Nutritional Problems In Adolescents
Dr. Bela Sachdeva Consultant Pediatrician*
Noida, Delhi *
There are 1.4 billion adolescents aged 10-19 yrs. in developing nations, making up one fifth to one quarter of their country's 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
NUTRITIONAL ISSUES IN ADOLESCENTS
  • Inadequate and unhealthy eating habits
  • Eating disorders: Anorexia Nervosa and Bulimia Nervosa
  • Undernutrition: Stunting, Thinness
  • Micronutrient Deficiencies
  • Obesity and its risks
  • Early pregnancy and associated risks
ASSESSING NUTRITIONAL STATUS
WHO recommends the use of vertical board with an attached metric rule and a horizontal head broad for measurement of height and a leveled platform scale with a beam and movable weights for the measurement of weight in adolescents.
WATERLOW'S CLASSIFICATION

WT FOR HT

W/H >M-2SD

W/H <M-2SD

HT FOR AGE

 

 

H/A > M-2SD

NORMAL

WASTED

H/A < M-2SD

STUNTED

STUNTED & WASTED



  • Body Mass Index (BMI) - a measure of thinness
  • Equal to a person's weight in kilograms divided by (height in meters) 2 or (kg) / (m2)
THINNESS
  • WT FOR AGE <3RD CENTILE
  • WT FOR HT <5TH CENTILE
  • BMI FOR AGE & SEX <5TH CENTILE


SMR BMI <5 TH CENTILE
2 13.5 (BOTH SEXES)
3 M <14 F <15
4 M <14 F <16
5 M <15.5 F<16.5


PREVALENCE OF STUNTING & THINNESS
Thinness as defined by a BMI <5th percentile was present in 43.8% of boys and 30.1% of girls. As per the NCHS norms prevalence of thinness among boys varies between 31% to 52% without any clear trend. In girls, it varies between 4% to 59%. The prevalence of thinness in girlsis lower than in boys. A high prevalence of stunting has been reported from India. The report on regional WHO Consultation on nutritional status of adolescent girls reported 45% prevalence of stunting among girls and 20% among boys with an average of 32% in both sexes.

Table 1 - Prevalence of Stunting


* Aggarwal et al. (10) . ** NCHS standards (7).

Table II - Prevalence of Thinness


* As recommended by WHO.

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:
  • Affects their ability to learn and work at maximum productivity
  • Increases the risk of poor obstetric outcomes for teen mothers
  • 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 women's reproductive life.
MICRONUTRIENT DEFICIENCIES
The prevalence of anemia as defined by WHO. The prevalence of anemia is 27.8% in young boys (12 yrs-14 yrs; n = 79) compared to 41.3% in older boys (15 yrs-18 yrs; n = 92). Anemia is present in 51% of young girls (n = 68) compared to 38.5% (n = 39) in older girls. The mean hemoglobin is higher in boys as compared to girls in both the age groups.

Iron Deficiency is by far most prevalent amongst micronutrient deficiencies in adolescents. Adolescents (both boys and girls) are at risk of developing iron deficiency and iron deficiency anemia because of the increased iron requirements for growth. Infectious diseases such as malaria, schistosomiasis, and hookworm affect both boys and girls, contributing toanemia by affecting the absorption of or increasing the loss of iron. Following the end of their growth spurt, boys rapidly regain adequate iron status, whereas girls may continue to be or become more deficient because of the increased requirements for iron due to menstruation, pregnancy, and lactation

Folate deficiency, if not addressed during the pre or peri-conceptual period, may cause irreversible fetal 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. The unplanned nature of many adolescent pregnancies underscores the need to take a preventive approach to this specific nutritional issue for youth.
In settings of endemic iodine deficiency, girls are affected disproportionately relative to boys, although all individuals are affected. Besides goiter, detrimental cognitive effects occur including neural impairment and poor school performance. The fetus of an iodine-deficient mother is at risk of spontaneous abortion as well as a range of neurological and intellectual impairments.
Other micronutrients that may be deficient in adolescents include vitamin A, zinc, and calcium. The latter two are particularly important for achieving maximum growth potential. Calcium intake in adolescence is also important for preventing osteoporosis (brittle bones) later in life. Vitamin A deficiency appears to negatively affect growth and possibly sexual maturation. It is critical for healthy immune system functioning and optimal vision.

