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Interventions to Improve Adolescent Nutrition: A Systematic Review and Meta-Analysis

      Abstract

      Adequate adolescent nutrition is an important step for optimal growth and development. In this article, we systematically reviewed published studies till December 2014 to ascertain the effectiveness of interventions to improve adolescent nutrition. We found one existing systematic review on interventions to prevent obesity which we updated and conducted de novo reviews for micronutrient supplementation and nutrition interventions for pregnant adolescents. Our review findings suggest that micronutrient supplementation among adolescents (predominantly females) can significantly decrease anemia prevalence (relative risk [RR]: .69; 95% confidence interval [CI]: .62–.76) while interventions to improve nutritional status among “pregnant adolescents” showed statistically significant improved birth weight (standard mean difference: .25; 95% CI: .08–.41), decreased low birth weight (RR: .70; 95% CI: .57–.84), and preterm birth (RR: .73; 95% CI: .57–.95). Interventions to promote nutrition and prevent obesity had a marginal impact on reducing body mass index (standard mean difference: −.08; 95% CI: −.17 to .01). However, these findings should be interpreted with caution due to significant statistical heterogeneity.

      Keywords

      Adolescent nutrition is crucial for proper growth and development and a prerequisite for achieving full developmental potential. Suboptimal nutrition may contribute to delayed and stunted growth [
      • Story M.
      Nutritional requirements during adolescence.
      ] as well as impaired development. As adolescents undergo a period of rapid growth and development, adequate nutrient intake (of both macro and micronutrients) is critical. Many of the risk factors that impact maternal and newborn health exist right from adolescence, including nutritional deficiencies. Prepregnancy wasting in adolescents is usually reflected as low body mass index (BMI < 18.5). Low BMI significantly increases perinatal risks including stillbirths, preterm births, small for gestational age, and low birth weight (LBW) babies [
      • Black R.E.
      • Victora C.G.
      • Walker S.P.
      • et al.
      Maternal and child undernutrition and overweight in low-income and middle-income countries.
      ]. Iron deficiency anemia is among the top 10 causes of disability-adjusted life years lost among adolescents [
      • Black R.E.
      • Victora C.G.
      • Walker S.P.
      • et al.
      Maternal and child undernutrition and overweight in low-income and middle-income countries.
      ]. Concern is especially warranted for adolescent girls because their iron requirements are relatively high (due to growth spurts, sexual maturation, and menstrual losses) and because they may be on the cusp of motherhood. While most programs are targeted at pregnant women, the depletion of iron stores in women starts during adolescence with the onset of menstruation. More recently, there has been a growing interest in adolescent girls' nutrition as a means to improve the health of women and children. Each year around 16 million babies are born to adolescent girls between the ages of 15 and 19 years, accounting for over 10% of the total births each year [
      World Health Organization
      Adolescent pregnancy.
      ]. Pregnancy in adolescence is associated with greater risk to the mother and newborn—including anemia, mortality, stillbirths, and prematurity—especially since the adolescent girls are not physically mature themselves [
      World Health Organization
      Adolescent pregnancy.
      ]. Adolescent girls are two to five times more likely to die from pregnancy-related causes than women aged 20–29 years [
      World Health Organization
      Adolescent pregnancy.
      ]. Girls younger than 19 years have a 50% increased risk of stillbirths and neonatal deaths, as well as an increased risk for preterm birth, LBW, and asphyxia [
      World Health Organization
      Adolescent pregnancy.
      ]. These health risks further increase for girls who become pregnant earlier than 15 years and are somewhat reduced for older adolescents aged 18–19 years.
      Over the last two decades, increasing rates of overweight and obesity among children and adolescents have been observed in many countries [
      • Rokholm B.
      • Baker J.L.
      • Sørensen T.I.A.
      The levelling off of the obesity epidemic since the year 1999—a review of evidence and perspectives.
      ,
      • Nichols M.S.
      • de Silva-Sanigorski A.M.
      • Cleary J.E.
      • et al.
      Decreasing trends in overweight and obesity among an Australian population of preschool children.
      ]. Many low- and middle-income countries (LMICs) now bear a double burden of nutritional disorders due to the emerging issue of overweight and obesity along with the existing high rates of stunting and other micronutrient deficiencies [
      • Lobstein T.
      • Baur L.
      • Uauy R.
      Obesity in children and young people: A crisis in public health.
      ,
      • Popkin B.M.
      • Gordon-Larsen P.
      The nutrition transition: Worldwide obesity dynamics and their determinants.
      ]. Childhood overweight is associated with multiple immediate and long-term risks including raised cholesterol, raised triglycerides, type 2 diabetes, high blood pressure, adult obesity, and its associated consequences [
      • Koplan J.P.
      • Liverman C.T.
      • Kraak V.I.
      Preventing childhood obesity: Health in the balance: Executive summary.
      ,
      • Lloyd L.J.
      • Langley-Evans S.C.
      • McMullen S.
      Childhood obesity and risk of the adult metabolic syndrome: A systematic review.
      ]. Prepregnancy overweight has been linked to two of the foremost causes of maternal mortality (hypertensive disorders of pregnancy and gestational diabetes mellitus) [
      • Baeten J.M.
      • Bukusi E.A.
      • Lambe M.
      Pregnancy complications and outcomes among overweight and obese nulliparous women.
      ,
      • Doherty D.A.
      • Magann E.F.
      • Francis J.
      • et al.
      Pre-pregnancy body mass index and pregnancy outcomes.
      ,
      • Lu G.C.
      • Rouse D.J.
      • DuBard M.
      • et al.
      The effect of the increasing prevalence of maternal obesity on perinatal morbidity.
      ,
      • Chu S.Y.
      • Kim S.Y.
      • Schmid C.H.
      • et al.
      Maternal obesity and risk of cesarean delivery: A meta analysis.
      ] as well as other adverse pregnancy outcomes, including poor lactation practices [
      • Li R.
      • Jewell S.
      • Grummer-Strawn L.
      Maternal obesity and breast-feeding practices.
      ,
      • Hilson J.A.
      • Rasmussen K.M.
      • Kjolhede C.L.
      High prepregnant body mass index is associated with poor lactation outcomes among white, rural women independent of psychosocial and demographic correlates.
      ], obstetric anesthesia–related complications [
      • Saravanakumar K.
      • Rao S.G.
      • Cooper G.M.
      Obesity and obstetric anaesthesia.
      ], prolonged gestation [
      • Chan B.
      • Zacharin M.
      Maternal and infant outcome after pamidronate treatment of polyostotic fibrous dysplasia and osteogenesis imperfecta before conception: A report of four cases.
      ,
      • Rayco-Solon P.
      • Fulford A.J.
      • Prentice A.M.
      Maternal preconceptional weight and gestational length.
      ], maternal infectious morbidity [
      • Myles T.D.
      • Gooch J.
      • Santolaya J.
      Obesity as an independent risk factor for infectious morbidity in patients who undergo cesarean delivery.
      ], and decreased success with trials of labor.
      This article is part of a series of reviews conducted to evaluate the effectiveness of potential interventions for adolescent health and well-being. Detailed framework, methodology, and other potential interventions have been discussed in separate articles [
      • Salam R.A.
      • Faqqah A.
      • Sajjad N.
      • et al.
      Improving adolescent sexual and reproductive health: A systematic review of potential interventions.
      ,
      • Salam R.A.
      • Das J.K.
      • Lassi Z.S.
      • Bhutta Z.A.
      Adolescent health and well-being: Background and methodology for review of potential interventions.
      ,
      • Das J.K.
      • Salam R.A.
      • Arshad A.
      • et al.
      Systematic review and meta-analysis of interventions to improve access and coverage of adolescent immunizations.
      ,
      • Das J.K.
      • Salam R.A.
      • Arshad A.
      • et al.
      Interventions for adolescent substance abuse: An overview of systematic reviews.
      ,
      • Das J.K.
      • Salam R.A.
      • Lassi Z.S.
      • et al.
      Interventions for adolescent mental health: an overview of systematic reviews.
      ,
      • Salam R.A.
      • Arshad A.
      • Das J.K.
      • et al.
      Interventions to prevent unintentional injuries among adolescents: A systematic review and meta-analysis.
      ,
      • Salam R.A.
      • Das J.K.
      • Lassi Z.S.
      • Bhutta Z.A.
      Adolescent health interventions: Conclusions, evidence gaps, and research priorities.
      ]. In this article, we systematically reviewed published literature to ascertain the effectiveness of interventions to promote nutrition among adolescents comprising of micronutrient supplementation, nutrition interventions for pregnant adolescents, and interventions to prevent obesity.

