Breaking the Malnutrition Cycle, Combating the Sustainable Development Goals

___________________________________________________________________________
____________

BREAKING THE
MALNUTRITION CYCLE
“It all starts with that
undernourished young adolescent
girl that grows into an
undernourished mother and gives
birth to an undernourished child,
then the cycle begins again”.
improving nutrition will be a catalyst for
achieving multiple goals throughout the
SDGs. When the health nutrition status
of adolescents is improved, they will be
able to get educated (SDG4), contribute
to climate change (SDG13), and bring
more innovations (SDG9) hence it is
important to question ourselves, are we
paying much attention to the
adolescent Nutrition?

BREAKING THE MALNUTRITION CYCLE

Inclusion of adolescent nutrition to eliminate child malnutrition Sandra Phiri

______________________________________________________________________________________________________
Breaking the Malnutrition Cycle, Combating the Sustainable Development Goals

Introduction: Malnutrition and the Adolescents

The larger world population is made up of adolescents and adolescence is a period of
acquiring new capacities. This is a stage of vulnerability to risky behavior, that can have life-
long consequences, especially on education, career, nutrition, and health. Involving them in
developmental solutions through harnessing their voices and letting them partake in
nutrition crucial decision making will make a huge difference in improving their nutrition.
Targeting adolescent nutrition is important to preventing malnutrition in the next
generation. They must be involved every step of the way.
Malnutrition in all its forms is a major impediment to development. This often happens when
an individual is taking less food or more food but with the wrong nutrients, often called
“hidden hunger” According to World Health Organization (WHO),(Ekholuenetale et al.,
2020) approximately two billion people suffer from “hidden hunger” globally and this occurs
when a person is suffering from nutrition deficiency.
Nutrition is a key component of achieving many of the other targets, including SDG 2 'End
hunger, achieve food security and improved nutrition, and promote sustainable agriculture,'
and is a major focus of the SDGs' nutritional aspects,(Grosso et al., 2020) which aim to
promote healthy and sustainable diets while also ensuring food security. Using the SDGs to
address the underlying causes of malnutrition will result in considerable progress in the
battle against malnutrition. (Grosso et al., 2020)
I urge everyone who reads this report to take action to guarantee that the global nutrition
targets are met, not simply one for nutrition, but one in which inclusion of adolescent
nutrition catalyses achieving sustainable development goals in all countries, for all people,
and by all.
The Malnutrition Cycle
Malnutrition has been a great concern for decades, but the question could be how we have
been dealing with malnutrition cases. As the malnutrition cycle states that: “It all starts
with that undernourished young adolescent that grows into an undernourished
young woman then gives birth to an undernourished child then the cycle begins
again,” (Refer to figure 1 below) the question could be are we paying attention to
nutrition in adolescents? The extra demands for growth during adolescence to pregnancy
require additional micronutrients (Arlinghaus et al., 2018). Are the adolescents aware of the
implications?

1 of 7
Breaking the Malnutrition Cycle, Combating the Sustainable Development Goals

