Eating behavior of adolescent girls in countries with a high prevalence of stunting under five: a systematic review

Background Adolescence is critical for physical and psychological growth, making healthy dietary behavior essential. Several countries face nutritional challenges due to a high prevalence of stunting in children under five, which can impact adolescent girls’ eating behavior. This systematic review aims to provide evidence on the eating behavior of adolescent girls in such countries, offering insights for stunting prevention programs. Methods We conducted a systematic review following PRISMA guidelines and registered it in PROSPERO. We employed a comprehensive search strategy across multiple databases. Study selection involved three stages: deduplication, title/abstract screening, and full-text review, with inter-reviewer agreement assessment. Results The search identified 15 eligible studies from various countries, primarily utilizing cross-sectional designs. The studies focused on age ranges within adolescence and varied in sample size and assessment tools. The primary objective of these studies was to assess eating behavior, with outcomes related to dietary patterns, eating disorders, body image, and nutritional knowledge. The results revealed diverse eating behaviors among adolescent girls, including restrained eating, dieting for weight loss, craving-induced eating, and unhealthy dietary patterns. Many girls exhibited low dietary diversity, contributing to micronutrient deficiencies. Suggestions To address these issues effectively, stunting prevention programs and policies should prioritize the following strategies: implementing comprehensive nutritional education programs to enhance adolescents’ knowledge of healthy eating habits and dietary diversity, providing resources and support for positive body image development to reduce the pressure for unhealthy dieting, improving access to affordable, nutrient-rich foods in both urban and rural areas, raising awareness about eating disorders and emphasizing early identification and intervention, engaging parents, caregivers, and communities in promoting healthy eating behaviors, and maintaining rigorous research and monitoring to adapt strategies based on evolving trends in adolescent eating behaviors. Conclusion Adolescent girls in countries with high stunting prevalence exhibit diverse eating behaviors that can impact their nutritional status and overall health. Addressing these behaviors is essential to prevent stunting and its long-term consequences, emphasizing the importance of comprehensive strategies and support for this vulnerable population. Systematic review registration https://www.crd.york.ac.uk/prospero/#recordDetails, identifier CRD42023389909.


Introduction
The high stunting rate in children under five persists worldwide.Globally, 149.2 million children under five suffered from stunting in 2020 (World Health Organization, 2021).This number can increase given the limited nutritional intake during the COVID-19 pandemic, the impact of which is stunting, which may only manifest itself in the next few years (Aditri et al., 2022).The World Health Organization has set a maximum tolerance limit for stunting for toddlers at 20% (World Health Organization, 2021).Talking about malnutrition is often associated with children who do not get enough food.However, the reality in Indonesia and several other countries is more complex.Teenagers face a nutritional crisis (Mahriani et al., 2022).Adolescence is a nutritionally vulnerable period when rapid physical growth increases nutritional needs.Dietary behaviors formed in adolescence can contribute to nutrition-related problems that have long-term health consequences (Lassi et al., 2017;Mahriani et al., 2022).
The UN defines adolescents as those aged between 10 and 19, comprising 1.2 billion people worldwide or approximately 16% of the global population.Most of these adolescents live in low-or middle-income countries and face various social and economic challenges.Investing in the rights and development of adolescents can contribute significantly to their full participation in society, a competitive workforce, sustainable economic growth, better governance, and more dynamic civil society.It can also accelerate progress toward achieving the Sustainable Development Goals (SDGs) set by the United Nations (UNICEF, 2018).
Adolescents are increasingly seen as a window of opportunity with the recognition that investment in the health and wellbeing of young people is crucial for a country's future and overall development.Evidence shows that adolescence provides a second chance to influence developmental trajectories (including cognitive growth and development), shape future habits, and compensate for some negative childhood experiences -second only to early childhood (UNICEF, 2018;United Nations Children's Fund, 2021).Investing in adolescents protects future generations of adults and consolidates investments in early childhood health, survival, and education.
Malnutrition, in all its forms, can have long-term detrimental effects on the development of children -and can even be passed down from generation to generation.In addition to poor cognitive performance and low work productivity, adolescent girls with anemia, for example, are more likely to give birth to low birth weight babies at risk of growth stunting (Setiawan et al., 2022).In countries with a high prevalence of stunting, adolescent girls may face additional challenges in their eating behavior.Several factors that may contribute to this include: first, limited access to nutritious food -adolescent girls may live in areas where access to nutritious food is limited, resulting in a lack of essential nutrients and an increased risk of malnutrition.Second, poverty-adolescent girls who live in poverty may not have the resources to buy varied and nutritious food, leading to food insecurity and malnutrition.Third, beliefs and cultural practices-adolescent girls may be subject to beliefs and cultural practices that limit their food choices, such as food taboos and gender-based food consumption patterns.Fourth, lack of education-adolescent girls may not have access to education on nutrition and healthy eating habits, resulting in poor food choices.Lastly, time constraints-adolescent girls in countries with high stunting prevalence may have to spend much time on household chores, leaving them with little time to prepare food, which can lead to skipping meals or consuming fast food.
Healthy habits developed during adolescence, such as healthy eating and physical activity, can last a lifetime and help break the cycle of intergenerational malnutrition (Frech, 2012).However, programs aimed at improving nutrition during these formative years are still too few, especially concerning preventing stunting, so they must be quickly increased.Therefore, a study was conducted to evaluate the eating behavior of adolescent girls in several countries with a high prevalence of stunting in young children, above the standard set by WHO.The study aimed to provide an accurate picture of the eating behavior of adolescent girls and its impact and to serve as a basis for developing future policies and strategies in achieving the SDGs 2030 targets related to nutrition.

