Interventions to Improve Adolescent Nutrition: A Systematic Review and Meta-Analysis

Identifying effective obesity prevention intervention components: An umbrella review mapping systematic review evidence

This overview of reviews synthesizes the effectiveness of obesity prevention interventions in children and adults on BMI/zBMI, following JBI and Cochrane Handbook guidelines. The protocol was prospectively registered in OSF in September 2020. Searches for eligible reviews were run in five databases and gray literature in May 2022. Systematic reviews published in 2010 and assessed BMI/zBMI outcomes of obesity prevention interventions were eligible. Screening, data extraction, and quality assessment were performed independently and in duplicate using standardized tools. For similar interventions, the more recent, higher-quality review was included. Thirty reviews reporting on 60 discrete interventions (i.e., a specific intervention component), mapped to 14 of 21 IOM sub-domains, were included. Nine interventions were classified as effective in improving BMI outcomes, including digital health or counseling interventions for adults in 'healthcare environments', behavioral interventions for children (broadly nutrition education), physical education curriculum modifications, and policies targeting food and beverages in 'School environments'. This review extends on previous reviews by consolidating evidence from high-quality, recent reviews to identify effective intervention components. Thus, this review provides direction for implementation efforts and highlights research gaps, where future research is warranted. However, as primary studies were not directly analyzed, gaps may reflect a lack of systematic reviews rather than primary research.

Association of malnutrition and main-meal- and snack-predominant intake among female adolescent students in boarding schools in Tasikmalaya, Indonesia

Background: Balanced dietary intake is needed to prevent malnutrition which is one of the nutritional problems faced by adolescents. Aim: To study the association between predominant dietary intake and nutritional status of female adolescent students in boarding schools in Tasikmalaya, Indonesia. Method: This cross-sectional study was conducted on 323 female adolescent students residing full-time in eight boarding schools in Tasikmalaya, West Java. Students' dietary intake was measured using the 3-non-consecutive-day 24-h recall method. The association between the predominant dietary intake and nutritional status was evaluated using binary logistic regression. Results: Of the 323 students, 59 (18.3%) were overweight/obese (OW/OB) and 102 (31.6%) had stunted growth. The predominant dietary intake in the OW/OB group was snacks, whereas, in the stunted group, it was main meals. Snack-predominant dietary intake was a risk factor for overweight and obesity (p  =  0.008; adjusted odds ratio [AOR]: 2.276; 95% confidence interval [CI]: 1.244-4.164), but it was a protective factor against stunting (p  =  0.008; AOR: 0.521; 95% CI: 0.322-0.842). Conclusion: The predominance of main meals and snacks as components of total dietary intake affected the nutritional status of female adolescent students living in boarding schools. Therefore, the dietary intake interventions should tailor and design the nutritional contents of main meals and snacks according to the nutritional status of the targeted individuals.

Adherence to Mediterranean Diet and Health Outcomes in Adolescents: An Umbrella Review

CONTEXT

Proper nutrition represents 1 of the domains of adolescents' well-being. In this context, the Mediterranean diet (MD), as a healthy, traditional, and sustainable dietary pattern, plays a crucial role in promoting adequate growth and preventing chronic noncommunicable diseases.

OBJECTIVE

The currently available evidence on the effects of adherence to the MD (AMD) in association with several physical health outcomes in adolescence is summarized in this review.

DATA SOURCES

Five electronic databases were searched.

STUDY SELECTION

Systematic reviews with or without meta-analysis of observational studies and randomized clinical trials, published in English during 2013-2022, and that assessed the health impact of AMD among adolescents were eligible.

DATA EXTRACTION

Details on study design, methods, population, assessment of dietary patterns, health outcomes, and main results were extracted.

RESULTS

The search yielded 59 references after removal of duplicates. Applying PICOS criteria, 4 systematic reviews and 3 meta-analyses ultimately were included in this review. The AMD was evaluated in association with overweight/obesity and adiposity in 2 studies, musculoskeletal health in another 2, inflammation in 1 study, and cardiometabolic health in 1 study. The seventh review examined all mentioned health outcomes (overweight and obesity, musculoskeletal health, inflammation, and cardiometabolic health) in relation to AMD.

CONCLUSIONS

Overall, this umbrella review showed limited evidence and a lack of consistency about the relation between AMD and health outcomes of interest in adolescence, indicating the need for more studies to better understand it.

SYSTEMIC REVIEW REGISTRATION

PROSPERO registration no. CRD42023428712.

Perceived Barriers and Enablers for Taking Iron-Folic Acid Supplementation Regularly Among Adolescent Girls in Indonesia: A Pilot Study

Non-compliance with iron and folic acid (IFA) supplementation is a significant contribution to the high prevalence of anemia among adolescent girls in Indonesia. This pilot study aims to explore the perceived barriers and enablers to regular IFA supplement consumption among adolescent girls. Using a qualitative approach, data were collected through focus group discussions (FGDs) conducted in Makassar and Padang City. The FGD involved 32 grade eight and nine students from four junior high schools. In-depth interviews were also conducted with health workers, teachers, and parents to triangulate the findings. A thematic analysis was performed using a social cognitive theory framework. The average age of the informants was 13.6 ± 0.6 years. Despite receiving IFA supplements at school, only 47% of informants reported consuming them regularly. Key barriers to regular supplementation included dislike of the taste and smell, parental prohibition, negative experience consuming IFA supplements, the belief that IFA supplements increase menstrual blood flow and volume, and forgetfulness factors. Enablers include self-awareness of the supplement's benefits, trust in school-provided supplements, and positive support from parents and peers. The findings highlight that both barriers and enablers play a crucial role in influencing IFA supplementation adherence. Addressing these factors is essential for improving compliance and reducing anemia rates among adolescent girls. Given the small sample size and convenience sampling method, this study serves as a pilot, and further research is needed to validate these findings on a larger scale.

Menarche and pubertal progression: a cross-sectional analysis of timing and influencing factors in North-Eastern Ghana

Menarche and pubertal onset vary across populations but understanding age-at-menarche (AAM) and pubertal growth tempo is limited in low-income settings. Identifying factors influencing pubertal development is vital for creating targeted health and education programmes supporting adolescent girls' well-being. Baseline data (n = 1045) from the Ten2Twenty-Ghana study were analysed to examine menarche attainment, pubertal development, AAM, and the associated factors among girls aged 10-17 years in the Mion district, Ghana. The data collection methods included anthropometry, body composition, haemoglobin status, a qualitative 24-hour dietary recall, a food frequency questionnaire, and a pubertal development score (PDS). Binary logistic and linear regression analyses were used to model odds ratios for menarche attainment and regression coefficients for AAM and PDS. About 19.9% of the girls had experienced menarche, with a mean AAM of 13.4 ± 1.5 years. Among post-menarche girls (n = 205/1045), 12.2% and 15.1% experienced early (AAM < 12 years) and late menarche (AAM < 15 years), respectively. The mean PDS was 1.8 ± 0.7 out of 4. Among the adolescent girls, 36.2% were prepubertal, 17.0% early -pubertal, 18.6% mid-pubertal, 27.9% late pubertal, and less than 1% were in the post-pubertal stage. An increase in fat mass (FM), fat-free mass (FFM), height-for-age-z-score (HAZ), and body mass index-for-age-z-score (BAZ) was observed with puberty progression, but a steep decline in HAZ was noticed for girls in late puberty, increasing again post-puberty. Being older (adjusted odds ratio (AOR) = 2.06, 95% C.I.: 1.83, 2.31), stunted (AOR= 0.20, 95% C.I.: 0.10, 0.40), thin (AOR = 0.30, 95% C.I.: 0.11, 0.80), and overweight/obese (AOR = 7.29, 95% C.I.: 2.60, 20.43) were the significant predictors of menarche attainment. Being older (β = 0.39, P < 0.0001), stunted (β= -0.92, P = 0.01), thin (β = 1.25, P = 0.01), and having a literate mother (β = -0.72, P = 0.03) were significantly associated with AMM. A higher HAZ, FM, FFM, age, and Konkomba ethnicity were positively associated with higher PDS. This study highlights the complexity of factors influencing menarche and pubertal development. These insights are essential for developing targeted health and educational programmes that address nutritional and socio-demographic disparities to promote adolescent girls' well-being and healthy pubertal development.

Effect of double-duty interventions on double burden of malnutrition among adolescents in Debre Berhan Regiopolitan City, Ethiopia: a cluster randomised controlled trial

Combating the double burden of malnutrition (DBM) in adolescents is a critical public health challenge in low-income countries like Ethiopia. However, past efforts have lacked focus and exhibited diverse governance strategies. Therefore, this study assesses the effect of selected double-duty interventions (DDIs) on DBM among adolescents in Central Ethiopia. The DBM status (thinness, normal, overweight/obesity) was determined using WHO AnthroPlus software. A two-arm parallel cluster randomised controlled trial was used among 708 adolescents (356 for the intervention group [IG] and 352 for the control group [CG]) from 13 October 2022 to 30 June 2023. The intervention's effect was analysed through difference-in-difference (DID) analysis and a multivariable multinomial generalised estimating equation (GEE) model with significance set at P < 0.05. The overall DBM prevalence decreased by nearly 7% (4.7% for thinness, 2.2% for overweight/obesity) in the DID analysis. After adjusting for possible confounders, the GEE model indicated that adolescents in the IG were 34% less likely to have higher DBM than those in the CG (AOR = 0.66, 95% CI [0.46, 0.94]). Additionally, the probability of DBM decreased by 59% at the end line compared to baseline measurements (AOR = 0.41, 95% CI [0.03, 0.92]). Adolescents in the category of time and IG interaction were 44% less likely to have increased DBM (AOR = 0.56, 95% [CI 0.02, 0.38]). Thus, this study underscores the effectiveness of selected DDIs in addressing DBM among adolescents using a health belief model. These results advocate for the integration of DDI strategies into existing nutrition guidelines, programmes, and policies. The trial was registered prospectively in ClinicalTrials.gov with registration number NCT05574842.