Figure 1: The Malnutrition Cycle

Well-nourished children will always grow up to be healthy, with no stunting or wasting, and
will be able to learn and contribute to the nation hence achieving quality
education(SDG4).(Ferguson and Roofe, 2020) Malnutrition, on the other hand, denies these
children their basic entitlement. The fitness effects of obesity and weight problems
contribute to an expected four million deaths (7.1% of all deaths) and one hundred twenty
million wholesome years of lifestyles lost. (Alaimo, Chilton and Jones, 2020) The global food
insecurity turned into 10.2% in 2017, affecting 770 million people. Lack of food and
malnutrition are because of unequal and unjust distribution of nourishing meals because of
deficiencies in social, economic, political, and ecological systems. (Alaimo et al., 2020)
Malnutrition, in any form, includes a negative impact on children's long-term development
and might even be handed down through generations. Anaemic adolescent girls, (Pojda and
Kelley, 2000)as an example, are more likely to become anaemic mothers, birth to low-
birthweight babies who are liable to grow stunted, additionally to poor cognitive
performance and low job productivity. In many parts of Africa and other Asian countries,
about 1/2 of all pregnant mothers are anaemic due to the absence of vitamins and minerals
in their diet. Low birthweight babies (less than 2500 grams) have an exceptionally high risk
of morbidity and mortality from infectious disease and are underweight, stunted, or wasted
beginning in the neonatal period through childhood. Infants weighing 2000-2499 g at birth
are 4 times more likely to die during their first 28 days of life than infants who weigh 2500-
2999 g, and 10 times more likely to die than infants weighing 3000-3499 g. (Pojda and Kelley,
2000)
Several nutrition projects only focus on the results (the undernourished/malnourished
children) if we take a minute and think of why we have several underweight babies, several
stunted babies, it all goes back to that adolescent woman who gave birth to that
undernourished child, back to the first step of the malnutrition cycle. There is little attention
given to the nutrition status of adolescent girls. (Davies and Pinto, 2015)
A Nutrition research study done in Nepal found out that several adolescents from joint
families were malnourished, the study results had a mean age and family size of 15.28 ± 0.77
and 5.25 ± 1.56 respectively. Among the total 25.7% of the adolescents were malnourished,
where 21.8% underweight, 3.1% overweight, and 0.8% obese. (Bhattarai and Bhusal, 2019)
These young women are at a stage where they are active, growing into a woman and ready

2 of 7
Breaking the Malnutrition Cycle, Combating the Sustainable Development Goals

to have children. If we ignore them at this stage, they will develop severe acute malnutrition
(Lelijveld et al., 2016) resulting in thinness, hence being unable to breastfeed and the world
will keep on having underweight babies, stunted and undernourished babies, who will
further grow into undernourished young women then history shall keep repeating itself. A
cohort research study in Malawi (Severe Acute Malnutrition-SAM) (Lelijveld et al., 2016)
suggested Generation Nutrition, to be a major campaign, emphasizing the long-term health
effects of SAM.

Global Interventions in Breaking the Malnutrition Cycle.

Over the last two decades, increasing rates of overweight and obesity among children and
adolescents have been observed in many countries. Several interventions have already been
put into place, but we may as well consider engaging the adolescents themselves to be part
of developing the solutions (Hamdan et al., 2005), part of the entire process to deal with
adolescent malnutrition because if we involve them, they will remember and practice the
proper ways of staying nutritionally fit. A research study on the perceptions of adolescents
involved in peer-led school-based nutrition promotions in Minnesota high schools found out
that highly involved students gained more nutrition skills than those not involved.(Hamdan
et al., 2005)
Firstly, there is a need to create health care services that are youth-friendly and easily
accessible for these adolescents where they can acquire proper information on how to take
care of their bodies nutritionally wise in preparation for the childbearing stage. There is a
need to provide mechanisms that will give a platform to the young adolescents so that their
voices are not only heard but included in dialogues and recommended. Adolescents need to
be empowered to take charge of their health (Muturi et al., 2018). Cultural preference also
plays a big role in many parts of Africa, providing culturally appropriate maternity advice to
adolescents through youth health care services could be a great way of advancing in
adolescent childbearing preparation.

The introduction and implementation of participatory learning and action cycles with
adolescents and women groups could assist the adolescents in learning more from their
elder women on how they can improve their nutrition health status. (Tripathy et al., 2016) A
Cluster Randomised Trial in India found out that, both participatory women's groups and
postnatal home visits have been shown to reduce neonatal mortality.(Tripathy et al., 2016)
These groups can be community-based in rural areas and will provide a safe space for
discussion where women and adolescent girls can identify priority problems and advocate
for local solutions for maternal nutrition and infant nutrition health. Community
participation (Tripathy et al., 2016) in dealing with quality maternity care services is highly
recommended to acquire well-nourished children. For example, Maternity Waiting Homes
(MWH) can be established very close to the health care facilities where they will have easy
access to acquire all the vitamins and minerals required during their pregnancy. In Ghana
where these facilities (MWH) are available, they are used by a very small percentage of
women.(Wilson et al., 1997) And adolescent girls do not even know they exist.

