The interrelations between nutrition, social and economic trajectories during adolescence among girls in Ghana

A dearth of data on the trends, efficacy, and timing (regarding menarche) of intervention impedes progress in the design of targeted policies and interventions that can holistically improve adolescents’ nutrition. This thesis primarily aims to examine the interrelations between nutrition, social, and economic trajectories during adolescence among girls in Ghana using a systematic narrative literature review on the socio-cultural and economic (SCE) determinants and consequences of adolescent undernutrition, analyses of secondary cross-sectional data in Ghana, and a randomised placebo-controlled trial among adolescent girls in north-eastern Ghana. Chapter 1 provides the background and rationale that informed the thesis and describes the specific research objectives for each chapter.

In chapter 2, we undertook a systematic review of published literature to provide a narrative overview of the SCE determinants and consequences associated with undernutrition among adolescents in low and lower-middle-income countries. We identified 98 articles from PubMed, SCOPUS and CAB-Abstracts on determinants and consequences of undernutrition as defined by stunting, thinness, overweight and micronutrient deficiencies. At the individual level, significant determinants included age, sex, birth order, religion, ethnicity, educational and literacy level, working and marital status. At the household level, parental education and occupation, household size and composition, income, socio-economic status, and resources were associated with undernutrition. Few determinants were found at the broader community level, which included the residence, sanitation, school type, and seasonality. The sex-specific differences in undernutrition for adolescents were inconclusive. The consequences of adolescent undernutrition were mainly related to education and cognition. Most studies were cross-sectional in design, limiting inferences of causality to the description of associations, and very few studies were found for sub-Saharan Africa, indicating clear research gaps that informed the next parts of this study.

In chapter 3, we describe a secondary data analysis of baseline data of an impact evaluation of the Ghana School Feeding Programme indicating that anaemia is a severe public health problem among rural school-aged children (6-9 years; n=323) and adolescents (10-17 years; n=319) in Ghana, irrespective of sex. The mean haemoglobin was 113.8 ± 13.1g/L and the overall prevalence of anaemia was 52.3%, being higher among school-aged children (55.1%) compared to adolescents (49.5%). Agro-ecological zone and age were independent predictors of anaemia, but the effect of age was only significant for girls and not boys.

Chapter 4 examines the trends-over-time and the factors associated with malnutrition among adolescent girls in Ghana using cross-sectional data from 3 nationwide Ghana Demographic and Health Surveys (GDHS) conducted in 2003 (n=983), 2008 (n=955) and 2014 (n=857). Stunting was about 8% among the adolescent girls in 2003, declining by only 1.5% points in 2014. Although only 2% of the girls were thin in 2003, the prevalence decreased by <1.0% point in 2014. However, overweight/obesity among the girls increased by 4.3% points in 2014 from 10.0% in 2003, after adjusting for significant predictors of overweight/obesity including household size, wealth index, and the marital status of the girl. Anaemia remained severe (2003: 44.3%; 2008: 62.1% and 2014: 47.3%) without a clear trend.

We also undertook a comparative analysis of data of non-pregnant adolescent girls (n=857) and adolescent boys (n=870) aged 15–19 years from the 2014 GDHS to assess and contrast the association between malnutrition, pre-hypertension/hypertension (PHH) and sex among adolescents (Chapter 5). Compared to adolescent girls, boys were more than twice likely to be stunted [Prevalence ratio (PR) 2.58, 95% C.I (1.77, 3.76)], thinness [PR 2.67, 95% C. I (1.41, 5.09)] and about twice likely to have PHH [PR 1.96, 95% C. I (1.47, 2.59)] but less likely to be overweight/obese [PR 0.85, 95% C.I (0.08, 0.29)]. Girls were more at risk of the detrimental effects of poor education on stunting and PHH. A higher empowerment index while inversely associated with stunting for girls [PR 0.82, 95% C.I (0.67, 0.99)] also increased their risk of overweight/ obesity [PR 1.31, 95% C.I (1.02, 1.68)]. A higher household wealth index increased the likelihood of overweight/obesity for adolescent girls but was inversely associated with stunting and PHH for adolescent boys.

Chapter 6 describes the implementation of our primary study, Ten2Twenty-Ghana, a 26-week randomised placebo-controlled trial with multiple-micronutrient fortified biscuits (MMB) compared to unfortified biscuits (UB) among adolescent girls in north-eastern Ghana. The study evaluated the effect of consuming MMB 5 days/week for 26 weeks compared to UB on micronutrient status, height, and cognitive performance of female adolescents. We also explored to what extent the intervention effect varied in girls that had or did not yet experience menarche. We found no effect of the intervention on plasma ferritin, transferrin receptor concentration and retinol-binding protein. MMB consumption did not affect anaemia, micronutrient deficiencies and anthropometric indices at the population level. After adjusting for the girl’s baseline age, height-for-age z-score and baseline micronutrient status, vitamin A deficiency increased by 6.15% (95% C.I 0.72, 11.59) for pre-menarche girls in the MMB compared to the UB group, but deficient/low vitamin A status decreased substantially by 9.63% (95% C.I -18.94, -0.32) for MMB girls who were post-menarche compared to their UB peers. In anaemic subjects, we found evidence that MMB consumption improves mathematics scores and working memory of pre-menarche girls.

Overall, our findings pointed to a triple-burden of malnutrition for Ghanaian adolescent girls which included a steady burden of protein-energy undernutrition, an increasing burden of overnutrition, which was associated with cardiovascular risk and a persistent burden of severe anaemia, affirming the need for double duty actions to holistically tackle malnutrition. Intervention programmes must tackle a broad range of context-specific socio-cultural and economic factors at several levels (individual, household, and community) that influence adolescent nutritional status. We concluded in our primary study that MMB consumption did not improve micronutrient status, cognition, and height, but reduced the prevalence of deficient/low vitamin A status for post-menarche girls. This thesis also suggests menarche may influence the vitamin A status of girls, but this warrants further investigation. Our findings also suggest boys are likewise affected by malnutrition and poor cardiovascular health; hence they should be included alongside girls in nutrition and health intervention programmes.