      Methods

      For the purpose of this review, the adolescent population was defined as aged 11–19 years; however, since many studies targeted youth (aged 15–24 years) along with adolescents, exceptions were made to include studies targeting adolescents and youth. Studies were excluded if they targeted age groups other than adolescents and youth or did not report segregated data for the age group of interest. Searches were conducted till December 2014, and we did not apply any limitations on the start search date or geographical settings. Outcomes were not prespecified, and we included all the outcomes reported by the study authors. We searched systematically for existing reviews and took a systematic approach to consolidate the existing evidence through the following methodologies:
      • 1.
        De novo review: For interventions where no reviews existed, we conducted a new review; and
      • 2.
        Updating existing reviews: We updated the existing systematic reviews only if the existing review included evidence before 2011.

      Methodology for de novo reviews

      For de novo reviews, our priority was to select existing randomized, quasi-randomized and before/after studies, in which the intervention was directed toward the adolescent age group and related to nutritional outcomes. A separate search strategy was developed for each aspect using appropriate keywords, Medical Subject Heading, and free text terms. The following principal sources of electronic reference libraries were searched to access the available data: The Cochrane Library, Medline, PubMed, Popline, LILACS, CINAHL, EMBASE, World Bank's Jolis search engine, CAB Abstracts, British Library for Development Studies at Institute of Development Studies, the World Health Organization regional databases, Google, and Google Scholar. The titles and abstracts of all studies identified were screened independently by two reviewers for relevance and matched. Any disagreements on selection of studies between these two primary abstractors were resolved by the third reviewer. After retrieval of the full texts of all the studies that met the inclusion/exclusion criteria, data from each study were abstracted independently and in duplicate into a standardized form. Quality assessment of the included randomized controlled trials (RCTs) was done according to the Cochrane risk of bias assessment tool. We conducted meta-analysis for individual studies using the software Review Manager, version 5.3 (Cochrane Collaboration, London, United Kingdom). Pooled statistics were reported as the relative risk (RR) for categorical variables and standard mean difference (SMD) for continuous variables between the experimental and control groups with 95% confidence intervals (CIs). A grade of “high,” “moderate,” “low,” and “very low” was used for grading the overall evidence indicating the strength of an effect on specific health outcome according to the Grading of Recommendations Assessment, Development and Evaluation criteria [
      • Walker N.
      • Fischer-Walker C.
      • Bryce J.
      • et al.
      Standards for CHERG reviews of intervention effects on child survival.
      ].

      Methodology for updated reviews

      We updated the existing systematic reviews only if the most recent review on a specific intervention was conducted before December 2011. For updating the existing reviews, we adopted the same methodology and search strategy mentioned in the existing review to update the search and find all the relevant studies after the last search date of the existing review. After retrieval of the full texts of all the articles that met the inclusion/exclusion criteria, data from each study were abstracted independently and in duplicate into a standardized form. Information was extracted on study design, geographical setting, intervention type and description, mode of delivery, and outcomes assessed. We then updated the estimates of reported outcomes by pooling the evidence from the new studies identified in the updated search and reported new effect size for the outcomes of interest with 95% CIs. We then assessed and reported the quality of included reviews using the 11-point assessment of the methodological quality of systematic reviews criteria [
      • Shea B.J.
      • Grimshaw J.M.
      • Wells G.A.
      • et al.
      Development of AMSTAR: A measurement tool to assess the methodological quality of systematic reviews.
      ].

      Results

      Based on our search results, we updated one systematic review and conducted two de novo reviews.
      For the impact of “micronutrient supplementation among adolescents” and “nutrition interventions for pregnant adolescents,” we conducted de novo reviews (as there were no relevant existing reviews) while for interventions to prevent obesity, we updated an existing Cochrane review by Waters et al. [
      • Waters E.
      • de Silva-Sanigorski A.
      • Hall B.J.
      • et al.
      Interventions for preventing obesity in children.
      ]. Figure 1A describes the search flow, and the characteristics of the included studies for the de novo reviews are detailed in Table 1.
      Figure thumbnail gr1
      Figure 1(A) Search flow diagram for de novo reviews (micronutrient supplementation and nutrition for pregnant adolescents). (B) Search flow diagram for review update (interventions to prevent obesity).
      Table 1Characteristics of included studies
      Author, yearStudy designCountrySettingInterventionTarget populationOutcome assessed
      Micronutrient supplementation
       Agarwal et al., 2003
      • Agarwal K.N.
      • Gomber S.
      • Bisht H.
      • Som M.
      Anemia prophylaxis in adolescent school girls by weekly or daily iron-folate supplementation.
      QuasiIndiaGovernment schoolIron and folic acid11- to 18-year-old girlsHemoglobin
       Ahmed et al., 2005
      • Ahmed F.
      • Khan M.R.
      • Akhtaruzzaman M.
      • et al.
      Efficacy of twice-weekly multiple micronutrient supplementation for improving the hemoglobin and micronutrient status of anemic adolescent schoolgirls in Bangladesh.
      Before–afterBangladeshSchoolTwice weekly IFA or MMN + IFA14- to 18-year-old anemic girlsAnemia
       Ahmed et al., 2010
      • Ahmed F.
      • Khan M.R.
      • Akhtaruzzaman M.
      • et al.
      Long-term intermittent multiple micronutrient supplementation enhances hemoglobin and micronutrient status more than iron+ folic acid supplementation in Bangladeshi rural adolescent girls with nutritional anemia.
      RCTBangladeshSchoolIFA, MMN11- to 17-year-old anemic girlsHemoglobin, serum ferritin, serum vitamin A
       Angeles-Agdeppa et al., 1997
      • Angeles-Agdeppa I.
      • Schultink W.
      • Sastroamidjojo S.
      • et al.
      Weekly micronutrient supplementation to build iron stores in female Indonesian adolescents.
      RCTIndonesiaSenior government schoolIFA, vitamin C, retinol14- to 18-year-old adolescentsAnemia, low ferritin, low retinol
       Bruner et al., 1996
      • Bruner A.B.
      • Joffe A.
      • Duggan A.K.
      • et al.
      Randomised study of cognitive effects of iron supplementation in non-anaemic iron-deficient adolescent girls.
      RCTU.S.A.Catholic schoolsIron13- to 18-year-old girlsHemoglobin, serum ferritin
       Chiplonkar and Kawade, 2012
      • Chiplonkar S.A.
      • Kawade R.
      Effect of zinc-and micronutrient-rich food supplements on zinc and vitamin A status of adolescent girls.
      QuasiIndiaSchoolZn supplement, diet supplement with Zn and MMN10- to 16-year-old girlsHemoglobin
       Clark et al., 1999
      • Clark P.J.
      • Eastell R.
      • Barker M.E.
      Zinc supplementation and bone growth in pubertal girls.
      RCTU.K.SchoolZinc supplements11- to 14-year-old girlsSerum zinc
       Deshmukh et al., 2008
      • Deshmukh P.R.
      • Garg B.S.
      • Bharambe M.S.
      Effectiveness of weekly supplementation of iron to control anaemia among adolescent girls of Nashik, Maharashtra, India.
      Before–afterIndiaCommunity basedIFA14- to 18-year-old girlsAnemia, hemoglobin levels
       Dongre et al., 2011
      • Dongre A.R.
      • Deshmukh P.R.
      • Garg B.S.
      Community-led initiative for control of anemia among children 6 to 35 months of age and unmarried adolescent girls in rural Wardha, India.
      Before–afterIndiaCommunity basedIFA12- to 19-year-old girlsAnemia
       Eftekhari et al., 2006
      • Eftekhari M.H.
      • Simondon K.B.
      • Jalali M.
      • et al.
      Effects of administration of iron, iodine and simultaneous iron-plus-iodine on the thyroid hormone profile in iron-deficient adolescent Iranian girls.
      RCTIranSchool basedIron and iodineHigh-school girlsHemoglobin, serum ferritin
       Februhartanty et al., 2002
      • Februhartanty J.
      • Dillon D.
      • Khusun H.
      Will iron supplementation given during menstruation improve iron status better than weekly supplementation?.
      QuasiIndonesiaCommunity basedIFA11- to 15-year-old girlsHemoglobin, serum ferritin
       Friis et al., 2003
      • Friis H.
      • Mwaniki D.
      • Omondi B.
      • et al.
      Effects on haemoglobin of multi-micronutrient supplementation and multi-helminth chemotherapy: A randomized, controlled trial in Kenyan school children.
      RCTKenyaSchoolMMN9- to 18-year-old childrenHemoglobin
       Goyle and Prakash, 2011
      • Goyle A.
      • Prakash S.
      Effect of supplementation of micronutrient fortified biscuits on haemoglobin and serum iron levels of adolescent girls from Jaipur city, India.
      Before–afterIndiaSchoolIFA, vitamin A, vitamin C, iodine11- to 16-year-old girlsHemoglobin, serum iron
       Guillemant et al., 2011
      • Guillemant J.
      • Le H.T.
      • Maria A.
      • et al.
      Wintertime vitamin D deficiency in male adolescents: Effect on parathyroid function and response to vitamin D3 supplements.
      QuasiFranceJockey training schoolVitamin D16- to 18-year-old malesSerum vitamin D, serum PTH
       Hettiarachchi et al., 2008
      • Hettiarachchi M.
      • Liyanage C.
      • Wickremasinghe R.
      • et al.
      The efficacy of micronutrient supplementation in reducing the prevalence of anaemia and deficiencies of zinc and iron among adolescents in Sri Lanka.
      RCTSri LankaSchoolIron, zinc12- to 15-year-old childrenHemoglobin, serum ferritin, serum zinc
       Horjus, 2005
      • Horjus P.
      • Aguayo V.M.
      • Roley J.A.
      • et al.
      School-based iron and folic acid supplementation for adolescent girls: Findings from Manica Province, Mozambique.
      Before–afterMozambiqueSchoolIFA11- to 18-year-old girlsHemoglobin, anemia
       Ilich-Ernst et al., 1998
      • Ilich-Ernst J.Z.
      • McKenna A.A.
      • Badenhop N.E.
      • et al.
      Iron status, menarche, and calcium supplementation in adolescent girls.
      RCTU.S.A.Community basedCalcium supplements8- to 14-year-old girlsHemoglobin
       Kanani and Poojara, 2000
      • Kanani S.J.
      • Poojara R.H.
      Supplementation with iron and folic acid enhances growth in adolescent Indian girls.
      QuasiIndiaCommunity basedIFA10- to 18-year-old girlsHemoglobin
       Khadilkar et al., 2010
      • Khadilkar A.V.
      • Sayyad M.G.
      • Sanwalka N.J.
      • et al.
      Vitamin D supplementation and bone mass accrual in underprivileged adolescent Indian girls.
      RCTIndiaSchoolVitamin D and calcium14- to 15-year-old girlsSerum vitamin D, serum PTH
       Kianfar et al., 2000
      • Kianfar H.
      • Kimiagar M.
      • Ghaffarpour M.
      Effect of daily and intermittent iron supplementation on iron status of high school girls.
      RCTIranSchoolIronHigh-school girlsAnemia
       Kotecha et al., 2009
      • Kotecha P.V.
      • Nirupam S.
      • Karkar P.D.
      Adolescent girls' anaemia control programme, Gujarat, India.
      Before–afterIndiaSchoolIFA14- to 17-year-old girlsAnemia, low serum
       Lehtonen-Veromaa et al., 2002
      • Lehtonen-Veromaa M.
      • Möttönen T.
      • Nuotio I.
      • et al.
      The effect of conventional vitamin D[2] supplementation on serum 25(OH)D concentration is weak among peripubertal Finnish girls: A 3-y prospective study.
      QuasiFinlandLocal club and school basedVitamin D9- to 15-year-old girlsSerum vitamin D
       Mann et al., 2002
      • Mann S.K.
      • Kaur S.
      • Bains K.
      Iron and energy supplementation improves the physical work capacity of female college students.
      Before–afterIndiaUniversityIron and energy supplements16- to 20-year-oldsHemoglobin, serum iron
       Mwaniki et al., 2002
      • Mwaniki D.
      • Omondi B.
      • Muniu E.
      • et al.
      Effects on serum retinol of multi-micronutrient supplementation and multi-helminth chemotherapy: A randomised, controlled trial in Kenyan school children.
      RCTKenyaSchoolMMN, antihelminthics9- to 18-year-oldsSerum retinol
       Rousham et al., 2013
      • Rousham E.K.
      • Uzaman B.
      • Abbott D.
      • et al.
      The effect of a school-based iron intervention on the haemoglobin concentration of school children in north-west Pakistan.
      RCTPakistanSchoolIron5- to 17-year-oldsAnemia
       Sen and Kanani, 2009
      • Sen A.
      • Kanani S.J.
      Impact of iron-folic acid supplementation on cognitive abilities of school girls in Vadodara.
      QuasiIndiaSchoolIFA9- to 13-year-old girlsHemoglobin
