An overview of malnutrition among adolescents and pregnant women

1. MALNUTRITION IN
ADOLESCENTS AND
PREGNANT WOMEN
PRESENTED BY 500 LEVEL MEDICAL STUDENTS
DEPARTMENT OF COMMUNITY HEALTH AND PRIMARY HEALTH CARE.
LAGOS STATE UNIVERSITY COLLEGE OF MEDICINE, IKEJA.
1

2. GROUP MEMBERS
1. 110711033 ISAWUMI, IFEOLUWA IMAOBONG
2. 100711034 OLUGBOGI, IBUKUN REBECCA
3. 110711041 OKOROJI, U. QUEENETH
4. 110711001 ABODE, MICHELLE EMILOMO
5. 110711005 AFOLABI HALIMA
6. 110711040 MUSA JOLAADE
7. 100711024 HAMZAT ZAHEED
8. 110711044 OLASUNKANMI OLATUNBOSUN
9. 110711014 ANIMASHAUN DAMILARE
10. 110711003 ADEKOYA TOBI
11. 110711025 EHUWA KOMIYO
12. 120711071 LAYENI ABIMBOLA
13. 110711023 DEINDE-DIPEOLU ISAAC
14. 110711038 BABATUNDE LAWAL
15. 110711050 OMOSEHIN DANIEL
16. 110711043 OLARIBIGBE BASHIR
17. 100711017 BAKRE HAMZAT
18. 100711042 SAPARA ADEOLA
19. 110711063 ASUQUO THERESA
20. 100711014 ASHADE OLAMIDE
21. 110711011 ALAKIJA OPRAL
22. 110711035 KADIRI PETER
23. 110711057 SOKEFUN SEYI
2

3. Outlines:
Introduction
Malnutrition in adolescents
Control of malnutrition in adolescents
Malnutrition in pregnant women
Control of malnutrition in pregnant women
Conclusion
References
3

4. INTRODUCTION
Malnutrition is an important public health problem that is
caused by a deficient or excess intake of nutrients in relation
to requirements.
Undernutrition (nutrient deficiency) is the prevalent type of
malnutrition in tropical developing countries.
At most risk are the poor and disadvantaged, particularly
women of reproductive age and young children.
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5. FOOD PYRAMID
5