Knowledge, attitude, and practices of adolescents and peer educators in relation to the components of the National Adolescent Health Program in India: findings from a cross-sectional survey

Background

Adolescence is a critical period of growth and development. Many adverse health outcomes in adulthood begin during adolescence, often due to insufficient knowledge and attitudes resulting from a lack of education. Therefore, appropriate knowledge, attitudes, and practices (KAP) regarding various aspects of health are essential for holistic adolescent and lifelong health. In India, the Rashtriya Kishore Swasthya Karyakram (RKSK or National Adolescent Health Strategy) has utilized an innovative peer-education approach to engage with adolescents and improve their KAPs. Amid limited evidence, we aimed to assess the KAP of adolescents regarding the six themes of the RKSK, with a particular focus on the status of peer educators (PEs). Our objective was to evaluate these aspects disaggregated by sex and to examine how engagement with the RKSK peer-education program influenced their KAP.

Methods

A cross-sectional survey of 238 peer educators and 2885 adolescents enrolled under peer educators was conducted in two localities; Madhya Pradesh and Maharashtra states. KAPs were estimated using descriptive statistics then disaggregated by gender. Practice scores of nutrition and non-communicable disease (NCD) were modelled upon engagement with RKSK (graded as 0, 1, 2, 3).

Results

Knowledge was highest regarding substance misuse and lowest in the domains of sexual and reproductive health, and violence and injury. PEs possessed greater knowledge in most domains as compared to adolescents enrolled under them. Attitudes toward abstention from substance misuse were positive, whereas attitudes toward injury and violence, and sexual health, were suboptimal. Boys exhibited better practices related to NCDs, while their nutritional practices were comparatively worse than girls. The RKSK engagement was associated with better nutritional practices: adjusted relative risks (RRs) being 1.04 (95% confidence interval [CI]: 0.94-1.15), 1.12 (1.04-1.21), and 1.21 (1.13-1.31), respectively, for engagement scores 1, 2, and 3 with reference to score 0. The relationship between RKSK engagement and NCD-related practices was restricted to the top engagement group.

Conclusion

The knowledge regarding sexual health, and injury and violence, was grossly deficient in adolescents. These components must be prioritized in the program because they are critical for health not only across the life course of individuals but also across generations. However, the RKSK engagement was associated with better practices in a variety of domains, which should be leveraged in the future.

Impact of weekly iron-folic acid supplementation on nutritional status and parasitic reinfection among school-age children and adolescents in Sub-Saharan Africa: a systematic review and meta-analysis

Background

Two significant etiological factors contributing to iron deficiency anemia, and undernutrition posing substantial public health challenges in Sub-Saharan Africa, are soil-transmitted helminths and malaria. This study carried out the effect of weekly iron-folic acid supplementation (WIFAS) on the nutrition and general health of school-age children and adolescents in Sub-Saharan Africa, a systematic review and meta-analysis have been conducted.

Methods

To find pertinent publications for this study, a thorough search was carried out on May 20, 2023, across five databases: Pubmed (MEDLINE), Web of Science, Scopus, Cochrane Library, and Google Scholar. In addition, a search was conducted on August 23, 2023, to capture any new records. The inclusion criteria for the studies were based on school-age children and adolescent populations, randomized controlled trials, and investigations into the effects of WIFAS. The outcomes of interest were measured through anthropometric changes, malaria, and helminthic reinfection.

Results

A systematic review of 11 articles revealed that WIFAS significantly decreased the risk of schistosomiasis reinfection by 21% among adolescents (risk ratio = 0.79, 95%CI: 0.66, 0.97; heterogeneity I 2 = 0.00%, P = 0.02). However, no significant impact was observed on the risk of malaria reinfection (risk ratio = 1.02, 95%CI: 0.92, 1.13; heterogeneity I 2 = 0.00%, P = 0.67) or A. Lumbricoides reinfection (risk ratio = 0.95, 95%CI: 0.75, 1.19; heterogeneity I 2 = 0.00%, P = 0.65). Moreover, the analysis demonstrated that there is no significant effect of iron-folic acid supplementation in measured height and height for age Z-score (HAZ) of the school-age children (Hedge's g -0.05, 95%CI: -0.3, 0.2; test for heterogeneity I 2 = 0.00%, P = 0.7) and (Hedge's g 0.12, 95%CI: -0.13, 0.37; test for heterogeneity I 2 = 0.00%, P = 0.36) respectively.

Conclusion

The effectiveness of WIFAS in reducing the risk of schistosomiasis reinfection in adolescents has been demonstrated to be greater than that of a placebo or no intervention. Additionally, the narrative synthesis of iron-folic acid supplementation has emerged as a potential public health intervention for promoting weight change. However, there was no significant association between WIFAS and Ascariasis, trichuriasis, and hookworm. Moreover, the certainty of the evidence for the effects of WIFAS on height and malaria is low and therefore inconclusive. Whereas, the certainty of the evidence for the effectiveness of WIFAS on Schistosomiasis is moderate. Even though the mechanisms need further research WIFAS may be implemented as part of a comprehensive public health strategy to address schistosomiasis in adolescents.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023397898, PROSPERO (CRD42023397898).

A randomized controlled trial of sweet basil leaf powder-enriched cookies for anemia management in adolescent girls

The study aimed to evaluate the effectiveness of sweet basil leaf powder as a natural source of iron for the treatment of anemia in adolescent girls. Purposive sampling technique of two-stage sampling; part of the nonprobability sampling approach. Out of 2400 approached adolescent girls, 1645 agreed to participate and their nutritional status was assessed. Of these, 89.95% had clinical signs and symptoms of anemia, and 59.79% were found to be anemic based on Hb levels. From the anemic group, 65.18% were randomly selected to receive either B0 (Control), B1 (12.699 g FeSO4.7H2O/100 g), and B3 (16 g SBLP/100 g) cookies for 4 months. At the end of the intervention, the assessment of nutritional status, complete blood count, serum iron, serum ferritin, serum total iron-binding capacity (TIBC), and transferrin saturation was explored. Hematological parameters such as Hb, Hct, TIBC, MCV, MCH, MCHC, serum iron, and serum ferritin were significant (p ≤ .05). The result showed that the serum Fe was highest in group B3 while a significant decline was noted for group B0. Serum ferritin for B1 was better than B3. The entire treatment for transferrin saturation showed a highly significant increasing trend in B3 and B1, regardless of the control. TIBC levels raised in the control group while in all other treatments, it declined. The study demonstrated that SBLP-fortified cookies can be an effective treatment option for anemia, as evidenced by significant improvements in key hematological parameters.

Preconception Care Interventions for Adolescents and Young Adults to Prevent Adverse Maternal and Child Health Outcomes: Protocol for an Evidence Gap Map

BACKGROUND

Preconception is the period before a young woman or woman conceives, which draws attention to understanding how her health condition and certain risk factors affect her and her baby's health once she becomes pregnant. Adolescence and youth represent a life-course continuum between childhood and adulthood, in which the prepregnancy phase lacks sufficient research.

OBJECTIVE

The aim of the study is to identify, map, and describe existing empirical evidence on preconception interventions that enhance health outcomes for adolescents, young adults, and their offspring.

METHODS

We will conduct an evidence gap map (EGM) activity following the Campbell guidelines by populating searches identified from electronic databases such as MEDLINE, Embase, CINAHL, and Cochrane Library. We will include interventional studies and reviews of interventional studies that report the impact of preconception interventions for adolescents and young adults (aged 10 to 25 years) on adverse maternal, perinatal, and child health outcomes. All studies will undergo title or abstract and full-text screening on Covidence software (Veritas Health Innovation). All included studies will be coded using the Evidence for Policy and Practice Information (EPPI) Reviewer software (EPPI Centre, UCL Social Research Institute, University College London). Cochrane Risk of Bias tool 2.0 and Assessing the Methodological Quality of Systematic Reviews-2 (AMSTAR-2) tool will be used to assess the quality of the included trials and reviews. A 2D graphical EGM will be developed using the EPPI Mapper software (version 2.2.4; EPPI Centre, UCL Social Research Institute, University College London).

RESULTS

This EGM exercise began in July 2023. Through electronic search, 131,031 publications were identified after deduplication, and after the full-text screening, 18 studies (124 papers) were included in the review. We plan to submit the paper to a peer-reviewed journal once it is finalized, with an expected completion date in May 2024.

CONCLUSIONS

This study will facilitate the prioritization of future research and allocation of funding while also suggesting interventions that may improve maternal, perinatal, and child health outcomes.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56052.