       Shah and Gupta, 2002
      • Shah B.K.
      • Gupta P.
      Weekly vs daily iron and folic acid supplementation in adolescent Nepalese girls.
      RCTNepalSchoolIFA11- to 18-year-old girlsAnemia
       Soekarjo et al., 2004
      • Soekarjo D.D.
      • De Pee S.
      • Kusin J.A.
      • et al.
      Effectiveness of weekly vitamin A (10 000 IU) and iron (60 mg) supplementation for adolescent boys and girls through schools in rural and urban East Java, Indonesia.
      Before–afterIndonesiaSchoolIFA, vitamin A12- to 15-year-old childrenHemoglobin, anemia, low serum retinol
       Tee et al., 1999
      • Tee E.S.
      • Kandiah M.
      • Awin N.
      • et al.
      School-administered weekly iron-folate supplements improve hemoglobin and ferritin concentrations in Malaysian adolescent girls.
      RCTMalaysiaSchoolIFA12- to 17-year-old girlsAnemia
       Viljakainen et al., 2006
      • Viljakainen H.T.
      • Natri A.-M.
      • Karainen M.
      • et al.
      A positive dose response effect of vitamin D supplementation on site specific bone mineral augmentation in adolescent girls: A double blinded randomized placebo controlled 1 year intervention.
      RCTFinlandSchoolVitamin D11- to 12-year-old girlsSerum vitamin D, serum PTH
       Yusoff et al., 2012
      • Yusoff H.
      • Wan Daud W.N.
      • Ahmad Z.
      Nutrition education and knowledge, attitude and hemoglobin status of Malaysian adolescents.
      RCTMalaysiaSchoolIFA, vitamin C16- to 17-year-old childrenHemoglobin
      Nutrition in pregnant adolescents
       Chan et al., 2006
      • Chan G.M.
      • McElligott K.
      • McNaught T.
      • Gill G.
      Effects of dietary calcium intervention on adolescent mothers and newborns: A randomized controlled trial.
      RCTU.S.A.ClinicOrange juice fortified with calciumPregnant adolescents ages 15–17 yearsSerum electrolyte values, weight, height, blood pressure, and 2-day dietary record
       Cherry et al., 1993
      • Cherry F.F.
      • Sandstead H.H.
      • Wickremasinghe A.R.
      Adolescent pregnancy. Weight and zinc supplementation effects.
      RCTU.S.A.ClinicZinc supplementationPregnant adolescentsIncidence of low birth weight
       Corbett and Burst, 1983
      • Corbett M.A.
      • Burst H.V.
      Nutritional intervention in pregnancy.
      QuasiU.S.A.ClinicHiggins Nutrition Program: consists of an assessment of each pregnant adolescent's risk profile for adverse pregnancy outcomes and an individualized nutritional rehabilitation program based on that profilePregnant adolescentsIncidence of low birth weight
       Dubois et al., 1997
      • Dubois S.
      • Coulombe C.
      • Pencharz P.
      • et al.
      Ability of the Higgins Nutrition Intervention Program to improve adolescent pregnancy outcome.
      QuasiCanadaClinicHiggins Nutrition Program: consists of an assessment of each pregnant adolescent's risk profile for adverse pregnancy outcomes and an individualized nutritional rehabilitation program based on that profilePregnant adolescentsIncidence of low birth weight, preterm delivery, and perinatal mortality
       Elster et al., 1987
      • Elster A.B.
      • Lamb M.E.
      • Tavare J.
      • Ralston C.W.
      The medical and psychosocial impact of comprehensive care on adolescent pregnancy and parenthood.
      QuasiU.S.A.ClinicMedical, psychosocial, and nutritional services to pregnant adolescentsPregnant adolescents younger than 18 yearsIncidence of low birth weight and preterm delivery
       Felice et al., 1981
      • Felice M.E.
      • Granados J.L.
      • Ances I.G.
      • et al.
      The young pregnant teenager: Impact of comprehensive prenatal care.
      QuasiU.S.A.ClinicIntensive nutritional, psychosocial, and medical intervention and optimal obstetric care.Pregnant adolescents younger than 15 yearsIncidence of low birth weight
       Hardy et al., 1987
      • Hardy J.B.
      • King T.M.
      • Repke J.T.
      The Johns Hopkins Adolescent Pregnancy Program: An evaluation.
      QuasiU.S.A.ClinicNutritional education, group discussions, and psychosocial supportPregnant adolescents younger than 18 yearsIncidence of low birth weight, preterm delivery, and perinatal mortality
       Heins et al., 1987
      • Heins Jr., H.C.
      • Nance N.W.
      • Ferguson J.E.
      Social support in improving perinatal outcome: The Resource Mothers Program.
      QuasiU.S.A.ClinicResource Mother Program: Each resource mother is assigned to a pregnant teenage primigravida and serves as part of her support system throughout pregnancy and until the infant's first birthday.Pregnant adolescents younger than 19 yearsIncidence of low birth weight and perinatal mortality
       Hun et al., 2002
      • Hun D.J.
      • Stoecker B.J.
      • Hermann J.R.
      • et al.
      Effects of nutrition education programs on anthropometric measurements and pregnancy outcomes of adolescents.
      QuasiU.S.A.ClinicHave a Healthy Baby nutrition education programPregnant adolescents 14–19 yearsMean birth weight
       Korenbrot et al., 1989
      • Korenbrot C.C.
      • Showstack J.
      • Loomis A.
      • Brindis C.
      Birth weight outcomes in a teenage pregnancy case management project.
      QuasiU.S.A.CommunityTeenage Pregnancy and Parenting ProgramPregnant adolescents younger than 18 yearsIncidence of low birth weight
       Long et al., 2002
      • Long V.A.
      • Martin T.
      • Janson-Sand C.
      The great beginnings program: Impact of a nutrition curriculum on nutrition knowledge, diet quality, and birth outcomes in pregnant and parenting teens.
      QuasiU.S.A.ClinicSupplemental Nutrition ProgramPregnant adolescentsNutrition knowledge, diet quality, and infant birth weight
       Meier et al., 2002
      • Meier P.
      • Nickerson H.
      • Olson K.
      • et al.
      Prevention of iron deficiency anemia in adolescent and adult pregnancies.
      RCTU.S.A.ClinicIron supplementPregnant adolescents 15–18 yearsBirth weight, gestational age, and iron deficiency anemia
       Paige et al., 1981
      • Paige D.M.
      • Cordano A.
      • Mellits E.D.
      • et al.
      Nutritional supplementation of pregnant adolescents.
      QuasiU.S.A.SchoolNutritional supplementPregnant adolescentsMean birth weight
       Piechnik and Corbett, 1983
      • Piechnik S.L.
      • Corbett M.A.
      Reducing low birth weight among socioeconomically high-risk adolescent pregnancies: Successful intervention with certified nurse-midwife-managed care and a multidisciplinary team.
      QuasiU.S.A.ClinicPrenatal screening, patient education, psychosocial evaluation and counseling, nutritional assessment and counseling, intrapartum care, and postpartum follow-upPregnant adolescents 12–17 yearsIncidence of low birth weight, anemia, and pre-eclampsia
       Silva et al., 1993
      • Silva M.O.
      • Cabral H.
      • Zuckerman B.
      Adolescent pregnancy in Portugal: Effectiveness of continuity of care by an obstetrician.
      QuasiPortugalClinicSpecialized prenatal carePregnant adolescents younger than 18 yearsIncidence of low birth weight and preterm delivery
       Smoke and Grace, 1988
      • Smoke J.
      • Grace M.C.
      Effectiveness of prenatal care and education for pregnant adolescents: Nurse-midwifery intervention and team approach.
      QuasiU.S.A.ClinicSpecialized education programPregnant adolescents younger than 18 yearsIncidence of low birth weight, preterm delivery, and pregnancy complications
      IFA = iron folic acid; MMN = multiple micronutrients; PTH = parathyroid hormone; RCT = randomized controlled trial.
      The outcome quality for micronutrient supplementation was rated as “moderate quality” because for various outcomes there was considerable heterogeneity; and generalizability was limited to females because most of the studies included female participants. A summary of quality of evidence is provided in Table 2. The quality of outcomes for interventions for pregnant women was rated to be moderate to low due to the study design limitations, heterogeneity, and limited generalizability of the interventions (Table 3). The quality of outcomes for promoting healthy nutrition and preventing obesity was rated to be of “moderate” quality due to design limitation, heterogeneity, and limited generalizability to high-income countries (HICs) only (Table 4).
      Table 2Summary of findings for the effect of micronutrient supplementation
      Quality assessmentSummary of findings
      Number of studiesDesignLimitationsConsistencyDirectnessNumber of participantsRR (95% CI)
      Generalizability to population of interestGeneralizability to intervention of interestInterventionControl
      Anemia: moderate
      Downgraded for study design and heterogeneity.
      outcome specific quality of evidence
       11RCT/quasiEight studies had unclear allocation concealment and sequence generationTwo studies showed significant improvement

