Adolescent Nutrition
at a glance
Why tackle the problems of
malnutrition in adolescents?
There are 1.2 billion adolescents ages 10-19 in
developing nations, making up one fifth to one
quarter of their countrys populations. Adolescents
have typically been considered a low risk group for
poor health, and often receive few healthcare
resources and scant attention. However, this
approach ignores the fact that many health problems
later in life can be improved or avoided by adopting
healthy lifestyle habits in adolescence.
Adolescence is a unique intervention point in the life
cycle. It offers a chance to acquire knowledge about
optimal nutrition during young adulthood that could
prevent or delay adult-onset diet-related illnesses later
on. It is a stage of receptivity to new ideas and a
point at which lifestyle choices may determine an
individuals life course.
There is evidence from research in countries as
diverse as Peru and India that this population can be
highly amenable to public health information as it
relates to their own well-being. Adolescent boys and
girls can be motivated to adopt nutrition behaviors
that improve their looks, school achievement and
athletic performance. Potentially, behavior change
messages embraced by adolescents will contribute to
more sustained health and nutrition impacts within a
population as the cohort of adolescents moves
through its adult years. Although good nutrition for
boys is an important goal on its own, an unanswered
research question is the extent to which inclusion of
adolescent boys in nutrition and healthy lifestyle
programs will contribute to the improved nutrition and
health of women during childbearing and for infants
and young children in the critical early years of life.
Undernutrition (being too thin or too short, frequently
caused by chronic energy deficiency) in adolescents
frequently goes unrecognized by young people or
their families. We now know that it:
o Affects their ability to learn and work at maximum
productivity
o Increases the risk of poor obstetric outcomes for
teen mothers
o Jeopardizes the healthy development of future
children
Children born to short, thin women are more likely
themselves to be stunted and underweight (low
weight for age). In addition, the heightened obstetric
risk caused by stunting in childhood and adolescence
persists throughout a womans reproductive life.
If adolescents are HIV+, some research suggests that
undernutrition may increase the speed with which
they develop full-blown AIDS, and heighten the
chance that infected girls will transmit the virus to
their babies. Lack of adequate nutrition diminishes the
already poor quality of life of persons living with
HIV/AIDS.
We have little information about the nutritional status
of adolescents and nutrition. Resources have
traditionally been directed at young children and
pregnant women. These conditions: lack of data; low
policymaker interest in the nutritional problems of
adolescents; little program experience; and the
dearth of resourcescontribute to a critical lost
opportunity to bolster the health, development, and
economic progress of nations.
What are the main nutritional
issues for adolescents?
Adolescence is the second most critical period of
physical growth in the life cycle after the first year.
Twenty five percent of adult height is attained during
adolescence. For many adolescents, inadequate
quality and quantity of food are the prime
determinants of nutrition problems. These conditions
may be due to household food insecurity,
intrahousehold allocation of food that does not meet
their full range of dietary needs, livelihoods
insecurity, and lack of nutrition knowledge.
Micronutrient malnutrition and chronic energy
deficiency resulting in thinness (low Body Mass Index
or BMI1) and stunting stem primarily from poor diet.
Excessive physical activity patterns (e.g., heavy
workloads and walking long distances) and infection
may also contribute to undernutrition.
Stunting (short stature) in both adolescent boys and
girls was prevalent in 9 of 11 studies conducted by
1. Body Mass Index (BMI) is a measure of thinness in adolescents
and adults; it is equal to a persons weight in kilograms divided by
height in meters2 or (kg)/(m2)
June 2003
ADOLESCENT NUTRITION AT-A-GLANCE
This table summarizes the core interventions, their intended beneficiaries, and indicators to track achievement of primary nutrition objectives for adolescents.
Objectives
Prevent and reduce general malnutrition
Promote optimal linear growth
and prevent thinness (low
Body Mass Index)
Prevent overweight and obesity
Prevent and treat micronutrient deficiencies
For all deficiencies
Core Interventions
Skills-based nutrition education2 for adequate
energy/protein consumption
Reduce excess energy expenditures (e.g.,
improved household food processing technology;
decreased household labor production demands)
Infectious disease control (e.g., sexually
transmitted diseases, malaria, Tb)
Micronutrient strategies (see below)
Targeted supplementary feeding for at-risk
adolescents (e.g., during natural or manmade
disasters; in food insecure communities)
Comprehensive antenatal care for pregnant
adolescents including counseling on preventive
health and nutrition self-care practices
Targeted supplementary feeding for at-risk girls
during pregnancy/lactation
Skills-based nutrition education for optimal
energy/protein consumption (for healthy weight
maintenance and/or healthy weight reduction)
Facilitate favorable environments/opportunities
for physical activity (e.g., School-based physical
education programs; urban design to promote
mixed land use, recreation space/facilities)
Skills-based nutrition education for consumption of All adolescents accessible through
diverse food sources rich in micronutrients;
counseling on the use of fortified food and
supplements
Beneficiaries/Target Groups
Adolescent boys and girls at risk of
stunting, thinness
Pregnant adolescent girls
Adolescent boys and girls at risk for
obesity (LBW; children with retarded
growth both height and weight in
infancy/early childhood; adolescents
living in obesogenic environments)
schools or other youth programs
Indicators
% adolescents falling below cutoff for
height-for-age3
% adolescents falling below cutoff for
BMI-for-age4
Low birthweight (LBW) incidence rate
and trends
Weight gain during pregnancy if
feasible
% adolescents falling above cutoff for
BMI-for-age5
Blood levels of iron, vitamin A, or
clinical signs of deficiencies
Urinary iodine
Dietary diversity/intake results on dietary
history, 24-hour recall, or food frequency
surveys
Objectives
Vitamin A deficiency (VAD)
prevention and treatment
Iodine deficiency disorders
prevention and treatment
Iron deficiency and anemia
prevention and treatment:
Strategy will be an integrated
package, depending on the
specific causes of iron
deficiency and anemia in a
given setting
Core Interventions
Above plus fortification of widely consumed foods All adolescents
with vitamin A
VA supplementation in deficient populations
(10,000 IU daily or 25,000 IU weekly 4-8 weeks
for pregnant adolescent girls)
Universal salt iodization and consumer education
Short-term supplementation (iodized oil; iodized
water) where iodized salt is not available in
iodine-deficient areas
Fortification of widely consumed foods with
iron/folate
Iron/folic acid supplements (weekly for non-
pregnant; daily throughout pregnancy for
pregnant teens)
Regular deworming of adolescents in high
parasite-load settings (girls at higher risk than
boys)
Malaria control/treatment
Beneficiaries/Target Groups
All adolescents (girls affected
disproportionately)
All adolescents
Adolescents in supervised settings such
as schools, workplace
All adolescents living in areas with low
moderate malaria transmission
In areas of high transmission (e.g.,
Sub-Saharan Africa), pregnant
adolescent girls
Indicators
% of vulnerable adolescents consuming
VA fortified foods
% vulnerable households consuming
iodized salt
Proportion of target population with
urinary iodine level < 100mg/L OR
Proportion of school children with
palpable enlarged thyroid
% vulnerable households consuming iron
fortified foods
Prevalence of anemia in target
population
% target population receiving iron/folate
supplements
% of target population receiving
deworming treatment
% of at-risk population sleeping under
insecticide-treated bednets or other
materials
% at-risk population with uncomplicated
malaria receiving correct treatment
according to national guidelines within
24 hrs. of onset of symptoms
% pregnant girls who have taken
chemoprophylaxis or intermittent drug
treatment according to national policy
 Objectives Core Interventions Beneficiaries/Target Groups Indicators

Address underlying causes of malnutrition

Postpone/avoid adolescent Increase age at marriage; delay first pregnancy Adolescent girls Age at marriage
pregnancy to reduce including provision of family planning and
nutritional losses reproductive health information and services Service statistics for adolescent RH
for adolescents services

Adolescent access to/control Increase educational attainment of adolescents All adolescents Increased completion rates for secondary
over food schooling
Parent education about meeting the nutritional
needs of adolescents

Increase income earning potential (adult literacy % target population consuming < 80%
ed; skills training; inputs/microcredit for of daily energy requirements OR < two
small business enterprise development) meals per day

Increase household livelihood security (e.g., food % of households with expenditure on

policy reforms; off-farm income generation; food > 50% of household expenditure
safety nets including targeted income transfers)

Hygiene and sanitation Infrastructure/supplies for schools (e.g., wells; School-going adolescents % of schools with functioning sanitation
sanitation facilities; soap) facilities

Increased gross enrollment rates of girls

Improve access to adequate water and sanitation All adolescents % hhs with access to potable water;
in households latrines

Gender equity Gender-sensitive school environment/policies
(e.g, safety/privacy for girls at school; flexible
hours for girls; programs to support school
retention for adolescent mothers; raise proportion
of female teachers)
Adolescent girls Female secondary school enrollment
ratio (or gross enrollment rate of girls)
Increased age of sexual debut

Foster girls self-esteem (e.g., sports programs; Increased age of first pregnancy
community-service projects; mentoring programs
to expand girls expectations for the future)

2. Skills-based nutrition education includes such techniques as counseling with age-tailored messages for dietary decision-making and healthy lifestyle fundamentals; shopping for best nutrition buys; food
handling/safety and preparation skills
3. % <5th percentile NCHS/WHO height-for-age (Kurz and Johnson-Welch, 1994)
4. % <5th percentile NCHS/WHO BMI-for-age (Kurz and Johnson-Welch, 1994)
5. % >95th percentile NCHS/WHO BMI-for-age (Kurz and Johnson-Welch, 1994)
the International Center for Research on Women in the include neural impairment and poor school performance.
early 90s, ranging from 27 to 65 percent. Data on The fetus of an iodine-deficient mother is at risk of
underweight (thinness indicated by low BMI for spontaneous abortion as well as a range of neurological
adolescents and adults) are largely unavailable for and intellectual impairments.
adolescents. ICRW reported low BMI ranging from 3 to
Other micronutrients that may be deficient in adolescents
53 percent. Adolescents in India, Nepal, and Benin were
include vitamin A, zinc, and calcium. The latter two are
the most severely affected among the 11 study sites.
particularly important for achieving maximum growth
Overweight/obesity data are not widely reported for potential. Calcium intake in adolescence is also
adolescents, but there is growing concern about these important for preventing osteoporosis (brittle bones) later
problems. WHO estimates that 60 percent of deaths in life. Vitamin A deficiency appears to negatively affect
globally are due to noncommunicable diseases growth and possibly sexual maturation. It is critical for
associated with unhealthy diets and physical inactivity, healthy immune system functioning and optimal vision.
with 79 percent of these deaths occurring in developing
A related health issue is adolescent pregnancy. It is often
countries. The same changes in diet and physical activity
associated with nutritional, obstetric, and perinatal health
contribute to the increased prevalence of obesity in
risks for teen mothers and their babies. Incomplete
youth, often seen side by side in communities with under-
maternal growth heightens the risk of obstructed labor.
nutrition. There is also some evidence that low birth
There is evidence that competition for nutrients will favor
weight may predispose individuals to obesity and
the still-growing mother, placing offspring at risk for low
associated chronic diseases later in life. In Chile, 12
micronutrient stores and low birth weight. Concurrent
percent of schoolchildren are obese; 17 percent of older
pregnancy and growth worsen maternal micronutrient
adolescent girls in South Africa are obese; and in China,
deficienciesiron and calcium for example. Children of
one study found that the prevalence of overweight and
adolescent mothers are also often at greater risk of poor
obesity (BMI >25), in young adults has moved up from
nutritional care and feeding practices.
10 to 15 percent for urban areas, and from 6 to 8
percent in rural areas, over a ten year period
(1982-1992). Investing in the nutritional status
Iron deficiency is the most prevalent micronutrient of adolescentsthe costs of
deficiency among adolescents. Iron deficiency and non-intervention
anemia are associated with impaired cognitive
Information on the economic returns to various types of
functioning, lower school achievement and most likely
investment in youth development is scarce. But a recent
lower physical work capacity. WHO estimates that 27
cost-benefit analysis for iron supplementation of
percent of adolescents in developing countries are
secondary school children estimated a benefit cost ratio
anemic; the ICRW studies documented high rates in
between 26 and 45 depending on the assumptions. And
India (55 percent), Nepal (42 percent), Cameroon (32
we know something about the magnitude of the cost of
percent) and Guatemala (48 percent). Adolescents (both
non-investment. For example, it is estimated that for every
boys and girls) are at risk of developing iron deficiency
kilogram less of weight at birth, an American child will
and iron deficiency anemia because of the increased
achieve 15 percent less in adult earnings over his/her
iron requirements for growth. Infectious diseases such as
lifetime. The average lifetime cost of care of a child born
malaria, schistosomiasis, and hookworm affect both boys
with a neural tube defect in the US is over $500,000. In
and girls, contributing to anemia by affecting the
settings with high incidence of goiter, it is estimated that
absorption of or increasing the loss of iron. Following the
iodine deficiency disorders depress average intelligence
end of their growth spurt, boys rapidly regain adequate
by 13 IQ points. Deficits in adult height result in
iron status, whereas girls may continue to be or become
productivity losses (e.g., in the Philippines, a 1 percent
more deficient because of the increased requirements for
deficit was associated with a 1.38 percent loss in
iron due to menstruation, pregnancy, and lactation.
agricultural wages). Anemia in adults is associated with
Folate deficiency, if not addressed during the pre or a 17 percent reduction in productivity for heavy manual
periconceptual period, may cause irreversible fetal labor and 5 percent for less strenuous work.
damage. Addressing folate deficiency beyond the middle
of the first trimester of pregnancy will not correct neural
tube defects that occur in the early weeks of pregnancy.
How can adolescent malnutrition be
The unplanned nature of many adolescent pregnancies addressed?
underscores the need to take a preventive approach to There are several solutions on hand for the nutrition
this specific nutritional issue for youth. problems that face adolescents but there is limited
In settings of endemic iodine deficiency, girls are affected experience with implementation of nutrition programs in
disproportionately relative to boys, although all this population group. Operational research is needed to
individuals are affected. Detrimental cognitive effects better understand how to effectively integrate nutrition
components into programs that reach and work with
adolescents.
The table summarizes a wide range of recommended
core interventions. The complex interplay of determinants
of malnutrition means that intervention strategies could
include food and dietary intake approaches, infection
control (including parasites), education, improved
agricultural practices, and enhanced decision-making
and control of personal and household resources, to
name a few. Depending on the specific nutritional issue
of concern and the type of program used to deliver
services, one or more of these suggested core
interventions could be incorporated into an integrated
program for healthy youth development.
Dos and Donts of reaching and
working with adolescents
o Do involve youth in the design of program messages
and intervention strategiesthey are your best source
of information about effective communication
techniques (e.g., Nutrition is boring, but food is
fun.)
o Do segment the target adolescent population by
narrow age bands (e.g., parents of 10-12 yr olds are
usually responsible for diet and nutrition decisions for
this age group, while 15-18 yr olds may purchase
and prepare food for themselves and the household).
How to reach young people will vary by multiple
determinants of the population (e.g., in/out of school;
at worksites; through community recreational centers
or marriage registries; teen pregnancy programs, etc.)
o Do deliver integrated programs. Work with other
sectors to incorporate nutrition interventions to
strengthen the results of broader investment in youth
development. Teaching adolescent boys how to cook
as part of a life skills curriculum breaks down
traditional gender barriers and increases awareness
of good nutrition. Sports programs for girls may
benefit from actions to improve the nutritional status of
their adolescent participants.
Expanded versions of the at a glance series, with e-linkages to resources and more information, are available on
the World Bank Health-Nutrition-Population web site: www.worldbank.org/hnp
o Do use nutrition education and behavior change
communications strategies for healthy lifestyles as
entry points for reaching adolescents with information
on more sensitive topics such as human sexuality, STIs,
and substance abuse.
o Dont forget the boys. Depending on the setting, they
experience the same or greater levels of malnutrition
as girls in adolescence. In addition, providing
accurate information about diet and nutrition needs at
this stage may insure better care and health outcomes
for women and children in their households later on.
For more information
Nutrition Thematic Group (TG): Milla Mclachlan
Nutrition Advisory Services: Please send e-mail to
nutrition@worldbank.org
Children and Youth Thematic Group (TG):
Viviana Mangiaterra
Key references
Kurz K and Johnson-Welch C. The nutrition and lives of
adolescents in developing countries: Findings from the
nutrition of adolescent girls research program.
Washington, DC: International Center for Research on
Women (1994).
Gillespie S. Improving adolescent and maternal nutrition:
An overview of benefits and options. UNICEF Staff
Working Papers Nutrition Series Number 97-002. New
York: UNICEF (1997).
Delisle H, Chandra-Mouli MD and de Benoist B. Should
adolescents be specifically targeted for nutrition in
developing countries: To address which problems and
how?
WHO: http://www.who.int/child-adolescent-health/
New_Publications/NUTRITION/Adolescent_nutrition_
paper.pdf (posted in 2000).