This presentation was made possible by the American people through the U.S. Agency for International

Development (USAID) under Cooperative Agreement No. AID-OAA-A-11-00031, the Strengthening

Partnerships, Results, and Innovations in Nutrition Globally (SPRING) project.

Moving the Adolescent

Nutrition Agenda Forward Peggy Koniz-Booher, Senior Advisor Nutrition SBCC

SPRING Nutrition Project

CORE Group… April 14, 2015

Technical Meeting on the Diet and Eating

Practices of Adolescent Girls and Women

March 16 – 17 2015

PAHO/WHO, Washington, DC

Some background on rationale

for this technical meeting

• The 2013 Lancet Series on Maternal and Child Nutrition provided

new evidence on the importance of the nutrition of women at the time

of conception and during pregnancy, not only to ensure optimal fetal

growth and development but also for the health of the mother.

• The series also identified adolescent girls as a key priority and

highlighted the importance of a life course approach, placing them

together with women of reproductive age and mothers at the center

of nutrition interventions.

• Despite the recognized importance of adolescent girls’, women’s and

maternal nutrition for their health and that of their children, this group

is virtually neglected in nutrition programming with the exception of

provision of iron and folic acid supplements during pregnancy.

Background/rationale (cont.)

• In 2012, there were 1.2 billion adolescents in the world – defined as

young people between the ages of 10 and 19 years.

• The vast majority of adolescents (90%) live in low- or middle-income

countries (LMIC). In some countries, as many as half of all adolescents

are stunted, with impact on physical and cognitive development

• About 16 million girls aged 15 to 19 and some 1 million girls under 15

give birth every year—most in LMIC. Complications during pregnancy

and childbirth are the second cause of death for 15-19 year-old girls

• Alarming shift in BMI globally - growing rates of overweight and obesity in

many LMIC. (Throughout LAC, the prevalences of overweight and

obesity is around 50%. This is also true for Central and Eastern Europe.)

Meeting Objectives

1. Review insights and lessons learned

from two discussion papers

commissioned by SPRING

2. Identify characteristics of and issues

related to key diet and eating

practices for strengthening policies

and programs for adolescent girls’

and WRA’s nutrition

3. Propose next steps in development

of a set of key diet and eating

practices

Began by reflecting on the Guiding Principles: Goal: To develop a set of unified, scientifically based guidelines

that could be adapted to local feeding practices and conditions

This earlier review provided the

scientific basis for 9/10 principles

(active feeding not evidence based)

Target audience: Policy makers,

program planners, health care

providers and community leaders

WHO Evidence-Informed

Guideline Development Process

Countries have been proliferating Food-

Based Dietary Guidelines for about 20 yrs

FAO recently launched an on-line repository of

~100 country FBDGs and associated resources.

A “descriptive summary” project by Mary Arimond, Jennie Coats and Anna Herforth.

Objectives of Background Paper #1:

Nutrition of Adolescent Girls and WRA

• Present the current landscape

of nutritional status of

adolescent girls, women of

reproductive age, women

during pregnancy and during

lactation

• Summarize potential key

nutrition actions and

interventions to improve

nutritional status of these

population groups

Objectives of Background Paper #2:

Review of Programmatic Responses

• Conduct a rapid review of the

literature & programmatic

documentation to:

Provide information on global

programmatic experiences to

improve the nutrition of adolescent girls and WRA

Summarize inputs, outcomes, and lessons learned from

implementers who have/are

carrying out nutrition programs

Some highlights #1:

Distributions of height among women of reproductive

age by UN region (Kozuki et al., submitted)

UN MDG

region

< 145 cm 145 < 150 cm 150 < 155 cm > 155 cm

Oceania 2.3 8.5 16.8 72.4

Eastern Asia 2.0 7.8 22.6 67.7

Western Asia 1.3 7.2 22.3 69.1

SE Asia 8.9 23.6 35.8 31.6

South Asia 10.7 24.6 33.2 31.5

Caucasus &

Central Asia

0.7 3.7 15.3 80.2

Northern Africa 1.5 5.4 17.7 75.5

Sub-Saharan

Africa

2.6 7.0 18.8 71.6

Latin America

& Caribbean

4.8 13.0 24.1 58.1

US (NHANES)

--

Counterfactual

0.6 3.0 9.7 86.7

145 cm is 4’9”; 150 cm is~ 4’11”; 155 cm is 5’1” tall

BMI status of women 20+years by region

(Ng et al, 2014; Stevens/WHO [unpublished])

Low prevalences of

underweight except in SSA

(not Southern),Southeast

and South Asia

Only in South Asia are >

20% women underweight

Throughout LAC, the

prevalences of overweight

and obesity surround the

50% mark

This is also true for Central

and Eastern Europe 0 20 40 60 80 100 120

Asia-Central

Asia-East

Asia-South

Asia-Southeast

SSA-Central

SSA-Eastern

SSA-Southern

SSA-Western

LAC-Andean

LAC-Tropical

LAC-Southern

LAC-Central

LAC-Caribbean

N Africa & ME

Oceania

HI-Y: Asia Pacific

HI-Y: N America

Hi-Y: Austral-Asia

Europe-Western

Europe-Eastern

Europe-Central

BMI < 18.5 kg/m2 BMI 18.5-25 kg/m2 BMI 25-30 kg/m2 BMI 30+ kg/m2

Changes in prevalence of underweight, overweight

and obese women in LMIC from 1980 to 2008

(Black et al., 2013)