6.  The nutritional status of a woman before and during pregnancy is
important for a healthy pregnancy outcome.
 Maternal malnutrition is a key contributor to poor fetal growth, low
birthweight (LBW) and infant morbidity and mortality and can
cause long-term, irreversible and detrimental cognitive, motor
and health impairments.
 Undernutrition in females may occur during childhood, adolescence
and pregnancy, and has a cumulative adverse impact on the
birthweight of future babies and later developmental milestones.
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7. MALNUTRITION IN ADOLESCENTS
 Adolescent, defined by World Health Organization (WHO) as individuals
between the ages of 10 and 19 years. adolescents make up approximately
20% of the world’s population.
 Although adolescence is a time of enormous physiological, cognitive, and
psychosocial change, WHO acknowledges that adolescents remain “a
neglected, difficult-to-measure and hard-to-reach population”.
 There is, in fact, a dearth of research on adolescent nutrition in developing
countries. Most studies of malnutrition in developing countries have
concentrated on young children or on the pregnancy period.
 There have been few population based studies examining the prevalence of
undernutrition (defined as body mass index for age, less than the 5th
percentile of WHO/NCHS(National Center for Health Statistics ) reference data)
among adolescents and in turn, fewer examinations with prevalence
disaggregated by region or socio-economic status.
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8.  To date, much of what known about adolescent nutrition in developing countries
comes from eleven studies of non-pregnant adolescents, supported by the
International Center for Research on Women (ICRW).
 The primary findings of the ICRW studies, later supported by other studies,
reveals that stunting is highly prevalent among adolescents, younger adolescents
tend to be more undernourished than older adolescents, and that boys are almost
twice as undernourished as girls.
 The ICRW studies also found that, in contrast to the data on height gains during
adolescence, body mass indices (BMI) increased substantially more during the
adolescent years for girls after 16 years of age. This decline in the prevalence of
low BMI with age among adolescents has been confirmed by other studies.
 Clearly, adolescence is a pivotal stage of the life cycle, and in turn, provides a
unique opportunity to foster a healthy transition from childhood to adulthood.
 Ensuring that the nutritional needs of adolescents are met is essential to this
transition, but critically needed information is sorely lacking.
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9. ADOLESCENT GROWTH
 Adolescence is a time of intense growth, second only to infancy. It is the only
period in an individual’s life when growth velocity increases.
 During adolescence, individuals can gain 15% of their ultimate adult height
and 50% of their adult weight.
 This rapid growth is accompanied by an increase in nutrient demand, which
also is significantly influenced by infection and energy expenditure.
 During this period, body proportion, including indices using height and
weight measurements, changes substantially.
 Adolescent boys generally build more muscle mass, gain weight at a faster
rate, have a larger skeleton, and deposit less fat than girls.
 For adolescent girls, the greatest gain in height and weight normally occurs
in the year preceding menarche, and the growth spurt continues for two years
after menarche.
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10. MEASUREMENT OF ADOLESCENT NUTRITIONAL
STATUS AND GROWTH
 Heald and Gong recommend that nutritional assessment of adolescents take
into account key developmental changes such as the gender differential in
timing of growth, as well as individual variations in the onset of puberty,
body composition, and growth spurt.
 The overall nutritional status is better assessed with anthropometry, in
adolescence as well as at other stages of the life cycle. Anthropometry is
the single most inexpensive, non-invasive and universally applicable
method of assessing body composition, size and proportions (de Onis and
Habicht, 1997)
 WHO recommends standards using National Center for Health Statistics
(NCHS) data on US adolescents as a reference population.
 Both NCHS and WHO use BMI (weight/height2) as a proxy measure for
nutritional status of adolescents. BMI and height for age below the 5th
percentile are used as the reference data for determining undernutrition.
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11. NUTRIENT NEEDS OF ADOLESCENTS11
 Growth not age should be ultimate indicator of nutrient needs.
 Energy needs are greater during adolescence than at any other time of life with exception of pregnancy & lactation.
 Energy & Proteins RDAs
Males
Age (yrs) Kcal/kg Kcal/day Proteins g/kg Proteins gm/day
11-14 55 2500 1.0 45
15-18 45 3000 0.9 59
Females
Age (yrs) Kcal/kg Kcal/day Proteins g/kg Proteins gm/day
11-14 47 2200 1.0 46
15-18 40 2200 0.9 44
 Vitamins & Minerals
 Higher vitamins and minerals needs.
 Three nutrients of importance i.e. vitamin A, iron and calcium.
 For calcium 1300 mg/day, for iron is 11 mg/day (boys) and 15 mg/day (girls).
 Improving fruit & vegetable intake will help in obtaining adequate vitamin A.

12. CONCEPTUAL FRAMEWORK FOR THE ANALYSIS OF
NUTRITIONAL PROBLEMS IN ADOLESCENCE. (UNICEF 1990)12

13. Based on our review and other documents dealing with
nutrition in adolescence (Gillespie 1997; Chungong 1998;
Treffers 1998), the following are seen as the main nutritional
issues of adolescents in low- and middle-income countries:
Undernutrition and associated deficiencies, often originating
earlier in life;
 Iron deficiency anaemia and other micronutrient
deficiencies;
 Obesity and associated cardiovascular disease risk markers;
 Early pregnancy;
 Inadequate or unhealthy diets and lifestyles.
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14. UNDERNUTRITION
 In Nigeria, a study among adolescent girls (Brabin et al, 1997) showed that
undernutrition was more widespread in rural than in urban areas: 10% of
rural and 5% of urban girls were stunted and 16% vs 8% could be considered
thin. However, there may be wide infra-urban variations according to
socioeconomic status (SES), which is not known.
 Similarly, in urban Bangladesh, Ahmed et al (1998) reported inadequate
intakes in a high proportion of schoolgirls aged 10-16 years, although these
girls may be considered more privileged than their non-school counterparts,
whether urban or rural. Only 9% met the recommended daily allowance
(RDA) for energy and 17% for protein.
 Overall nutrition status was shown to be very poor among adolescent girls of
poor rural groups in India. Chaturvedi et al (1996) reported that 79% suffered
severe chronic energy deficiency (BMI <16), 74% from anaemia and 44%
had signs of vitamin B complex deficiency. On the basis of national
recommended dietary allowances, intakes were grossly inadequate both in
terms of energy and protein.
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15. IRON DEFICIENCY AND ANAEMIA
 Anaemia, whether or not the primary cause is iron deficiency, is generally recognized as the main nutritional
problem in adolescents.
 In the ICRW/USAID studies (Kurz and Johnson-Welch, 1994), anaemia in adolescents was quite high in Nepal
(42%), India (55%) one of the two Guatemalan studies (48%) and Cameroon (33%). It was lower in Ecuador
(17%) and Jamaica (16%).
 In Nigeria, Brabin et al (1997) found that adolescent girls who had low Hb (<10g/dl) were more likely to have a
low BMI that those who had higher Hb levels, suggesting that overall malnutrition is associated with anaemia.
 Heavy menstrual blood loss may be an important factor of iron deficiency anaemia, as observed in Nigerian girls,
and it might also be related to vitamin A deficiency (Barr et al, 1998). A 12% menorrhagia rate was found among
nulliparous, menstruating girls aged less than 20. Menorrhagia was suspected to be an important contributor to the
high rate of anaemia (40%).
 Iron deficiency and anaemia may be common among adolescent athletes, owing to chronic urinary and
gastrointestinal blood loss and to intravascular hemolysis that are associated with strenuous exercise combined
with endurance events (Raunklar and Sabio, 1992).
 Because of muscle mass development, boys have high iron requirements, although girls are usually expected to
have higher anaemia rates due to onset of menarche. However, as the growth of adolescents slows down, boys’
iron status improves.
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16. MICRONUTRIENTS DEFICIENCY.
 The relationship of serum retinol binding protein and retinol with
puberty level suggests an important role of vitamin A in sexual
maturation (Herbeth et al, 1991).
 Iodine deficiency affects all age groups, but goitre primarily affects
people aged 15-45 years, in particular women, as shown for
example in Côte d’Ivoire (Kouame et al, 1998).
 While adolescence is a time of high calcium requirements, surveys
suggest that adolescent diets are often inadequate in calcium, at least
in high income countries such as the USA (Morgan et al, 1985).
Girls are apparently twice as likely as boys to be deficient, 85% vs
43% respectively (Key and Key, 1994). Calcium deficiency is
associated with high post-menopausal bone loss.
 Quite a few micronutrients are suspected to be in short supply in
adolescence, at least in certain population groups.
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17. OBESITY
 Globally, it is estimated that at least half a billion adolescents have
the most severe form of overweight, with a BMI of 30 +, obesity.
While the highest prevalence is observed in countries with higher
income, we can see a sizeable presence in countries with lower
income.
17
Source : FAO SOFA 2013

18. BODY MASS INDEX (BMI)
 BMI= Weight in kilograms/Height in metres2
 An adult is:
 Severely underweight if BMI <16;
 Underweight if BMI <18.5;
 Overweight if BMI >2S;
 Obese if BMI >30;
 Normal if BMI =18.5-24.9.
 THERE IS NO AGREED INDICATOR FOR ADOLESCENT.
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19. CARDIOVASCULAR DISEASE RISKS
 Atherosclerosis and blood lipids: measuring waist circumference of adolescents, in addition to
BMI, could help identify those who likely have adverse lipid and insulin concentrations, and
who should be targeted for weight reduction and risk-factor surveillance.
 According to NHANES III (Hickman et al, 1998) as in previous surveys in the USA, it was
found that mean total cholesterol was higher in female than male adolescents, and that the
highest levels were found in 9 to 11-year olds.
 Hypertension: High blood pressure in childhood and adolescence may be associated with
impaired foetal growth evidenced by low birth weight, and this was also observed in Africa
(Pharaoh et al, 1998; Woelk et al, 1998).
 Other nutrition-related chronic diseases such as CVD, NIDDM and certain types of cancer may
only appear in adult life, but are associated with dietary and lifestyle risk factors at adolescence,
many of which are in association with obesity.
 Obesity, a high purine diet, and regular alcohol consumption are well-known risk factors for gout
(Emmerson 1996). Evidence suggests that a sedentary lifestyle, and a diet rich in animal fat, in
refined sugars, and poor in vegetable fats and fibre are also significant risk factors for gallstone
formation. Weight loss also seems to be associated with increased risk (WHO 1998a).
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20. INADEQUATE OR UNHEALTHY DIETS AND LIFESTYLES.
 In the Minnesota Adolescent Health Survey (Neumark-Sztainer et
al, 1998), 12% of girls reported chronic dieting, 30% binge eating,
and 12% self-induced vomiting. Such disordered eating behaviours
were also high among non-overweight girls. Dissatisfaction with
weight was highly prevalent even among the non-overweight girls
(and some boys).
 Eating disorders and disturbances have become the third leading
chronic illness among adolescent females in the USA and other
high-income countries (Fisher et al, 1995). Anorexia nervosa or
bulimia represent only one extreme of a broad spectrum.
 Anorexia nervosa is less common than bulimia and tends to start in
somewhat younger adolescents (Elster and Kuznets, 1995). Binge
eating and night eating syndrome are eating disorders that are
primarily found among obese persons.
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21. EARLY PREGNANCY, A WELL-DOCUMENTED FACTOR OF
HEALTH AND NUTRITIONAL RISK IN ADOLESCENT GIRLS
 It is estimated that 25% of women have their first child before the age of 20
(Senderowitz 1995). Early pregnancy is a problem worldwide, in high-,
middle-, or low-income populations alike.
 Physical growth, mental and sexual development of girls during
adolescence may have a critical effect on their capacity to carry successful
pregnancies, and the health and nutritional status of today’s adolescent girls
will largely determine the quality of the next generation (Ahmed et al,
1998).
 Total nutritional requirements of pregnant adolescents who are at least two-
year post-menarche are reportedly similar to those of pregnant adults
(Gutierrez and King, 1993). However, the problem is that they often enter
pregnancy with reduced nutritional stores and hence at increased risk of
nutritional deficiencies.
 Do adolescent girls experience more poor outcomes of childbearing
than adult women?
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22. EFFECTS OF MALNUTRITION IN ADOLESCENTS
 Impairs immunity
 Delay physical growth and mental maturation
 Reduce work capacity
 Obesity
 Cardiovascular risk diseases
 High Maternal mortality and morbidity (Royston and Armstrong,
1989; Kurz 1997)
 Low birth weight and prematurity
 Poorer lactation performance of adolescent mothers. (Motil et al
1997).
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23. STRATEGIES AND APPROACHES TO IMPROVE
ADOLESCENTS’ NUTRITION23

24. FEEDING GUIDELINES FOR ADULTS
 Eat 2-3 meals a day.
 Eat plenty of, and a variety of the following foods: staple foods (cereals, starchy
roots and fruits), legumes, oilseeds, fruits and vegetables (particularly deep
coloured ones), and flavouring foods (e.g. garlic, onions, herbs).
 Eat fish as often as possible.
 Eat iron-providing foods, such as meat and offal, when possible (see 'Specific
micronutrient deficiencies').
 Obtain fat from plant oils or unrefined foods such as nuts, beans, fish; limit intake
of fat from meat, milk products and fast/processed foods.
 Limit intake of alcohol and foods high in fat, sugar or salt.
 Limit intake of foods that are heavily preserved (e.g. pickled, salted).
 Use iodized salt and other fortified foods.
 Take micronutrient supplements if and as prescribed.
 Food needs increase with pregnancy, lactation and activity.
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25. MALNUTRITION IN PREGNANT WOMEN
 Implications of poor nutrition in women include poor pregnancy
outcomes, high susceptibility to diseases with slow recovery rates
and reduced productivity.
 Among pregnant women in particular, malnutrition can increase the
risk of obstructed labour, cause poor foetal development, and
prevent production of high quality breast-milk. (Nigeria Population
Commission/Inner City Fund International, 2014).
 It can also increase the risk of death due to post-partum
haemorrhage and overall morbidity and mortality in both the mother
and child; the prevalence of maternal mortality in Nigeria is reported
to be 30% (UNICEF, 2009).
 Therefore, maintaining a healthy nutrition among pregnant women
is of utmost importance.
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26. Both obesity and undernutrition have severe consequences
on the health of women. Some of these include increased
rates of infection, lethargy and general body weakness –
leading to reduced productivity, increased risk of maternal
complication and death.
Obesity in particular increases the risk of developing
cardio-vascular diseases in women and in pregnancy it
induces gestational diabetes and hypertension.
Micronutrient deficiency is the most common form of
malnutrition found among pregnant and lactating mothers.
Micronutrients are only needed in small amounts;
however, any form of their deficiency can be severe.
26

27. NUTRIENT NEEDS
 Energy (kcalories)
 Additional 340 in 2nd trimester
 Additional 450 in 3rd trimester
 Select nutrient-dense foods
 Carbohydrates
 Additional 175 g
 Fiber for constipation
 Protein
 Additional 25 g
 Protein supplements are discouraged
 Fats
 Little room for oil, margarine, & butter
 Need essential fatty acids
27

28.  Iron-rich food: Liver, oysters, Meat, fish, Dried fruits, Legumes,
Dark green vegetables.
 Daily supplement
30 mg iron
2nd & 3rd trimester
 Vitamin C-rich foods enhance absorption
 Zinc: found in foods of high protein content, deficiency predicts low
birthweight.
 Vitamin D, calcium, phosphorus, magnesium
 Intestinal absorption of calcium doubles early in pregnancy
 Final weeks, more than 300 mg transferred to fetus
 Calcium-fortified soy milk & orange juice
28

29. CONCEPTUAL FRAMEWORK FOR THE ANALYSIS
OF NUTRITIONAL PROBLEMS IN PREGNANCY.29

30. Micronutrient deficiency
 In most developing countries, Nigeria inclusive, where there is high
level of poverty and nutrition ignorance, low intake of
micronutrients arising from sub-optimal dietary patterns have often
times led to multiple micronutrient deficiency among pregnant and
lactating women.
 Other causes of micronutrient deficiency may include presence of
diseases in individuals, leading to reduction in the absorption of
micronutrients from foods.
 In developing countries, the common forms of micronutrient
deficiency among women are iron deficiency, causing iron
deficiency anaemia (IDA); vitamin A deficiency, causing Vitamin A
deficiency disorder (VADD); iodine deficiency, causing iodine
deficiency disorder (IDD) (Tyndall et al., 2012)
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31. COMMON PROBLEMS ASSOCIATED WITH
PREGNANCY
 Nausea and vomiting: up to 80% of pregnant women experience this at some point, usually
beginning between the 4th and 7th weeks after their last period and ending for most women by the
20th week.
 Cravings and aversions: Probably due to hormone-induced changes in taste or sensitivities to smells.
Not all women experience this sensations. One study found that food cravings occurred in only 61%
of pregnant women, whereas aversions occurred in 54% pregnant women.(Bayley et al, 2002)
 Heartburn: likely caused by hormonal changes in early pregnancy. Later, the pressure of the baby
pushing upward against the mother’s stomach may worsen the problem.(Ali & Egan, 2007).
 Morning sickness: Comes from hormonal changes in early pregnancy. Smells often trigger it.
 Gestational diabetes
 Hypertension.
 Pica
 Preeclampsia
31