3 of 7
Breaking the Malnutrition Cycle, Combating the Sustainable Development Goals

Reducing marriage before the age of 18 years.(Santhya and Jejeebhoy, 2015) This has been
an ongoing solution for adolescent girls’ optimal nutrition health. Interventions need to be
undertaken to delay the marriage of girls until 18 years. (Santhya and Jejeebhoy, 2015) The
UN declared that child marriage violates children’s rights. Involvement of key stakeholders
like the Community leaders, parents, and political leaders could be the best way, these are
the key agents to formulate and enforce laws and policies to prohibit the marriage of girls
before 18 years of age and engage with various families to enforce family and community
norms regarding early marriages. If this is achieved, adolescents will have more time to
boost their nutrition health status before childbearing.

Reduction of under 20 pregnancies is another solution in achieving adolescent nutrition and

health. Countries with a high rate of adolescent marriages have a high rate of under 20
pregnancies. (Rowlands, 2010) All community stakeholders including the adolescents
themselves, parents, and guardians must be involved in developing policies and strategies. An
article from best practice & research clinical obstetrics(2010) indicated that the proportion
of under 20 years of Child births is 1.7% in Sweden, 6.5% in England and Wales, and 10.4%
in the USA (Rowlands, 2010). The education sector needs to be more vigilant in
incorporating life skills education in the school syllabus, this could be sexuality, nutrition,
and health education as well as reproductive health education. Efforts must be taken to
maintain and improve the retention of girls in school, at both primary and secondary levels.

Maximizing the efforts in dealing with adolescent malnutrition and breaking the
malnutrition cycle

The world at large is already doing a great job in dealing with malnutrition hence a further
step needs to be taken to involve adolescents. Several Non-Governmental Organizations
have implemented school feeding programs (Mitchell, 2003) in achieving goal number 4
(Quality education) In Malawi (Nkhoma et al., 2013) a few organizations provide nutritious
soybean flour porridge to the learners in primary school, other organizations provide
plumpy nuts and in hospitals, there is a special children’s unit which is called: Nutrition
Rehabilitation Unit (NRU) (Nkhoma et al., 2013) all the malnourished admitted children
receive F100 and F75 milk as well as nutritious porridge.
All the above-mentioned projects are targeting children below the age of 10. The question
still comes: are we paying attention to nutrition in adolescents? creating youth-
friendly nutrition health care services would solve several nutrition issues, this will be a
locally based point where the adolescent group will meet, acquire advice from their fellow
youth health professionals as well as acquire nutrition and health assistance for example
provision of vitamins and minerals or training them how to prepare nutritious food using
their own locally available food items.
Teenage pregnancies as indicated in the above paragraphs must be reduced, but if these
adolescents happen to be in the situation, what can we do to assist them? Do we have the
available health care services that are easily accessible by the adolescent groups? Below are
some of the interventions to be incorporated in addressing teen pregnancies regarding
infant nutrition:

4 of 7
Breaking the Malnutrition Cycle, Combating the Sustainable Development Goals

