20 December 2017

Stuck in the Middle: Nutrition Programming for Adolescents

Adolescents (or “Generation Z” as businesses call them) are a group that are both talked about and ignored by the nutrition community.
Everyone is talking about them right now. There are two workshops that I know of on the topic in the past couple of months: one in Washington organised by Pan American Health Organization/World Health Organization (WHO)USAID/SPRING and partners, and one in London organised by ENNSave the Children UK and the London School of Hygiene and Tropical Medicine (LSHTM). There are probably more. And yet adolescents are also ignored: there is little data on them, and few nutrition interventions designed by or even for them.
I attended the London workshop earlier this week. It was very well organised around population groups, outcomes and interventions.
Some things I noted/learned/realised:
  1. Adolescents can make good nutrition status time travel. Adolescents are a bridge across generations, biologically of course due to the growth spurts they experience and in terms of their future role as parents, but also in terms of norm setting and social and emotional development.

  1. The cost of the adolescent girl diet is one of the most expensive in a household as found by the World Food Programme (WFP)’s research. This is because girl adolescents have a high nutrient requirement and these are found in relatively expensive foods.

  1. Age matters – for nutrition and neuroscience. GAIN is finding different anthropometric trends among adolescents 10-14 and 15-19 years in Bangladesh. There is an accelerated decrease in stunting and underweight among younger adolescents, but also an increased acceleration of overweight and obesity as compared to the older adolescents. Behavioural research from the UK finds that adolescents 12-15 years of age are more likely to pay attention to health messages whereas 15-19 year olds are more distracted by competing issues. Also the younger age group is more likely to be influenced by parental views, whereas the older group are influenced by their peers. In fact, the risk loving behaviour of adolescents is similar to those of people in their 20s, but only if peers are not involved. Once they are involved the 15 year olds get heavily influenced by peer pressure. We cannot treat adolescents as a single target group.

  1. There are likely important rural/urban differences. For example we heard about how all adolescents in Malawi tell us their food choices are influenced by resources (cost, time, knowledge), context (availability, family dynamics, information sources) and ideals (modernity, tradition). Yet for the urban groups modernity was much more valued than for rural groups.

  1. Function matters. There is a need to put more focus on function when it comes to indicators: height and body mass index are important to predict risk of birth obstruction (on one end of the malnutrition spectrum) and non-communicable disease (on the other end). But in the nutrition world we rarely measure function (physical, cognitive and psychosocial). Can’t we do so more directly if that is what we are interested in?

  1. The nutrition community is coming late to the adolescent party. For example, adolescent health has been championed by WHO through its longstanding efforts on adolescent responsive health systems and the more recent call to action: Global Accelerated Action for the Health of Adolescents (AA-HA!): guidance to support country implementation.  The human immunodeficiency virus (HIV) and sexual reproductive health colleagues have for years been experimenting and learning how to work with adolescents. In nutrition, we are just starting to understand the challenges of programming for adolescent nutrition. We don’t even routinely break out reporting from survey data such as Demographic Health Survey (DHS) & Multiple Indicator Cluster Surveys (MICS) for adolescent girls from the women of reproductive age group (15-49).

  1. The unintended consequences of getting programming wrong for adolescents are not trivial. For example early puberty may be one outcome, which may lead to early age at first pregnancy and poor outcomes for mother and child. In addition, programs that target girls only may risk backlash from boys who feel excluded.

  1. Most programmes aimed at improving adolescent nutrition will have to work through other sectors. This is because there are many different (but short lived opportunities) to find the “hour in the day” that adolescents can control and engage with programs. This means that nutrition champions have to really think hard about what they have to offer these other sectors.  For instance, can improved adolescent nutrition really improve school outcomes in a cost effective way? If yes, why wouldn’t education leaders embrace it? We need to do the research and then influence the education leaders.

For me the key is for nutrition to learn from others. How do those who design policies and programmes for adolescents in education, HIV prevention, sports and recreation, the prevention of violence and decent work reach these age groups?
In fact, is there even a role for stand-alone nutrition interventions for adolescents beyond micronutrient supplements? Will all the effective interventions be found in the nutrition sensitive space? Should the nutrition field put more effort into shaping the food systems (access) in which adolescents live or preparing adolescents to make the best food choices possible (demand)? I don’t know.
What I do know is that we have to learn from others, adapt the learning, try the most plausible, evaluate them rigorously and then share the findings in an engaging way. What we can’t do is nothing.  One of the most memorable quotes from the presentations in London was from a Cambodian girl drawing a picture of herself crossing a line, saying “This is me—in the middle”.
When adolescents are going through such rapid transitions we can’t leave them stranded in the middle without adequate support. We need to design and implement new approaches to address adolescent nutrition. Adolescents are looking for allies, for people to listen to them, and for investors and others to take a chance on programmes that will help them through the sometimes wonderful, sometimes frightening turbulence of this time in their lives.
As the 2017 World Health Assembly said, lack of evidence is no longer an adequate excuse for inaction.
I would like to thank Alison Tumilowicz who leads GAIN’s adolescent research for her valuable inputs to this blog.

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