Adolescent Nutrition: Policy and programming in SUN+ countries

Summary of report1

This summary was prepared by Emily Mates (ENN) who undertook the review as an independent consultant together with Tanya Khara (independent), with the support of Frances Mason, Save the Children.


Location: Global

What we know: Ninety per cent of 1.2 billion adolescents in the world live in low or middle income countries where up to half may be stunted. Sixteen million adolescent girls give birth every year, which heightens maternal and infant risk.

What this article adds: A recent review found that programmes to support adolescent nutrition in SUN countries and India are lagging behind international attention. ‘Promising’ interventions (Lancet 2013) are not yet widely implemented or planned. Gap areas include needs assessment, policy provision, access to services, the evidence base and adolescent consultation. Identified actions include reaching clarity on UN mandates and leadership on adolescent nutrition, acknowledging adolescents as a distinct category, developing links to reproductive health programmes and stronger inter-sectoral collaboration. The SUN Movement could play an important role in bringing adolescent nutrition to the fore.


Save the Children recently undertook a review of what is being done in Scaling Up Nutrition (SUN) countries and in India to address adolescent nutrition through policy and practice. The report is targeted at ministers in SUN countries who are responsible for the welfare of adolescent girls; senior officials in the United Nations, international agency programme implementers and policy-makers in SUN countries; and officials in donor governments and agencies. The main points of the report are outlined below.

 Adolescents – a neglected group

“Adolescents are in many contexts a marginalised and disempowered group. They lack a voice on the social stage, have constrained access to resources, are likely to drop out of education and are vulnerable to exploitation and violence.” (Burman and McKay 2007)2

In 2012, there were 1.2 billion adolescents in the world – with adolescents defined as those between the ages of 10 and 19 years. Ninety per cent live in low or middle-income countries. In some countries, as many as half of all adolescents are stunted, meaning that their physical and cognitive development has been restricted because of inadequate nutritional status.  The first 1000 days of life - from the start of the mother’s pregnancy to the child’s second birthday - is critical and has been the focus of the nutrition community over recent years.  But with 16 million adolescent girls giving birth each year, tackling undernutrition in women once they are pregnant is often too late to break the intergenerational cycle of malnutrition. These 16 million adolescent girls giving birth each year are more likely to die themselves during childbirth, or be left nutritionally depleted. Their babies are also more likely to die or be born with nutritional deficits. The infants who survive have a greater risk of continued nutritional deficits during childhood and grow up to be stunted mothers or fathers themselves. In order to prevent malnutrition being passed on to the next generation, adolescent girls and communities must be supported both for improved nutrition and to delay marriage and pregnancy. The economic benefits of this could amount to up to 30% of a country’s Gross Domestic Product (GDP.3


There are 1·2 billion adolescents (aged 10–19 years) in the world4.     

90% live in low and middle income countries (LMICs), where they make up 19% of the population.5

Sub Saharan Africa is expected to have more adolescents than any other region by 2050.6


What is being done?

Programmes to support adolescent nutrition are lagging behind the international call for focus on this area and the general increase in attention on nutrition nationally and internationally. The promising interventions for adolescent nutrition identified by the Lancet 2013 series are not yet being widely implemented and are reflected in only a minority of the country plans written by those countries that have signed up to the SUN Movement.  In the SUN countries where plans were available (22), just less than half (10) included any detail on adolescent nutrition. Only seven included support for adolescent nutrition or improvement of adolescent nutrition status as part of a strategic objective or result (Bangladesh, Benin, Ethiopia, Guatemala, Mozambique, Nepal). Just two of these countries (Mozambique and Nepal) reported assessing the status of adolescent nutrition in country and none had plans to include adolescents in their monitoring and evaluation. It was noted that only Nepal7 was conducting a national assessment of the situation of adolescents in country as part of their plans. India, the only country not part of the SUN Movement included in this review, where 55% of adolescents are anaemic, provides the largest scale example of direct nutrition interventions being targeted to adolescents.