Early initiation of breastfeeding among adolescent mothers

Pregnant adolescents require additional nutrients on top of the increased nutritional needs
of adolescence. Therefore, they shouldn’t have pregnancies at this stage. (Arlinghaus et al.,
2018)
Newly born children need to be introduced to breast milk within one hour of birth. It may
seem quite easy for all experienced mothers, but when it comes to adolescents, this is not
the case, they often leave out their newborn without breastfeeding. (Arlinghaus et al., 2018)
Hence the need to educate them on the importance of the first 1000 days. (Schwarzenberg
et al., 2018) The baby receives colostrum’s from their mother, and this reduces infant
mortality and ill health. Breastfeeding must be continued exclusively until 6 months. (Haider
et al., 2000)Breast milk can provide 75% of the vitamin A that a child needs as long as the
mother is not deficient in vitamin A. Adding Vitamin A and Zinc to the food will assist to
boost resistance to diseases. (Communication, 2009)
Improving child development and reducing health costs result in economic gains for
individual families as well as at the national level. Longer durations of breastfeeding also
contribute to the health and well-being of mothers and their children in so doing we are
breaking the malnutrition cycle.
Supporting Adolescent mothers for optimal Breastfeeding
Breaking the Malnutrition cycle requires proper support to the adolescent mothers to
achieve optimal breastfeeding for their children. The actions that help protect, promote, and
support breastfeeding include, adoption of policies such as the International Labor
Organization’s Maternity Protection. (Longer duration of leave and higher benefits), The
International Code of Marketing Breast-milk Substitutes and subsequent, Implementation of
Ten(Nyqvist et al., 2013) steps to successful Breastfeeding which is specified in the Baby-
Friendly Hospital Initiative, including Skin to skin contact between mother and baby
immediately after birth and initiation of breastfeeding within the first hour of life,
breastfeeding on demand. (Nyqvist et al., 2013)

Provision of supportive adolescent health services with infant and young child feeding
counseling during all contacts with caregivers and young children, such as during antenatal
and postnatal care and postnatal care, well-child and sick-child visits, and immunization.
Scaling up Nutrition (SUN) Movement
The Scaling Up Nutrition (SUN) Movement {Nabarro, 2010} is a renewed effort to eliminate
all forms of malnutrition. The movement is unique in the sense that it brings different groups
of people together: Governments, Civil Society, the United Nations, donors, businesses, and
scientists. All of them are in a collection action to improve nutrition. The movement focuses
on the 1,000 days between a woman’s pregnancy and her child’s 2nd birthday which are
described as a critical period to address irreversible damage, such as, child deaths. This is a
great movement; it is one unique movement currently focusing on young women during
pregnancy up to when the child is born and reaches the age of 2 years.

5 of 7
Breaking the Malnutrition Cycle, Combating the Sustainable Development Goals

Adolescent Nutrition in difficult circumstances Including the Covid 19 Pandemic

Adolescents in difficult circumstances for example in war regions/ pandemic/ natural
disasters require special attention and practical support. Breastfeeding remains the
preferred mode of infant feeding in almost all situations, for instance: Low -birth weight or
premature infants, HIV-infected mothers, Adolescent Mothers, Infants, and young
children who are malnourished, Families suffering the consequences of complex
emergencies, and HIV and infant feeding. If we are to achieve good nutrition, there is a need
to pay more attention to young children, adolescents, pregnant and lactating women.
(Pérez‐Escamilla, Cunningham, and Moran, 2020) The Covid 19 pandemic has also caused a
huge gap in addressing children and adolescent nutrition, many young adolescents are
suffering in silence. To ensure that the collateral damage of COVID-19 is as limited and
short-term as possible There is an urgent need to formulate immediate policies for both
acute and long-term care with a focus on children and adolescents. (Jansen et al., 2020)
Cooking Demonstrations Using Locally Available Food Items in Africa
Adolescent girls and all youth groups need to know food preparation and nutrition,
especially the six food groups, which is critical in reducing stunting and wasting to provide
children the opportunity to grow to their full potential. Knowledge of six food groups can
help to stump out stunting and wasting of under-five children, to enable them to
achieve maximum mental and physical growth hence breaking the malnutrition cycle. This
can be achieved through creating care groups with the responsibility to teach nutrition
lessons among the adolescent groups and conduct open days to showcase food groups and
lead cooking demonstrations using locally available foods. (Goh et al., 2009)
Fortification of foods commonly eaten in a particular country/region
Fortifying commonly consumed foods with vitamins and minerals: Food fortification—adding
safe levels of essential vitamins and minerals to commonly consumed foods such as salt,
flour, and cooking oil—is one of the most scalable, sustainable, and cost-effective ways to
reduce malnutrition worldwide, but it has yet to reach its full potential.
Fortification of cornmeal and maize flour as well as food-grade with iodine. fortification of
maize flour and cornmeal with iron is recommended to prevent iron deficiency in
populations, particularly vulnerable groups such as children and women.
Fortification of Eggs with Folic Acid as a Possible Contribution to Enhance the Folic Acid
Status of Populations. This is a very good intervention where enrichment of folic acid in eggs
is done by supplementing hens’ diet. According to a recent research study(Roth-Maier and
Böhmer, 2007) where Seventy-two hens (LSL) were assigned to 5 dietary groups and
supplemented with 0, 0.5, 1.0, 2.0, and 4.0 mg folic acid/ kg feed during 8 weeks and the
content of folic acid in eggs increased significantly the availability of folate in eggs was
determined as 68%, which means that one fortified egg provides up to 52 μ g folate
equivalent to 13% of the recommended daily intake.
Daily iron supplementation in adult women and adolescent girls. Daily iron supplementation
is recommended as a public health intervention in menstruating adult women and adolescent
girls living in settings where anaemia is highly prevalent (40% or higher prevalence of
anaemia), for the prevention of anaemia and iron deficiency. (Low et al., 2016)

6 of 7
Breaking the Malnutrition Cycle, Combating the Sustainable Development Goals

Focused Agriculture for Adolescents and Young Women

As far as maternal and infant nutrition is concerned there is a need to create women’s
empowerment in Agriculture. The young women especially those of adolescent stage are
often left out as such there is a need to measure the change in five domains: Women’s
household decision making, access to credit and land, adequacy of Women’s income
concerning food access, community leadership roles and women’s labor time allocations. A
nutrition-Sensitive agriculture program is the best approach. (Nichols, 2021)
Ensuring gender equality in agriculture is the smart thing to do: When the status of women
improves, agricultural production increases, poverty decreases, and nutrition improve.
Unleashing women’s potential by closing the gender gap in the agricultural sector is a win-
win strategy where multiple goals are being achieved and we are Breaking the
intergenerational cycle of malnutrition.
In conclusion, several interventions may be undertaken to address adolescent nutrition.
Implement interventions to inform and empower girls, in combination with interventions to
influence family and community norms, to delay the age of marriage among girls under 18
years of age. According to World Health Organization, the needs and responses required to
address adolescent nutrition may vary with the context. In addition, designing and
implementing programs to address adolescent nutrition should allow the participation of
adolescents in governance and program design, implementation, monitoring, and evaluation.
Adolescent-friendly health services need to be accessible, equitable, acceptable, appropriate,
comprehensive, effective, and efficient. Breaking the malnutrition cycle by focusing on
adolescent nutrition, will decrease the global burden of infant malnutrition. Perhaps it is time
we introduce the Nutrition Booster vaccine for severely malnourished children.

7 of 7
Breaking the Malnutrition Cycle, Combating the Sustainable Development Goals

References
Alaimo, K., Chilton, M., and Jones, S. J. (2020) 'Food insecurity, hunger, and malnutrition,
Present Knowledge in Nutrition: Elsevier, pp. 311-326.
Arlinghaus, K. R. et al. (2018) 'An Intergenerational Approach to Break the Cycle of
Malnutrition', Current Nutrition Reports, 7(4), pp. 259-267.
Bhattarai, S. and Bhusal, C. K. (2019) 'Prevalence and associated factors of malnutrition
among school goingon adolescents of Dang district, Nepal', AIMS Public Health, 6(3), pp. 291.
Communication, U. D. o. (2009) Tracking progress on child and maternal nutrition: a survival and
development priority. Unicef.
Davies, M.-A. and Pinto, J. (2015) 'Targeting 90–90–90–don't leave children and adolescents
behind', Journal of the International AIDS Society, 18(7Suppl 6).
Ekholuenetale, M. et al. (2020) 'Socioeconomic inequalities in hidden hunger, undernutrition,
and overweight among under-five children in 35 sub-Saharan Africa countries', Journal of the
Egyptian Public Health Association, 95(1).
Ferguson, T. and Roofe, C. G. (2020) 'SDG 4 in higher education: Challenges and
opportunities, International Journal of Sustainability in Higher Education.
Goh, Y.-Y. et al. (2009) 'Using community-based participatory research to identify potential
interventions to overcome barriers to adolescents’ healthy eating and physical activity',
Journal of behavioral medicine, 32(5), pp. 491-502.
Grosso, G. et al. (2020) 'Nutrition in the context of the Sustainable Development Goals',
European journal of public health, 30(Supplement_1), pp. i19-i23.
Haider, R. et al. (2000) 'Effect of community-based peer counsellors on exclusive
breastfeeding practices in Dhaka, Bangladesh: a randomised controlled trial', The lancet,
356(9242), pp. 1643-1647.
Hamdan, S. et al. (2005) 'Perceptions of adolescents involved in promoting lower-fat foods in
schools: associations with level of involvement', Journal of the American Dietetic Association,
105(2), pp. 247-251.
Jansen, D. et al. 2020. Child and adolescent health needs attention now, and in the aftermath
of the COVID-19 pandemic. Springer.
Lelijveld, N. et al. (2016) 'Chronic disease outcomes after severe acute malnutrition in
Malawian children (ChroSAM): a cohort study', The Lancet Global Health, 4(9), pp. e654-e662.
Low, M. S. Y. et al. (2016) 'Daily iron supplementation for improving anaemia, iron status
and health in menstruating women', Cochrane Database of Systematic Reviews, (4).
Mitchell, A. (2003) 'School feeding: now more than ever', Food, nutrition and agriculture, 33,
pp. 6-12.
Muturi, N. et al. (2018) 'Examining the role of youth empowerment in preventing
adolescence obesity in low-income communities', Journal of adolescence, 68, pp. 242-251.
Nichols, C. E. (2021) 'Spaces for women: Rethinking behavior change communication in the
context of women's groups and nutrition-sensitive agriculture', Social Science & Medicine,
285, pp. 114282.
Nkhoma, O. W. et al. (2013) 'Early-stage primary school children attending a school in the
Malawian School Feeding Program (SFP) have better reversal learning and lean muscle mass
growth than those attending a non-SFP school', The Journal of nutrition, 143(8), pp. 1324-
1330.
Nyqvist, K. H. et al. (2013) 'Expansion of the baby-friendly hospital initiative ten steps to
successful breastfeeding into neonatal intensive care: expert group recommendations',
Journal of Human Lactation, 29(3), pp. 300-309.
Pérez‐Escamilla, R., Cunningham, K. and Moran, V. H. 2020. COVID‐19 and maternal and
child food and nutrition insecurity: a complex syndemic. Wiley Online Library.

8 of 7
Breaking the Malnutrition Cycle, Combating the Sustainable Development Goals

Pojda, J. and Kelley, L. (2000) Low birthweight: UN ACC Sub-Committee on Nutrition.

Roth-Maier and Böhmer (2007) 'Fortification of eggs with folic acid as a possible
contribution to enhance the folic acid status of populations', International journal for vitamin
and nutrition research, 77(4), pp. 297-301.
Rowlands, S. (2010) 'Social predictors of repeat adolescent pregnancy and focussed
strategies', Best Practice & Research Clinical Obstetrics & Gynaecology, 24(5), pp. 605-616.
Santhya, K. and Jejeebhoy, S. J. (2015) 'Sexual and reproductive health and rights of
adolescent girls: Evidence from low-and middle-income countries', Global public health, 10(2),
pp. 189-221.
Schwarzenberg, S. J. et al. (2018) 'Advocacy for improving nutrition in the first 1000 days to
support childhood development and adult health', Pediatrics, 141(2).
Tripathy, P. et al. (2016) 'Effect of participatory women's groups facilitated by Accredited
Social Health Activists on birth outcomes in rural eastern India: a cluster-randomised
controlled trial', The Lancet Global Health, 4(2), pp. e119-e128.
Wilson, J. et al. (1997) 'The maternity waiting home concept: the Nsawam, Ghana
experience', International Journal of Gynecology & Obstetrics, 59, pp. S165-S172.

9 of 7