      Considerable heterogeneity, I2 = 72%
      All interventions targeted adolescents from both developing and developed countries. Most of the studies involved females onlyMajority of the studies involved diet, exercise and behavior change for lifestyle modification, and micronutrient supplementation6,3505,511.69 (.62–.76); (I2: 72%)
      CI = confidence interval; RCT = randomized controlled trial; RR = relative risk.
      a Downgraded for study design and heterogeneity.
      Table 3Summary of findings for the effect of nutrition interventions for pregnant adolescents
      Quality assessmentSummary of findings
      Number of studiesDesignLimitationsConsistencyDirectnessNumber of eventsRR/SMD (95% CI)
      Generalizability to population of interestGeneralizability to intervention of interestInterventionControl
      Mean birth weight: low
      Downgraded for study design and heterogeneity.
      outcome-specific quality of evidence
       8RCT/quasiSix studies not randomized, selective reporting of outcomes in one studyOnly one study suggests benefit

      Moderate heterogeneity, I2 = 50%
      All studies targeted pregnant adolescentsInterventions included nutritional supplementation and counseling1,6341,513.25 (.08–.41)
      Low birth weight (<2,500 g): low
      Downgraded for study design and heterogeneity.
      outcome-specific quality of evidence
       9QuasiNone of the studies were randomizedFive studies suggest benefit

      Considerable heterogeneity, I2 = 67%
      All studies targeted pregnant adolescentsInterventions included nutritional supplementation and counseling4161,011.70 (.57–.84)
      Serum calcium: moderate
      Downgraded for study design and heterogeneity.
      outcome-specific quality of evidence
       2RCTSelective reporting of outcomes in both studiesNo study suggests benefit

      Low heterogeneity, I2 = 33%
      All studies targeted pregnant adolescentsInterventions included nutritional supplementation and counseling4946−.17 (−.58 to .23)
      Preterm birth (before 37 weeks): low
      Downgraded for study design and heterogeneity.
      outcome-specific quality of evidence
       2RCT/quasiOne study not randomized, selective reporting of outcomes in one studyOne study suggests benefit

