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Adolescent Nutrition

June 2003
Why tackle the problems of malnutrition in adolescents?
What are the main nutritional issues for adolescents?
Investing in the nutritional status of adolescents -- the costs of non-intervention?
How can adolescent malnutrition be addressed?
Do's and Don'ts of reaching and working with adolescents
For More Information...
Key References
PDF Versions (English, French, Spanish)

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Why tackle the problems of malnutrition in adolescents?

There are 1.2 billion adolescents ages 10-19 in developing nations, making up one fifth to one quarter of their country's populations. Adolescents have typically been considered a low risk group for poor health, and often receive few healthcare resources and scant attention. However, this approach ignores the fact that many health problems later in life can be improved or avoided by adopting healthy lifestyle habits in adolescence.

Adolescence is a unique intervention point in the life cycle. It offers a chance to acquire knowledge about optimal nutrition during young adulthood that could prevent or delay adult-onset diet-related illnesses later on. It is a stage of receptivity to new ideas and a point at which lifestyle choices may determine an individual's life course.

There is evidence from research in countries as diverse as Peru and India that this population can be highly amenable to public health information as it relates to their own well-being. Adolescent boys and girls can be motivated to adopt nutrition behaviors that improve their looks, school achievement and athletic performance. Potentially, behavior change messages embraced by adolescents will contribute to more sustained health and nutrition impacts within a population as the cohort of adolescents moves through its adult years. Although good nutrition for boys is an important goal on its own, an unanswered research question is the extent to which inclusion of adolescent boys in nutrition and healthy lifestyle programs will contribute to the improved nutrition and health of women during childbearing and for infants and young children in the critical early years of life.

Undernutrition (being too thin or too short, frequently caused by chronic energy deficiency) in adolescents frequently goes unrecognized by young people or their families. We now know that it:

  • Affects their ability to learn and work at maximum productivity
  • Increases the risk of poor obstetric outcomes for teen mothers
  • Jeopardizes the healthy development of future children

Children born to short, thin women are more likely themselves to be stunted and underweight (low weight for age). In addition, the heightened obstetric risk caused by stunting in childhood and adolescence persists throughout a woman's reproductive life. If adolescents are HIV+, some research suggests that undernutrition may increase the speed with which they develop full-blown AIDS, and heighten the chance that infected girls will transmit the virus to their babies. Lack of adequate nutrition diminishes the already poor quality of life of persons living with HIV/AIDS.

We have little information about the nutritional status of adolescents and nutrition. Resources have traditionally been directed at young children and pregnant women. These conditions: lack of data; low policymaker interest in the nutritional problems of adolescents; little program experience; and the dearth of resources-contribute to a critical lost opportunity to bolster the health, development, and economic progress of nations.

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What are the main nutritional issues for adolescents?

Adolescence is the second most critical period of physical growth in the life cycle after the first year. Twenty five percent of adult height is attained during adolescence. For many adolescents, inadequate quality and quantity of food are the prime determinants of nutrition problems. These conditions may be due to household food insecurity, intrahousehold allocation of food that does not meet their full range of dietary needs, livelihoods insecurity, and lack of nutrition knowledge. Micronutrient malnutrition and chronic energy deficiency resulting in thinness (low Body Mass Index or BMI [1. Body Mass Index (BMI) is a measure of thinness in adolescents and adults; it is equal to a person's weight in kilograms divided by height in meters2 or (kg)/(m2)]) and stunting stem primarily from poor diet. Excessive physical activity patterns (e.g., heavy workloads and walking long distances) and infection may also contribute to undernutrition.

Stunting (short stature) in both adolescent boys and girls was prevalent in 9 of 11 studies conducted by the International Center for Research on Women in the early 90's, ranging from 27 to 65 percent. Data on underweight (thinness indicated by low BMI for adolescents and adults) are largely unavailable for adolescents. ICRW reported low BMI ranging from 3 to 53 percent. Adolescents in India, Nepal, and Benin were the most severely affected among the 11 study sites.