Overweight/Obesity: Data are not widely reported for adolescents, but there is growing concern about these problems. WHO estimates that 60 percent of deaths globally are due to non-communicable diseases associated with unhealthy diets and physical inactivity, with 79 percent of these deaths occurring in developing countries. The same changes in diet and physical activity contribute to the increased prevalence of obesity in youth, often seen side by side in communities with undernutrition. There is also some evidence that low birth weight may predispose individuals to obesity and associated chronic diseases later in life. BMI > 25 in Adolescents has more than doubled from 7-10 percent for urban areas, and from 4 to 5 percent in rural areas, over a 20 year period (1982-2002).

A related health issue is adolescent pregnancy. It is often associated with nutritional, obstetric, and perinatal health risks for teen mothers and their babies. Incomplete maternal growth heightens the risk of obstructed labor. There is evidence that competition for nutrients will favor the still-growing mother, placing offspring at risk for low micronutrient stores and low birth weight. Concurrent pregnancy and growth worsen maternal micronutrient deficiencies - iron and calcium for example. Children of adolescent mothers are also often at greater risk of poor nutritional care and feeding practices.
INVESTING IN NUTRITIONAL HEALTH OF ADOLESCENT VS COST OF NON- INTERVENTION
Information on the economic returns to various types of investment in youth development is scarce. But a recent cost-benefit analysis for iron supplementation of secondary school children estimated a benefit cost ratio between 26 and 45 depending on the assumptions. And we know something about the magnitude of the cost of non-investment. For example:
  1. It is estimated that for every kilogram less of weight at birth, a child will achieve 15 percent less in adult earnings over his/her lifetime.
  2. In settings with high incidence of goiter, it is estimated that iodine deficiency disorders depress average intelligence by 13 IQ points
  3. Deficits in adult height result in productivity losses (e.g., a 1 percent deficit was associated with a 1.38 percent loss in agricultural wages).
  4. Anemia in adults is associated with a 17 percent reduction in productivity for heavy manual labor and 5 percent for less strenuous work

What is Healthy Eating? The 2005 Dietary Guidelines give the following advice:
  • Eat a variety of foods
  • Balance the food you eat with physical activity
  • Eat plenty of grain products, vegetables, and fruits
  • Choose a diet that is low in fat, saturated fat, and cholesterol and moderate in sugars, salt and sodium
BENEFITS OF HEALTHY EATING
  • Helps young people grow, develop, and do well in school
  • Helps prevent childhood and adolescent health problems such as overweight, eating disorders, dental caries, and iron deficiency anemia
  • Eat plenty of grain products, vegetables, and fruits
  • Helps prevent health problems later in life, including heart disease, cancer, and stroke - the three leading causes of death
NUTRITIONAL INTERVENTION AT COMMUNITY LEVEL
  • Early detection of malnutrition and intervention according to severity
  • Balance the food you eat with physical activity
  • Integrated health package e.g., ICDS, MCH, immunizations, etc.
  • Parent education about nutritional needs of adolescents
  • Promotion of family planning
  • Increase income earning potential
  • Improve access to adequate water and sanitation in households
  • Gender-sensitive school environment / policies
  • Infrastructure / supplies for schools (e.g., wells; sanitation facilities; soap)
  • Skills-based nutrition education for adequate energy / protein consumption
  • Infectious diseases, malaria, TB
  • Reduce excess energy expenditures
  • Targeted supplementary feeding for at-risk adolescents
  • Universal salt iodization and consumer education. lodine def areas supplement with iodized (oil; iodine water)
  • Fortification of widely consumed foods with vitamin A
  • 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)
  • Increase age at marriage; delay first pregnancy School Nutritional Programmes - food supplementation, nutritional education
SCHOOL-BASED NUTRITIONAL PROGRAMS
The CDC guidelines state that school-based nutrition education programs are most likely to be effective when they:
  • Help young people learn skills (not just facts)
  • Give students repeated chances to practice healthy eating
  • Make nutrition education activities fun and participatory
  • Involve teachers, administrators, families, community leaders, and students in delivering strong, consistent messages about healthy eating as part of a coordinated school health program
The guidelines include seven recommendations for ensuring a quality school program to promote lifelong healthy eating.
  1. Policy: The policy should commit the school to:
    • Provide adequate time for nutrition education
    • Offer healthy, appealing foods (such as fruits, vegetables, and low-fat grain products) wherever food is available and discourage the availability of foods high in fat, sodium, and added sugars (such as soda, candy, and fried chips) on school grounds and as part of fund-raising activities
    • Discourage teachers from using food to discipline or reward students
    • Provide adequate time and space for students to eat meals in a pleasant, safe environment
  2. Curriculum: As part of a sequential, comprehensive health education curriculum that begins in preschool and continues through secondary school, implement nutrition education designed to help students adopt healthy eating behaviors.
    • Ensure that students also learn general health skills, such as how to assess their health habits and set goals for improvement
  3. Instructions: Provide nutrition education through activities that are fun, participatory, developmentally appropriate, and culturally relevant. These activities should: a. Emphasize the positive, appealing aspects of healthy eating rather than the harmful effects of unhealthy eating. b. Give students many opportunities to taste foods that are low in fat, sodium, and added sugars, and high in vitamins, minerals, and fiber.
  4. Program Co-ordination
    Coordinate school food service with nutrition education and with other components of the school health program to reinforce healthy eating.
  5. Staff Training.
    Provide staff with adequate pre-service and ongoing in-service training that focuses on teaching strategies for promoting healthy eating habits.
  6. Family and Community Involvement
  7. Regular Evaluation of plan effectiveness and re-planning