      Considerable heterogeneity, I2 = 74%
      All studies targeted pregnant adolescentsInterventions included nutritional supplementation and counseling294569.73 (.57–.95)
      Iron deficiency anemia: low
      Downgraded for study design and heterogeneity.
      outcome-specific quality of evidence
       1RCTSelective reporting of outcomes in one studyOnly one studyAll studies targeted pregnant adolescentsInterventions included nutritional supplementation and counseling410.34 (.13–.89)
      CI = confidence interval; RCT = randomized controlled trial; RR = relative risk; SMD = standard mean difference.
      a Downgraded for study design and heterogeneity.
      Table 4Summary of findings for the effect of interventions to promote healthy nutrition and preventing obesity
      Quality assessmentSummary of findings
      Number of studiesDesignLimitationsConsistencyDirectnessNumber of participantsMD (95% CI)
      Generalizability to population of interestGeneralizability to intervention of interestInterventionControl
      Mean change in BMI: moderate
      Downgraded for heterogeneity.
      outcome-specific quality of evidence
       10RCTIncomplete reporting of outcomes in three studiesThree studies showed significant improvement

      Considerable heterogeneity, I2 = 67%
      All studies targeted adolescentsInterventions included diet changes, educations programs, and school-based physical activity programs.6,1914,595−.08 (−.17 to .01)
      CI = confidence interval; BMI = body mass index; MD = mean difference; RCT = randomized controlled trial.
      a Downgraded for heterogeneity.

      Micronutrient supplementation for adolescents

      A total of 31 studies were included, of which 23 were conducted in LMICs [
      • Agarwal K.N.
      • Gomber S.
      • Bisht H.
      • Som M.
      Anemia prophylaxis in adolescent school girls by weekly or daily iron-folate supplementation.
      ,
      • Ahmed F.
      • Khan M.R.
      • Akhtaruzzaman M.
      • et al.
      Efficacy of twice-weekly multiple micronutrient supplementation for improving the hemoglobin and micronutrient status of anemic adolescent schoolgirls in Bangladesh.
      ,
      • Ahmed F.
      • Khan M.R.
      • Akhtaruzzaman M.
      • et al.
      Long-term intermittent multiple micronutrient supplementation enhances hemoglobin and micronutrient status more than iron+ folic acid supplementation in Bangladeshi rural adolescent girls with nutritional anemia.
      ,
      • Angeles-Agdeppa I.
      • Schultink W.
      • Sastroamidjojo S.
      • et al.
      Weekly micronutrient supplementation to build iron stores in female Indonesian adolescents.
      ,
      • Bruner A.B.
      • Joffe A.
      • Duggan A.K.
      • et al.
      Randomised study of cognitive effects of iron supplementation in non-anaemic iron-deficient adolescent girls.
      ,
      • Chiplonkar S.A.
      • Kawade R.
      Effect of zinc-and micronutrient-rich food supplements on zinc and vitamin A status of adolescent girls.
      ,
      • Clark P.J.
      • Eastell R.
      • Barker M.E.
      Zinc supplementation and bone growth in pubertal girls.
      ,
      • Deshmukh P.R.
      • Garg B.S.
      • Bharambe M.S.
      Effectiveness of weekly supplementation of iron to control anaemia among adolescent girls of Nashik, Maharashtra, India.
      ,
      • Dongre A.R.
      • Deshmukh P.R.
      • Garg B.S.
      Community-led initiative for control of anemia among children 6 to 35 months of age and unmarried adolescent girls in rural Wardha, India.
      ,
      • Eftekhari M.H.
      • Simondon K.B.
      • Jalali M.
      • et al.
      Effects of administration of iron, iodine and simultaneous iron-plus-iodine on the thyroid hormone profile in iron-deficient adolescent Iranian girls.
      ,
      • Februhartanty J.
      • Dillon D.
      • Khusun H.
      Will iron supplementation given during menstruation improve iron status better than weekly supplementation?.
      ,
      • Friis H.
      • Mwaniki D.
      • Omondi B.
      • et al.
      Effects on haemoglobin of multi-micronutrient supplementation and multi-helminth chemotherapy: A randomized, controlled trial in Kenyan school children.
      ,
      • Goyle A.
      • Prakash S.
      Effect of supplementation of micronutrient fortified biscuits on haemoglobin and serum iron levels of adolescent girls from Jaipur city, India.
      ,
      • Guillemant J.
      • Le H.T.
      • Maria A.
      • et al.
      Wintertime vitamin D deficiency in male adolescents: Effect on parathyroid function and response to vitamin D3 supplements.
      ,
      • Hettiarachchi M.
      • Liyanage C.
      • Wickremasinghe R.
      • et al.
      The efficacy of micronutrient supplementation in reducing the prevalence of anaemia and deficiencies of zinc and iron among adolescents in Sri Lanka.
      ,
      • Ilich-Ernst J.Z.
      • McKenna A.A.
      • Badenhop N.E.
      • et al.
      Iron status, menarche, and calcium supplementation in adolescent girls.
      ,
      • Kanani S.J.
      • Poojara R.H.
      Supplementation with iron and folic acid enhances growth in adolescent Indian girls.
      ,
      • Khadilkar A.V.
      • Sayyad M.G.
      • Sanwalka N.J.
      • et al.
      Vitamin D supplementation and bone mass accrual in underprivileged adolescent Indian girls.
      ,
      • Kianfar H.
      • Kimiagar M.
      • Ghaffarpour M.
      Effect of daily and intermittent iron supplementation on iron status of high school girls.
      ,
      • Kotecha P.V.
      • Nirupam S.
      • Karkar P.D.
      Adolescent girls' anaemia control programme, Gujarat, India.
      ,
      • Lehtonen-Veromaa M.
      • Möttönen T.
      • Nuotio I.
      • et al.
      The effect of conventional vitamin D[2] supplementation on serum 25(OH)D concentration is weak among peripubertal Finnish girls: A 3-y prospective study.
      ,
      • Mann S.K.
      • Kaur S.
      • Bains K.
      Iron and energy supplementation improves the physical work capacity of female college students.
      ,
      • Mwaniki D.
      • Omondi B.
      • Muniu E.
      • et al.
      Effects on serum retinol of multi-micronutrient supplementation and multi-helminth chemotherapy: A randomised, controlled trial in Kenyan school children.
      ,
      • Rousham E.K.
      • Uzaman B.
      • Abbott D.
      • et al.
      The effect of a school-based iron intervention on the haemoglobin concentration of school children in north-west Pakistan.
      ,
      • Sen A.
      • Kanani S.J.
      Impact of iron-folic acid supplementation on cognitive abilities of school girls in Vadodara.
      ,
      • Shah B.K.
      • Gupta P.
      Weekly vs daily iron and folic acid supplementation in adolescent Nepalese girls.
      ,
      • Soekarjo D.D.
      • De Pee S.
      • Kusin J.A.
      • et al.
      Effectiveness of weekly vitamin A (10 000 IU) and iron (60 mg) supplementation for adolescent boys and girls through schools in rural and urban East Java, Indonesia.
      ,
      • Tee E.S.
      • Kandiah M.
      • Awin N.
      • et al.
      School-administered weekly iron-folate supplements improve hemoglobin and ferritin concentrations in Malaysian adolescent girls.
      ,
      • Viljakainen H.T.
      • Natri A.-M.
      • Karainen M.
      • et al.
      A positive dose response effect of vitamin D supplementation on site specific bone mineral augmentation in adolescent girls: A double blinded randomized placebo controlled 1 year intervention.
      ,
      • Yusoff H.
      • Wan Daud W.N.
      • Ahmad Z.
      Nutrition education and knowledge, attitude and hemoglobin status of Malaysian adolescents.
      ,
      • Horjus P.
      • Aguayo V.M.
      • Roley J.A.
      • et al.
      School-based iron and folic acid supplementation for adolescent girls: Findings from Manica Province, Mozambique.
      ]. Studies evaluated the effectiveness of iron, folic acid, vitamin A, vitamin D, vitamin C, calcium, zinc, and multiple micronutrients supplementation to adolescent population. Thirteen studies evaluated the impact of iron/iron folic acid supplementation alone, nine studies evaluated the impact of iron/iron folic acid in combination with other micronutrients, two studies evaluated the impact of multiple micronutrients alone, two studies evaluated zinc supplementation while five studies supplemented with calcium and vitamin D. The intervention was mostly implemented in schools with the exception of five community-based studies [
      • Walker N.
      • Fischer-Walker C.
      • Bryce J.
      • et al.
      Standards for CHERG reviews of intervention effects on child survival.
      ,
      • Shea B.J.
      • Grimshaw J.M.
      • Wells G.A.
      • et al.
      Development of AMSTAR: A measurement tool to assess the methodological quality of systematic reviews.
      ,
      • Waters E.
      • de Silva-Sanigorski A.
      • Hall B.J.
      • et al.
      Interventions for preventing obesity in children.
      ,
      • Agarwal K.N.
      • Gomber S.
      • Bisht H.
      • Som M.
      Anemia prophylaxis in adolescent school girls by weekly or daily iron-folate supplementation.
      ,
      • Ahmed F.
      • Khan M.R.
      • Akhtaruzzaman M.
      • et al.
      Efficacy of twice-weekly multiple micronutrient supplementation for improving the hemoglobin and micronutrient status of anemic adolescent schoolgirls in Bangladesh.
      ]. Most studies evaluated the impact of micronutrient supplementation on adolescent girls except for nine studies that included adolescent boys and girls.
      Findings from moderate-quality evidence suggest an overall significant reduction in anemia (as defined by study authors) with iron/iron folic acid supplementation alone or in combination with other micronutrient supplementation (RR: .69; 95% CI: .62–.76; Figure 2). Subgroup analysis according to the delivery settings suggests that school-based delivery significantly reduced anemia (RR: .67; 95% CI: .60–.74) while evidence from community-based delivery was underpowered. School-based delivery of iron/iron folic acid supplementation alone or in combination with other micronutrient supplementation was also associated with improved serum hemoglobin (mean difference [MD]: 1.94 g/dl; 95% CI: 1.48–2.41), ferritin (MD: 3.80 mcg/L; 95% CI: 2.00–5.59), and iron (MD: 6.97 μmol/L; 95% CI: .19–13.76). Zinc supplementation led to improved serum zinc concentrations (MD: .96 mcg/dl; 95% CI: .81–1.12) while calcium and vitamin D supplementation did not have a clear impact on vitamin D levels and parathyroid hormone. Gender-specific subgroup analysis suggests significant improvements in both genders; however, most of the studies were conducted on adolescent girls.
      Figure thumbnail gr2
      Figure 2Impact of iron/iron folic acid supplementation on anemia. IFA = iron folic acid; IV = inverse variance; SE = standard error.