Determinants of Stunting in Young Women Age 13-15 Years in South Galesong District, Takalar Regency, Indonesia: a Cross-sectional Study

Background and Objective

Malnutrition is a serious public health problem in developing countries, including Indonesia. Based on RISKESDAS 2018, the prevalence of stunting aged 13-15 years in Takalar Regency is 24.83%. This study aimed to assess the prevalence of stunting and the determinants of stunting in adolescent girls aged 13-15 years in the South Galesong District, Takalar Regency.

Methods

This is a cross-sectional study using purposive sampling method that included 247 adolescent girls in selected junior high schools. Data collection used questionnaires and anthropometric measurements. An anthropometric measurement was converted to the indices of nutritional status using World Health Organization Anthro Plus software.

Results

The prevalence of stunting was 25.1%. Bivariate analysis showed determinant factors related significantly to stunting were energy intake (p<0.001), protein intake (p<0.001), iron intake (p<0.005), and zinc intake (p<0.001). Multivariate analysis showed determinant factors related significantly to stunting were zinc intake (p<0.001, OR=7.993), protein intake (p<0.05, OR=2.248), and knowledge level (p<0.05, OR=2.032).

Conclusion

The occurrence of stunting is related to the quality and quantity of food and the level of adolescent knowledge about balanced nutrition. It is necessary to hold educational programs and interventions on improving nutrition initiated by stakeholders and the department of health, in this case, the health center is needed to reduce stunting rates, especially among adolescents.

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).

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.

Undernutrition in older children and adolescents in peri-urban Zambia

Background

Adolescents make up roughly a quarter of the population in Zambia; however, most nutrition-related programming is targeted at the under-five population. Understanding the scale of undernutrition in older children and adolescents is fundamental to alleviating food insecurity and addressing undernutrition across all age groups.

Methods

A cross-sectional survey was performed in four low-income, peri-urban compounds in Chilanga District which included anthropometric measurements of children between ages 6 months-19 years and a household-level diet diversity and food security questionnaire. Wasting was used for children under 5 and thinness for children 5-19 years. Descriptive analysis and multivariate logistic regression were conducted to quantify the prevalence and distribution of malnutrition and understand the impact of food security.

Results

We surveyed 393 households and 1,004 children between the ages of 6 months and 19 years. Children aged 6-9 years had the highest prevalence of severe thinness (5.2%) and adolescents (10-19 years) had the highest rates of moderate thinness (6.5%). Across all age groups, more than 75% of children were in households that worried about running out of food in the previous month. 24.9% of adolescents and 28.4% of older children were in households were more likely to go a whole day without eating compared to 16.9% of children under 5.

Conclusion

Our survey indicated that malnutrition in adolescents and older children living in Chilanga district was comparable to those under 5. Interventions to address undernutrition must be targeted at older children and adolescents in order to ameliorate this burden.

Factors associated with anemia among school-going adolescents aged 10-17 years in Zanzibar, Tanzania: a cross sectional study

BACKGROUND

Anemia among adolescents (ages 10-19 years) is a leading cause of morbidity and mortality in low- and middle-income countries and carries long-term health and economic consequences. To address the issue, policymakers and programmers require evidence of the burden of anemia among adolescents in specific contexts, as well as an understanding of the factors associated with anemia in this population.

METHODS

We conducted a cross-sectional survey as a baseline assessment to determine the prevalence and factors associated with anemia in secondary school students, as part of a cluster-randomized effectiveness trial testing different micronutrient supplementation strategies in addressing anemia among adolescents in Zanzibar. Between March 7th to 25th, 2022 the survey was conducted on 2,479 school-going adolescents aged 10-17 years from 42 schools on the island of Zanzibar, Tanzania. Hemoglobin concentration was measured along with the collection of socio-demographics, health, food frequency, and water, sanitation and hygiene data.

RESULTS

Based on the World Health Organization cutoffs for anemia, 53.3% of the sample had anemia (mild, moderate, or severe). Using chi-square tests and logistic regressions, we determined that females had higher odds of anemia than males (Adjusted OR = 1.47; 95% CI: 1.24, 1.74), those in the highest wealth quintile had lower odds of anemia than those in the lowest wealth quintile (Adjusted OR = 0.7; CI: 0.54, 0.91), stunted adolescents had higher odds of anemia than non-stunted students (Adjusted OR = 1.38; 95% CI: 1.06,1.81), and those who used shared toilets had higher odds of moderate or severe anemia than those with private toilet access (Adjusted OR = 1.68; CI: 1.07, 2.64).

CONCLUSIONS

The high prevalence of anemia in this sample indicates an urgent need to address anemia among adolescents in Zanzibar, and the factors associated with anemia point to the importance of water, sanitation, and hygiene interventions in addition to dietary and nutritional support.

TRIAL REGISTRATION

NCT05104554, registered 03/11/2021.

Remote Implementation of a School-Based Health Promotion and Health Coaching Program in Low-Income Urban and Rural Sites: Program Impact during the COVID-19 Pandemic

BACKGROUND

Adapting existing health programs for synchronous remote implementation has the potential to support vulnerable youth during the COVID 19 pandemic and beyond.

METHODS

The Stanford Youth Diabetes Coaches Program (SYDCP), a school-based health promotion and coaching skills program, was adapted for remote implementation and offered to adolescents from low-income communities in the US: an urban site in San Jose, CA and rural sites in Lawrence County, MO, and Central Valley, CA. Participants completed online pre- and post- surveys. Analysis included paired T-tests, linear regression, and qualitative coding.

RESULTS

Of 156 enrolled students, 100 completed pre- and post-surveys. Of those: 84% female; 40% Hispanic; 37% White; 28% Asian; 3% African American; 30% other race. With T-tests and regression models, the following measures showed statistically significant improvements after program participation: health knowledge, patient activation, health understanding and communication, consumption of fruits and vegetables, psychosocial assets of self-esteem, self-efficacy, problem-solving, and ability to reduce stress. Technology barriers were frequently reported at Lawrence County site. 96% participants reported making a lifestyle change after program participation.

CONCLUSIONS

Remote implementation of health promotion programs for vulnerable youth in diverse settings has potential to support adoption of healthy behaviors, enhance patient activation levels, and improve psychosocial assets.

Influence of ecoregional and lifestyle factors on growth and body composition of I ndian children and adolescents aged 9–18 years—A multicenter study

OBJECTIVES

Ecoregion comprises all the environmental factors such as climate, vegetation, geomorphology, and soil taken together. The objectives of this study were to (1) assess differences in growth and body composition (BC) in 9-18-year-old children and adolescents (CA), across six ecoregions of India, (2) evaluate and compare the magnitude of the effect of ecoregional and lifestyle factors (LSF) on growth and BC in urban (U) and rural (R) children and adolescents, and (3) reassess the applicability of Bergmann's Rule and Allen's Rule to humans.

SUBJECTS AND METHODS

Data on 1845 CA (925 boys; 920 girls) were collected (2016-2017) from urban and rural areas of six ecoregions of India. Anthropometric and BC parameters were measured; Z-scores were computed. Lifestyle Index score (LIS) based on LSF-(socioeconomic status [SES], diet, physical activity) was computed (categorized as low, medium, high-indicates better LSF). Univariate analysis was performed to estimate effect size.

RESULTS

Significant differences were observed in growth and BC across urban and rural ecoregions. CA with high LIS were taller and heavier than those with low LIS (p < .05). Ecoregion had greater effect on growth (Partial eta square (η² ) for R = 0.136 vs. U = 0.057) and BC (η² for R = 0.094 vs. U = 0.058) of rural CA than urban (p < .01). LSF had more effect on the BC of urban CA (η²  = 0.017) than rural (η²  = 0.002, p < .01).

CONCLUSION

Disparities among the six ecoregions were not large enough to fully support Bergmann's Rule and Allen's Rule. Ecoregion had greater effect on growth and BC of rural CA than urban, while lifestyle factors had more effect on the BC of urban CA.

Nutritional Behaviour of Adolescents and the Impact of Covid-19 on A Diet in Saudi Arabia

Background In recent decades, changes in food consumption among adolescents in Arabic speaking countries, including The Kingdom of Saudi Arabia (KSA), has resulted in increased burden of overweight and obesity. COVID-19 related restrictions have further impacted lifestyle and diet among adolescents in KSA. Aim The present study aimed to assess the knowledge, attitude, behaviour and dietary patterns of adolescents and the impact of the COVID-19 pandemic related restrictions on these behaviours. Methods A cross-sectional study was conducted in six intermediate schools among 1500 adolescents (11-15 years) via an anonymous online survey. The Chi Square test was used to compare gender stratified nutritional knowledge, attitude and behaviour of adolescents and the impact of COVID-19 related restrictions. To determine the factors associated with nutritional change during COVID-19 lockdown, logistic regression was employed using the categorisation of nutritional change during COVID-19 restrictions versus no change in univariate and multivariate analyses. Results A good level of nutrition-related knowledge and attitude was demonstrated both by female and male students, with 66% and 57% of participants scoring above the median of the total possible knowledge and attitude score, respectively. After adjusting for all variables, higher nutrition knowledge score predicted students to be less likely to report increased food consumption during COVID-19 restrictions, whereas students with higher nutrition attitude scores and with a higher risk of increased food consumption were more likely to increase food consumption during COVID-19 restrictions. Conclusions Unhealthy dietary habits among Saudi adolescents are of paramount public health concern and the COVID-19 restriction period exacerbated the pre-pandemic nutrition-related unhealthy behaviours. Therefore, school-based interventions aiming to promote healthy lifestyles and the wellbeing of Saudi adolescents and use of qualitative recall dietary diary is also crucial to develop programs that prevent unhealthy lifestyles in adolescents in Saudi Arabia.

