In a presentation at the Global Health Practitioner Conference, April 13-17, 2015, JSI's Peggy Koniz Booher shared an overview of a literature ant programmatic review on improved nutrition for adolescents, pregnant and lactating women, and women of reproductive age. This presentation included findings from a technical meeting on recommendations on key dietary practices to be used in strengthening policies and programs.

1. This presentation was made possible by the American people through the U.S. Agency for International
Development (USAID) under Cooperative Agreement No. AID-OAA-A-11-00031, the Strengthening
Partnerships, Results, and Innovations in Nutrition Globally (SPRING) project.
Moving the Adolescent
Nutrition Agenda Forward
Peggy Koniz-Booher, Senior Advisor Nutrition SBCC
SPRING Nutrition Project
CORE Group… April 14, 2015

2. Technical Meeting on the Diet and Eating
Practices of Adolescent Girls and Women
March 16 – 17 2015
PAHO/WHO, Washington, DC

3. Some background on rationale
for this technical meeting
• The 2013 Lancet Series on Maternal and Child Nutrition provided
new evidence on the importance of the nutrition of women at the time
of conception and during pregnancy, not only to ensure optimal fetal
growth and development but also for the health of the mother.
• The series also identified adolescent girls as a key priority and
highlighted the importance of a life course approach, placing them
together with women of reproductive age and mothers at the center
of nutrition interventions.
• Despite the recognized importance of adolescent girls’, women’sand
maternal nutrition for their health and that of their children, this group
is virtually neglected in nutrition programming with the exception of
provision of iron and folic acid supplements during pregnancy.

4. Background/rationale (cont.)
• In 2012, there were 1.2 billion adolescents in the world – defined as
young people between the ages of 10 and 19 years.
• The vast majority of adolescents (90%) live in low- or middle-income
countries (LMIC). In some countries, as many as half of all adolescents
are stunted, with impact on physical and cognitive development
• About 16 million girls aged 15 to 19 and some 1 million girls under 15
give birth every year—most in LMIC. Complications during pregnancy
and childbirth are the second cause of death for 15-19 year-old girls
• Alarming shift in BMI globally - growing rates of overweight and obesity in
many LMIC. (Throughout LAC, the prevalences of overweight and
obesity is around 50%. This is also true for Central and Eastern Europe.)

5. Meeting Objectives
1. Review insights and lessons learned
from two discussion papers
commissioned by SPRING
2. Identify characteristics of and issues
related to key diet and eating
practices for strengthening policies
and programs for adolescent girls’
and WRA’snutrition
3. Propose next steps in development
of a set of key diet and eating
practices

6. Began by reflecting on the Guiding Principles:
Goal: To develop a set of unified, scientifically based guidelines
that could be adapted to local feeding practices and conditions
This earlier review provided the
scientific basis for 9/10 principles
(active feeding not evidence based)
Target audience: Policy makers,
program planners, health care
providers and communityleaders

7. WHO Evidence-Informed
Guideline Development Process

8. Countries have been proliferating Food-
Based Dietary Guidelines for about 20 yrs
FAO recently launched an on-line repository of
~100 country FBDGs and associated resources.
A “descriptive summary” project by Mary Arimond, Jennie Coats and Anna Herforth.

9. Objectives of Background Paper #1:
Nutrition of Adolescent Girls and WRA
• Present the current landscape
of nutritional status of
adolescent girls, women of
reproductive age, women
during pregnancy and during
lactation
• Summarize potential key
nutrition actions and
interventions to improve
nutritional status of these
population groups

10. Objectives of Background Paper #2:
Review of Programmatic Responses
• Conduct a rapid review of the
literature & programmatic
documentation to:
 Provide information on global
programmatic experiences to
improve the nutrition of
adolescent girls and WRA
 Summarize inputs, outcomes,
and lessons learned from
implementers who have/are
carrying out nutrition programs