Presented are the prevalences of maternal body mass index (BMI) < 18.5, > 25 and > 30 kg/m2

Under-W Over-W Obese

Africa Americas and the Caribbean

Asia Global

BMI status of girls < 20 years and women

20+ year by region (Ng et al, 2014)

0 20 40 60 80 100 120

Asia-Central

Asia-East

Asia-South

Asia-Southeast

SSA-Central

SSA-Eastern

SSA-Southern

SSA-Western

LAC-Andean

LAC-Tropical

LAC-Southern

LAC-Central

LAC-Caribbean

N Africa & ME

Oceania

HI-Y: Asia…

HI-Y: N America

Hi-Y: Austral-…

Europe-Western

Europe-Eastern

Europe-Central

Girls < 20 years

BMI < 25 kg/m2 BMI 25-30 kg/m2 BMI 30+ kg/m2

0 20 40 60 80 100 120

Asia-Central

Asia-East

Asia-South

Asia-Southeast

SSA-Central

SSA-Eastern

SSA-Southern

SSA-Western

LAC-Andean

LAC-Tropical

LAC-Southern

LAC-Central

LAC-Caribbean

N Africa & ME

Oceania

HI-Y: Asia…

HI-Y: N…

Hi-Y: Austral-…

Europe-Western

Europe-Eastern

Europe-Central

Women 20+ years

Anemia in women and children and changes from

1995 to 2011 (Stevens et al., 2013)

Prevalence of anemia is declining

in most regions

Children Pregnant women

Non-pregnant women

Anemia 47% to 43%

43% to 38% 33% to 29%

Severe anemia

3.7% to 1.5%

2.0 %to 0.9%

1.8% to 1.1%

(Anemia: < 110 g/L for children and

pregnant women; and 120 g/L for women)

(Severe anemia < 70 g/L for children

and pregnant women; < 80 g/L for women)

Prevalence of micronutrient deficiencies among

adult women and during pregnancy

Region

Vitamin A deficiency among pregnant women1

Insufficient iodine intake in general population2

Inadequate zinc intake in general population3

Night blindness (%)

Serum retinol < 0.70 umol/L (%)

Urinary iodine concentration < 100 ug/L (%)

Zinc available < EAR (%)

Globe 7.8 15.3 28.5 17.3

Africa 9.4 14.3 40.0 17.1-25.6

Americas & Caribbean

4.4 2.0 13.7 6.4-17.0

Asia 7.8 18.4 31.6 7.8-29.6

Europe 2.9 2.2 44.2 9.6

1reported in WHO (2009) and in Black et al (2013) 2reported in Andersson et al (2012) and in Black et al (2013) 3reported in Wessells and Brown, 2012; see also Wessells et al., 2012

Status of global prevention of folic-acid

preventable birth defects, 2012

(Source: Youngblood et al. 2013)

Estimated intakes of selected “healthy” and

“unhealthy” foods by region among women 20-29 y

(Imamura et al., 2015)

What are

recommended

intakes to ensure

nutrient needs are

met for WRA?

How do we

combine goals for

maternal nutrition

and chronic

disease

prevention?

Horizontal lines represent the mean of the theoretical minimal risk exposure distribution

Energy intakes of adolescent girls and women of

reproductive age (WRA) by region Adolescent girls WRA

Protein intakes (% energy) of adolescent girls and

women of reproductive age (WRA) by region Adolescent girls WRA

Fat intakes (% energy) of adolescent girls and women

of reproductive age (WRA) by region

Calcium intakes of adolescent girls and women

of reproductive age (WRA) by region

Iron intakes of adolescent girls and women

of reproductive age (WRA) by region

Some Key Findings

• Reducing short maternal stature requires continued

improvements in nutrition lifecycle of girls.

• Key nutrition interventions include support for

maternal nutrition during pregnancy and lactation,

IYCF and development of healthy eating patterns.

• Nutritional interventions during later childhood

and/or adolescence need study (efficacious?).

• Family planning to delay age at first pregnancy

likely contributes to improving maternal stature.

Key Findings (cont.)

• The nutritional status of

WRA has shifted over time,

with some reductions in the

prevalence of underweight,

and shifts from normal

weight to overweight/obesity.

• The problem of underweight

at the national level is less

10% in all areas except for

some parts of Sub-Saharan

Africa, and South Asia.

Key Findings (cont.)

• The problem of under-weight

among adolescent girls,

particularly those 15-19 is less

well characterized, but appears to

be consistent with those of women

20+, except in South Asia where it

may be as high as 40%.

