Nutrition Education as a Global Health Intervention: Effects Among Nicaraguan Adolescent Girls
BY LISA PAWLOSKI
Adolescent girls in developing countries are often considered a nutritionally at-risk group. Nutritional anthropologists study the impact of nutrition on adolescent growth and development and the sociocultural factors which influence nutritional status. Ten years ago, I examined the nutritional status of adolescent girls living in Mali, West Africa, and found them to be chronically malnourished due to high energy demands, large family size, and poor dietary intake. Today those girls who participated in the study have been shown to still suffer from chronic undernutrition and a new problem related to overweight and obesity has emerged within this group. In another study related to adolescent nutrition, Mason’s Dr. Jean Moore and I examined the nutritional status of Nicaraguan adolescent girls and found evidence of both undernutrition and overweight. This phenomenon related to the rise in obesity in developing countries once only plagued with individuals not receiving enough calories and nutrients has come to be known as the “nutrition transition” and was first recognized in South and Central America.
For nutritionists and global health practitioners, one of the challenges of alleviating this double burden is to develop nutrition intervention programs that address both under and over nutrition. Most nutrition intervention programs today are focused on micronutrient deficiencies. These programs range from those on supplementation to fortification to education. In the past such programs were primarily focused on protein and energy consumption. More recently, data have revealed that most diets in developing countries are often sufficient in calories however they are lacking in variety and nutrient density; thus interventions focusing on improving micronutrient consumption are now more common.
In Central America, very few nutrition intervention programs have focused on the adolescent population’s nutritional situation. Those which do exist have initiated supplementation or fortification programs. For example, one of the most recent intervention programs in Nicaragua has attempted a vitamin A sugar fortification program. While this appears to be an effective means of improving the vitamin A status of Nicaraguans, it again comes at fairly high cost. Another nutrition intervention project targeting Nicaraguan children has been initiated by a nongovernmental organization, SOYNICA. It has been focusing on supplementing school children’s meals with a leaf extract high in micronutrients and has found significant decreases in anemia. These kinds of fortification and supplementation programs are difficult to sustain and are costly. Nutrition education programs allow for a less-expensive and preventive means to improve nutritional status, yet rely on improving nutrition knowledge and behavior, which can be challenging.
Following are some of the findings of a nutrition education intervention that Dr. Moore and I implemented in Nicaragua between 2001 and 2004. This program was quite innovative, because not only did it use a low-cost sustainable program, it targeted adolescent girls, which has not been done before in Central America.
Nicaragua is considered to be the poorest country in Central America and is in great need of improving the health and nutrition of its people. World Bank data reports that Nicaragua has the lowest per capita income in Central America at less than $745 US per year. Malnutrition is quite prevalent throughout the country in young children. Approximately 17 percent of children under three years of age suffer from severe malnutrition and the infant mortality rate is 33 out of 1,000 births. Nicaragua has been plagued by poverty, wars, hurricanes and earthquakes which have inhibited any long-term economic recovery. These factors have all significantly contributed to the high numbers of malnourished children and high mortality rates.
This study was conducted in a squatter community (barrio) within Nicaragua’s capital city Managua. The barrio has a total population of close to 2,000 residents. Roads within the barrio are not paved, phone lines are not readily available and few people have access to running potable water. The families in the barrio moved to Managua from rural surrounding communities approximately 10 years before the beginning of the study to escape poor conditions in the rural areas brought about by natural and political disasters. Thus, most families have had to develop new relationships with their neighbors and have very few relatives living within the barrio.
In order to determine the effectiveness of our nutrition intervention program on Nicaraguan adolescent girls we utilized a pre-test posttest design. Our initial sample size was 97 girls; however, of those girls, only 40 girls attended all of the education classes between 2001 and 2004. The high rate of attrition of the girls in the nutrition education programs is due to the fact that many girls found jobs or traveled to visit their relatives in rural areas.
Anthropometric data including heights and weights were collected to determine nutritional status. The tempo of growth appears to be one of the first things that is affected by poor nutrition and growth deficiencies give the initial warning signs of malnutrition. Stunting, or low height-for-age, predicts chronic malnutrition, and has been shown to be marker of many adverse consequences such as increased risk for disease and poor performance in school. Low weight-for-age gives evidence of acute malnutrition (wasting or underweight). Further, height and weight variables may be used to calculate Body Mass Index (BMI), which may provide evidence of overweight and obesity.
Z-scores were generated for each of the height and weight data which allowed for comparisons with a reference population such that a z-score of “0” represents the mean of the reference population. For these analyses, the HHANES data were used as a reference. This reference data includes heights and weights collected from a large sample of healthy, well-nourished individuals of Mexican descent living in the United States. Comparisons were made with this reference population because there are no healthy wellnourished reference populations in Nicaragua with which to make comparisons. These kinds of large-scale reference data are commonly used in studies throughout the world and facilitate comparisons between samples. For the BMI data, the anthropometric data were entered into Epi Info, which generated BMI-for-age z-scores (BMIZ) using the CDC 2000 reference data. Girls were given pretests and post-tests during each of the nutrition intervention programs to determine nutritional knowledge. The content covered materials which were relevant to the girls’ nutritional risk.
Within this population, a baseline study identified the girls as being both undernourished and overweight and reported consuming high intakes of high starch foods such as tortillas and less protein rich foods such as beans and meat. Most girls also reported consuming very few fruits and vegetables because they were difficult to purchase being found only at the larger, more distant markets. Participants also reported that they ate few fruits and vegetables because there were few recipes that contained a significant amount of fruits and vegetables. Therefore the education programs taught girls about the importance of fruits and vegetables and their accessibility in the barrio. The education interventions focused on the importance of nutrient dense, micronutrient rich foods and avoidance of foods that contained few nutrients such as soda and cookies. In effort to make the interventions interesting to teenage girls, we used visual aids, hands on cooking classes, skits, videos and dancing. This variety of activities allowed for a high attendance at each intervention program.
T-tests revealed (Table 1) statistically significant differences for HAZ and WAZ before the intervention and after the intervention (p<.05), such that HAZ and WAZ had values closer to the reference population after the intervention program.
The results suggest that when the mean height and weight data are compared, fewer girls are undernourished after the intervention than before the intervention. However, no such improvement appears to occur regarding evidence of obesity. The results also show that there is significant improvement in nutritional knowledge two years after the nutrition intervention program was initiated. Yet, while knowledge is an important step for this program, it does not necessarily indicate changes in nutrition behavior and thus an overall change in nutritional status.
These findings are the first to report not only the nutritional status of adolescent girls in Nicaragua but also the impact of a two-year nutrition intervention program targeted on adolescent girls. These data show that the nutrition intervention program may have an impact on girls’ nutritional status related undernutrition but it is not clear whether such a program has had any impact regarding the overweight and obese girls. Further, these data show significant improvement in nutritional knowledge after the implementation of the nutrition intervention program.
This study provides clues that the kind of nutrition education program used here may have an impact on girls’ nutritional status as well as their nutritional knowledge. These findings, while with limitations, are important evidence to suggest that nutritional intervention programs can make an impact on adolescents. Most of the nutritional intervention programs today in developing countries are focused on young children and mothers in order to try to assist in preventing nutritional problems early on. These data support the importance of intervening during adolescence as well as early childhood, particularly among those at risk of undernutrition.
More work needs to be done with this population to develop more effective interventions to reduce the growing problems of overweight and obesity. There are significant numbers of nutrition education programs in the United States aimed to reduce and prevent obesity; however the numbers of overweight and obese children continue to rise. Thus the challenge of creating an effective, appropriate nutrition intervention to reduce and prevent obesity still remains a significant challenge worldwide.
Lisa Pawloski (lpawlosk@gmu.edu) is associate professor and chair of the department of Global & Community Health in the College of Health and Human Services (http://www.gmu.edu/depts/chhs/gch).