11. Some highlights #1:

12. Distributions of height among women of reproductive
age by UN region (Kozuki et al., submitted)
UN MDG
region
< 145 cm 145 < 150 cm 150 < 155 cm > 155 cm
Oceania 2.3 8.5 16.8 72.4
Eastern Asia 2.0 7.8 22.6 67.7
Western Asia 1.3 7.2 22.3 69.1
SE Asia 8.9 23.6 35.8 31.6
South Asia 10.7 24.6 33.2 31.5
Caucasus &
Central Asia
0.7 3.7 15.3 80.2
Northern Africa 1.5 5.4 17.7 75.5
Sub-Saharan
Africa
2.6 7.0 18.8 71.6
Latin America
& Caribbean
4.8 13.0 24.1 58.1
US (NHANES)
--
Counterfactual
0.6 3.0 9.7 86.7
145 cm is 4’9”; 150 cm is~ 4’11”; 155 cm is 5’1” tall

13. BMI status of women 20+years by region
(Ng et al, 2014; Stevens/WHO [unpublished])
Low prevalences of
underweight except in SSA
(not Southern),Southeast
and South Asia
Only in South Asia are >
20% women underweight
Throughout LAC, the
prevalences of overweight
and obesity surround the
50% mark
This is also true for Central
and Eastern Europe
0 20 40 60 80 100 120
Asia-Central
Asia-East
Asia-South
Asia-Southeast
SSA-Central
SSA-Eastern
SSA-Southern
SSA-Western
LAC-Andean
LAC-Tropical
LAC-Southern
LAC-Central
LAC-Caribbean
N Africa & ME
Oceania
HI-Y: Asia Pacific
HI-Y: N America
Hi-Y: Austral-Asia
Europe-Western
Europe-Eastern
Europe-Central
BMI < 18.5 kg/m2 BMI 18.5-25 kg/m2 BMI 25-30 kg/m2 BMI 30+ kg/m2

14. Changes in prevalence of underweight, overweight
and obese women in LMIC from 1980 to 2008
(Black et al., 2013)
Presented are the prevalences of maternal body mass index (BMI) < 18.5, > 25 and > 30 kg/m2
Under-W Over-W Obese
Africa Americas and the Caribbean
Asia Global

15. BMI status of girls < 20 years and women
20+ year by region (Ng et al, 2014)
0 20 40 60 80 100 120
Asia-Central
Asia-East
Asia-South
Asia-Southeast
SSA-Central
SSA-Eastern
SSA-Southern
SSA-Western
LAC-Andean
LAC-Tropical
LAC-Southern
LAC-Central
LAC-Caribbean
N Africa & ME
Oceania
HI-Y: Asia…
HI-Y: N America
Hi-Y: Austral-…
Europe-Western
Europe-Eastern
Europe-Central
Girls < 20 years
BMI < 25 kg/m2 BMI 25-30 kg/m2 BMI 30+ kg/m2
0 20 40 60 80 100 120
Asia-Central
Asia-East
Asia-South
Asia-Southeast
SSA-Central
SSA-Eastern
SSA-Southern
SSA-Western
LAC-Andean
LAC-Tropical
LAC-Southern
LAC-Central
LAC-Caribbean
N Africa & ME
Oceania
HI-Y: Asia…
HI-Y: N…
Hi-Y: Austral-…
Europe-Western
Europe-Eastern
Europe-Central
Women 20+ years

16. Anemia in women and children and changes from
1995 to 2011 (Stevens et al., 2013)
Prevalence of anemia is declining
in most regions
Children Pregnant
women
Non-pregnant
women
Anemia 47% to
43%
43% to 38% 33% to 29%
Severe
anemia
3.7% to
1.5%
2.0 %to
0.9%
1.8% to 1.1%
(Anemia: < 110 g/L for children and
pregnant women; and 120 g/L for women)
(Severe anemia < 70 g/L for children
and pregnant women; < 80 g/L for women)

