Adolescent Nutrition_Ruel-Bergeron

1. Adolescents in Low and
Middle-Income Contexts
Julie Ruel-Bergeron
Program in Human Nutrition
April 14, 2015

2. ©2015, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.
Adolescent Demographics in LMIC:
Global Trends
1.2 billion and
growing  18% of
the world’s
population, 90% of
which live in LMIC
Source: UNICEF, 2012

3. ©2015, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.
Adolescent Demographics in LMIC:
Regional Trends
Source: UNICEF, 2012

4. © 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.© 2014, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.
Nutrition: Determinants of Nutritional
Status in Adolescence
Source: WHO, 2005.

5. © 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.© 2014, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.
Risks and Challenges in Adolescence:
Nutrition, Early Marriage and Early
Pregnancy
• Adolescent girls often enter pregnancy with reduced
nutritional stores
– Competition for dietary energy and nutrients
• Physical immaturity of the mother
– More immature = ↑ obstetric risk
– ↑ maternal mortality
– ↑ prematurity, LBW
• Higher incidence of poor child health care and child
feeding behaviors
– Varies by SES
– Interference of pregnancy with schooling completion

6. © 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.© 2014, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.
Impact of Adolescent Pregnancy on Birth
Outcomes: LBW and Preterm
Gibbs et al, Pediatr Perinatal Epi 2012

7. © 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.© 2014, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.
Predictors of Stunting in Pregnant and Non-
Pregnant Adolescent Girls (Bangladesh)
Source: Rah et al., 2009.

8. © 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.© 2014, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.
Annual changes in anthropometric
measurements by pregnancy status

9. © 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.© 2014, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.
Mean annual changes in height by time
since menarche and pregnancy status
Rah et al., 2008.

10. © 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.© 2014, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.
Mean Annual Changes, by Time Since
Menarche
Rah et al., 2008.

11. The Condition of the Adolescent in LMIC:
Burkina Faso, Indonesia, Zambia
Risks and Challenges

12. © 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.© 2014, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.
Population characteristics
Burkina Faso Indonesia Zambia

13. © 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.© 2014, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.
Risks and Challenges: Education,
Reproductive Health, Sexual Practices
and Marriage
• Disparities by residence, wealth quintiles, and sex in
young adolescents
• In some instances, disparities become more
pronounced in older adolescents (education gap)
• Some unexpected trends:
• Early marriage in Indonesia
• Family planning in Indonesia and Zambia

14. © 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.© 2014, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.
Risks and Challenges in Adolescence:
Nutritional
• Girls at greater risk of suffering nutritional difficulties than boys,
with more severe consequences as it relates to childbearing and
perpetuating the cycle of malnutrition
– Underweight
– Stunting
– Micronutrient deficiencies (anemia especially)
– Obesity
Sources: UNICEF 2011, UNICEF 2012

15. © 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.© 2014, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.
Risks and Challenges in Adolescence:
Nutritional (cont)
• Lifestyle and eating behaviors, and underlying psychosocial factors also
threaten adequate nutrition
• Adolescent pregnancy  imposes additional physiological and
nutritional stress, especially in stunted or underweight mothers

16. Reaching Adolescents:
Delivery Platforms

17. © 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.© 2014, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.
School and Education-Based
Programming
• School feeding
• Anemia control
• Nutrition-friendly school initiatives
• Other school-based adolescent-focused
programs
– India’s Saloni Swasth Kishori Yojna, Uttar Pradesh
– Zambia’s UN Girls Education Initiative

18. © 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.© 2014, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.
Social Safety Net Programing
• Cash Transfers: conditional and unconditional
– Impact on HIV and education in Malawi
– Unconditional
• Varying impact based on recipient (mother/father)
and conditionality
– Conditionality matters more than recipient in terms of
improved child health outcomes
• Not a lot of evidence specific to adolescents, but a
promising avenue for addressing factors proximally
associated with adolescent nutrition and with
broader social benefits
– Education, early marriage, sexual behaviors, STIs, and early
pregnancy
• Microfinance interventions

19. © 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.© 2014, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.
Youth Development and Community-
Based Approaches
• Peer education
• Adolescent and youth centers
• Faith-based community approaches
• Other community-based approaches
– Indonesia linking of marriage registries to target
health messages and IFA supplementation
– Promotion of gender equality at the community
level to address violence and SRH

20. © 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.© 2014, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.
Technology-Based Platforms and
Sensitization/Mobilization
• Mhealth/nutrition
• Mass media communication
• Community-based sensitization

21. © 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.© 2014, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.
Other Interventions/Programming
• Health Center-Based Programming
– Youth-Friendly Health and Nutrition Services
• Policy-level interventions
– National-level
• Incentives to delay early marriage (India and
Bangladesh)
• Scholarships for secondary education or life-skills
training
• HIV-specific legislation
– Policies by large donor institutions
• USAID’s Youth in Development Policy

22. © 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.© 2014, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.
Summary and Key Points
• Adolescents face many health and nutritional risks
– Injuries are the leading cause of death
– Other risks and challenges include mental health, substance
abuse, sexual and reproductive health (HIV especially),
education, violence and abuse
– Girls are more vulnerable nutritionally, as a result of the link
with early pregnancy and its impact on education, maternal
obstetric outcomes, and child outcomes.
• Various types of delivery platforms to reach
populations with health and nutrition services in LMIC
exist, but their potential for reaching adolescents
(girls especially) has yet to be unleashed

23. Questions?