Materials and methods
This review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher et al., 2009).Additionally, it was registered in the International Prospective Register of Systematic Reviews database (PROSPERO) with registration number CRD42023389909.

Participant Adolescent girls
Studies with participants other than adolescent girls, such as studies involving adult women, men, or children, will be excluded

Intervention
The systematic review did not focus on a specific intervention but aimed to evaluate the eating behavior of adolescent girls in countries with a high prevalence of stunting in young children Since the review doesn't focus on a specific intervention, there may not be specific exclusion criteria related to interventions

Search strategy
The search strategy was determined based on research questions as well as inclusion and exclusion criteria based on the PICOS (Participants, Intervention, Comparison, Outcomes, and Study design model) (Chandler et al., 2022) as shown in Table 1: The search strategy used in PubMed for this systematic review is designed to identify relevant studies related to adolescent girls' eating behavior and its association with stunting.The strategy includes the following components; Participants (P): MeSH Term: "adolescent" and Keywords in Title/Abstract: "girls, " Outcome (O): MeSH Term: "feeding behavior" and Keywords in Title/Abstract: N/A (MeSH term covers the outcome), Exposure (E): Keywords: "growth disorders, " "growth, " "stunting, " "stunted." The Boolean operators "AND" and "OR" are used to combine these components effectively.The search seeks to find studies that involve adolescents (using MeSH terms and title/abstract keywords), address eating behavior (using MeSH term), and explore the association with growth disorders, including stunting (using various keywords).
The search strategy aims to be comprehensive by including both MeSH terms and additional keywords to ensure that relevant studies are captured.This approach helps in identifying a wide range of articles that match the research focus of the systematic review.
The search started in the PubMed database in January 2023 (as seen in Table 2) and has been filtered since 2000.Later, it was replicated in three other databases: CINAHL, EMBASE, and Scopus.Then, two clusters of search terms were designed.The first term includes terms related to stunting, while the second relates to eating behavior.Finally, words were selected from the Medical Subject Headings (MeSH) thesaurus to develop an advanced representative search.

Study selection process
This review was conducted in three main stages.The first stage was identifying and removing duplications.The second stage was selecting studies based on inclusion/exclusion criteria by reviewing article titles and abstracts.The final stage was reviewing the eligible articles by reading their full text.Two independent reviewers conducted all of these stages, and if there was a disagreement, a third reviewer was assigned to resolve it.The inter-reviewer agreement for the overall study selection was good, with a Cohen Kappa Index of 0.82 (95% CI, 0.49-1.00)(McHugh, 2012).

Result Study selection
The search strategy resulted in a total of 601 potentially relevant studies.Of these, 408 studies met the inclusion criteria based on a review of the title and abstract.After reading the complete text, 393 articles were excluded because they did not meet the inclusion criteria, such as not being conducted in countries with a high prevalence of stunting or not focusing on adolescent girls.Finally, only 15 studies met the eligibility criteria and proceeded to the next stage.The screening process can be seen in Figure 1.

Study characteristics
The variables reviewed in the selected studies have been described in Table 3:

Dietary pattern
There were no significant differences in the ages or physical activities of the two populations of girls studied.Consumption of cereal, vegetables, sweets, sugars, fats, meat, and eggs was similar between the two groups, although slight differences were found with regard to legumes, milk, and fruit consumption.
Berheto with the age range mentioned in the text, along with the study number and corresponding reference.

Sample size
There is a difference in sample size among these studies, ranging from 24 subjects in the qualitative design study 20 to 4,993 subjects in the sizeable community-based study in Bangladesh.Therefore, this systematic review evaluated 9,831 participants.

Objective, outcomes, and result
Table 3 also displays this systematic review's objective, outcome, and result.All studies have a similar objective: to assess eating/dietary behavior in adolescent girls.Four studies link diet habits to the activities of adolescent girls in school (Maria Soares and Yamarat, 2014;Birru et al., 2018;Javaid et al., 2020;Kurschner et al., 2020), two studies are related to body image perception (Mishra and Mukhopadhyay, 2011;Debasish et al., 2021), one study examines the transition of eating behavior in urban, rural, and slum areas (Dixit et al., 2014), two studies assess eating disorders directly in adolescent girls (Soo et al., 2008;Visser et al., 2014), three studies examine dietary diversity, patterns, or habits (Alam et al., 2010;Tengia-Kessy and Killenga, 2020;Mahriani et al., 2022;Worku et al., 2022), and the last study aims to provide data information to policymakers or planners (Berheto et al., 2015).The outcomes of this study can be summarized as dietary restraint, unhealthy dietary patterns, dietary types, and eating behavior in adolescent girls.
The results of the studies generally show the presence of various eating behaviors in adolescent girls in the countries where the studies were conducted.Adolescent girls who diet to maintain body shape may avoid or skip meals to remain thin (Mishra and Mukhopadhyay, 2011;Javaid et al., 2020;Debasish et al., 2021;Worku et al., 2022), especially in urban areas (Mishra and Mukhopadhyay, 2011).However, poor eating behavior was also found among adolescent girls in rural areas, potentially leading to stunting (Dixit et al., 2014).There is also a tendency among adolescent girls to eat only when they feel hungry (Mahriani et al., 2022).Unfortunately, unhealthy dietary habits associated with excess body weight can lead to the consumption of unhealthy foods (Tengia-Kessy and Killenga, 2020).A study also reported a healthy eating pattern of three meals a day, but the meals were not well-balanced (Agofure et al., 2021).For example, in a study conducted in Timor Leste, adolescent girls were found to consume insufficient calories and protein in their meals (Maria Soares and Yamarat, 2014).
Eating behavior is also related to Dietary Diversity (DD), which refers to consuming various food groups or types within a specific period.Consuming diverse foods is advantageous for obtaining a variety of macro and micronutrients and is essential for ensuring sufficient nutrient intake (Weerasekara et al., 2020).The adolescent girls in this reviewed study were found to have low dietary diversity, associated with several factors, including spending too much time on social media, consuming more sweet foods, and again, fear of gaining weight (Worku et al., 2022).
Irregular or disrupted eating schedules can also factor in developing unhealthy eating behaviors.Busy school schedules often cause adolescent girls to skip meals or rush through them, leading to loss of appetite or more meal skipping and irregular snacking (Kurschner et al., 2020).Inadequate dietary diversity was found in adolescent girls who consume few fruits and a large number of starchy staples (Birru et al., 2018).The type of food also became the focus of the review study.Adolescent girls in Ethiopia more frequently consume staple foods such as rice or wheat than nonstaple foods such as eggs, meat, and fish.Fruits are more commonly consumed according to their seasonal availability (Alam et al., 2010;Berheto et al., 2015).Possible eating disorders were reported in one study (Visser et al., 2014).

Quality of studies
The Newcastle-Ottawa Quality Assessment Scale (NOS) (Stang, 2010;Lo et al., 2014) was utilized to evaluate the quality of the studies.This tool was designed to aid systematic reviews in reaching quality criteria while minimizing bias risks.The NOS comprises three main categories: selection, comparability, and outcome, each consisting of several items about the features of observational studies, with several answer options.At least one answer within each category is accompanied by a star (6) which signifies a low risk of bias.Upon completion of the scale, the stars are tallied, and if the score is less than seven stars, there may be a high risk of bias.Additionally, if the reviewers select answers without stars, it is important to examine possible study biases.NOS scores are categorized into three groups: very high risk of bias (0-3 stars), high risk of bias (4-6 stars), and low risk of bias (7-9 stars) (Lo et al., 2014).
Two independent reviewers assessed the quality of each study, with a third reviewer assigned in case of disagreements.The final consensus is presented in Table 4.The Cohen Kappa Index was used to measure the level of agreement among reviewers in assessing the overall quality of the studies.The findings indicated a strong agreement (Cohen Kappa Index = 0.76; 95% CI, 0.60-0.89) in evaluating the individual scores of each study.Based on this analysis, it can be inferred that all fifteen studies had a minimal risk of bias.

Discussion
During adolescence, there is a need for greater nutritional intake to support rapid growth and ensure a healthy lifestyle for teenagers.An additional study indicated that teenagers' choices regarding their lifestyle and diet could either negatively affect their health during this transition period or contribute positively to their overall wellbeing as they become adults (Amer and Kateeb, 2021).

Relationship between eating disorders and extreme weight-loss behaviors
The first crucial finding of this systematic review underscores the connection between eating disorders and extreme weightloss behaviors among adolescent girls.Only four per cent of the surveyed teenage girls were diagnosed with an eating disorder using the EAT-26 measurement tool.Notably, individuals who engaged in extreme weight-loss behaviors in the past year were likelier to score higher on the EAT-26, indicating a potential risk of eating disorders (Visser et al., 2014).These results emphasize the need for early identification and support for individuals at risk for or already experiencing disordered eating patterns.Psychological, genetic, environmental, and cultural factors may contribute to the development of eating disorders (Loth et al., 2014).
Additionally, the study found that perceiving oneself as overweight was a predictor of higher total scores on the EAT-26 and a score equal to or greater than 20, often used as a cut-off point for identifying individuals at risk for an eating disorder.This finding aligns with previous research showing a correlation between perceiving oneself as overweight and experiencing eating problems during adolescence.It also suggests that individuals who perceive themselves as overweight may be more likely to engage in weight-loss behaviors (Mateos-Padorno et al., 2010).These findings highlight the importance of recognizing the relationship between extreme weight-loss behaviors, body perception, and the risk of developing an eating disorder.Identifying individuals who exhibit these behaviors and perceptions can help in early intervention and support for individuals at risk for or already experiencing disordered eating patterns (Visser et al., 2014).

Body perception and risk of eating disorders
Our second key finding revolves around body perception and its role in the risk of developing eating disorders among adolescent girls.Notably, perceiving oneself as overweight predicted higher total scores on the EAT-26.This aligns with prior research showing a correlation between perceiving oneself as overweight and engaging in extreme weight-loss behaviors.Recognizing this relationship is crucial for targeted interventions and support.
Adolescent girls commonly experience dissatisfaction with their body image and negative self-perception, affecting their eating behavior.In the study we reviewed, most participants reported skipping at least one meal per day.Among this group, some intentionally skipped meals to lose weight, commonly called dieting.When comparing the practice of dieting among all the reasons for skipping meals with the participants' self-perception of their body shape, it was observed that those who engaged in dieting were only individuals who perceived their body shape as fat or normal, while none of those who considered themselves as thin reported dieting (Debasish et al., 2021).

Influence of body image on dieting behaviors
In our third finding, we delve into body image's influence on adolescent girls' dieting behaviors.It was observed that those who engaged in dieting were exclusively individuals who perceived their body shape as fat or normal, while none of those who considered themselves thin reported dieting.This underscores the complexity of body image perceptions and their impact on adolescent dietary choices.
Initially, the process of perceiving body image is believed to be narrow.Still, over time it can develop into body distortion, where there is a significant alteration in the perception of body size.This means that individuals may perceive themselves as fat even when dangerously underweight (Farid and Kamrani, 2016).This tendency to desire thinness was also observed quantitatively in the current study.There was a lack of agreement between adolescents' perceptions of themselves and their actual body size.Therefore, it became evident that their beliefs about their bodies were based on a mistaken notion.It was concerning that those girls who perceived themselves as normal or fat in the present study were underweight.A study conducted in Korea on adolescents (Su-Jung and Jong-Ho, 2021) found that underweight or normal-weight individuals who perceived themselves as overweight were at a higher risk of developing eating disorders such as anorexia nervosa.

Restrained eating behavior
Our fourth important finding highlights restrained eating (RE) behaviors among young adolescents.This vulnerability is linked to increased weight concerns, body dissatisfaction, and problematic eating behaviors.Adolescents who exhibited RE behaviors tended to eat only when hungry or craving, which contradicts previous notions.Understanding the factors contributing to cravinginduced diet behavior, such as limited access to food at school, is critical for developing effective interventions.
The restrained eating (RE) identified in four reviewed studies (Soo et al., 2008;Alam et al., 2010;Kurschner et al., 2020;Tengia-Kessy and Killenga, 2020;Agofure et al., 2021) indicates that young adolescents are especially susceptible to RE.This vulnerability stems from their increased likelihood of experiencing weight concerns, body dissatisfaction, and problematic eating 10.3389/fpsyg.2023.1228413behaviors.The restrained eating behavior exhibited by adolescents in Mahriani et al.'s (2022) study involves only eating when hungry or craving, contradicting findings that suggest adolescents frequently experience hunger (Kral et al., 2010;Savard et al., 2022).However, Mahriani et al.'s (2022) study reveals that the cravinginduced diet behavior is primarily attributed to adolescents' lack of knowledge regarding the benefits of proper nutrition and the difficulty in accessing food while they are at school.

Unhealthy eating patterns during adolescence
Our fifth finding sheds light on the unhealthy eating patterns prevalent during adolescence, characterized by skipped meals, increased consumption of processed and fast foods, and decreased intake of fruits and vegetables.Despite knowledge about the importance of a balanced diet, adolescents frequently indulged in junk food, indicating that factors beyond knowledge influence their dietary choices.
During adolescence, characterized by rapid growth, individuals experience significant physical, psychological, hormonal, cognitive, and social changes.These transformations lead to fluctuations in the nutritional requirements, eating habits, and food preferences of the body.The eating pattern of adolescents differs from that of children.The higher academic and socio-economic pressures associated with this growth stage often result in skipped meals, an increased intake of processed and fast foods, and a decrease in the consumption of fruits and vegetables (Onyiriuka et al., 2013).The unhealthy eating patterns identified in the reviewed study indicate that adolescents tend skipped meals or to have inadequate consumption of vegetables and fruits while frequently indulging in junk food (Agofure et al., 2021).Furthermore, despite knowing the importance of a balanced diet for maintaining a healthy life, this knowledge did not reflect in the nutritional status of the respondents.This suggests that factors other than knowledge influence the dietary choices of adolescent girls (Ogunkunle and Oludele, 2013).

Low-diversity diet and micronutrient deficiencies
The last crucial finding pertains to the presence of a lowdiversity diet among adolescent girls, reflected in sub-optimal dietary intake and micronutrient deficiencies (Birru et al., 2018;Worku et al., 2022).This sub-optimal nutrition during adolescence can lead to delayed puberty, contracted pelvis, and unfavorable birth outcomes, including stunted growth in newborns.Recognizing the importance of dietary diversity is essential for addressing these nutritional challenges.
The dietary diversity score (DDS) is a measure that counts the number of different food groups consumed over a specific period (Davis, 2016).It reflects the diet quality at the household or individual level.Optimal nutrition is crucial during adolescence since this period is responsible for gaining 50% of adult weight, 20% of adult height, and 50% of skeletal mass (Hadush et al., 2021).
However, research indicates that 45-60% of adolescent girls have sub-optimal dietary intake (Shashikantha et al., 2016), leading to various micronutrient deficiencies, including Vitamin A, iron, and iodine (Birru et al., 2018).Similar findings were observed in Ethiopia, where 29 and 30% of adolescent girls had thinness and anemia, respectively (Central Statistical Agency Ethiopia, 2016).These nutritional deficiencies can result in delayed puberty, contracted pelvis, and unfavorable birth outcomes, including stunted growth in newborns (Setiawan et al., 2022).
While this systematic review provides valuable insights into eating behaviors among adolescent girls in countries with high stunting prevalence, it is essential to acknowledge its limitations: Limited Generalizability: The findings of this review are based on studies conducted in specific countries or regions with high stunting prevalence.As such, the generalizability of the results to a broader global context may be limited.Cultural, socioeconomic, and environmental factors that influence eating behaviors can vary significantly between regions, potentially affecting the applicability of these findings elsewhere.
Variability in Study Designs: The included studies in this review may have employed diverse methodologies, assessment tools, and criteria for measuring eating behaviors.This variability in study designs could introduce heterogeneity into the review, making it challenging to draw uniform conclusions.
Language Bias: The review's search strategy may have been limited to studies published in English, which could introduce language bias.Relevant studies published in other languages may have been excluded, potentially affecting the comprehensiveness of the review.
Publication Bias: There is a possibility of publication bias, where studies with statistically significant or more sensational findings are more likely to be published.This bias could skew the review's findings, potentially overemphasizing certain aspects of eating behaviors among adolescent girls.
Cross-Sectional Nature of Studies: Many of the included studies may have adopted cross-sectional designs, which provide a snapshot of eating behaviors at a specific point in time.Crosssectional studies are limited in their ability to establish causality or track changes in eating behaviors over time.
Self-Reported Data: Several studies may have relied on selfreported data from adolescents.Self-reporting can introduce recall and social desirability biases, as participants may underreport or overreport certain behaviors due to social or cultural pressures.
Lack of Longitudinal Data: Longitudinal data that track eating behaviors and their consequences over an extended period are crucial for understanding trends and potential long-term effects.The absence of such longitudinal data may limit the review's ability to explore the persistence and impact of certain eating behaviors.
Limited Focus on Interventions: This review primarily describes eating behaviors rather than evaluating interventions or prevention programs.While identifying eating behaviors is valuable, a more comprehensive review might explore the effectiveness of interventions in addressing these behaviors.
Evolving Nature of the Field: The field of nutrition and eating behaviors continually evolves.The review's findings are based on studies available up to a specific date (knowledge cutoff in September 2021).Since then, new research may have emerged that could provide additional insights or alter the conclusions.Potential Biases in Included Studies: The individual studies in the review may have biases and limitations, which can propagate to the review itself.The quality and rigor of the original studies can impact the overall strength of the review's conclusions.

Conclusion
In conclusion, the eating behaviors of adolescent girls in countries with a high prevalence of stunting exhibit concerning patterns, including a low diversity diet, sub-optimal dietary intake, and the development of various micronutrient deficiencies.These challenges are compounded by eating disorders, such as retained and craving-induced diet, which further impact their nutritional status.These eating disorders contribute to an unhealthy relationship with food and can harm their physical and mental wellbeing.Addressing these multifaceted issues requires a comprehensive approach encompassing nutritional education, promoting balanced diets, addressing the underlying factors contributing to eating disorders, and providing appropriate support and intervention for those affected.By addressing these eating behaviors and disorders, we can strive to improve adolescent girls' overall health and wellbeing in these countries and reduce the prevalence of stunting and its associated consequence.

FIGURE 1 PRISMA
FIGURE 1PRISMA flow diagram of the included and excluded studies throughout the systematic review protocol.

TABLE 1
Inclusion and exclusion criteria.