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FEX66 Editorial

Welcome to the 66th edition of Field Exchange, which we are delighted to announce is a special issue focusing on adolescents and school-aged children. The importance of investing in this age group is backed up by evidence and science; for building life-long health and maximising both their potential and that of future generations, and also because of their key contribution to meeting the global Sustainable Development Goals. 'Improving the nutrition of adolescents and school-aged children is a topic that ENN is passionate about. We’ve been slowly building information and ev­idence over the past few years as part of the Adolescent Nutrition Interest Group1, an informal group coordinated by ENN. We’re very excited to produce this special edition, to summarise latest research and showcase innovative projects. It has been particularly interesting to have en­gaged with so many authors on what is hap­pening for this age group in the nutrition sector, the many challenges that exist and what the priorities are moving forwards. Of course, the COVID-19 pandemic continues to be a focus across Field Exchange and its impact on efforts towards improving the nutrition status of adolescents and school-aged children is outlined in almost every article included in this edition.

A key challenge that has been highlighted is the lack of international targets and goals for adolescents and school-aged children, in addition to limited systematic tracking of nutrition and mortality data. This is partly due to the wide variety of indicators used, the different age groups targeted and multiple references used for each, as outlined by Lelijveld in a research summary. These data gaps mean that it is difficult to assess the burden of malnutrition in this age group, to monitor trends over time and to assess the impact of strategies and interventions. The lack of data constrains decision-making, prioritisation and advocacy with governments. However, a news piece by Rukundo Benedict describes some positive improvements that are on the way in Demographic and Health Surveys (DHS), including the use of BMI-for-age z-scores to help assess adolescent nutritional status and the addition of several new nutrition-related indicators. Although DHS only collects data for the 15-19 year old age group and therefore gaps remain for 5-14 year olds, this is a good start in helping the right data to be collected and utilised to advocate for the needs of adolescents and school-aged children, and hopefully for programmes to better track impact in the future.

Schools remain a critical delivery platform for health and nutrition interventions for adolescents and school-age children, as highlighted by Bhutta et al in the 2021 Lancet Maternal and Child Undernutrition series update2. A views article by Bouterakos et al describes the importance of school feeding programmes; ever more important given the number of children who were out-of-school for so long due to the COVID-19 pandemic. The urgency of encouraging attendance once again, both for education reasons and to increase access to health and nutrition interventions, cannot be overstated. Not only is school feeding important for the learners themselves, when intergenerational effects are considered, the linear growth benefits of school feeding for children six to 10 years of age are much greater than previously understood. This was outlined by Chakrabarti et al when describing the success of India’s Mid-Day Meal scheme. The value of school-based programming is also described by Hemler et al when summarising the current evidence on anaemia in school-age children and adolescents. Here, multiple micronutrient supplements offer an avenue for success but many questions remain around how to reach those out-of-school. Nevertheless, while there are still gaps in evidence on the best way to address adolescent and school-age nutrition through school and community platforms, we do already know enough to start intervening at greater scale now. In addition, few articles discuss the challenge of how to best reach and support out-of-school adolescents and school-aged children. An increased focus is needed on those who are not in school long-term, who are hardest to reach but likely furthest behind and who are the greatest risk for both their own development and that of future generations.

The importance of well-functioning food systems for both individual and planetary health has been gaining traction over the past few years. It is encouraging to see a number of articles in this edition focus on the importance of food systems and food environments for adolescents’ nutrition. Matonga et al highlight the value of food systems in the nutrition-sensitive agricultural arm of their intervention and the article from Mexico highlights how behaviour change initiatives, no matter how successful, can only go so far if obesogenic environments limit access to and availability of nutritious diets. In Gaza it was noted how hostilities negatively affected food security of adolescents and school-aged children, highlighting the importance of strengthening food systems within protracted conflicts, which are sadly becoming more prevalent across the globe. Finally, the cost of the diet analysis conducted by Turowska et al, looking at the differences between dietary needs of adult men and adolescent girls (in order to look at the cost and affordability of meeting adolescent girls’ nutrient needs relative to those of other household members, to estimate the comparative risk of nutritional deficiencies), describes how nutritious diets are largely inaccessible for the poorest communities. They suggest that a focus on local production and gearing food systems towards nutrient diverse foods, such as beans and legumes, could help to safeguard the health of vulnerable adolescents, particularly young girls. However, as Sharma and Tyler outline in their views piece, a holistic, multisectoral systems approach should be taken to effectively address the drivers and determinants of malnutrition in this age group, one that goes beyond food systems to also include health, education, water and sanitation, and social protection systems.

Another theme that came through strongly in this edition was the importance of ensuring that the youth themselves lead on designing and implementing programmes and projects intended to address the challenges they face, in order to create ‘youth-friendly’ interventions. For example, in Zimbabwe, Katete et al, demonstrated how young people can be champions of change at their schools amongst peers, in the spirit of ‘for young people, by young people’. More and more, media is being used to reach this age group as we progress through the digital age and innovative case studies are presented from Timor Leste, the Pacific Islands, India and Zimbabwe in Wrottesley’s article on the use of media to engage school-aged children and adolescents to improve their nutrition and health status.

While much promising work has been done to develop policies and guidelines and to advocate for prioritising these age groups, a common theme across all field experiences described, due to the lack of agreed metrics and indicators for this age group, is that it is difficult to determine impact as a result. Many projects struggle to capture impact data related to their interventions, even where key stakeholders see the value in prioritising adolescent and school-aged children and are mobilised to respond. This particular challenge highlights the role that UN organisations, such as UNICEF, can have in supporting governments and partners to monitor the impact of programmes. One example of this is in Mexico, where UNICEF is supporting the government to develop appropriate monitoring and evaluation for the ‘Vida Saludable’ programme to better track progress and impact on the nutritional status of adolescents and school-aged children. Only with effective monitoring and improved evaluation can we hope to assess impact and thus better serve this critical age group.

Despite a public announcement calling for content for this edition, very little was received for school-aged children, in particular the period of middle childhood (aged 5-9 years). We anticipated that this may be the case but it is a sobering reminder of the little we know about this age group, both in terms of their nutritional status and what interventions can be effective in improving it. Identifying agreed evidence gaps and priorities for research for both in- and out-of-school adolescents is critical for mobilising attention and financing and this will be helped by a series of papers from the influential Lancet journal that will be released imminently regarding adolescent nutrition; we’re eagerly awaiting the excellent summaries of latest evidence, interventions and recommendations. Additionally, ENN will shortly finalise and publish a research prioritisation exercise for the nutrition of school-aged children and adolescents using the CHNRI methodology, so watch this space!

Finally, this 66th edition of Field Exchange coincides with ENN’s 25th birthday! The foundations of ENN are rooted in Field Exchange, with the first edition put together by hand and with a lot of sticky tape back in 1996. It is fascinating to look back at what Field Exchange has reported on through the years; while some challenges have been addressed, many of the key discussions are sadly still relevant today. Marie McGrath, a longstanding Co-Editor of Field Exchange, looks back on some of the issues discussed over the years in a summary news piece included in this edition. We would love to hear your perspective on some of the issues mentioned or other reflections on previous Field Exchange content, so please do send in your letters to the editors. In the meantime, happy reading!

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Editorial. Field Exchange 66, November 2021. p3. www.ennonline.net/fex/66/fex66editorial

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