32. LIFE-STYLE INTERACTION AND
PREGNANCY
 The American College of Obstetrician and Gynecologist (ACOG)
recommends that pregnant women without medical or obstetric
complications engage in 30 minutes or more of moderate exercise a
day in a week if not everyday.
 Women who maintain high level of physical activity during
pregnancy will have relative caloric needs higher than less-active
women who are in the same stage of pregnancy.
 Contraindication to exercise during pregnancy include: pregnancy-
induced hypertension, preterm rupture of membranes, preterm
labour, incompetent cervix.
32

33.  Avoid Cigarette Smoking:
 Nicotine & cyanide are toxic to a fetus
 Second-hand smoke is also problematic
 Blood flow is restricted
 Slows fetal growth
 Low birthweight
 Avoid drinking of alcohol: Fetal alcohol syndrome (FAS)
Irreversible brain damage
Mental retardation
Facial abnormalities
Vision abnormalities
 No amount is safe.
33

34. STRATEGIES AND APPROACHES TO IMPROVE PREGNANT
WOMEN’S NUTRITION
 Micronutrient Supplementation: Globally, various attempts are being made
by public health experts to combat malnutrition, particularly, micronutrient
deficiencies among populations.
34
Supplement Timing Dosage
Vitamin A (in Vitamin-A deficient
populations)
During Pregnancy: after the first trimester 10,000 IU daily or a maximum of 25,000 IU
weekly
Maximum dose of 200,000 IU
Iron/Folate
Iron/Folate Prevention of Anaemia
Anaemia prevalence >40%: 6months during
pregnancy through 3months post-partum
Anaemia Prevalence ≤40%
6months during pregnancy
Treatment of Anaemia
Until resolved or a minimum of 3months, then
continue with prevention regimen
60 mg iron and 400 μg folic acid daily
120 mg iron and 800 μg folic acid daily
Iodine
Iodine Before conception or as early in pregnancy as
possible in high risk areas where iodised salt is
not available
Single dose of 400-600 mg (2-3 capsules)

35.  Dietary Diversification with Nutrition Education: Women are encouraged to
eat a wide variety of food during pregnancy. Dark green leafy vegetables are
particularly a good source of vitamin A and folate. Animal sources including fish,
red meat and poultry are needed for protein and iron while milk and milk products
are essential for calcium.
 Fortification: Food fortification is another approach to addressing malnutrition,
particularly the micronutrient malnutrition scourge. Fortification can take the form
of mass fortification as implemented by the government through salt iodisation
and Vitamin A fortification of flour, vegetable oil and other food vehicles.
 In Nigeria, policies promoting food fortification have been in place since 1990
and reports have shown that nationwide goitre rates, for example, have improved
from a prevalence of 20% in 1993 to 8% in 2004 (Busari, 2013).
 Bio-fortification: A newer technology in the line of fortification is the use of bio
fortified foods to combat micronutrient deficiencies. Bio fortification is the
process of enhancing the nutrient content of staple crops through traditional
breeding and modern technology (Berti et al., 2014). New varieties of indigenous
staple foods are being bred haven being fortified with necessary micronutrients so
as to make such available at a wider scale.
35

36. CONCLUSION
 The severe consequences of poor nutrition on adolescents and
pregnant women health cannot be over emphasised and households
that are poor are particularly at risk.
 Nutrition promotion should be championed among the adolescents
in school, community and society at large.
 Prevention of early pregnancy and other preventable diseases
associated with malnutrition should get proper attention.
 Interventions that have worked in different settings are available to
combat the scourge of malnutrition, particularly, micronutrient
deficiency.
 Micronutrient supplementation during pregnancy has shown great
results, however, there is need to employ a more robust and holistic
approach to addressing malnutrition, through the introduction and
sustenance of food-based strategies.
36

37. 37

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