Report of the Stakeholders Consultation on Adolescent Girls’ Nutrition

Front page of document. Strip of artist renderings of adolescent women from different countries across top. Title of document below.

Executive Summary

This report details a two-day high-level stakeholder consultation that was organized and co-hosted by United States Agency for International Development (USAID); SPRING; and the Pan American Health Organization (PAHO). The meeting was held at the PAHO headquarters in Washington, DC, on October 30–31, 2017. More than 40 global leaders working in adolescent girls’ nutrition participated, representing many academic and research institutions, nongovernmental organizations, UNICEF, the World Health Organization (WHO), and donor agencies.

This consultation built on an earlier meeting hosted by USAID, SPRING, PAHO, and the Food and Nutrition Technical Assistance III Project (FANTA) in 2015: the Technical Meeting on the Diet and Eating Practices of Adolescent Girls and Women of Reproductive Age. The 2017 stakeholder consultation brought experts in the field together again to review a new draft report—Diet and Eating Practices among Adolescent Girls in Low- and Middle-Income Countries: A Systematic Review. The consultation participants also discussed a summary of the forthcoming WHO document— Effective actions for improving adolescent nutrition—to share new background data and guidance documents and to define key evidence and implementation gaps, prioritize future research, and propose next steps in moving the adolescent nutrition agenda forward.

A growing focus on adolescent girls’ nutrition: The nutrition of the 900 million adolescent girls (ages 10–19) living today will have a profound impact on their current and future health. By sustaining healthy diet and eating practices during adolescence, they have the potential to address nutritional deficits and linear growth-faltering generated during the first decade of life and may limit harmful behaviors contributing to the epidemic of obesity and non-communicable diseases (NCD) in adulthood. Investing in female adolescent health brings triple dividends: better health for adolescents now, for their future adult lives, and for the lives of their children. Given that 16 million girls between the ages of 15 and 19 give birth each year, their nutritional status is important not only for them, but also for the health of their offspring.

The nutrition of adolescent girls was identified as a key priority in the 2013 The Lancet series on maternal and child nutrition. Furthermore, the global Accelerated Action for the Health of Adolescents (AA-HA!) Guidance to support country implementation revealed stark differences in the causes of death and disabilities when separating the adolescent age groups and sexes. The Global Strategy for Women's, Children's and Adolescents' Health 2016-2030—which aims to achieve the highest attainable standard of health for all women, children, and adolescents—underscores the importance of adolescent girls’ nutrition, for themselves and for their infants and children, if and when they become mothers.

However, current nutrition programming often does not prioritize this critical population. Although adolescent girls have shown growing interest in nutrition, knowledge of their current dietary practices and the impact of the changing food environment is limited, especially in low- and middle-income countries. Additionally, evidence is limited on the effectiveness of program interventions specifically targeting adolescent girls.

How the stakeholder consultation was structured: USAID, SPRING, and PAHO worked together to design the agenda for the stakeholder consultation, prioritizing issues and identifying research and program experiences to share. They invited experts and structured the agenda around three topics: evidence, guidance, and gaps. The objectives focused on reviewing the current state of evidence, existing guidance, relevant program and implementation experience, and research gaps and priorities related to adolescent girls’ nutrition. The presentations included (1) a review of the current evidence, with an in-depth presentation from the Demographic and Health Surveys (DHS) program on the comparative analyses of adolescent nutrition indicators by Dr. Rukundo Benedict; (2) the methods and findings from the systematic review on diet and eating practices among adolescent girls in low- and middle-income countries by Dr. Zulfiqar Bhutta and Dr. Emily Keats; (3) current WHO nutrition-related recommendations targeting adolescents by Dr. Pura Rayco-Solon; (4) Brazil’s food-based dietary guidelines by Dr. Carlos Montiero; (5) the interaction between food systems, food environments, diets, and nutrition among adolescents by Dr. Jessica Fanzo; and (6) the double burden and double duty actions for adolescents by Dr. Corinna Hawkes. Dr. Luz María De-Regil, Dr. Alison Tumilowicz, and Marcia Griffiths also presented examples of their work and facilitated discussions on program implementation, gaps, and challenges. Reflecting on the earlier presentations and inputs from various stakeholders, Dr. Rafael Pérez-Escamilla and Dr. Zulfiqar Bhutta led a final discussion on research gaps, challenges, and recommendations for future research.