      Nutrition interventions among “pregnant adolescents”

      A total of 16 studies were included outlining interventions intended to modify maternal diet and reduce adverse maternal and perinatal outcomes. The study participants were low-income, pregnant adolescents from prenatal clinics in urban areas in Chile, Ecuador, United States of America, or Canada, between the ages of 13 and 20 years. All included studies were clinic based except for one school-based [
      • Paige D.M.
      • Cordano A.
      • Mellits E.D.
      • et al.
      Nutritional supplementation of pregnant adolescents.
      ] and one community-based [
      • Korenbrot C.C.
      • Showstack J.
      • Loomis A.
      • Brindis C.
      Birth weight outcomes in a teenage pregnancy case management project.
      ] study. The intervention commenced between 20 and 27 weeks of gestation and continued until delivery. The intervention strategies mainly involved provision of micronutrient supplementation such as calcium and zinc, in addition to the routine iron folic acid supplementation to adolescent mothers or engaging them in nutritional education sessions to enable them to improve nutritional intake. Long-term nutritional counseling was frequently employed whereby pregnant adolescents would have access to a nutritionist whom they would consult as part of antenatal care. Pooled data from moderate- to low-quality evidence suggested a statistically significant improvement in mean birth weight (SMD: .25; 95% CI: .08–.41; Figure 3), reduced LBW (birth weight < 2500 g; RR: .70; 95% CI: .57–.84; Figure 4), and preterm birth (before 37 weeks; RR: .73; 95% CI: .57–.95). These results must be interpreted with caution due to high heterogeneity and very small impact.
      Figure thumbnail gr3
      Figure 3Impact of nutritional interventions for pregnant women on mean birth weight. IV = inverse variance; SD = standard deviation.
      Figure thumbnail gr4
      Figure 4Impact of nutritional interventions for pregnant women on low birth weight. IV = inverse variance; SE = standard error.

