Should adolescents be specifically targeted for nutrition in developing countries

ABSTRACT Concern for nutrition in adolescence has been rather limited, except in relation to pregnancy. This paper reviews adolescent-specific nutritional problems, and discusses priority issues for the health sector, particularly in developing countries. Chronic malnutrition in earlier years is responsible for widespread stunting and adverse consequences at adolescence in many areas, but it is best prevented in childhood. Iron deficiency and anaemia are the main problem of adolescents world-wide; other micronutrient deficiencies may also affect adolescent girls. Improving their nutrition before they enter pregnancy (and delaying it), could help to reduce maternal and infant mortality, and contribute to break the vicious cycle of intergenerational malnutrition, poverty, and even chronic disease. Food-based and health approaches will oftentimes need to be complemented by micronutrient supplementation using various channels. Promoting healthy eating and lifestyles among adolescents, particularly through the urban school system, is critical to halt the rapid progression of obesity and other nutrition- related chronic disease risks. There are pressing research needs, notably to develop adolescent-specific anthropometric reference data, to better document adolescents' nutritional and micronutrient status, and to assess the cost-effectiveness of multinutrient dietary improvement (or supplements) in adolescent girls. Our view is that specific policies areneeded at country level for adolescent nutrition, but not specific programmes.

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s underlined above, but meanwhile, existing height and BMI reference data (48) are useful, provided adjustments are made for maturity. At the individual 17 level, obesity needs to be confirmed with skinfold thickness or waist circumference measurements, as high BMI may not correspond to obesity. Adolescent-specific reference data for international use will need to be developed and validated against other measures of obesity, and also, against co-morbidity risk factors. Two years after puberty, adult BMI cut- offs may be used for overweight, and it has been suggested that equivalent cut-offs be defined for BMI-for-age at adolescence (129). Overweight grade I, or BMI above 25 in adults, corresponds roughly to the 80th percentile, and grade II (BMI >30), to the 95th. Nutritional assessment also involves dietary assessment (and looking for clinical signs of specific nutritional deficiencies as appropriate). Dietary assessment is all too often by-passed as unnecessary or too complex in health and nutrition work, at population or individual level. Yet, it is essential, and simple dietary quality scores may be developed, or else, adapted from existing tools (130-131). There should be a systematic dietary enquiry in adolescents, at least in cases of too low or too high BMI, during pregnancy, and when specific micronutrient deficiencies are suspected. 3.2.2. Control of micronutrient deficiencies Iron deficiency and anaemia need to be controlled and prevented, particularly in girls, and ahead of pregnancy as much as possible. Iron deficiency is the predominant cause of anaemia (132), and correcting it is an investment in adult productive and reproductive lives. Successful anaemia control programmes are indeed recognised as highly cost-effective, as underlined by the World Bank (108). Adolescents are to us a key target group for inclusive approaches combining sanitation, parasite control, and dietary intake. Iron from animal sources is more highly bioavailable, but consumption is constrained by income. However, there are accessible means of improving bioavailability of inorganic iron, notably consumption of vitamin C-rich foods, and avoidance of iron absorption inhibitors, such as tea, with meals. Fermentation and germination of cereals and legumes are also beneficial, although often overlooked. Iron deficiency is often accompanied with other micronutrient deficiencies such as folate, and particularly in developing countries, vitamin A and possibly also zinc. Macronutrient intake may even be inadequate in certain cases. It is therefore wise to focus on food-based approaches to improve the quality of diets of adolescents. Schools are the primary entry point, through education, school-feeding programmes, and gardening; other community-based approaches also have to be considered. Micronutrient supplementation may be indicated based on prevalence data of anaemia and vitamin A deficiency. However, for one, data on adolescents is seldom collected. Furthermore, adolescents (and even school children) are 18 usually not a priority target group for iron and vitamin A supplementation. Improving diets may be more realistic, and schools are an excellent setting to pilot-test location-specific measures to improve the nutritional quality of diets. In the case of vitamin A at least, there is now enough examples of successful dietary-based programmes (123, 133-134) to argue for such approaches. In the long-run, it is more cost-effective to stimulate local production, processing, and trade of micronutrient-dense foods, rather than to increase micronutrient supplement imports. Additionally, foods are not only nutrient mixtures; heretofore unknown protective factors are increasingly identified in various foods. Youth groups may also be resourceful for programmes designed to increase production and intake of provitamin A providing foods. In addition to education and dietary diversification, schools may be an effective vehicle for micronutrient-fortified foods. In Turkey, zinc-fortified bread was pilot-tested in school-age children, with positive preliminary results (135). There is scope for the concept of multi- nutrient fortified snacks or drinks for school children, as successfully tested in South Africa (136). Nonetheless, food-based approaches may not suffice, and adolescent girls should be a priority target group for iron-folate supplements to be distributed through schools, community workers, and youth groups. Weekly dosage may be appropriate outside of pregnancy, as some findings suggest (137-138). 3.2.3. Nutritional management of adolescent pregnancy Early pregnancy is also a nutritional issue, and preventing it should be the objective. Nutrition has to be an important dimension of antenatal (and postnatal) care particularly in adolescents. There have been reports of low effectiveness of antenatal care in general and for adolescents in developing countries, even among those attending care (139-140). Pregnant adolescents are usually at high obstetric risk by definition, and particularly so if they are immature, short and underweight (<25th percentile of BMI) at the onset of pregnancy. Adequate weight gain may even be more critical than in adult women (141), which implies close monitoring. Benchmarks for weight gain have been suggested (142). A frequent weakness of weight monitoring however, whether in pregnancy or childhood, is that inadequate weight does not seem to trigger adequate nutrition responses. Health care providers may not have a clear idea of relevant and context-specific dietary advice that can be given to pregnant women, adolescent or not, or of the counselling approach, even if by chance they do a careful dietary enquiry. It is suggested that location-specific guidelines (adapted from generic ones) be 19 developed or made available for appropriate integration of nutrition counselling in antenatal health care. Regarding food supplementation during pregnancy in order to improve foetal growth, there may be high benefit in malnourished women (143-144). There is unfortunately no specific data on adolescents, and the possibility of an adverse effect on foetal growth is a concern, as already discussed. Micronutrient supplements do not seem to pose this problem, and based on available evidence, pregnant adolescents with marginal micronutrient status may derive particular benefit from supplements of vitamin A, zinc, and calcium, in addition to iron-folate, as they are more liable to be deficient that adult women. A controlled zinc supplementation trial in African-American pregnant women with low plasma zinc resulted in a significant and substantial increase in birth weight, particularly in low BMI women, without unduly increasing the risk of cephalopelvic disproportion (145). Vitamin A supplementation during pregnancy resulted in a spectacular reduction of maternal mortality in Nepal (18). Calcium supplements may reduce the risk of premature delivery (but not intra-uterine growth retardation), pre-eclampsia and pregnancy-induced hypertension, according to systematic reviews and meta-analyses of nutrition interventions in pregnancy (146). As pregnant adolescents are at higher risk of pregnancy-induced hypertension and pre-eclampsia, calcium supplements may be of benefit (147). Furthermore, calcium supplements during pregnancy were associated with significantly lower blood pressure in the offspring, according to a controlled trial (148). In the Gambia, Prentice et al (149) observed no benefit of calcium supplements for one year after delivery on breastmilk calcium or on maternal bone mineral content, although dietary calcium intakes were low. Pregnant adolescents should be a priority subgroup for observational and intervention studies on calcium nutriture in different populations. Before pregnancy, or as early as possible, it is important to supply iodine in endemic areas without a salt iodization programme, in order to improve survival and prevent mental abnormalities in the new-born (150). Nutritional care in the postpartum may be particularly important in teenage mothers, (151). In addition to micronutrient supplementation as appropriate and diet counselling, support for breastfeeding is likely even more critical than in adult mothers, in view of reports of poorer 20 lactation performance and practices in adolescents, and of higher nutritional risk in the offspring, particularly among low-income mothers (97). 3.2.4. Management of severe malnutrition in adolescents Prevention of malnutrition in adolescents is done primarily through promotion of healthy eating, and food security measures for adequate access to food. The school has a key role in the former, while agriculture and community-based approaches are the main vehicle for the latter. In adolescents, malnutrition may be more common than normally assumed in emergency situations, and as part of emergency health care, the health sector should address this issue. Once detected, severe malnutrition is reportedly to be treated much the same as in younger children (152), although refeeding may be more difficult because of anorexia and resistance to tube feeding, and because protein content of the diet is more critical because of more common oedema. The problem is that owing to inadequate scientific basis for screening, management, and discharge criteria, severe malnourished adolescents are seldom included in therapeutic or supplementary feeding programmes offered younger children in emergency settings, other than on an ad hoc basis. Furthermore, unless the nutritional status of adolescents is appraised, it is uneasy to draw attention on high malnutrition rates, and on the need to provide nutritional support. This raises again the issue of inadequate anthropometric indicators for assessing nutritional status of adolescents. Not only height and BMI, but also the mid-arm circumference should be validated in adolescents. 3.2.5. Prevention (management) of obesity Prevention of obesity among adolescents is highly relevant wherever it is widespread in certain population segments, or else where it may soon become so. It would likely be irrelevant only in poorer groups of low income countries, particularly in rural areas. Except perhaps in poorest countries, clustering of obesity and other chronic diseases is observed in the lower income population groups. The risk behaviours are first established in society sectors with time and money to access processed foods, motorised transportation, tobacco and alcohol; as such items become accessible, the risks spread to other groups, while the more privileged are switching to healthier foods and lifestyles (50). Primary prevention of obesity is predominantly done through promoting healthy eating and physical activity, and schools are consequently the main entry point. It is not much different among adolescents and younger 21 school-age children, except that obesity prevention should be given more emphasis in adolescents. Essentially the same messages on eating hold, whether for general health, and for the prevention of obesity and other chronic diseases (see above). Where obesity is increasing and leanness is becoming a social norm, prevention of eating disturbances through strengthening self-esteem and a positive body image is more pertinent at adolescence, and particularly in girls. Schools appear as an ideal setting, as it can be assumed that in developing countries, the related problems of obesity and eating disturbances are more likely to be encountered in better-off adolescents, whose majority would still be in school, and who are under a marked influence of western youth lifestyles and values. Based on suggestions of Rosen and Neumark-Sztainer (76), school-based prevention programmes should target the following: 1) Reducing body dissatisfaction; 2) Critical thinking about socio-cultural and peer norms; 3) Understanding physical development; 4) improved knowledge about nutrition and weight control; and 5) Skill development for healthy eating and weight management. Ideally, this should be combined with opportunities for healthy eating right at school. As suggested above, BMI monitoring could be done in schools through systematic, perhaps yearly, measuring of weights and heights. Those above the cut-off for overweight (as well as the underweight school-children and adolescents) could be referred to health services for further assessment and counselling. Confirmation of obesity can be based upon skinfold thickness (or waist circumference: see 57). Children or adolescents who are referred for obesity, and whose birth record indicates that they were born at term but were of small size, as well as those who have a family history of diabetes or cardiovascular disease, are at particularly high risk. They should get relevant advice and support, and benefit from closer monitoring for body weight reduction/maintenance. Sensible snacking, staying away from dieting, avoidance of meal skipping, breakfast in particular, are additional dietary advice for weight control. While breakfast may be useful in the framework of weight control (153), it is observed that adolescents have a tendency to skip it, and obese people as well (154). Physical activity requires particular emphasis. As recommended by the American Medical Association (155), early signs of eating disorders are a low BMI (<5th percentile), or loss of 2 BMI units or loss of 10% of previous weight, combined with inappropriate feelings of being overweight, or extreme measures reported to lose weight. In addition to individual counselling, obesity/eating disorder prevention could involve small group work with those at particular risk. 22 3.3. Clinical nutrition case management This may not receive as much attention as the other two components of the global strategy for adolescent nutrition, but it is nonetheless indispensable for health care services to deal with nutritional aspects of diseases in adolescents in an appropriate manner. Although conditions requiring special diets would normally be handled by specialised health personnel, health service providers have to be aware of basic principles of nutritional management of common diseases. Among adolescents, diabetes and HIV are relevant and particularly challenging nutrition-wise. Type 1 diabetes is in industrialised countries the third most common disease in young people after asthma and cerebral palsy (156). With increasing obesity, there is evidence of growing incidence of type-2 diabetes among adolescents of developed countries. It is likely that among the diseases that call for modified diets in adolescence, diabetes is close to the top of the list. There are quite a few reports of declining metabolic control of type-1 diabetes in adolescents, owing in part to reduced self-management (157-158). A consistent observation is that family support is associated with better control of diabetes in adolescence (159-160). Group approaches to self-care may be even more effective than in adults. In contrast with type-1, those with type-2 diabetes are generally obese, and the primary aim of treatment should be gradual and sustained weight loss for glucose control and reduction of blood lipids. However, treatment of adolescents with type-2 diabetes is reportedly very difficult. Specific education, a strong interaction with the health care team, and direct involvement of the family, have been advocated (161). Regarding HIV/AIDS, adequate nutrition can improve the status and course of the disease, in adolescents and other affected age groups. However, in developing countries where malnutrition is widespread owing to poverty, and where adolescents are not a priority group for nutrition, improving the quality of diet may be quite a challenge. Multiple micronutrient supplements may have benefits (162). These supplements, and basic hygiene with food and water, may be the only feasible and the most cost-effective measures in many developing countries where HIV-infected people cannot afford the costly medication. A practical guide for nutrition in HIV has been recently developed in Zimbabwe (163). There is a risk of vertical transmission of HIV by breastmilk, but it has to be measured against the advantages of breastfeeding. It has been suggested, based on current research data, that women with HIV could breastfeed for 4 months without increasing the transmission risk (164). However, the 23 final decision is in the hands of mothers, who need to be adequately informed by health care providers, particularly adolescents. Multivitamin supplementation of infected women during pregnancy was shown to reduce low birth weights in Tanzania, while improving the immunity (165). Pregnant adolescents should be the first to receive these supplements wherever available. 4. Conclusions and recommendations Nutritional vulnerability may in certain respects be lower in adolescence than early childhood, although adolescent pregnancy is a high risk condition. It is mostly because adolescence provides a window of opportunity for long term positive impact that nutrition should be a programmatic priority in adolescents. It is a challenge, however, considering that while health is not a major concern at that age, promotion of healthy nutrition behaviours is the core element. Furthermore, there is very little data on adolescent nutrition to back up programmes and their funding. Adolescents who are not attending school may also be quite difficult to reach in certain settings. Nutrition promotion is to be the pillar of the global strategy to address nutrition issues in adolescence. Schools, more than health care centres, appear as the main entry point: adolescents are generally healthy, nutrition can be integrated in health promoting school programmes, and nutrition activities may be school-led to also reach those adolescents that are no longer in school. Schools ought to develop close links with health services for prevention and management of specific nutrition disorders, and with community development programmes to address food security problems. To us, a global strategy of this nature can be implemented without necessarily requiring a specific programme for adolescent nutrition. It is felt that explicit policies are needed at country level, however, to identify local priority issues, and to address these in a cohesive manner. WHO could provide guidance to nation states for developing their policy on adolescent nutrition. A high priority in nearly all contexts is to improve nutritional status of girls, with emphasis on micronutrients, preferably before, and at least early in their first pregnancy. This could go a long way towards curbing maternal and infant mortality, and contribute to breaking the vicious cycle of intergenerational malnutrition, poverty, and even chronic disease. School- 24 based, health facility-based, and community-based activities carried out in a coordinated fashion should be considered to improve nutrition of adolescent girls. Another relevant priority world-wide is the prevention of obesity (and