Adolescents Guidelines

ADOLESCENT
NUTRITION AND
SUPPLEMENTATION
GUIDELINES
FOR PAKISTAN
2019
Nutrition Wing
Ministry of National Health Services,
Regulations & Coordination.
Government of Pakistan
2019
Contents

/
( )

( / )
( / )

ADOLESCENT NUTRITION AND SUPPLEMENTATION GUIDELINES FOR PAKISTAN

List of Tables
Table 1. Recommendations on micronutrients including fortification and supplementation in adolescents. 20
Table 2. WHO recommendations for the promotion of preconception and antenatal nutrition in
adolescents in Pakistan (31) 23
Table 3. WHO reproductive health recommendations for delaying pregnancy in adolescent girls (21) 24
Table 4. WHO recommendations for promoting healthy diets in adolescents in Pakistan 26
Table 5. WHO recommendations on access to safe environment and hygiene for adolescents (38) 27
Table 6. Adolescent nutrition recommendation as per wealth quintile. 30
Table. A: Potential contribution of adolescent nutrition to WHA targets for 2025(1) 36
Table. B: VAS scheme in pregnant women for the prevention of night blindness in areas with a severe public
health problem related to vitamin A 37
Table. C: Summary of evidence for VAS and recommendation for Pakistan 37
Table. D: Weekly iron folate supplementation. 38
Table. E: Food and portion sizes for adolescents (age 10-19 years) (48). 38
Table. F: Sample menu for adolescents (age 10-19 years) (48) 39
Table. G: Micronutrient rich foods for a healthy diet 40
Table. H: Global standards to improve the quality of adolescent friendly health-care services 41
Table I: Set of interventions recommended for adolescent girls (advocacy recommendations) 42
Table J: Interventions recommended for adolescent girls. 42

Acknowledgments
This guideline has been developed by the Nutrition Wing of Ministry of National Health Services,
Regulations and Coordination (MoNHSR&C), with the support of World Health Organization (WHO)
Pakistan, Country Office. The report has been compiled under the leadership of Dr. Baseer Khan
Achakzai (MoNHSR&C) along with the coordination of Dr. Khawaja Masuood Ahmed (MoNHSR&C), Dr.
Lamia Mahmoud (WHO) and Dr. Noureen Aleem Nishtar (WHO). The team supervised the prepara-
tion and also provided the technical backstopping for finalization of the guidelines.
The Ministry and WHO are particularly grateful to Mr. Shahid Fazal (Consultant, MoNHSR&C/WHO) for
the development of this document and for his extensive contribution in the consultations and
reviews. WHO acknowledges the technical support and inputs provided by the Technical Advisory
Committee (TAC) formed to inform development of these guidelines. The following individuals provided
their inputs: Dr. Khawaja Masuood Ahmed (MoNHSR&C), Dr. Lamia Mahmoud (WHO), Dr. Noureen
Nishtar (WHO), Dr. Qudsia Uzma (WHO), Mr. Fakhar Gulzar (WHO), Dr. Saba Shuja (UNICEF), Mr. Saeed
Qadir (UNICEF), Dr. Asma Badar (White Ribbon Alliance), Mr. Faiz Rasool (GAIN), Dr. Ijaz Habib
(WFP), Dr. Irshad Danish (NI), Dr. Rozina Khalid (NI), and Dr. Faaria Ahsan (NI).
Special Thanks to Dr. Ayoub Al Jawaldeh, Regional Advisor Nutrition EMRO, for his valuable inputs.
Financial Support
Ministry of National Health Services Regulations & Coordination
and World Health Organization
Photo-Credits: UNICEF/Pakistan, WHO and Concept Promos

Abbreviations/Acronyms
Abbreviations/Acronyms Full Form
AA-HA Global Accelerated Action For The Health Of Adolescents
AKUH Aga Khan University Hospital
AN Adolescent Nutrition
BMI Body Mass Index
CBOs Community Based Organizations
DALYs Disability Adjusted Life Years
DHS Demographic Health Survey
DoH Department of Health
EPI Expanded Programme On Immunization
FAO Food And Agriculture Organization
FFP Food Fortification Programme
GAIN Global Alliance For Adolescent Nutrition
GDP Gross Domestic Product
IDA Iron Deficiency Anemia
IEC Information, Education, Communication
IRMNCH Integrated Reproductive Maternal Newborn, Child Health
IYCF Infant Young Child Feeding
KP Khyber Pakhtunkhwa
LHV Lady Health Visitor
LHWs/CHWs Lady Health Workers/Community Health Workers
MHM Menstrual Hygiene Management
MMN Multiple Micro-Nutrient
MO Medical Officer
MoE Ministry Of Education
MoH Ministry Of Health
MoNHSR&C Ministry Of National Health Services, Regulation And Coordination
MoU Memorandum Of Understanding
NCD Non-Communicable Diseases
NFSI Nutrition-Friendly Schools Initiative
NGO Non-Governmental Organizations
NI Nutrition International
PLW Pregnant And Lactating Women
PMA Pakistan Medical Association
PMNS Pakistan Multi-Sectoral Nutrition Strategy
RNIs Reference Nutrient Intake
RHIA Reproductive Health Information For Adolescents

Abbreviations/Acronyms Full Form
SBCC Social And Behavior Change Communication
SDGs Sustainable Development Goals
SGA Small For Gestational Age
SH&NSs School Health And Nutrition Supervisors
SOGP Society Of Obstetrics & Gynecology Pakistan
STC Short Term Care
SRH Sexual And Reproductive Health
SUN Scaling Up Nutrition
TAC Technical Advisory Committee
ToRs Terms Of Reference
UN United Nations
UNICEF United Nation Children’s Fund
VAD Vitamin A Deficiency
VDD Vitamin D Deficiency
VAS Vitamin A Supplementation
VYA Very Young Adolescents
WASH Water, Sanitation And Hygiene
WFP World Food Programme
WHA World Health Assembly
WHO World Health Organization
WIFA Weekly Iron And Folic Acid
WMO Women Medical Officer
WRA Women Of Reproductive Age

Executive Summary
Nutrition has a profound impact on the current and future health and well-being of adolescents. A
sustainable healthy diet and healthy eating practices during adolescence have the potential to limit
nutritional deficits and linear-growth faltering generated during early childhood. It may also limit
harmful behaviors contributing to the epidemic of non-communicable diseases (NCDs) in adulthood.
Investing in adolescent’s health brings triple dividends; better health for adolescents now, improved
well-being and productivity in their future adult & productive life and reduced health risks for
their children. Hence, there is a need for assuring optimal nutrition among adolescents, requiring
coordinated actions across multiple sectors.
Evidence shows that 16 million adolescent girls are giving birth each year. Targeting women and girls
only when they are pregnant is often too late to break the intergenerational cycle of malnutrition (1).
However, the first 1,000 days of life – from the start of the mother’s pregnancy to the child’s second
birthday – are critical for healthy development.
Adolescence is a critical stage of the human life cycle, both physically and psychosocially. The fact
is that adolescent girls and boys have remained a neglected target group for health and nutrition
interventions in Pakistan and over half of adolescents aged 15-19 years suffer from anemia. However, the
evidences for the 10-14 years age bracket of adolescent girls and boys are not sufficient to draw any
conclusion. Overall, that translates into maternal anemia and a subsequently anemic neonate, low birth
weight and premature births contributing to the vicious cycle of malnutrition and its health risks.
Along-with high prevalence of anemia, low diet diversity is the main factor of undernourishment in
adolescents, despite the evidence gaps to support the claim and to measure the impact of low dietary
diversity and deficiency of multi-micronutrients among adolescents.
The objective of this document is to develop national harmonized guidelines for adolescent’s nutrition
and supplementation with a set of key interventions to maximize the anticipated impact in addressing
malnutrition among adolescents. The process of developing these guidelines started with the emerging
need for a context based guideline clearly targeting specific audience and learning from the WHO
global guidelines 2018. These guidelines are developed through joint efforts of Ministry of National
Health Services Regulations & Coordination (MoNHSR&C), WHO and all relevant stakeholders. Consulta-
tive workshops and in-person interviews were held, and continuous inputs from experts were sought
from time to time to make this document effective and efficient. Final endorsement and consent on
the contents of the guidelines was sought by presenting the outcome to stakeholders through a
consultative workshop in September 2018. A Technical Advisory Committee (TAC) was formed and
consulted for inputs, ongoing initiatives and their suggested recommendations as documented in this
guideline. Moreover, the WHO 2018 global guideline for adolescent nutrition has been the main guiding
framework to develop this document.
The guidelines provide key actions to improve adolescent nutrition, well aligned with the action areas
recommended by the 2018 WHO Global Framework on Adolescent Nutrition. These recommendations
are as follow:
(1) Adolescent Fact Sheet, WHO_RHR
ADOLESCENT NUTRITION AND SUPPLEMENTATION GUIDELINES FOR PAKISTAN 1

Managing acute malnutrition in adolescent boys and girls
Screening of adolescent girls (Body Mass Index-BMI, anemia) is recommended at School, health(2)
facility and community level. The diagnosed anemic and/or under-weight adolescents found in
community by Lady Health Workers/Community Health Workers (LHWs/CHWs) (in
uncovered/unreached areas)/School Health and Nutrition Supervisors (SH&NSs) shall be
referred to health facility for proper health checkup and supplementation.
Enroll the adolescents at risk of malnutrition, in programmes where nutritional assessment,

counseling and support are available.
Providing additional micronutrients through supplementation/food

fortification initiatives
Fortification of wheat flour meal with zinc, iron, Vitamin B12 and folic acid is recommended to
prevent iron and zinc deficiency in populations.
Fortification of oil and ghee with Vitamin A and D is recommended to prevent Vitamin A and D
deficiencies in the general population particularly benefiting adolescents.
All food-grade salt, used in household and food processing, should be fortified with iodine. The
currently active provincial Food authorities (Khyber Pakhtunkhwa, Sindh and Punjab) have
approved regulations for the mandatory iodization of edible salt.
Daily iron and folic acid supplementation is recommended as a public health intervention in
menstruating adult women and adolescent girls and pregnant adolescents, living in settings
where anemia is highly prevalent (40% or higher prevalence of anemia)for the prevention of
anemia and iron deficiency.
Intermittent iron and folic acid supplementation is recommended as a public health intervention
in menstruating women, preschool and school-age boys and girls living in settings where anemia
is highly prevalent to improve hemoglobin concentration and iron status.
Reduce the risk of anemia in populations where the prevalence of anemia among non-pregnant
Women Of Reproductive (WRA) age is 20% or higher.
WHO recommends Vitamin A Supplementation (VAS) for pregnant women (not recommended for
first trimester) only in those areas where Vitamin A Deficiency (VAD) is a severe public health
problem with a dose of up to 10,000 IU vitamin A per day, or a weekly dose of up to 25,000 IU.
Calcium (1.5-2.0 grams elemental calcium/day, divided in three doses in one day) and Vitamin D (in
the case of documented Vitamin D Deficiency), supplement may be given at the current Reference
Nutrient Intake ( RNIs = 5.0 mcg OR 200IU/day) supplementation as recommended by WHO/FAO
(Food And Agriculture Organization) in pregnant women.
(2) Health facility in this document refers to all public and private health facilities and to the services provided by the respective
public and private health care providers.
2 ADOLESCENT NUTRITION AND SUPPLEMENTATION GUIDELINES FOR PAKISTAN

Provision of multi-micronutrient tablets to underweight non-pregnant married women is one
tablet per day for three months.
Provision of Multi Micronutrient tablets during pregnancy and lactation is 180 tablets in each
stage to underweight women in the respective phases at the rate of one tablet per day.
Promoting Preconception and Antenatal Nutrition in adolescents

(child bearing)
Antenatal counseling about healthy and balanced diet and keeping themselves physically active
during pregnancy is recommended for pregnant women to stay healthy and to prevent
excessive weight gain during pregnancy unless advised otherwise by the obstetrician
(e.g. placenta praevia etc.)
Preventing adolescent pregnancy and poor reproductive outcomes

Encourage political leaders, planners and community leaders to formulate and enforce
implementation of laws and policies, to prohibit marriage of girls before 18 years of age,
hence reducing pregnancy before the age of 20 years.
Increase use of skilled preconception, antenatal, childbirth and postnatal care including exclusive
breastfeeding among adolescents to ensure healthy newborns/infants.
Educational and awareness sessions on issues of early age pregnancy should also be considered
for key messages.
Promoting healthy diets in adolescents

Special attention may be needed to promote intake of fruits and vegetables and discourage
intake of energy-dense micronutrient-poor foods and sugar-sweetened beverages. Limiting the
exposure of adolescents to heavy marketing of these products and providing necessary
information and skills to make healthy food choices are additional measures to enhance
adolescent nutrition.
School meals shall be regulated by the food authorities and unhealthy snacks, energy drinks and
soft drinks sale shall be prohibited in and around educational settings.
Providing access to safe environment and hygiene for adolescents

Ensure the provision of safe drinking water and safe storage of water; provide sanitation facilities;
promote appropriate waste disposal and ensure safe school food services.
Ensure access to nearby safe, separate and private sanitation facilities, essential for menstrual
hygiene management, dignity, comfort and health of the adolescent girl.
Ensure biannual preventive chemotherapy (deworming), or the periodic large-scale

administration of anthelminthic medications to populations at risk (deworming).

Promoting physical activity in adolescents
Policy-makers should ensure availability of spaces in school and public places for physical activity
and devise multi-component programmes to promote and encourage structured sports and
physical activity in schools, the community and at the workplace.
WHO’s global policy on physical activity and diet also recommends encouraging regular,
structured sports activities, providing guidance on physical activity for younger adolescents.
Based on the importance identified by the TAC at Pakistan, it is recommended that the targeted
interventions shall be adjusted to the requirements of in-school and out of school adolescents to
ensure maximum coverage.
Delivery platforms for implementing adolescent nutrition interventions

Nutrition-sensitive interventions in Pakistan will show medium and long term outcomes by
addressing malnutrition multi-sectorally while also emphasizing on Social and Behavior Change
Communication (SBCC) and healthy eating and physical activity patterns. In this context, there is a
need to achieve the short terms goals and priority interventions. The two recommended priorities
are preventive supplementation with Weekly Iron and Folic Acid (WIFA) for WRA, starting from
adolescent age, in school (3) /Madrassa and out of school, combined with the promotion of improved
diets across the age groups and gender strata. While for adolescent girls and boys aged 10-14 years,
appropriate diet can be focused at school for optimum nutrients required. The SBCC channels
suggested for the out of school adolescents are through Community Health Workers (CHWs) and the
Community Based Organizations (CBO). Moreover, these interventions should be combined with the
ongoing efforts to improve Infant Young Child Feeding (IYCF) and women’s nutrition. The package of
interventions can be piloted on a small scale and progressively scaled up, based on the lessons
learned and experiences gained. The suggested SBCC and educational interventions for both
in-school and out-of-school adolescents are detailed in the recommendations sections.
Way forward
There is a need to scale up national/provincial actions to improve nutrition and health of
adolescent girls and boys. Stakeholders and partners should work together to:
a) Fill the knowledge gaps using upcoming surveys for primary data collection on this age group;
and invest in adolescent’s behavior insights surveys to improve the understanding of their food
values, food behaviors, beliefs, motivations and aspirations.
b) Create dialogue and build alliances across sectors, identifying platforms and building
coordination mechanism, where nutrition interventions for adolescents can be integrated
(economic livelihood development, education, gender, life skills) and consider new
platforms (community clubs, social media) with multi-sectoral approach.
(3) In this guideline “school” shall refer to all educational institutes relevant to the adolescent age groups, including schools,
colleges, vocational training schools as well as Madrassas (religious education centers)

c) Address the social determinants of adolescent health through reviews of sectoral policies at
the national and provincial levels to identify gaps in addressing adolescent nutrition and
opportunities to allocate budget for interventions targeting adolescent girls and boys - taking
into account the urban/rural divide and differences in income level and educational status.
Adolescent friendly policies can provide an enabling environment to address the needs
of this vulnerable group, namely ensure a healthy food environment in schools and other
places where adolescents gather. It is required to create nutrition literacy among
adolescent boys, girls and their families and prevent and control micronutrient
deficiency among vulnerable groups through distribution mechanisms that reach
menstruating adolescent girls. It is pertinent to take measures that reduce or eliminate
early marriage, early pregnancy and unsafe abortions among adolescents; establish and
expand access to adolescent-friendly antenatal and maternal care services and provide
safe water and sanitation facilities in schools and other public institutions.

Preamble
Improving the nutrition status of adolescents is vital for future economic growth. Adolescents are our
future human capital. They are our future in the form of entrepreneurs, employees, parents and
caregivers. All these roles are negatively affected by poor nutrition status. Yet, data on the nutrition
status of this population group is limited and evidence for nutrition-specific interventions is scarce
(2) . Not enough is known about the underlying drivers and motivators of adolescents’ health,
nutrition and food consumption behavior, or, indeed, the best channels to communicate with them
about this behavior (3).
SDGs will not be met without investing in adolescent health. Wellbeing and the nature and scale of
adolescent health needs differ between countries. In this context a stakeholder’s consultation meeting
was conducted by Nutrition Section of MoNHSR&C with support from WHO in May 2017. The Global
Accelerated Action for the Health of Adolescents (AA-HA!) framework was used as the guiding tool for
the discussions during this consultation. During this activity, stakeholders identified the need for
standardized national guidelines and training material on adolescent nutrition and supplementation.
With this backdrop, the National Nutrition Wing/MoNHSR&C with support from WHO assigned this
task to develop the “National Guidelines and Training Package on Adolescent Nutrition and
Supplementation” through a consultative process. It is pertinent to note that the National Nutrition
Wing of MoNHSR&C is also working closely with UNICEF to develop National Dietary Diversity Strategy
to improve nutritious diet for Children under 5 years. The two initiatives are expected to complement
each other by addressing the different age groups of children under 5 years and adolescents, and
defining the national nutrition protocols for respective age groups.
Objectives of the guideline
The basic objective of this document is to develop national harmonized guidelines for adolescent’s
nutrition and supplementation with a set of key interventions to maximize the anticipated impact
in addressing malnutrition among adolescents. The WHO global adolescent’s nutrition guidelines
2018 are contextualized in this regard to the context of Pakistan.
Rationale
Evidence suggests that nutrition indicators in Pakistan are in a dismal state. The need for developing a
standardized national guidelines and training material on adolescent nutrition and supplementation
for Pakistan was identified through a stakeholder consultation, while the secondary literature review
depicted a major gap in addressing nutrition in adolescents, as it is a neglected group.
Target audience
The recommendations and principles presented in this derivative guideline are intended for a
wide audience, including policy-makers, expert advisers, technical and programmes staff at the
relevant ministries, academia, provincial departments, donors and development partners
involved in the design, implementation and scaling-up of programmes for adolescent’s health
and nutrition.

The process
The process of developing guidelines started with the emerging need of context based
guidelinclearly targeting specific audience. These guidelines are developed with the joint venture of
Ministry of Health (MoH), WHO, and all relevant stakeholders. The consultative workshops, in-person
interviews, and continuous inputs from experts were sought from time to time to make this document
effective and efficient. The final endorsement and consent on the contents of the guidelines was sought
by presenting the outcome to stakeholders through a consultative workshop in September 2018. A TAC
was formed and consulted for inputs, ongoing initiatives and their suggested recommendations were
documented in this guideline.
Moreover, the WHO 2018 guideline for adolescent nutrition has been the main guiding framework to
develop this document. The technical committee intends to keep the guideline as a live document that
can be modified with advancements in the field. The chronology of the process was as follows:
1. Terms of Reference (ToRs) shared with MoNHSR&C, one United Nations (UN) group for
concurrence and approval.
2. Technical Advisory Committee (TAC) agreed by the MoNHSR&C
3. Secondary review of literature: major documents reviewed:
WHO Adolescent Nutrition Guideline Lines 2018
WHO AA-HA! framework
Global Alliance for Integrated Nutrition (GAIN) Adolescent Nutrition (AN) report Pakistan
Integrated Reproductive Maternal, Neonatal Child Health & Nutrition (IRMNCH) Program
Punjab PC-1
Peer Reviewed Journals
Other Guidelines from STC, UNICEF, NI, GAIN, (Aga Khan University Hospital (AKUH) etc.
4. Expert consultative meetings held (MoNHSR&C, WHO, UNICEF, World Food Program,
Nutrition International, GAIN, White Ribbon Alliance)
5. WHO Regional Office Review
6. Stakeholders Consultative Workshop
7. Finalization of the National Adolescent Nutrition Guidelines

Background Growth rates in girls typically increase between
the ages of 10 and 12 years, approximately
1.5–2 years before menarche. Boys usually show
Adolescents are tomorrow’s adult population, the first physical changes of puberty between
and their health and well-being are crucial for the ages of 10 and 16 years. They tend to grow
future generations. It is a transitional period most quickly between 12 and 15 years. The
between childhood and adulthood, and growth spurt in boys is, on average, about 2
provides an opportunity to prepare for a years later than that in girls (5)(6).
healthy and productive life. However,
adolescents have greater demand for calories During the past decade, birth rates have
and nutrients due to the dramatic increase in declined globally while child survival has
physical growth and development over a increased. Hence, there are more adolescents
relatively short period of time. Adolescence is a and young people today than ever before (3). As
time of changing lifestyles and food habits that more children survive into the second decade
affect both nutrient needs and intake. Moreover, of their lives, it is paramount that their
the adolescent’s growth spurt is sensitive to evolving/emerging nutrition needs are
energy and nutrient deprivation. Chronically addressed. Furthermore, if a child’s nutritional
low energy intakes can lead to delayed status is to be optimized, it is vitally important
puber ty or growth retardation (4). to target adolescent girls in particular as future
mothers. The millions of adolescent girls who
The first 1,000 days of a child’s life - from the give birth each year are more likely to die
start of a woman’s pregnancy to her child’s 2nd during childbirth than older women, or to be
birthday - is the window of opportunity to take left nutritionally depleted. Their babies are also
action and prevent irreversible damages more likely to die or be born with nutritional
caused by poor nutrition (1). Ensuring good deficits. The infants, who survive, have a
nutrition for women and adolescent girls is greater risk of growing up to be stunted
critical to laying a strong foundation for mothers or fathers themselves. In order to
healthy and productive adults and children. prevent malnutrition being passed to the next
Undernourished women are likely to give birth generation, adolescent girls, their families and
to children prone to stunting, wasting, and communities must be supported not only to
micronutrient deficiencies which prevent improve adolescents’ access to nutrition, but to
them from attaining their full growth and future delay marriage and pregnancy. The economic
economic potential. Thus, under-nutrition benefits of doing so could amount to 30% of a
pushes individuals into a vicious cycle of ill country’s Gross Domestic Product (GDP)(7).
health, poverty, and unnecessary suffering
perpetuated across generations. Furthermore, The promising interventions for adolescent
under-nutrition in the womb also sets the stage nutrition identified by The Lancet 2013 Series
for non-communicable diseases (NCDs) in are yet to be widely implemented and are
later life. reflected in only a minority of the country plans
prepared by countries signatory to the Scaling
The second decade of life marks a period of up Nutrition (SUN) Movement. Therefore, in the
rapid physical, cognitive, social, emotional and majority of countries, adequate focus/emphasis on
ethical transformation. It is a time of increased adolescent nutrition is lacking. Progress on
engagement with the environment and direct interventions has been more substantial
receptivity to new ideas. Early adolescence but, even so, the extent to which adolescents
(10–14 years) is dominated by pubertal, sexual are genuinely being covered and the effectiveness
and brain development, while late adolescence of interventions in addressing nutrition
(15–19 years) is characterized by continuing outcomes is mostly unknown. Adolescents’
physiological development and brain maturation. participation in the design and implementation

of programmes – despite being a strong
recommendation from those working with
National Trends in
adolescents – does not seem to have been Adolescent Nutrition
adopted by nutrition programmers.
Adolescents make up roughly 20% of the total
Pak istan is home to about 40 million world population. In developing countries like
adolescents (aged 10-19), equivalent to 23% Pakistan, adolescents have an even higher
of the total population (8). A recent report by demographic weight, comprising 22%. Broken
GAIN(9) points out that, with such a large down by age, Very Young Adolescents (VYA),
adolescent and youth population, the demo- aged 10-14 years, comprise 11% of the total
graphic dividend could be enormous if investments population and likewise older adolescents
are made in the right age group, at the right (15-19 years) comprise a similar proportion
time. The available data on adolescents in (13). Many macro and micro-nutrient related
Pakistan, points to an alarmingly high level of deficiencies for instance anemia have serious
malnutrition amongst adolescent girls (aged negative impact on growth and development
15-19). In addition, the cultural expectation during adolescence. Iron-deficiency anemia is
for adolescent girls is to marry young (median manifested as fatigue, low cognitive abilities,
age of first marriage is 19 years) and start breathlessness and other severe morbidities.
childbearing right away. This puts the Vitamin D Deficiency (VDD) is linked to ocular
adolescent girl or young woman at higher risk effects, skin rashes and low immunity. Vitamin
for poor birth outcomes for both herself D and Calcium deficiencies are mainly associated
and her child, and limits her potential to with musculoskeletal issues being one of the
pursue educational and skill-development top causes of morbidity and mortality among
opportunities and hence limits later young women. All these factors collectively
opportunities for herself and her family. reflect the dire need for focusing on adolescent’s
nutrition and supplementation to directly
In Pakistan, the common consequences of benefit their nutrition and health status in the
malnutrition in adolescent age are Iron Deficiency long term.
Anemia (IDA), Vitamin A and zinc deficiencies,
low levels of education, low present learning During adolescence, weight and height increases
and future earning capacities, and inability by about 50% and 20% of adult weight and
to maintain appropriate mental and physical height respectively that puts a greater
growth. The determinants of adolescent demand of nutrients which could be only met
malnutrition are low literacy rates in adolescent through consumption of nutrients dense
population, poverty, low intake of diverse diversified foods (14).The recent GAIN publication
diet, early marriages and early pregnancies, highlights, that data on the nutritional status
low access to information related to Sexual of this population group are limited. Evidence
Reproductive Health (SRH) (10). for nutrition-specific interventions is scarce,
and very little is known about the underlying
Given the global evidence, it is clear that drivers and motivators of adolescent girl’s
support (or lack of support) for adolescent health, nutrition and food consumption behavior
nutrition may have important implications for or indeed the best channels to communicate
the ability of countries to achieve international with them about this behavior (3).
health targets. These include the World
Health Assembly (WHA) global nutrition National Nutrition Survey (NNS) 2018(15)
targets for 2025 (11) and the proposed shows that almost one in eight adolescent
Post-2015 (12) Sustainable Development girls (11.8%) is underweight. Adolescent
Goals (SDGs). boys (21.1% underweight) are more affected than
adolescent girls, with one in five underweight.

More adolescent girls are overweight compared WRA have urinary iodine deficiency. Of these,
to their male peers, at 11.4% and 10.2% 12.9% have moderate and 4.6% have severe
respectively. More than half (56.6%) of deficiency. Both severe and moderate urine
adolescent girls in Pakistan are anemic, however iodine deficiency is more prevalent in women
only 0.9% have severe anemia. Adolescent in rural areas (18.6%) than in urban areas (16%)
girls in rural areas are more likely (58.1%) to .
be anemic than their counterparts in urban Moreover, the key findings of the GAIN landscape
areas (54.2%). analysis show that 54% of adolescent girls
(15-19 years) in Pakistan suffer from anemia,
The NNS 2018 highlights the dismal state of 16% are overweight and 22% of the same
nutrition indicators among WRA including category experience linear stunted growth (3).
the adolescent girls in Pakistan. The WRA According to Pakistan Demographic Health
aged 15–49 years bear a double burden of Survey (PDHS) 2012-13, only 22% of women
malnutrition. One in seven (14.4%) are took iron tablets daily for 90 or more days
undernourished, a decline from 18% in 2011 during their last pregnancy, 8% took iron
to 14%, while overweight and obesity are supplements for 60 to 89 days, and 14% took
increasing. In NNS 2011; 28% were reported supplements for fewer than 60 days. 55% of
to be overweight or obese, rising to 37.8% in pregnant women did not take iron supplements
2018. Urban/rural disparity is apparent; at all.
women in rural areas are more malnourished,
while overweight and obesity are higher in Infections caused by helminths (intestinal
urban women. parasites) are one of the factors contributing
to anemia among pregnant women.
The majority of WRA (79.7%) are affected by D e wo r m i n g d u r i n g p re gn a n c y i s a
VDD, with 54.0% experiencing moderate VAD c o s t - e ff e c t i v e intervention against
and 25.7% experiencing severe deficiency. intestinal worms that allows better
VDD is more common in urban (83.6%) than absorption of nutrients and iron, thus
in rural settings (77.1%). Over a quarter of reducing the prevalence of anemia. Only 3%
WRA (27.3%) are deficient in vitamin A, with of women took deworming medication
22.4% experiencing moderate and 4.9% during their last pregnancy (16).
severe deficiency. This is more prevalent
among WRA in rural settings (29.3%). Due to the high prevalence of VAD in Pakistan, a
Baluchistan (34.6%) has the highest proportion single dose of vitamin A is typically given to
of WRA with VAD, about 18.2% of WRA are iron women within 45 days of childbirth, aimed at
deficient. This is more pronounced among increasing the mother’s vitamin A level and
women residing in rural (18.7%) than urban the content of the vitamin in her breast milk
(17.4%) settings. Sind has the highest proportion for the benefit of her child. The same dose is
of iron deficiency anemia with about a quarter not recommended for pregnant women due
(23.8%) of all WRA affected, followed closely to the high risk of teratogenesis (abnormal
by Baluchistan (19.0%) and Punjab (18.7%). development of the fetus) resulting from high
doses of vitamin A during pregnancy in first
About 26.5% of WRA are hypocalcaemic while trimester. Only 14% of women received
0.4% are hypercalcaemic. Zinc deficiency vitamin A dose during the postpartum period,
(22.1%) is more common in rural settings which is a lower proportion than in PDHS
(24.3%) than in urban areas (18.7%). Punjab 2006-07 figure of 20% (17).
has the highest proportion of WRA with zinc
deficiency (24.1%) followed by Baluchistan Gestational hypertensive disorders are the
(23.4%) and Sindh (21.4%), while KP has the second leading cause of maternal morbidity
lowest prevalence (15.9%). About 17.5% of and mortality and are associated with

increased risk of preterm birth and fetal has declined in Pakistan over the past 20 years
growth restriction. Calcium supplementation but adolescence childbearing is still common
during pregnancy in women at risk of low in the later years of adolescence. In fact, 1 out
calcium intake has been shown to reduce of 6 girls (16.8%) aged 19 have either given
maternal hypertensive disorders and birth or are pregnant with their first child. Early
preterm birth. A Cochrane review by pregnancy is nearly twice as common in rural
Hofmeyr and colleagues assessed 13 trials areas (9.1%) versus urban areas (5.5%). It is four
and showed that calcium supplementation times more common for girls with little or no
during pregnancy reduced the incidence of education (10.5% and 12.9% respectively)
gestational hypertension by 35%, preeclampsia compared to those with slightly higher levels
by 55%, and preterm births by 24% (18). of education (3.7% and 4.8% for middle and
secondary education respectively)( 17).
Underlying socio-economic determinants of
malnutrition include education, literacy, Access to information and services related to
early marriage and early pregnancy which SRH varies. There is a wide disparity in proportion
were significant causes of concern (17). Food of adolescents receiving antenatal care visits (4
consumption is also inadequate, for example or more), according to wealth quintile, with
only 15% of adolescent girls (10-19 years) only 18% receiving antenatal care in the poorest
reported to consume any green leafy vegetables quintile and 73% in the richest quintile. According
on the previous day, and that the typical diet to the PDHS 2012-2013, the use of family
of adolescent girls was of poor dietary planning methods remains extremely low
quantity and quality (low in iron), leading across the board even amongst married
to micronutrient deficiencies (Food adolescents. A mere 10% of married adoles-
Consumption Survey, 2014-15). cents, 15-19 years, use some type of family
planning. Several surveys suggest education
Among the socio-economic, education and is regarded by adolescent girls as an important
health service related factors that contribute priority, yet cultural barriers to accessing
to the poor nutritional status of adolescents, education especially secondary and tertiary
the following are highlighted: education persist. According to Multiple
Indicator Cluster Survey (MICS, 2010-11)
Early pregnancy and early marriage are still again adolescent literacy rates vary widely
common practices in rural areas. In 2013 according to wealth quintiles; literacy is only
about half of the women (20-49 years) were 31% for the poorest but 97% for the richest
married between 15-19 years with the quintile. Also according to PDHS 2013, up to
median age at first marriage of about 19 one-third of all adolescent girls are illiterate,
years (though median age is 18 in Baluchistan with much higher rates (up to 70%) in the
and KP)(17). Early pregnancy is a direct result poorest quintile group. The average number
of early marriage. Cultural pressure for married of years of education completed by adolescents
women to conceive shortly after marriage, aged 15-19 years in Pakistan is 3.4 for girls and
and poor sexual and reproductive services 3.2 for boys (19)
available to delay the age of first or following
pregnancies. Early pregnancy is a major risk The surveys like NNS 2018 and Cost of Diet
factor for under nutrition during adolescence (2018) in different regions have started
as an adolescent mother who is stunted or focusing adolescent group and in short span
still growing herself is competing for nutrients of time, the results will be shared focusing the
with the developing child. Additionally, this Department for International Development
puts both her and her baby at risk; for example (DFID) group and will provide a platform to
obstructed labour during childbirth. set targets and plans to enhance the situation
Although the proportion of teenage pregnancy and track the progress. The surveys have the

capacity to assess both IDA and anemia support of UNICEF and The National
caused by other factors, including various Dietary Guidelines and the Food Composition
micronutrients, infection and inflammation Table for Pakistan led by Ministry of Planning
of various origins. The findings of the Development & Reform and FAO will all
current ongoing Opti-food Analysis, Cost provide appropriate information for future
of Diet S u r ve y a n d Co m p l e m e n t a r y contextualizing of these National Adolescent
F e e d i n g Assessment led by National Nutrition and Supplementation Guidelines.
N u t r i t i o n Wi n g M o N H S R & C w i t h t h e

Evidence-informed Guidelines and Protocols for
Adolescent Nutrition in Pakistan
Targeted nutrition interventions for adolescents offer a window of opportunity to improve their health,
educational attainment and economic opportunities, as well that of children to come – thereby
disrupting the intergenerational cycle of malnutrition. The enhanced focus on nutrition in Pakistan and
subsequent development of provincial plans for nutrition interventions (PC-1s), did not result in an
equally enhanced emphasis on adolescent nutrition. The recently developed National Health Vision
2016-25 puts significant emphasis on nutrition of adolescent girls as one of the ten priority actions for
improving IRMNCH&NP in the country. The government of Pakistan commits to various aspects of nutrition in
the National Health Vision 2016-2025 document. In order to create new opportunities and to change the
way nutrition is approached at national, local and individual levels, Pakistan Multi-Sectoral Nutrition
Strategy (PMNS) 2018-2025 has been developed to guide and give strategic direction to nutrition
specific and sensitive interventions aiming to address the widespread malnutrition. Advocacy is needed
during the subsequent planning and support by the Health Sector to ensure that implementation of
these Adolescent Nutrition and Supplementation Guidelines is included within the stated commitments
for nutrition, and that the adolescent groups are included in the target beneficiaries.
The National Health Vision also indicates a challenge in cross sectoral linkages stating that “A large
number of preventable deaths and disabilities among children, pregnant/lactating women, young adults
and aging population can be averted but action lies beyond the scope and mandate of health sector”.
This indicates a strong need for scaling up multi-sectoral interventions and designing adolescent focused
nutrition sensitive programs/assessments for a holistic and sustainable solution to the said age group.
The WHO 2018 Framework of Interventions and

Determinants of Adolescent Nutrition
A logical framework for national adolescent health programming was presented in Global AA-HA!(20).
The framework takes a unified approach to the planning and evaluation of adolescent programmes
and illustrates that adolescent programming will need; government leadership, adolescent participation,
adequate financing and national accountability, the four overarching conditions for successful
programming. Health is a key sector in achieving universal coverage but will need coordinated actions
across multiple sectors.
Based on the underlying causes of malnutrition and their corresponding solutions, eight evidence-based
nutrition interventions and policies have been identified in the WHO Adolescent Nutrition Guidelines
(2018) that could affect adolescent nutrition (Fig. 1) (21).

Fig. 1 Framework of interventions and determinants of adolescent nutrition.
Outcomes in adolescence and adulthood
Prevention of adolescent and Prevention of non Optimal maternal health Increased work capacity
adult malnutrition in all its forms communicable diseases and birth outcomes and productivity
Improved adolescents health and nutrition
Adolescents are protected from disease,

Adolescents are well nourished
injury, infection and early pregnancy
Adolescents are able to access Adolescents are able to contribute Adolescents are able to
a nutritious diet to their healththrough positive behaviors access essential health services
Preventing Adolescent pregnancy

Promoting healthy diets
and poor reproductive outcomes
Promoting physical activity
Promoting additional
Providing access to safe
micronutrients through
environment and hygiene
fortification
Promoting preconception
and antenantal nutrition
Managing acute Disease prevention
mainutrition and managment
Adolescents peers and interpersonal networks Families and communities are empowered
positively influence their social competence, and engaged in supporting actions towards
understanding and development better adolescent nutrition

The existing WHO evidence-informed interventions and policies relevant to adolescent nutrition
were grouped into eight main actions according to the framework above:Promoting healthy
diets;
Providing additional micronutrients through fortification of staple foods and targeted
supplementation;
Managing acute malnutrition;
Preventing adolescent pregnancy and poor reproductive outcomes;
Promoting preconception and antenatal nutrition;
Providing access to safe environment and hygiene;
Promoting physical activity; and Disease prevention and management
Based on the importance identified by the TAC at Pakistan, it is recommended that the targeted
interventions shall be adjusted to the requirements of, at school and out-of-school adolescents to
ensure maximum coverage. The Lancet Series 2013 on maternal and child nutrition identified adolescent
health and preconception nutrition as one of the main nutrition-specific interventions, and outlined a
number of promising actions (see Annexure Box 1). The box clearly shows that multiple sectors will need
to collaborate, in order to drive forward actions in these promising areas. Furthermore, the potential
contribution to support adolescent nutrition may be used to achieve (or not achieve) the WHA targets is
provided in Annexure (Table A).
The health system is an important potential source of support for adolescents, but they face barriers to
accessing these services. These barriers need to be lowered or removed. Also, working within the health
system is not enough. Examples of other delivery platforms that can be leveraged for improved adolescent
nutrition include schools, community-based programs, and social media/marketing approaches.

Summary of Sex and Age Disaggregated Suggestion to Promote Adolescent Nutrition in Pakistan
16
A brief summary of the recommended age and sex disaggregated adolescent nutrition interventions is given below:
Suggested Interventions As Per The Adolescent Age Groups

Boys 10-19 years Girls 10-14 years Girls 15-19 years Pregnant/Lactating
Adolescent Girls
Fill the evidence gap of nutrition Fill the evidence gap of nutrition
status in this age group in upcoming status in this age group upcoming
national and regional surveys national and regional surveys
Nutrition awareness sessions on Nutrition awareness sessions on Awareness session on issues of Counseling about healthy eating
appropriate diet and optimum appropriate diet and optimum early marriages, pre-conception and keeping physically active
nutrient requirements in adolescent nutrient requirements in adolescent care and early pregnancy should during pregnancy is recommended
age along with culturally sensitive age along with culturally sensitive be considered for this age group for pregnant women to stay
Information, Education IEC material to be conducted for healthy and to prevent excessive
Communication (IEC) material to be both at school and out of school - Organizing counseling and weight gain during pregnancy
conducted for both at school and girls. awareness sessions about diet
out of school boys. diversification, balanced diet, - The utilization of Ante Natal Care
- Organizing individual counseling and personal hygiene with the (ANC) and Post Natal Care (PNC)
- Organizing individual counseling and education sessions about diet aim to reduce under nutrition in visits has to be improved where
and education sessions about diet diversification, balanced diet, and the adolescent age. reinforcement of adolescent
diversification, balanced diet, and personal hygiene with the aim to nutrition shall be done. The
personal hygiene with the aim to reduce under nutrition in the - Specialized topics on IYCF, breastfeeding and complementary
reduce under nutrition in the adolescent age. menstrual hygiene management feeding promotion shall be
adolescent age. and nutrition during pregnancy increased along with the utilization
- Specialized topics on IYCF, and lactation in formal educa- of Expanded Programme on
menstrual hygiene management tion curricula and community Immunization (EPI) services.
and nutrition during pregnancy and IEC materials
lactation in formal education
curricula and community IEC
materials
Adolescent Girls
Screening camps for adolescent Screening camps for adolescent Screening camps for adolescent Regular assessment of nutrition
boys at schools and community girls at schools, hospitals and girls at schools, hospitals and assessment through anthropometry
levels on a quarterly basis to community levels on a frequent community levels on a frequent to keep track of the maternal
assess anthropometry and anemia basis to assess anthropometry and basis to assess anthropometry nutrition during and after pregnancy
status. anemia status. and anemia status. through ANC and PNC clinics.
-Biochemical tests for anemia and

other associated conditions at ANC
and PNC visits.
Enforce the school/college meals Enforce the school/college meals The school/college meals shall be The school/college meals shall be
regulations by the Food safety regulations by the Food safety regulated by the Food safety regulated by the Food safety
Authorities to prevent use of Authorities to prevent use of Authorities and unhealthy snacks, Authorities and unhealthy snacks,
unhealthy snacks, energy drinks unhealthy snacks, energy drinks energy drinks and soft drinks sale energy drinks and soft drinks sale
and soft drinks and sale of these and soft drinks and sale of these shall be prohibited in school/college shall be prohibited in school/college
items shall be prohibited in items shall be prohibited in premises. premises.
school/college premises. school/college premises.
Enforce and regulate the marketing Enforce and regulate the marketing The marketing of unhealthy foods The marketing of unhealthy foods
of unhealthy foods and beverages of unhealthy foods and beverages and beverages such as foods high in and beverages such as foods high in
17
such as foods high in saturated fats, such as foods high in saturated fats, saturated fats, trans-fatty acids, free saturated fats, trans-fatty acids, free
trans-fatty acids, free sugars or salt. trans-fatty acids, free sugars or salt. sugars or salt shall be regulated sugars or salt shall be regulated
Preventive chemotherapy Preventive chemotherapy Preventive chemotherapy Preventive chemotherapy

(deworming), using annual or (deworming), using annual or (deworming), using annual or (deworming) using single-dose
biannual single-dose albendazole biannual single-dose albendazole biannual single-dose albendazole albendazole (400 mg) or mebendazole
(400 mg) or mebendazole (500 mg), (400 mg) or mebendazole (500 mg), (400 mg) or mebendazole (500 mg), (500 mg), is recommended as a public
is recommended is recommended is recommended health intervention for pregnant
women, after the first trimester
Adolescent Girls
18
Intermittent iron and folic acid Suggested scheme for intermittent Daily oral iron and folic acid Daily oral iron and folic acid supple-
supplementation is recommended iron and folic acid supplementation supplementation with 30–60 mg mentation with 30–60 mg of elemental
as a public health intervention in in menstruating non-pregnant of elemental iron and 400 μg (0.4 iron and 400 μg (0.4 mg) of folic acid is
boys where the prevalence of women to improve hemoglobin mg)of folic acidis recommended recommended for pregnant adolescents
anemia is high. concentration and iron status and as a public health intervention in to prevent maternal anemia, puerperal
reduce the risk of anemia in populations menstruating adolescent girls, sepsis, low birth weight and preterm
birth.
where the prevalence of anemia living in settings where anemia
among non-pregnant WRA age is is highly prevalent (40% or In settings where anemia is highly
20% or higher higher prevalence of anemia) for prevalent (40% or higher prevalence of
the prevention of anemia and anemia), a daily dose of 60 mg of
Iron: 60 mg of elemental iron iron deficiency elemental iron is preferred. If a wom-
Folic acid: 2800 μg (2.8 mg) an/adolescent is diagnosed with anemia
This dosage shall be taken for 3 during pregnancy, her daily elemental
WIFA- Once per week supplement consecutive months in an year. iron should be increased to 120 mg until her
given for 3 months followed by 3 Hb concentration rises to normal (Hb
months of no supplementation 110 g/L or higher)
after which the provision of
Oral iron supplementation, either alone
supplements should restart with
or in combination with folic acid
the target group of all menstruating supplementation, may be provided to
adolescent girls. postpartum women for 6–12 weeks
following delivery for reducing the risk
If feasible, intermittent supplements of anemia in settings where gestational
could be given throughout the anemia is of public health concern.
school or calendar year
-Vitamin A supplementation in
postpartum women is not recommended
by WHO for the prevention of maternal
and infant morbidity and mortality
Provision of Multi Micronutrient tablets

Provision of Multi-Micronutrient Provision of Multi-Micronutrient
during pregnancy and lactation is 180
tablets to underweight adolescent tablets to underweight tablets in each stage to underweight
girls for 2 months biannually. non-pregnant married women women in the respective phases at the
one tablet per day for three rate of one tablet per day.
months.
The action areas identified in the Framework of determinants and interventions of adolescent nutrition are detailed below.
Managing Acute Malnutrition in Adolescents
Under-nutrition among adolescents takes the available nutrient-rich or fortified supple-

form of severe acute malnutrition or thinness mentary foods, as necessary to restore
(low weight-for-height or low BMI-for-age), normal nutritional status. Pregnant
usually caused by recent and severe weight loss women should achieve an average weekly
due to extreme deprivation and famine; or minimum weight gain of approximately
micronutrient-related malnutrition due to 300 g in the second and third trimesters
inadequate micronutrient intake or absorption.
The utilization of Ante Natal Care (ANC)
All adolescents presenting with weight and Post Natal Care (PNC) visits has to be
loss should be assessed for underlying improved where reinforcement of
causes and managed accordingly adolescent nutrition Adolescent Nutrition
shall be done. The breastfeeding and
Offer nutritional counseling and information
complementary feeding promotion shall
on optimal, healthy weight
be increased along with the utilization of
If available, enroll adolescents at risk of EPI services(23)
malnutrition in programmes where
Screening(24) of adolescent girls:
nutritional assessment, counseling and
(Screening: BMI, Mid Upper Arm Circumference
support are available
– MUAC, Anemia): Performing health screenings
Integrate this age group in large scale during adolescence can play a vital role in helping
population surveys (both quantitative them achieve lifelong healthy behaviors. The
and qualitative) as planned in the NNS overall nutritional status is better assessed
2018 with anthropometry, in adolescence as well as
at other stages of the life cycle. Screening camps
Develop national standard cutoff points
for adolescent girls shall be arranged frequently
for BMI, MUAC etc. also develop standardized
at School, Health facility and Community level.
indicators and data collection tools for
Boys can be included in these screening camps
measuring, assessing, and monitoring the
for Anthropometry and Anemia on a quarterly
diet quality and patterns
basis. The diagnosed anemic and/or under-
An adequate diet, containing all essential weight adolescent in community by LHWs and
macro and micronutrients is necessary for by CHWs in uncovered/unreached areas/SH&NS
the well-being and health of all adolescents, shall be referred to health facility for proper
including those with tuberculosis or other health checkup and supplementation. In
infections humanitarian emergencies and areas where BMI
cannot be followed the alternate, screening for
Older adolescents (15–19 years), including adolescents shall be done through MUAC.
Pregnant Lactating Women (PLW), with Screening process, responsibility, counseling areas
moderate under nutrition, who fail to and supplementation is given below:
regain normal BMI after 2 months’ of
nutrition treatment (such as the targeted
Supplementary Feeding programs where Screening Process:
available), as well as those who are losing
weight during treatment, should be Anthropometric Measurements /BMI/MUAC
evaluated for adherence and co-morbid
conditions such as tuberculosis and Anthropometric Measurements: Height
diabetes. They should also receive and weight
nutrition assessment and counseling
and, if indicated, be provided with locally
Calculation of BMI Weight (kg)/height (m)2

MUAC below 21cm for Adolescent girls and BMI-for-age Z-score
pregnant/lactating Adolescents are classified Severe thinness: <-3SD
as malnourished Thinness: = -3 SD &< -2 SD
Overweight: >+1SD & =+2 SD
WHO recommends that acute malnutrition Obesity: >+2SD
among children and adolescents 5-19 years be
assessed by calculating BMI, and then adjusting Checking physical signs of nutritional
for age to generate BMI-for-age. BMI is calculated deficiencies
based on the weight (in kg) divided by the Pallor and oral ulcers- Anemia
square of the height (in m) of the individual. Dry skin, decreased skin turgor- Dehydration
BMI-for-age should be presented as Swelling in neck - Goiter
Z-scores based on the 2007 WHO Growth Anemia-can determine the Blood Hbat
Reference (WHO GR) for children and adolescents facility level by a HemoCue device.
5 to 19 years of age.
Classification of children and adolescents 5-19

years of age
Level & responsibilities

Community Level Health Facility Level School/College Level
LHW (limited) check for signs and symptoms and Medical Officers (MOs) SH&NSs
refer to health facilities/ Community Midwives / Women Medical
(CMW). The CHW (like TBAs, Marvi workers) and Officers (WMOs) /
other Community Based Organizations (CBOs) Midwives / Nurse/ LH
can take this role in the LHW uncovered areas
Providing Additional Micronutrients through Supplementation/

Food Fortification Initiatives
Poor nutrition is often associated with inadequate intake of healthy foods and includes multiple
micronutrient deficiencies, such as Iron, Folic acid, Vitamin A and Vitamin B12. Requirements for
Iron, Vitamin A, Calcium, Zinc and Vitamin D increase during adolescence, and consuming fortified
foods and supplements can help provide the essential micronutrients that adolescents need when
access to a healthy, diverse and nutrient-rich diet is neither feasible nor affordable(25).
IDA reduces physical capacity and work performance and is the leading cause of lost Disability
Adjusted Life Years (DALYs) for adolescents globally(26). In addition, there is a higher risk of adverse
maternal and neonatal outcomes when entering pregnancy with suboptimal iron reserves, (27).VAD
occurs “when routine diets have insufficient Vitamin A for the basic needs of growth and
development, for physiological functions, and for periods of added stress due to illness” (28).
Table 1 presents relevant recommendations for the provision of additional micronutrients including
fortification of staple foods and oral supplementation. The recommendations should complement
efforts to promote a healthy diet, which, as described above, includes the consumption of diverse foods
rich in micronutrients and bio-available iron.

Table 1. Recommendations on micronutrients including fortification and supplementation in adolescents
20
Ecological Levels Actions and Implementation Recommendations For Pakistan

Considerations
Macro Prevent and control iron deficiency Scale up fortification programme as it targets national level population
(public policy) level and iron deficiency anemia
Education/ awareness about the importance of fortified foods through media campaign and
Reduce the risk of folic acid Supplementation program
deficiencies and occurrence of
births with neural tube defects Fortification of wheat flour with iron, Zinc, Vitamin B12 and folic acid is recommended to
prevent Iron-Folate and Zinc deficiency in populations, particularly vulnerable groups such
Fortify staple foods such as flour as children, adolescents and women.
with micronutrients
Fortification of Oil and Ghee with Vitamin A and D is recommended to prevent Vitamin A and
Vitamin D deficiencies in the general population particularly benefiting the Adolescents (21)
Prevent and control iodine All food-grade salt, used in household and food processing, should be fortified with iodine
deficiency disorders as a safe and effective strategy for the prevention and control of iodine deficiency disorders
Fortify condiments such as salt with in populations living in stable and emergency settings. And all edible salt iodization shall be
appropriate fortificants deemed mandatory and regulated by the relevant food authorities.
Meso Prevent and control micronutrient Daily iron and folic acid supplementation is recommended as a public health intervention in
(community) level deficiency among vulnerable menstruating adult women, adolescent girls and pregnant adolescents living in settings
groups where anemia is highly prevalent (40% or higher prevalence of anemia), for the prevention
of anemia and iron deficiency(21).
Set distribution mechanisms to
reach menstruating adolescent Intermittent iron and folic acid supplementation is recommended as a public health
girls in areas where anemia is a intervention in menstruating women, preschool and school-age boys and girls living in
significant public health problem settings where anemia is highly prevalent, to improve haemoglobin concentration and iron
status and reduce the risk of anemia in populations where the prevalence of anemia among
non-pregnant WRA is 20% or higher. For guidance on Deworming, refer to Table 5.
4 60 mg of elemental iron equals 300 mg of ferrous sulfate heptahydrate, 180 mg of ferrous fumarate or 500 mg of ferrous gluconate.
5 A single dose of a vitamin A supplement greater than 25,000 IU is not recommended as its safety is uncertain, and might be teratogenic if consumed between day 15 and day 60 from conception (22)
Ecological Levels Actions and Implementation Recommendations For Pakistan
Considerations
Individual) level Prevent and control Micronutrient Suggested scheme for intermittent iron and folic acid supplementation in adolescent girls
deficiency among Menstruating and non-pregnant WRA (WIFA)
non-pregnant adolescents Iron: 60 mg of elemental iron
Folic acid: 2800 μg (2.8 mg)
Once per week supplement given for 3 months followed by 3 months of no supplementation
after which the provision of supplements should restart with the target group of all menstru-
ating adolescent girls and adult women
Oral iron supplementation, either alone or in combination with folic acid supplementation,
may be provided to postpartum women for 6–12 weeks following delivery for reducing the
risk of anemia in settings where gestational anemia is of public health concern.
Routine use of multiple micronutrient powders during pregnancy is not recommended as an

alternative to standard iron and folic acid supplementation during pregnancy for improving
maternal and infant health outcomes (24).
WHO recommends VAS for pregnant women (not recommended in first trimester) only in
those areas where Vitamin A disorders is a severe public health problem with a dose of up to
10,000 IU vitamin A per day, or a weekly dose of up to 25,000 IU(22).
21
Calcium (1.5-2 gram elemental calcium/day divided in three doses in one day) and vitamin D
(in the case of documented deficiency) Vit. D supplement may be given at the current RNIs =
5mcg OR 200IU/day) supplementation as recommended by WHO/FAO in pregnant women.
Provision of Multi-Micronutrient tablets to underweight adolescent girl

Provision of Multi-Micronutrient tablets to underweight non-pregnant married women one
tablet per day for three months
Provision of Multi-Micronutrient tablets during pregnancy and lactation is 180 tablets in each
stage to underweight women in the respective phases at the rate of one tablet per day.
Since physical accessibility of the health facilities is a major issue due to remote locations of the health centers, non-availability of transport,
restricted women’s mobility, and uncertain law and order situation, therefore supplementation should be implemented through all community
based health and nutrition cadres in Pakistan to achieve maximum coverage and should be included in their services package. Again, it would be
of utmost importance to ensure an uninterrupted supply of these supplements and fortificant at community level and all delivery points to ensure
continued provision of services.
Levels and responsibilities
Community Level Health Facility Level School/College Level
LHW/CHW/Community Midwives (CMW) MOs/WMOs, LHVs SH&NSs
Recommendations from the TAC on Micronutrient Supplementation

and Fortification for Adolescents:
Programmes on WIFA (WIFAS) for WRA, starting from adolescence and targeting both school girls and
girls out of school can be effectively established by developing a strong partnership between MoH and
Ministry of Education(MoE). Partner agencies may be asked to support communication and social mobili-
zation campaigns to launch this new initiative, and to help procure this new type of supplements.
For supplementation initiatives, the Society of Obstetrics & Gynecology, Pakistan(SOGP) and the
Pakistan Medical Association (PMA) has to be involved in recommending the clinical doses appropriate
for the population of Pakistan.
Iron/folate shall be incorporated into the essential drug list of Pakistan and caseload calculation shall be
done for the additional needs of adolescent girls for future programming, costing and procurement.
Trails on bio-fortification of crops with Iron/folate and Zinc shall be done as a gradual transition
measure from supplementation/fortification to ready availability of Iron/folate and Zinc in crops.
The Food Fortification Programme (FFP) can act as a bridge and advocate for this transition and
will provide iron rich wheat through their program interventions.
Supplementation should always be promoted together with improved diets and the correction of wide-
spread practices such as tea-drinking with or immediately after meals, which severely inhibit iron absorption,
similarly prolonged cooking of vegetables which inactivates heat-labile vitamins like folate and other B-vita-
mins. These programmes should be combined, wherever possible, with the establishment of school
gardens and school canteens for the preparation of healthy school meals.
Promoting Preconception and Antenatal Nutrition in Adolescents (Child Bearing)

When a growing adolescent becomes pregnant, there is a competition for nutrients between the
mother and the fetus. This can result in cessation of the prospective mother’s linear growth and increase
her risk of stunting, and can also lead to fetal growth restriction and low birth weight (defined as a birth
weight of less than 2,500 grams) and early death (29). They are also likely to experience obstructed labor and
other obstetric complications. Additionally, children born to anemic mothers are more likely to die before
the age of one year, and be sick, undernourished and anemic, thus perpetuating the intergenerational
cycle of maternal and child malnutrition (30).
The WHO recommendations for the promotion of adolescent preconception and antenatal nutrition can help
address nutritional deficiencies in pregnancy, and improve both fetal and maternal outcomes (Table 2).
4 60mg of elemental iron equals 300mg of ferrous sulfate heptahydrate, 180mg of ferrous fumarate or 500mg of ferrous gluconate.
5 A single dose of a vitamin A supplement greater than 25,000 IU is not recommended as its safety is uncertain, and might be teratogenic
if consumed between day 15 and day 60 from conception (22)

Table 2. WHO recommendations for the promotion of preconception and antenatal nutrition in adolescents in Pakistan (31)
Actions And Implemen- WHO Recommendations
23
tation Considerations
Ensure access to Counseling about healthy eating and keeping physically active during pregnancy is recommended for pregnant women to stay
adolescent-friendly healthy and to prevent excessive weight gain during pregnancy
antenatal, maternity and
newborn services Birth preparedness and complications readiness interventions are recommended to increase the use of skilled care at birth and
to increase the timely use of facility care for obstetrics and newborn complications
Address delays in seeking Improved self-care of women, improved home care practices for women and newborns, improved use of skilled care during
and receiving appropriate pregnancy, childbirth and the postnatal period for women and newborns, and increase in the timely use of facility care for
maternal health care obstetrics and newborn complications
Use of LHW/CHW, including trained traditional birth attendants, to deliver the following interventions is recommended, with
Ensure the availability of targeted monitoring and evaluation.
adolescent-friendly antenatal
health services that are Distribution of certain oral supplement-type interventions to pregnant women (calcium supplementation in women living
accessible, acceptable and in areas with known low levels of calcium intake; routine iron and folate supplementation in pregnant women; intermittent
appropriate for adolescents presumptive therapy in malaria in pregnant women living in endemic areas; vitamin A supplementation in pregnant
women living in areas where severe VAD is a serious public health problem and multiple Micronutrient supplementation
Expand availability of Use of LHWs, including trained traditional birth attendants, is recommended for promoting the uptake of a number of
antenatal, childbirth and maternal- and newborn-related health-care behaviours and services, providing continuous social support during labour in
postnatal care to adolescents the presence of a skilled birth attendant, and administering misoprostol to prevent postpartum haemorrhage.
Community participation in programme planning, implementation and monitoring is recommended to improve use of skilled
care during pregnancy, childbirth and the postnatal period for women and newborns, increase the timely use of facility care
for obstetric and newborn complications and improve maternal and newborn health. Mechanisms that ensure women’s
voices are meaningfully included are also recommended.
Preventing adolescent pregnancy and poor reproductive outcomes

Preventing unintended pregnancies and reducing adolescent childbearing through universal access to SRH carries crucial to the health and
well-being of women, children and adolescents. Interventions aimed at empowering girls, promoting family planning and supporting communities to
reduce pregnancy before the age of 20 years and marriage before the age of 18 years are important strategies to address maternal mortality and complications
from pregnancy and childbirth. Secondary school education and increasing enrollment and school retention rates is an important protective factor against
child marriage. Girls with secondary school education are six times less likely to marry as children compared with girls having no education.
Enforce laws and policies to prohibit marriage of girls before 18 years of age(23). Married and/or out-of-school adolescents are difficult to reach
through school-based, peer-led or work-based programmes. Furthermore, they may not know which services they need or how to access them.
Safe spaces, such as those provided to adolescent girls in times of crises, can provide opportunities for girls to access information and services in a
confidential and non-stigmatizing way. The Advisory committee recommends to further contextualizing this aspect, religious scholars shall also be
consulted to provide further religious recommendations related to early marriages and pregnancy.
Table 3. WHO reproductive health recommendations for delaying pregnancy in adolescent girls (21)
Ecological Levels Implementation Considerations WHO Recommendations
Meso Prohibit and reduce unintended and/or Reducing marriage before the age of 18 years
(community) level early pregnancy
Encourage political leaders, planners and community leaders to formulate and enforce
laws and policies to prohibit marriage of girls before 18 years of age.
Expand adolescents’ access to culturally Increase educational opportunities for girls through formal and non-formal channels, to
appropriate information and services delay marriage until 18 years of age.
around SRH and Family Planning Reducing pregnancy before the age of 20 years
Advocate for adolescent pregnancy prevention among all stakeholders through interven-
tions such as: information provision, sexual and reproductive health education, life skills
building and culturally appropriate family planning counseling.
24
Maintain and improve efforts to retain girls in school, at both primary and secondary
levels.
Reducing coerced sex among adolescents

Empower communities to prevent early
marriage, coerced sex and unintended Continue efforts with political leaders, planners and the community to formulate laws and
pregnancy policies that punish perpetrators of coerced sex involving adolescent girls, to enforce
these laws and policies in a way that empowers victims and their families, and to monitor
their enforcement.
Prevent and control
Micronutrient deficiency among Increasing use of skilled antenatal, childbirth and postnatal care among adolescents
Menstruating non-pregnant
adolescents Expand the availability and access to basic emergency obstetric care and comprehensive
emergency obstetric care to all populations, including adolescents.
Promoting healthy diets in adolescents
Healthy diets have a critical role in protecting against all forms of malnutrition. A healthy diet provides
adequate energy, protein, vitamins and minerals (macro - and micronutrients) obtained through the
consumption of foods such as fruits, vegetables, legumes, nuts and whole grains.
Population nutrient intake goals as percentage of total energy should include between 15% and 30%
of calories from fat, between 55% and 75% of calories from carbohydrate (with no more than 5–10%
of these derived from added sugars) and between 10% and 15% of calories from protein (31). Many
adolescents consume inadequate amounts of fruits, vegetables and whole grains, insufficient
vitamins and minerals (including folic acid, vitamins A, D, E and B6, calcium, iron, zinc, magnesium)
and fiber, and excess fat, sodium, cholesterol and added sugars(32).
Adolescence period is accompanied by increased physiological and psychological changes with rapid
physical growth and development that require increased amounts of nutrients to fulfill the body
requirements. At puberty and at peak weight and height accretion, adolescents gain about 3-5
kg/year weight and 6-7 cm/year height, respectively. After the age of 17 years, weight and height gain
of adolescents reduces substantially to 1.5-2kg/year and 0.5-1.0 cm/year, respectively. Adolescents by
and large attain 50% of adult weight and 20% of adult height for which optimal nutrition is essential.
Energy requirements for adolescent boys and girls are estimated at 55-65 Kcal/kg/day and 45-60
Kcal/kg/day, respectively. Recommended protein requirements for adolescents are 1.1-1.2 g/kg/-
day(33). The proposed food and portion sizes and sample menu for adolescents (age 10-19 years) are
given in Table E and F of Annexure which recommends the food for adolescents of age group 10-19
years in Pakistan extracted from the draft Pakistan food based dietary guidelines. The TAC recommended
promoting local recipes of nutrient dense diets targeting this age group and to promote social protection
schemes to address the non-affordability issue at family level.
Special attention may be needed to promote intake of fruits and vegetables and discourage intake of
energy-dense micronutrient-poor foods and sugar-sweetened beverages. Limiting the exposure of
adolescents to heavy marketing of these products and providing necessary information and skills to
make healthy food choices are additional measures to enhance adolescent nutrition. Some examples
of foods rich in micronutrients are listed in Annexure (Table G).
The WHO recommendations related to the promotion of healthy diets (Table 4) may be applied in
conjunction with national-level food-based dietary guidelines to guide effective public health and
nutrition policies and programmers to promote a healthy diet.

Table 4. WHO recommendations for promoting healthy diets in adolescents in Pakistan
Ecological Actions and Implementation Recommendations
26
Levels Considerations
Meso Develop food policies and WHO recommends a reduced intake of free sugars throughout the life course.
(public policy) standards In both adults and children, WHO recommends reducing the intake of free sugars to less than 10% of total
level energy intake.
WHO suggests a further reduction of the intake of free sugars to below 5% of total energy intake.
Set clear definitions for the key WHO suggests an increase in potassium intake from food to control blood pressure in children aged 2–15
components of food policies, years. The recommended potassium intake of at least 90 mmol/day in adults should be adjusted down-
thereby allowing for a standard ward for children, based on the energy requirements of children relative to those of adults
implementation process
WHO recommends a reduction in sodium intake to control blood pressure in children aged 2–15 years. The
recommended maximum level of intake of 2.0 g/day sodium in adults should be adjusted downward
based on the energy requirements of children relative to those of adults
Ensure government The school/college meals shall be regulated by the Food Safety Authorities and unhealthy snacks, energy
regulatory policies support drinks and soft drinks sale shall be prohibited in school/college premises.
healthier composition of staple The marketing of unhealthy foods and beverages such as foods high in saturated fats, trans-fatty
foods acids, free sugars or salt shall be regulated.
Legislation on sale, promotion, advertisement and marketing of unhealthy foods shall be approved by
the relevant Food Authorities.
At the mesa or community level, policy-makers can create healthy food environments in schools and other public institutions by promoting
weight management interventions for obese adolescents or those at risk of developing NCDs. Also developing and implementing high-intensity
school-based interventions that focus on diets and include supportive school environment and policies and healthy food options available
through school food services, including sale of competitive foods in school kiosks. There should be implementation of high-intensity
school-based interventions including a curriculum on diet, taught by the trained teachers and contains a parental or family component
(34) in line with the Nutrition-Friendly Schools Initiative (NFSI).
The TAC recommends recruiting nutrition qualified professionals for school nutrition programs, promoting dietary diversity focusing on
nutrient dense diets and creating awareness about food labeling.
Providing access to safe environment and hygiene for adolescents

Inadequate access to safe water, hygiene and sanitation services is a major issue. Consumption of contaminated food and water along with
exposure to unhealthy environments, diarrheal diseases; such as enteric diarrheal disease, soil-transmitted helminth infections (ascariasis,
trichuriasis and hookworm), lymphatic filariasis, trachoma, schistosomiasis, and malaria are all considered as risk factors associated with
malnutrition (35). Food and waterborne diarrheal diseases rank as the second and fourth leading causes of death globally in younger and
older adolescents, respectively (26).
In approximately half of the households worldwide, women and girls are the primary water collectors. This task uses energy that might have
been spent on other activities, including education, and it also increases risk of exposure to sources of infection such as intestinal helminths,
which may lead to anemia (36). WHO recommendations that pertain to preventive chemotherapy(deworming), or the periodic large-scale
administration of anthelminthic medications to populations at risk are listed in Table 5.
Table 5. WHO recommendations on access to safe environment and hygiene for adolescents (38)
Implementation Considerations WHO Recommendations
Improved access to safe WASH Protect drinking water (ensure clean and safe water) and store water safely and provide sanitation facilities by
(Water, Sanitation and Hygiene) disposing of waste quickly, properly and safely. Also ensure safe school food services by increasing the role of Food
services, and practices to reduce the Authorities to ensure provision of safe, healthy and hygienic food in the community at large
incidence of infections and improve
nutritional outcomes Ensure access to nearby, safe, separate and private sanitation facilities essential for menstrual hygiene management,
dignity, comfort and health of the adolescent girl
Ensure appropriate equity based WASH facilities and awareness at school/colleges
Ensure adolescent friendly service provision and enabling environment
Promote preventive periodic
large-scale chemotherapy Preventive chemotherapy (deworming), using annual or biannual single-dose of albendazole (400 mg) or mebenda-
(deworming) campaigns to zole (500 mg), is recommended as a public health intervention for all young children both boys and girls (12–23
27
populations at risk, to reduce the months), preschool (24–59 months) and school-age children living in areas where the baseline prevalence of any
burden of worms caused by soil-transmitted infection is 20% or higher among children, in order to reduce the worm burden of soil-transmitted
soil-transmitted helminth infections
helminth infections
Preventive chemotherapy (deworming), of annual or biannual single-dose albendazole (400 mg) or mebendazole (500 mg),
is recommended as a public health intervention for all adolescent boys, non-pregnant adolescent girls (10–19 years) and
non-pregnant WRA (15–49 years) living in areas where the baseline prevalence of any soil-transmitted helminth infection is
20% or higher among non-pregnant adolescent girls and non-pregnant WRA, in order to reduce the worm burden of
soil-transmitted helminth infection
Preventive chemotherapy (deworming) using single-dose albendazole (400 mg) or mebendazole (500 mg), is recom-
mended as a public health intervention for pregnant women, after the first trimester, living in areas where both:
(i) The baseline prevalence of hookworm and/or Trichuris Trichiura infection is 20% or higher among
pregnant women,
(ii) Anemia is a severe public health problem, with a prevalence of 40% or higher among pregnant women,
in order to reduce the worm burden of hookworm or T. Trichiura infection.
Lack of adequate school sanitation facilities encouraging regular, structured sports
contributes to sporadic school attendance and activities, providing guidance on physical activi-
increases chances of dropping out, which, in ty for younger adolescents(40). In the context of
turn, makes the adolescent girl more vulnerable Pakistan safe environments shall be provided
to early marriage and early childbearing (37). separately for both boys and girls who shall be
Where possible the education of adolescents done through advocacy with policy makers to
(specifically girls) shall be incentivized so as to include into better town planning, layouts of
increase retention at school. school premises and planning other sports
events on regular bases. Involvement of all
Adolescents’ health can improve with low-cost students in physical activities shall be promoted.
interventions to the physical environment at
schools. Policy-makers should ensure that
action is taken in schools to protect drinking Implementation
water (that is, ensure clean and safe water) and
store water safely, provide sanitation facilities, Considerations
dispose waste quickly, properly and safely and
ensure safe school food services (38). The presence Research Gaps
of all these conditions and facilities in schools is
essential to good health and nutrition. The lack of empirical evidence and documented
practical experience on what should be done to
Optimal WASH services are important in schools support adolescent nutrition and how (particularly
due to the Menstrual Hygiene Management across sectors), represents a fundamental
(MHM) requirements of adolescent girls and its challenge, and one that is reflected in the many
association with increased school dropouts at research gaps related to operational issues. Such
menstruation age and lack of attendance gaps include the lack of clear data on adolescents
during the monthly menstrual cycles. There is in general and on adolescent nutrition in
dire need of increasing the per-head number of particular. This is partly due to the limited clarity
sanitation facilities for adolescent girls due to around methods of assessment of adolescents,
their additional needs of menstrual hygiene and and it is encouraging that some initiatives to
prevent their absence at school. These optimal address this are already underway. As a result,
WASH services can be ensured through joint evidence of programme effectiveness on
working of the MoH, MoE and the Ministry of adolescents is hard to come by and evidence of
Public Health Engineering. cost effectiveness even more so. Furthermore,
there is a particular gap in terms of assessments
Promoting physical activity of how health and nutrition interventions that
are targeted more generally (at households or
in adolescents women) affect adolescents.
Regular physical activity is fundamental to There are several programs in Pakistan address-
energy balance, weight control and prevention ing nutritional needs of mothers and children
of obesity with long term benefits to adolescent but a very few are specifically targeting adolescent
population. At the mesa or community level, girls and boys and they are also neglected in
policy-makers should ensure availability of both evidence (specifically boys) and interventions. It
school and public spaces for physical activity is notable that adolescent boys in particular are
and devise multi-component programmes to barely mentioned in the literature reviewed,
promote and encourage structured sports and especially in relation to nutrition. Additionally,
physical activity in schools, the community and the question of how to reach adolescent boys
the workplace (39). WHO’s global policy on with nutrition interventions remains largely
physical activity and diet also recommends unanswered. The future evidence shall also

inform to what extent would inclusion of Adolescent nutrition
adolescent boys in nutrition and healthy lifestyle
recommendations according to the
programmes contribute to the improved
nutrition and health of women during wealth quintile
childbearing, and for infants and young
children in the critical early years of life. In line with the evidences and figures stated it is
vivid that the literacy regarding adolescent
Other Important Considerations nutrition varies from richest to poorest, so does
the prevalence of malnutrition and micronutrient
deficiency. Therefore, it is recommended that
Health services for adolescents are often highly
separate approaches should be taken to reach
fragmented, poorly coordinated and uneven in
out the audiences in all above mentioned areas.
quality. Adolescents often find mainstream primary
According to the prevalence stated, poorest
care services unacceptable because of perceived
population is the priority to address the issue,
lack of respect, privacy and confidentiality, fear of
however, no one should be left out.
stigma and discrimination, and imposition of the
moral values of health-care providers.
In terms of availability of the resources, different
quintiles need different approaches especially for
Building on country experiences, WHO has
behavior change communication and reducing
produced publications on global standards for
the prevalence of malnutrition. The below table 6
quality of care in health-care services for adoles-
articulates the different approaches for specific
cents, implementation guides and monitoring
target groups according to wealth quintiles:
tools (40). Global AA-HA! goes further by using
the “adolescent health in all policies” approach to
take into account adolescent-specific
programming across the multiple sectors
involved in national, regional and global health (41).
Some important implementation considerations

in Adolescent Nutrition Programming in Pakistan
are as follows (3):
Integrated approaches: the public health

system and school based delivery platforms
have been utilized at a minimal scale to target
primary school children to improve their
nutritional status and school enrolment.
In addition to the health system, integrated

approaches and additional channels need
to be considered in order to effectively
reach this target group and to effectively
address the health, nutrition and social
wellbeing of adolescent girls
In order to ensure deeper routed social

change and influence current social norms
around adolescent girls, interventions should
also target male peers, adolescent boys, as
well as parents and the community at large.

Table 6. Adolescent nutrition recommendation as per wealth quintile
S/No Target Group As Recommendation For Quintile

Per Wealth Quintile
1 Richest/Rich As the resources are available to this group, a media campaign, online
streaming of behavior change communication material and debates in
schools/colleges can bring a positive change
According to the availability, and access of the resources, these

adolescent can volunteer as an ambassador for the fellow girls and boys
to roll out the messages in the community. Similarly the change in diet
can be suggested for the adolescent considered to be obese by the
institutions they are enrolled in, by doing so, the preference of healthy
diet can be promoted as a part of awareness education
2 Poorest/Poor Due to lack of resources, a program including the SBCC and provision of
supplementation is required to target the group and involvement of the girls
and boys to be a role model and conveyor of the messages is required at
larger scale
The prevalence is high in this group and requires special attention and
immediate action to involve both the genders in identification and
delivery of the messages
Recommendations support from all the family members towards

copying the situation.
for Adolescent Boys
Similar to the adolescent girls; adolescent boys

Adolescent-Friendly Health Services
cannot be left out as they contribute a significant
chunk of the population. According to the study For health services to be considered adolescent
the adolescent boys are as prone to anemia and friendly, they must be accessible, acceptable,
stunting as the girls that can affect their physical equitable, appropriate and effective. Health
and mental development in these specific services are accessible when adolescents are able
years (42). However, the evidence gap is the major to obtain them; acceptable when adolescents are
limitation towards spelling out the exact willing to obtain available services; equitable
situation of adolescent boys and the relevant when all adolescents are able to obtain available
prevalence rates. services; appropriate when the right health
services are provided; and effective when the
Howsoever, the involvement of the adolescent right health services are provided in the right way
(43). Table H in annexure lists the eight global
boys in behavior change communication and
forming boys to boys support groups are highly standards set to improve the quality of
recommended. Similarly, further studies are adolescent-friendly health-care services.
recommended to generate evidences to fill the
gap and suggest the most appropriate way of The global standards require action at national,
approaching the group. district and facility levels in areas of governance,
workforce capacity, financing and drug supplies
Along-with the formation of boys to boys technology. At the national level, an essential first
support groups, fathers to fathers support step entails reviewing existing laws, policies
groups are evenly recommended to enhance the and systems with regard to issues related to:

assessing and defining a comprehensive package decision-makers to tap into adolescents’ unique
of health services; financial protection measures; perspectives, knowledge and experience for a
provisions for confidentiality; standards and better understanding of the latter’s needs and
requirements for age of consent; equitable problems. This then leads to better-suited
service provision to adolescents. Also adoles- solutions, and benefits from immediate feedback
cents’ participation in planning, monitoring, in tracking progress.
evaluation and provision of services; provisions
to ensure that services are welcoming; and data Several guidelines that are aimed at a wider age
collection and age and sex disaggregation within group or the population as a whole also benefit
the health management information system (40). adolescents. Because the period of adolescence
(10–19 years) overlaps with both childhood
Equity and Other Social (0–17 years) and young adulthood (18–24 years),
many recommendations targeted specifically
Considerations towards children (for example, related to
management of acute malnutrition) or women
Policy actions can address social determinants of (for example, related to reproductive health) also
health as well as of inequities in health. Three address major adolescent health conditions.
broad approaches to reduce health inequities However, adolescents may not benefit as much
that may inform policies are: targeted as they should from these recommendations if
programmes for disadvantaged populations; the implementation of these recommendations
closing health gaps between worse-off and ignore the specific needs of adolescents. For
better-off groups; and addressing the social example, an iron supplementation programme
health gradient across the whole population. By targeting both non-pregnant women and
combining approaches that reduce health adolescent girls may require separate distribution
inequities and the ecological framework, systems to reach both groups effectively and
adolescent well-being becomes the outcome of equitably.
the interaction of several complementary levels.
At the national level, an essential first step entails
As the adolescents grow older, they are likely to reviewing existing laws, policies and systems
have an increasing desire for confidentiality and with regard to issues related to: assessing and
autonomy, and greater capacity to seek health defining a comprehensive package of health
care in comparison with younger children. Many services; financial protection measures; provisions
of the actions required to improve adolescent for confidentiality; standards and requirements
nutrition require changes in behaviours, such as for age of consent; equitable service provision
improving dietary intake, balancing physical to adolescents; adolescents’ participation in
activity, reducing injury and infection, and avoiding planning, monitoring, evaluation and provision
early pregnancy. As powerful societal assets, the of services; provisions to ensure that services are
contributions of adolescents to their communities welcoming; and data collection and age and sex
and to their own health care can be nurtured and disaggregation within the health management
augmented through meaningful engagement information system(40). It is important to gain
and participation. further understanding of needs, preferences and
circumstances of different groups of adolescents
Respecting adolescent views regarding their own on which to strengthen existing and build new
health care promotes their right to participate in service delivery mechanisms that ensure
decision-making, ensures that more adolescents health equity, non-discrimination and active
will seek and remain engaged in care, and is also participation of adolescents.
a way to promote health equity (41). Adolescent’s
participation in policy decisions not only To attain equity and non-discrimination; the
acknowledges their capacity for self-deter- health facility should provide quality services to all
mination but it is also pragmatic. It allows adolescents, irrespective of their ability to pay, age,

sex, marital status, education level, ethnic origin, treatment of anemia among adolescents;
sexual orientation or other characteristics. manage acute malnutrition and other forms of
Adolescents should be involved in the planning, malnutrition; ensure nutritional support during
monitoring and evaluation of health services and in the antenatal period; and encourage regular
decisions regarding their own care, as well as in physical activity in forms that are accessible and
certain appropriate aspects of service provision. acceptable to adolescents.
Policy Considerations Policy development so far has mainly focused

on SRH as an entry point, which holds cultural
sensitivities in the Pakistani context. While
Improving adolescent nutrition requires advocating for SRH rights of women and girls is
multi-sectoral policies and laws that both important, such cultural sensitivities could
understand and consider adolescent needs in possibly be overcome by taking a nutrition and
the societal context in relation to their physical, socio-economic empowerment lens to girls and
psychological and psychosocial development. young women programming.
This begins with developing policies that meet
the needs of adolescents, so that they can be
well-nourished and protected from disease, Monitoring and Evaluation
injury, infection and early pregnancy. An
effective response must engage the sectors of Monitoring and evaluation should be built into
food and agriculture, health, WASH, education, the implementation process, in order to
social protection and others. provide important lessons for uptake and
further implementation. Pakistan should
A three-step national-level prioritization conduct periodic evaluations to assess the
process involves: (1) needs assessment, (2) degree to which their adolescent health
landscape analysis and (3) priority setting. The programme is meeting its goals and targets, on
needs assessment evaluates the health situation both coverage and quality (45).
and problems among adolescents; the landscape
analysis reviews existing adolescent health Ideally, monitoring and evaluation of
programmes, polices and related legislation; and programmes designed to improve the health of
the prioritization exercise identifies the highest adolescents should always include the opinions
priority conditions requiring attention as well as the of adolescents themselves and adolescent
most feasible, evidence-based interventions (44). engagement is required from the planning
stage of new programmes. Such engagement
At the societal level, policies can include clear may include active and meaningful
standards to support healthier foods, regulate participation by adolescents in formulating the
the marketing of unhealthy foods and beverages, recommendations emerging from the periodic
and fortification of foods that adolescents are programme evaluations. This means extra
likely to consume, ensure availability of and consultation is often required with adolescents,
access to safe water, and plan public spaces that their families and their communities prior to
reduce the barriers to physical activity. data collection. When evaluating data on
sensitive topics, legal and ethical provision of
To empower adolescents to adopt and maintain protection and access to services should be
optimal nutrition and health practices, community considered. All monitoring and evaluation
stakeholders (including teachers and health should take account of adolescents’ evolving
workers) need to support those practices. capacity and provide appropriate protection.
At the micro or individual and interpersonal

level, policies can promote healthy dietary
habits, ensure assessment, diagnosis and

Delivery Platforms for Implementing
Adolescent Nutrition Interventions
Below are the delivery platforms recommended by the TAC for all interventions in order to ensure
coverage of both at school and out of school adolescents.
Promoting Health and Nutrition Awareness in Adolescents

(In-School/College Adolescents)
Promoting nutrition education and counseling to adolescents can focus and prepare/update life skills
related resources (procedural manual) provide health and nutrition related education, pre-marital
counseling, and training to adolescent. Major activities will be to develop instruction /IEC materials with
a focus on improving maternal, infant and young child nutrition and reducing chronic malnutrition in
community.
Raise adolescent girls’ and boys’ knowledge and skills on reduction of chronic malnutrition: This
will support, formation/strengthening of adolescent’s knowledge within both school and community
settings, by organizing counseling and awareness sessions about diet diversification, balanced diet,
and personal hygiene with the aim to reduce undernutritionin the adolescent age.
Prepare/update resource materials on parenting education for improved child-care and

feeding practices: This will support preparation of resource materials such as preparation of
IEC/educational materials on nutrition during pregnancy and on infant and young child feeding and
care (Resource book, Record book and Orientation Package); preparation of the training manual,
resource materials, self-learning and IEC materials on nutrition for parents, community members.
The following topics can be covered for different awareness raising initiatives targeting the
adolescent population:
Diet Diversification - Balanced Diet and Intake of Fortified Foods
Personal Hygiene - Hand Washing & Menstrual Hygiene
WASH – Safe Water, Sanitation Hygiene
Knowledge and Skills on Reduction of Chronic Malnutrition
Parenting Education for Improved Child-care and Feeding practices
Below are the key recommendations to utilize educational forums/premises for the promotion of
adolescent nutrition:
The adolescent nutrition efforts in terms of school health and nutrition shall be initiated by the
government at scale where nutrition promotion, deworming, menstrual hygiene management
and supplementation shall be ensured
Other cross sectoral efforts shall be ensured to increase school enrollment of both and girls of the
adolescent age group. School drop outs and absence due to lack of hygiene facilities shall be
prevented
School nutrition programs to regulate school/college meals while restricting unhealthy snacks,
soft and energy drink through the Food Safety Authorities. Counseling shall be done for school
college children to ensure taking breakfast at home and where possible to take lunch box with a
healthy school snack from home
Curriculum needs to be developed with basic nutrition messages culturally suitable for both boys

and girls. At minimum, a weekly 2 hours nutrition sermon class be arranged to acquaint these
children with the basic concepts of nutrition, healthy diet and the nutritional requirements of
growing age particularly 10-19 years
Adolescent girls’ specific nutrition key messages can be provided through the same weekly
nutrition session at girls’ schools, where messages on menstrual hygiene, supplementation,
mother and child health and adequate maternal and child nutrition can be provided.
Nutrition fairs shall be conducted periodically (quarterly) at schools and nutrition topic shall be
kept as a theme for parent teacher meetings
These sessions can also be used for deworming, supplementation of weekly iron folate and also
for screening through anthropometry. Vitamin A, D and Calcium supplements were also recommended.
For deworming locally produced Mebendazole and iron syrups are also recommended
Promote girls’ education with retention through incentivize interventions
Raise awareness among adolescents of available services
Provide capacity building to community workers (LHWs & CHWs) to facilitate counseling of
adolescents on various issues
Conduct awareness seminars in schools/colleges to provide education and discussions on
adolescent health issues
Advocacy with government and (Non-Governmental Organizations) NGOs to provide more
adolescents and youth friendly services/corners within educational institutions, with standard
package of health services, possibly with special operating hours, with assured privacy, friendly
and competent counseling services
Implement more effective RH classes/discussions and activities in schools and communities
NGOs to expand peer to peer education and counseling on Reproductive health, FP, MHM,
Nutrition issues
Education department has been identified by all members as a strong delivery point for Adolescent
Nutrition Interventions. This requires written Memorandum of Understanding (MoUs) between health
and education departments whereby the Department of Health (DoH) can train master trainer teachers
for onwards dissemination of health and nutrition messages at school. A joint monitoring mechanism
shall also be set between education and health departments to support and monitor the progress the
activities. There are other community routes of interventions also which can cater the nutrition needs
of the out of school children.
Promoting SBCC for Optimal Adolescent Nutrition

(Out Of School/College Adolescents)
A broader Social and Behavior Change Communication (SBCC)Strategy for both boys and girls,
out-of-school shall be developed with easy messages, the delivery points and responsible persons
clarified. The SBCC activities shall also acquaint LHWs, community leaders and the adolescent
population on functions, benefits and side effects of the supplements hence promoting safe
utilization and compliance of these essential micronutrients.
The advantage of community-based interventions is the proximity to reach the most vulnerable
girls, who have dropped out of school, however their coverage is limited. Their success will
require significant capacity of well-chosen CBOs and a significant investment in advocacy and
demand creation as adolescents need to be willing, and parents need to allow their children, to
participate in these activities.

Other venues were recommended by the advisory members for Adolescent Nutrition
Interventions and Supplementation for this group. A considerable number of the out of
school adolescent age group boys and girls can be covered by nutrition interventions through
the different public and development sector skills development programs, the social welfare
department programs, the rural support networks, community based organizations, social
protection schemes, national and international NGOs, and vocational training schools. The target
areas of intervention and/or nutrition promotion for these children are street theatres, farmer field
schools, vocational schools and sports venues (through nutrition posters in school grounds).
The ideal delivery channel for outreach to this group of children is the LHW cadre. There is a need
to focus on improved counseling skills and quality time provided by the relevant stakeholders
(LHWs, public and private medical practitioners, teachers, youth leaders) on adolescent nutrition
as this is an age group more influenced by the environment and the critical age which determines
the dietary habits. The counseling skills shall be monitored by the relevant authorities and the
SBCC shall be evaluated in surveys.
Social marketing/Social franchises: A noteworthy approach for programmes targeting adolescents,

highlighted in the recent GAIN report, is social marketing and social franchises to sell products and
services to adolescent girls or to households with girls and young women.
Social media and mass media: The utilization of social and mass media could act as mechanism
of awareness-raising for adolescent girls not easily reached through other channels. In addition,
this channel holds great opportunity to influence attitudes and behaviours of this target audience
as well as their families. This presents an innovative opportunity as a platform for social and
behaviour change communication worth further exploration.

ANNEXES
Table. A: Potential contribution of adolescent nutrition to WHA targets for 2025(1)
WHA Target Contribution of adolescent nutrition to target
40% reduction in the global Adolescent pregnancies, particularly where girls are themselves stunted, are
number of children under five more likely to result in low birth-weight, preterm birth and small for
who are stunted gestational age (SGA) babies, which are in turn more likely to be stunted
during childhood
50% reduction in anemia in Adolescence has the joint highest prevalence of anemia of any age group
WRA Young maternal age increases the risk of maternal anemia during pregnancy
Adolescents are less likely than older women to be covered by existing nutrition
supplementation services
30% reduction in babies born Adolescent pregnancies, particularly where girls are themselves stunted, have
with low birth-weight heightened risk of resulting in babies with low birth-weight
No increase in childhood Obesity levels in adolescents are increasing

overweight
Increase the rate of exclusive Adolescents are less likely than older mothers to breastfeed and to receive
breastfeeding in the first six support for breastfeeding
months up to at least 50%
Reduce and maintain child- Adolescent pregnancies, particularly where girls are themselves underweight
hood wasting to less than 5% and/or stunted, are more likely to result in SGA, low birth-weight or preterm
babies who, some evidence suggest, may then be at increased of wasting
during childhood
Box 1: ‘Promising’ interventions for adolescent nutrition (Bhutta et al , 2013)
Maternal nutrition interventions targeted to pregnant adolescents – including multiple micronutrient (MMN)
supplementation, calcium supplementation, balanced energy protein supplementation, malaria prevention, mater-
nal deworming, obesity prevention
Preconception care via reproductive health and family planning interventions for adolescents aimed at reducing unwant-
ed pregnancies and optimizing age at first pregnancy and birth intervals
Antenatal care – ensuring access, given that adolescents are particularly at risk of complications
Nutrition promotion – via schools
Combined behavioral and lifestyle interventions – for overweight and obese adolescents

Table. B: VAS scheme in pregnant women for the prevention of night blindness in areas
with a severe public health problem related to vitamin A
Target group Pregnant women
Dose Up to 10, 000 IU vitamin A (daily dose) OR

Up to 25, 000 IU vitamin A (weekly dose)
Frequency Daily or weekly
Route of administration Oral liquid, oil-based preparation of retinyl palmitate or retinyl acetate
Settings Populations where the prevalence of night blindness is 5 percent or higher in

pregnant women 1 or 5 percent or higher in children 24–59 months of age
IU: international units; RE: Retinol Equivalent
Table. C: Summary of evidence for VAS and recommendation for Pakistan
Age/Condition WHO recommendation Conclusion for Pakistan
Newborn (first 28 Not recommended Not recommended

days after birth)
Infants 1–5 Not recommended Not recommended

months of age
Infants and High dose VAS recommended as VAD is a public health With 56% children 0-59
children 6–59 problem i.e. months of age having VAD,
months of age -Prevalence of night blindness is 1% or higher in children VAS is recommended
24–59 months of age or
- Prevalence of VAD (serum retinol 0.70 μmol/l or lower) is ≥
20% in infants and children 6–59 months of age)
Pregnant women Then VAS is recommended in infants and children 6–59 With 49% pregnant women
months of age. having VAD, VAS is recom-
VAS only recommended to prevent night blindness, if VAD is mended
a severe public health problem in the area i.e.
- If ≥ 5% of women in a population have a history of night
blindness in their most recent pregnancy in the previous 3 –
5 years that ended in a live birth, or
- If ≥ 20% of pregnant women have a serum retinol level <
0.70 μmol/L
Postpartum Not recommended Not recommended

Table. D: Weekly iron folate supplementation
Suggested* scheme for intermittent iron and folic acid supplementation in menstruating adolescent girls
and non-pregnant WRA
Supplement composition Iron: 60 mg of elemental iron** - Folic acid: 2800 μg (2.8 mg)
Frequency One supplement per week
Duration and time 3 months of supplementation followed by 3 months of no

interval between periods supplementation after which the provision of supplements
of supplementation should restart
Target group All menstruating adolescent girls and non-pregnant adult WRA
Settings Populations where the prevalence of anemia among non-pregnant

WRA is 20% or higher
*WHO RECOMMENDATIONS: In populations where the prevalence of anemia among non-pregnant WRA is 20% or higher, intermittent
iron and folic acid supplementation is recommended as a public health intervention in menstruating women, to improve their
hemoglobin concentrations and iron status and reduce the risk of anemia.
** 60 mg of elemental iron equals 300 mg of ferrous sulfate heptahydrate, 180 mg of ferrous fumigate or 500 mg of ferrous gluconate.
Table. E: Food and portion sizes for adolescents (age 10-19 years) (48)
Food Group Servings/day Portion size and description
Milk and milk 3-4 1 serving=1cup of milk or 1 cup of yogurt or 1 slice of cheese, 1 cup of kheer
products or feerni or other milk-based products equivalent to nutrients supplied by 1
cup of milk. 1 cup of whole milk will provide 15 g carbohydrates, 6 g protein,
8 g fat and 150 calories.
Cereals 5-6 1 serving= 2 slice of bread (toast) or 1 chapati or 1 cup of cooked rice or 1
cup of cereals equivalent to nutrients supplied by 2 slice of bread). One
serving of cereal bread =(2 toast x 28 g=56 g) shall provide 30 g carbohy-
drates, 6 g protein, 0-2 g fat and 160 Kcal.
Vegetables 2-3 1 serving= ½ cup of cooked non-starchy vegetables or ½ cup of vegetables

juice/soup or 1 cup of fresh vegetables/salad). One serving of vegetables will
provide 5 g carbohydrates, 2 g protein and 25 calories. One serving of
starchy vegetables: 1 potato (100 g) or maize (1/2 cup) or peas green ½ cup)
will provide 15 g carbohydrates, 3 g protein, 0-1 g fat and 80 calories.
Fruit 2-3 1 serving=1 medium size banana or 1 apple or 1 peach or 2-3 plums or 3-4
apricots. Each serving will provide 15 g carbohydrates and 80 calories.
Meat and 2-3 1 serving of meat (28 g lean meat=2-3 small pieces of meat or 1-2 pieces of
pulses fish or 1 egg, or ½ cup of cooked pulses). One serving of lean meat will
provide 7 g protein, 0-3 g fat and 45 calories. One serving of meat with
medium fat will provide 7 g protein, 4-7 g fat and 75 calories. One serving of
meat with high fat will provide 7 g protein, 8 or more g fat and 100 calories.

Table. F: Sample menu for adolescents (age 10-19 years) (48)
Time Food Portion Size Calories (Kcal) Protein (g)

Breakfast Milk† 1 cup 150 6
Egg fried‡ 1 medium 90 6
Roti/toast/cereals* ½-1 chapatti 80-160 3-6
Snack Apple or any other seasonal fruit¶ 1 medium 80 ----------
Potato cutlet § 1-2 49-98 1-2
Lunch Lentil‡ ½ plate 70 4
Roti 1-2 chapatti 160-320 6-12
Yogurt† ½ cup 75 3
Salad§ ½-1 bowl 13-25 -----
Snack Banana or any other seasonal fruit¶ 1 medium 80 ----
Peanuts 1 serving 160 7
Dinner Aloo ghost‡ 1 plate 174 6-8
Roti 1-2 chapatti 160-320 6-12
Salad§ ½-1 bowl 13-25 -----
Raita† ½-1 cup 75-150 3-6
Guava or any other seasonal fruit¶ 1 medium 80 ----------
Snack Carrot halwa† 1 cup 250 6
Total 1758-2307 Kcal 57-78 g
† 1 cup milk or 1 cup kheer or 1 cup yogurt or 1 cup ice cream or 1 slice cheese or any other
milk-based product providing a similar amount of calories and proteins; ‡ Egg fried or meat,
chicken, fish or lentil or chickpea or red beans or shami kabab or any other meat based curry
providing a similar amount of calories and proteins;*1-2 toast or ½-1 chapatti or ½-1 cup cere-
als or ¼-1/2 paratha or any other cereal providing a similar amount of calories and proteins; ¶
Banana or any other seasonal fruit providing a similar amount of calories; §Potato cutlet
or vegetable-based product providing a similar amount of calories and proteins; †carrot
halwa or any other milk-based dessert providing a similar amount of calories and protein;
** Peanuts or any other nuts providing a similar amount of calories and proteins
1 Cup =250 ml; 1 plate pulao or dal or vegetables (100 g cooked food); 1 bowl fresh salad= (100 g);
1 serving peanuts=1 ounce peanuts

Table. G: Micronutrient rich foods for a healthy diet
Food Sources And Considerations For Absorption Micronutrients

Haem iron: meat, poultry and fish. Iron
Non-Haem iron: cereals, pulses, legumes, fruits and vegetables.
Haem iron is absorbed more efficiently than non-haem iron. Consuming foods containing
non-haem iron with food that contains vitamin C can improve the absorption and
non-haem iron in a meal.
Calcium inhibits iron absorption and they should not be consumed together.
Leafy green vegetables (bok choy, Chinese cabbage, broccoli, kale, mustard greens), fish Calcium
eaten whole, soy products and soy milk), dairy.
Oxalic acid limits the bioavailability of calcium contained in spinach, beetroot and sweet
potatoes.
Diets high in animal protein and/or phytates (phytates are found in most plant foods,
particularly whole grains and legumes, unleavened bread)limit calcium absorption.
Diets high in processed foods containing sodium, provide useable calcium because Potassium
sodium causes calcium loss in urine.
Leafy green vegetables, root vegetables, beans and peas, fruits from vine-based plants Zinc
(for example, tomatoes, cucumbers, cougrettes, aubergines and pumpkin), and tree fruits.
Nuts, legumes, whole grains, watermelon, blackberries, seeds, shellfish, poultry, eggs, red
meat and dairy products.
Consumption of phytates (see note for calcium above), which are present in diets with
little or no meat consumption, limits zinc absorption.
Iron and calcium supplements decrease zinc absorption.
Deeply colored fruits and vegetables, oily fruits, and red palm oil. Vitamin A
Intestinal infection and diarrhea limit vitamin A absorption, as does consumption of alcohol
Citrus fruits, bell peppers, green beans, strawberries, papaya, guava, kiwi fruit, potatoes, Vitamin C
broccoli, and tomatoes.
Oily fish, liver, egg yolks, yeast and mushrooms. Vitamin D
The most potent source of vitamin D is the sun.
Box 2: SUMMARY OF FINDINGS (3) on PROGRAMMES addressing nutrition for adolescent girls in Pakistan
Box 2: SUMMARY OF FINDINGS on PROGRAMMES addressing nutrition for adolescent girls in Pakistan
• There are several ongoing nutrition-sensitive programmes, mainly in areas of education and SRH, however there is
limited inclusion of nutrition-specific interventions within these programmes.
• Both nutrition-specific and nutrition sensitive interventions directly targeting adolescent girls have very low
geographical coverage.
• Integrated approaches: the public health system and school based delivery platforms have been utilized at a minimal
scale to target primary school children to improve their nutritional status and school enrolment.
• In addition to the health system, other channels need to be considered in order to effectively reach this target group.
• An integrated approach is needed to effectively address the health, nutrition and social wellbeing of adolescent girls.
• In order to ensure deeper routed social change and influence current social norms around adolescent girls,
interventions should also target male peers, adolescent boys, as well as parents and the community at large.

Table. H: Global standards to improve the quality of adolescent friendly health-care services
Standard Definition
Adolescents’ The health facility implements systems to ensure that adolescents are knowledgeable
Health Literacy about their own health, and they know where and when to obtain health services.
Community The health facility implements systems to ensure that parents, guardians and other
Support community members and community organizations recognize the value of providing
health services to adolescents and support such provision and the utilization of services
of adolescents.
Appropriate The health facility provide a package of information, counseling, diagnostic, treatment
Package of and care services that fulfils the needs of all adolescents. Services are provided in the
Services facility and through referral linkages and outreach. Service provision in the facility
should be linked, a relevant, with service provision in referral-level health facilities,
schools and other community settings.
Providers’ Health-care providers demonstrate the technical competence required to provide
Competencies effective health services to adolescents. Both health-care providers and support staff
respect, protect and fulfill adolescents’ rights to information, privacy, confidentiality,
non-discrimination, non-judgmental attitudes and respect.
Facility The health facility has convenient operating hours, a welcoming and clean environment
Characteristics and maintains privacy and confidentiality. It has the equipment, medicines, supplies and
technology needed to ensure effective service provision adolescents.
Equity and Non- The health facility provides quality services to all adolescents irrespective of their ability
Discrimination to pay, age, sex, marital status, education, level, ethnic origin, sexual orientation or other
characteristics.
Data And The health facility collects, analyses and uses data on service utilization and quality of
Quality care, disaggregated by age and sex, to support quality improvement. Health facility staff
Improvement is supported to participate in continued quality improvement.
Adolescents’ Adolescents are involved in the planning, monitoring and evaluation of health services
Participation and in decisions regarding their own care, as well as in certain appropriate aspects of
service provision.

Table I: Set of interventions recommended for adolescent girls (advocacy recommendations)
Nutrition and health counseling/SBCC is the most common direct intervention in national
plans targeted at adolescent girls, followed by iron folic acid (IFA) supplementation, or
ensuring access to IFA supplementation. Provision of nutrient-rich food for adolescent girls
was noted in the plans of several countries and included via school feeding or school gardens
in selected areas. Indirect interventions for adolescents linked to a nutrition objective are
limited (see Table 7). The most common references are to the provision of adolescent-friendly
reproductive health services for boys and girls (including via schools), promotion of girls’
education, and promotion of economic empowerment and income generation for various
groups of adolescents.
Table J: Interventions recommended for adolescent girls
Intervention
Direct
IFA Supplementation
Nutrition and Health Counseling
Provision of Nutrient Rich Foods
Deworming
Access to Iodized Salt
Adolescent Friendly Reproductive Health Services

Indirect
Promotion of Hygiene Practices to Households with Adolescents

Promotion of Girls Education
Nutrition Education in Schools
Promotion of Economic Empowerment and Income Generation
Cash Transfer for Households with at Risk of Malnourished Adolescents

REFERENCES
1. Save the Children.Adolescent Nutrition Policy and Programming in SUN Countries. 2015.
2. Evidence-based interventions for improvement of maternal and child nutrition:

What can be done at what cost? Bhutta ZA, Das JK, Rizvi A, Gaffey MF, Walker N, Horton S, Webb
P, Lartey A, Black RE. s.l. : The Lancet, 2013, Vol. 380. 452-477.
3. (GAIN), Global Alliance for Improved Nutrition.Embodying the Future:

How to improve the nutrition status of adolescent girls in Pakistan? June 2017.
4. Nutritional dwarfing: growth, dieting, and fear of obesity.

Lifshitz F, Moses N. Vol. J Am Coll Nutr. 1988;7(5):367-376.
5. Adolescent growth and development.BA., Spear. s.l. : J Acad Nutr Diet, 2002. 102: S23–S29.
6. Adolescent nutrition.Kleinman RE, Greer FR, editors. In. Illinois :

Pediatric nutrition, American Academy of Pediatrics, 2013. 175-88.
7. Adolescent health in 21st Century. Blum RW, Bastos, FI, Kabiru, CW and Le, LC. 9826, s.l. :
The Lancet, 2012, Vol. 379. 1567-8.
8. UNICEF. Pakistan Statistics 2013.

www.unicef.org/. [Online] UNICEF, December 27, 2013. [Cited: May 15, 2018.]
www.unicef.org/infobycountry/Pakistan_pakistan_statistics.html.
9. Nutrition and Health of the Adolescent Girls in Pakistan.

Van Liere M, ZA Bhutta, Hartvig-Bloomber J., Mahmood S. s.l. : GAIN, 2017.
10. Notes from Advisory Group Meeting.
11. WHO. World Health Assembly Nutrition Targets. www.who.int.

[Online] WHO, 2015. www.who.int/nutrition/topics/nutrition_globaltargets2025/en/
12. The UN Conference on Sustainable Development Goals (SDGs). Rio : United Nations, 2015.
13. Youth in Pakistan: Priorities, realities and policy responses. Sathar, Zeba.www.popcouncile.org.
[Online] 2016. https://www.popcouncil.org/uploads/pdfs/2016pgy_youthinpakistan.pdf.
14. Nutrition in Adolescence: Issues in adolescent Health and Development. Geneva : s.n., 2015.
15. GoP.Pakistan, National Nutrition Survey. 2018.
16. Draft: Anemia Prevalence, Main Causes and programmes in Pakistan situation Analysis.
Cavalli-Sforza, LT. 2018.

17. GoP.Pakistan Demographic and Health survey . 2013.
18. Calcium Supplementation During Pregnancy. Bhutta et al., Hofmeyr et al. 2014.
19. UNESCO.Education for All 2015. 2008.
20. Organization, World Health.Global accelerated action for the health of adolescents
(AA-HA!): guidance to support country. Geneva : s.n., 2017. (http://apps.who.int/iris/bitstre.
21. Global guidelines on implementing effective actions for improving adolescent nutrition.
s.l. : WHO, 2018.
22. Guideline: Vitamin A Supplementation in Pregnant Women. Geneva : WHO, 2011.
23. Commented by Advisory Committee.
24. PC-1 Chief Minister's Stunting Reduction Program for 11 Southern Districts of Punjab
(ADP Scheme No. 1970) - July 2017 - June 2020. s.l. : Government of Sindh, Pakistan.
25. Vitamin and Mineral Requirements in Human Nutrition. Geneva :

Food and Agriculture Organization and World Health Organization, 2005.
26. Global Health Estimates - DALYs by cause, age, sex by country and by region, 2000-2015.
www.who.int. [Online] 2015. [Cited: January 30, 2018.]
www.who.int/healthinfo/global_burden_disease/estimates/en/index2.html.
27. Child Health Epidemiology Reference Group - Moderate to Severe but not Mild,
Material Anemia is associated with increased risk of small-for-gestational-age outcomes.
Kozuki N, Lee AC, Katz J,. 358, 2012 : Nutrition Journal, Vol. 142. 62.
28. WHO. Using immunization contacts as the gateway to eliminating vitamin a deficiency:
a policy document. . 1994, http://apps.who.int/iris/bitstream/10665/59439/1/who_epi_gen_94.9.pdf.
29. Opinion: Adolescent Pregnancy, its impact on the growth and nutrition status of young
mothers: what does the evidence say? JH., Rah. s.l. : Sight Life, 2013. 27(3):37-8.
30. Maternal and Child Nutrition Study Group - Maternal and Child Undernutrition and Over-
weight in low income and middle income countries. Black RE, Victoro CG, Walker SP, Bhutta ZA,
Christian P, De Onis M, Ezzati M, Grantham-Mc-Gregor S, Katz J, Martorell R, Uauy R,. s.l. : The Lancet,
2013. 380: 427-451.
31. Diet, Nutrition and the Prevention of Chronic Diseases. Geneva :

Report of a Joint WHO/FAO Expert Consultation, 2003.
32. Relationships between Vitamin and Mineral Supplement Use, Dietary Intake and Dietary

Adequacy among Adolescent. Stang J, Story MT, Harnack L, Neumark-Sztainer D. s.l.:
J Am Diet Associates, 2000. 100(8):905-10.
33. Growth Reference Data for 5-19 years.

[Online] World Health Organization. www.who.int/growthref/en/.
34. Intervention on Diet and Physical Activity: What works. www.who.int.

[Online] [Cited: January 30, 2018.]
www.who.int/iris/bitstream/10665/44140/1/9789241598248_eng.pdf?ua=1.
35. Preventing disease through healthy environments -

A global assessment of the burden of disease from environmental risks.
Pruss-Ustun A, Neira M. Geneva : World Health Organization, 2016.
36. Swimming Upstream: Why sanitation, hygiene and water are so important to mothers and
their daughters? Brocklehurst C, Bartram J. s.l. : World Health Organization, 2010. 88 (7):482.
37. The physical school environment: an essential component of a health-promoting school.

www.who.int/.
[Online] 2004. [Cited: January 04, 2018.]
http://www.who.int/school_youth_health/media/en/physical_sch_environment.pdf?ua=1.
38. Local Action: Creating health promoting schools. www.who.int.

apps.who.int.iris/bitstream/10665/66576/1/WHO_NMH_HPS_003.pdf.
39. Promoting Physical Activity in schools: an important element of a health-promoting schools.

www.who.int. [Online] 2007. [Cited: January 30, 2018.]
apps.who.int/iris/bitstream/10665/43733/1/9789241595995_eng.pdf.
40. Global standards for quality health-care services for adolescents. www.who.int.
apps.who.int/iris/bitstream/10665/183935/9789241549332_vol2_eng.pdf?ua=1.
41. Global Accelerated Action for the health of adolescents (AA-HA!): Guidance to support coun-
try implementation. www.who.int. [Online] 2017. [Cited: October 19, 2017.]
apps.who.int/iris/bitstream/10665/255415/1/9789241512343-eng.pdf?ua=1.
42. Adolescent Nutrition: A Review of the Situation in Selected South-East Asian Countries. s.l. :
World Health Organization, 2006.
43. Making health services adolescent friendly. www.who.int.

apps.who.int/iris/bitstream/10665/75217/1/9789241503594_eng.pdf?ua=1.

44. Technical guidance for priortizing adolescent health. www.who.int.
www.unfpa.org/sites/default/files/pub-pdf/UNFPA_EWEC_Report_EN_WEB.pdf.
45. Monitoring, evaluation and review of national health strategies. A country-led platform for
information and accountability. www.who.int.
www.who.int/healthinfo/country_monitoring_evaluation/1085_IER_131011_web.pdf.
46. Draft Pakistan food based dietary guidelines. s.l. :

Ministry of Planning, Development and Reforms in collaboration with Food and Agriculture
Organization of the United Nations.
47. GAIN and The Aga Khan University.Landscape Analysis with the aim to provide a first
level compilation of available data on nutrition and social wellbeing of adolescent
girls in Pakistan. 2017.
48. Pakistan National Nutrition Survey. s.l. : The Aga Khan University, 2011.
49. Using Immunization contacts as the gateway to eliminating vitamin A deficiency.

Policy Document.
[Online] 1994. http://apps.who.int/iris/bitstream/10665/59439/1who_epi_gem_94.9.pdf.
50. WHO recommendations on Health Promotion Interventions for Maternal and Newborn
Health. 2015.
51. Preventive Chemotherapy to control soil-transmitted helminth infections in at risk

population groups. 2017. 121.

FOR MORE INFORMATION, PLEASE CONTACT:
National Coordinator Nutrition & NFA
Nutrition Wing
NIH, Chak Shahzad, Islamabad.
Email: nfapakistan@gmail.com
Nutrition Wing
Government of Pakistan

Adolescents Guidelines

Uploaded by

Copyright:

Available Formats

Adolescents Guidelines

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Adolescents Guidelines

Uploaded by

Copyright:

Available Formats

ADOLESCENT

ADOLESCENT NUTRITION AND SUPPLEMENTATION GUIDELINES FOR PAKISTAN

ADOLESCENT NUTRITION AND SUPPLEMENTATION GUIDELINES FOR PAKISTAN

Photo-Credits: UNICEF/Pakistan, WHO and Concept Promos

ADOLESCENT NUTRITION AND SUPPLEMENTATION GUIDELINES FOR PAKISTAN

ADOLESCENT NUTRITION AND SUPPLEMENTATION GUIDELINES FOR PAKISTAN

ADOLESCENT NUTRITION AND SUPPLEMENTATION GUIDELINES FOR PAKISTAN

(1) Adolescent Fact Sheet, WHO_RHR

ADOLESCENT NUTRITION AND SUPPLEMENTATION GUIDELINES FOR PAKISTAN 1

Enroll the adolescents at risk of malnutrition, in programmes where nutritional assessment,

Providing additional micronutrients through supplementation/food

2 ADOLESCENT NUTRITION AND SUPPLEMENTATION GUIDELINES FOR PAKISTAN

Promoting Preconception and Antenatal Nutrition in adolescents

Preventing adolescent pregnancy and poor reproductive outcomes

Promoting healthy diets in adolescents

Providing access to safe environment and hygiene for adolescents

Ensure biannual preventive chemotherapy (deworming), or the periodic large-scale

ADOLESCENT NUTRITION AND SUPPLEMENTATION GUIDELINES FOR PAKISTAN 3

Delivery platforms for implementing adolescent nutrition interventions

4 ADOLESCENT NUTRITION AND SUPPLEMENTATION GUIDELINES FOR PAKISTAN

ADOLESCENT NUTRITION AND SUPPLEMENTATION GUIDELINES FOR PAKISTAN 5

Objectives of the guideline

6 ADOLESCENT NUTRITION AND SUPPLEMENTATION GUIDELINES FOR PAKISTAN

ADOLESCENT NUTRITION AND SUPPLEMENTATION GUIDELINES FOR PAKISTAN 7

8 ADOLESCENT NUTRITION AND SUPPLEMENTATION GUIDELINES FOR PAKISTAN

ADOLESCENT NUTRITION AND SUPPLEMENTATION GUIDELINES FOR PAKISTAN 9

10 ADOLESCENT NUTRITION AND SUPPLEMENTATION GUIDELINES FOR PAKISTAN

ADOLESCENT NUTRITION AND SUPPLEMENTATION GUIDELINES FOR PAKISTAN 11

12 ADOLESCENT NUTRITION AND SUPPLEMENTATION GUIDELINES FOR PAKISTAN

The WHO 2018 Framework of Interventions and

ADOLESCENT NUTRITION AND SUPPLEMENTATION GUIDELINES FOR PAKISTAN 13

Outcomes in adolescence and adulthood

Improved adolescents health and nutrition

Adolescents are protected from disease,

Preventing Adolescent pregnancy

14 ADOLESCENT NUTRITION AND SUPPLEMENTATION GUIDELINES FOR PAKISTAN

ADOLESCENT NUTRITION AND SUPPLEMENTATION GUIDELINES FOR PAKISTAN 15

Suggested Interventions As Per The Adolescent Age Groups

-Biochemical tests for anemia and

Preventive chemotherapy Preventive chemotherapy Preventive chemotherapy Preventive chemotherapy

Provision of Multi Micronutrient tablets

Under-nutrition among adolescents takes the available nutrient-rich or fortified supple-

19 ADOLESCENT NUTRITION AND SUPPLEMENTATION GUIDELINES FOR PAKISTAN

Classification of children and adolescents 5-19

Level & responsibilities

Providing Additional Micronutrients through Supplementation/

ADOLESCENT NUTRITION AND SUPPLEMENTATION GUIDELINES FOR PAKISTAN 20

Ecological Levels Actions and Implementation Recommendations For Pakistan

Routine use of multiple micronutrient powders during pregnancy is not recommended as an

Provision of Multi-Micronutrient tablets to underweight adolescent girl

LHW/CHW/Community Midwives (CMW) MOs/WMOs, LHVs SH&NSs

Recommendations from the TAC on Micronutrient Supplementation

Promoting Preconception and Antenatal Nutrition in Adolescents (Child Bearing)

22 ADOLESCENT NUTRITION AND SUPPLEMENTATION GUIDELINES FOR PAKISTAN

Preventing adolescent pregnancy and poor reproductive outcomes

Ecological Levels Implementation Considerations WHO Recommendations

Reducing coerced sex among adolescents

ADOLESCENT NUTRITION AND SUPPLEMENTATION GUIDELINES FOR PAKISTAN 25

Providing access to safe environment and hygiene for adolescents