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

The high stunting rate in children under five persists worldwide. Globally, 149.2 million children under five suffered from stunting in 2020. 1 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. 2 The World Health Organization has set a maximum tolerance limit for stunting for toddlers at 20%. 1 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. 3 Adolescence is a nutritionally vulnerable period when rapid physical growth increases nutritional needs. Dietary behaviours formed in adolescence can contribute to nutrition-related problems that have long-term health consequences. 3,4 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 middleincome 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 towards achieving the Sustainable Development Goals (SDGs) set by the United Nations. 5 Adolescents are increasingly seen as a window of opportunity with the recognition that investment in the health and well-being 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. 5,6 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 anaemia, for example, are more likely to give birth to low birth weight babies at risk of growth stunting. 7 In countries with a high prevalence of stunting, adolescent girls may face additional challenges in their eating behaviour. Several factors that may contribute to this include: first, limited access to nutritious food -adolescent girls may live in areas where access to nutritious PAGE \* Arabic \* MERGEFORMAT 3 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. 8 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 behaviour 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 behaviour 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.This review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. 9 Additionally, it was registered in the International Prospective Register of Systematic Reviews database (PROSPERO) with registration number CRD42023389909.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 10 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 behaviour. 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 to 1.00). 11The 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. The variables reviewed in the selected studies have been described in Table 3: Table 3. Study characteristics Country and design of the studies Most of the studies in this review utilized a cross-sectional design, with only one using a mixedmethod explanatory design 12 . The studies were conducted in India [12][13][14] , Malaysia 15 , Indonesia 3 , Ethiopia 16- 18 , South Africa 19 , Guatemala 20 , Bangladesh 21 , Tanzania 22 , Nigeria 23 , Pakistan 24 , and Timor Leste 25 .Although the target population of this study is adolescent girls, not all studies focus on the same age range, the adolescent period is divided into three stages: early (ages 11-14), mid (ages 15-17), and late (ages 18-21). 3 In this study, two studies only focused on the early stage, 19,24 one study on the mid-stage, 15 three studies on the early to mid-stage, 3,18,25 two studies on the mid to late-stage 13,20 , and the majority of studies focused on the entire adolescent period from early to late 12,14,16,17,[21][22][23] . These studies are listed with the age range mentioned in the text, along with the study number and corresponding reference.There is a difference in sample size among these studies, ranging from 24 subjects in the qualitative design study20 to 4,993 subjects in the sizeable community-based study in Bangladesh. Therefore, this systematic review evaluated 9,831 participants.All studies utilize different assessment tools to evaluate changes in eating behaviour targets. Four studies employed self-designed questionnaires 14,17,23,25 , while the others used standardized, validated scales such as the Food Frequency Questionnaire 13,22 , Dutch Eating Behavior Questionnaire 15 , Adolescent Food Habit Checklist 3 , Household Food Security 16,18 , and Eating Attitude Test 19 . Qualitative research employs assessment tools in the form of open-ended questionnaires delivered through focus group discussions (FGD) 12 and interviews 20,21,24 .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 behaviour in adolescent girls. Four studies link diet habits to the activities of adolescent girls in school 17,20,24,25 , two studies are related to body image perception 12,13 , one study examines the transition of eating behaviour in urban, rural, and slum areas 14 , two studies assess eating disorders directly in adolescent girls 15,19 , three studies examine dietary diversity, patterns, or habits 3,16,21,22 , and the last study aims to provide data information to policymakers or planners 18 . The outcomes of this study can be summarized as dietary restraint, unhealthy dietary patterns, dietary types, and eating behaviour in adolescent girls.The results of the studies generally show the presence of various eating behaviours 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 12,13,16,24 , especially in urban areas 13 . However, poor eating behaviour was also found among adolescent girls in rural areas, potentially leading to stunting. 14 There is also a tendency among adolescent girls to eat only when they feel hungry. 3 Unfortunately, unhealthy dietary habits associated with excess body weight can lead to the consumption of unhealthy foods. 22 A study also reported a healthy eating pattern of three meals a day, but the meals were not well-balanced. 23 For example, in a PAGE \* Arabic \* MERGEFORMAT 3 study conducted in Timor Leste, adolescent girls were found to consume insufficient calories and protein in their meals. 25 Eating behaviour 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. 26 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. 16 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. 20 Inadequate dietary diversity was found in adolescent girls who consume few fruits and a large number of starchy staples. 17 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 non-staple foods such as eggs, meat, and fish. Fruits are more commonly consumed according to their seasonal availability. 18,21 Possible eating disorders were reported in one study. 19 The Newcastle-Ottawa Quality Assessment Scale (NOS) 27,28 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). 27 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 to 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.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 well-being as they become adults. 29 In this systematic review involving fifteen studies, a comprehensive overview of eating behaviour in adolescent girls in countries with high stunting prevalence was obtained. The observed eating behaviours from this systematic review include eating disorder 15,19 , weight reduction diet 12,13 , restrained eating 15,[20][21][22][23] , craving-induced eating 3 , unhealthy dietary pattern 23 , and low diversity diet 16,17 .The first crucial finding of this systematic review underscores the connection between eating disorders and extreme weight-loss behaviours 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 behaviours in the past year were likelier to score higher on the EAT-26, indicating a potential risk of eating disorders. 19 These results emphasise the need for early identification and support for individuals at risk for or already eating patterns. and cultural factors may contribute to the development of eating disorders. 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