Results and recommendations: The consultation produced a list of key evidence and implementation gaps about the diet and eating practices of adolescent girls in low- and middle-income countries and a summary of areas where additional guidelines and/or policy guidance may be needed:

Evidence Gaps, Research Actions, and Future Directions

Evidence Gaps and Research Actions Future Directions
  • Collect more quality nutrition data: Collect contextual, nationally representative data on adolescent health and nutrition across the full age range and by country, including distribution on micronutrient deficiencies and body composition information.
  • Develop indicators and gain consensus on measurement: Develop standardized indicators and data collection instruments for measuring, assessing and monitoring diet, diet quality, and dietary patterns. Gain consensus on indicators and data collection instruments. This is relevant for ongoing surveys and national surveys using increasingly standardized tools.
  • Conduct implementation research: Conduct implementation research to assess factors (barriers and enablers) that affect implementation quality and impact in nutrition programs for adolescents.
  • Identify efficacious interventions: Identify and conduct research on efficacious interventions (as well as appropriate delivery platforms) aimed to improve the diets of adolescents, and use this information to influence the development and implementation of future interventions.
  • Identify dietary patterns: Identify current dietary patterns and factors that shape dietary behaviors and preferences among adolescents in different contexts. When assessing dietary patterns, the surrounding micro-food environments (urban slum, rural, school, conflict zones), information technology and marketing, and the adolescents’ psycho-social context must be considered.
  • Look at behavior and age: Understand how younger adolescents differ from older adolescents in neurological development and behavior and how this may influence program design.
  • Learn how to engage adolescents: Understand how to effectively engage and partner with adolescents in policy decisions, program design, and intervention delivery. Look at lessons from SRH programming.
  • Consider household food insecurity: Understand the impact of household food insecurity on dietary behaviors and psychosocial well-being of adolescents.
  • Look at food industry influences: Understand how low-income countries are being exposed to the food industry and how they are being affected. Learn from the tactics used by the food industry to market their products among adolescents (including social media). Look at middle-income countries for guidance on how to deal with food industry encroaching on diets and dietary patterns in low-income countries.
  • Assess impact of taxes: Look at how excise taxes on sugar-sweetened beverages and junk foods, front of package food labeling, marketing regulation, and food product reformulation affect adolescents’ dietary choices and practices.
  • Physical activity: Gain a deeper understanding of adolescents’ physical activity behavior and how it can be improved. Assess the impact of open space physical activity programs (e.g., Ciclovías Recreativas) on adolescents’ physical activity behaviors.
  • Conduct a global survey: Conduct a representative high-quality global survey on adolescent health and nutrition, including nutrition environment and risk factor mapping.
  • Conduct social network analysis: Conduct social network analysis to understand how best to reach and disseminate programs among adolescents.
  • Monitor dietary patterns: Monitor dietary patterns. Include the total diet (not simply nutrient or individual food intakes) and household food insecurity among adolescents.
  • Differentiate between age groups: Differentiate between younger and older adolescents in all research and evaluations with potential links to school –age children.
  • Include all adolescents: Include both girls/women and boys/men in the adolescent agenda. The behaviors and nutrition of adolescent boys are important in themselves and as they relate to the nutrition of adolescent girls. Include adolescents in the dialogue throughout the entire program and policy development process and give them meaningful opportunities to contribute and shape actions to meet their needs.
  • Disseminate and operationalize WHO recommendations for adolescent nutrition: Support the dissemination, country adaptation, and implementation process for the WHO adolescent nutrition guidance.
  • Design integrated programs employing best practices: Develop behavioral profiles of adolescents in relation to their diet and eating patterns, and design food and nutrition programs through effective behavior change interventions that take into account known dietary behaviors (e.g., breakfast skipping, high consumption of SSBs and junk food, etc.) in the context of the key brain development milestones during adolescence. Conduct and use Program Impact Pathways (PIP) analyses to guide the development, implementation, and evaluation of food and nutrition programs targeting adolescents.
  • Evaluate at-scale interventions: Conduct rigorous evaluations of large-scale interventions to improve adolescent dietary patterns and eating practices and nutrition status.
  • Work multi-sectorally: Generate new and strengthen existing partnerships for effectively engaging in multi-sectoral action.

By the end of the consultation, stakeholders agreed on the need to raise further awareness about the evidence and implementation gaps, and to provide investment guidance. They also expressed interest in disseminating and operationalizing WHO recommendations on adolescent nutrition; conducting a global survey on adolescent nutrition, including qualitative research; developing indicators and gaining consensus on measurement; employing best practices in program design, encouraging investment in, and evaluating at-scale interventions; working multi-sectorally and including adolescents—to the greatest extent possible—throughout the entire research, program, and policy development processes.