Overweight/obesity data are not widely reported for adolescents, but there is growing concern about these problems. WHO estimates that 60 percent of deaths globally are due to noncommunicable diseases associated with unhealthy diets and physical inactivity, with 79 percent of these deaths occurring in developing countries. The same changes in diet and physical activity contribute to the increased prevalence of obesity in youth, often seen side by side in communities with undernutrition. There is also some evidence that low birth weight may predispose individuals to obesity and associated chronic diseases later in life. In Chile, 12 percent of schoolchildren are obese; 17 percent of older adolescent girls in South Africa are obese; and in China, one study found that the prevalence of overweight and obesity (BMI >25), in young adults has moved up from 10 to 15 percent for urban areas, and from 6 to 8 percent in rural areas, over a ten year period (1982-1992).

Iron deficiency is the most prevalent micronutrient deficiency among adolescents. Iron deficiency and anemia are associated with impaired cognitive functioning, lower school achievement and most likely lower physical work capacity. WHO estimates that 27 percent of adolescents in developing countries are anemic; the ICRW studies documented high rates in India (55 percent), Nepal (42 percent), Cameroon (32 percent) and Guatemala (48 percent). Adolescents (both boys and girls) are at risk of developing iron deficiency and iron deficiency anemia because of the increased iron requirements for growth. Infectious diseases such as malaria, schistosomiasis, and hookworm affect both boys and girls, contributing to anemia by affecting the absorption of or increasing the loss of iron. Following the end of their growth spurt, boys rapidly regain adequate iron status, whereas girls may continue to be or become more deficient because of the increased requirements for iron due to menstruation, pregnancy, and lactation.

Folate deficiency, if not addressed during the pre or periconceptual period, may cause irreversible fetal damage. Addressing folate deficiency beyond the middle of the first trimester of pregnancy will not correct neural tube defects that occur in the early weeks of pregnancy. The unplanned nature of many adolescent pregnancies underscores the need to take a preventive approach to this specific nutritional issue for youth.

In settings of endemic iodine deficiency, girls are affected disproportionately relative to boys, although all individuals are affected. Detrimental cognitive effects include neural impairment and poor school performance. The fetus of an iodine-deficient mother is at risk of spontaneous abortion as well as a range of neurological and intellectual impairments.

Other micronutrients that may be deficient in adolescents include vitamin A, zinc, and calcium. The latter two are particularly important for achieving maximum growth potential. Calcium intake in adolescence is also important for preventing osteoporosis (brittle bones) later in life. Vitamin A deficiency appears to negatively affect growth and possibly sexual maturation. It is critical for healthy immune system functioning and optimal vision.

A related health issue is adolescent pregnancy. It is often associated with nutritional, obstetric, and perinatal health risks for teen mothers and their babies. Incomplete maternal growth heightens the risk of obstructed labor. There is evidence that competition for nutrients will favor the still-growing mother, placing offspring at risk for low micronutrient stores and low birth weight. Concurrent pregnancy and growth worsen maternal micronutrient deficiencies—iron and calcium for example. Children of adolescent mothers are also often at greater risk of poor nutritional care and feeding practices.

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Investing in the nutritional status of adolescents -- the costs of non-intervention?

Information on the economic returns to various types of investment in youth development is scarce. But a recent cost-benefit analysis for iron supplementation of secondary school children estimated a benefit cost ratio between 26 and 45 depending on the assumptions. And we know something about the magnitude of the cost of non-investment. For example, it is estimated that for every kilogram less of weight at birth, an American child will achieve 15 percent less in adult earnings over his/her lifetime. The average lifetime cost of care of a child born with a neural tube defect in the US is over $500,000. In settings with high incidence of goiter, it is estimated that iodine deficiency disorders depress average intelligence by 13 IQ points. Deficits in adult height result in productivity losses (e.g., in the Philippines, a 1 percent deficit was associated with a 1.38 percent loss in agricultural wages). Anemia in adults is associated with a 17 percent reduction in productivity for heavy manual labor and 5 percent for less strenuous work.

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How can adolescent malnutrition be addressed?

There are several solutions on hand for the nutrition problems that face adolescents but there is limited experience with implementation of nutrition programs in this population group. Operational research is needed to better understand how to effectively integrate nutrition components into programs that reach and work with adolescents.

The table summarizes a wide range of recommended core interventions. The complex interplay of determinants of malnutrition means that intervention strategies could include food and dietary intake approaches, infection control (including parasites), education, improved agricultural practices, and enhanced decision-making and control of personal and household resources, to name a few. Depending on the specific nutritional issue of concern and the type of program used to deliver services, one or more of these suggested core interventions could be incorporated into an integrated program for healthy youth development.

