Proceedings of the Nutrition Society (2023), 82, 142–156 doi:10.

1017/S0029665123002689
© The Author(s), 2023. Published by Cambridge University Press on behalf of The Nutrition Society.
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First published online 16 March 2023

The Nutrition Society Irish Section Conference 2022 was a hybrid event held at the University College Cork on 15–17 June 2022

Conference on ‘Impact of nutrition science to human health: past perspectives and

future directions’
Postgraduate Symposium

Adolescent nutrition and health: characteristics, risk factors and

opportunities of an overlooked life stage
Proceedings of the Nutrition Society

Aoibhín Moore Heslin* and Breige McNulty

UCD Institute of Food and Health, School of Agriculture and Food Science, University College Dublin, Belfield,
Dublin 4, Ireland

Adolescence is a pivotal, yet frequently overlooked, period of life, with this age group often
no longer receiving the focus, care and protection devoted to other life stages. Nutritional
vulnerability increases in adolescence due to heightened nutritional requirements, yet the
quality of the diets consumed by this age group often deteriorates significantly. Poor-quality
dietary patterns and insufficient nutrient intakes are frequently observed amongst adoles-
cents both in Ireland and globally. This deterioration in diet quality is greatly influenced
by individual, social and environmental determinants of behaviour and health. The
influences of each of these factors change and increase as adolescents begin to interact
independently with the surrounding world. Poor nutrition during adolescence can result
in several immediate and long-term health consequences, including micronutrient deficien-
cies, increased risk of overweight/obesity and increased presentation of cardiometabolic
risk factors, all of which have been observed as persistent issues amongst adolescents in
Ireland and internationally. Adolescence is a critical period of intervention to protect
youth both now and into their future lives. This age group can be particularly receptive
to the influence of society and the surrounding environment, posing several avenues in
which to influence adolescents towards more health-promoting behaviour. This review
aims to summarise the key nutritional and dietary characteristics of adolescents, to provide
an overview of the causes and consequences of poor nutrition in adolescence, and to high-
light potential opportunities for intervention to protect the health of this age group, with a
particular focus on evidence from an Irish context.

Key words: Adolescent: Nutrition: Diet quality: Deficiency: Obesity

Adolescents are estimated to make up 16 % of the global from 10 to 24 years(2). Ultimately, adolescence is the per-
population, with approximately 1⋅3 billion adolescents in iod of transition from childhood to adulthood, generally
the world today(1). The classification of the adolescent co-occurring with the onset of puberty and culminating
period can vary, with the UN defining it as the period with the achievement of legal independence from par-
of life between 10 and 19 years of age, and the WHO ents/guardians i.e. ‘adulthood’(3). Adolescence is a crit-
expanding the age of adolescence to encompass those ical life stage characterised by major biological,

*Corresponding author: Aoibhín Moore Heslin, email [email protected]

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 Adolescent nutrition and health 143

psychological, emotional, and social growth and devel- is consistently identified as failing to meet recommenda-
opment. The rapid pace of physical and cognitive growth tions for a variety of nutrients(17) while also displaying a
in adolescence is second only to the growth of infancy, rising incidence of energy overnutrition and overweight/
with this time classed as the second ‘developmental obesity(18). Both adolescent undernutrition and obesity
period’(4,5). coexist across low- and middle-income countries(18,19),
Consequentially, nutritional needs increase during with the issue of obesity tending to be the most pervasive
adolescence, with requirements for most nutrients higher dietary challenge amongst youth in high-income coun-
than those of adults relative to body weight and energy tries(20). The increased nutrient requirements of adoles-
requirements(6,7). Despite the importance of this life cence, coupled with changes in dietary habits,
stage, the health priorities of adolescents remain some- behaviours, and environmental exposures mean that
what neglected, with their needs widely overlooked this age group generally have a high risk of dietary inad-
in global health and nutrition policies(8). The Lancet equacy(11,21). Adolescents, along with women and chil-
Commission on Adolescent Health and Wellbeing dren, have been identified as bearing much of the
brought this issue to the fore and has labelled adolescent global burden of micronutrient deficiency(22), with vita-
nutrition as a ‘hidden crisis’(9). The commission criticised mins A, B6, B2, D, E, folate, calcium, iron, iodine,
the general omission of adolescents from global policies zinc and selenium reported as micronutrients of particu-
and emphasised the need for investment to protect the lar concern for this age group(10,23,24), both in Ireland(25)
health of youth and future adult populations(8). As a and internationally(26–30).
Proceedings of the Nutrition Society

transitional life stage and period of increased autonomy, Iron inadequacy is a common dietary deficiency in this
this age group often no longer receive the benefits and age group, with a particularly high burden in lower-
protection of the care devoted to childhood(10). affluence countries(31). Iron requirements increase sub-
Additionally, adolescence is largely considered a period stantially in adolescence to facilitate intensive muscular
of good health and decreased susceptibility to disease, and cognitive growth and development, increased blood
leading to this age group generally being overlooked in volume and the onset of menstruation in females(32).
public health discourse(9). However, as a pivotal life Inadequate iron intake is a prevalent issue for female
stage in which the foundations of health are laid(11) and adolescents across Europe, with policy-based interven-
exposure to health risks increases(12), the exclusion of tions proposed as a potential avenue to reduce the scale
adolescents from global nutrition efforts is an oversight of iron deficiency(24). Albeit, Irish adolescents in general
that could undermine the progress that has been made display sufficient intakes of dietary iron(25,33), largely
in childhood health(13). Consideration of this age group’s attributed to the widespread consumption of fortified
nutrition and health needs, and action to ensure these ready-to-eat breakfast cereals and meat(34). However,
needs are fulfilled and protected, is critical in ensuring female adolescents in Ireland do tend to consume lower
a healthy population, both now and in the future. amounts of dietary iron(35) and 9 % display intakes
This review aims to present key considerations and below recommendations(25), indicating that attention is
characteristics of adolescent nutrition and health, iden- still required to ensure adequate consumption of this
tify a selection of the causes and consequences of poor essential mineral amongst this population group.
nutrition in adolescence, and highlight potential oppor- Adolescence is a pivotal stage of bone mineralisation,
tunities to improve nutrition and health within this age with approximately 40–60 % of adult bone mass accrued
group, with a focus on evidence and opportunities within during adolescence(36). Hence, requirements for cal-
an Irish context. cium(37) and phosphorus(38) are higher in adolescence
than in all other stages of life, with an increased intake
of Vitamin D also advised for this age group(39). With
Nutritional and dietary characteristics of adolescents that being said, there is a high prevalence of inadequate
intakes of calcium and vitamin D amongst adolescents,
Nutritional vulnerability in adolescence with evidence from Europe(24), the UK(40,41), the
Adequate nutrient intake is critical in all stages of life but USA(42) and Brazil(43) indicating that the majority of
particularly during the adolescent years, not only to adolescents fail to meet recommendations for these nutri-
facilitate rapid physiological growth and development ents. Within an Irish context, 94 % of adolescents have
but also to lay the foundations of good health for later been identified as having inadequate intakes of vitamin
life(14). Consistent increases in life expectancy mean D, and 67 % consume below the recommendations for
that the youth of today are projected to live long and pro- calcium(44). Evidence of declining consumption of dairy
ductive lives(15). The quality and quantity of nutrition foods(45) and low intake of supplements(25) amongst
consumed during the formative years of adolescence Irish adolescents raises significant concerns regarding
has long-term effects on health and well-being through- future consequences on bone health for this age group.
out life(14). Leading nutrition experts have emphasised The adolescent years have been suggested to pose the
the need for societies to prioritise the nutritional needs potential for catch-up nutrition and growth, providing
of youth and provide clear dietary guidance and action a possible opportunity for childhood nutritional deficien-
on nutrition for adolescents(14). cies and insufficient growth to be somewhat amelio-
Adolescents are vulnerable to the ‘triple burden’ of rated(46). The brain undergoes intense growth and
malnutrition, encompassing undernutrition, micronu- remodelling during adolescence, with this life stage con-
trient deficiencies and overnutrition(16). This age group sidered a time of heightened cognitive malleability(47,48).

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 144 A. Moore Heslin and B. McNulty

This heightened neuroplasticity increases the vulnerabil- excessive weight gain is fast becoming the forerunning
ity of the brain to nutritional and environmental risks issue for adolescent health globally(18). While energy
such as dietary deficiencies(11). Nutritional intake can requirements increase substantially in adolescence, mod-
have profound effects on the construction and strength- ern lifestyle behaviours such as decreased energy expend-
ening of neurocircuitry, with energy and protein under- iture, increased sedentary activity and high consumption
nutrition, consumption of high fat and high sugar diets of energy-dense foods mean that adolescents can easily
and inadequate intake of essential nutrients including B tend towards a daily energy surplus(60). This energy
vitamins, iron, iodine zinc, and PUFA all considered imbalance is the main driver of excessive weight gain
risks to neurodevelopment(11,49–51). Therefore, ensuring and can be particularly heightened during adolescence,
adequate nutrient intake, particularly essential micronu- with analyses of adolescent cohorts across several coun-
trients, is imperative in establishing good health in youth tries showing clustering of unhealthy energy-balance-
and equipping them to lead long, healthy and productive related behaviours during this life stage(61).
lives.
Optimisation of nutritional intake during adolescence
is essential in ensuring the health of adolescents them- Dietary intakes: deterioration of diet quality during
selves and protecting the health of future offspring. adolescence
Globally, nearly one-third of women become pregnant
during their adolescent years, highlighting the critical Consumption of a poor-quality diet is one of the largest
Proceedings of the Nutrition Society

need to ensure nutritional adequacy for the health of vul- contributors to the global burden of non-communicable
nerable young women and infants(52). Suboptimal micro- diseases and is considered a key modifiable risk factor
nutrient status is a key nutritional challenge amongst for chronic diseases(62). Adolescents have been consist-
adolescent mothers, with iron, iodine and folic acid ently identified as displaying the poorest quality diets
emphasised as nutrients of particular concern(52). Iodine of all population groups(63), with the Dietary
is a vital mineral in the production of thyroid hormones Guidelines for Americans highlighting that the difference
and normal neurodevelopment, with iodine deficiency in between recommended food group intakes and actual
youth associated with impairments in mental and phys- consumption is greatest for adolescents aged 14–18
ical functioning(53). Adequate iodine intakes become par- years compared to other age groups(21). Diet quality
ticularly essential as women enter childbearing age, with tends to decrease in the transition from childhood to ado-
iodine deficiency leading to intellectual impairments and lescence, with those aged 14–18 years ranking approxi-
cognitive and behavioural problems in offspring(54). mately ten points lower in Healthy Eating Index scores
European adolescents, particularly females, have been than younger children(64). Poor-quality diets have been
identified as consistently displaying lower iodine intakes consistently identified amongst adolescents across a
than other age groups(55). National dietary surveys of range of countries and regions, including Brazil(65),
Irish adolescents have indicated a decline in milk con- Turkey(66), Canada(67), the USA(68), the UK(69) and
sumption(25) and consistently low intakes of fish and sea- Europe(70), with poor diet quality generally characterised
food(35), raising concerns about iodine intakes amongst by low consumption of fruit, vegetables, wholegrains,
this age group. lean meat and low-fat dairy, and high intake of confec-
The commencement of supplementation with folic tionery, high-sugar beverages, fats, processed meats,
acid is recommended for all women upon reaching child- refined grains, and ready meals(68–70). ‘Unhealthy’ and
bearing age to prevent the occurrence of neural tube ‘sandwich’ dietary patterns have been previously iden-
defects in pregnancy(56). However, awareness of the tified as the most predominant amongst Irish adolescents,
need for folic acid is poor amongst adolescent females, with these patterns associated with a higher intake of fat,
with low consumption of folic acid supplements across saturated fat, and total sugars, and lower intakes of fibre
this age group globally(57). Indeed, in Ireland, overall and vitamins(71). Additionally, poor dietary habits such
supplement use is low amongst all adolescents, with as meal skipping and replacement of meals with snacks
only 14 % reporting consuming a supplement(25). While are frequently reported amongst adolescents glo-
voluntary fortification of food products with folic acid bally(72,73) and contribute to significant deteriorations
has resulted in the improvement of folate status at a in diet quality amongst this age group(74–76).
population level(58), there is a clear need for increased The quality of the diet consumed by adolescents has
folic acid fortification and the use of education and out- shown slight improvements in recent years, with US
reach to promote folic acid intake amongst young youth showing a modest improvement in diet quality
women. The overall risk of complications in maternal scores from 1999 to 2016, characterised by decreased
and neonatal health outcomes is substantially greater consumption of sugar-sweetened beverages and added
for adolescent mothers compared to those of adult sugar, and increased intake of wholegrains, fruit and
women(59), meaning that ensuing nutritional adequacy vegetables, poultry and eggs(68). However, poor diet
in adolescent females is one of the several essential efforts quality remains a persistent issue amongst adolescents,
that should be made to improve the lives and safety of with those aged 12–19 years displaying the highest preva-
these young women. lence of a poor-quality diet in the USA(68). Gradual
While undernutrition remains a prevalent dietary chal- improvements in dietary intake have been observed in
lenge for adolescents in lower affluence countries, the regions of Europe and North America, with evidence
issue of overnutrition and its resultant effects on of increased fruit and vegetable consumption by

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 Adolescent nutrition and health 145

adolescents across most countries, including Ireland, macronutrient intakes from early-to-mid-adolescence(92)
from 2002 to 2010(77). However, infrequent consumption and from adolescence into young adulthood(93).
of fruit and vegetables remains a characteristic of adoles- Nevertheless, the establishment of healthful dietary pat-
cents globally(78,79). Some improvements have been terns is imperative in meeting the nutritional require-
observed in the current diets of Irish adolescents, with ments of adolescence and could potentially aid in the
modest increases in the consumption of fruit, vegetables creation of lifelong healthy behaviours.
and high-fibre cereals and slight reductions in the intake
of free sugars and salt(25). However, Irish adolescents still
display poor adherence to food and nutrient recommen- Risk factors related to adolescent nutrition and health:
dations, with an average daily intake of fewer than three causes and consequences
portions of fruit and vegetable, poor intake of fibre, and
excessive intake of salt, saturated fat, and ‘top-shelf’ Causes of poor nutrition and diet in adolescence
foods(25). Poor compliance with dietary guidelines is Adolescents’ dietary behaviours and nutrient intake are
characteristic of adolescents globally, with this age influenced by a plethora of different factors, from
group consistently displaying low intakes of recom- individual-level decisions to broader social and structural
mended foods and excessive intakes of more unfavour- determinants. A summary of the complex interplay of
able foods(64,80,81). factors that influence this age group’s food-related beha-
Analysis of trends in the dietary intakes of US adoles- viours is presented in Fig. 1.
Proceedings of the Nutrition Society

cents has identified an increased consumption of ultra- Individual factors influencing adolescent nutrition and
processed foods in recent years, with 68 % of adolescent health. Adolescence has long been considered a period
energy intake derived from ultra-processed foods in of ‘storm and stress’ in which disruptions in mood,
2018(82). While the level of processing is not a marker increases in risk-taking behaviour, and increased conflict
of the healthfulness of food, nutrient profiling of the con- with parents/guardians can contribute to turbulent
sumed foods did also suggest a higher proportion of car- thoughts, emotions, and behaviours(94). The adolescent
bohydrates, added sugars, sodium, and lower level of years bring drastic changes in lifestyle, eating
protein and fibre in foods classed as ultra-processed v. behaviours, and increased exposure to environmental
unprocessed foods(82). Intake of highly processed foods is influences, all of which can increase the nutritional
similarly pervasive amongst Irish adolescents, with high vulnerability of this age group(10). Motivations and
intakes of white bread, pizza, savoury snacks, chips, barriers to healthy food choices in adolescents have
processed meats, and confectionery noted in 2020(35). been presented in a previous review(95), with personal
Diets with a high proportion of highly processed, energy- factors such as body image, preferences, level of
dense, nutrient-poor foods, encompassing fast foods, autonomy, interest in health, and nutrition knowledge
confectionery, snacks, cakes, refined grains, and sugar- identified as key considerations for health and food
sweetened beverages, are increasingly prevalent amongst choices in this age group. Additionally, there are
this age group(83,84) and have been associated with an numerous psychosocial factors including attitudes,
increased risk of overweight/obesity(85). The widespread beliefs, self-efficacy, food preferences, mood, and mental
consumption of industrially produced convenience foods health(96), and biological determinants such as appetite,
poses these foods as potential targets for reformulation hunger, taste, weight status, and allergies(97) which exert
and dietary intervention to improve the diets of adoles- strong influences on adolescent eating behaviour and
cents and indeed the general population. dietary intake.
Adolescence is a pivotal time of personal development, Self-restriction of food intake and poor eating patterns
in which lifelong traits and habits can be discovered and are considerable challenges to adolescent nutrition and
established. This life stage has been highlighted as an risk factors for poor nutritional status(10). Adolescents
important but overlooked time for the establishment of have an increased susceptibility to food fads(98), restrict-
lasting health behaviours, with adolescence posed as a ive diets(99) and disordered eating(100), which, in addition
‘window of opportunity’ for the establishment of dietary to habits of skipping and substituting meals(72), pose
patterns(86). Childhood dietary behaviours have been significant risks to nutritional adequacy and quality of
shown to track relatively strongly into adulthood, with diets consumed by this age group. Intrapersonal factors
behaviours from late adolescence displaying the strongest such as perceived benefits, self-regulation, goals, and
continuation into adulthood(87). An energy-dense, high- motivation are associated with the consumption of a
fat, low-fibre dietary pattern has been shown to track better-quality diet during adolescence(101). However,
from early-to-late adolescence(88), with overall diet qual- these personal factors are subject to strong influences
ity generally tending to decrease with age(64,89). Certain from the outside world, with the effects of the social
longitudinal cohort studies have indicated that adoles- and physical environment suggested as more prominent
cents with the closest adherence to dietary patterns, in the determination of adolescent food choice than
including ‘traditional’, ‘health-conscious’, ‘high-protein, individual factors(102).
high-fat’ and ‘vegetarian-style’, display significant track- Social factors influencing adolescent nutrition and
ing of similar dietary patterns 20 years later(90,91). health. Adolescence is a period of enhanced social
However, the longevity of adolescent dietary patterns interaction and engagement with family members,
in later life has been questioned, with other longitudinal peers, work colleagues, and wider society. The
evidence showing poor tracking of energy and development of the ‘social brain’ in adolescence makes

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 146 A. Moore Heslin and B. McNulty
Proceedings of the Nutrition Society

Fig. 1. Individual, social, and environmental factors influencing adolescent nutrition and diet.

this age group particularly aware of and receptive to the with adolescents’ consumption of both healthy foods,
influence of others on their decision-making(103). The such as wholegrain and dairy, and negative dietary com-
family unit remains one of the strongest influential ponents including fast food, sugar-sweetened beverages,
factors and has been identified by Irish adolescents as and snacks similar to those of their peers(110). This peer
the most important thing in their lives(104). Parental influence is present in person and online, with adoles-
characteristics such as education level, social class, cents’ social media accounts frequently portraying food
income, health, marital relationships, parenting style, images, the majority of which are high in energy and
stress, efficacy, habits, and preferences have been low in nutrients(111).
identified as exerting a relevant influence on the lives, Social class and socioeconomic status are amongst the
and indeed the diets, of adolescents(104,105). Parental strongest determinants of health-related behaviours, as
weight status has been consistently associated with a financial resources, job type and education level often
higher risk of overweight and obesity and less healthful determine the environments people are exposed to and
behaviours amongst adolescent offspring(106,107), with how they interact with them. A strong income gradient
parents’ attitudes and behaviours relating to diet and of weight status and dietary intake has been repeatedly
exercise often reflected in their children(108). Siblings observed, with those who experience greater levels of
also exert an influence on adolescents’ dietary deprivation consistently displaying poorer quality diets
behaviours, with a systematic review indicating that and the highest risk of overweight and obesity(112–115).
this influence is often more negative than positive(109). A similar socioeconomic gradient has been observed in
The social and emotional importance of peers Ireland, where adolescents from lower affluence back-
increases during adolescence, with peers and social grounds have lower consumption of fruit and vegetables,
norms exerting strong influences on decision-making higher consumption of sugar-sweetened beverages and
and behaviour(109). This includes dietary behaviours, chips(116) and a significantly increased risk of

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 Adolescent nutrition and health 147

overweight/obesity(117). Socioeconomic factors are con- Consequences of poor nutrition and dietary intake
sidered high-priority determinants of adolescent obesity in adolescence
due to strong links between social disadvantage and Nutritional deficiencies: impairments in adolescent
obesity-related behaviours(118). Socioeconomic position growth and development. Poor dietary patterns and
and financial resources determine adolescents’ inter- inadequate intake of nutrients are reflected in suboptimal
action with the wider environment, with those affected nutrient status amongst adolescents. Vitamin D
by social disadvantage more vulnerable to obesogenic deficiency is a highly prevalent condition in this age
environments due to lack of choice and less financial group, with 80 % of European adolescents displaying
freedom(119). suboptimal serum vitamin D concentrations(129). Irish
Environmental factors influencing adolescent nutrition adolescents have a higher prevalence of vitamin D
and health. Physical, economic, social, cultural, and deficiency than younger children(130), with a fifth of this
political environments exert major influences on dietary group identified as being at an increased risk of
and health behaviours. External environmental factors deficiency(44). Vitamin D deficiency is negatively
have been identified as the most influential on the food associated with adolescent bone density(131) and is
choice of Irish adolescents, with price, convenience, possibly linked to an increase in infectious and
food characteristics, and the surrounding physical and autoimmune diseases(132), posing concerns for immediate
social environment exerting a greater effect on food and future health in this age group.
choice than intrapersonal factors such as emotions and
Proceedings of the Nutrition Society

Folate has been highlighted as a nutrient of predomin-

restraint(120,121). These results indicate that influencing ant concern amongst adolescents, with 35 and 30 % of
the external food environment and the use of targeted European adolescents displaying insufficient concentra-
health promotion messaging may aid in improving
tions of plasma folate and erythrocyte folate, respect-
adolescents’ food choices.
ively(70). Additionally, 71 % of European adolescent
Adolescents’ consumption of ‘non-core’, high-sugar
females displayed erythrocyte folate concentrations
and high-fat foods is considerably higher outside the
below the threshold of 906 nmol/l deemed to be max-
home(122), with the offerings of the school and retail
imally protective against neural tube defects(70). In add-
environments often saturated by affordable and
ition to folate, the status of other essential B vitamins
appealing nutrient-poor, energy-dense foods(123). The
including B12, B6 and riboflavin(133) have been shown
presence of school vending machines and additional
to decrease from childhood to adolescence, potentially
food outlets close to the school has been associated
due to increased physiological requirements, posing
with poorer dietary intake and an increased risk of
risks to neurological, psychological and cardiovascular
obesity in adolescent students(124). External food
health(134).
options have been associated with poorer dietary
Iron deficiency is the leading contributor to adolescent
habits in Irish adolescents, with students attending
disability-adjusted life years associated with micronu-
schools that were near fast-food establishments having
trient deficiencies(135) and is amongst the leading causes
a lower likelihood of consuming fruit and vegeta-
of death, illness, and disability in young women(136).
bles(116). The proximity of schools to unhealthy food
Suboptimal iron status and anaemia in adolescence can
retailers is a particular issue in Ireland, with 46 % of
have significant effects on academic performance and
Irish secondary schools found to be within a 1 km
school attendance due to symptoms of increased fatigue
radius of a fast-food restaurant in 2012, with a higher
and susceptibility to infectious diseases(10). Intervention
concentration in more deprived areas(125). Available
to improve the iron status of adolescents, particularly
food options can determine adolescents’ lunch choices
amongst at-risk females, is imperative in protecting the
and nutritional intake, with an analysis of lunches con-
health and future of this vulnerable group.
sumed by Irish adolescents indicating a poorer nutri-
Analysis of the iodine status of adolescent females
tional profile of lunches from school and food outlets in Ireland indicated that this age group was generally
compared to homemade lunches(126). Indeed, results iodine sufficient, with median urinary iodine concentra-
from a systematic review found a direct association tion within the lower end of the sufficient range(137).
between proximity to ‘unhealthy’ food establishments However, analysis of similarly aged schoolgirls in the
and overweight/obesity in youth(127). In addition to UK found indications of mild iodine deficiency within
the physical food environment, online and social this age group(138), showing that iodine status remains
media are increasingly becoming the primary avenues in a relatively precarious position amongst adolescents.
for adolescent exposure to food messaging and market- With intakes of dairy and fish low amongst Irish adoles-
ing. From peer posting of food images, prolific food cents, monitoring of iodine status is required to ensure
advertising, product placement, and increasing use of this age group remains within the range of iodine
online food delivery services, the exposure of adoles- sufficiency.
cents to readily available unhealthy food products is Adolescent overweight and obesity. Overweight and
just as, if not more, pervasive in the online space as obesity is a chronic non-communicable disease and is
in the physical environment (128). Consideration of associated with a range of acute and long-lasting health
and intervention in all elements of the modern food issues in adolescents(139,140). Obesity is increasingly
environment are required to safeguard the health of identified as disproportionately affecting adolescents,
adolescents. with the recent plateauing of childhood obesity levels

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 148 A. Moore Heslin and B. McNulty

observed in affluent countries(141), including Ireland(142), prevention. Therefore, a drastic scaling up of obesity
not reflected in trends in the weight status of treatment and prevention is required to subside and pre-
adolescents(117). A rapidly increasing prevalence of vent the epidemic of adolescent obesity.
adolescents living with obesity has become apparent in Impairments in metabolic health. Dietary risks and
recent years, with one in four adolescents in Europe overweight/obesity are leading risk factors for
identified as living with overweight/obesity in 2022(143). non-communicable diseases and are strongly associated
Similar rising trends have been observed across several with impairments in health and metabolic functioning(143).
high-income regions including the USA(144) and much While the health consequences of a poor-quality diet
of Europe(145), with adolescent obesity identified as a arise mainly in later life, the quality of the diet
serious public health challenge(118). The rising rates of consumed during adolescence can mediate the
overweight/obesity have also been observed in Irish development of metabolic risk factors that contribute
adolescents, with 24 % of adolescents identified as to disease development(160). Numerous studies have
living with overweight/obesity in 2020, a significant indicated associations between the consumption of a
increase from 18 % in 2006 and 13 % in 1990(146). The poor-quality diet and increased biomarkers of
issue of adolescent overweight/obesity is not confined cardiovascular and metabolic risk amongst
only to high-income countries, with an estimated 21⋅4 adolescents(161–165). However, the consequences of a
% of adolescents in low- to middle-income countries poor-quality diet on metabolic health may not
affected by overweight/obesity(19). necessarily become immediately apparent, with other
Proceedings of the Nutrition Society

Overweight/obesity in adolescence has long-term asso- analyses indicating a presentation of cardiometabolic risk
ciations with adult weight status, with longitudinal studies factors only in late adolescence(166) or later in life(167).
consistently reporting a significant association between Adolescents are increasingly presenting with abnormal
adolescent overweight/obesity and increased risk of obes- blood lipid profiles early in life(168), with a significant pro-
ity and severe obesity in adulthood(147–150). Additionally, portion of this age group increasingly identified as having
adolescents are increasingly presenting with a higher high total cholesterol concentrations and low
grade of obesity, with this age group found to display HDL-cholesterol(168). Older youth and adolescents living
the highest prevalence of severe obesity of all youth age with obesity are more likely to be affected, with the preva-
groups(151). Immediate physical consequences of obesity lence of low HDL-cholesterol almost five times higher
in adolescents include obstructive sleep apnoea, musculo- amongst youth with obesity compared to those with
skeletal complaints, and deteriorations in psychosocial healthy body weight(168). Irish adolescents with excess
health(152). Living with a high grade of obesity in adoles- adiposity have been shown to display a more unfavour-
cence is associated with increased cardiometabolic risks, able metabolic health profile, characterised by increased
with adolescent-onset obesity demonstrating a more LDL-cholesterol, TAG and C-reactive protein(169).
severe lifelong impact of comorbidities than adult-onset Early exposure to CVD risk factors has been robustly
obesity(153). Obesity is associated with a substantial mental linked to poor cardiometabolic health in adulthood,
health burden and decreased quality of life, with adoles- with findings from long-term epidemiological studies indi-
cents living with obesity displaying an increased presenta- cating that abnormal blood lipid profiles in adolescence
tion of psychological comorbidities including depression, predict pre-clinical atherosclerosis(170), adverse cardiovas-
anxiety and low self-esteem(154). These psychological con- cular events(171), type 2 diabetes(172) and premature mor-
sequences are often mediated by the negative societal atti- bidity and mortality in adulthood(173). Blood lipid
tudes and weight stigma frequently experienced by those screening and evaluation of cardiovascular risk factors
living with obesity, with these pressures having a particu- in youth have been long recommended by guidelines(174)
larly strong effect on adolescents(155). but are conducted rarely in practice(175). The increasing
It is suggested that the primary prevention of obesity presentation of metabolic risk factors early in life accent-
in adolescence should become a public health priority, uates the need for early detection, treatment and mitiga-
with this life stage considered a critical period for obesity tory action for adolescents to aid in the primordial
development(156). Exposure to obesity-related risk factors prevention of metabolic diseases.
increases during this time as youth begin to interact with
their environment. The short period in which the expo-
nential increase in adolescent overweight/obesity has Opportunities to improve adolescent nutrition and health
occurred indicates that current trends are likely attribu- Adolescents as agents of change. The years of
ted to drastic changes in the modern food environment adolescence are a period of increased opportunity for
and lifestyles as opposed to biological changes(157). As change as youth become more active agents in their
the prevalence of adolescents affected by overweight is lives(176). The current generation of adolescents is termed
currently greater than the prevalence of those living the ‘do-it-yourself’ generation based on their increased
with obesity, there is vast potential for early obesity pre- sense of autonomy and self-reliance due to a heightened
vention strategies targeting youth with overweight who awareness of societal issues and the ability to
are at high risk of developing obesity(158). The chronic, immediately share their thoughts(177). This motivation is
refractory nature of obesity, underpinned by mechanisms apparent in the various youth-led social movements of
such as the biological defence of body weight(159) and recent years(178,179). Adolescents’ desire to improve the
consolidation of dietary and lifestyle behaviours(87) status quo is translating into the area of nutrition, with
poses adolescence as a critical stage for effective obesity youth-led campaigns such as Bite Back 2030(180) and

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 Adolescent nutrition and health 149

Act4Food Act4Change(181) leading calls for the to tailor interventions to be appropriate, understandable,
improvement of the food system to protect youth health. applicable and easily implemented by the family and
The increased autonomy that growing up brings, adolescents themselves. Additionally, peer-led interven-
coupled with the beginnings of financial freedom mean tions have been emphasised as feasible and acceptable
that adolescents exercise greater choice and control amongst adolescents(197), with evidence indicating some
over what and when they eat(182). Adolescents have improvements in dietary behaviour using positive peer
been shown to possess a modest level of nutrition knowl- modelling(198) and youth role models who can serve as
edge(183) and tend to be relatively accurate in their assess- beacons of influence(199).
ments of their diet quality, with a higher level of dietary Environmental interventions such as the optimisation
awareness associated with consumption of a better- of schools and community food systems and regulation
quality diet(184). However, the accuracy of adolescents’ of the cost and marketing of food and drinks may be
self-assessment of their diet can vary, with a study of effective in improving adolescent food choices(200).
Brazilian adolescents showing that more than half of Schools play a critical role in promoting the health of
those objectively deemed to have a poor-quality diet con- adolescents and can be useful avenues for health promo-
sidered their diet to be very good/good(185). Additionally, tion and obesity prevention. Results from a qualitative
adolescents sometimes struggle to define some processed study of Irish secondary schools indicated diverging
and energy-dense foods as being healthy or unhealthy, views between school staff and students regarding facili-
with mixed dishes, chips, biscuits and confectionery listed tators and barriers to healthy eating, with teachers
Proceedings of the Nutrition Society

as the most difficult foods to categorise(186). Efforts have emphasising the role of education and knowledge,
been made to integrate nutrition education and skills into while adolescents themselves instead identified the issue
school curricula in Ireland and elsewhere(187–190), with of unsupportive food environments(193). The study iden-
analyses of the impact of nutrition education interven- tified a clear mandate by students for schools to create
tions showing positive attitudes(191) and some evidence healthy food spaces, implement healthy eating policies
of beneficial dietary behaviour change amongst adoles- and take responsibility for student welfare(193). While
cent participants(192). there is a definite role in equipping adolescents with
However, nutritional knowledge does not always nutritional literacy to encourage healthy eating, the con-
translate into action, as reflected in the sentiment of tribution of the wider food environment in influencing
‘We know what we should eat but we don’t’ which is per- adolescents’ food choices should be examined and tar-
vasive amongst Irish adolescents(193). While the provision geted for change.
of tailored evidence-based dietary information is crucial The design and offerings of the physical and online
in informing adolescents, education only goes so far in retail food environment strongly influence adolescents’
improving health. Indeed, education-based interventions food choices. Food retailers and manufacturers have
are listed as only more effective than ‘monitoring/doing increasingly been engaging in efforts to encourage
nothing’ on the Nuffield intervention ladder(194). There healthier diets through responsible marketing policies,
is a need to move towards a whole systems approach to accessible nutrition labels and the promotion of fruit
improve the upstream environmental determinants of and vegetables(201). However, certain practices have
adolescent health. been highlighted as causes for concern, including differ-
Transformation of the food environment to promote ent definitions of ‘healthy’ products, slow progress on
health in adolescents. The current trajectories of voluntary product reformulation and poor compliance
transitions in the modern food environment are with recommendations for marketing products to
detrimental in their contribution to diet-related youth(201). There is much scope for improvement in the
non-communicable diseases. There is an urgent need practices of food retailers, with concerns that certain
for transformation of the global food system to protect supermarkets target those in lower socioeconomic areas
the health and future of both people and planet(195). with unhealthy food choices, likely contributing to obes-
Independent interaction with and exposure to the wider ity and health-related issues in these areas(202).
world occurs for the first time in adolescence, with this Additionally, online advertising of unhealthy food is pro-
age group particularly susceptible to the structure, lific and poorly regulated compared to traditional
influences and offerings of the obesogenic food media(203). As frequent users of online and social
environment. The home, school, retail and online food media, adolescent exposure to online food advertising
environments are particularly salient in the lives of is a common occurrence and can significantly influence
adolescents, with each offering unique opportunities for their food-related thoughts and behaviours(128).
intervention. Engagement with food retailers to modify food environ-
Parental modelling of healthy behaviour has been ments has the potential to be very effective in promoting
associated with a lower BMI amongst adolescents, with more healthful dietary choices, as shown by the reduc-
a need for parental consistency in words and actions to tions in intakes of sugar-sweetened beverages as a result
encourage a healthy diet and physical activity and create of traffic light labelling(204), increased prices(205), and
a healthy home environment(196). Family based behav- marketing of healthier alternatives within retail
ioural interventions targeting diet, sedentary behaviours, settings(206).
physical activity and sleep quality have been recom- Society has a duty of care towards adolescents and
mended as a first-line approach for the treatment of ado- should take responsibility for protecting the health of
lescent obesity(157) and dietary improvement, with a need our future. Supportive food environments that enable

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 150 A. Moore Heslin and B. McNulty

and promote healthy choices as the easiest and most labelling, skills which may be somewhat underdeveloped
accessible options are essential in protecting adolescent in this age group.
health. However, improvement of these food environ- There is a need for a whole system, life course
ments will not occur without action across all elements approach to improve adolescents’ dietary intake and
of the environment, with a need for strong policies to health-related behaviours, where rather than just target-
motivate and monitor improvements in these areas. ing individual, social, or environmental factors in isola-
Policies to protect adolescent nutrition and health. tion, all determinants are combined and targeted
The omission of adolescents from health and nutrition holistically. Adolescents themselves should be at the
policies has been criticised by global leaders in nutrition centre of all interventions and should ideally be
and health(9), with the need for consideration and direct involved in each stage of the conception, research, plan-
involvement of adolescents in policy emphasised as key ning, implementation, and evaluation of interventions
in improving and protecting the health of this age to ensure they are understandable, applicable and
group(207). Strong policy action to transform the current effective for them. The effectiveness of this approach
obesogenic environment is essential in encouraging and has been evidenced by the CO-CREATE project, in
promoting healthy behaviours in adolescents and indeed which youth collaborate as equal partners in the devel-
the wider population. opment, testing, and communication of policy ideas to
There can be at times a myopic focus on personal address the factors that influence obesity(207). All
responsibility in diet and obesity intervention, with the resources, interventions, and policies intended for this
Proceedings of the Nutrition Society

influence of the social and environmental determinants age group should be tested for acceptability and rele-
often overlooked. Leading behavioural scientists have vance amongst adolescents themselves, with them
highlighted issues with targeting individual frame involved as ‘active partners’ in local and global efforts
actions to combat societal issues without changing the to promote health(216).
wider system in which these individuals operate(208).
While these ‘individual-frame’ nudge approaches have
been proposed as a promising avenue for influencing
healthy food choices(209), care must be taken not to Conclusions
frame policy issues in terms of the individual rather
than the wider system. Indeed, systemic actions such Promoting and protecting adolescent health to ensure
as taxation and regulation can often prove to be more optimal growth and development is an extremely wise
effective in enabling healthier choices and actions(208). investment to protect our future. Global trends of ageing
This is evidenced by the taxation of sugar-sweetened populations and declines in fertility accentuate the need to
beverages, with a 10 % reduction in purchasing and con- avoid a loss of human potential caused by preventable
sumption apparent following the introduction of the issues in youth. Adolescent health should not be left as
tax(210). A recent systematic review found little evidence solely the responsibility of the health sector, with action
of efficacy for individual-orientated and school-based required across all areas of society including education,
adolescent overweight/obesity prevention measures retail, government, and infrastructure to cultivate a
and emphasised the need to target the environmental more health-promoting environment for this age group.
determinants of adolescent obesity, with a particular This review highlights the growing breadth of research
focus on social inequalities(211). and evidence pertaining to adolescent nutrition and
Improving the nutritional content of commonly con- health. There is now a need for this evidence to be trans-
sumed foods through reformulation and fortification is lated into public health action to effect real benefits for
a promising method to improve the quality of diets con- adolescents. Failure to improve nutritional intake and
sumed by adolescents(212). Reformulation is likely to dietary behaviours during this life stage is likely to have
have significant impacts on adolescent nutrition, with severe repercussions on lifelong health, well-being, and
modelling scenarios from the USA indicating the poten- the ability of future generations to face impending and
tial of a 5 % reduction in consumption of total sugars, a inevitable challenges. Adolescents require and deserve
4 % reduction in intake of saturated fat and an 11 % action in protecting their health, not only as their needs
increase in dietary fibre intake if foods popular amongst are different to and indeed greater than other stages of
adolescents were reformulated to meet current USA life, but also because they, as current and future agents
healthfulness standards(213). Laws regulating the nutri- of change, will confer great benefits to society and will
tional standards of school food have prompted food be whom we come to rely upon. Therefore, it is impera-
manufacturers to reduce the energy, saturated fat, tive that their health is protected and promoted during
sodium and sugar content of school snack products(214), their formative years to provide them with the greatest
suggesting that similar laws may have the potential to opportunities and foundations for success.
improve the standard of school food globally. Product
reformulation has been proposed to be potentially more
effective than enhanced front-of-pack labels in promot-
ing more healthy consumer food purchasing behav- Acknowledgements
iour(215). This may be particularly applicable for The authors acknowledge the Irish Section of the
adolescents, as a certain degree of nutritional knowledge, Nutrition Society for the opportunity to present this
literacy and interest is required to interpret nutritional review as part of the Postgraduate Competition 2022.

https://doi.org/10.1017/S0029665123002689 Published online by Cambridge University Press

 Adolescent nutrition and health 151

Financial Support adolescent girls and young women: priorities for imple-
mentation and research. Ann N Y Acad Sci 1393, 61–71.
This work was supported by funding from the Irish 14. Koletzko B, de la Guéronnière V, Toschke AM et al. (2004)
Department of Agriculture, Food and the Marine Nutrition in children and adolescents in Europe: what is the
under the project; ‘National Teen’s Food Survey II’. scientific basis? Introduction. Br J Nutr 92, 67–73.
15. Kontis V, Bennett JE, Mathers CD et al. (2017) Future
life expectancy in 35 industrialised countries: projections
with a Bayesian model ensemble. Lancet 389, 1323–1335.
Conflict of Interest 16. Rah JH, Melse-Boonstra A, Agustina R et al. (2021) The
triple burden of malnutrition among adolescents in
The authors declare no conflict of interest. Indonesia. Food Nutr Bull 42, S4–S8.
17. Christian P & Smith ER (2018) Adolescent undernutri-
tion: global burden, physiology, and nutritional risks.
Ann Nutr Metab 72, 316–328.
Authorship 18. NCD Risk Factor Collaboration (NCD-RisC) (2017)
A. M. H. completed the review article. B. Mc.N. advised Worldwide trends in body-mass index, underweight, over-
in relation to the content and critically reviewed the weight, and obesity from 1975 to 2016: a pooled analysis
manuscript. Both authors reviewed and approved the of 2416 population-based measurement studies in 128⋅9
final manuscript submitted for publication. million children, adolescents, and adults. Lancet 390,
Proceedings of the Nutrition Society

2627–2642.
19. Caleyachetty R, Thomas GN, Kengne AP et al. (2018)
The double burden of malnutrition among adolescents:
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