The lifetime opportunity cost of adolescent pregnancy in Uganda, for example, amounts to an estimated 30% of the countries annual GDP.8


Adequate assessment of adolescents is therefore missing in the majority of countries. Progress on direct interventions has been more substantial, but even in these cases, the extent to which adolescents are really being covered and the effectiveness of interventions in addressing nutrition outcomes is mostly unknown. Participation of adolescents in the design and implementation of programmes, despite being a strong recommendation from those working with adolescents, does not seem to have been adopted by nutrition programmers.


Iron deficiency anaemia is the third most important cause of lost Disability Adjusted Life Years (DALYs) in adolescents worldwide at 3%, behind alcohol and unsafe sex.9


It is clear that a range of programmes may have important impacts on adolescent nutrition across health and other sectors such as education, family planning, social protection and water, sanitation and hygiene (WASH). Multi-sectoral approaches, as well as those taking account of the particular experiences and social position of adolescents, are therefore urgently required. Ethiopia, Mozambique and Nepal, in particular, stand out for making inroads into integrated approaches for adolescent nutrition across the sectors. Further investigations into the effectiveness of approaches in these countries to inform the wider community would be useful.  


In India 55·8% of adolescents aged 15–19 years are reported to be anaemic.10


The nature of adolescent nutrition means that the responsibilities for supporting it need to span a wide range of ministries and actors at country level. The SUN Movement could play an important role in promoting such inter-sectoral collaboration for nutrition, particularly in bringing adolescent nutrition issue to the fore and encouraging all actors to adopt the sort of holistic approach required to tackle them.


What are the challenges?

A number of important challenges, research gaps and missed opportunities were identified in this review, including:

  • Insufficient policy attention on adolescent nutrition, perhaps as a result of the successful focus within the nutrition community on the first 1,000 days.
  • A lack of empirical evidence and documented practical experience on what should be done to support adolescent nutrition and a large number of continued research gaps related to operational issues. As a result, evidence of how to assess adolescents and programme effectiveness is lacking and evidence of cost effectiveness even more so.
  • Finding ways to reach adolescents both within existing services and specific targeted interventions/promotion is a major challenge. There is a common, but flawed assumption that adolescents will be automatically included in any maternal health programmes.
  • Adolescents are not being consulted about the extent to which nutrition services are currently serving them, or how they can be better designed in order to meet their particular needs.


1 in 3 girls in developing countries are married before the age of 18 and a startling 1 in 9 before the age of 15.11

About 16 million adolescent girls give birth each year, roughly 11% of all births worldwide, with almost 95% of these births occurring in LMICs.12


 What actions need to be taken?

  • International actors should give greater attention to meeting adolescents’ nutritional needs. To do this, there needs to be more research (including age- and sex-disaggregated data) to generate empirical evidence about what works in reaching adolescents with nutrition interventions. As such, there is an urgent need for clarity on UN mandates and leadership in addressing adolescent nutrition so that the issue gets the leverage it needs. In the meantime, a multi-agency group should be created to find a way forward for policy and programming. This group should prioritise a research agenda and review strategies for the scale up of promising interventions.
  •  SUN country governments should consider the long term economic and health benefits that can be gained from strengthening adolescent nutrition and prioritise it in their policies and practice. Interventions should find ways to reach adolescents and include them in the programme design phase. Adolescents should be acknowledged as a distinct category, with their own needs and capacities, rather than be subsumed within the broader mother and child care programmes. Systems and structures should be put in place to monitor and evaluate outcomes for adolescents.
  •  A multi-sectoral approach in policy and practice is critical. Links with policies and programmes aiming to delay marriage and first pregnancy are a priority alongside other reproductive health programmes (contraception promotion, HPV vaccination). There is also a need for more research to assess the extent to which health, education, WASH, social protection and agriculture interventions could be made more nutrition-sensitive for adolescents. Strategies need to consider the context-specific burdens of malnutrition including undernutrition, obesity and eating disorders. Coordination must be undertaken at the ministerial level, with guidance from the relevant UN organisations particularly the WHO, UNICEF and UNFPA.
  •  Given the challenges involved in reaching this neglected demographic group, it is necessary to capitalise on the mechanisms that multi-sectoral programmes use to reach adolescents. Nutrition and health practitioners need to use social media to provide innovative opportunities for engaging adolescents, including particularly hard-to-reach adolescents who are not receptive to the more traditional health and nutrition education approaches or platforms.
  •  Finally, while the inclusion of adolescents in the proposed post 2015 Sustainable Development Goals (SGDs) is welcome, it is critical that this focus is translated into practice. A first step is to scale up the existing ‘promising interventions’ as listed by the Lancet 2013 (see Box 1) and ensure that these interventions reach adolescents. If so, they should provide essential stepping stones to achieve the SDGs by 2030. In the same vein, the role that adolescents themselves can play in helping to reach the WHA nutrition targets for 2025 (WHO 2015) -through inclusive consultation, must be kept at the forefront of the minds of those aiming to achieve them. Future Global Nutrition Reports should include an analysis of adolescent nutrition intervention coverage and impacts.