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.

Malnutrition in Devbhumi Dwarka: A Situation Analysis

Background Malnutrition among children, adolescent girls and women is a serious public health issue in India. Malnutrition among adolescent girls is likely to carry on this vicious cycle by giving birth to low birthweight babies. Moreover, low birthweight babies who survive are likely to suffer growth retardation and illness throughout their childhood, adolescence and adulthood. Present situation analysis highlights not only the overall nutrition picture of Devbhumi Dwarka but also narrates the uptake of current nutrition and healthcare services in the Devbhumi Dwarka district. Methods A descriptive cross-sectional study was conducted with 3,738 study population (1,301 children, 1,185 pregnant and lactating women and 1,252 adolescent girls) across four blocks of the Devbhumi Dwarka district of Gujarat. Anthropometric assessments were carried out and the WHO Asia Pacific classification was used for the assessment of malnutrition. Results The prevalence of wasting, underweight and stunting was 14%, 17% and 32%, respectively, in children under two years of age. The prevalence of anaemia among pregnant women (Hb <11 g/dL) was 72.92%; 91.36% of lactating women were anaemic (Hb <12 g/dL). The prevalence of underweight (<-2 SD) among adolescent girls was 19.6%. Block-wise variation in prevalence was observed. Overall, utilization of integrated child development services and health services by these target groups remained sub-optimal. Conclusion The study has revealed the suboptimal nutritional status of children, pregnant and lactating women and adolescent girls of Devbhumi Dwarka, which signifies the need for urgent attention. Several areas of priority have been identified and discussed to improve the overall nutrition status in the district.

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.

Global burden and inequality of iron deficiency: findings from the Global Burden of Disease datasets 1990-2017

BACKGROUND

Iron deficiency (ID) impairs patient physical activity, recognition and life quality, which is difficult to perceive but should not be underestimated. Worldwide efforts have been made to lower ID burden, however, whether it decreased equally in different regions and sexes is unclear. This study is to examine regional and sex inequalities in global ID from 1990 to 2017.

METHODS

We conducted a longitudinal, comparative burden-of-disease study. Disability-adjusted life-years (DALYs) of ID were obtained from Global Burden of Disease Report 2017. Human Development Index (HDI) data were obtained from Human Development Report 2017. Gini coefficient and the concentration index were calculated to assess the equities in global burden of ID.

RESULTS

A downward trend of global ID burden (from 569.3 (95% Uncertainty Interval [UI]: 387.8-815.6) to 403.0 (95% UI: 272.4-586.6), p < 0.001), age-adjusted DALYs per 100,000 population) but an uptrend of its inequalities (from 0.366 to 0.431, p < 0.001, Gini coefficients) was observed between 1990 and 2017. ID burden was heavier in women than that in men ([age-adjusted DALYs per 100,000 population from 742.2 to 514.3] vs [from 398.5 to 291.9]), but its inequalities were higher in men since 1990. The between-sex gap of ID burden was narrowed with higher HDI (β =  - 364.11, p < 0.001). East Asia & Pacific and South Asia regions made a big stride for ID control in both sexes over decades [age-adjusted DALYs per 100,000 population from 378.7 (95% UI: 255.8-551.7) in 1990 to 138.9 (95%UI: 91.8-206.5) in 2017], while a heavy burden among Sub-Saharan African men was persistent[age-adjusted DALYs per 100,000 population, 572.5 (95% UI: 385.3-815) in 1990 and 562.6 (95% UI: 367.9-833.3) in 2017].

CONCLUSIONS

Redistributing attention and resources to help countries with low HDI, especially take care of women with low socioeconomic status (SES) and men under high ID burden may help hold back the expanding ID inequality.

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.

A Life Course Approach to the Prevention of Iron Deficiency Anemia in Indonesia

Iron deficiency anemia (IDA) has a long-term impact on each life stage and remains worldwide a major public health problem. Eleven experts were invited to participate in a virtual meeting to discuss the present situation and the available intervention to prevent iron deficiency anemia in Indonesia. The experts consisted of obstetric gynecologists, pediatricians, nutritionists, midwives, a clinical psychologist, and an education expert. Existing interventions focus attention on preconception and early childhood stages. Considering the inter-generational effects of IDA, we call attention to expanding strategies to all life stages through integrating political, educational, and nutritional interventions. The experts agreed that health education and nutritional intervention should be started since adolescence. Further research to explore the effectiveness of these interventions would be important for many regions in the world. The outcome of this Indonesian consensus is applicable worldwide.

Investigating the disjoint between education and health policy for infant feeding among teenage mothers in South Africa: a case for intersectoral work

BACKGROUND

Many low-and-middle-income countries, including South Africa, have high rates of teenage pregnancy. Following the World Health Organisation recommendations, South African health policy on infant feeding promotes exclusive breastfeeding until six months of age, with gradual weaning. At the same time, South Africa's education department, in the interest of learners, promotes adolescents' early return to school post-partum. Yet infant feeding at school is currently not perceived as a realistic option.

METHODS

Recognising his this policy tension, we aimed to explore how policies are interpreted and implemented by the health and education sectors through interviews with key informants who produce, interpret and implement these policies. Using an interview guide developed for this study, we conducted in-depth interviews with 24 health policy makers, managers in both sectors, school principals and nursing staff who manage adolescent mothers (aged 16-19) and their babies. Data was analysed using thematic analysis.

RESULTS

Informants from both sectors expressed discomfort at pregnant learners remaining in school late in pregnancy and were uncertain about policy regarding when to return to school and how long to breast-feed. Educators reported that new mothers typically returned to school within a fortnight after delivery and that breastfeeding was not common. While health professionals highlighted the benefits of extended breastfeeding for infants and mothers, they recognised the potential conflict between the need for the mother to return to school and the recommendation for longer breastfeeding. Additionally, the need for ongoing support of young mothers and their families was highlighted.

CONCLUSIONS

Our findings suggest educators should actively encourage school attendance in a healthy pregnant adolescent until delivery with later return to school, and health providers should focus attention on breastfeeding for the initial 4-6 weeks postpartum, followed by guided support of formula-feeding. We encourage the active engagement of adolescents' mothers and extended families who are often involved in infant feeding and care decisions. Education and health departments must engage to facilitate the interests of both the mother and infant: some exclusive infant feeding together with a supported return to school for the adolescent mother.

Improving adolescent knowledge and attitude toward the intergenerational cycle of undernutrition through audiovisual education: findings from RESEPIN study in Yogyakarta, Indonesia

Background:

Adolescent health and nutrition contribute to the intergenerational cycle of undernutrition.

Objectives:

The aim of this study is to examine the effect of audiovisual education on adolescent knowledge and attitude toward the intergenerational cycle of undernutrition.

Material and Methods:

A clustered quasi-experimental study with a pre-and posttest design in Kulon Progo District, Yogyakarta, Indonesia. Participants were female adolescent students enrolled in Grade 7 at two junior high schools in Sentolo (n = 120) and Kalibawang (n = 96) subdistricts. We provided six topics related to adolescent health and nutrition throughout six online meetings for the intervention and control groups. In addition, the intervention group received audiovisual education through recorded videos, whereas the control group received education through e-leaflets following the online meetings. We assessed adolescent knowledge and attitude during pre-and posttest evaluations using Google Forms. Paired t-test was performed to analyze the data.

Results:

Both audiovisual and e-leaflet educations increased adolescent knowledge and attitude. Adolescents who received audiovisual education had significantly higher knowledge (P = 0.046) and attitude (P = 0.034) scores than adolescents who received education through e-leaflets.

Conclusions:

The audiovisual education intervention improved adolescent knowledge and attitude toward the intergenerational cycle of undernutrition than using e-leaflets.

Review Nutritional interventions during adolescence and their possible effects

Nutrition is one of the most important factors affecting pubertal development. Increasing demands for energy proteins and micronutrients are necessary to cope with the rapid linear pubertal growth and development, change in body composition, and increased physical activity. Adequate nutrition is a key permissive factor for the normal timing and tempo of pubertal development. Severe primary or secondary malnutrition also can adversely delay the onset and progression of puberty. The higher incidence of anorexia nervosa and bulimia in adolescents imposes a nutritional risk on pubertal development. Here we provide an overview of nutritional requirements (macronutrients and micronutrients) necessary to cope with these changes. In addition, we discuss possible nutritional interventions trials and their effects on several aspects of growth and development in undernourished and stunted adolescents, in low- and middle-income countries (LMIC), who require nutritional rehabilitation. This mini-review sums up some important findings in this important complex that links between nutrition, nutritional interventions, and pubertal development.

Exploring influences on adolescent diet and physical activity in rural Gambia, West Africa: food insecurity, culture and the natural environment

OBJECTIVE

To explore, from the perspectives of adolescents and caregivers, and using qualitative methods, influences on adolescent diet and physical activity in rural Gambia.

DESIGN

Six focus group discussions (FGD) with adolescents and caregivers were conducted. Thematic analysis was employed across the data set.

SETTING

Rural region of The Gambia, West Africa.