• In South Asia, there is urgent

need to address the problem of

underweight among girls and

women.

Key Findings (cont.)

• When examined by age,

overweight and obesity increased

among women 20-30, suggesting

postpartum weight retention as an

explanatory factor

• There is a need to characterize

BMI status for local programming;

in most areas the goal of having

normal BMI means weight loss

rather than weight gain.

Key Findings (cont.)

• Postpartum weight

management is needed.

• Progress has been achieved

in reducing maternal

deficiencies of vitamin A and

iodine, as well as anemia,

but the problems remain.

• Inadequate zinc intake in

LMIC appears significant.

• Folic acid fortification

coverage is not optimal

Key Findings (cont.)

• Average nutrient intakes are inadequate in LMIC

across regions and target groups. Importantly,

adolescent girls, WRA and pregnant and lactating

women do not face dietary concerns distinct from

one another in terms of imbalanced macronutrient

intakes, and inadequate micronutrient intakes

• More studies are needed and a comprehensive

strategy for nutrition during lactation is needed

• Improvements in nutrient intake need to be placed

within the context of overall weight management.

Key Findings (cont.)

• Promotion of nutrient dense foods or foods

providing key nutrients within the context of weight

maintenance or loss (shift in consumption) is

different from promotion of greater food intake (of

the same or greater nutrient density) within the

context of increasing BMI to normal.

• The relative effectiveness of interventions to reduce

“unhealthy foods” (e.g., sugar-sweetened beverage)

consumption and/or increase consumption of

“healthy foods” requires research in LMIC.

Goals for Diet and

Eating Practices Achieve normal weight • Low maternal BMI is a widely accepted risk factor for poor

pregnancy outcomes

• For underweight women, it sets up a recommendation for

higher gestational weight gains that may not be achievable

• Entering pregnancy overweight/obese increases the

likelihood of complications, including fetal demise

• For overweight women, gestational gain and postpartum

weight retention contribute to obesity

Maintain or improve diet quality as a lifestyle goal • Adequate intakes of calcium, iron, vitamin C, vitamin A, folic

acid, whole grains, vegetables and fruits, reduce alcohol

intake

Goals for Diet and

Eating Practices (cont.) Maintain or improve physical activity level/active

lifestyle

• Important since physical activity tends to decline during

pregnancy, and starting new physical activity is not

recommended)

Other

• Prevent/treat anemia and achieve adequate iron stores

• Maintain sufficient iodine intake to avoid thyroid disorders

• Maintain sufficient vitamin A intake to maintain retinol

concentrations;

• Ensure folic acid intake of 400 ug/d

Some Gaps in Evidence

• In places where you have women of low BMI (South Asia,

West/Central/East Africa), what is the evidence around the

efficacy of interventions to increase BMI on women entering

pregnancy with low BMI?

• “Eating down” during pregnancy to avoid a large baby –

is the practice less common than the concept?

• Catch-up growth in adolescence – what is the contribution of

animal source foods?

• What is the efficacy of dietary guidelines - do they actually

change behaviors?

• Can the balance within meals and the timing of meals avoid

spikes in blood sugar levels, macronutrient and caloric intake

• What are the determinants of dietary behavior?

• What is the impact of marketing of products to adolescents?

Outcome: Draft set of food based-practices or

principles for an optimal diet - adolescents

Whole grains cereals and legumes (over highly refined grains*)

Eat appropriate portion sizes (population & BMI specific /balance

energy intakes with energy needs, balance types of foods)

Limit sugar & sweetened beverages

Limit salts, salty condiments, salty snacks (iodized if salt is added)

Limit highly refined and ultra processed foods

Drink potable water

Safe storage, preparation, and handwashing

Moderate consumption of animal flesh and animal source foods*

(iron, zinc, b12, calcium, vitamin D, etc.)

Separate recommendation for adolescent girls and perhaps WRA

Fruits/vegetables (include dark green leafy & yellow/orange flesh)

Distinguish legumes vs dark green/vegetables

Eat a variety of foods

Oil (placeholder – needs further development)

Avoid skipping meals, eat breakfast

Overarching Dietary Principles – Food Safety,

Adequacy, Moderation, Balance, Variety (define all) Problem

Anchors

Mortality

NCDs

High blood

pressure

Cardiovascular

Diabetes

Cancer

Cognitive devel

& productivity

Pregnancy

outcomes

Infections

Linear growth

and BMI

Depression

Next steps

• Finalize meeting report, with proposed way forward

(next steps) in establishing food based-

principles/practices for an optimal diet. Circulate.

• Finalize 2 background papers (copyright issues and

incorporate feedback). Circulate. Publish /present.

• Finalize the set(s) of draft principles/practices for an

optimal diet for adolescent girls and WRA.

• Circulate food-based principles/practices for review

by participants and other stakeholders.

• Conduct additional systematic reviews (if/as

needed).

• Move through agreed upon mechanism……

www.spring-nutrition.org/events

For more information on the technical meeting

(background materials and presentations),

please visit: