https://orcid.org/0000-0003-2592-1327
Figures
Abstract
Background
Ethiopia has undergone rapid economic growth over the last two decades that could influence the diets and nutrition of young people. This work systematically reviewed primary studies on adolescent nutrition from Ethiopia, to inform future interventions to guide policies and programs for this age group.
Method
A systematic search of electronic databases for published studies on the prevalence of and interventions for adolescent malnutrition in Ethiopia in the English language since the year 2000 was performed using a three-step search strategy. The results were checked for quality using the Joanna Bridge Institute (JBI) checklist, and synthesized and presented as a narrative description.
Results
Seventy six articles and two national surveys were reviewed. These documented nutritional status in terms of anthropometry, micronutrient status, dietary diversity, food-insecurity, and eating habits. In the meta-analysis the pooled prevalence of stunting, thinness and overweight/obesity was 22.4% (95% CI: 18.9, 25.9), 17.7% (95% CI: 14.6, 20.8) and 10.6% (7.9, 13.3), respectively. The prevalence of undernutrition ranged from 4% to 54% for stunting and from 5% to 29% for thinness. Overweight/obesity ranged from 1% to 17%. Prevalence of stunting and thinness were higher in boys and rural adolescents, whereas overweight/obesity was higher in girls and urban adolescents. The prevalence of anemia ranged from 9% to 33%. Approximately 40%-52% of adolescents have iodine deficiency and associated risk of goiter. Frequent micronutrient deficiencies are vitamin D (42%), zinc (38%), folate (15%), and vitamin A (6.3%).
Conclusions
The adolescent population in Ethiopia is facing multiple micronutrient deficiencies and a double-burden of malnutrition, although undernutrition is predominant. The magnitude of nutritional problems varies by gender and setting. Context-relevant interventions are required to effectively improve the nutrition and health of adolescents in Ethiopia.
Citation: Abera M, Workicho A, Berhane M, Hiko D, Ali R, Zinab B, et al. (2023) A systematic review and meta-analysis of adolescent nutrition in Ethiopia: Transforming adolescent lives through nutrition (TALENT) initiative. PLoS ONE 18(4): e0280784. https://doi.org/10.1371/journal.pone.0280784
Editor: Chiranjivi Adhikari, Pokhara University, NEPAL
Received: July 28, 2022; Accepted: January 7, 2023; Published: April 6, 2023
Copyright: © 2023 Abera et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting Information files.
Funding: The study was funded by a Global Challenges Research Fund/Medical Research Council pump priming grant (grant number: MC_PC_MR/R018545/1). The funders had no involvement in the design, implementation, analysis or decision to prepare a manuscript or to publish the finding.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Adolescence, the transition from childhood to adulthood, is a period of rapid growth and development, second only to fetal life and infancy. About 20% and 40% of the final adult height and weight respectively are attained during this stage [1]. Physical growth (muscle and bone size and density), the onset of puberty and (in girls) menstruation, and major psychological, emotional and cognitive maturation, are vital changes taking place during adolescence, creating a greater demand for protein and energy [2], and a continued need for micronutrients [3]. Equally, the rapid mental, psychological and social development during adolescence increases the risk of psychosocial problems, [4] which may alter adolescents’ nutrition behavior.
A 2018 United Nation Children’s Fund (UNICEF) report showed that globally, adolescents constitute 16% of the population [5]. However, this figure in Ethiopia is 34% [6]. Traditionally, under nutrition has been the predominant public health nutrition problem in low income settings, while in high income countries overnutrition (overweight and obesity) was more prevalent. However, as many low- and middle-income countries (LMICs) are experiencing rapid economic growth, with concomitant urbanisation and lifestyle transformations, overweight and obesity are emerging as significant problems among the adolescent population. This, alongside persisting undernutrition in large sections of the population results in a double burden of malnutrition in LMICs [7], compounded by low levels of government investment to solve the problem [8, 9].
Malnutrition in LMICs often starts prenatally, continues through childhood and adolescence, and even extends to adulthood. This creates a vicious cycle of malnutrition contributing to adverse intergenerational effects, such as low birth weight, which in turn has lifelong effects on health [10]. Adolescence can be viewed as a period of opportunity in which catch-up growth can occur and when nutritional status can be optimized prior to parenthood [11]. Thus designing appropriate interventions to support safe, healthy and productive transition from childhood to adulthood is a critical step to end malnutrition and improve the overall health and wellbeing of society [12].
Although nutritional interventions are growing rapidly in Ethiopia, most of these are targeted to young children, and pregnant and lactating women, leaving adolescents a relatively neglected group. Many of the successes achieved in maternal and child health in Ethiopia over the last few decades are the result of specific investment in the health and nutrition of children and women. Though the 2017 revised National Nutrition Program (NNP) and the 2018 Food and Nutrition Policy (FNP) [13, 14] highlighted issues of adolescent nutrition, there is no equivalent investment in adolescents’ distinctive health and nutrition needs in Ethiopia [15]. In order to inform this process, we have conducted this systematic review and meta-analysis of original research from Ethiopia, thereby collating current evidence on nutritional status of Ethiopian adolescents and the effectiveness of nutritional interventions in this age group.
Methods
Search strategy
We adopted a rigorous systematic approach [16, 17]. The first step was to formulate objectives/research questions as follows.
- From observational studies and surveys, what is known about the nutritional status of Ethiopian adolescents (boys and girls age 10–19 years) in terms of: a) body size and energy balance (chiefly weight, BMI and height), b) micronutrient status, c) dietary intake, diversity and quality, and d) dietary behaviours?
- From their associations with population characteristics, what is known about the possible determinants of these aspects of nutritional status? Which adolescents are at risk of nutritional problems?
- From intervention studies, what is known about the effectiveness of nutritional interventions in the Ethiopian population?
A three-step comprehensive literature search strategy was used to locate relevant literature published over the last 20 years from Ethiopia. Firstly, we set relevant key words and terms, using a logic grid for each key term. The terms used included “nutrition”, “micronutrient”, “malnutrition”, “undernutrition”, stunting”, “thin”, “obesity”, “food insecurity” “dietary diversity” “anemia”, "iron", "folic", "vitamin", "zinc", "iodine", "copper", "magnesium", "selenium" and “eating disorder”. The terms we used to define the population were “adolescent”, “teenage”, “youth”, “school children” and “young child”, and setting in “Ethiopia”.
Data sources/base
The search query was first developed for PubMed and later extended to EBSCO/ERIC and EBSCO/CINAHL to identify different concepts in the literature. Secondly, we carried out the search, expanding all terms in specific databases. Thirdly, we manually searched the reference lists of the identified studies.
Study selection process
Following the search, two researchers (AW & DH) screened studies by title. Then two independent researchers (BZ & RA) screened the abstracts and assessed the eligibility for full text retrieval. Selected full-text studies were compared between the reviewers, with disagreements being resolved through discussion and consensus with a 3rd researcher (MA).
Outcomes
Nutritional status measured by anthropometric indices: Stunting (Height-for-age z-score <-2) Thinness (BMI-for-age z-score <-2), underweight (weight-for-age z-score <-2), overweight (Body mass index-for-age z-score is >1), Obesity (Body mass index-for-age z-score is >2), combined overweight/obesity (Body mass index-for-age z-score is >1) micronutrient status, dietary diversity score (DDS) measured with the Food and Agriculture Organization of the United Nations (FAO), and food insecurity score assessed with Household Food Insecurity Access Scale (HFIAS).
Study selection criteria
Inclusion criteria.
The inclusion criteria were developed through discussion in an iterative process. Primary studies or national government surveys (DHS and Micronutrient survey) involving human subjects, reporting quantitative outcomes, published in English between the year 2000 and 2020, conducted in Ethiopia, among adolescents aged 10–19 years were included. Therefore, in this review, studies which researched nutritional status including but not limited to under nutrition, over nutrition, micronutrient status or deficiency, food insecurity, diet diversity, dietary behavior, diet quality, eating disorders and protein energy deficiency among adolescents in Ethiopia were included. A PRISMA flow diagram is included to inform the study selection process.
Exclusion criteria.
Unpublished studies, articles published in a language other than English, reviews, book reviews, commentaries, letters to the editor and case reports, publications with only an abstract, and studies conducted outside Ethiopia were excluded. Qualitative studies were excluded because these are reviewed elsewhere by the TALENT collaboration [18].
Data charting and synthesis of the results
Data were extracted using a pre-tested two-step process. Firstly, we developed a template (authors, year, settings (urban/rural), methodology, study question, study design, population, outcomes, and study quality). Secondly, each reviewer independently extracted data, which was then compared and any discrepancies discussed and resolved. The study findings are synthesized using narrative descriptions based on individual indicators that emerged. Meta-analysis was done for stunting, thinness and overnutrition (overweight/obesity) using random effect model with restricted maximum likelihood (REML) method. We used STATA version 17 for the meta-analysis. Forest plot for proportion with 95% confidence interval (CI) was reported. A Preferred Reporting Items for Systematic reviews and Meta-Analyses Checklist was used to guide reporting [19].
Results
Study selection
The initial search strategy and additional manual search identified 4153 records of which 3220 were removed due to the age of the study population (1810), outcomes mixed with other non-relevant indicators (1131), year of publication (275), language (2) and duplicates (2), leaving 933 records (Fig 1). Of these, 25 studies were secondary reviews or meta-analyses, which resulted in 908 records for full text review. Through full text review, 830 records were excluded as they were not relevant to our objectives, leaving 78 studies. Then finally a total of 74 articles were used for data extraction. No studies were excluded because of poor quality. Our last search date was on 1, November 2022.
Characteristics of included studies
The majority of the reviewed studies were observational and cross sectional; there were six longitudinal [22–27] and one interventional (quasi experimental) [28] studies. The outcomes assessed included body size and growth (41 studies) [22, 28–66], micronutrient status and deficiencies (15 studies) [39, 67–80], diet diversity (9 studies) [28, 44, 72, 80–85] and food insecurity (7 studies) [23–27, 46, 86]. There were two studies which addressed eating disorders [87, 88]. Ten studies reported multiple outcomes, and are described in more than one section of the review.
Findings of the review
Nutritional status defined by anthropometry, and its determinants.
Forty studies, on a sample of 25 397 adolescents, and one demographic and health survey (DHS) [75] addressed nutritional status as defined by height, weight and BMI. Five specifically assessed over-nutrition (overweight and/or obesity) [43, 44, 48, 50, 53], Eight assessed both undernutrition (stunting, thinness or underweight) and over-nutrition [29, 31, 32, 39–41, 45, 89] and 25 reported only undernutrition [22, 30, 33–38, 42, 46, 47, 49, 51, 52, 55–66]. The national adolescent nutrition surveys (DHS) reported stunting, thinness and overweight. Twenty one (including the DHS) were conducted in mixed urban and rural settings while thirteen and six studies were conducted only in urban and rural settings respectively. Two did not describe the study setting.
From studies that reported Z-scores for adolescents’ height-for-age (HAZ) and body-mass-index (BMI)-for-age (BAZ) using the 2007 WHO growth reference, the minimum and maximum mean HAZ was -1.5 [33] and -0.5 [41] while they were -1.29 [33] and 0.44 [89] for BAZ respectively. A comparison between urban and rural adolescents showed that the mean BAZ and HAZ were significantly higher in urban than rural adolescents, with mean differences of 0.2 (95% confidence interval (CI): 0.02–0.34) and 0.58 (95% CI 0.45–0.72), respectively [32]. Both HAZ and BAZ, even for urban adolescents were, however, lower than the WHO reference data [32].
In the meta-analysis the pooled prevalence of stunting, thinness and overnutrition (overweight/obesity) were 22.4% (95% CI: 18.9, 25.9), 17.7% (95% CI: 14.6, 20.8) and 10.6% (7.9, 13.3), respectively as shown in Figs 2–4.
Nutritional status by sex and setting.
Fig 5 shows the prevalence of stunting, thinness, underweight and overweight/obesity across the studies included, arrayed by year of publication; these outcomes are also shown stratified by sex and setting (rural/urban) in Figs 6–11. Among studies that measured the prevalence of undernutrition, the prevalence of stunting ranged from 4.4% in girls (urban 1.9% & rural 6.9%) in southwest Ethiopia [32] and 5.2% (5.9% boys, 4.4% girls, 4.2% urban & 8.8% rural) in Wolaita Sodo (south Ethiopia) [41] to 53.9% (urban 48.4% & rural 55.3%) in a sample of both sexes from northwest Ethiopia [30]. In terms of sex, stunting ranged from 5.9% in boys and 4.4% in girls in Wolaita Sodo town [41] and 7.2% in boys and 6.9% in girls (total 7.7%) in Addis Ababa city [31] to 47.4% in boys and 47.4% in girls in rural northwestern Ethiopia [57]. The prevalence of thinness ranged from 4.9% (boys 3.1%, girls 6.6%) in central Northern Ethiopia [59] to 44% (54.7% in boys and 33.7% in girls) in eastern Tigray (north Ethiopia) [36]. Thinness, in terms of sex, ranged from 3.1% [59] to 54.5% [36] in boys, and from 1.4% [51] to 48.4% [61] in girls. In terms of setting, stunting ranged from 1.9% in urban and 6.9% in rural settings [32] to 48.4% urban and 55.3% rural settings [30]. The prevalence of overweight/obesity ranged from 0.6% in girls (urban 1% & rural 0.3%) in southwestern Ethiopia [32] to 17% (boys 14% & girls 20%) in Addis Ababa city [50].
In ten of the fourteen studies that reported stunting in both sexes, the prevalence was higher in boys [22, 31, 33, 36, 41, 46, 49, 51, 55, 63] while in four stunting was higher in girls [38, 45, 59, 62]. Nine of twelve studies, reported more thinness in boys than girls [33, 36, 41, 45, 46, 51, 55, 62, 63]. In all of the five studies that have reported overnutrition, the prevalence of overweight/obesity was higher in girls [29, 31, 41, 43–45, 50, 53], and in three of four studies that have reported under nutrition, the prevalence of underweight was higher in boys [29, 31, 36].
Nutritional status by age.
In eight of fifteen and in nine of thirteen studies, the prevalence of stunting and thinness was higher in younger (10–14 years) compared to older (15–18 years) adolescents. The prevalence of stunting ranged from 2.1% [47] to 38.5% [64] in younger (10–13 years), and from 3.5% [46] to 61.7% [47] in older (16–18 years) adolescents. Thinness in younger adolescents ranged from 11% in Jimma zone, southwestern Ethiopia [45] to 64.3% early (10–13 years) in northwest Ethiopia [56], and in older adolescents it ranged from 3.8% in southwestern Ethiopia (Wollega Zone) [55] to 39.7% in eastern Ethiopia [52].
Nutritional status trends over time.
We searched for individual articles published since 2000, but data on the nutritional status of adolescents was only available between 2010 and 2022 The data from individual studies showed no clear pattern across time (Figs 2–8); and both undernutrition and overnutrition have co-existed over the last 10 years. A high prevalence of stunting (54% and 51%) was documented in 2014 and 2018, respectively; while a prevalence of 80.8% underweight and 44% thinness was documented in 2015. Likewise, the highest prevalence of overweight (17%) was documented in 2018.
Predictors of nutritional status.
In ten of thirteen studies, adolescents from rural areas were more likely to be stunted compared to urban adolescents [22, 30, 32, 33, 39, 41, 51, 59, 62, 64]. The prevalence of thinness was higher among adolescents from less educated mothers, adolescents who have <3 meals per day and those from households comprising more than five people. In addition, adolescents who were physically inactive and adolescents with sedentary lifestyles were more likely to be obese than others [44].
The reviewed articles [22, 30, 32, 33, 39, 41, 51, 59, 62, 64] also identified common predictors for under- as well as overnutrition. Low dietary diversity, low frequency of daily food intake, higher household family size, low maternal education, food insecurity, and poor quality sources of drinking water were associated with undernutrition. In contrast, residency in urban settings, female sex, low levels of physical activity and a more sedentary life style are predictors of overweight/obesity (Table 1).
Micronutrient deficiencies.
Thirteen studies [39, 67, 68, 70–74, 76–80], on a sample of 7 019 adolescents, and one national micronutrient survey [69] on a sample of 722, and the DHS [75] on adolescent nutrition reported micronutrient status. The national micronutrient survey reported a mean Vitamin A concentration (retinol) of 1.20 μmol/l and 6.3% with retinol <0.7 μmol/l in the age group 12–14 years; equivalent data for the 15–19 year age group were 1.40±0.43, and 3.2% [69]. In the same survey for the same age group, zinc deficiency was found in 38%, Vitamin B12 deficiency (<203 pg/ml) in 13.6%, severe iodine deficiency (<20 μg/L) in 1.9%, moderate iodine deficiency (50–99.9 μg/L) in 25.2% and mild iodine deficiency (20–49.9 μg/L) in 20.5%. Excess iodine (>300 μg/L) was 12.2% in 12–14 years age groups [69].
Based on the micronutrient survey, the national prevalence of anaemia was 14.9% (14.4% moderate (Hb 8–12 g/dL, 0.5% severe (Hb<8g/dL) in adolescents aged 12–14 years and 11.8% (10.5% moderate and 1.3% severe) in the age group 15–19 years [69]. Iron deficiency (ferritin<15 μg/L) was 8.6% and iron deficiency anemia (IDA) was 2.6% in the age group 12–14; equivalent data for the 15–19 year age group were 10.0% and 3.2% [69].
Site specific studies in northwestern Ethiopia indicated a prevalence of anaemia of 13.4% (Hb < 12 g/dl [68] and 25.5% (92.4% mild, 5.9% moderate and 1.7% severe) with the odds of having anaemia higher in those with inadequate diet diversity score (DDS) (AOR = 2.1;95% CI; 1.3, 3.5) [71]. However, a study from eastern Ethiopia reported a prevalence of anaemia of 32% (HGB<12), 1.8% severe (Hb<7), 3.8% moderate (Hb 7–9.9), and 26.3% mild (Hb 10–11.9) [39].
The national prevalence of anaemia by sex and setting was similar (20.4%) for rural girls and boys while it was 16.7% for girls and 8.6% for boys in urban settings. The national trends in anemia prevalence in girls aged 15–19 years between 2000 and 2016 showed a steady reduction: 23.6% (1.0% severe, 12.7% moderate, and 9.8% mild) in 2005, 13.3% (1.0% severe, 4.7% moderate, and 7.5% mild) in 2011, and 19.6% (0.9% severe, 7.3% moderate and 11.4% mild) in 2016. Equivalent data for boys were 17.7% (0.4% severe, 2.4% moderate and 14.9% mild) in 2011 and 18.2% (severe 0.1%, moderate 3.6%, and mild 14.4%) in 2016 [75].
Two studies in Adama city (Central Ethiopia) by the same authors reported that the average serum vitamin D (25(OH)D) was 54.5nmol/L [73] and the prevalence of vitamin D deficiency (serum 25(OH)D <50 nmol/L) was 42% (female 51.5%, male 29.3%) [70]. Females (AOR1.8; 95% CI: 0.8, 3.8), older adolescents (AOR 1.4; 95% CI: 0.7, 3.1) and urban adolescents (AOR 10.5; 95% CI: 3.9, 28.2) were at higher risk of Vitamin D deficiency [70].
Two papers investigated the prevalence of iodine deficiency; it was 1.88% for severe deficiency (<20μg/L), 25.2% for moderate deficiency (50–99.9 μg/L) and 20.5% for mild deficiency (20–49.9 μg/L), and excess iodine (>300 μg/L) was found in 12.2%, in the age group12-14 years. The prevalence of goitre was 48.9% (girls 65%, boys 35%). Factors include female sex (AOR = 3.5; 95% CI: 2.6–4.9), living in a temperate climate (AOR = 0.6; 95% CI: 0.4–0.9), and a low frequency of iodized salt use (AOR = 0.5; 95% CI: 0.3–0.7) (67). The magnitude of serum folate deficiency (<6.8nmol/L) was 14.7% [69] (Table 2).
Diet diversity.
Nine studies [28, 44, 72, 80–85] on a sample of 6 112 adolescents collected dietary data through food frequency questionnaires or 24 hour recalls. Three of these included both girls and boys [28, 44, 81], and the rest included only girls. Six included adolescents from both urban and rural [28, 80–83, 85] settings, two were from urban settings [44, 84] and one was from a rural setting [72]. The lowest prevalence of adequate dietary diversity ((DDS ≥5) was 4.3%, reported in girls from rural areas of Arisi zone (Southeast Ethiopia) in Oromia region [72]. Moreover, a high prevalence of low DDS was reported in different settings: 85.3% in rural and 58.5% in urban adolescents in northwestern Ethiopia [81]. Only 17.5% of adolescents consumed animal source foods in this study [81]. Another study from urban and rural areas of northwestern Ethiopia reported a similar prevalence of low DDS (85.5%) with food secure adolescents more likely to have an adequate DDS (AOR = 1.5, 95% CI 1.03, 2.1) compared to their food-insecure counterparts [82]. In urban settings of northwestern Ethiopia,75.4% (95% CI: 72.3, 78.6) of adolescents had an adequate DDS, higher among those from private schools (AOR = 3.2; 95% CI:1.9,5.3) and from merchant (well-off) families (AOR = 2.4; 95% CI: 1.1,5.5) [84].
Three studies reported mean DDS scores below the average recommended value; 3.3 in southwest Ethiopia [80], 3.5 in northern Ethiopia [83], and 4.3 in Jimma Town [85]. Only one study from an urban setting in south western Ethiopia (Jimma town) reported mean DDS above average (6.97) and cereal based (99.6%) and vegetables (73.9%) diet were the two commonly consumed food types. However, this study did not report the prevalence of low/high DDS [44].
In terms of site preference for nutrition interventions, as reported by adolescents, schools (45%), health centers (27%) and health posts (26%) were the preferred public facilities for provision of iron supplements to school adolescents, while schools (11%), health centers (47%) and health posts (41%) were the preferred public facilities for provision of iron supplements to out-of-school adolescents [83]. In the same study, it was indicated that a lack of nutrition messages specifically for young people, low community awareness about adolescent nutrition, religious and cultural influences, perceiving iron as a contraceptive than a nutrition product, and lack of confidence in the supplementation value of iron tablets are barriers to the uptake of adolescent nutrition interventions in northern Ethiopia (Table 3).
Food insecurity.
Seven studies [23–27, 46, 86] with a sample size of 10 866 adolescents assessed food insecurity, of which five came from the Jimma Longitudinal Family Survey of Youth (JLFSY) study [23–27] which followed 2 084 adolescents over three years. The remaining two studies were cross sectional surveys with a sample size of 784 adolescents in areas producing Khat (a common evergreen plant in eastern Africa used for its psychoactive properties) and coffee. Food insecurity was assessed using the adolescent food insecurity assessment scale adopted from household food security questionnaire [107], which enquires about their experience or concern about access to food or money.
The prevalence of food insecurity in Jimma zone (urban and rural settings) was 59.6% [86]. In this study, female adolescents (AOR = 2.2, 95%CI:1.4, 3.5), household food insecurity (AOR = 9.4,95%CI:5.5, 16.2), a male head of household (AOR = 2.8, 95% CI:1.4, 5.3), a high dependency ratio (AOR = 2.5, 95% CI: 1.5, 4.5), a household head with no formal education (AOR = 4.9, 95% CI: 2.6,9.2) and a family which does not own farming land (AOR = 2.5, 95% CI: 1.2, 5.0) were positively associated with food insecurity [86]. The prevalence of food insecurity in Khat and Coffee producing areas of Sidama zone was lower at 38.0% (boys 40.2% and girls 35.9%; p-value 0.412) [46]. The prevalence of food insecurity was higher in coffee (43%) compared to khat producing areas (32.4%) [46].
The Jimma Longitudinal Family Survey of Youth (JLFSY) study was started in 2005 and has 3-yearly follow-ups [23–27]. In this longitudinal cohort, 20.4%, 48.4% and 20.6% of adolescents were food insecure during each consecutive round of the survey respectively [27]. In addition, 5.5% girls and 4.4% boys (P = 0.331) were from food insecure households in all three follow ups [25]. The mean height of food insecure girls was shorter by 0.87 cm (P<0.001) compared with food secure girls at baseline [25]. Predictors of food insecurity in the longitudinal study include, urban households within low (AOR = 1.7; 95% CI: 1.2, 2.5) and middle (AOR = 1.8; 95% CI: 1.2, 2.6) compared to high income tertiles were nearly twice as likely to suffer from chronic food insecurity [24]. Female sex (AOR = 1.6; 95% CI: 1.2, 2.1), high dependency ratio (AOR = 1.5; 95% CI: 1.0, 2.2) and household food insecurity (AOR = 2.7; 95% CI: 2.0, 3.6) among adolescents in urban, semi-urban, and rural areas were positively associated with food insecurity, while higher educational status was negatively associated (AOR = 0.5; 95% CI: 0.3, 0.8) [24]. Food insecure adolescents had lower DDS (P = 0.001), low mean food variety score (P = 0.001) and a lower frequency of consuming animal source foods (P = 0.001) compared to food secure adolescents [23] (Table 4).
Eating disorders
Two studies [87, 88], both from Addis Ababa, assessed disordered eating and unhealthy weight control behaviors in adolescents [87, 88]. The prevalence of eating disorders was 8.6% (95% CI 4.9, 12.3) [87]. Female sex (AOR = 1.8; 95% CI: 1.0, 3.0) and being from less educated mother predicted a higher risk of eating disorders. Compared with no maternal schooling, maternal primary level education was associated with an AOR of 0.3 (95% CI: 0.1, 0.8), certificate/diploma with an AOR of 0.2 (95% CI: 0.1, 0.6) and a university degree or above with an AOR of 0.2 (95% CI: 0.1, 0.4) [87]. The prevalence of unhealthy weight control behavior was 31%, specifically purging behavior was 1.5% and non-purging weight control behavior was 30% [88]. In this study, predictors of unhealthy weight control behavior were being adolescent from a wealthier family (medium wealth index: AOR = 1.99; 95% CI:1.15, 3.45) and higher wealth index: AOR = 2.07; 95% CI: 1.30, 2.8), high perceived body weight (AOR = 3.01; 95% CI: 1.11, 8.11), higher BMI/overweight (AOR = 3.28; 95% CI:1.54, 7.01), and adolescent with severe depression (AOR = 4.09; 95% CI: 1.73,9.96) [88].
Discussion
In this review, it was possible to extract, synthesize and summarize considerable data on nutritional status and associated factors, food insecurity, dietary diversity, micronutrient status, and disordered eating from studies among adolescents in Ethiopia. The review generally showed that there is more undernutrition (stunting, thinness and micronutrient deficiencies) than overweight among adolescents. The prevalence of thinness and stunting is higher among boys and rural adolescents whereas overweight and obesity are higher among girls and urban adolescents. The review also revealed that adolescent food insecurity and low dietary diversity are common. Consequently, a large proportion of adolescents have one or more micronutrient deficiencies. About 80% and 60% of adolescents from rural and urban settings respectively were found to have low dietary diversity. Our review supports a report from WHO [108] which documented that the magnitude of undernutrition, micronutrient deficiency, over-nutrition, inadequate or unhealthy diet and life styles is high among adolescents in LMICs. The finding from the current review showed that the magnitude of undernutrition and low DDS is substantial. Although the prevalence of overweight is low compared to that of undernutrition, it appears that problems of overnutrition are emerging before Ethiopia has dealt with the burden of under-nutrition. This is in line with global data which shows that a double burden of malnutrition is increasing in LMICs [109] as they experience rapid economic growth, urbanization, and changes in dietary habits and levels of physical activity.
Undernutrition (underweight, stunting and thinness) is more prevalent in younger adolescents, boys, and rural adolescents, whereas overnutrition (overweight and obesity) is higher in females and urban adolescents. Adolescents in rural settings are more likely to be engaged in various labour intensive (energy consuming) domestic activities to support their family. In addition, household food insecurity is higher in rural compared to urban communities because of low literacy rates, recurrent droughts, and lack of diversity in sources of income. In contrast, because of urbanization and concomitant changes in lifestyle, urban adolescents are more likely to consume low quality foods such as sweets and fast foods, have more screen time and spend more time sedentary. There are more limited opportunities for physical activity in urban environments, especially for girls, because of overcrowding and lack of space. In a recent qualitative study, we identified that boys have more opportunity for leisure time and outdoor physical activity than girls [110].
Geographically, undernutrition is higher in northern compared to southern Ethiopia. The community in the north Ethiopia is characterized by subsistence farming where crops are the main source of income, there is greater food insecurity, and nutritional habits and experience are greatly influenced by cultural values [111] such as fasting (no animal-source meals for the majority of months of the year) [112]. In contrast, the southern region of the country is known for highly-productive horticulture of fruits and vegetables in addition to other crops, which are easily accessible to the local community.
Trends in the nutritional status of adolescents over the study period showed no clear secular trends. This could happen for the fact that the reviewed studies covered quite a limited time period, and importantly were not truly longitudinal (they represent separate studies in different populations) and are therefore not ideal for a trend analysis. The prevalence of undernutrition and overnutrition has changed little, and both have coexisted in the community over the last decade. This could happen because, despite rapid economic growth and urbanization, wide wealth disparity persists in Ethiopia. The United Nations have adopted the first ever UN Decade of Action on Nutrition, from 2016–2025 to realize the goal set to eliminate all forms of malnutrition by 2030 [113]. To date, several of the nutrition targets which were agreed upon remain unmet and on the contrary, the double burden of malnutrition challenge is increasing. It is predicted that, if current trends continue, the absolute number of overweight people will have increased from almost 2 billion today, to 3.3 billion by 2030, equal to one third of the projected world population [114]. Nutrition interventions for the current generation of adolescents in Ethiopia would require context- and community-specific intervention approaches to address all forms of malnutrition.
Micronutrient deficiencies are also common in adolescents, with deficiencies of iron, zinc, iodine, folic acid, and vitamins A and B12 being the most common. Factors that could contribute are a lack of dietary diversity, a lack of fortified foods, food insecurity and low general knowledge and awareness about the need for micronutrients for health. While there was a steady reduction in iron deficiency anemia in girls between 2000 and 2016, there is an increase in boys over the same time period. This can be explained by the targeting of national initiatives selectively towards women of reproductive age over recent decades. Despite the high burden, there are no national or regional initiatives to tackle micronutrient deficiencies in the adolescent population at ground level.
Risk factors for undernutrition identified in this review include low socioeconomic status, maternal education and dietary diversity, food insecurity, higher family size, attending a public school, younger age, male sex and living in a rural setting. Risk factors for overnutrition included female sex, urban settings, lower levels of physical activity or more sedentary lifestyles, and coming from more wealthy families, having access to sweets/fast foods, older age and attending private schools. The sociodemographic and economic factors are modifiable causes of malnutrition, which could be addressed through effective context-relevant interventions, designed with the involvement of policy makers, experts, adolescents and their families.
The impact from the double burden of malnutrition could occur at the level of individual, household or nation. Individuals who were under-nourished as infants can have increased weight gain and obesity during adolescence or late in adulthood, while it is also possible for an obese person to have micronutrient deficiencies concomitantly. In the same household, some family members may be under-nourished while others are obese. The situation is the same for a given country.
Effective intervention strategies are required to tackle the double burden of malnutrition emerging in Ethiopia. The national strategy for adolescent and youth health and nutrition [115], produced by the ministry of health, recommends promoting participation and leadership by adolescents in the planning and implementations of adolescent-related nutrition programmes, implementing innovative health education and prevention programmes using the health extension programmes, schools, mass media and digital technologies. Specifically recommended interventions [115] include improving consumption of a balanced diet, with an emphasis on locally available and iron-rich foods, promoting healthy dietary habits, creating awareness of the intergenerational effects of malnutrition, creating community awareness on gender bias in household food distribution, targeted supplementation of iron and folic acid, the scaling up of facility-based nutrition assessment and counselling programs, advocacy and promotion of food fortification. These recommendations are in line with the WHO guide for implementation of effective action for improve adolescent nutrition [116]. These efforts will be more effective if global co-ordination, collaboration and integration can be achieved.
As adolescents are open for new ideas, and are concerned and interested about their health and life perspective, they could serve as the agents for change. Adolescence is therefore a window of opportunity for intervention [11, 117]. Habits and experiences built during adolescence are more likely to last throughout life to some extent. Engaging adolescents in the design of their own nutrition and health interventions is likely to influence them positively. Involving young people as educators and intervention providers enables them to take responsibility for their nutritional health and is a way of allowing research to reach wider and hard-to-reach communities. A comprehensive intervention model that considers health, nutrition and wellbeing in general is more acceptable and impactful than targeting a single problem [116]. Such intervention models could combine counseling for nutrition and wellbeing, family life education, life skill trainings and positive behavior promotion (rather than focusing on discouraging negative behavior) to empower young people [118].
Strengths and limitations
Strengths of this review included a rigorous, standardised methodological approach and the involvement of multidisciplinary expertise through the TALENT collaboration. We have used definition of BMI for age z-score >1 for overweight and BMI for age z-score>2 for obesity in the meta-analysis for overnutrition. A limitation was that we were not able to use data for overweight when it was defined by weight for age z-score. Trend analysis overtime was not possible because of the limited range of years covered by the studies and the studies are mostly separate surveys in different populations rather than longitudinal data in the same population or setting.
Conclusions
While the magnitude of undernutrition remains high in Ethiopia, overnutrition is an emerging problem, leading to a double burden of malnutrition. Stunting and thinness are higher in boys and in rural settings while overweight and obesity are higher in girls and in urban settings. Half of adolescents found to have at least one micronutrient deficiency. There is a paucity of evidence from intervention studies to improve adolescent health and nutrition in Ethiopia. Therefore, appropriate and context-relevant intervention studies that address the various forms of malnutrition among adolescents should be designed and implemented, preferably with the active participation of adolescents themselves.
Acknowledgments
The researchers would like to acknowledge Jimma University for facilitating local arrangements to the study and the TALENT collaborative network for adolescent nutrition and health in sub-Saharan Africa and India for technical support.
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