17. Prevalence of micronutrient deficiencies among
adult women and during pregnancy
Region
Vitamin A deficiency among
pregnant women1
Insufficient
iodine intake
in general
population2
Inadequate
zinc intake in
general
population3
Night
blindness
(%)
Serum retinol
< 0.70 umol/L
(%)
Urinary
iodine
concentratio
n < 100 ug/L
(%)
Zinc
available <
EAR (%)
Globe 7.8 15.3 28.5 17.3
Africa 9.4 14.3 40.0 17.1-25.6
Americas
&
Caribbean
4.4 2.0 13.7 6.4-17.0
Asia 7.8 18.4 31.6 7.8-29.6
Europe 2.9 2.2 44.2 9.6
1reported in WHO (2009) and in Black et al (2013)
2reported in Andersson et al (2012) and in Black et al (2013)
3reported in Wessells and Brown, 2012; see also Wessells et al., 2012

18. Status of global prevention of folic-acid
preventable birth defects, 2012
(Source: Youngblood et al. 2013)

19. Estimated intakes of selected “healthy” and
“unhealthy” foods by region among women 20-29 y
(Imamura et al., 2015)
What are
recommended
intakes to ensure
nutrient needs are
met for WRA?
How do we
combine goals for
maternal nutrition
and chronic
disease
prevention?
Horizontal lines represent the mean of the theoretical minimal risk exposure distribution

20. Energy intakes of adolescent girls and women of
reproductive age (WRA) by region
Adolescent girls WRA

21. Protein intakes (% energy) of adolescent girls and
women of reproductive age (WRA) by region
Adolescent girls WRA

22. Fat intakes (% energy) of adolescent girls and women
of reproductive age (WRA) by region

23. Calcium intakes of adolescent girls and women
of reproductive age (WRA) by region

24. Iron intakes of adolescent girls and women
of reproductive age (WRA) by region

25. Some Key Findings
• Reducing short maternal stature requires continued
improvements in nutrition lifecycle of girls.
• Key nutrition interventions include support for
maternal nutrition during pregnancy and lactation,
IYCF and development of healthy eating patterns.
• Nutritional interventions during later childhood
and/or adolescence need study (efficacious?).
• Family planning to delay age at first pregnancy
likely contributes to improving maternal stature.

26. Key Findings (cont.)
• The nutritional status of
WRA has shifted over time,
with some reductions in the
prevalence of underweight,
and shifts from normal
weight to overweight/obesity.
• The problem of underweight
at the national level is less
10% in all areas except for
some parts of Sub-Saharan
Africa, and South Asia.

27. Key Findings (cont.)
• The problem of under-weight
among adolescent girls,
particularly those 15-19 is less
well characterized, but appears to
be consistent with those of women
20+, except in South Asia where it
may be as high as 40%.
• In South Asia, there is urgent
need to address the problem of
underweight among girls and
women.

28. Key Findings (cont.)
• When examined by age,
overweight and obesity increased
among women 20-30, suggesting
postpartum weight retention as an
explanatory factor
• There is a need to characterize
BMI status for local programming;
in most areas the goal of having
normal BMI means weight loss
rather than weight gain.

29. Key Findings (cont.)
• Postpartum weight
management is needed.
• Progress has been achieved
in reducing maternal
deficiencies of vitamin A and
iodine, as well as anemia,
but the problems remain.
• Inadequate zinc intake in
LMIC appears significant.
• Folic acid fortification
coverage is not optimal

30. Key Findings (cont.)
• Average nutrient intakes are inadequate in LMIC
across regions and target groups. Importantly,
adolescent girls, WRA and pregnant and lactating
women do not face dietary concerns distinct from
one another in terms of imbalanced macronutrient
intakes, and inadequate micronutrient intakes
• More studies are needed and a comprehensive
strategy for nutrition during lactation is needed
• Improvements in nutrient intake need to be placed
within the context of overall weight management.