Box 1 - ‘Promising’ interventions for adolescent nutrition

Maternal nutrition interventions targeted to pregnant adolescents – including multiple micronutrient (MMN) supplementation, calcium supplementation, balanced energy protein supplementation, malaria prevention, maternal deworming, obesity prevention.

Preconception care via reproductive health and family planning interventions for adolescents aimed at reducing unwanted pregnancies and optimising age at first pregnancy and birth intervals.

Antenatal care – ensuring access, given that adolescents are particularly at risk of complications

Nutrition promotion – via schools

Source: Bhutta et al (2013)13.

1?Adolescent nutrition. Policy and programming in SUN+ countries. Save the Children. 2015. Available in English and French at:

2Burman, ME and McKay, S (2007). ‘Marginalisation of girl mothers during reintegration from armed groups in Sierra Leone’, International Nursing Review 54, 4, pp 316–23. doi: 10.1111/j.1466-7657.2007.00546.x.

3Chaaban, J and Cunningham, W (2011). Measuring the Economic Gain of Investing in Girls: the Girl Effect Dividend, World Bank Policy Research Working Paper 5753, The World Bank.

4Cappa, C, Wardlaw, T, Langevin-Falcon, C and Diers, J (2012). ‘Progress for children: a report card on adolescents’, The Lancet 379, 9834, pp 2323–5. doi: 10.1016/S0140-6736(12)60531-5.

5Black, RE, Victora, CG, Walker, SP, Bhutta, ZA, Christian, P, de Onis, M, Ezzati, M, Grantham McGregor, S, Katz, J, Martorell, R, Uauy, R, and Maternal and Child Nutrition Study Group (2013). ‘Maternal and child undernutrition and overweight in low-income and middle-income countries’, The Lancet 382, 9890, pp 427–51. doi: 10.1016/S01406736(13)60937-x.

6UNICEF (2011) ‘Adolescence an age of opportunity’, Executive summary, in The State of the World’s Children 2011, UNICEF. Sawyer et al, 2012

7This report was produced prior to the earthquakes in Nepal.

8See footnote 3.

9Sawyer, SM, Afifi, RA, Bearinger, LH, Blakemore, SJ, Dick, B, Ezeh, AC and Patton, GC (2012). Adolescence: a foundation for future health. The Lancet 379, 9826, pp 1630–40. doi: 10.1016/S01406736(12)60072-5.

10UNICEF (2012). Progress for Children: A report card on adolescents, UNICEF, index_62280.html (accessed 12 February 2015.

11UNFPA (2012).  Marrying too Young: End child marriage, United Nations Population Fund, (accessed 12 February 2015).

12WHO (2014a). ‘Adolescent pregnancy’, WHO factsheet no 364, (accessed 11 February 2015).

13Bhutta  ZA, Das, JK, Rizvi, A, Gaffey, MF, Walker, N, Horton, S, Webb, P, Lartey, A, Black, RE, Lancet Nutrition Interventions Review Group, and Maternal and Child Nutrition Study Group (2013) ‘Evidence based interventions for improvement of maternal and child nutrition: what can be done and at what cost?’ The Lancet 382, 9890, pp 452–77. doi: 10.1016/S01406736(13)60996-4.

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