Objective: Improve Knowqledge, Attitudes, and Behaviors of Young People

ObjectivesCore InterventionsBeneficiaries/Target Groups  Indicators 
Prevent and reduce general malnutrition
Promote optimal linear growth and prevent thinness (low Body Mass Index)Skills-based nutrition education (2) for adequate energy/protein consumption  Adolescent boys and girls at risk of stunting, thinness% adolescents falling below cutoff for height-for-age (3) 
 

Reduces excess energy expenditures (e.g., improved household food processing technology; decreased household labor production demands)

  % adolescents falling below cutoff for BMI-for-age (4)
  Infectious deises control (e.g., sexually transmitted diseases, malaria, TB)
 
   
  Micronutrient strategies (see below)
 
   
  Targeted supplementary feeding for at-risk adolescents (e.g., during natural or manmade disasters; in food insecure communities)
 
   
  Comprehensive antenatal care for pregnant adolescents including counseling on preventive health and nutrition self-care practices
 
Pregnant adolescent girlsLow birthweight (LBW) incidence rate and trends
  Targeted supplementary feeding for at-risk girls during pregnancy/lactation
 
  Weight gain during pregnancy if feasible
Prevent overweight and obesity

Skills-based nutrition education for optimal energy/protein consumption (for healthy weight maintenance and/or healthy weight reducation)

Facilitate favorable environments/opportunities for physical activity (e.g., School-based physical education programs;  urban design to promote mixed land use, recreation space/facilities)

Adolescent boys and girls at risk for obesity (LBW; children with retarded growth - both heigh and weight - in infancy/early childhood; adolescents living in obesogenic environments)% adolescents falling above cutoff for BMI-for-age (5)

Prevent and treat micronutrient deficiencies 
For all deficienciesSkills-based nutrition education for consumption of diverse food sources rich in micronutrients; counseling on the use of fortified food and supplements  All adolescents accessible through schools or other youth programsBlood levels of iron, vitamin A, or clinical signs of deficiencies 
      Urinary iodine
      Dietary diversity/intake results on dietary history, 24-hour recall, or food frequency surveys

Vitamin A deficiency (VAD) prevention and treatmentAbove plus fortification of widely consumed foods with vitamin A  All adolescents  % of vulnerable adolescents consuming VA fortified foods 
  VA supplementation in deficient populations (10,000 IU daily or 25,000 IU weekly 4-8 weeks for pregnant adolescent girls)   

Iodoine deficiency disorders prevention and treatmentUniversal salt iodization and consumer education  All adolescents (girls affected disporoportionately)% vulnerable households consuming iodized salt 
  Short-term supplementation (iodized oil; iodized water) where iodized salt is not available in iodine-dificient areas 

Proportion of target population with urinary iodine level < 100mg/L OR
Proportion of school children with palpable enlarged thyroid


Iron deficiency and anemia prevention and treatmentFortification of widely consumed foods with iron/folate  All adolescents% vulnerable households consuming iron fortified foods
Strategy will be an integrated package, depending on the specific causes of iron deficiency and anmeia in a given settingIron/folic acid supplements (weekly for non-pregnant; daily throughout pregnancy for pregnant teens)  Adolescents in supervised settings such as schools, workplace  Prevalence of anemia in target population 
       % target populatioin receiving iron/folate supplements
  Regular deworming of adolescents in high parasite-load settings (girls at higher risk than boys)  % of target population receiving deworming treatment
  Malaria control/treatmentAll adolescents living in areas with low moderate malaria transmission % of at-risk population sleeping under insecticide-treated bednets or other materials 
      % at-risk population with uncomplicated malaria receiving correct treatment according to national guidelines within 24 hrs. of onset of symptoms 
    In areas of high transmission (e.g., Sub-Saharan Africa), pregnant adolescent girls% pregnant girls who have taken chemoprophylaxis or intermittent drug treatment according to national policy
Address underlying causes of malnutrition
Postpone/avoid adolescent pregnancy to reduce nutritional lossesIncrease age at marriage; delay first pregnancy including provision of family planning and reproductive health information and services for adolescents  Adolescent girls  Age at marriage 
      Service statistics for adolescent RH services

Adolescent access to/control over foodIncrease education attainment of adolescentsAll adolescentsIncreased completion rates for secondary schooling
Parent education about meeting the nutritional needs of adolescents
Increase income earning potential (adult literacy ed; skills training; inputs/microcredit for small business enterprise development)% target population consuming ,80% of daily energy requirements OR , two meals per day
Increase household livelihood security (e.g., food policy reforms; off-farm income generation; safety nets including targeted income transfers)% of househols with expenditure on food . 50% of household expenditure

Hygiene and sanitationInfrastructure/supplies for schools (e.g., wells; sanitation facilities; soap)School-going adolescents  % of schools with functioning sanitation facilities
      Increased gross enrollment rates of girls
  Improve access to adequate water and sanitation in householdsAll adolescents  % hhs with acces to potable water; latrines

Gender equityGender-sensitive school environment/policies (e.g., safety/privacy for girls at school; flexible hours for girls; programs to support school retention for adolescent mothers; raise proportion of female teachers)Adolescent girlsFemale secondary school enrollment ratio (or gross enrollment rate of girls)
Increased age of sexual debut
Foster girls' self-esteem (e.g., sports programs; community-service projects; mentoring programs to expand girls' expectations for the future)Increased age of first pregnancy

(2) Skills-based nutrition education includes such techniques as counseling with age-tailored messages for dietary decision-making and healthy lifestyle fundamentals; shopping for best nutrition buys; food handling/safety and preparation skills

(3) % <5th percentile NCHS/WHO height-for-age (Kurz and Johnson-Welch, 1994)</font /><5th percentile NCHS/WHO height-for-age (Kurz and Johnson-Welch, 1994)

(4) % <5th percentile NCHS/WHO height-for-age (Kurz and Johnson-Welch, 1994)</font /><5th percentile NCHS/WHO height-for-age (Kurz and Johnson-Welch, 1994)</font /><5th percentile NCHS/WHO BMI-for-age (Kurz and Johnson-Welch, 1994)

(5) % >95th percentile NCHS/WHO BMI-for-age (Kurz and Johnson-Welch, 1994)

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Do's and Don'ts of reaching and working with adolescents

  • Do involve youth in the design of program messages and intervention strategies—they are your best source of information about effective communication techniques (e.g., "Nutrition is boring, but food is fun.")
  • Do segment the target adolescent population by narrow age bands (e.g., parents of 10-12 yr olds are usually responsible for diet and nutrition decisions for this age group, while 15-18 yr olds may purchase and prepare food for themselves and the household). How to reach young people will vary by multiple determinants of the population (e.g., in/out of school; at worksites; through community recreational centers or marriage registries; teen pregnancy programs, etc.)
  • Do deliver integrated programs. Work with other sectors to incorporate nutrition interventions to strengthen the results of broader investment in youth development. Teaching adolescent boys how to cook as part of a life skills curriculum breaks down traditional gender barriers and increases awareness of good nutrition. Sports programs for girls may benefit from actions to improve the nutritional status of their adolescent participants.
  • Do use nutrition education and behavior change communications strategies for healthy lifestyles as entry points for reaching adolescents with information on more sensitive topics such as human sexuality, STIs, and substance abuse.
  • Don't forget the boys. Depending on the setting, they experience the same or greater levels of malnutrition as girls in adolescence. In addition, providing accurate information about diet and nutrition needs at this stage may insure better care and health outcomes for women and children in their households later on.

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For More Information...

Nutrition Thematic Group (TG): Milla Mclachlan
Nutrition Advisory Services: Please send e-mail to nutrition@worldbank.org
Children and Youth Thematic Group (TG): Viviana Mangiaterra

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Key References

Kurz K and Johnson-Welch C. The nutrition and lives of adolescents in developing countries: Findings from the nutrition of adolescent girls research program. Washington, DC: International Center for Research on Women (1994).

Gillespie S. Improving adolescent and maternal nutrition: An overview of benefits and options. UNICEF Staff Working Papers Nutrition Series Number 97-002. New York: UNICEF (1997).

Delisle H, Chandra-Mouli MD and de Benoist B. Should adolescents be specifically targeted for nutrition in developing countries: To address which problems and how? WHO: http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/Adolescent_nutrition_paper.pdf (posted in 2000).

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PDF Versions (English, French, Spanish)

English (65kb)

French (45kb)

Spanish (43kb)

 

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