31. Key Findings (cont.)
• Promotion of nutrient dense foods or foods
providing key nutrients within the context of weight
maintenance or loss (shift in consumption) is
different from promotion of greater food intake (of
the same or greater nutrient density) within the
context of increasing BMI to normal.
• The relative effectiveness of interventions to reduce
“unhealthy foods” (e.g., sugar-sweetened beverage)
consumption and/or increase consumption of
“healthy foods” requires research in LMIC.

32. Goals for Diet and
Eating Practices
Achieve normal weight
• Low maternal BMI is a widely accepted risk factor for poor
pregnancy outcomes
• For underweight women, it sets up a recommendationfor
higher gestational weight gains that may not be achievable
• Entering pregnancy overweight/obese increases the
likelihood of complications,including fetal demise
• For overweight women, gestational gain and postpartum
weight retention contribute to obesity
Maintain or improve diet quality as a lifestyle goal
• Adequate intakes of calcium, iron, vitamin C, vitamin A, folic
acid, whole grains, vegetables and fruits, reduce alcohol
intake

33. Goals for Diet and
Eating Practices (cont.)
Maintain or improve physical activity level/active
lifestyle
• Important since physical activity tends to decline during
pregnancy, and starting new physical activity is not
recommended)
Other
• Prevent/treat anemia and achieve adequate iron stores
• Maintain sufficient iodine intake to avoid thyroid disorders
• Maintain sufficient vitamin A intake to maintain retinol
concentrations;
• Ensure folic acid intake of 400 ug/d

34. Some Gaps in Evidence
• In places where you have women of low BMI (South Asia,
West/Central/East Africa), what is the evidence around the
efficacy of interventions to increase BMI on women entering
pregnancy with low BMI?
• “Eating down” during pregnancy to avoid a large baby –
is the practice less common than the concept?
• Catch-up growth in adolescence – what is the contribution of
animal source foods?
• What is the efficacy of dietary guidelines - do they actually
change behaviors?
• Can the balance within meals and the timing of meals avoid
spikes in blood sugar levels, macronutrient and caloric intake
• What are the determinants of dietary behavior?
• What is the impact of marketing of products to adolescents?

35. Outcome: Draft set of food based-practices or
principles for an optimal diet - adolescents
 Whole grains cereals and legumes (over highly refined grains*)
 Eat appropriate portion sizes (population & BMI specific /balance
energy intakes with energy needs, balance types of foods)
 Limit sugar & sweetened beverages
 Limit salts, salty condiments, salty snacks (iodized if salt is added)
 Limit highly refined and ultra processed foods
 Drink potable water
 Safe storage, preparation, and handwashing
 Moderate consumption of animal flesh and animal source foods*
(iron, zinc, b12, calcium, vitamin D, etc.)
 Separate recommendation for adolescent girls and perhaps WRA
 Fruits/vegetables (include dark green leafy & yellow/orange flesh)
 Distinguish legumes vs dark green/vegetables
 Eat a variety of foods
 Oil (placeholder – needs further development)
 Avoid skipping meals, eat breakfast
Overarching Dietary Principles – Food Safety,
Adequacy, Moderation, Balance, Variety (define all)
Problem
Anchors
 Mortality
 NCDs
 High blood
pressure
 Cardiovascular
 Diabetes
 Cancer
 Cognitive devel
& productivity
 Pregnancy
outcomes
 Infections
 Linear growth
and BMI
 Depression

36. Next steps
• Finalize meeting report, with proposed way forward
(next steps) in establishing food based-
principles/practices for an optimal diet. Circulate.
• Finalize 2 background papers (copyright issues and
incorporate feedback). Circulate. Publish /present.
• Finalize the set(s) of draft principles/practices for an
optimal diet for adolescent girls and WRA.
• Circulate food-based principles/practices for review
by participants and other stakeholders.
• Conduct additional systematic reviews (if/as
needed).
• Move through agreed upon mechanism……

38. www.spring-nutrition.org/events
For more information on the technical meeting
(background materials and presentations),
please visit: