Nutrition Publication

NNIW80 - Adolescents' and Young Women's Health and Nutrition: Programming for Future Generations

Editor(s): Z. Bhutta, M. Makrides, A. Prentice. 80

The 80th Nestle Nutrition Institute workshop brought together leading scientists in the field of maternal nutrition and covered the the topics of global disease epidemiology & risk factors, the role of nutrition in adolescent health and evidence based interventions before and during pregnancy

Related Articles

Adolescent Health Globally Issues and Challenges

Author(s): G. Patton, S. Sawyer

Rapid declines in fertility, increasing survival through infancy and childhood and greater longevity mean that this generation of adolescents will be the largest in human history. In low income countries, the “youth bulge” has the potential to bring great economic prosperity. In contrast, many high income countries face a “demographic cliff” where a smaller pool of young people poses major economic and social challenges. In both contexts, the health and well-being of this generation of adolescents will determine future national development. Shifts in adolescent development have major implications for health. Falls in the age of puberty together with a rising age of marriage have, for example, given rise to more sexually active unmarried adolescents. In settings where healthcare needs are well met, the benefits are clear in terms of lower pregnancy rates, lower maternal mortality and lower rates of HIV and other STIs. Conversely, where this shift occurs in settings with poor adolescent health care, where sexual activity in young unmarried women is stigmatised and where poverty forces young women into early marriage or selling sex, both health and life outcomes can be catastrophic. In this context, poor and social marginalised adolescents, particularly those out of school, without stable accommodation or family, or in juvenile detention, have the worst health profiles. The opportunities for gain or loss are great across all aspects of health in adolescence. It is during these years that the risks for injury and mental disorders are highest, and when risks for later-life non-communicable diseases (cancer, cardiovascular and respiratory disease) such as tobacco use, obesity and inactivity are established. The great majority of adult mental disorders begin in adolescents. So too injuries rise sharply with high rates of suicide, motor vehicle injury and violence, including sexual violence in these years. All will affect the future health, social adjustment and economic prospects of today’s adolescents. It will in turn affect their capacities as parents and a healthy start to life for their children. There is great variation between countries, even within the same region, in patterns of adolescent health. For low income countries, key indicators at national and district levels should include rates of maternal mortality, HIV and STIs, age of onset of sexual activity, early childbirth, availability of contraception and age of marriage. Countries should also have data on adolescent nutrition including anaemia, patterns of injury including sexual violence and coercion, mental health and disorder, and substance abuse. At a local level, data on family functioning (e.g. violence, conflict), educational engagement, peer behaviour and community attitudes (e.g. to providing contraception to sexual active unmarried adolescents) is also needed to effectively guide programming and health service delivery. The evidence base for prevention in adolescence is stronger than ever before. Public health approaches that use multiple coordinated actions at national and local levels show great promise. These typically involve steps of using ‘best available’ data to evaluate local needs, identifying priority targets for intervention, implementing evidence-based programs and policies followed by monitoring, commonly using the same indicators that framed need. 

Preconception Care and Nutrition Interventions in Low- and Middle-Income Countries

Author(s): Z. Bhutta, Z. Lassi

Maternal nutrition plays an important role for pregnancy outcomes and for the health of newborn; and providing simple nutritional interventions before pregnancy can prevent a significant proportion of maternal and neonatal mortality and morbidity. Evidence suggests that maternal pre-pregnancy overweight and obesity increase the propensity for gestational hypertension and diabetes, and the risk of stillbirths and congenital heart defects; underweight women have a higher incidence of stillbirths, preterm birth, low birth weight and small-for-gestational-age babies. While it is important to maintain normal body weight, preconception micronutrient status of women is also crucial. Substantial evidence exists for the potential of preconception folic acid supplementation to more than halve the risk of neural tube defects. Multivitamin supplementation lowers the rates of preeclampsia and multiple congenital anomalies. On the other hand, iron deficiency anemia is significantly associated with increased risk of fetal growth restriction and low-birth-weight. It is, therefore, important to scale up these interventions particularly in low and middle income countries where the scenario is grave. Healthcare providers should be encouraged to provide preconception care to all adolescent girls, women and couples of reproductive age. 

Adolescent Health and Nutrition in the US and Canada An Overview of Issues and Determinants

Author(s): M. Kaufman

Adolescent development includes solidification of personal identity, ethical beliefs, approach to the world, patterns of friendships, cognitive sophistication and sexual/gender identity. Rapid brain development accounts for many of the changes of adolescence, but this can be affected by environmental and social factors. In the US, the top 3 causes of adolescent death are unintentional injuries (often involving motor vehicles), homicide and suicide. In Canada, the top 3 are unintentional injuries (more than a third of deaths in 15-19 year olds), suicide (about a fifth of deaths) and neoplasia. This paper does not discuss some major areas of health and determinants, including gay, lesbian and transgender youth; gender inequality and mental health. Issues for aboriginal youth include those of education, nutrition, housing and racism. Racism is not limited to this group and is also intertwined with the issues faced by immigrant youth. Access to high quality education is particularly problematic in the United States. Alcohol and other substance use lead to health issues and also educational problems. Adolescent pregnancy, parenting and access to abortion are issues in both countries (more extreme in the US). Finally, the care of children by the state leads to issues in adolescence and adulthood. 

Nutrition Challenges and Issues of Relevance to Adolescents in Low- and Middle-Income Countries

Author(s): A. Prentice

Adolescence represents a key period in human development during which children metamorphose into sexually active adults and capable of reproduction. This transition period is associated with incremental nutritional needs that must be met in order to optimize their parenting capacity, and hence the health of future generations. The key nutritional issues can be listed as follows: a) adolescence provides a fresh opportunity for stunted children to cross centiles and catch-up with international peers; b) this opportunity may be lost if pubertal growth is prematurely terminated by a pregnancy; c) competition for nutrients between the adolescent growth drive and an adolescent pregnancy can have sequelae for both the mother and her child; d) the onset of menstruation in girls makes them more vulnerable to anemia and merits special control programmes; and e) adolescent mothers may have less than ideal micro-nutrient status which could affect the epigenome of their offspring with long-term and intergenerational consequences. The best way to avoid these nutritional hazards is to avoid adolescent pregnancies.

Interventions before and during Pregnancy to Minimize the Risks of an Overweight Pregnancy

Author(s): M. Nitert, K. Matusiak, H. Barrett, L. Callaway

Rates of overweight and obesity are high in the obstetric population. In pregnancy, overweight and obesity are associated with increased risk of complications of pregnancy for both the mother and the infant. These complications include gestational diabetes mellitus, preeclampsia, instrumental delivery or delivery by Caesarean section in the mother. In the baby, there are increased risks for infants being born macrosomic or large for gestational age, birth injuries, neonatal hypoglycemia and increased admittance to neonatal special care nurseries. Both prepregnancy interventions and interventions during pregnancy are used to prevent complications from arising in the high-risk group of overweight and obese women. This article provides an overview of interventions used in clinical practice and their rates of success. 

Obesity, Prediabetes and Diabetes in Adolescents and Women: Evidence-Based Interventions

Author(s): Z. Lassi, T. Mansoor, Z. Bhutta

Around the world, the prevalence of obesity and diabetes is alarming a grave scenario as the occurrence of obesity in adolescents has tripled and in general population has doubled in the past 30 years. This signals a global crisis as obesity and diabetes surfaces as a widely rampant form of health concern for individuals worldwide that needs to be immediately addressed. Evidence has shown higher chances of adverse pregnancy outcomes in women who are overweight/obese. Simple interventions such as diet, physical activity and strict glycemic control can reduce adiposity in young girls and women. The evidence of benefit for physical activity on gestational diabetes is also more convincing as it reduces the risk by 53%. Physical activity and diet for maintaining normal weight in women has shown improvements in pregnancy outcomes. Similarly dietary counseling and glycemic monitoring in women with pre-diabetes and diabetes has also shown improvements. Given that weight is a modifiable risk factor, public health campaigns should direct their focus on young and adolescent girls to make them aware of the importance of healthy eating, physical activity and maintaining normal weight for their own wellbeing as well as for the problems they could face during pregnancy.

Platforms for Delivery of Adolescent-Friendly Health Care

Author(s): S. Sawyer, G. Patton

There has been a dramatic shift in the type of health issues that affect adolescents across the world, with a resulting requirement for health services to re-orient themselves to address these problems. Sexual and reproductive health is still a major problem in many lowand middle-income countries (LMIC), but is increasingly relevant for unmarried as well as married young women. While undernutrition remains a key problem, the obesity epidemic is increasingly affecting adolescents in LMIC. Mental disorder and risks for later noncommunicable diseases (e.g. tobacco use) typically have their onset during adolescence, and accidents and injuries disproportionately affect the young. Yet, historically, health services in LMIC settings have assumed that adolescence is a healthy period of life, and that adolescents have little need to engage in health services. Adolescent-friendly health care refers to the provision of quality healthcare for adolescents. The goal is that health services are available and able to respond to the changing needs of young people and can actively engage them in their own healthcare, while supporting their parents and carers. Yet there are many barriers. The most important relate to access, acceptability and appropriateness of healthcare. A particular challenge is to provide healthcare that is private and confidential, and that ‘goes beyond the presenting complaint’ as there is often a gap between the illnesses that young people present with to health services and their wider concerns. Psychosocial history taking is the most effective tool for engaging young people in their health care and identifying the range of health issues they experience. Active engagement helps set expectations around self-management practices, is a prerequisite to behavior change, and a strategy to support future engagement with adult health services. A challenge for health educators and health services is to ensure that the contemporary health workforce is appropriately skilled to provide adolescent-friendly healthcare to all young people and that health services have an appropriate policy framework in place to deliver the health services that young people need. Increasing participation in secondary schools offers an additional platform to deliver primary care services. Beyond this, there is much interest in the role of immunization as a point of contact with health services that could offer a wider range of interventions. Media-based interventions also provide great promise as a platform for health education and behavior change interventions, although trials of mediabased interventions are still very limited with modest effect sizes. 

Polycystic Ovary Syndrome in Young Women Issues and Consequences

Author(s): R. Norman, L. Moran

Polycystic ovary syndrome (PCOS) is the commonest endocrine condition encountered in young women and has many reproductive, metabolic and psychological features that lead to patients consulting medical practitioners and the health service. Overweight and obesity are common among many groups of young women with PCOS and may precipitate subsequent reproductive and metabolic disorders that require expensive and invasive care. Attention to nutrition and diet is important in management of these young women.While there is little evidence from a metabolic cause for changes in appetite and fat deposition, there is a need for intervention to prevent weight gain and promote weight loss. It appears as if caloric restriction is the most important feature of treatment ahead of changes to the macronutrient component of the diet. Introduction of an active lifestyle is also encouraged.As obesity rates increase and infertility is more common, nutritional interventions have a role to play in fertility. Given the rising increase in risk in diabetes mellitus and the potential effects on cardiovascular events that will arise, health services need to approach polycystic ovarian syndrome with adequate nutritional resources for dietary intervention and advice.

Social Determinants of Health in Adolescents and Young Women’s Health and Nutrition: Current Evidence

Author(s): A. Fatusi, B Bello

Adolescence is a nutritionally vulnerable stage of life as a result of physical, physiological, lifestyle and social factors. Nutrition is a leading adolescent health challenge globally; the main problems are under-nutrition, obesity, and iron deficiency anaemia. Obesity is a greater challenge in high income countries, while undernutrition constitutes a higher challenge in low and middle income countries (LMICs), although the level of obesity is also rapidly increasing in many LMICs. Early pregnancy exerts additional nutritional burden on adolescent girls. The prevalence of underweight among adolescent females (15-19 years) is as high as 34% in Niger and Senegal, 35% in Bangladesh, and 47% in India. This paper reviews the current evidence about the Social Determinants of Health (SDH) – “the conditions in which people are born, grow, live, work and age” – as regards adolescents and young women’s health and nutrition. Important structural determinants include macroeconomic and policy contexts (e.g. level of national wealth and inequity, youth unemployment level) and socioeconomic positions (e.g income, gender, education). Intermediary determinants include material conditions, behaviour and biological system, psychosocial factors, and the health system. Adolescent health policy and programmatic interventions need to take SDH into account in order to reduce inequities, and improve health and well-being.

Understanding Drivers of Dietary Behavior before and during Pregnancy in Industrialized Countries

Author(s): L. Malek, W. Umberger, S. Zhou, M. Makrides

A comprehensive understanding of the factors influencing women’s dietary choices is central to motivating positive dietary behavior before, during and after pregnancy. Findings are synthesized from 34 studies which assessed modifiable individual and environmental factors influencing dietary behavior during preconception and pregnancy. Influencing factors included perceptions regarding benefits, risks and need; psychological factors; self-efficacy and control-beliefs; nutrition knowledge; financial constraints; social environment and perceived social pressure; healthcare providers (HCP); and the food environment. Studies consistently found that the key factors influencing positive dietary behavior were women’s desire to optimise maternal and fetal health and advice received from HCPs. HCPs are in a unique position to encourage healthier choices at a time when women are strongly motivated to make positive change. Therefore, strategies targeting the education of HCPs to ensure they have the knowledge and resources to support women to act on evidence-based dietary recommendations are of key importance. Other strategies include using persuasive communication methods to aid in educating and influencing young women and the wider community; providing pregnant women with automated daily feedback regarding their adherence with dietary recommendations; and changing the food environment to make healthy choices easier. A collaborative, multidisciplinary approach is required to further develop, test and implement the suggested strategies which have the potential to improve maternal and child nutrition beyond the immediate prenatal period.