OBESITY: Obesity is defined broadly as BMI over 30 kg/m2 and overweight as per western standards and BMI of over 25 kg/m2 as per Indian standards as Indians have truncal obesity which predisposes them to greater cardiac risk over-weight and obesity in adolescence as per SMR rating and BMI centile.

SMR

Sex

OWT > 85% tile

OBS > 95% tile

2

M/F

19/19

22/21

3

M/F

19/21

22/23

4

M/F

22/22

25/24

5

M/F

22/25

26/27



  • Research suggests that not having breakfast can affect children's intellectual performance, and can rather lead to obesity.
  • Poor eating habits and inactivity are the root causes of overweight and obesity. They prevalence of overweight among children ages 6 to 11 has more than doubled in the past 20 years, going from 7% in 1980 to 18.8% in 2004. Overweight among youth ages 12 to 19 has tripled in the same time period, going from 5% to 17.4%.
  • Overweight children have a higher rate of low self-esteem, type 2 diabetes, sleep apnea, bone and joint problems, and gall bladder disease.
  • It has been estimated that as many as 7 to 8% of females suffer from anorexia nervosa and/or bulimia nervosa in their lifetime.
MANAGING OBESITY
Early intervention after consulting specialist trained doctors:
Multidisciplinary approach with family involvement.

STRATEGY:
  • Reduce calorie intake
  • Increase physical activity levels
  • Decrease sedentary behavior
  • Family behavior modification


Deliberately restricting food over long periods leads to poor growth and delayed sexual
development. Many students use smoking to control their appetite and weight. Reported even in 9 years olds. Young persons involved in competitive sports are at risk for unsafe weight-loss practice. A national survey of 8th & 10th-class students found that 32% skipped meals, 22% fasted, 7% used diet pills, 5% induced vomiting after meals, 3% used laxatives to lose wt. Adolescents should know the dangers of unsafe weight loss.

NUTRITIONAL GOALS 2010
  • Reduce overweight prevalence to around 15% among adolescents aged 12-19.
  • Reduce average dietary fat intake to Pound 30% of calories and average saturated fat intake to Pound 10% of calories among children aged > 2 yrs.
  • Increase complex carbohydrates and fiber-containing foods in the diets of adolescents to > 5 daily servings for vegetarians (including legumes) and fruits and to>6 daily servings for grain products.
  • Increase to 350% overweight people aged > 12 yrs with sound dietary practices and regular physical activity to attain an appropriate BW.
  • Increase calcium intake so 350% of youth aged 12-24 and pregnant and lactating teens consume > 3 servings daily of Ca. rich foods.
  • Decrease salt and sodium intake so that 365% of home meal is prepared without adding salt, 380% of people avoid using salt at the table.
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