PARTICIPANTS

Participants were selected using purposive sampling. Four FGD, conducted with forty adolescents, comprised: girls aged 10-12 years; boys aged 10-12 years; girls aged 15-17 years, boys aged 15-17 years. Twenty caregivers also participated in two FGD (mothers and fathers).

RESULTS

All participants expressed an understanding of the association between salt and hypertension, sugary foods and diabetes, and dental health. Adolescents and caregivers suggested that adolescent nutrition and health were shaped by economic, social and cultural factors and the local environment. Adolescent diet was thought to be influenced by: affordability, seasonality and the receipt of remittances; gender norms, including differences in opportunities afforded to girls, and mother-led decision-making; cultural ceremonies and school holidays. Adolescent physical activity included walking or cycling to school, playing football and farming. Participants felt adolescent engagement in physical activity was influenced by gender, seasonality, cultural ceremonies and, to some extent, the availability of digital media.

CONCLUSIONS

These novel insights into local understanding should be considered when formulating future interventions. Interventions need to address these interrelated factors, including misconceptions regarding diet and physical activity that may be harmful to health.

Nutrition-specific interventions for preventing and controlling anaemia throughout the life cycle: an overview of systematic reviews

BACKGROUND

Anaemia is a prevalent health problem worldwide. Some types are preventable or controllable with iron supplementation (pills or drops), fortification (sprinkles or powders containing iron added to food) or improvements to dietary diversity and quality (e.g. education or counselling).

OBJECTIVES

To summarise the evidence from systematic reviews regarding the benefits or harms of nutrition-specific interventions for preventing and controlling anaemia in anaemic or non-anaemic, apparently healthy populations throughout the life cycle.

METHODS

In August 2020, we searched MEDLINE, Embase and 10 other databases for systematic reviews of randomised controlled trials (RCTs) in anaemic or non-anaemic, apparently healthy populations. We followed standard Cochrane methodology, extracting GRADE ratings where provided. The primary outcomes were haemoglobin (Hb) concentration, anaemia, and iron deficiency anaemia (IDA); secondary outcomes were iron deficiency (ID), severe anaemia and adverse effects (e.g. diarrhoea, vomiting).

MAIN RESULTS

We included 75 systematic reviews, 33 of which provided GRADE assessments; these varied between high and very low. Infants (6 to 23 months; 13 reviews) Iron supplementation increased Hb levels and reduced the risk of anaemia and IDA in two reviews. Iron fortification of milk or cereals, multiple-micronutrient powder (MMNP), home fortification of complementary foods, and supplementary feeding increased Hb levels and reduced the risk of anaemia in six reviews. In one review, lipid-based nutrient supplementation (LNS) reduced the risk of anaemia. In another, caterpillar cereal increased Hb levels and IDA prevalence. Food-based strategies (red meat and fortified cow's milk, beef) showed no evidence of a difference (1 review). Preschool and school-aged children (2 to 10 years; 8 reviews) Daily or intermittent iron supplementation increased Hb levels and reduced the risk of anaemia and ID in two reviews. One review found no evidence of difference in Hb levels, but an increased risk of anaemia and ID for the intermittent regime. All suggested that zinc plus iron supplementation versus zinc alone, multiple-micronutrient (MMN)-fortified beverage versus control, and point-of-use fortification of food with iron-containing micronutrient powder (MNP) versus placebo or no intervention may increase Hb levels and reduce the risk of anaemia and ID. Fortified dairy products and cereal food showed no evidence of a difference on the incidence of anaemia (1 review). Adolescent children (11 to 18 years; 4 reviews) Compared with no supplementation or placebo, five types of iron supplementation may increase Hb levels and reduce the risk of anaemia (3 reviews). One review on prevention found no evidence of a difference in anaemia incidence on iron supplementation with or without folic acid, but Hb levels increased. Another suggested that nutritional supplementation and counselling reduced IDA. One review comparing MMN fortification with no fortification observed no evidence of a difference in Hb levels. Non-pregnant women of reproductive age (19 to 49 years; 5 reviews) Two reviews suggested that iron therapy (oral, intravenous (IV), intramuscular (IM)) increased Hb levels; one showed that iron folic acid supplementation reduced anaemia incidence; and another that daily iron supplementation with or without folic acid or vitamin C increased Hb levels and reduced the risk of anaemia and ID. No review reported interventions related to fortification or dietary diversity and quality. Pregnant women of reproductive age (15 to 49 years; 23 reviews) One review apiece suggested that: daily iron supplementation with or without folic acid increased Hb levels in the third trimester or at delivery and in the postpartum period, and reduced the risk of anaemia, IDA and ID in the third trimester or at delivery; intermittent iron supplementation had no effect on Hb levels and IDA, but increased the risk of anaemia at or near term and ID, and reduced the risk of side effects; vitamin A supplementation alone versus placebo, no intervention or other micronutrient might increase maternal Hb levels and reduce the risk of maternal anaemia; MMN with iron and folic acid versus placebo reduced the risk of anaemia; supplementation with oral bovine lactoferrin versus oral ferrous iron preparations increased Hb levels and reduced gastrointestinal side effects; MNP for point-of-use fortification of food versus iron and folic acid supplementation might decrease Hb levels at 32 weeks' gestation and increase the risk of anaemia; and LNS versus iron or folic acid and MMN increased the risk of anaemia. Mixed population (all ages; 22 reviews) Iron supplementation versus placebo or control increased Hb levels in healthy children, adults, and elderly people (4 reviews). Hb levels appeared to increase and risk of anaemia and ID decrease in two reviews investigating MMN fortification versus placebo or no treatment, iron fortified flour versus control, double fortified salt versus iodine only fortified salt, and rice fortification with iron alone or in combination with other micronutrients versus unfortified rice or no intervention. Each review suggested that fortified versus non-fortified condiments or noodles, fortified (sodium iron ethylenediaminetetraacetate; NaFeEDTA) versus non-fortified soy sauce, and double-fortified salt versus control salt may increase Hb concentration and reduce the risk of anaemia. One review indicated that Hb levels increased for children who were anaemic or had IDA and received iron supplementation, and decreased for those who received dietary interventions. Another assessed the effects of foods prepared in iron pots, and found higher Hb levels in children with low-risk malaria status in two trials, but no difference when comparing food prepared in non-cast iron pots in a high-risk malaria endemicity mixed population. There was no evidence of a difference for adverse effects. Anaemia and malaria prevalence were rarely reported. No review focused on women aged 50 to 65 years plus or men (19 to 65 years plus).

AUTHORS' CONCLUSIONS

Compared to no treatment, daily iron supplementation may increase Hb levels and reduce the risk of anaemia and IDA in infants, preschool and school-aged children and pregnant and non-pregnant women. Iron fortification of foods in infants and use of iron pots with children may have prophylactic benefits for malaria endemicity low-risk populations. In any age group, only a limited number of reviews assessed interventions to improve dietary diversity and quality. Future trials should assess the effects of these types of interventions, and consider the requirements of different populations.

Birth outcomes across the spectrum of maternal age: dissecting aging effect versus confounding by social and medical determinants

BACKGROUND

Given the trend of increasing maternal age and associated adverse reproductive outcomes in the US, this study aimed to assess whether this association is due to an independent aging or confounded by sociodemographic, biomedical, or behavioral determinants in a predominantly Black US population.

METHODS

Data was from 8509 women enrolled in the Boston Birth Cohort. Adverse reproductive outcomes included spontaneous preterm delivery, cesarean delivery, and low birth weight. Covariates included sociodemographic (parity, race/ethnicity, education, marital status, income, receipt of public assistance, nativity); biomedical (obesity, hypertensive disorders, diabetes mellitus); and behavioral (consistent intake of multivitamin supplements, support from father of baby, support from family, major stress in pregnancy, cigarette smoking, alcohol intake). Analysis included Lowess and marginal probability plots, crude and adjusted sequential logistic regression models to examine age-outcome associations and to what degree the association can be explained by the above covariables.

RESULT

Overall, the study sample had high levels of spontaneous preterm birth (18%), cesarean delivery (33%) and low birth weight (26%). Unadjusted models showed no significant difference odds of spontaneous preterm birth by maternal age but higher odds of cesarean section (aOR: 1.77, 95% CI: 1.60, 1.95) and low birth weight (aOR: 1.15, 95% CI: 1.04, 1.28) among women 30 years or older. Adjustment for sociodemographic factors, biomedical conditions and behavioral factors revealed higher odds of spontaneous preterm birth: (aOR: 1.30, 95% CI: 1.14, 1.49), cesarean section deliveries (aOR: 1.68, 95% CI: 1.51, 1.87) and low birth weight (aOR: 1.36, 95% CI: 1.21, 1.53). Across all ages, optimal BMI status and consistent multivitamin supplement intake were protective of spontaneous preterm birth and low birth weight.

CONCLUSION

In this high-risk minority population, we demonstrated that the association between increasing maternal age and adverse pregnancy outcomes was due to an independent aging effect and the presence of confounding by sociodemographic, biomedical, and behavioral factors. Some modifiable risk factors to counteract aging effect, include optimizing BMI and consistent intake of multivitamin supplement. A fundamental change in how care is provided to women, particularly low income Black women, is needed with emphasis on the protective role of optimal nutritional status.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03228875.

Growth dynamics among adolescent girls in Bangladesh: Evidence from nationally representative data spanning 2011-2014

BACKGROUND

Adolescence is the last opportunity to reverse any growth faltering accumulated from fetal life through childhood and it is considered a crucial period to optimize human development. In Bangladesh, a growing double burden of underweight and obesity in adolescents is recognized, yet limited data exists on how, when, and where to intervene. This study assesses the dynamics of growth among adolescent girls in Bangladesh, providing insight about critical junctures where faltering occurs and where immediate interventions are warranted.

METHODS

We pooled data from Bangladesh's Food Security and Nutrition Surveillance Project collected between 2011 and 2014 to document the age dynamics of weight and linear growth. 20,572 adolescent girls were measured for height and 19,345 for weight. We constructed growth curves for height, weight, stunting, and underweight. We also stratified growth dynamics by wealth quintile to assess socioeconomic inequities in adolescent trajectories.

RESULTS

Height-for-age z-score (HAZ) in Bangladeshi girls deteriorates throughout adolescence and especially during the early years. Mean HAZ decreases by 0.20 standard deviations (sd) per year in early adolescence (10-14 years) vs 0.06 sd/year during late adolescence (15-19 years), while stunting increases by 16 percentage points (pp) vs 6.7 pp, respectively. Conversely, BMI-for-age z-score (BAZ) increases by 0.13 sd/year in early adolescence vs 0.02 sd/year in late adolescence, and underweight decreases by 12.8 pp vs 3.2 pp. Adolescent girls in all socioeconomic groups show a similar pattern of HAZ and BAZ dynamics, but the curve for the richest quintile stays above that of the poorest across all ages.

CONCLUSIONS

Trends and levels of stunting and underweight among adolescent girls in Bangladesh are worrisome, suggesting substantial linear growth faltering in early adolescence, with improving weight-for-age occurring only as linear growth slows and stops. Given the rising burden of non-communicable diseases (NCDs) in Bangladesh and emerging evidence of the link between stunting and later chronic diseases, greater attention to adolescent growth and development is needed. Our findings suggest that, to address stunting, interventions in early adolescence would have the greatest benefits. School-based interventions could be a way to target this population.

Association of iron supplementation and dietary diversity with nutritional status and learning outcomes among adolescents: Results from a longitudinal study in Uttar Pradesh and Bihar, India

BACKGROUND

Poor nutritional status and educational outcomes are associated with adverse health consequences throughout the life course.

OBJECTIVES

We examined the associations of sex, iron and folic acid (IFA) supplementation, deworming, and dietary diversity with nutritional status and learning outcomes among Indian adolescents.

METHODS

Data of 12 035 adolescents from two rounds (2015-16 and 2018-19) of the Understanding the Lives of Adolescents and Young Adults surveys in Uttar Pradesh and Bihar, India were used. Multivariate linear and logistic regression models were used to estimate the prospective relationships of explanatory variables in the first round of the survey with nutritional status (ie, hemoglobin, BMI- and height-for-age z-scores, and incidence of anemia, stunting, and underweight) and learning outcomes (ie, reading proficiency, math proficiency, and school dropout) in the second round of the survey. The multivariable models were adjusted for a range of confounders, clustering by the population sampling unit and sampling weights.

RESULTS

Girls had a lower hemoglobin (adjusted mean difference (aMD) = -2.07; 95% confidence interval (CI) = -2.20, -1.94; P < 0.001) and height-for-age z-score (aMD = -0.45; 95% CI = -0.53, -0.38; P < 0.001) and higher BMI-for-age z-score (aMD = 0.36; 95% CI = 0.27, 0.44; P < 0.001) compared to boys. Girls had poorer reading (adjusted odds ratio (aOR) = 0.81; 95% CI = 0.70, 0.95; P = 0.01) and math proficiency (adjusted odds ratio aOR = 0.36; 95% CI = 0.31, 0.42; P < 0.001), and increased risk of school dropout (aOR = 1.65; 95% CI = 1.40, 1.95; P < 0.001) than boys. Receiving IFA tablets was not significantly associated with hemoglobin levels of adolescents overall, however we noted a significant beneficial relationship among girls (aMD = 0.41; 95% CI = 0.00, 0.82) but not among boys (aMD = 0.02; 95% CI = -0.38, 0.43) (P for interaction = 0.09). Receiving IFA tablets was positively associated with reading proficiency (aOR = 1.47; 95% CI = 1.07, 2.01; P = 0.02), math proficiency (aOR = 1.51; 95% CI = 1.16, 1.98; P < 0.001) and a reduced risk of school dropout (aOR = 0.72; 95% CI = 0.54, 0.96; P = 0.03). Deworming was not associated with nutritional status and learning outcomes. Diverse dietary intake was positively associated with hemoglobin, height-for-age z-score and math proficiency, and a reduced risk of school dropout in adolescents.

CONCLUSION

Integrated nutritional and health interventions and strengthening the existing nutrition supplementation program are critical to address adolescents' nutritional needs and improve educational outcomes.

Frequent Consumption of Micronutrient-Rich Foods Is Associated With Reduced Risk of Anemia Among Adolescent Girls and Boys in Indonesia: A Cross-Sectional Study

BACKGROUND

Anemia is a global public health concern. Its devastating consequences include impaired cognitive and motor development, reduced work productivity, and adverse birth outcomes, all of which apply to adolescents, as well as adults and children.

OBJECTIVE

This study aimed to examine the determinants of anemia in Indonesian adolescent girls and boys from Klaten and Lombok Barat districts.

METHODS

A total of 2150 adolescents who participated in a cross-sectional household survey were included in the analysis. The dietary intake of adolescents was assessed using a 7-day food frequency questionnaire. The relationship between anemia status, dietary intake, and other hypothesized determinants was assessed for adolescent girls and boys on a separate basis, using complex samples Cox regression analysis. Variables were selected for inclusion in multivariate models if they were significantly associated with the dependent variable in univariate models (P < .05).

RESULTS

The prevalence of anemia among adolescent girls and boys was 19% and 5%, respectively. In multivariate analyses, frequent consumption of animal-based iron-rich foods was significantly associated with a lower risk of anemia (prevalence ratio [PR]: 0.59; 95% CI: 0.36-0.97) among adolescent girls, whereas a higher intake of vitamin A-rich fruits and vegetables was associated with a reduced risk of anemia (PR: 0.41; 95% CI: 0.20-0.85) among adolescent boys, after adjustment for all potential confounders.

CONCLUSIONS

Increased consumption of iron- and vitamin A-rich foods through the implementation of gender-responsive Social Behaviour Change Communication (SBCC) interventions is warranted. This should be coupled with improved coverage and quality of iron and folic acid supplementation programs in adolescents.

A Qualitative Analysis of Program Fidelity and Perspectives of Educators and Parents after Two Years of the Girls' Iron-Folate Tablet Supplementation (GIFTS) Program in Ghanaian Secondary Schools

BACKGROUND

To address the burden of anemia in adolescent girls in Ghana, the Girls' Iron-Folate Tablet Supplementation (GIFTS) program was established in 2017. An evaluation found that although iron and folic acid (IFA) supplementation reached nearly all adolescent girls in schools during year 1, most girls received fewer than the minimum effective number of tablets over the school year. Barrier analyses highlighted schools as drivers of adherence, though information was incomplete on the reasons for the disparities among schools. Information was also lacking on the implementation of health and nutrition education.

OBJECTIVES

At the start of year 3 of an integrated adolescent anemia prevention program with IFA supplementation, the present study sought to illuminate differences in program fidelity among schools and across time and potential factors that drive such differences.

METHODS

After stratifying by school level, size, geographic location, and intake adherence during year 1, 16 schools were purposively selected. For each school, semistructured key informant interviews were conducted with 1 coordinator at the district level, 3 educators at the school level, and 1 parent leader. Following thematic analysis methods, recorded and transcribed interviews were coded and organized into deductive and inductive themes.

RESULTS

Limited training, challenges during distribution of IFA, lack of incentives, and inconsistent health and nutrition education diminished program fidelity. Strong supply chain, widespread awareness promotion, improved acceptability, and intrinsically motivated educators improved program fidelity. After 2 y of implementation, schools had made program adaptations, and widespread changes in attitudes and beliefs about the IFA tablets had improved their acceptability. However, limitations remained related to supply chain, program ownership, communication between health and education sectors, training, motivation, and resources.

CONCLUSIONS

The fidelity of Ghana's GIFTS program is strengthened by its supply chain, acceptability, and motivated stakeholders; however, training, curricula, clear communication, and incentives could improve it.

A School-Based Weekly Iron and Folic Acid Supplementation Program Effectively Reduces Anemia in a Prospective Cohort of Ghanaian Adolescent Girls

BACKGROUND

School-based iron and folic acid (IFA) supplementation is recommended for adolescent girls in countries with high burdens of anemia.

OBJECTIVES

We aimed to evaluate the context-specific effectiveness of a school-based, integrated anemia control program with IFA supplementation in Ghana.

METHODS

Using data from a pre-post, longitudinal program evaluation, we evaluated the effectiveness of school-based weekly IFA supplementation in reducing the burden of anemia and increasing hemoglobin concentrations (Hb; primary outcomes) in 2 regions of Ghana. Generalized linear mixed effects models with schools (clusters) as random effects were used to quantify the change in the anemia prevalence and the mean Hb associated with cumulative IFA tablet consumption over 1 school year (30-36 weeks), controlling for participant-level potential confounders. A cut point for minimum effective cumulative IFA consumption that is reflective of adequate Hb was derived following logistic regression. This cut point was verified by a restricted cubic spline model of IFA consumption and Hb.

RESULTS

The analytical sample included 60 schools and 1387 girls ages 10-19 years. The prevalence of anemia declined during 1 school year of the intervention, from 25.1% to 19.6% (P = 0.001). Students consumed a mean of 16.4 IFA tablets (range, 0-36). IFA consumption was positively associated with Hb and negatively associated with anemia. Each additional IFA tablet consumed over the school year was associated with a 5% (95% CI, 1-10%) reduction in the adjusted odds of anemia at follow-up, though the relationship is nonlinear. The cut point for minimum effective consumption was 26.7 tablets over a 30-36-week school year, with tablets provided weekly.

CONCLUSIONS

School-based weekly IFA supplementation is effective in improving Hb and reducing the anemia prevalence among schoolgirls in Ghana, though most participants consumed fewer than the minimum effective number of IFA tablets. Increasing intake adherence may further improve anemia outcomes in this population.

Effects of preconception care and periconception interventions on maternal nutritional status and birth outcomes in low- and middle-income countries: A systematic review

Background

The preconception period is an ideal time to introduce interventions relating to nutrition and other lifestyle factors to ensure good pregnancy preparedness, and to promote health of mothers and babies. In adolescents, malnutrition and early pregnancy are the common challenges, particularly among those who live in low- and middle-income countries (LMIC) where 99% of all maternal and newborn deaths occur. These girls receive little or no attention until their first pregnancy and often the interventions after pregnancy are too late to revert any detrimental health risks that may have occurred due to malnutrition and early pregnancy.

Objectives

To synthesise the evidence of the effectiveness of preconception care interventions relating to delayed age at first pregnancy, optimising inter-pregnancy intervals, periconception folic acid, and periconception iron-folic acid supplementation on maternal, pregnancy, birth and child outcomes.

Search Methods

Numerous electronic databases (e.g., CINAHL, ERIC) and databases of selected development agencies or research firms were systematically searched for all available years up to July 2019. In addition, we searched the reference lists of relevant articles and reviews, and asked experts in the area about ongoing and unpublished studies.

Selection Criteria

Primary studies, including large-scale programme evaluations that assessed the effectiveness of interventions using randomised controlled trials (RCTs) or quasi-experimental designs (natural experiments, controlled before-after studies, regression discontinuity designs, interrupted time series [ITS]), that targeted women of reproductive age (i.e., 10-49 years) during the pre- and periconceptional period in LMICs were included. Interventions were compared against no intervention, standard of care or placebo.

Data Collection and Analysis

Two or more review authors independently reviewed searches, selected studies for inclusion or exclusion, extracted data and assessed risk of bias. We used random-effects model to conduct meta-analyses, given the diverse contexts, participants, and interventions, and separate meta-analyses for the same outcome was performed with different study designs (ITS, RCTs and controlled before after studies). For each comparison, the findings were descriptively summarised in text which included detailing the contextual factors (e.g., setting) to assess their impact on the implementation and effectiveness of each intervention.

Main Results

We included a total of 43 studies; two of these were included in both delaying pregnancy and optimising interpregnancy intervals resulting in 26 studies for delaying the age at first pregnancy (14 RCTs, 12 quasi-experimental), four for optimising interpregnancy intervals (one RCT, three quasi-experimental), five on periconceptional folic acid supplementation (two RCTs, three quasi-experimental), and 10 on periconceptional iron-folic acid supplementation (nine RCTs, one quasi-experimental). Geographically, studies were predominantly conducted across Africa and Asia, with few studies from North and Central America and took place in a combination of settings including community, schools and clinical. The education on sexual health and contraception interventions to delay the age at first pregnancy may make little or no difference on risk of unintended pregnancy (risk ratio [RR], 0.42; 95% confidence internal [CI], 0.07-3.26; two studies, =490; random-effect; χ 2 p .009; I 2 = 85%; low certainty of evidence using GRADE assessment), however, it significantly improved the use of condom (ever) (RR, 1.54; 95% CI, 1.08-2.20; six studies, n = 1604; random-effect, heterogeneity: χ 2 p .004; I 2 = 71%). Education on sexual health and and provision of contraceptive along with involvement of male partneron optimising interpregnancy intervals probably makes little or no difference on the risk of unintended pregnancies when compared to education on sexual health only (RR, 0.32; 95% CI, 0.01-7.45; one study, n = 45; moderate certainty of evidence using GRADE assessments). However, education on sexual health and contraception intervention alone or with provision of contraceptive showed a significant improvement in the uptake of contraceptive method. We are uncertain whether periconceptional folic acid supplementation reduces the incidence of neural tube defects (NTDs) (RR, 0.53; 95% CI, 0.41-0.77; two studies, n = 248,056; random-effect; heterogeneity: χ 2 p .36; I 2 = 0%; very low certainty of evidence using GRADE assessment). We are uncertain whether preconception iron-folic acid supplementation reduces anaemia (RR, 0.66; 95% CI, 0.53-0.81; six studies; n = 3430, random-effect; heterogeneity: χ 2 p < .001; I 2 = 88%; very low certainty of evidence using GRADE assessment) even when supplemented weekly (RR, 0.70; 95% CI, 0.55-0.88; six studies; n = 2661; random-effect; heterogeneity: χ 2 p < .001; I 2 = 88%; very low certainty of evidence using GRADE assessments),and in school set-ups (RR, 0.66; 95% CI, 0.51-0.86; four studies; n = 3005; random-effect; heterogeneity: χ 2 p < .0001; I 2 = 87%; very low certainty of evidence using GRADE assessment). Data on adverse effects were reported on in five studies for iron-folic acid, with the main complaint relating to gastrointestinal side effects. The quality of evidence across the interventions of interest was variable (ranging from very low to moderate) which may be attributed to the different study designs included in this review. Concerning risk of bias, the most common concerns were related to blinding of participants and personnel (performance bias) and whether there were similar baseline characteristic across intervention and comparison groups.

Authors' Conclusions

There is evidence that education on sexual health and contraception interventions can improve contraceptive use and knowledge related to sexual health, this review also provides further support for the use of folic acid in pregnancy to reduce NTDs, and notes that weekly regimes of IFA are most effective in reducing anaemia. However the certainty of the evidence was very low and therefore more robust trials and research is required, including ensuring consistency for reporting unplanned pregnancies, and further studies to determine which intervention settings (school, community, clinic) are most effective. Although this review demonstrates promising findings, more robust evidence from RCTs are required from LMICs to further support the evidence.

Effective interventions to address maternal and child malnutrition: an update of the evidence

Malnutrition-consisting of undernutrition, overweight and obesity, and micronutrient deficiencies-continues to afflict millions of women and children, particularly in low-income and middle-income countries (LMICs). Since the 2013 Lancet Series on maternal and child nutrition, evidence on the ten recommended interventions has increased, along with evidence of newer interventions. Evidence on the effectiveness of antenatal multiple micronutrient supplementation in reducing the risk of stillbirths, low birthweight, and babies born small-for-gestational age has strengthened. Evidence continues to support the provision of supplementary food in food-insecure settings and community-based approaches with the use of locally produced supplementary and therapeutic food to manage children with acute malnutrition. Some emerging interventions, such as preventive small-quantity lipid-based nutrient supplements for children aged 6-23 months, have shown positive effects on child growth. For the prevention and management of childhood obesity, integrated interventions (eg, diet, exercise, and behavioural therapy) are most effective, although there is little evidence from LMICs. Lastly, indirect nutrition strategies, such as malaria prevention, preconception care, water, sanitation, and hygiene promotion, delivered inside and outside the health-care sector also provide important nutritional benefits. Looking forward, greater effort is required to improve intervention coverage, especially for the most vulnerable, and there is a crucial need to address the growing double burden of malnutrition (undernutrition, and overweight and obesity) in LMICs.

Effectiveness of lifestyle interventions in preventing harmful weight gain among adolescents: A systematic review of systematic reviews

Obesity in adolescence is associated with stigma during school years, early emergence of co-morbidities in adulthood and premature mortality. Adolescence presents a key window of opportunity to intervene for building healthy eating and physical activity routines and prevent weight gain. This review of reviews assesses the evidence on the effectiveness of prevention interventions conducted with adolescents. Nine reviews assessing the effects of lifestyle interventions in adolescents (defined as age 10 to 19 years old) on weight gain were identified from the 10 health databases searched. Only four reviews conducted meta-analyses, of which, three (two exercise-focused) demonstrated positive changes in primary outcomes of body mass index (BMI) and/or BMI z-score (range of decrease in BMI from 0.06 to 0.47 kg/m²⁾ ). Most were conducted in school settings, and all but two reviews were of low quality. Few reviews reported external validity components that would enable clearer directions for policy makers to implement in real-world settings. More than 140 distinct interventions were included in the reviews, but there remains a serious gap in evidence for effective interventions in adolescents.

Cardiovascular health decline in adolescent girls in the NGHS cohort, 1987-1997

Adolescence is a critical time for the preservation or loss of cardiovascular health. We aimed to describe trajectories of cardiovascular health in adolescent girls and identify early adolescent factors associated with cardiovascular health in young adulthood. We used data from the National Growth and Health Study, a longitudinal cohort of 2,379 girls followed annually from ages 9-19 years. We classified participants as having ideal, intermediate, or poor levels of the seven cardiovascular health metrics at four developmental stages: early (ages 9-11), middle (ages 12-14), and late (ages 15-17) adolescence, and early young adulthood (ages ≥ 18). We calculated total cardiovascular health scores (range 0-14) at each stage and empirically identified patterns of cardiovascular health trajectories. We examined associations between trajectory group membership and various demographic, behavioral, and physiological factors. Mean cardiovascular health scores declined with age from 10.8 to 9.4 in white girls and 10.3 to 8.9 in black girls; 17% of white girls and 23% of black girls had low cardiovascular health (score < 8) by early young adulthood. We identified five cardiovascular health trajectories: high-stable (14% of participants), high-to-moderate (48%), high-to-low (20%), moderate-stable (10%), and moderate-to-low (8%). Exceeding 14 h per week of television in early adolescence and teen pregnancy were associated with higher odds of being in several less healthy trajectory groups. In conclusion, cardiovascular health declines during adolescence and black-white disparities begin before early adolescence. Key targets for improving cardiovascular health in adolescent girls may include reductions in sedentary behavior and prevention of teen pregnancy.

Primary prevention of overweight and obesity in adolescents: An overview of systematic reviews

The aim of this overview of systematic reviews was to summarize evidence from up-to-date reviews of the effectiveness of interventions aimed at preventing overweight and obesity in adolescents aged 10 to 19 years. We searched nine databases for systematic reviews published between January 2008 and November 2019. We used A Measurement Tool to Assess Systematic Reviews (AMSTAR) 2 to assess the quality of reviews, excluding those of critically low quality, and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool to grade the certainty of included evidence. We included 13 reviews. Three reviews focused on dietary behaviour, six on physical activity, and four on both types of behaviours. Individual-oriented and school-based interventions dominated. Results across reviews showed little or no effect on body mass index, or physical activity levels of adolescents, whereas results from a couple of reviews suggest possibly beneficial effects of public health interventions on dietary behaviours (i.e., consumption of sugar-sweetened beverages). The certainty of evidence was low to very low for all outcomes. Overall, the evidence base for the effect of primary interventions to prevent overweight and obesity in adolescents is weak. In particular, there is a lack of reviews assessing the impact of environmental interventions targeting adolescents, and reviews addressing social inequality are virtually absent from this body of literature.

'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.

Eating behaviour of Indonesian adolescents: a systematic review of the literature

OBJECTIVES

Global evidence has shown that behaviour acquired during adolescence often lasts into adulthood. Diet quality of and malnutrition in Indonesian adolescents is a neglected area of research. The current study reviews all studies related to eating behaviour in Indonesian adolescents to support evidence-based policy to improve diets.

DESIGN

We searched electronic databases (six international and one local), from January 2000 to April 2018. The search terms used were (1) prevalence (prevalence OR number* OR case*, incidence OR survey), (2) adolescents (adolescen* OR school-age OR young adult), (3) Indonesia (Indonesia*) and (4) eating pattern (eat* OR fruit OR vegetable OR food recall OR food OR frequenc* OR consumption OR dietary intake). Articles were assessed against a critical appraisal tool.

SETTING

Indonesia.

PARTICIPANTS

10-19 years.

RESULTS

We discovered 15 studies related to eating behaviour, 5 of which were secondary analyses of nationally representative surveys and one was a nationwide survey. Of the nine studies, one study was conducted in multiple cities, and the rest were conducted in a single city or smaller area. There were seven main topics from the included studies: nutrient adequacy, fruit and vegetable consumption, water and beverage intake, Na intake, breakfast habit, snacking frequency and western fast food consumption.

CONCLUSIONS

Adolescents consume inadequate amounts of protein, fruits and vegetables, and excessive amounts of Na and western fast food. Measures are needed to improve and motivate adolescents to adopt healthier eating patterns. Furthermore, there is a need to have one standard definition and measurement of eating behaviour in Indonesia.

Eating behaviour styles in Irish teens: a cross-sectional study

OBJECTIVES

To describe the eating behaviour styles of Irish teens and to explore the relationships between demographic factors, BMI and dietary intake and these eating behaviour styles.

DESIGN

Cross-sectional data from the Irish National Teens' Food Survey (2005-2006). The Dutch Eating Behaviour Questionnaire assessed three eating behaviour styles in teens: restrained, emotional and external eating. Data were stratified by sex and age groups.

SETTING

The Republic of Ireland.

PARTICIPANTS

Nationally representative sample of teens aged 13-17 years (n 441).

RESULTS

The highest scoring eating behaviour style was external eating (2·83 external v. 1·79 restraint and 1·84 emotional). Girls scored higher than boys on all three scales (Restraint: 2·04 v. 1·56, P < 0·001, Emotional: 2·15 v. 1·55, P < 0·001 and External: 2·91 v. 2·76, P = 0·03), and older teens scored higher than younger teens on the Emotional (1·97 v. 1·67, P < 0·001) and External scales (2·91 v. 2·72, P = 0·01). Teens classified as overweight/obese scored higher than those classified as normal weight on the Restraint scale (2·15 v. 1·71, P < 0·001) and lower on the External scale (2·67 v. 2·87, P < 0·03). Daily energy intake was negatively correlated with the Restraint (r -0·343, P < 0·001) and Emotional scales (r -0·137, P = 0·004) and positively correlated with the External scale (r 0·110, P = 0·02).

CONCLUSIONS

External eating is the predominant eating behaviour style among Irish teens, but sex, age, BMI and dietary differences exist for each eating behaviour style. Including measures of eating behaviour styles into future dietary research could help understand both how and why as well as what people eat.

Barriers to and Facilitators of Iron and Folic Acid Supplementation within a School-Based Integrated Nutrition and Health Promotion Program among Ghanaian Adolescent Girls

BACKGROUND

Anemia is a moderate public health problem among adolescent girls in Ghana.

OBJECTIVES

We aimed to evaluate the barriers to and facilitators of program fidelity to a school-based anemia reduction program with weekly iron and folic acid (IFA) supplementation.

METHODS

Authors analyzed directly observed weekly IFA consumption data collected longitudinally and cross-sectional data from a representative survey of 60 secondary schools and 1387 adolescent girls in the Northern and Volta regions of Ghana after 1 school year (2017-2018) of the intervention (30-36 wk). A bottleneck analysis was used to characterize the levels of IFA coverage and used adjusted generalized linear mixed-effects models to quantify the school and student drivers of IFA intake adherence.

RESULTS

Of girls, 90% had ever consumed the tablet, whereas 56% had consumed ≥15 weekly tablets (mean: 16.4, range: 0-36), indicating average intake adherence was about half of the available tablets. Among ever consumers, 88% of girls liked the tablet, and 27% reported undesirable changes (primarily heavy menstrual flow). School-level factors represented 75% of the variance in IFA consumption over the school year. Total IFA tablets consumed was associated with the ability to make up missed IFA distributions (+1.4 tablets; 95% CI: +0.8, +2.0 tablets), junior compared with senior secondary school (+5.8; 95% CI: +0.1, +11.5), educators' participating in a program-related training (+7.6; 95% CI: +2.9, 12.2), and educator perceptions that implementation was difficult (-6.9; 95% CI: -12.1, -1.7) and was an excessive time burden (-4.4; 95% CI: -8.4, -0.4).

CONCLUSIONS

Although the program reached Ghanaian schoolgirls, school-level factors were barriers to adherence. Modifications such as expanded training, formalized make-up IFA distributions, sensitization (awareness promotion), and additional support to senior high schools may improve adherence. Spreading the responsibility for IFA distribution to other teachers and streamlining monitoring may reduce the burden at the school level. Strengthening the health education component and improving knowledge of IFA among students may also be beneficial.

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.

Erosion of the Mediterranean diet among adolescents: evidence from an Eastern Mediterranean Country

At a time when the health benefits of the Mediterranean diet (MD) are pervasively recognised, a paradoxical observation is the decreasing adherence to this dietary pattern in its native countries. This study aims to investigate temporal trends in adherence to the MD among adolescents (10–19 years old) in Lebanon. Data were drawn from three national cross-sectional surveys conducted at three points in time: 1997 (n2004), 2009 (n3656) and 2015 (n1204). Dietary intake was assessed using 24-h dietary recalls, and adherence to the MD was assessed using two country-specific indexes: the composite Mediterranean diet (c-MED) index and Lebanese Mediterranean diet (LMD) index. Significant decreases in c-MED and LMD scores and in the proportion of adolescents adhering to the MD were observed between 1997 and 2015, with more consistent results among females (P< 0·05). Projections for the year 2030 showed further decreases, with less than a quarter of adolescents remaining adherent to the MD. Based on linear regression analyses, belonging to the year 2009 was associated with significantly lower MD scores compared with 1997, even after adjustment for potential covariates (c-MEDβ= –0·16, 95 % CI –0·30, –0·01; LMDβ= –0·42, 95 % CI –0·67, –0·17). Similar results were obtained when comparing survey year 2015 with 1997 (c-MED scoreβ= –0·20, 95 % CI –0·33, –0·06; LMD scoreβ= –0·60, 95 % CI –0·82, –0·37). Findings highlight the erosion of the MD among Lebanese adolescents and underline the need for a comprehensive food system approach that fosters the promotion of the MD as a nutritionally balanced and sustainable dietary pattern.