δheight-SDS declined in 'poor' consumers and the placebo group of the same age (p = 0.033).

CONCLUSION

Intervention with a multi-nutrient, protein-rich formula was effective in increasing weight-SDS, fat-free-mass, muscle mass and BMI-SDS in short and lean prepubertal male adolescents. Good consumption of the formula prevented Δheight-SDS decline in the older participants.

Seasonal patterns of malaria, genital infection, nutritional and iron status in non-pregnant and pregnant adolescents in Burkina Faso: a secondary analysis of trial data

Background

Adolescents are considered at high risk of developing iron deficiency. Studies in children indicate that the prevalence of iron deficiency increased with malaria transmission, suggesting malaria seasonally may drive iron deficiency. This paper examines monthly seasonal infection patterns of malaria, abnormal vaginal flora, chorioamnionitis, antibiotic and antimalarial prescriptions, in relation to changes in iron biomarkers and nutritional indices in adolescents living in a rural area of Burkina Faso, in order to assess the requirement for seasonal infection control and nutrition interventions.

Methods

Data collected between April 2011 and January 2014 were available for an observational seasonal analysis, comprising scheduled visits for 1949 non-pregnant adolescents (≤19 years), (315 of whom subsequently became pregnant), enrolled in a randomised trial of periconceptional iron supplementation. Data from trial arms were combined. Body Iron Stores (BIS) were calculated using an internal regression for ferritin to allow for inflammation. At recruitment 11% had low BIS (< 0 mg/kg). Continuous outcomes were fitted to a mixed-effects linear model with month, age and pregnancy status as fixed effect covariates and woman as a random effect. Dichotomous infection outcomes were fitted with analogous logistic regression models.

Results

Seasonal variation in malaria parasitaemia prevalence ranged between 18 and 70% in non-pregnant adolescents (P < 0.001), peaking at 81% in those who became pregnant. Seasonal variation occurred in antibiotic prescription rates (0.7–1.8 prescriptions/100 weekly visits, P < 0.001) and chorioamnionitis prevalence (range 15–68%, P = 0.026). Mucosal vaginal lactoferrin concentration was lower at the end of the wet season (range 2–22 μg/ml, P < 0.016), when chorioamnionitis was least frequent. BIS fluctuated annually by up to 53.2% per year around the mean BIS (5.1 mg/kg², range 4.1–6.8 mg/kg), with low BIS (< 0 mg/kg) of 8.7% in the dry and 9.8% in the wet seasons (P = 0.36). Median serum transferrin receptor increased during the wet season (P < 0.001). Higher hepcidin concentration in the wet season corresponded with rising malaria prevalence and use of prescriptions, but with no change in BIS. Mean Body Mass Index and Mid-Upper-Arm-Circumference values peaked mid-dry season (both P < 0.001).

Conclusions

Our analysis supports preventive treatment of malaria among adolescents 15–19 years to decrease their disease burden, especially asymptomatic malaria. As BIS were adequate in most adolescents despite seasonal malaria, a requirement for programmatic iron supplementation was not substantiated.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11819-0.

Adolescent Nutrition-Developing a Research Agenda for the Second Window of Opportunity in Indonesia

BACKGROUND

Recently, adolescence has been identified as a second window of opportunity for the correction of nutritional inadequacies. However, there is a lack of knowledge on evidence-based integrated nutrition strategies for adolescents in Indonesia.

OBJECTIVE

To provide a research agenda and the prioritization of research actions to tackle outstanding knowledge gaps on adolescent nutrition in Indonesia.

METHODS

A preliminary set of research topics was listed based on a desk study of the academic literature and policy documents. Second, a stakeholder meeting was held to further identify and discuss research topics related to adolescent nutrition in Indonesia. Third, an online survey was conducted in which respondents were asked to indicate priority research themes for the next 3 to 5 years and to rank a total of 23 research questions.

RESULTS

Most (52%) of the respondents who returned the survey (n = 27) prioritize research on implementation and program evaluation, while 30% prefer descriptive and explanatory research, and 19% place priority with intervention and discovery research. However, when we followed up with specific topics for each of these broad research areas, a more nuanced picture emerged, with intervention and discovery research taking a more prominent standing.

CONCLUSIONS

In order to support the design, implementation, and effectiveness of integrated nutrition programs for Indonesian adolescents, in-depth studies should question the best intervention strategies, modes of delivery, and long-term outcomes, while nationwide and disaggregated data should investigate associations and trends over time and identify vulnerable groups.

Family influences on health and nutrition practices of pregnant adolescents in Bangladesh

Adolescent pregnancy can result in serious risks to the mother and her baby; yet, adolescents are among the least likely to access healthcare. Specific nutrition or antenatal care (ANC) guidelines for supporting pregnant adolescents are not available. To understand experiences and decision-making of pregnant adolescents in Bangladesh related to ANC and nutrition practices, peer interviewers were trained to conduct qualitative interviews in Dhaka and Rangpur with pregnant adolescents (n = 48), adolescent mothers (n = 48), adolescents' family members (n = 64) and health service providers (n = 32). Key themes explored included perception and support of adolescent pregnancy, experiences in seeking ANC, dietary practices, sources of information and roles of male and female family members. Spheres of influence on adolescent pregnancy were identified through analytical framework informed by the socio-ecological model. Respondents felt that adolescent pregnancy is risky and that adolescents require support and guidance through this experience. Families were highly influential on the care seeking, health and nutrition of pregnant adolescents, and mothers/mothers-in-law primarily took on the decision-making roles, with husbands actively participating. Adolescents valued family support but felt a loss of autonomy and agency upon becoming pregnant. Financial constraints were the greatest perceived barrier to appropriate nutrition and healthcare; yet, both were valued. There is sometimes discord of health and nutrition beliefs between families and health service providers; more research is needed to understand this further. It is essential to engage family members and adolescents in initiatives to increase access to quality ANC for pregnant adolescents, improve dietary practices and support the ability to delay pregnancy.

Effect of maternal zinc supplementation or zinc status on pregnancy complications and perinatal outcomes: An umbrella review of meta-analyses

Zinc is an essential trace element involved in different physiological functions. During pregnancy, it plays a crucial role in healthy embryogenesis. This umbrella review, therefore, aimed to summarize the existing literature of meta-analyses evaluating the effect of maternal zinc supplementation or zinc status on maternal and neonatal outcomes. Two databases, PubMed and Scopus, were selected to search the available literature without any temporal restriction. The literature search was performed during October 2020 and a total of 192 records were identified through the literature search. After screening the titles and applying the inclusion/exclusion criteria, finally, 15 articles were included in this umbrella review. This umbrella review showed that maternal zinc supplements reduce the risk of preterm birth. Although no substantial effect of zinc supplements was found for other feto-maternal outcomes. Also, we found a significant relationship between low maternal zinc status and risk of pregnancy complications. Zinc supplements reduce the risk of preterm birth. Long-term interventions and cohort studies are needed for future research directions. Further studies and a thorough investigation will help to decide the recommended zinc dose or intake during pregnancy.

A Survey on Wellness and Its Predictors Amongst Fiji High School Students

Background: Adolescent population face a number of health concerns which calls for objective and comprehensive assessment of their wellness during their critical development phase. This study aimed to determine adolescent wellness and its predictors amongst adolescents in secondary schools in Fiji. Methods: This quantitative cross sectional study was conducted in four purposively selected schools in Suva and the greater Suva area, Fiji, between August and September, 2019. Students of Fijian nationality, enrolled into years 11-13 in the selected schools were purposively selected. A structured self-administered questionnaire was used to collect data on four dimensions of wellness including physical, emotional, social, and spiritual. Spearman's Rho correlation was conducted to test for associations. Descriptive and inferential statistical tests were applied to analyze the data by the SPSS software version 25. A p-value < 0.05 was considered significant. Results: A total of 350 students participated in the study. Mean raw scores for wellness dimensions were as follows: physical = 51 (out of 60), psychological = 63 (out of 80), social = 42 (out of 50), and spiritual = 34 (out of 40). For overall wellness, two significant differences were observed: students of Fijian Itaukei descent (193.68 ± 14.2) and participants with a family income of $40,000-50,000 (199.08 ± 12.60) (p = 0.04) had a higher overall wellness score. There were three significant differences observed for psychological wellness dimension; Fijians of Indian descent (64.68 ± 9.30), participants enrolled into year 13 (64.68 ± 9.30) and those with a family income of $40,000-50,000 had higher psychological score. For social wellness, a significant difference was observed: Itaukei participants had higher scores (43.34 ± 4.42) when compared to other ethnic groups (p < 0.05). In terms of spiritual wellness, a significant difference was observed for ethnicity: Itaukei participants had a higher mean score (35.59 ± 4.26) when compared to other ethnic groups (p < 0.05). Strong correlations were observed for all dimensions of wellness. Conclusions: Findings of this study highlighted different factors affecting adolescents' wellness in Fiji. It is recommended that health education and awareness program be carried out for developing adolescent wellness by considering these factors. It is also recommended that parental and family support are provided to adolescents.

How do we improve adolescent diet and physical activity in India and sub-Saharan Africa? Findings from the Transforming Adolescent Lives through Nutrition (TALENT) consortium

OBJECTIVE

Adolescent diet, physical activity and nutritional status are generally known to be sub-optimal. This is an introduction to a special issue of papers devoted to exploring factors affecting diet and physical activity in adolescents, including food insecure and vulnerable groups.

SETTING

Eight settings including urban, peri-urban and rural across sites from five different low- and middle-income countries.

DESIGN

Focus groups with adolescents and caregivers carried out by trained researchers.

RESULTS

Our results show that adolescents, even in poor settings, know about healthy diet and lifestyles. They want to have energy, feel happy, look good and live longer, but their desire for autonomy, a need to 'belong' in their peer group, plus vulnerability to marketing exploiting their aspirations, leads them to make unhealthy choices. They describe significant gender, culture and context-specific barriers. For example, urban adolescents had easy access to energy dense, unhealthy foods bought outside the home, whereas junk foods were only beginning to permeate rural sites. Among adolescents in Indian sites, pressure to excel in exams meant that academic studies were squeezing out physical activity time.

CONCLUSIONS

Interventions to improve adolescents' diets and physical activity levels must therefore address structural and environmental issues and influences in their homes and schools, since it is clear that their food and activity choices are the product of an interacting complex of factors. In the next phase of work, the Transforming Adolescent Lives through Nutrition consortium will employ groups of adolescents, caregivers and local stakeholders in each site to develop interventions to improve adolescent nutritional status.

Transtheoretical model-based nutritional interventions in adolescents: a systematic review

BACKGROUND

Literature has shown a tendency of inadequate dietary intake among youth, consequently, nutritional interventions are required. The transtheoretical model (TTM) classifies individuals based on their readiness to change. This model is widely used for health education interventions with proven efficacy.

PURPOSE

This review aimed to weigh the strength of evidence about the TTM usage in nutritional interventions for adolescents and its effectiveness regarding dietary intake.

METHODS

This study followed the PRISMA guidelines. Eligible studies were input into Mendeley software. The Adolec, Google Scholar, LILACS, PsycINFO, PubMed, Science Direct and Web of Science databases were searched. Only full original articles written in English, Spanish or Portuguese on randomized controlled trials and quasi-experimental designs that applied the TTM in the design of nutritional interventions targeting adolescents were included, with no restrictions on publication date. The quality and risk of bias was evaluated with the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies.

RESULTS

The initial search yielded 3779 results. Three studies were rated as strong, six as moderate and five as weak. The final sample of 14 articles included adolescents that were mostly recruited from schools, with interventions ranging from one month to three years. The TTM was used alone or combined with other behavior-change theories and most of the interventions involved digital technology. The nutritional topics covered included fruit and vegetable consumption, low-fat diet, and cooking skills. Four studies presented improvement in fruit and vegetable consumption and four progressed through stages of change. Participants from two interventions reduced fat intake. At the end of one intervention, all the participants were in action and maintenance stages.

CONCLUSION

The TTM seems to be a successful strategy for nutritional intervention aiming at improving dietary intake in adolescents. Its application in different contexts shows that the TTM is flexible and possible to be implemented in many settings. The use of the model is shown to be restricted to the stage of change' construct. Further studies should use all constructs of the TTM in the design and compare the TTM with other behavior-change theories to better understand its effectiveness.

'I should be disease free, healthy and be happy in whatever I do': a cross-country analysis of drivers of adolescent diet and physical activity in different low- and middle-income contexts

OBJECTIVE

To explore perceptions of how context shapes adolescent diet and physical activity in eight low- and middle-income (LMIC) sites at different stages of societal and economic transition.

DESIGN

Novel qualitative secondary analysis of eight data sets generated as part of the international Transforming Adolescent Lives through Nutrition (TALENT) collaboration.

SETTING

Diverse sites in India and Sub-Saharan Africa.

PARTICIPANTS

Fifty-two focus group discussions with 491 participants (303 adolescents aged 10-17 years; 188 caregivers).

RESULTS

Analysis of pooled qualitative data identified three themes: (1) transitions in generational nutrition education and knowledge; (2) transition in caregiver-adolescent power balance and (3) the implications of societal and economic transition for diet and physical activity. Adolescents in urban and peri-urban areas could readily access 'junk' food. Diets in rural settings were determined by tradition, seasonality and affordability. Physical activity was inhibited by site-specific factors including lack of space and crime in urban settings, and the prioritisation of academic performance. Gender influenced physical activity across all sites, with girls afforded fewer opportunities.

CONCLUSIONS

Interventions to improve adolescent diet and physical activity in LMIC need to be complex, context-specific and responsive to transitions at the individual, economic and societal levels. Moreover, solutions need to acknowledge gender inequalities in different contexts, as well as structural and cultural influences on diet and physical activity in resource-limited settings. Programmes need to be effective in engaging and reconciling adolescents' and caregivers' perspectives. Consequently, there is a need for action at both the community-household level and also through policy.

Malnutrition, Hypertension Risk, and Correlates: An Analysis of the 2014 Ghana Demographic and Health Survey Data for 15-19 Years Adolescent Boys and Girls

The sex differences in malnutrition and hypertension during adolescence is largely inconclusive. There is also a paucity of data on the sex-specific correlates of malnutrition and hypertension for adolescents. Hence, this study aimed to assess the association between malnutrition, pre-hypertension/hypertension (PHH) and sex among adolescents. The study also aimed to determine and contrast the factors associated with these risks in Ghana. We analysed data of non-pregnant adolescent girls (n = 857) and adolescent boys (n = 870) aged 15–19 years from the 2014 Ghana Demographic and Health Survey (DHS). We modelled the prevalence risk ratio (PRR) of malnutrition and PHH using Cox proportional hazard models. Compared to adolescent girls, boys were more than twice likely to be stunted (PRR = 2.58, 95% C.I (1.77, 3.76)) and underweight (PRR = 2.67, 95% C.I (1.41, 5.09)) but less likely to be overweight/obese (PRR = 0.85, 95% C.I (0.08, 0.29)). Boys were also about twice likely to have PHH (PRR = 1.96, 95% C.I (1.47, 2.59)) compared to their female peers. Girls were more at risk of the detrimental effects of poor education on stunting and PHH. Empowerment index while protective of stunting for girls (PRR = 0.82, 95% C.I (0.67, 0.99)) also increased their risk of overweight/obesity (PRR = 1.31, 95% C.I (1.02, 1.68)). A higher household wealth index (HWI) increased the risk of overweight/obesity for adolescent girls but was protective of stunting and PHH for adolescent boys. Improvement in household water, hygiene, and sanitation (WASH) reduced the risk of stunting by 15% for adolescent boys. Overall, our findings suggest a double-burden of malnutrition with an up-coming non-communicable disease burden for adolescents in Ghana. Our findings may also be highlighting the need to target adolescent boys alongside girls in nutrition and health intervention programmes.

Effectiveness of Lifestyle Interventions for Prevention of Harmful Weight Gain among Adolescents from Ethnic Minorities: A Systematic Review

The escalating obesity among adolescents is of major concern, especially among those from an ethnic minority background. The adolescent period offers a key opportunity for the implementation of positive lifestyle behaviours as children transition to adulthood. The objective of this review was to examine the effectiveness of lifestyle interventions for adolescents and their impact in ethnic and racial minorities for the prevention of overweight and obesity. Seven electronic databases were searched from 2005 until March 2019 for randomized controlled trials of lifestyle programs conducted in this population. The main outcome was change in Body Mass Index (BMI) z-score (kg/m2) or change in BMI and secondary outcomes were changes in physical activity and diet. Thirty studies met the inclusion criteria. Seven studies reported and/or conducted subgroup analysis to determine if ethnic/racial group affected weight change. None demonstrated an overall decrease in BMI z-score. However, six of the seven demonstrated changes in secondary measures such as fruit and vegetable intake and screen time. Results did not differ by ethnic/racial group for primary and secondary outcomes. Overweight and obesity prevention among adolescents from ethnic minorities is an area that needs further research. There is a lack of interventions that include analyses of effectiveness in ethnic minorities.

Systematic Review: Effect of Health Education Intervention on Improving Knowledge, Attitudes and Practices of Adolescents on Malnutrition

Adolescence is a phase in the life cycle of human beings. Adequate knowledge, attitudes and practices towards malnutrition are necessary for proper growth and development and for their future children. This systematic review aimed to determine the effect of health education intervention to improve the knowledge, attitudes and practices of adolescents on malnutrition. PubMed, Scopus, clinical trials, CINAHL, SAGE, Science Direct and Medline were searched according to Preferred Reporting Item for Systematic Reviews and Meat-analysis (PRISMA) guidelines to identified published studies from January 2013 to December 2019 based on the inclusion and exclusion criteria. A total of eight studies were included in this review. Data extraction was done based on randomized controlled trial only. Three out of the eight studies had low risk of bias, the overall evidence of the study was moderate. Findings from this study suggest that health education intervention among adolescents have significantly improved their knowledge, attitudes and practices. More specific interventions should be conducted in low and middle income countries since they bear more of the burden of malnutrition globally.

Growing up strong: The importance of physical, mental, and emotional strength during childhood and adolescence with focus on dietary factors

Childhood and adolescence are critical time periods for growth and development. Given the current physical and psychological health concerns affecting United States youth, an emerging area of interest exists supporting the importance of physical and psychological aspects of strength for health, resilience, and well-being through these life stages. This synopsis highlights the key concepts that were presented within the 2018 Strength Summit conference, entitled The Role of Strength in Optimal Health and Well-being. During the conference, strength was broadly defined as the ability to successfully respond to a challenge. Although much of the current research focuses on strength from a muscle function and performance perspective, mental and emotional strength are also important components of overall health and well-being, especially in children and adolescents. This paper provides a brief overview of the clinical and/or research-based strength outcomes, summarizes the relationship between strength and health, and discusses evidence-based dietary factors that promote strength in children and adolescents. Novelty Building physical, mental, and emotional strength during childhood and adolescence lays the foundation for health and well-being. Emerging evidence indicate positive associations between diet quality and strength in children and adolescents. Promising areas include the promotion of family-based meals, with focus on breakfast, for improved strength in United States youth.

Sociocultural and economic determinants of stunting and thinness among adolescent boys and girls in Nepal

Despite the increasing interest in the determinants of adolescent undernutrition in low- and middle-income countries, a comprehensive multi-level overview at the country level is missing. Using the nationally representative 2014 Nepal Adolescent Nutrition Survey, this study aimed to provide a comprehensive overview of the sociocultural and economic determinants of stunting and thinness of adolescent boys and girls in Nepal. Multivariate logistic regression models were used to estimate the associations between multiple individual, household and community determinants and stunting and thinness among 3773 adolescents aged 10-19 years (1888 boys and 1885 girls). The prevalence rates of stunting and thinness indicated suboptimal nutritional status and an inadequate growth environment in Nepali adolescents. The results highlighted an association of paternal occupation and education, household income, number of earning household members, geographical place of residence, caste/ethnicity and nutritional knowledge with stunting, with higher odds for males and older adolescents. Paternal occupation, education, household income, geographical region, caste/ethnicity and nutrition knowledge were associated with thinness, with higher odds for males and younger adolescents. The findings underscore the importance of involving adolescents, their parents and their communities in interventions. Such interventions should not only be aimed at improving adolescent nutrition but also at optimizing adolescents' growth environment for better health and development. Future research should focus on context-specific causal pathways and mechanisms through which sociocultural and economic determinants influence nutritional outcomes within broader societal, cultural and political settings. A longitudinal approach, including a range of dietary and nutrition indicators would allow understanding how and when the relative importance of these factors change during adolescence.

Dietary micronutrients in the wake of COVID-19: an appraisal of evidence with a focus on high-risk groups and preventative healthcare

Existing micronutrient deficiencies, even if only a single micronutrient, can impair immune function and increase susceptibility to infectious disease. Certain population groups are more likely to have micronutrient deficiencies, while certain disease pathologies and treatment practices also exacerbate risk, meaning these groups tend to suffer increased morbidity and mortality from infectious diseases. Optimisation of overall nutritional status, including micronutrients, can be effective in reducing incidence of infectious disease. Micronutrient deficiencies are rarely recognised but are prevalent in the UK, as well as much more widely, particularly in high-risk groups susceptible to COVID-19. Practitioners should be aware of this fact and should make it a consideration for the screening process in COVID-19, or when screening may be difficult or impractical, to ensure blanket treatment as per the best practice guidelines. Correction of established micronutrient deficiencies, or in some cases assumed suboptimal status, has the potential to help support immune function and mitigate risk of infection. The effects of and immune response to COVID-19 share common characteristics with more well-characterised severe acute respiratory infections. Correction of micronutrient deficiencies has proven effective in several infectious diseases and has been shown to promote favourable clinical outcomes. Micronutrients appear to play key roles in mediating the inflammatory response and such effects may be enhanced through correction of deficiencies. Many of those at highest risk during the COVID-19 pandemic are also populations at highest risk of micronutrient deficiencies and poorer overall nutrition. Correction of micronutrient deficiencies in established COVID-19 infection may contribute to supporting immune response to infection in those at highest risk. There is a need for further research to establish optimal public health practice and clinical intervention regimens.

Effects of preventive nutrition interventions among adolescents on health and nutritional status in low- and middle-income countries: A systematic review

Background

Malnutrition is one of the most common causes of morbidity and mortality among children and adolescents and is now considered to be one of the largest risk factors responsible for the global burden of diseases along with poor diet.

Objectives

The objective of this review was to assess the impact of preventive nutrition interventions (including nutrition education and counselling; micronutrient supplementation/fortification and macronutrient supplementation) to improve the health and nutritional status of adolescents aged 10-19 years in low- and middle-income countries (LMICs). The secondary objective of the review was to assess various contextual factors based on the World Health Organisation (WHO) health system building blocks framework that might potentially impact the effectiveness of these interventions for this age group.

Search Methods

The search was conducted on Cochrane Controlled Trials Register (CENTRAL), MEDLINE, EMBASE, CINAHL, PsycINFO, the WHO nutrition databases, CAB Global Health, Social Science Citation Index, Scopus, WHO Global Health Index, ADOLEC and EPPI until February 5, 2019. We searched Google Scholar along with key nutrition agencies database such as Nutrition International, the Global Alliance for Improved Nutrition, the World Food Programme and HarvestPlus to search for nonindexed, grey literature to locate relevant programme evaluations and any additional trials. All searches were performed without any restrictions on publication date, language or publication status.

Selection Criteria

We included randomised controlled trials, quasiexperimental studies, controlled before-after studies and interrupted time series evaluating the effectiveness of preventive nutrition interventions among adolescents between 10 and 19 years of age from LMICs.

Data Collection and Analysis

Two review authors independently assessed trials for inclusion, assessed risk of bias and extracted data from included studies. Meta-analysis was conducted separately for each outcome and intervention. For dichotomous data, we reported risk ratios (RR) with 95% confidence intervals (CI). For continuous data, we reported the mean difference (MD) or standard mean difference (SMD) with 95% CI.

Main Results

This review summarises findings from a total of 10 studies from 15 papers including 10,802 participants. All the studies included in this review assessed the impact of micronutrient supplementation/fortification on health and nutritional status among adolescents in LMIC. We did not find any study assessing the impact of nutrition education and counselling or on macronutrient supplementation among adolescents. Micronutrient supplementation/fortification interventions included calcium/vitamin D supplementation/fortification, iron supplementation with or without folic acid, zinc supplementation and multiple micronutrient (MMN) fortification. The majority of the studies (eight out of 10 studies) included adolescent girls aged between 10 and 19 years of age. We did not find any large scale preventive nutrition intervention programmes targeting adolescents in LMICs. We are uncertain of the effect of iron supplementation with or without folic acid on anaemia (daily supplementation; RR: 1.04, 95% CI 0.88, 1.24; one study; 1,160 participants; low quality evidence. Weekly supplementation; RR: 1.07, 95% CI: 0.91, 1.26; one study; 1,247 participants; low quality evidence). We are uncertain of the effect of various micronutrient supplementation/fortification on body mass index (calcium/vitamin D supplementation; (MD: -0.01 kg/m2; 95% CI: -1.20, 1.17; two studies; 730 participants; I 2 94%; very low quality evidence, iron supplementation with or without folic acid; MD: 0.29 kg/m2; 95% CI: -0.25, 0.83; two studies; 652 participants; I 2 69%; very low quality evidence, zinc supplementation; MD: 0.35 kg/m2; 95% CI: -0.15, 0.85; one study; 382 participants; very low quality evidence) and MMN fortification; MD: 0.23 kg/m2, 95% CI: -0.11, 0.57; two studies; 943 participants; I 2 22%; very low quality evidence). None of the included studies reported any other primary outcomes including morbidity or adverse effects. Iron supplementation with or without folic acid may improve haemoglobin concentrations (MD: 0.42 g/dL, 95% CI: 0.13, 0.71; four studies; 1,020 participants; I 2 89%; low quality evidence). Calcium/vitamin D supplementation may improve serum 25(OH) D levels (standardised mean difference [SMD]: 2.85, 95% CI: 0.89, 4.82; two studies; 395 participants; I 2 99%; low quality evidence). We are uncertain of the effect of calcium only supplementation (MD: 0.02 g/cm2, 95% CI: -0.00, 0.04; one study; 233 participants; low quality outcome) and calcium + vitamin D supplementation (MD: 0.02 g/cm2, 95% CI: -0.00, 0.04; one study; 235 participants; low quality evidence) on total bone mineral density (BMD). We are uncertain of the effect of MMN fortification on haemoglobin concentrations (MD: -0.10 g/dL, 95% CI: -0.88, 0.68; two studies; 1102 participants; I 2 100%; very low quality evidence); calcium supplementation on total body bone mineral content (BMC); (MD: 30.20 g, 95% CI: -40.56, 100.96; one study; 233 participants; low quality evidence), calcium + vitamin D supplementation on total body BMC (MD: 21.60 g, 95% CI: -45.32, 88.52; one study; 235 participants; low quality evidence) and zinc supplementation on serum zinc levels (SMD: 6.94, 95% CI: -4.84, 18.71; two studies; 494 participants; very low quality evidence). One study reported the impact of iron supplementation with or without folic acid on cognition of adolescent girls suggesting improved cognition in most of the tests with daily or twice weekly supplementation compared to once weekly or no supplementation. None of the other secondary outcomes were reported including any other development outcomes and all-cause mortality. These findings warrant caution while interpreting due to very few studies and high heterogeneity.

Authors' Conclusions

There is limited evidence of micronutrient supplementation/fortification among adolescents on health and nutritional status in LMICs, with lack of evidence on nutrition education and counselling and macronutrient supplementation. The findings are generaliseable for adolescent girls since all studies (except one) targeted female adolescents.

Iron Status of Burkinabé Adolescent Girls Predicts Malaria Risk in the Following Rainy Season

High levels of storage iron may increase malaria susceptibility. This risk has not been investigated in semi-immune adolescents. We investigated whether baseline iron status of non-pregnant adolescent girls living in a high malaria transmission area in Burkina Faso affected malaria risk during the following rainy season. For this prospective study, we analysed data from an interim safety survey, conducted six months into a randomised iron supplementation trial. We used logistic regression to model the risk of P. falciparum infection prevalence by microscopy, the pre-specified interim safety outcome, in relation to iron status, nutritional indicators and menarche assessed at recruitment. The interim survey was attended by 1223 (82%) of 1486 eligible participants, 1084 (89%) of whom were <20 years at baseline and 242 (22%) were pre-menarcheal. At baseline, prevalence of low body iron stores was 10%. At follow-up, 38% of adolescents had predominantly asymptomatic malaria parasitaemias, with no difference by menarcheal status. Higher body iron stores at baseline predicted an increased malaria risk in the following rainy season (OR 1.18 (95% CI 1.05, 1.34, p = 0.007) after adjusting for bed net use, age, menarche, and body mass index. We conclude that routine iron supplementation should not be recommended without prior effective malaria control.

Evolutionary Perspectives on the Developing Skeleton and Implications for Lifelong Health

Osteoporosis is a significant cause of morbidity and mortality in contemporary populations. This common disease of aging results from a state of bone fragility that occurs with low bone mass and loss of bone quality. Osteoporosis is thought to have origins in childhood. During growth and development, there are rapid gains in bone dimensions, mass, and strength. Peak bone mass is attained in young adulthood, well after the cessation of linear growth, and is a major determinant of osteoporosis later in life. Here we discuss the evolutionary implications of osteoporosis as a disease with developmental origins that is shaped by the interaction among genes, behavior, health status, and the environment during the attainment of peak bone mass. Studies of contemporary populations show that growth, body composition, sexual maturation, physical activity, nutritional status, and dietary intake are determinants of childhood bone accretion, and provide context for interpreting bone strength and osteoporosis in skeletal populations. Studies of skeletal populations demonstrate the role of subsistence strategies, social context, and occupation in the development of skeletal strength. Comparisons of contemporary living populations and archeological skeletal populations suggest declines in bone density and strength that have been occurring since the Pleistocene. Aspects of western lifestyles carry implications for optimal peak bone mass attainment and lifelong skeletal health, from increased longevity to circumstances during development such as obesity and sedentism. In light of these considerations, osteoporosis is a disease of contemporary human evolution and evolutionary perspectives provide a key lens for interpreting the changing global patterns of osteoporosis in human health.

Association between Adherence to the Mediterranean Diet and Physical Fitness with Body Composition Parameters in 1717 European Adolescents: The AdolesHealth Study

Obesity, low levels of physical fitness, and unhealthy eating patterns are responsible for part of the health problems of adolescents today. The current study aimed at examining the association between the adherence to the Mediterranean diet (MD), through each answer to the items of the Adherence to the MD Questionnaire (KIDMED), and physical fitness with body composition parameters (body mass index (BMI), percentage of body fat, and waist circumference) in 1717 European adolescents (N = 900 boys, N = 817 girls). Data of body composition, physical fitness results, and the answers to KIDMED were analyzed by the Student’s t-test. Additionally, the effect size (ES) was calculated and a Chi-square test analyzed the proportion of participants with and without over waist circumference, overfat, and overweight in each KIDMED question. The relative risk of suffering over waist circumference, overfat and overweight in relation to the responses was calculated by Odd-Ratio. Adherence to the MD did not influence the condition of over waist circumference, overfat and overweight, although certain dietary habits were identified as risk factors for their development. Over waist circumference, overfat, and overweight boys and girls presented higher levels of body mass, waist circumference, body fat percentage, and BMI (p < 0.001; ES = 1.73–3.38), as well as lower levels of all the parameters of the physical fitness analyzed (p < 0.001; ES = 0.45–1.08), except the handgrip test. A direct relationship between fitness and over waist circumference, overfat, and overweight was found.

Effects of Preventive Nutrition Interventions among Adolescents on Health and Nutritional Status in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

The objective of this review was to assess the impact of preventive nutrition interventions on health and nutritional status of adolescents aged 10–19 years in low- and middle-income countries (LMICs). We searched the databases until 5 February 2019 without any restrictions on publication, date, language, or publication status. A total of 10 studies (15 papers) including 10,802 participants assessing the impact of micronutrient supplementation/fortification were included in this review. We did not find any study assessing the impact of nutrition education and counseling or macronutrient supplementation among adolescents. Among primary outcomes, we are uncertain of the effect of iron supplementation with or without folic acid on anemia (daily supplementation; relative risk (RR): 1.04, 95% confidence interval (CI) 0.42, 2.57; one study; 1160 participants; low-quality evidence; weekly supplementation; RR: 1.07, 95% CI: 0.46, 2.52; one study; 1247 participants; low-quality evidence). We are also uncertain of the effect of various micronutrient supplementation/fortification on body mass index (BMI) (calcium/vitamin D supplementation; (MD: −0.01 kg/m²; 95% CI: −1.20, 1.17; two studies; 730 participants; I² 94%; very-low-quality evidence, iron supplementation with or without folic acid; MD: 0.47 kg/m²; 95% CI: −0.17, 1.11; two studies; 652 participants; I² 37%; very-low-quality evidence, zinc supplementation; MD: 0.35 kg/m²; 95% CI: −0.15, 0.85; one study; 382 participants; very-low-quality evidence) and multiple micronutrient (MMN) fortification; MD: 0.23 kg/m², 95% CI: −0.11, 0.57; two studies; 943 participants; I² 22%; very-low-quality evidence). None of the included studies reported any other primary outcomes including morbidity or adverse effects. Among secondary outcomes, iron supplementation with or without folic acid may improve hemoglobin concentrations, and calcium/vitamin D supplementation may improve serum 25(OH)D levels, while calcium only supplementation and calcium and vitamin D supplementation may marginally improve total body bone mineral density (BMD). We are uncertain of the effect of MMN fortification on hemoglobin concentrations, calcium supplementation on total body bone mineral content (BMC), calcium + vitamin D supplementation on total body BMC, and zinc supplementation on zinc levels. There is limited evidence of micronutrient supplementation/fortification among adolescents, especially adolescent boys, on health and nutritional status in LMICs. These findings should be interpreted with caution due to the low quality and limited number of studies.

Do restrictive gender attitudes and norms influence physical and mental health during very young Adolescence? Evidence from Bangladesh and Ethiopia

Adolescence is seen as a window of opportunity for intervention but also as a time during which restrictive gender attitudes and norms become more salient. This increasingly gendered world has the potential to profoundly influence adolescents' capabilities, including their physical and mental health. Using quantitative data on 6,500 young adolescents (10-12) from the Gender and Adolescence: Global Evidence (GAGE) program, this paper analyses the association between restrictive gender attitudes (RGAs) at the individual level and restrictive gender norms (RGNs) at the community level and physical and mental health in Bangladesh and Ethiopia. We find significant associations between RGAs and RGNs and height-for-age z-scores, body mass index z-scores, self-reported health, adolescent hunger, psychological well-being, and self-esteem. We find no relationship between RGAs or RGNs and illness. We also find heterogeneity across country and urbanicity. We find surprisingly limited variation by gender, and the differences we do see point to important vulnerabilities for both boys and girls. Our results point to the powerful role that distal factors such as culture and beliefs, as manifested through RGAs and RGNs, can play in shaping health outcomes for both boys and girls and suggest important next steps for future research and policy.

Global Patterns of Adolescent Fruit, Vegetable, Carbonated Soft Drink, and Fast-Food Consumption: A Meta-Analysis of Global School-Based Student Health Surveys

BACKGROUND

Adolescence presents an opportunity to influence diet, which impacts present and future health outcomes, yet adolescent diets globally are poorly understood.

OBJECTIVE

We generate evidence on adolescent diets globally and explore patterns and trends by subpopulation.

METHODS

We estimated mean frequency of consumption and prevalence of less-than-daily fruit and vegetable consumption, at-least-daily carbonated beverage consumption, and at-least-weekly fast-food consumption among school-going adolescents aged primarily 12 to 17 years from the Global School-based Student Health Surveys in Africa, Asia, Oceania, and Latin America between 2008 and 2015. Random-effects meta-analysis was used to pool estimates globally and by subgroup.

RESULTS

On average, adolescents consumed fruit 1.43 (95% confidence interval [CI] 1.26-1.60) times per day, vegetables 1.75 (1.58-1.92) times per day, carbonated soft drinks 0.99 (0.77-1.22) times per day, and fast food 1.05 (0.78-1.32) times per week. Overall, 34.5% (95% CI 29.4-39.7) consumed fruit less than once per day, 20.6% (15.8-25.9) consumed vegetables less than once per day, 42.8% (35.2-50.7) drank carbonated soft drinks at least once per day, and 46.1% (38.6-53.7) consumed fast food at least once per week. Mean daily frequency of fruit consumption was particularly low in South and East Asia (1.30 [1.02-1.58]); carbonated soft drink consumption high in Latin America (1.54 [1.31-1.78]), high-income countries (1.66 [1.29-2.03]), and modern food system typologies (1.44 [0.75-2.12]); and mean weekly fast food consumption high in mixed food system typologies (1.29 [0.88-1.71]).

CONCLUSIONS

School-going adolescents infrequently consume fruits and vegetables and frequently consume carbonated soft drinks, but there is wide variability by subpopulation.

An Intergenerational Approach to Break the Cycle of Malnutrition

PURPOSE OF REVIEW

This article examines how nutritional status is treated throughout the lifecycle. In doing so, the review identifies promising life stages during which intervention may improve nutritional status of future generations.

RECENT FINDINGS

A life course perspective suggests that nutritional changes are most likely to be sustained when they occur during times of developmental transition, such as pregnancy or adolescence. Adolescence is a unique period in which malnutrition in future generations may be addressed because it is the first life stage at which pregnancy becomes feasible and individuals seek independence from parents. A need exists to begin investigating not just how nutrition changes are sustained throughout the lifespan, but how nutritional intervention in one generation impacts the next. This intergenerational approach should be undertaken with cross-discipline collaboration to have the best chance at impacting underlying determinants of malnutrition like poverty and women's education.

Nutrient supplementation during the first 1000 days and growth of infants born to pregnant adolescents

Few studies have evaluated the impact of nutritional supplementation among pregnant adolescents. We examined the effects of the Rang Din Nutrition Study (RDNS) interventions on children born to mothers <20 years of age. The RDNS was a cluster‐randomized effectiveness trial with four arms: (1) women and children both received small‐quantity lipid‐based nutrient supplements (LNS‐LNS), (2) women received iron and folic acid (IFA) and children received LNS (IFA‐LNS), (3) women received IFA and children received micronutrient powder (MNP) (IFA‐MNP), and (4) women received IFA and children received no supplements (IFA‐Control). We enrolled 4011 women at <20 weeks gestation; 1552 were adolescents. Among adolescents, prenatal LNS reduced newborn stunting by 25% and small head size by 28% and had a marginally significant effect on newborn wasting, compared with IFA. Low birth weight and preterm birth were reduced only among adolescents with lower food security. Effects on subsequent growth status were observed only among female children in the LNS‐LNS group: less stunting at 18 months (versus IFA‐MNP) and lower prevalence of small head circumference and wasting at 24 months (versus IFA‐Control). Initiatives targeting pregnant adolescents in similar settings should consider inclusion of small‐quantity LNS, particularly for adolescents living in food‐insecure households.

Perspective: Challenges in Use of Adolescent Anthropometry for Understanding the Burden of Malnutrition

Improving nutritional status during adolescence is an opportunity to improve the lives of this generation and the next. Estimating the burden of malnutrition at a population level is fundamental to targeting interventions and measuring progress over time, and for adolescents, we usually depend on survey data and the 2007 WHO Growth Reference to do so. There is substantial risk of misguided conclusions regarding adolescent prevalence estimates, however, when underlying methodological limitations of the indicators and reference are not adequately considered. We use national prevalence estimates among girls and young women 10-22 y of age from the 2014 State of Food Security and Nutrition in Bangladesh report as an example to demonstrate that determining the true prevalence of undernutrition, overweight, and obesity is complicated by racial/ethnic variation across populations in timing of the adolescent growth spurt, growth potential, and body build. Further challenging the task are inherent limitations of the body mass index as an indicator of thinness and adiposity, and cutoffs that poorly distinguish a well-nourished population from a malnourished one. We provide recommendations for adolescent nutrition policy and program decision-making, emphasizing the importance of 1) critically interpreting indicators and distributions by age when using the 2007 WHO Growth Reference; 2) examining what is happening before and after adolescence, when interpretation of anthropometry is more straightforward, as well as trends over time; and 3) complementing anthropometry with other information, particularly dietary intake. Finally, we advocate that nutrition researchers prioritize exploration of better methods to predict peak height velocity, for development of standardized indicators to measure dietary quality among adolescents, and for studies that will illuminate causal paths so that we can effectively improve adolescent dietary intake and nutritional status.

Hemoglobin concentration and anemia diagnosis in venous and capillary blood: biological basis and policy implications

Anemia is an important public health challenge and accurate prevalence estimates are needed for program planning and tracking progress. While venous blood assessed by automated hematology analyzers is considered gold standard, most population‐based surveys use point‐of‐care diagnostics and capillary blood to estimate population prevalence of anemia. Several factors influence hemoglobin (Hb) concentration, including human and analytic error, analysis method, and type of instrument, but it is unclear whether biological variability exists between venous and capillary blood. The objective of this paper was to systematically review sources of Hb variability and the potential biological basis for venous and capillary differences. We use data from a recent survey in the state of Uttar Pradesh, India, to illustrate the implications on anemia prevalence estimates. Significant differences in Hb concentration between capillary and venous blood samples are common. Most but not all find capillary Hb concentration to be higher than venous. Instrument/method variability and human error play an important role, but cannot fully explain these differences. A normative guide to data collection, analysis, and anemia diagnosis is needed to ensure consistent and appropriate interpretation. Further research is needed to fully understand the biological implications of venous and capillary Hb variability.

Adolescent girls' health, nutrition and wellbeing in rural eastern India: a descriptive, cross-sectional community-based study

BACKGROUND

India is home to 243 million adolescents. Two million (9%) of them belong to Scheduled Tribes living in underserved, rural areas. Few studies have examined the health of tribal adolescents. We conducted a cross-sectional survey to assess the health, nutrition and wellbeing of adolescent girls in rural Jharkhand, eastern India, a state where 26% of the population is from Scheduled Tribes. We aimed to identify priorities for community interventions to serve adolescents and their families.

METHODS

Between June 2016 and January 2017, interviewers visited all households in 50 purposively sampled villages of West Singhbhum district, Jharkhand. They aimed to interview all girls aged 10-19. Interviewers conducted face-to-face interviews with girls to administer a survey about physical and mental health, disability, nutrition, sexual and reproductive health, gender norms, decision-making, education and violence. Interviewers also measured girls' height, weight, and Mid-Upper Arm Circumference.

RESULTS

Interviewers collected data from 3324 (82%) of an estimated 4068 girls residing in the study area. Their mean age was 14.3 (SD 2.9). 82% were from Scheduled Tribes. 89% of younger girls aged 10-14 and 46% of older girls aged 15-19 were in school or college. Girls dropped out of school because they were required for household work (37%) or work on the family farm or business (22%). Over a third reported symptoms of anaemia in the past month, but less than a fifth had a blood test. The prevalence of thinness (<-2SD median BMI for age and sex) was 14% for younger girls and 6% for older girls. 45% of girls were stunted (<-2SD median height for age and sex). 40% reported emotional violence in the past year, 14% physical violence, and 0.7% sexual violence. 12% had problems associated with depression or anxiety. 30% aged 15-19 had heard of contraception. Among married girls and their husbands, only 10% had ever used methods to prevent or delay pregnancy.

CONCLUSIONS

Our study identified several priorities to improve adolescent girls' health, nutrition and wellbeing in largely tribal areas of Jharkhand: reducing violence, early marriage and undernutrition, as well as improving mental health, knowledge about contraception and school retention.

Prevalence and correlates of anemia among adolescents in Nepal: Findings from a nationally representative cross-sectional survey

Anemia is regarded as major public health problem among adolescents in Low and Middle-Income Countries (LMICs) but there is limited primary data in many countries, including Nepal. This study investigated the prevalence and correlates of anemia in a nationally representative sample of adolescents within the 2014 National Adolescent Nutrition Survey in Nepal. A total of 3780 adolescents aged 10 to 19 years were selected from a cross-sectional survey through multi-stage cluster sampling. Structured interviews, anthropometric measurements and hemoglobin assessments of capillary blood were obtained. Bivariate and multivariable analyses were undertaken to compute the Adjusted Odds Ratio (aOR) for socio-demographic, behavioral and cluster characteristics. The overall prevalence of anemia was 31% (95%CI: 28.2, 33.5), 38% (95%CI: 34.0, 41.8) in female and 24% (95%CI: 20.6, 27.1) in male. The likelihood of anemia was significantly higher among older adolescents (aOR 1.75, 95%CI: 1.44, 2.13), females (aOR 2.02; 95%CI: 1.57, 2.60), among those who walk barefoot (aOR 1.78, 95%CI: 1.08, 2.94), and those residing in the Terai (aOR 1.80, 95%CI: 1.18, 2.77). Food consumption from more than four food groups (aOR 0.71, 95%CI: 0.57, 0.88) was protective against anemia. In conclusion, anemia is common in Nepali adolescents. Efforts to improve the nutritional status of this high-risk age group require nutrition that focus on eating habits, sanitation, iron supplementation and the treatment of hookworm infection.

Nutritional status and related factors of schoolchildren in Çorum, Turkey

OBJECTIVE

We aimed to determine nutritional status and related factors among schoolchildren in Çorum, Central Anatolia, Turkey.

DESIGN

Schoolchildren's height and weight were measured to calculate BMI and BMI Z-scores. Height, weight and BMI Z-scores were analysed and nutritional status classified according to the WHO.

SETTING

Central Anatolia, Turkey.ParticipantsSchoolchildren aged 5-17 years (n 1684) participated in study.

RESULTS

Of children, 4·2% were stunted, 6·9% thin, 13·8% overweight and 6·6% were obese. Proportions of stunting, thinness and overweight/obesity were significantly higher in children aged &gt;10 years (78·6, 75·0 and 64·9%, respectively) than in those aged ≤10 years (21·4, 25·0 and 35·1%, respectively; all P &lt;0·001). Median (range) birth weight and breast-feeding duration in children with stunting (2750 (1400-3600)g; 10 (0-36) months) were significantly lower and shorter, respectively, than those of normal height (3200 (750-5500)g; 15 (0-72) months) and tall children (3500 (2500-4900)g; 18 (0-36) months; P &lt;0·001, &lt;0·001, 0·011 and 0·016, respectively). The same relationship was observed in thin children (3000 (1000-4500)g; 12 (0-36) months) compared with normal-weight (3200 (750-5500)g; 15 (0-72) months) and overweight/obese children (3300 (1200-5500)g; 16 (0-48) months; P=0·026, &lt;0·001, 0·045 and 0·011, respectively).

CONCLUSIONS

Overweight and obesity are health problems that must be addressed in schoolchildren. Adolescents also have a risk of double malnutrition. Promoting normal birth weight and encouraging long duration of breast-feeding are important to support normal growth in children.

Potential interventions targeting adolescent nutrition in Indonesia: a literature review

Objective

The present study aimed to take stock of nutrition interventions that warrant consideration as a minimum package of interventions in Indonesia to improve four key nutrition indicators for adolescents: stunting, thinness, overweight and anaemia.

Design

We conducted a review of the peer-reviewed literature published between 1995 and 2017 on nutrition-specific and nutrition-sensitive interventions that target adolescents in Indonesia. The search to identify studies was conducted in PubMed, Google Scholar and EMBASE, using key search terms. We also explored programmatic and policy documents from the grey literature as they related to adolescents and/or Indonesia. Our search yielded thirty-five peer-reviewed articles and programmatic documents.

Setting

Indonesia.

Subjects

Adolescent girls and boys.

Results

There is very limited evidence on the impact of interventions specifically among adolescents in Indonesia. Nevertheless, findings from our review suggest the minimum package of interventions in Indonesia could include the following nutrition-specifc interventions: (i) iron–folic acid supplements, paired with antihelminths delivered at scale via school-based platforms and through health centres; and (ii) diet counselling and nutrition education provided through school-based platforms, adolescent youth centres/peer education and technology-based platforms. The minimum package could also include the following nutrition-sensitive interventions: (i) improving access to reproductive health services; and (ii) increasing the coverage of interventions designed to increase school attendance.

Conclusions

Programmes and policies targeting adolescent nutrition are relatively new and coverage is low. To improve the nutritional status of this vulnerable population, additional evaluations of adolescent programming and surveillance data on adolescents are needed.