      Promoting healthy nutrition and preventing obesity

      We updated the existing Cochrane review on promotion of healthy nutrition and preventing obesity by Waters et al. [
      • Waters E.
      • de Silva-Sanigorski A.
      • Hall B.J.
      • et al.
      Interventions for preventing obesity in children.
      ] for the age group 11–19 years with an assessment of the methodological quality of systematic reviews rating of 11 for the update. A total of 10 studies (five from the existing review + five new studies) from HICs were included. Overall, the impact on BMI was marginally significant (SMD: −.08; 95% CI: −.17 to .01; Figure 5). Further subgroup analysis revealed that physical activity or dietary control alone did not have any significant impact on BMI reduction while school-based delivery strategies were found to be more effective than interventions in noneducational settings.
      Figure thumbnail gr5
      Figure 5Impact of interventions to prevent obesity on mean change in body mass index. IV = inverse variance; SD = standard deviation.

      Discussion

      Our review suggests that micronutrient supplementation among adolescents can significantly decrease the prevalence of anemia in this age group with school-based supplementation having significant impact while evidence from community-based studies was found to be underpowered. It must be noted, however, that most of these studies were centered on female adolescents and did not take into account the male adolescent population hence limiting the generalizability of the intervention. Most studies on adolescent micronutrient supplementation were conducted in LMICs making the findings context specific and relevant since these settings bear most of the global burden of undernutrition and micronutrient deficiencies. The impact of individual micronutrients and gender-specific impacts could not be segregated. Furthermore, included studies targeted overlapping age groups among the adolescent population that might lead to variations in the outcome effect. However, these findings should be interpreted with caution due to high heterogeneity.
      Interventions to improve nutritional status of pregnant adolescents significantly improved neonatal birth weight, decreased LBW, and preterm birth. However, there were insufficient data to evaluate the impact on perinatal, maternal, and neonatal mortality. However, these findings should be interpreted with caution due to high heterogeneity. These findings have limited generalizability since all the findings were from HICs. There is a need to implement the proven interventions in LMIC settings with a higher burden of undernutrition and food insecurity. A focus on adolescent girls' nutrition is important not only to improve the health status of women but also to ensure optimal fetal growth and development to prevent the vicious cycle of intergenerational transmission of undernutrition. Further studies evaluating safety and potential long-term impact of such interventions and cost-effectiveness of these strategies are needed.
      Our review suggests that interventions to promote nutrition and prevent obesity can marginally reduce BMI. Evidence from the interventions to prevent obesity mostly comes from HICs hence limiting the generalizability of findings to HIC settings only. With the increasing trend of childhood obesity in LMICs, there is a need for future studies on obesity prevention in LMIC settings [
      • Greenough A.
      • Dimitriou G.
      • Prendergast M.
      • Milner A.D.
      Synchronized mechanical ventilation for respiratory support in newborn infants.
      ,
      • Lemyre B.
      • Davis P.G.
      • De Paoli A.G.
      Nasal intermittent positive pressure ventilation (NIPPV) versus nasal continuous positive airway pressure (NCPAP) for apnea of prematurity.
      ,
      • Imdad A.
      • Bautista R.M.M.
      • Senen K.A.A.
      • et al.
      Umbilical cord antiseptics for preventing sepsis and death among newborns.
      ]. Furthermore, these countries have much higher rates of LBW babies and stunting, and a consequent higher risk of adulthood obesity. There is strong evidence to suggest that once the adolescent is obese, it may be difficult to reverse, with obesity continuing through adulthood, strengthening the case for primary prevention and specific focus on LMICs [
      • Banks E.
      • Meirik O.
      • Farley T.
      • et al.
      Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries.
      ,
      • Conde-Agudelo A.
      • Rosas-Bermúdez A.
      • Kafury-Goeta A.C.
      Birth spacing and risk of adverse perinatal outcomes: A meta-analysis.
      ].
      Existing reviews on nutrition promotion and obesity prevention have overlapping age groups and include children, adolescents, and youth. Our findings are in concordance with other reviews that suggest beneficial impacts of programs that combine the promotion of healthy dietary habits and physical activity on preventing obesity in children and adolescents, especially school-based programs [
      • Flodmark C.-E.
      • Marcus C.
      • Britton M.
      Interventions to prevent obesity in children and adolescents: A systematic literature review.
      ,
      • Brown T.
      • Summerbell C.
      Systematic review of school-based interventions that focus on changing dietary intake and physical activity levels to prevent childhood obesity: An update to the obesity guidance produced by the National Institute for Health and Clinical Excellence.
      ]. Furthermore, evidence exists that a combination of interventions including nutrition, physical activity, knowledge, attitudes, or health-related behaviors has the potential to reduce the risk factors associated with obesity among preadolescent girls (7–11 years), although the sustainability of the effects of such interventions is less clear [
      • Kesten J.M.
      • Griffiths P.L.
      • Cameron N.
      A systematic review to determine the effectiveness of interventions designed to prevent overweight and obesity in pre-adolescent girls.
      ]. Some studies also highlighted important barriers to increasing physical activity among girls including lack of suitable places, resources, and social support for physical activity hence limiting compliance with the intervention program [
      • Waters E.
      • de Silva-Sanigorski A.
      • Hall B.J.
      • et al.
      Interventions for preventing obesity in children.
      ].
      Limitations of our review include high heterogeneity, lack of data from LMICs, and lack of data to conduct gender-specific subgroup analysis. There is sufficient evidence suggesting the importance of adolescent nutrition interventions and its impact on improved adolescent nutrition and birth outcomes. Countries should now specifically focus on this age group and design programs accordingly with a greater focus on reaching out to this vital segment of the population through schools. There is a need to adopt multisectoral approach in targeting the adolescent age group involving schools and communities through policies and programs to improve adolescent nutrition. Future studies, especially obesity related, should focus on LMICs and underprivileged populations in HIC settings to have maximum impact on improving adolescent nutrition status and reducing adverse neonatal outcomes in these settings. There is also a need to investigate the association of improved adolescent nutrition with improved cognition and future productivity.

      Acknowledgments

      All authors contributed to finalizing the manuscript.

      Funding Sources

      The preparation and publication of these papers was made possible through an unrestricted grant from the Bill & Melinda Gates Foundation (BMGF).

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      Linked Article

      • Evidence and Evidence Gaps in Adolescent Health
        Journal of Adolescent HealthVol. 59Issue 4
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          The momentum to bring adolescents and young adults to center stage in global health and international development is palpable. Adolescents are increasingly seen as a crucial group for the success of the newly adopted Agenda for Sustainable Development [1]. Sitting within the Agenda for Sustainable Development framework, the 2030 Global Strategy for Women's, Children's and Adolescents' Health has extended the Every Woman, Every Child agenda to adolescence [2]. The strategy articulates the need for adolescent responsive health systems as well as social determinants, a focus that extends to legal and policy environments [3].
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