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

GROUP MEMBERS1. 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

Outlines:

Introduction

Malnutrition in adolescents

Control of malnutrition in adolescents

Malnutrition in pregnant women

Control of malnutrition in pregnant women

Conclusion

References

3

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.

4

FOOD PYRAMID5

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.

6

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.

7

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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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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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.

10

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.

CONCEPTUAL FRAMEWORK FOR THE ANALYSIS OF

NUTRITIONAL PROBLEMS IN ADOLESCENCE. (UNICEF 1990)12

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.

13

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.

14

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.

15

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.

16

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

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.

18

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).

19

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.

20

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?

21

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).

22

STRATEGIES AND APPROACHES TO IMPROVE

ADOLESCENTS’ NUTRITION23

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.

24

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.

25

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

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

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

CONCEPTUAL FRAMEWORK FOR THE ANALYSIS

OF NUTRITIONAL PROBLEMS IN PREGNANCY.29

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)

30

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

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

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

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)

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

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

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