Researchers Encounter Challenges in Determining the Extent of Underweight in the Adolescent Population

31/07/06 While a great deal of research has been conducted on child and adult malnutrition in developing countries, there are only a handful of studies on adolescent malnutrition. James Levinson, PhD, faculty member at the Friedman School of Nutrition Science and Policy at Tufts University, and colleagues address problems of adolescent malnutrition in developing countries and assess seminal efforts undertaken by Bangladesh and Tanzania to improve the health of adolescents. In a peer-reviewed publication of the United Nations System Standing Committee on Nutrition, Levinson and colleagues recognize the positive effect that increased attention to adolescent malnutrition has had on these countries, but note that further research is needed, especially studies that focus on the cost-effectiveness of programmatic efforts in developing countries.

What little research there is indicates that "stunting is highly prevalent among adolescents, younger adolescents tend to be more undernourished than older adolescents, and, contrary to expectations, that boys are almost twice as undernourished as girls," write the authors. In addition, these few studies suggest that there are more undernourished adolescents in "South Asia than in South-East Asia or Sub-Saharan Africa, and a higher prevalence in rural than in urban areas."

Researchers face specific challenges when trying to determine the extent of underweight in the adolescent population. Nutritional assessments are particularly difficult due to differences in adolescent growth patterns and variations in the onset of puberty among different populations, both of which are partially attributable to differences in nutritional status. According to Levinson and colleagues, "due to the wide range of variations in the onset of puberty and the resulting growth spurt, determining adolescent nutrient requirements should be based on physiological or maturation age, as opposed to chronological age."

"Adolescence is the only time in a person's life where their rate of growth will increase," says Levinson, corresponding author on the paper. "Adolescents can gain 15 percent of their ultimate adult height and 50 percent of their adult weight in this time period. They simply need more nutrients to support that growth and to become healthy adults."

The authors highlight findings from programs in Bangladesh that illustrate the potential for government-driven solutions. The government of Bangladesh, along with multiple non-governmental organizations (NGOs) and international partners, created and operated the Bangladesh Integrated Nutrition Project (BINP) between 1996 and 2003. BINP developed programs such as the Adolescent Girls Forum, which focused on teaching young women about healthy diets, reproductive health, delaying pregnancy, and women's rights; and the Newly Married Couples initiative to help young women through their first pregnancy. According to the authors, it is highly desirable for adolescent girls to attain full growth prior to their first pregnancy due to severe nutritional demands that pregnancy places on a female's body.

While the effects of the Newly Married Couples initiative are presently being studied, an evaluation of the Adolescent Girls Forum program found that this initiative achieved significant success in delaying the average age of pregnancy and marriage. "The mean age of marriage was delayed approximately five months in project areas," said Levinson, "while the mean age of pregnancy was delayed by more than seven months." Highlighting the results, the writers report that "the evaluation found that adolescent girls in project areas were significantly more aware of the importance of adequate food intake, rest, as well as of the importance of initiation and optimal length of breastfeeding than adolescents in control areas."

Based on the success of this program for adolescent girls, the Bangladesh Rural Advancement Committee, the nation's largest NGO and a supporter of the BINP, is exploring new programs for adolescent boys that focus on male adolescent health as well as educating young men on women's reproductive health, women's rights, and infant and child care.

In Tanzania, there are two issues driving increased awareness of adolescent malnutrition. "Part of this is simple demographics because almost 23 percent of the population is teenagers," says Levinson. The other main driving force is the effect of AIDS, a leading cause of death for young people in Tanzania and many other African nations. "Recognizing that the country's future--its leaders, labour pool, parents, caregivers and providers--will emerge from this group [adolescents]...there is a growing commitment in Tanzania to invest in adolescents with a view to attaining a healthier and more productive adult population," write the authors.

The authors also present preliminary results of a Tufts study on adolescent health and nutrition in Tanzania which indicate that about 19 percent of adolescents in a large rural area of Tanzania are undernourished, a level that is consistent with others parts of Sub-Saharan Africa. As with other studies on adolescent growth, "boys were found to be almost twice as malnourished as girls (64 percent vs. 36 percent)."

"We are examining relationships between adolescent nutritional status and household food security, periodic household food shortages, skipping meals, school attendance, and orphan status," says Levinson. "This data will guide future efforts in Tanzania and permit the development of Tanzanian counseling materials comparable to those used by the programs in Bangladesh."

"Increased attention to adolescent malnutrition in developing countries, as reflected in some of the pioneering studies and project activities discussed in this paper, is heartening," conclude the authors. "However, more research is needed to better understand the full extent of the problem, its determinants, and--most importantly--to assess the cost-effectiveness of alternative means of addressing adolescent undernutrition in countries of Asia, Africa, and Latin America," says Levinson.