disordered eating), with a particular emphasis, again on adolescent girls because they are more susceptible. Urban schools are preferred settings, as it is assumed that those adolescents at higher risk of obesity are thereby targeted. There is at present so little data on adolescents' nutritional status and micronutrient nutrition, eating patterns and underlying influences, and on impact of nutrition intervention in adolescence, that research needs are immense. In order to develop appropriate anthropometric reference data, a multi-country study, with longitudinal and cross-sectional components, on adolescents’ somatic growth and maturation should be considered high priority. Such data are needed to define not only cut-off points, but also rates of too low or too high values that should trigger action at programme or individual level. Meanwhile, the feasibility of routine weight and height measurements in schools, including adolescents and younger children, deserves to be examined. BMI nomograms and tables with percentile cut-offs for under-, as well as over-weight, as well as appropriate guidelines for their use with adolescents (and younger school-age children), could be useful for schools and health services, while efforts are pursued to develop specific reference data. Another priority research need is for well-controlled studies on the effects of micronutrient status/supplements on bone mineralisation, the timing and magnitude of the growth spurt, and maturation in adolescent boys and girls, in particular vitamin A, calcium, zinc, and iron. It was suggested earlier that adolescents (and schools) were ideal targets for food-based approaches to improving micronutrient status, in particular vitamin A and iron. The effectiveness of pilot interventions focusing on achievable improvements of micronutrient status through food would urgently need to be evaluated, with considerations of process, cost and sustainability in addition to micronutrient status impact. Much research is still needed to provide a stronger base for effective nutrition monitoring and management in pregnancy in general, and adolescent pregnancy in particular. In this regard, studies on the effect of multiple micronutrient (or food supplementation) on maternal and 25 foetal outcomes in adolescent pregnancy are warranted, because it is as yet unclear how the adolescent mother and the foetus partition the extra nutrients. A better understanding of adolescents’ diets and eating behaviours is essential for relevant education programmes. Additionally, dietary enquiry tools specifically designed for adolescents are direly needed. The enquiry should encompass household food security, food diversity (as indicator of nutritional quality), eating practices and underlying influences, and physical activity. These tools need to be developed and validated in different settings, in connection with school-based or health centre-based intervention programmes rather than as free-standing research, for higher relevance. Participatory approaches are particularly well suited for research work with adolescents. Research on two contrasting themes – severe malnutrition and obesity in adolescents - is also recommended as a means of strengthening programmes. Studies on nutritional assessment, rehabilitation, and discharge criteria in severely malnourished adolescents are called for, as well as evaluation research on the impact of school-based pilot projects for nutrition promotion and prevention of obesity. 261 FIG.1. CONCEPTUAL FRAMEWORK OF NUTRITIONAL PROBLEMS AND CAUSAL FACTORS IN ADOLESCENCE Malnutrition during foetal life/ infancy/childhood; Low body stores Livelihood factors: -Sedentary lifestyle (or heavy physical work) -Alcohol - Smoking Malnutrition, micronutrient malnutrition, obesity, and other nutrition-related chronic diseases Infectious diseases & other health problems Socio-economic factors : Access to food; Food supplies Psycho-social factors : Eating patterns Eating disturbances Cultural patterns & practices Typical eating styles of adolescents Lack of access to nutritious and safe food (poverty) Changes in processed food supplies Early pregnancy DIETARY INADEQUACIES Food supply deficit 271 FIG 2. STRATEGY FOR NUTRITION INTERVENTION IN ADOLESCENCE CLINICAL CASE MANAGEMENT Diabetes HIV/AIDS Other PREVENTION- MANAGEMENT MICRONUTRIENT MALNUTRITION EARLY PREGNANCY UNDERNUTRITION/MALNUTRITION OBESITY (and associated chronic diseases) EATING DISORDERS NUTRITION PROMOTION HEALTHY EATING BREASTFEEDING PHYSICAL ACTIVITY SELF-ESTEEM 281 REFERENCES 15. Ahmed F, Khan MR, Karim R, et al. Serum retinol and biochemical measures of iron status in adolescent schoolgirls in urban Bangladesh. Eur J Clin Nutr 1996; 50:346-51 160. Anderson JA, Brackett J, Ho J, Laffel LMB. An office-based intervention to maintain parent-adolescent teamwork in diabetes management. Diabetes Care 1999; 22:713-21 137. Angeles-Agdeppa I, Schultink W, Sastroamidjojo S, et al. Weekly nutrient supplementation to build iron stores in female Indonesian adolescents. Am J Clin Nut 1997; 66:177-83 32. Aspray TJ, Prentice A, Cole TJ, et al. 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